Patients missing appointments? Implement a no-show policy to keep your income steady despite missed appointments!
Missed appointments have an impact on your physician’s schedule or
his availability to other patients, and can also pose a health threat to
the patient. Here are some no-show best practices to ensure your
practice is maximizing your physician’s time, and getting the
reimbursements it deserves.Tuesday, March 18, 2014
Thursday, February 27, 2014
Choose Between 782.9 and 705.89 for Body Odor
Question: A mother brought her 6-year-old daughter to our office because she was concerned about the daughter's body odor. She follows good hygiene. The physician assistant thought it might be thyroid related so wants to send the child for lab work. What diagnosis should we report?
CD-9 2007 Update: Using 997.99 to Report Bleb Infection?
New diagnosis codes include stages of post-trabeculectomy inflammations -- and a new code for ONH
When a patient presents with a post-op bleb infection, the current ICD-9 index guides you to 997.99 (Complications affecting other specified body systems, not elsewhere classified; other). Starting in October, however, you’ll be able to code the condition -- and the level of severity -- much more precisely.
Medicare has released 204 new ICD codes that should appear in your 2007 ICD-9 coding manual. Among them are four new blebitis codes that the American Academy of Ophthalmology asked for at the ICD-9 CM Coordination and Maintenance Committee meeting in September 2005.
When a patient presents with a post-op bleb infection, the current ICD-9 index guides you to 997.99 (Complications affecting other specified body systems, not elsewhere classified; other). Starting in October, however, you’ll be able to code the condition -- and the level of severity -- much more precisely.
Medicare has released 204 new ICD codes that should appear in your 2007 ICD-9 coding manual. Among them are four new blebitis codes that the American Academy of Ophthalmology asked for at the ICD-9 CM Coordination and Maintenance Committee meeting in September 2005.
Thursday, February 13, 2014
NCCI 11.3 Update: Include Duct Probe in Dacryocystorhinostomy
The latest bundles also clarify the rules for IOL exchanges
You probably won’t tear up when you see what NCCI is up to this quarter--unless your practice spends a fair share of its time performing nasolacrimal probes.
NCCI version 11.3, that took effect Oct. 1, specifies that CPT codes 68810 (Probing of nasolacrimal duct, with or without irrigation) and 68811 (… requiring general anesthesia) are included in:
• 31239--Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy
• 68530--Removal of foreign body or dacryolith, lacrimal passages
• 68720--Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity).
You probably won’t tear up when you see what NCCI is up to this quarter--unless your practice spends a fair share of its time performing nasolacrimal probes.
NCCI version 11.3, that took effect Oct. 1, specifies that CPT codes 68810 (Probing of nasolacrimal duct, with or without irrigation) and 68811 (… requiring general anesthesia) are included in:
• 31239--Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy
• 68530--Removal of foreign body or dacryolith, lacrimal passages
• 68720--Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity).
What HCPC code to use for just injection Lidocaine
A quick glance might make you think J2001 (Injection, Lidocaine HCl
for intravenous infusion 10 mg) might be a possibility, but don't go
that route. Code J2001 represents IV infusion of Lidocaine, which is
used for cardiac arrhythmias and not as a local anesthetic. A better
choice might be J3490 (Unclassified drugs) with a note in Box 19 to
indicate the drug and its concentration.
Caution: Many payers do not allow separate reimbursement for local aesthetic ,as they consider it to be part of the injection procedure."
Caution: Many payers do not allow separate reimbursement for local aesthetic ,as they consider it to be part of the injection procedure."
Tuesday, February 11, 2014
Partial vs. Total Ethmoidectomy
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: How would you code a right-side nasal sinus endoscopy with total ethmoidectomy, plus a left-side endoscopy with partial ethmoidectomy?
Question: How would you code a right-side nasal sinus endoscopy with total ethmoidectomy, plus a left-side endoscopy with partial ethmoidectomy?
Monday, February 10, 2014
Justify Your Choice of Jones Fracture Code in ICD-10
ICD-9 offers only a single code for closed fracture of metatarsal bone(s) – 825.25 (Fracture of metatarsal bone[s] closed).
Note that is the only code for the closed fracture of one or more
metatarsal bones and is not specific for a particular metatarsal bone.
You can report the same code for fracture in any metatarsal bone, first
to fifth.
Adopt this 3-step Approach for ICD-10 Codes
Adopt this 3-step Approach for ICD-10 Codes
Friday, February 7, 2014
CCI 8.1 Removes Inappropriate Edit for Electrophysiology Studies
Version 8.1 of the national Correct Coding Initiative (CCI)
(effective April 1, 2002-June 30, 2002) deletes an inappropriate edit
that defeated the purpose of a CPT revision for two electrophysiology
(EP) codes.
In version 8.0 (effective Jan. 1-March 31, 2002), CCI bundled a primary code (93620, Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia) into its add-on components, +93621 ( with left atrial pacing and recording from coronary sinus or left atrium [list separately in addition to code for primary procedure]) and +93622 ( with left ventricular pacing and recording [list separately in addition to code for primary procedure]).
As of Jan. 1, 2002, CPT revised these three codes. Code 93620 is no longer an extension of 93619 (... without induction or attempted induction of arrhythmia) and now stands alone. More significant, +93621 and +93622 were changed to add-on codes that may be reported in addition to 93620. Previously, +93621 and +93622 were comprehensive codes that incorporated all the elements of 93620 as well as left atrial or left ventricular study.
Refile Denied EPClaims
The CPT change resolved a long-standing issue about how EP studies that also involve the left atrium and/or the left ventricle should be coded. Although CCI bundled 93620 with +93621 and +93622, some EP physicians argued that, given the tiny increase in fees for performing the left-side study, both right-side (93620) and left-side (+93621 and/or +93622) studies should be separately reported.
"By changing +93621 and +93622 to add-on codes, the issue was supposed to go away," says Belinda Inabinet, CPC, technical support and coding manager at South Carolina Heart Center, a 21-physician practice in Columbia, S.C. "But CCI wasn't notified in time to correct the problem for the first-quarter edits, so they were not removed, and some Medicare and other carriers continued to deny the main procedure." Other carriers, she adds, allowed the claim to go through on appeal.
After they were designated as add-on codes, CMS revised their value. In 2001, before the change, +93621-26 ( Professional component) was assigned 21.20 relative value units (RVUs), whereas +93622-26 was valued at 21.32 RVUs. As add-on codes, the values have been drastically reduced (+93621, 3.13 RVUs; +93622, 5.07 RVUs).
The failure to remove the edit in 8.0 results in the denial of 93620-26 and its 17.01 RVUs, leaving the EP physician with payment only for 93621-26 and/or 93622-26, a fraction of the appropriate amount for performing the left- and right-side EP studies.
In version 8.0 (effective Jan. 1-March 31, 2002), CCI bundled a primary code (93620, Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia) into its add-on components, +93621 ( with left atrial pacing and recording from coronary sinus or left atrium [list separately in addition to code for primary procedure]) and +93622 ( with left ventricular pacing and recording [list separately in addition to code for primary procedure]).
As of Jan. 1, 2002, CPT revised these three codes. Code 93620 is no longer an extension of 93619 (... without induction or attempted induction of arrhythmia) and now stands alone. More significant, +93621 and +93622 were changed to add-on codes that may be reported in addition to 93620. Previously, +93621 and +93622 were comprehensive codes that incorporated all the elements of 93620 as well as left atrial or left ventricular study.
Refile Denied EPClaims
The CPT change resolved a long-standing issue about how EP studies that also involve the left atrium and/or the left ventricle should be coded. Although CCI bundled 93620 with +93621 and +93622, some EP physicians argued that, given the tiny increase in fees for performing the left-side study, both right-side (93620) and left-side (+93621 and/or +93622) studies should be separately reported.
"By changing +93621 and +93622 to add-on codes, the issue was supposed to go away," says Belinda Inabinet, CPC, technical support and coding manager at South Carolina Heart Center, a 21-physician practice in Columbia, S.C. "But CCI wasn't notified in time to correct the problem for the first-quarter edits, so they were not removed, and some Medicare and other carriers continued to deny the main procedure." Other carriers, she adds, allowed the claim to go through on appeal.
After they were designated as add-on codes, CMS revised their value. In 2001, before the change, +93621-26 ( Professional component) was assigned 21.20 relative value units (RVUs), whereas +93622-26 was valued at 21.32 RVUs. As add-on codes, the values have been drastically reduced (+93621, 3.13 RVUs; +93622, 5.07 RVUs).
The failure to remove the edit in 8.0 results in the denial of 93620-26 and its 17.01 RVUs, leaving the EP physician with payment only for 93621-26 and/or 93622-26, a fraction of the appropriate amount for performing the left- and right-side EP studies.
Wednesday, February 5, 2014
ICD-10: Prep Now for New Pneumonia Diagnosis Code
Starting this October, you’ll be required to report J18.9 for pneumonia.
Although your pediatric practice has grown accustomed to reporting a code from the 486 series for patients with pneumonia, that will change dramatically in October, when you’re required to start billing under the ICD-10 system.
ICD-9 Coding Rules: Currently, the ICD-9-CM code set provides one diagnosis code for pneumonia caused by an unspecified organism: 486 (Pneumonia organism unspecified). Coding guidelines specify that diagnosis 486 excludes hypostatic or passive pneumonia, inhalation or aspiration pneumonia due to foreign materials, or pneumonitis due to fumes and vapors.
If your provider does not document a specific organism that caused the patient’s pneumonia, you submit diagnosis 486.
ICD-10-CM Code: Starting in October, however, you’ll look to J18.9 (Pneumonia, unspecified organism) for this condition.
You’ll find the diagnosis in ICD-10 under Chapter 10, Diseases of the Respiratory System, the Influenza and Pneumonia block.
Documentation: Pneumonia may be suspected when the pediatrician examines the patient and hears coarse breathing or crackling sounds when listening to a portion of the chest with a stethoscope. There may be wheezing, or the sounds of breathing may be faint in a particular area of the chest. A chest X-ray may be ordered to confirm the diagnosis of pneumonia.
Additional tests to confirm a pneumonia diagnosis could include blood tests or taking sputum samples. The physician’s documentation of these tests must support any additional codes you report.
Coder Tips: ICD-10 guidelines provide numerous tips for coding pneumonia and other respiratory conditions. For example:
List any type of associated influenza first on your claim, if applicable (J09.01-, J09.11-, J10.0-, -J11.0-)
Use additional codes (when applicable) to identify exposure to tobacco smoke, history of tobacco use, or tobacco dependence.
Several codes in the J18 code block describe other types of pneumonia due to unspecified organism (bronchopneumonia, lobar pneumonia, hypostatic pneumonia). Verify that none of these diagnoses is a better reflection of the documentation before you submit J18.9.
If your pediatrician orders lab tests to confirm the diagnosis, your documentation must include a copy of the lab report.
Although your pediatric practice has grown accustomed to reporting a code from the 486 series for patients with pneumonia, that will change dramatically in October, when you’re required to start billing under the ICD-10 system.
ICD-9 Coding Rules: Currently, the ICD-9-CM code set provides one diagnosis code for pneumonia caused by an unspecified organism: 486 (Pneumonia organism unspecified). Coding guidelines specify that diagnosis 486 excludes hypostatic or passive pneumonia, inhalation or aspiration pneumonia due to foreign materials, or pneumonitis due to fumes and vapors.
If your provider does not document a specific organism that caused the patient’s pneumonia, you submit diagnosis 486.
ICD-10-CM Code: Starting in October, however, you’ll look to J18.9 (Pneumonia, unspecified organism) for this condition.
You’ll find the diagnosis in ICD-10 under Chapter 10, Diseases of the Respiratory System, the Influenza and Pneumonia block.
Documentation: Pneumonia may be suspected when the pediatrician examines the patient and hears coarse breathing or crackling sounds when listening to a portion of the chest with a stethoscope. There may be wheezing, or the sounds of breathing may be faint in a particular area of the chest. A chest X-ray may be ordered to confirm the diagnosis of pneumonia.
Additional tests to confirm a pneumonia diagnosis could include blood tests or taking sputum samples. The physician’s documentation of these tests must support any additional codes you report.
Coder Tips: ICD-10 guidelines provide numerous tips for coding pneumonia and other respiratory conditions. For example:
List any type of associated influenza first on your claim, if applicable (J09.01-, J09.11-, J10.0-, -J11.0-)
Use additional codes (when applicable) to identify exposure to tobacco smoke, history of tobacco use, or tobacco dependence.
Several codes in the J18 code block describe other types of pneumonia due to unspecified organism (bronchopneumonia, lobar pneumonia, hypostatic pneumonia). Verify that none of these diagnoses is a better reflection of the documentation before you submit J18.9.
If your pediatrician orders lab tests to confirm the diagnosis, your documentation must include a copy of the lab report.
Proposed IA Code Values Fill RVU Scale Void
Question: What immunization administration (IA) code should I use for FluMist? Because this is an inhaled product, CPT 90471 -90472 seem inappropriate. Do these codes contain no CMS values?
Ohio Subscriber
Answer: You are correct that you should report IA of an injected product with 90471-90472 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; …). When you administer an intranasal (FluMist) or oral immunization, you should instead assign 90473-90474 (Immunization administration intranasal or oral route …).
If a pediatrician or nonphysician practitioner provides vaccine counseling and the patient is under 8 years old, you should instead assign 90467-90468 (Immunization administration under 8 years of age … when the physician counsels the patient/family …) for intranasal or oral administration.
Great news: The Proposed Physician Fee Schedule (PPFS) for 2006 assigns relative value units (RVUs) to the four intranasal/oral IA codes (90467, 90468, 90473 and 90474). These codes now have an R status (Restricted coverage) and 0 RVUs. In 2006, the codes will still carry an “R,” which means “Special coverage instructions apply.” But CMS has assigned RVUs to the codes, so they will no longer be carrier-priced.
CMS assigned proposed values for the intranasal/oral IA codes that echo the corresponding injection IA code’s values. The PPFS lists the same new values for 90467 (Intranasal/oral IA with physician counseling; first administration) and 90473 (Intranasal/oral IA; one vaccine) that 90465 (Injection IA with physician counseling; first injection) and 90471 (Injection IA; one vaccine) now contain. The RVUs include:
• 0.17 for physician work
• 0.31 for nonfacility practice expense
• 0.49 for nonfacility total.
CMS also assigned the same values for add-on codes +90468 (Intranasal/oral IA with physician counseling; each additional administration) and +90474 (Intranasal/oral IA; each additional vaccine) as for add-on codes +90472 (Injection IA; each additional vaccine) and +90466 (Injection IA with physician counseling; each additional injection). The PPFS lists the following RVUs:
• 0.15 for physician work
• 0.13 for nonfacility practice expense
• 0.29 for nonfacility total.
Another possibility: The American Academy of Pediatrics would also like the final rule to list values for 92551 (Screening test, pure tone, air only) and 99173 (Screening test of visual acuity, quantitative, bilateral). The 2006 PPFS did not publish RVUs for the hearing and vision screening codes.
--Answers to You Be the Coder and Reader Questions provided by Richard A. Molteni, MD, FAAP, a neonatologist and medical director at Children’s Hospital and Regional Medical Center in Seattle; Dennis Padget, president of Padget and Associates in Simpsonville, Ky.; Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio; and Gretchen Segado, MS, CPC, director of reimbursement compliance at New York University School of Medicine.
Ohio Subscriber
Answer: You are correct that you should report IA of an injected product with 90471-90472 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; …). When you administer an intranasal (FluMist) or oral immunization, you should instead assign 90473-90474 (Immunization administration intranasal or oral route …).
If a pediatrician or nonphysician practitioner provides vaccine counseling and the patient is under 8 years old, you should instead assign 90467-90468 (Immunization administration under 8 years of age … when the physician counsels the patient/family …) for intranasal or oral administration.
Great news: The Proposed Physician Fee Schedule (PPFS) for 2006 assigns relative value units (RVUs) to the four intranasal/oral IA codes (90467, 90468, 90473 and 90474). These codes now have an R status (Restricted coverage) and 0 RVUs. In 2006, the codes will still carry an “R,” which means “Special coverage instructions apply.” But CMS has assigned RVUs to the codes, so they will no longer be carrier-priced.
CMS assigned proposed values for the intranasal/oral IA codes that echo the corresponding injection IA code’s values. The PPFS lists the same new values for 90467 (Intranasal/oral IA with physician counseling; first administration) and 90473 (Intranasal/oral IA; one vaccine) that 90465 (Injection IA with physician counseling; first injection) and 90471 (Injection IA; one vaccine) now contain. The RVUs include:
• 0.17 for physician work
• 0.31 for nonfacility practice expense
• 0.49 for nonfacility total.
CMS also assigned the same values for add-on codes +90468 (Intranasal/oral IA with physician counseling; each additional administration) and +90474 (Intranasal/oral IA; each additional vaccine) as for add-on codes +90472 (Injection IA; each additional vaccine) and +90466 (Injection IA with physician counseling; each additional injection). The PPFS lists the following RVUs:
• 0.15 for physician work
• 0.13 for nonfacility practice expense
• 0.29 for nonfacility total.
Another possibility: The American Academy of Pediatrics would also like the final rule to list values for 92551 (Screening test, pure tone, air only) and 99173 (Screening test of visual acuity, quantitative, bilateral). The 2006 PPFS did not publish RVUs for the hearing and vision screening codes.
--Answers to You Be the Coder and Reader Questions provided by Richard A. Molteni, MD, FAAP, a neonatologist and medical director at Children’s Hospital and Regional Medical Center in Seattle; Dennis Padget, president of Padget and Associates in Simpsonville, Ky.; Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio; and Gretchen Segado, MS, CPC, director of reimbursement compliance at New York University School of Medicine.
Find Out Where the Radiology Experts Stand on NCCI 12.0
See why these angioplasty bundles make sense
You’ve got mail! Letters to the National Correct Coding Initiative posted on the American College of Radiology Web site give you an inside look at the reasoning behind certain angioplasty bundles and tell you when it’s OK to override them.
Several months ago, the ACR and the Society of Interventional Radiology got a sneak peek at some potential NCCI Edits version 12.0 edits. In July 2005, CMS notified ACR that NCCI 12.0, effective Jan. 1, 2006, could include edits bundling brachiocephalic angioplasty codes 35475 and 35458 into intravascular stent placement codes 37215 and 37216. The reason: The value of the latter codes includes any necessary angioplasty. Stent placement code 0075T, though without an official value, should also include necessary angioplasty, CMS said.
CMS noted that you could break the bundle when the physician performs an angioplasty “on the brachiocephalic trunk or one of its branches other than the stented cervical carotid artery.” The final version of NCCI 12.0 only included the 0075T/35458 and 0075T/35475 edits. ACR and SIR posted a response indicating that they’re in full agreement with CMS for the reasons given.
You can find the letters on ACR’s Web site at www.acr.org/s_acr/sec.asp?CID=3625&DID=22920.
You’ve got mail! Letters to the National Correct Coding Initiative posted on the American College of Radiology Web site give you an inside look at the reasoning behind certain angioplasty bundles and tell you when it’s OK to override them.
Several months ago, the ACR and the Society of Interventional Radiology got a sneak peek at some potential NCCI Edits version 12.0 edits. In July 2005, CMS notified ACR that NCCI 12.0, effective Jan. 1, 2006, could include edits bundling brachiocephalic angioplasty codes 35475 and 35458 into intravascular stent placement codes 37215 and 37216. The reason: The value of the latter codes includes any necessary angioplasty. Stent placement code 0075T, though without an official value, should also include necessary angioplasty, CMS said.
CMS noted that you could break the bundle when the physician performs an angioplasty “on the brachiocephalic trunk or one of its branches other than the stented cervical carotid artery.” The final version of NCCI 12.0 only included the 0075T/35458 and 0075T/35475 edits. ACR and SIR posted a response indicating that they’re in full agreement with CMS for the reasons given.
You can find the letters on ACR’s Web site at www.acr.org/s_acr/sec.asp?CID=3625&DID=22920.
738.4 Represents Anterolisthesis
Question: What is the ICD-9 code for grade I anterolisthesis?
SuperCoder.com Member
Answer: Anterolisthesis is a form of spondylolisthesis. For acquired anterolisthesis, report 738.4 (Acquired spondylolisthesis). For congenital cases, look to 756.12 (Spondylolisthesis congenital).
The diagnosis: Spondylolisthesis is a spinal condition in which a vertebra slips forward or backward relative to the next vertebra. If the upper vertebral body slips forward on the one below, this is anterolisthesis (antero- means "before" or "front"). Grade I is a minor form of the condition. Typically, the diagnosis is confirmed by MRI.
SuperCoder.com Member
Answer: Anterolisthesis is a form of spondylolisthesis. For acquired anterolisthesis, report 738.4 (Acquired spondylolisthesis). For congenital cases, look to 756.12 (Spondylolisthesis congenital).
The diagnosis: Spondylolisthesis is a spinal condition in which a vertebra slips forward or backward relative to the next vertebra. If the upper vertebral body slips forward on the one below, this is anterolisthesis (antero- means "before" or "front"). Grade I is a minor form of the condition. Typically, the diagnosis is confirmed by MRI.
427.xx: Which Code(s) Describe AFib With RVR?
Question: What is the correct diagnosis code for atrial fibrillation with rapid ventricular response?
SuperCoder.com Member
Answer: You should report 427.31 (Atrial fibrillation) for this diagnosis, which you may see documented as Afib with RVR.
Codes 427.41 (Ventricular fibrillation) and 427.42 (Ventricular flutter) are specific to fibrillation and flutter respectively, so you should not use those codes without supporting documentation.
SuperCoder.com Member
Answer: You should report 427.31 (Atrial fibrillation) for this diagnosis, which you may see documented as Afib with RVR.
Codes 427.41 (Ventricular fibrillation) and 427.42 (Ventricular flutter) are specific to fibrillation and flutter respectively, so you should not use those codes without supporting documentation.
Monday, February 3, 2014
CCI 20.0 Updates for Ophthalmology
CCI version 20.0 went into effect on January 1,
2014 and this time it includes hundreds of procedures with the new code
for insertion of an aqueous drainage device.
CPT® code 66183 (insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach) describes an eye surgeon’s ability to use a single-piece stainless-steel implant which reduces intraocular pressure (IOP). So when you implant a surgical device in the treatment of refractory open-angle glaucoma to reduce intraocular pressure, you should use this code.
More than 200 procedure codes have been bundled into CPT® code 66183, such as:
- Integumentary surgical repair (closure) procedure codes 12001-13153
- Venous procedure codes 36000-36410 and 36420-36440
- Arterial procedure codes 36600 and 36640
- Naso- or oro-gastric tube placement code 43752
- Bladder catheter codes 51701-51703
- Spinal therapeutic injection codes 62310-62319
Some of the code pairs (such as the bundling of the surgical repair procedures into 66183) are marked with a modifier indicator “1”.) This allows you to report the codes separately with the correct modifier with relevant clinical circumstances. Others are marked with modifier indicator “0”, which means that you can never report the codes separately under any circumstances.
Visit this CMS page for the complete list of edits.
General Surgery 10 Tips to Ease Unna Boot Billing
Even though the coding is straightforward there’s just one Unna boot code this doesn’t always imply that confirming this particular service is going to be problem-free. An Unna boot is really a medicated dressing that surgeons utilize to treat varicose leg stomach problems, which might occur because of elevated venous pressure from venous deficit or any other output problems. Unna boots also are utilized to manage lymphatic edema and often can be used for sprains, strains, minor fractures and, sometimes, like a protective bandage for grafts on wound burns.
Use of an Unna boot is reported using 29580 (Strapping Unna boot), featuring its adding a bandage heavy-laden with Unna paste (gelatin, glycerin and zinc oxide) around the leg ulcer before the bandage becomes semirigid. The mixture of pressure and medicine helps the recovery process. .. .
Multiple remedies typically are needed, usually once per week and often more often, states Elaine Elliott, CPC, an over-all surgery coding and compensation specialist in Jensen Beach, Fla. .
Tip 1: Only significant and separate E/M services ought to be reported on the day that as Unna boot application. Because Unna boots are applied throughout a number of visits, E/M services (for instance, a recognised patient visit) shouldn’t be reported once the patient comes for scheduled treatment unless of course the individual has one other issue. In such instances, modifier -25 (Significant, individually identifiable evaluation and management service through the same physician on the day that from the procedure or any other service) ought to be appended towards the E/M code. .
The right E/M service code might be reported individually for that initial assessment from the condition that brought to the choice to use the Unna boot. .
Note: Most methods, including Unna boot strapping, add a preprocedure evaluation which involves routine follow-up care. Another diagnosis, while not essential for Medicare insurance service providers, always is useful by showing why the visit was separate and significant. .
Tip 2: Bill for supplies individually only when the company under consideration instructs you to do this on paper..
Although casts, splints along with other supplies might be individually due, Medicare insurance doesn’t include Unna boot dressings within the same category. Therefore, supplies (bandages, straps and paste) shouldn’t be reported individually to Medicare insurance service providers, and many private service providers will probably follow Medicare’s lead. .
Medicare insurance views the Unna boot a dressing as opposed to a cast and states it’s incorporated in 29580 the applying code ” Elliott states. .
Note: The process is worth 1.23 relative value models when carried out inside a nonfacility setting. .
Tip 3: You are able to bill for debridements individually..
Some patients (individuals with venous stasis stomach problems [454.] for example) may need debridements. In such instances another debridement code (typically 11040 Debridement skin partial thickness 11041 skin full thickness 11042 skin and subcutaneous tissue 11043 skin subcutaneous tissue and muscle or 11044 skin subcutaneous tissue muscle and bone) might be reported. .
When the Unna boot is used with a nurse or any other nonphysician specialist (NPP) like a physician assistant or perhaps a nurse specialist these debridement codes shouldn’t be reported even under “incident to ” states Marcella Bucknam CPC a and compensation specialist along with a coding instructor at Clarkson College in Omaha Neb. .
Rather Bucknam states the NPP’s services ought to be reported using 97601 (Elimination of devitalized tissue from wound[s] selective debridement without anesthesia [e.g. ruthless waterjet sharp selective debridement with scissors knife and forceps] including topical application[s] wound assessment and instruction[s] for ongoing care per session) or 97602 ( non-selective debridement without anesthesia [e.g. wet-to-moist dressings enzymatic abrasion] including topical application[s] wound assessment and instruction[s] for ongoing care per session). .
Tip 4: Bilateral remedies might be reported. If Unna boots are put on the right and left leg the methods ought to be reported to Medicare insurance service providers by appending modifier -50 (Bilateral procedure) to 29580 states Elliott. Some Medicare insurance service providers may request that modifiers -LT (Left side) and -RT (Right side) be utilized rather. Others for example Empire Medicare insurance Services the Medicare Part B company in Nj and areas of New You are able to condition instruct companies to make use of -LT or -RT if perhaps one for reds is carried out and also to append modifier -50 when the Unna boot is used bilaterally. .
Many private service providers may also require methods to become reported the following: .
29580
29580-50 .
or .
29580-LT
29580-RT. .
The bilateral Unna boot application ought to be refunded at 150 percent from the fee schedule rate according to Medicare’s bilateral surgery recommendations Elliott states. .
Tip 5: When the Unna boot is used in the hospital a smaller amount ought to be charged. The Medicare insurance fee schedule values 29580 at 1.23 RVUs within an office setting only .98 RVUs when the application is carried out within the hospital. A nearby medical review policy regarding Unna boot from CIGNA the Medicare Part B company in New York states that “if the procedure is carried out inside a facility setting a lower compensation is going to be permitted” (emphasis added). .
Tip 6: Nonphysician professionals may bill for that service under incident to recommendations. Although any connected debridements are charged using 97601 or 97602 the use of the Unna boot itself might be reported incident to if it’s carried out through the NPP underneath the “direct personal supervision” from the physician. Under incident to recommendations direct personal supervision means choices should be within the suite but do not need to maintain exactly the same room because the NPP once the Unna boot is used. .
Note: When the services are carried out inside a hospital by nursing staff it shouldn’t be reported through the surgeon because it will likely be reported through the hospital to Medicare insurance Medicare Part A. .
Tip 7: Contact company before using 29580 for just about any other strapping or dressing service. Doctors have obtained conflicting instructions regarding this problem. In This summer 1999 The mentioned that top-compression bandage systems for example PROFORE multilayer compression bandage or Dynaflex three-layer compression bandage ought to be reported using 29580 with modifier -22 (Unusual procedural services) appended. .
Note: Modifier -22 ought to be appended only when significant additional work or there was a time needed. Most coding specialists interpret that as a minimum of 25 % or even more. .
Some local medical review guidelines however condition that 29580 “signifies the Unna boot service of application only it’s not for use for billing other strapping or dressing changes.” These service providers may need that 29799 (Unlisted procedure casting or strapping) be reported for top-compression bandage systems. You need to contact the company for particular needs. An account from the procedure ought to be indexed by box 19 from the claim form. .
When the Unna boot can be used like a postoperative dressing it’s not a individually due service because payment for surgical dressings applied throughout someone encounter is incorporated within the fee schedule amount for that service Elliott adds. .
Tip 8: Make certain theis an approved diagnosis. Unna boot programs are covered for particular conditions only. Although service providers can vary greatly in the amount of released diagnoses that support Unna boot application most accept the next signs and diagnoses (frequently symbolized by several ICD-9 code): .
spider veins of lower limbs
venous deficit unspecified
chronic ulcer of skin
decubitus ulcer of lower extremity
ulcer of lower braches
edema of lower limbs.
Most service providers clearly will not pay for Unna boot programs for sprains strains or small fractures because other remedies for example elastic bandage or tape are simply as effective scientifically and price less. Spider veins or phlebitis from the calf isn’t covered but postphlebitic syndrome (459.1) and spider veins of lower extremity with ulcer and inflammation (454.-454.2) are reimbursable. .
Tip 9: Get yourself a waiver in the patient at the appropriate interval. When the Unna boot can be used for signs or diagnoses that aren’t approved request the individual to sign a waiver (for Medicare insurance funding beneficiary notice or ABN) to point that she or he knows that cash payment for remedies (as well as other arrangement) is needed. .
Tip 10: Don’t report removing the Unna boot individually. (Removal or bivalving gauntlet boot or body cast) shouldn’t be accustomed to report removing an Unna boot. Presuming choices examined the individual and recorded the encounter the boot removal can count toward a suitable-level E/M service. “
Use of an Unna boot is reported using 29580 (Strapping Unna boot), featuring its adding a bandage heavy-laden with Unna paste (gelatin, glycerin and zinc oxide) around the leg ulcer before the bandage becomes semirigid. The mixture of pressure and medicine helps the recovery process. .. .
Multiple remedies typically are needed, usually once per week and often more often, states Elaine Elliott, CPC, an over-all surgery coding and compensation specialist in Jensen Beach, Fla. .
Tip 1: Only significant and separate E/M services ought to be reported on the day that as Unna boot application. Because Unna boots are applied throughout a number of visits, E/M services (for instance, a recognised patient visit) shouldn’t be reported once the patient comes for scheduled treatment unless of course the individual has one other issue. In such instances, modifier -25 (Significant, individually identifiable evaluation and management service through the same physician on the day that from the procedure or any other service) ought to be appended towards the E/M code. .
The right E/M service code might be reported individually for that initial assessment from the condition that brought to the choice to use the Unna boot. .
Note: Most methods, including Unna boot strapping, add a preprocedure evaluation which involves routine follow-up care. Another diagnosis, while not essential for Medicare insurance service providers, always is useful by showing why the visit was separate and significant. .
Tip 2: Bill for supplies individually only when the company under consideration instructs you to do this on paper..
Although casts, splints along with other supplies might be individually due, Medicare insurance doesn’t include Unna boot dressings within the same category. Therefore, supplies (bandages, straps and paste) shouldn’t be reported individually to Medicare insurance service providers, and many private service providers will probably follow Medicare’s lead. .
Medicare insurance views the Unna boot a dressing as opposed to a cast and states it’s incorporated in 29580 the applying code ” Elliott states. .
Note: The process is worth 1.23 relative value models when carried out inside a nonfacility setting. .
Tip 3: You are able to bill for debridements individually..
Some patients (individuals with venous stasis stomach problems [454.] for example) may need debridements. In such instances another debridement code (typically 11040 Debridement skin partial thickness 11041 skin full thickness 11042 skin and subcutaneous tissue 11043 skin subcutaneous tissue and muscle or 11044 skin subcutaneous tissue muscle and bone) might be reported. .
When the Unna boot is used with a nurse or any other nonphysician specialist (NPP) like a physician assistant or perhaps a nurse specialist these debridement codes shouldn’t be reported even under “incident to ” states Marcella Bucknam CPC a and compensation specialist along with a coding instructor at Clarkson College in Omaha Neb. .
Rather Bucknam states the NPP’s services ought to be reported using 97601 (Elimination of devitalized tissue from wound[s] selective debridement without anesthesia [e.g. ruthless waterjet sharp selective debridement with scissors knife and forceps] including topical application[s] wound assessment and instruction[s] for ongoing care per session) or 97602 ( non-selective debridement without anesthesia [e.g. wet-to-moist dressings enzymatic abrasion] including topical application[s] wound assessment and instruction[s] for ongoing care per session). .
Tip 4: Bilateral remedies might be reported. If Unna boots are put on the right and left leg the methods ought to be reported to Medicare insurance service providers by appending modifier -50 (Bilateral procedure) to 29580 states Elliott. Some Medicare insurance service providers may request that modifiers -LT (Left side) and -RT (Right side) be utilized rather. Others for example Empire Medicare insurance Services the Medicare Part B company in Nj and areas of New You are able to condition instruct companies to make use of -LT or -RT if perhaps one for reds is carried out and also to append modifier -50 when the Unna boot is used bilaterally. .
Many private service providers may also require methods to become reported the following: .
29580
29580-50 .
or .
29580-LT
29580-RT. .
The bilateral Unna boot application ought to be refunded at 150 percent from the fee schedule rate according to Medicare’s bilateral surgery recommendations Elliott states. .
Tip 5: When the Unna boot is used in the hospital a smaller amount ought to be charged. The Medicare insurance fee schedule values 29580 at 1.23 RVUs within an office setting only .98 RVUs when the application is carried out within the hospital. A nearby medical review policy regarding Unna boot from CIGNA the Medicare Part B company in New York states that “if the procedure is carried out inside a facility setting a lower compensation is going to be permitted” (emphasis added). .
Tip 6: Nonphysician professionals may bill for that service under incident to recommendations. Although any connected debridements are charged using 97601 or 97602 the use of the Unna boot itself might be reported incident to if it’s carried out through the NPP underneath the “direct personal supervision” from the physician. Under incident to recommendations direct personal supervision means choices should be within the suite but do not need to maintain exactly the same room because the NPP once the Unna boot is used. .
Note: When the services are carried out inside a hospital by nursing staff it shouldn’t be reported through the surgeon because it will likely be reported through the hospital to Medicare insurance Medicare Part A. .
Tip 7: Contact company before using 29580 for just about any other strapping or dressing service. Doctors have obtained conflicting instructions regarding this problem. In This summer 1999 The mentioned that top-compression bandage systems for example PROFORE multilayer compression bandage or Dynaflex three-layer compression bandage ought to be reported using 29580 with modifier -22 (Unusual procedural services) appended. .
Note: Modifier -22 ought to be appended only when significant additional work or there was a time needed. Most coding specialists interpret that as a minimum of 25 % or even more. .
Some local medical review guidelines however condition that 29580 “signifies the Unna boot service of application only it’s not for use for billing other strapping or dressing changes.” These service providers may need that 29799 (Unlisted procedure casting or strapping) be reported for top-compression bandage systems. You need to contact the company for particular needs. An account from the procedure ought to be indexed by box 19 from the claim form. .
When the Unna boot can be used like a postoperative dressing it’s not a individually due service because payment for surgical dressings applied throughout someone encounter is incorporated within the fee schedule amount for that service Elliott adds. .
Tip 8: Make certain theis an approved diagnosis. Unna boot programs are covered for particular conditions only. Although service providers can vary greatly in the amount of released diagnoses that support Unna boot application most accept the next signs and diagnoses (frequently symbolized by several ICD-9 code): .
spider veins of lower limbs
venous deficit unspecified
chronic ulcer of skin
decubitus ulcer of lower extremity
ulcer of lower braches
edema of lower limbs.
Most service providers clearly will not pay for Unna boot programs for sprains strains or small fractures because other remedies for example elastic bandage or tape are simply as effective scientifically and price less. Spider veins or phlebitis from the calf isn’t covered but postphlebitic syndrome (459.1) and spider veins of lower extremity with ulcer and inflammation (454.-454.2) are reimbursable. .
Tip 9: Get yourself a waiver in the patient at the appropriate interval. When the Unna boot can be used for signs or diagnoses that aren’t approved request the individual to sign a waiver (for Medicare insurance funding beneficiary notice or ABN) to point that she or he knows that cash payment for remedies (as well as other arrangement) is needed. .
Tip 10: Don’t report removing the Unna boot individually. (Removal or bivalving gauntlet boot or body cast) shouldn’t be accustomed to report removing an Unna boot. Presuming choices examined the individual and recorded the encounter the boot removal can count toward a suitable-level E/M service. “
Diabetes And Surgery - Here's A Coding Challenge
Question: A patient with Type II diabetes is
admitted to home care following an amputation of three toes due to a
gangrenous diabetic ulcer. The patient has been diagnosed with
peripheral vascular disease and has chronic obstructive pulmonary
disease that is stable. The primary care will be dressing changes, but
the nurse also will teach the patient how to prevent further ulcers.
Answer: You should code the following:
M0230 - V58.3 (Attention to surgical dressings and sutures)
M0240b - V58.73 (Aftercare following surgery, circulatory system, NEC)
M0240c - 250.70 (Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled)
M0240d - 443.81 (Peripheral angiopathy in diseases classified elsewhere)
M0240e - V49.72 (Lower limb amputation status, other toe[s])
M0240f - 496 (Chronic airway obstruction, not elsewhere classified)
M0245a - 250.70 ( Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled)
M0245b - 785.4 (Gangrene)
Answer: You should code the following:
Friday, January 31, 2014
Don’t Let 2010’s Thrombosis Codes Derail Your Claims
Acute vs. chronic will be 1 key to your 2010 ICD-9 choice.
Whether you code for a hematologist in a Coumadin clinic or treat cancer patients who develop thromboembolic disease as a side effect, be sure you catch the big changes coming down the pike for embolism and thrombosis coding.
CMS is offering a sneak peak at the added, deleted, and revised codes youll need to know when ICD-9 2010 goes into effect Oct. 1, 2009. CMSs proposed Inpatient Prospective Payment System rule includes a list of the expected changes to ICD-9 2010 (http://edocket.access.gpo.gov/2009/pdf/E9-10458.pdf, page 409).
Heres Why Phlebitis Documentation Is Elusive
In 2009, your coding options are 451.0-451.9 (Phlebitis and thrombophlebitis) and 453.0-453.9 (Other venous embolism and thrombosis).
Problem: Thrombophlebitis is a term that is now rarely used, due to the lack of clinical significance of phlebitis, according to Patrick Romano, MD, MPH, professor of medicine and pediatrics at University of California at Davis, in his Phlebitis and Thrombophlebitis presentation to the ICD-9 Coordination and Maintenance Committee. He presented the proposal on behalf of the Agency for Healthcare Research and Quality.
Coding has paralleled this reduced use of thrombophlebitis, with 453.x (embolism and thrombosis) reported much more frequently than 451.x (phlebitis and thrombophlebitis), Romano said.
An expansion of the 453.x (embolism and thrombosis) range should help you choose codes more in line with current clinical terminology. As described below, the new codes offer options based on location as well as the acute vs. chronic nature of the problem. (See the new codes in the chart on page 62.)
Keep in mind: If you report embolism and thrombosis codes based on a catheter complication, you will need to consider additional codes for complication (such as 996.xx [Complications peculiar to certain specified procedures]) and an E code (such as E878.8 [Surgical operation and other surgical procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at the time of operation; other specified surgical operations and procedures]), says Cindy Parman, CPC, CPC-H, RCC, principal with Coding Strategies Inc. in Powder Springs, Ga.
Need for Upper Extremity Codes Answered
Trend: The increased use of PICC lines, central catheters, and tunnel dialysis catheters has increased incidence of DVT (deep venous thrombosis) in thorax and upper extremities, typically the axillary, subclavian, [and] brachiocephalic vein, Romano said.
But ICD-9 2009 doesnt offer the same specificity in upper extremity codes that it does for lower extremities.
451.x lower: The 2009 451.x codes allow you to distinguish phlebitis and thrombophlebitis involving:
" Superficial vessels of lower extremities (451.82)
" Deep veins of upper extremities (451.83)
" Upper extremities, unspecified (451.84).
451.x upper: But the 2009 embolism and thrombosis 453.x range doesnt offer codes to distinguish superficial thromboses or upper extremity thromboses, Romano said. You have to resort to 453.8 (Other venous embolism and thrombosis; of other specified veins). (Note that ICD-9 will delete 453.8 in 2010.)
ICD-9 2009 also doesnt offer codes for venous thrombosis affecting thorax and neck vessels, as the ICD-9-CM Coordination and Maintenance Committee Meeting, March 19-20, 2008, Diagnosis Agenda indicates (www.cdc.gov/nchs/data/icd9/agendaMa08.pdf).
453.x lower: ICD-9 2005 introduced 453.40-453.42 (Venous embolism and thrombosis of deep vessels of lower extremity &) which distinguished distal DVT from proximal DVT in the leg, Romano said.
453.x upper: This change did not address upper extremity or upper thoracic clots, Romano said.
The result is that you cant choose a specific code for upper extremity clots unless the physician uses the terminology of thrombophlebitis, Romano said, which is unlikely.
As indicated in the chart on page 62, the 2010 codes will allow you to choose more specific codes. To report the most specific option, you will need to know the location:
" Superficial veins of upper extremity
" Deep veins of upper extremity
" Axillary veins
" Subclavian veins
" Internal jugular veins.
Keep Watch for Chronic Vs. Acute
Your 2010 coding options wont be divided only based on location -- youll need to know whether the condition is acute or chronic, as well.
Why it matters: Physicians may keep DVT and pulmonary embolism patients on oral anticoagulation for three to six months or more. The patient may require a subsequent hospital admission to treat a complication, such as anticoagulant-related bleeding. When rehospitalized, these patients are generally coded with 451 or 453,
Romano said, but the condition is no longer acute.
So the ICD-9 responded to the need by including acute or chronic in the new 453.x code descriptors.
Revision red flag: ICD-9 2010 will revise a few codes, as well, to stay consistent with the acute vs. chronic wording, adding acute to the beginning of the 453.4x descriptors:
" 2009: 453.40 -- Venous embolism and thrombosis of unspecified deep vessels of lower extremity
" 2010: 453.40 -- Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity.
" 2009: 453.41 -- Venous embolism and thrombosis of deep vessels of proximal lower extremity
" 2010: 453.41 -- Acute venous embolism and thrombosis of deep vessels of proximal lower extremity.
" 2009: 453.42 -- Venous embolism and thrombosis of deep vessels of distal lower extremity
" 2010: 453.42 -- Acute venous embolism and thrombosis of deep vessels of distal lower extremity.
Resource: You can download Romanos presentation slides at www.cdc.gov/nchs/about/otheract/icd9/maint/classifications_of_diseases_and1.htm. Under Proposals (3/19-20, 2008), click on the Attachment 4 to Minutes --Romano link.
Whether you code for a hematologist in a Coumadin clinic or treat cancer patients who develop thromboembolic disease as a side effect, be sure you catch the big changes coming down the pike for embolism and thrombosis coding.
CMS is offering a sneak peak at the added, deleted, and revised codes youll need to know when ICD-9 2010 goes into effect Oct. 1, 2009. CMSs proposed Inpatient Prospective Payment System rule includes a list of the expected changes to ICD-9 2010 (http://edocket.access.gpo.gov/2009/pdf/E9-10458.pdf, page 409).
Heres Why Phlebitis Documentation Is Elusive
In 2009, your coding options are 451.0-451.9 (Phlebitis and thrombophlebitis) and 453.0-453.9 (Other venous embolism and thrombosis).
Problem: Thrombophlebitis is a term that is now rarely used, due to the lack of clinical significance of phlebitis, according to Patrick Romano, MD, MPH, professor of medicine and pediatrics at University of California at Davis, in his Phlebitis and Thrombophlebitis presentation to the ICD-9 Coordination and Maintenance Committee. He presented the proposal on behalf of the Agency for Healthcare Research and Quality.
Coding has paralleled this reduced use of thrombophlebitis, with 453.x (embolism and thrombosis) reported much more frequently than 451.x (phlebitis and thrombophlebitis), Romano said.
An expansion of the 453.x (embolism and thrombosis) range should help you choose codes more in line with current clinical terminology. As described below, the new codes offer options based on location as well as the acute vs. chronic nature of the problem. (See the new codes in the chart on page 62.)
Keep in mind: If you report embolism and thrombosis codes based on a catheter complication, you will need to consider additional codes for complication (such as 996.xx [Complications peculiar to certain specified procedures]) and an E code (such as E878.8 [Surgical operation and other surgical procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at the time of operation; other specified surgical operations and procedures]), says Cindy Parman, CPC, CPC-H, RCC, principal with Coding Strategies Inc. in Powder Springs, Ga.
Need for Upper Extremity Codes Answered
Trend: The increased use of PICC lines, central catheters, and tunnel dialysis catheters has increased incidence of DVT (deep venous thrombosis) in thorax and upper extremities, typically the axillary, subclavian, [and] brachiocephalic vein, Romano said.
But ICD-9 2009 doesnt offer the same specificity in upper extremity codes that it does for lower extremities.
451.x lower: The 2009 451.x codes allow you to distinguish phlebitis and thrombophlebitis involving:
" Superficial vessels of lower extremities (451.82)
" Deep veins of upper extremities (451.83)
" Upper extremities, unspecified (451.84).
451.x upper: But the 2009 embolism and thrombosis 453.x range doesnt offer codes to distinguish superficial thromboses or upper extremity thromboses, Romano said. You have to resort to 453.8 (Other venous embolism and thrombosis; of other specified veins). (Note that ICD-9 will delete 453.8 in 2010.)
ICD-9 2009 also doesnt offer codes for venous thrombosis affecting thorax and neck vessels, as the ICD-9-CM Coordination and Maintenance Committee Meeting, March 19-20, 2008, Diagnosis Agenda indicates (www.cdc.gov/nchs/data/icd9/agendaMa08.pdf).
453.x lower: ICD-9 2005 introduced 453.40-453.42 (Venous embolism and thrombosis of deep vessels of lower extremity &) which distinguished distal DVT from proximal DVT in the leg, Romano said.
453.x upper: This change did not address upper extremity or upper thoracic clots, Romano said.
The result is that you cant choose a specific code for upper extremity clots unless the physician uses the terminology of thrombophlebitis, Romano said, which is unlikely.
As indicated in the chart on page 62, the 2010 codes will allow you to choose more specific codes. To report the most specific option, you will need to know the location:
" Superficial veins of upper extremity
" Deep veins of upper extremity
" Axillary veins
" Subclavian veins
" Internal jugular veins.
Keep Watch for Chronic Vs. Acute
Your 2010 coding options wont be divided only based on location -- youll need to know whether the condition is acute or chronic, as well.
Why it matters: Physicians may keep DVT and pulmonary embolism patients on oral anticoagulation for three to six months or more. The patient may require a subsequent hospital admission to treat a complication, such as anticoagulant-related bleeding. When rehospitalized, these patients are generally coded with 451 or 453,
Romano said, but the condition is no longer acute.
So the ICD-9 responded to the need by including acute or chronic in the new 453.x code descriptors.
Revision red flag: ICD-9 2010 will revise a few codes, as well, to stay consistent with the acute vs. chronic wording, adding acute to the beginning of the 453.4x descriptors:
" 2009: 453.40 -- Venous embolism and thrombosis of unspecified deep vessels of lower extremity
" 2010: 453.40 -- Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity.
" 2009: 453.41 -- Venous embolism and thrombosis of deep vessels of proximal lower extremity
" 2010: 453.41 -- Acute venous embolism and thrombosis of deep vessels of proximal lower extremity.
" 2009: 453.42 -- Venous embolism and thrombosis of deep vessels of distal lower extremity
" 2010: 453.42 -- Acute venous embolism and thrombosis of deep vessels of distal lower extremity.
Resource: You can download Romanos presentation slides at www.cdc.gov/nchs/about/otheract/icd9/maint/classifications_of_diseases_and1.htm. Under Proposals (3/19-20, 2008), click on the Attachment 4 to Minutes --Romano link.
PQRI Participation Doesn’t Have to Be Hard
Question: Reporting on PQRI measures seems complicated. Im not sure my office has the time to report. How does our practice register for PQRI reporting, and how much do I have to report to earn my 2 percent payment on Medicare billing?
Michigan Subscriber
Answer: Your practice does not need to sign up or register to take part in the PQRI initiative. Simply send your claims with the correct Category II PQRI tracking codes, and you are part of the program. However, the later you begin, the less money you will be entitled to from the bonus program. The CMS PQRI Web site, www.cms.hhs.gov/PQRI, has additional information.
What you need to report: For claim-based submissions, you have two full-year participation options in 2009:
1. Report at least three PQRI measures (or one to two measures if less than three apply to the eligible professional), for 80 percent of applicable Medicare Part B patients;
2. Or, report all measures in one measure group, documented either for:
" 30 consecutive Medicare Part B fee-for-service (FFS) eligible patients from Jan. 1 through Dec. 31,2009, or
" 80 percent of applicable Part B FFS patients for each eligible professional (with a minimum of 30 patients) during the Jan. 1 through Dec. 31, 2009,reporting period.
For registry-based submission of measures groups,you must report:
" All measures for one measure group for 30 consecutive patients (Patients may include, but may not be exclusively, non-Medicare Part B FFS patients), or
" All measures for one measure group for 80 percent of applicable Medicare Part B FFS patients with a minimum of 30 patients.
Tuesday, January 28, 2014
CCI 10.1 Makes 52281 Component Of Many Cystourethroscopy Codes
Harder to bill for dilation of urethral stricture or stenosis separately
CPT code 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female) became a component of several other cystourethroscopy codes.
The column 1 codes with this code are 52007-52010, 52214-52234, 52250-52277, 52282, 52290-52300, 52305, 52317-52330, 52334-52510, 52606, 52614, 52620-52640 and 52700. You can't use a modifier to override these edits.
52281 was already a component of 52235 (Cystourethroscopy with fragmentation of ureteral calculus) and 52240 (cystourethroscopy, with fulguration...LARGE bladder tumors).
Often, coders bill 52281 separately for urethral dilation along with procedures like a cystoscopic examination, retrograde pyelogram and urethral stent placement for a urethral stone.
"There are a lot of commercial carriers that already lump it into a lot of the other codes," says Terry Vennell, billing manager for Knight, Boline & D'Amico in Harrisburg, Penn. "I'm not surprised that it's been included in a lot of them." Her practice doesn't bill 52281 frequently, "but I could see where someone would want to bill it separately."
"If they have to do a urethral dilation while they're doing something else, like a cystoscopy with full duration or cystoscopy with biopsy, I don't bill separately for the 52281," adds Vennell.
"I think they would typically do that with other procedures," says Laura Siniscalchi, a senior consultant with Deloitte and Touche in Boston. "That'll be an issue" for coders, she adds.
Separately, 76000 (Fluoroscopy, up to one hour) and 76001 (Fluoroscopy, more than one hour) became components of cystourethroscopy codes 52005-52007, 52310-52346 and 52351-52355. You can use a modifier to override these edits.
Separately, axillary lymphadenectomy code 38740 became a component of mastectomy code 19240. Chemotherapy code 96530 became a component of pump implantation codes 62367 and 62368. Muscle and range of motion testing codes 95831 and 95833 both became components of 95834, while 95832 became a component of 95833.
Needle oculoelectromyography code 92265 became a component of needle electromyography code 95868 (cranial nerve supplied muscles, bilateral). And ambulatory blood pressure monitoring code 93788 (Scanning analysis with report) became a component of 93784 (Recording, scanning analysis, interpretation and report).
CPT code 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female) became a component of several other cystourethroscopy codes.
The column 1 codes with this code are 52007-52010, 52214-52234, 52250-52277, 52282, 52290-52300, 52305, 52317-52330, 52334-52510, 52606, 52614, 52620-52640 and 52700. You can't use a modifier to override these edits.
52281 was already a component of 52235 (Cystourethroscopy with fragmentation of ureteral calculus) and 52240 (cystourethroscopy, with fulguration...LARGE bladder tumors).
Often, coders bill 52281 separately for urethral dilation along with procedures like a cystoscopic examination, retrograde pyelogram and urethral stent placement for a urethral stone.
"There are a lot of commercial carriers that already lump it into a lot of the other codes," says Terry Vennell, billing manager for Knight, Boline & D'Amico in Harrisburg, Penn. "I'm not surprised that it's been included in a lot of them." Her practice doesn't bill 52281 frequently, "but I could see where someone would want to bill it separately."
"If they have to do a urethral dilation while they're doing something else, like a cystoscopy with full duration or cystoscopy with biopsy, I don't bill separately for the 52281," adds Vennell.
"I think they would typically do that with other procedures," says Laura Siniscalchi, a senior consultant with Deloitte and Touche in Boston. "That'll be an issue" for coders, she adds.
Separately, 76000 (Fluoroscopy, up to one hour) and 76001 (Fluoroscopy, more than one hour) became components of cystourethroscopy codes 52005-52007, 52310-52346 and 52351-52355. You can use a modifier to override these edits.
Separately, axillary lymphadenectomy code 38740 became a component of mastectomy code 19240. Chemotherapy code 96530 became a component of pump implantation codes 62367 and 62368. Muscle and range of motion testing codes 95831 and 95833 both became components of 95834, while 95832 became a component of 95833.
Needle oculoelectromyography code 92265 became a component of needle electromyography code 95868 (cranial nerve supplied muscles, bilateral). And ambulatory blood pressure monitoring code 93788 (Scanning analysis with report) became a component of 93784 (Recording, scanning analysis, interpretation and report).
Monday, January 27, 2014
62 vs. 80
Modifier 62 (Two surgeons):
You should look to modifier 62 when your urologist participates in a
surgery with another physician. For you to appropriately use this
modifier, both surgeons should be working as primary surgeons and they
must each have distinctly separate parts in the same CPT procedure , according to the modifier’s code description.
Modifier 80 (Assistant surgeon): If your urologist only acts as a "second pair of hands" in the operating room, assisting the primary surgeon, you should append modifier 80 to the procedure code. An assistant surgeon does not have to provide his own operative notes, but the primary surgeon should note the second physician’s name as the assistant surgeon in his operative report.
596.54 Will Translate to ICD-10 Easily
The one-to-one code matchup makes updating your superbill a snap.
When your urologist treats a patient for neurogenic bladder -- for example, a pediatric patient who undergoes the Mitrofanoff procedure -- you would likely use ICD-9 Diagnosis code 596.54 (Neurogenic bladder NOS).
ICD-10 difference: When ICD-10 takes over on Oct. 1, 2013, you'll still have just one neurogenic bladder diagnosis code: N31.9 (Neuromuscular dysfunction of bladder, unspecified).
Physician documentation: Your physician is already documenting that the patient has a neurogenic bladder and you likely have ICD-9 code 596.54 on your superbill already. You won't have much to change in 2013. You'll just need to switch 596.54 to N31.9 on the superbill.
When your urologist treats a patient for neurogenic bladder -- for example, a pediatric patient who undergoes the Mitrofanoff procedure -- you would likely use ICD-9 Diagnosis code 596.54 (Neurogenic bladder NOS).
ICD-10 difference: When ICD-10 takes over on Oct. 1, 2013, you'll still have just one neurogenic bladder diagnosis code: N31.9 (Neuromuscular dysfunction of bladder, unspecified).
Physician documentation: Your physician is already documenting that the patient has a neurogenic bladder and you likely have ICD-9 code 596.54 on your superbill already. You won't have much to change in 2013. You'll just need to switch 596.54 to N31.9 on the superbill.
Friday, January 24, 2014
Try 726.4 for This Overuse Injury
Question: We performed an MRI for a patient with intersection syndrome of the wrist. Which diagnosis code should I report?
Michigan Subscriber
Answer: Your best option is 726.4 (Enthesopathy of wrist and carpus).
Here's why: One of many other terms for intersection syndrome is abductor pollicus longus bursitis, and ICD-9 includes wrist bursitis under 726.4.
Other terms you may see for this overuse syndrome include peritendinitis crepitans, crossover tendinitis, squeaker's wrist or oarsman's wrist. The condition typically develops where the wrist's first dorsal compartment muscles cross the second dorsal compartment muscles.
Michigan Subscriber
Answer: Your best option is 726.4 (Enthesopathy of wrist and carpus).
Here's why: One of many other terms for intersection syndrome is abductor pollicus longus bursitis, and ICD-9 includes wrist bursitis under 726.4.
Other terms you may see for this overuse syndrome include peritendinitis crepitans, crossover tendinitis, squeaker's wrist or oarsman's wrist. The condition typically develops where the wrist's first dorsal compartment muscles cross the second dorsal compartment muscles.
Thursday, January 23, 2014
4 Important Items You Don't Want to Miss In the Anesthesia Record
Extra units for reimbursement might be lurking in places other than the charge ticket.
Anesthesia coders have an edge over co-workers in other specialties: you have more resources when it's time to comb through charts for all the info you need. Use that access to the anesthesia record, charge ticket, and surgical report to find every detail that might help you in achieving medical billing and coding accuracy.
Unique challenge: A lot of practices use a charge ticket along with the anesthesia record. Many times, inconsistencies occur when information is transferred from the anesthesia record to the charge ticket. It's vital to compare the charge ticket to the anesthesia record, to ensure all key components are accounted for.
Read on for important medical billing and coding information you must focus on in your provider's anesthesia record.
1. Line Placements
Line placement is one service you can code together with the anesthesia service, so don't miss that chance.
Watch for notes concerning Swan-Ganz catheters (93503, Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes), arterial lines, CPT codes 36620-36625 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; …), or central venous catheter placement, CPT codes 36555-36571. Your provider must also evidently document the line's purpose, like additional monitoring or for use in postoperative pain management prior to the procedure.
2. Diagnosis and Procedure
You should know the procedure being carried out in order to select the accurate anesthesia code. General information concerning the patient's diagnosis and any past or present health conditions that can affect the procedure might change your coding.
Here's why: Conditions like hypertension, past coronary or pulmonary problems, or chronic diseases can escalate the anesthesiologist's risk or help explain the need for anesthesia. For instance, the anesthesiologist might need to take extra precautions during surgery on an obese patient with hypertension. A diagnosis of claustrophobia or Parkinson's can support medical necessity for anesthesia during "standard" procedures like an MRI.
3. Type of Anesthesia
Did the physician or CRNA offer general anesthesia, a regional, or observed anesthesia care (MAC)? The answer to this medical billing and coding question can definitely affect your coding, for instance when you need to append modifier G8 (Monitored anesthesia care [MAC] for deep complex, complicated, or markedly invasive surgical procedure) or G9 (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition) to the claim.
4. TEE, Fluoro, BIS Monitoring
You can sometimes distinctly report other services the anesthesiologist delivers during the procedure. Watch for documentation of these, including:
Anesthesia coders have an edge over co-workers in other specialties: you have more resources when it's time to comb through charts for all the info you need. Use that access to the anesthesia record, charge ticket, and surgical report to find every detail that might help you in achieving medical billing and coding accuracy.
Unique challenge: A lot of practices use a charge ticket along with the anesthesia record. Many times, inconsistencies occur when information is transferred from the anesthesia record to the charge ticket. It's vital to compare the charge ticket to the anesthesia record, to ensure all key components are accounted for.
Read on for important medical billing and coding information you must focus on in your provider's anesthesia record.
1. Line Placements
Line placement is one service you can code together with the anesthesia service, so don't miss that chance.
Watch for notes concerning Swan-Ganz catheters (93503, Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes), arterial lines, CPT codes 36620-36625 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; …), or central venous catheter placement, CPT codes 36555-36571. Your provider must also evidently document the line's purpose, like additional monitoring or for use in postoperative pain management prior to the procedure.
2. Diagnosis and Procedure
You should know the procedure being carried out in order to select the accurate anesthesia code. General information concerning the patient's diagnosis and any past or present health conditions that can affect the procedure might change your coding.
Here's why: Conditions like hypertension, past coronary or pulmonary problems, or chronic diseases can escalate the anesthesiologist's risk or help explain the need for anesthesia. For instance, the anesthesiologist might need to take extra precautions during surgery on an obese patient with hypertension. A diagnosis of claustrophobia or Parkinson's can support medical necessity for anesthesia during "standard" procedures like an MRI.
3. Type of Anesthesia
Did the physician or CRNA offer general anesthesia, a regional, or observed anesthesia care (MAC)? The answer to this medical billing and coding question can definitely affect your coding, for instance when you need to append modifier G8 (Monitored anesthesia care [MAC] for deep complex, complicated, or markedly invasive surgical procedure) or G9 (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition) to the claim.
4. TEE, Fluoro, BIS Monitoring
You can sometimes distinctly report other services the anesthesiologist delivers during the procedure. Watch for documentation of these, including:
- Transesophageal echocardiography (TEE) probe placement (93313, Echocardiography, transesophageal, real-time with image documentation [2D] [with or without M-mode recording]; placement of transesophageal probe only). Ask your providers to specify "monitoring" or "diagnostic" when they use TEE so you can code appropriately.
- Fluoroscopic guidance for blocks or catheters used to provide postoperative pain management or placement of a central venous or Swan-Ganz catheter. These services are signified by CPT codes like 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) and +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting [List separately in addition to code for primary procedure]).
How ICD-10 Disproportionally Affects Some Specialties
The whole health care industry is worried about the transition to ICD-10 code sets, but perhaps some should be more concerned than others. According to new research published in the Journal of the American Medical Informatics Association (JAMIA), the ICD-10 changeover is likely to impact certain specialties more so than others.
The research, conducted by a team at the University of Chicago, suggested that mappings between ICD-9-CM and ICD-10-CM were more convoluted for some specialties than for others. Specifically, the researchers found that hematology and oncology were positioned for the easiest transition, while obstetrics, psychiatry and emergency medicine were facing the most challenges in the changeover.
The researchers found that nearly half of infectious disease code mappings (42 percent) and 27 percent of emergency room diagnoses remain convoluted, meaning that the ICD-9 codes and ICD-10 codes have complex and non-reciprocal mappings. Musculoskeletal, injury and poisoning clinical classes were also found to include a large number of difficult-to-translate codes. The researchers identified five mapping motif categories that indicate the way ICD-9 codes translate to ICD-10 codes. These five categories include: identity, class-to-subclass, subclass-to-class, convoluted and no mapping. According to the research, one percent of ICD-9 codes had no corresponding codes in ICD-10.
In addition to studying how the ICD-10 transition will impact various specialties, the researchers created an online portal clinicians can use to see how convoluted code conversion will be. This portal will be a helpful tool for clinicians to see how much their codes will change and the level of documentation that will be needed to support ICD-10 codes.
So what should you do if you are in one of these specialties facing a more difficult transition to ICD-10 codes? Start preparing as early as possible. Invest in staff training and focus on the most commonly used codes and most complex mappings. Be aware that the more complex the transition is for your specialty, the more financial impact the transition could have on your practice.
The research, conducted by a team at the University of Chicago, suggested that mappings between ICD-9-CM and ICD-10-CM were more convoluted for some specialties than for others. Specifically, the researchers found that hematology and oncology were positioned for the easiest transition, while obstetrics, psychiatry and emergency medicine were facing the most challenges in the changeover.
The researchers found that nearly half of infectious disease code mappings (42 percent) and 27 percent of emergency room diagnoses remain convoluted, meaning that the ICD-9 codes and ICD-10 codes have complex and non-reciprocal mappings. Musculoskeletal, injury and poisoning clinical classes were also found to include a large number of difficult-to-translate codes. The researchers identified five mapping motif categories that indicate the way ICD-9 codes translate to ICD-10 codes. These five categories include: identity, class-to-subclass, subclass-to-class, convoluted and no mapping. According to the research, one percent of ICD-9 codes had no corresponding codes in ICD-10.
In addition to studying how the ICD-10 transition will impact various specialties, the researchers created an online portal clinicians can use to see how convoluted code conversion will be. This portal will be a helpful tool for clinicians to see how much their codes will change and the level of documentation that will be needed to support ICD-10 codes.
So what should you do if you are in one of these specialties facing a more difficult transition to ICD-10 codes? Start preparing as early as possible. Invest in staff training and focus on the most commonly used codes and most complex mappings. Be aware that the more complex the transition is for your specialty, the more financial impact the transition could have on your practice.
Source:http://www.successehs.com/item/icd-10-s-unequal-impact-how-icd-10-disproportionally-affects-some-specialties.htm
Wednesday, January 22, 2014
719.41 Could Be Peri-Scapular Pain Diagnosis
Question: What is the correct diagnosis code for peri-scapular pain?
Wisconsin Subscriber
Answer: The most accurate diagnosis in many cases is 719.41 (Pain in joint; shoulder region). If the patient experiences pain further up his or her neck, 723.1 (Cervicalgia) might be a better choice. Read your physician's notes carefully to pinpoint the location of pain.
Wisconsin Subscriber
Answer: The most accurate diagnosis in many cases is 719.41 (Pain in joint; shoulder region). If the patient experiences pain further up his or her neck, 723.1 (Cervicalgia) might be a better choice. Read your physician's notes carefully to pinpoint the location of pain.
Use 795.08 For Unsatisfactory Smear
ICD9-Cm 795.08 Unsatisfactory cervical cytology smear
Question: Which diagnosis should I use for a patient who comes in due to an unsatisfactory Pap smear - code 795.09 or 795.08?
Florida Subscriber
Answer: You should report 795.08 (Unsatisfactory smear). In the past, you would have reported 795.09 (Other abnormal Papanicolaou smear of cervix and cervical HPV), but as of 2004, ICD-9 revised the codes to indicate that 795.08 is now the correct code to use for an inadequate sample. This ICD-9 revision is another reason why you have to keep up with ICD-9 changes each year.
ICD-9-CM code 795.08 is a specific, billable medical code that can be used to indicate a diagnosis on a reimbursement claim.
Description
Short Description
Unsat cerv cytlogy smear
Unsatisfactory cervical cytology smear
Short Description
Unsat cerv cytlogy smear
Tuesday, January 21, 2014
Incision vs. Excision of Hemorrhoids
Question: Please explain the difference between codes 46083
and 46320. The definitions of both codes seem to mean the same thing. We
do a lot of incision and drainage (I&D) for thrombosed hemorrhoids
and need to know how this should be coded.
Delaware Subscriber
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Answer: Code 46083 (incision of thrombosed hemorrhoid, external) is for an incision, in which a puncture is made in the hemorrhoid and the blood is allowed to drain, relieving pressure, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator based in North Augusta, S.C. Code 46320 (enucleation or excision of external thrombotic hemorrhoid) describes excision or enucleation, in which the thrombosed area is cut out completely, much like excision of a cyst or tumor. If you are doing I&D, you should use 46083.
Delaware Subscriber
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Answer: Code 46083 (incision of thrombosed hemorrhoid, external) is for an incision, in which a puncture is made in the hemorrhoid and the blood is allowed to drain, relieving pressure, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator based in North Augusta, S.C. Code 46320 (enucleation or excision of external thrombotic hemorrhoid) describes excision or enucleation, in which the thrombosed area is cut out completely, much like excision of a cyst or tumor. If you are doing I&D, you should use 46083.
781.99 Is Best Sensory Integration Disorder Choice
Question: What diagnosis should we submit for sensory integration disorder?
Nevada Subscriber
Answer: Sensory integration disorder is not a recognized diagnosis in ICD-9, so the most accurate choice is 781.99 (Other symptoms involving nervous and musculoskeletal systems).
Also known as sensory integration dysfunction, SID is a neurological disorder that results from the brain's inability to integrate certain information received from the body's five basic sensory systems. Physicians often detect SID in young children. Signs can include (but are not limited to) oversensitivity to touch, movement, sights, or sounds; a tendency to be easily distracted; an activity level that is unusually high or unusually low; difficulty in making transitions from one situation to another; and delays in speech, language, or motor skills or academic achievement.
Nevada Subscriber
Answer: Sensory integration disorder is not a recognized diagnosis in ICD-9, so the most accurate choice is 781.99 (Other symptoms involving nervous and musculoskeletal systems).
Also known as sensory integration dysfunction, SID is a neurological disorder that results from the brain's inability to integrate certain information received from the body's five basic sensory systems. Physicians often detect SID in young children. Signs can include (but are not limited to) oversensitivity to touch, movement, sights, or sounds; a tendency to be easily distracted; an activity level that is unusually high or unusually low; difficulty in making transitions from one situation to another; and delays in speech, language, or motor skills or academic achievement.
44139 Doesn't Apply to Lap. Takedown
Question: If my physician performs colectomy (44140) and takes down the splenic flexure, I can report add-on code 44139.
If my physician does this same procedure laparoscopically (44204), how can I get reimbursed for takedown of the splenic flexure?
Maryland Subscriber
Answer: The code you-re looking for is +44213 (Laparoscopy, surgical, mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]). CPT added this code in 2006 to accompany primary procedure codes 44204-44208.
If the surgeon performs laparoscopic partial colectomy with takedown of the splenic flexure, you-d report 44204 (Laparoscopy, surgical; colectomy, partial with anastomosis) as the primary procedure, with add-on 44123 for the takedown.
Claiming 44123 correctly will add 3.5 physician work relative value units -- or approximately $125 dollars on average, for Medicare payers -- to your reimbursement.
The "open" equivalent of 44213 is, as you note, +44139 (Mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]). CPT instructions direct you to use add-on 44139 only with primary codes 44140-44147 (Colectomy, partial-).
If my physician does this same procedure laparoscopically (44204), how can I get reimbursed for takedown of the splenic flexure?
Maryland Subscriber
Answer: The code you-re looking for is +44213 (Laparoscopy, surgical, mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]). CPT added this code in 2006 to accompany primary procedure codes 44204-44208.
If the surgeon performs laparoscopic partial colectomy with takedown of the splenic flexure, you-d report 44204 (Laparoscopy, surgical; colectomy, partial with anastomosis) as the primary procedure, with add-on 44123 for the takedown.
Claiming 44123 correctly will add 3.5 physician work relative value units -- or approximately $125 dollars on average, for Medicare payers -- to your reimbursement.
The "open" equivalent of 44213 is, as you note, +44139 (Mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]). CPT instructions direct you to use add-on 44139 only with primary codes 44140-44147 (Colectomy, partial-).
Monday, January 20, 2014
410.31 or 410.32 for Follow-Up?
Question: The patient is seen in the hospital for a
410.31, and then is discharged. The patient is scheduled to be seen in
the office for a follow-up visit. For this follow-up visit, which is
less than 8 weeks from the myocardial infarction, is it appropriate to
use the fifth digit of "2" on the MI (410.32), or would you still use
410.31?
Answer: You should use 410.32 (Acute myocardial infarction of inferoposterior wall; subsequent episode of care) for this follow-up visit. ICD-9 notes with the 410.xx fifth digit options state that you should "use fifth-digit 2 to designate an episode of care following the initial episode when the patient is admitted for further observation, evaluation or treatment for a myocardial infarction that has received initial treatment, but is still less than 8 weeks old."
You should report 410.31 (Acute myocardial infarction of inferoposterior wall; initial episode of care) only during the initial episode of care. The fifth digit "1" applies until the patient is discharged, regardless of where the cardiologist provides the care. Notes in the ICD-9 manual clarify that you use "1" for the first episode of care, "regardless of the number of times a patient may be transferred during the initial episode of care."
If documentation doesn’t specify the episode of care (initial or subsequent), you should use fifth digit "0" (Episode of care unspecified).
If the patient returns more than eight weeks after the infarction, you should use 414.8 (Other specified forms of chronic ischemic heart disease). Notes with this code specify it is appropriate for "any condition classifiable to 410 specified as chronic, or presenting with symptoms after 8 weeks from date of infarction."
Answer: You should use 410.32 (Acute myocardial infarction of inferoposterior wall; subsequent episode of care) for this follow-up visit. ICD-9 notes with the 410.xx fifth digit options state that you should "use fifth-digit 2 to designate an episode of care following the initial episode when the patient is admitted for further observation, evaluation or treatment for a myocardial infarction that has received initial treatment, but is still less than 8 weeks old."
You should report 410.31 (Acute myocardial infarction of inferoposterior wall; initial episode of care) only during the initial episode of care. The fifth digit "1" applies until the patient is discharged, regardless of where the cardiologist provides the care. Notes in the ICD-9 manual clarify that you use "1" for the first episode of care, "regardless of the number of times a patient may be transferred during the initial episode of care."
If documentation doesn’t specify the episode of care (initial or subsequent), you should use fifth digit "0" (Episode of care unspecified).
If the patient returns more than eight weeks after the infarction, you should use 414.8 (Other specified forms of chronic ischemic heart disease). Notes with this code specify it is appropriate for "any condition classifiable to 410 specified as chronic, or presenting with symptoms after 8 weeks from date of infarction."
Follow these tips to Refresh your ERCP Coding Knowledge
Have you been meeting denials lately when your gastroenterologist
performs an endoscopic retrograde cholangiopancreatography (ERCP)?
Here’s a quick refresher for you to get the payment you deserve and lead
you in the right direction.
Know the Reason for the Procedure
Gastroenterologist can perform an ERCP procedure for diagnosis or therapeutic purposes. "A typical scenario for an ERCP is that the patient has continued epigastric pain in the ER, as an inpatient, or as an observation patient. A CT scan is done which is abnormal. Because of the abnormal CT, our physicians will perform an esophagogastroduodenoscopy (EGD) for the epigastric pain, then an ERCP for the abnormal CT," says Heather Copen, RHIT, CCS-P, Financial Advocate-Goshen OB/GYN and Goshen GI, IU Health-Goshen Physicians, Goshen, Indiana.
Over
the past couple of years, procedures such as endoscopic ultrasound and
magnetic resonance cholangiopancreatography, which are low-risk or
risk-free, are being increasingly used for diagnosis and have decreased
the use of ERCP for strictly diagnostic purposes. "We never do ERCPs for
screening procedures," adds Copen.
ERCP is carried out with therapeutic intent for the following reasons:
For example, the gastroenterologist might also place a stent in addition to removing of stone in the biliary duct. For this reason, it becomes necessary to scan the operative procedure in detail to know all the procedures that have been performed or you may risk losing reimbursement for additional work.
What to Do When Stent Is the Intent
If your gastroenterologist performs an ERCP with the intent of placing of a stent, then you will often see the procedure performed with a sphincterotomy in addition to the stent placement.
You would report it with 43268 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct). At time, your gastroenterologist might place more than one stent. In case the stents are placed in the same duct, then you should report the procedure with 43268. But if the stents are placed in different ducts, you can report the second stent by using 43268 twice. If multiple stents are placed, you can use the modifier 59 (Distinct procedural service) for your claims.
Example: If your gastroenterologist placed two stents in the biliary duct and another in the pancreatic duct, then you report the procedure with the CPT® code 43268 and 43268-59. You would need to support your claim with adequate documentation to inform the payer where the stents.
In case your gastroenterologist removes a previously placed stent and then inserts another stent in its place, you report the procedure with 43269 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent) and then with 43268. Carefully read through the procedure note to ascertain where the stent is being removed and where is it being placed.
"When a stent is removed and replaced in the same duct, then only the 43269 would be reported. If a stent is removed from the pancreatic duct but then a stent was placed in the common bile duct, you would report 43268 with a -59 modifier," says Copen. She further shares what she does. "I put a note on the claim that states that the 43269 was the pancreatic duct and the 43268 was the common bile duct. If one stent is placed in the common bile duct and one placed in the pancreatic duct, I report the 43268 twice. The second 43268 gets a -59 modifier and again I note that one is the common bile duct and the other is the pancreatic duct. This is allowable because the wording for the CPT® codes states bile or pancreatic duct, not both, so when a physician does both stents, then they are billable separately."
Know the Method in Stone Removal
When your gastroenterologist is performing a stone removal through ERCP, you report the procedure with 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts). The code remains the same irrespective of whether a balloon or a basket is used to remove the stone. "The CPT® code 43264 states that it is a removal of calculus/calculi from bilary and/or pancreatic duct. The code is also used for stone removal with balloon because a removal is a removal, no matter how it is removed," says Copen.
Warning: Stone removal with balloons should not be confused with dilation using balloons to relieve strictures that are reported with 43271 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct[s]). A stone removal with balloon should be reported with 43264. "The CPT® code 43271 specifies that it is a balloon dilation of the ampulla, biliary, and/or pancreatic duct(s) which would make this code unsuitable to use for removal of a stone with a balloon. The balloon dilation would be used if there was a stricture or stenosis of the ampulla, biliary, and/or pancreatic duct," says Copen.
If your gastroenterologist destroys the stone with lithotripsy, you report the procedure with 43265 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method).
Coding Tips: If your gastroenterologist performs a removal procedure with a basket or balloon and a lithotripsy in the same session, it is quite common to assume that these two procedures are mutually exclusive and cannot be reported together.
However, you should note that CPT® allows you to report both the procedures. As per multiple procedure payment reduction policy, you need to report 43265 first as this is of higher RVU value and you get a total claim. 43264 should be reported with modifier 51 (Multiple procedures), depending on payer’s preference, for consideration of both the claims.
Don’t Forget These Additional Procedures
Your gastroenterologist might also perform additional procedures such as a sphincterotomy along with stone removal. When your gastroenterologist needs to gain access to the bile duct or pancreatic duct, it is often necessary to cut the major papilla orifice with a wire. This is sphincterotomy or papillotomy and is a separate service not included in the other ERCP therapeutic codes.
In such a case, you need to report the primary procedure of the removal and then report sphincterotomy as a separate procedure with 43262 (Endoscopic retrograde cholangiopancreatography [ERCP]; with sphincterotomy/papillotomy). "If a sphincterotomy is performed with a stone removal and a stent placement then the three different codes are billable," says Copen. "When multiple sphincterotomies are performed at the same session than only one code would be allowed." This can occur when your gastroenterologist needs to gain access to both the major papilla and the nearby minor papilla.
If multiple sphincterotomies have been performed, you report the procedures using 43262 with modifier 59 (Distinct procedural service). Additionally, if your gastroenterologist took long at a difficult procedure which required multiple sphincterotomies in a single session, you append modifier 22 (Increased procedural service). "If the sphincterotomy is performed multiple times during the same session, then I would suggest putting a -22 modifier with the stipulation that the doctor documented the difficult procedure and the need to perform it multiple times," says Copen.
During the ERCP, your gastroenterologist might use a camera to visualize the bile duct or the pancreatic ducts. In such a circumstance, CPT® allows the use of an additional code and you report it with +43273 (Endoscopic cannulation of papilla with direct visualization of common bile duct[s] and/or pancreatic duct[s] [List separately in addition to code[s] for primary procedure]). You need to use this code if you see that your gastroenterologist performed a cannulation to view the ducts. The tiny camera device will often be referred to as a "Spyglass™" catheter.
Know the Reason for the Procedure
Gastroenterologist can perform an ERCP procedure for diagnosis or therapeutic purposes. "A typical scenario for an ERCP is that the patient has continued epigastric pain in the ER, as an inpatient, or as an observation patient. A CT scan is done which is abnormal. Because of the abnormal CT, our physicians will perform an esophagogastroduodenoscopy (EGD) for the epigastric pain, then an ERCP for the abnormal CT," says Heather Copen, RHIT, CCS-P, Financial Advocate-Goshen OB/GYN and Goshen GI, IU Health-Goshen Physicians, Goshen, Indiana.
Over
the past couple of years, procedures such as endoscopic ultrasound and
magnetic resonance cholangiopancreatography, which are low-risk or
risk-free, are being increasingly used for diagnosis and have decreased
the use of ERCP for strictly diagnostic purposes. "We never do ERCPs for
screening procedures," adds Copen.ERCP is carried out with therapeutic intent for the following reasons:
- Removal or destruction of stones in the biliary or the pancreatic ducts;
- For the placement/removal of stents;
- For conducting a sphincterotomy; and
- For investigating the cause of dilation of the biliary or pancreatic ducts.
For example, the gastroenterologist might also place a stent in addition to removing of stone in the biliary duct. For this reason, it becomes necessary to scan the operative procedure in detail to know all the procedures that have been performed or you may risk losing reimbursement for additional work.
What to Do When Stent Is the Intent
If your gastroenterologist performs an ERCP with the intent of placing of a stent, then you will often see the procedure performed with a sphincterotomy in addition to the stent placement.
You would report it with 43268 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct). At time, your gastroenterologist might place more than one stent. In case the stents are placed in the same duct, then you should report the procedure with 43268. But if the stents are placed in different ducts, you can report the second stent by using 43268 twice. If multiple stents are placed, you can use the modifier 59 (Distinct procedural service) for your claims.
Example: If your gastroenterologist placed two stents in the biliary duct and another in the pancreatic duct, then you report the procedure with the CPT® code 43268 and 43268-59. You would need to support your claim with adequate documentation to inform the payer where the stents.
In case your gastroenterologist removes a previously placed stent and then inserts another stent in its place, you report the procedure with 43269 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent) and then with 43268. Carefully read through the procedure note to ascertain where the stent is being removed and where is it being placed.
"When a stent is removed and replaced in the same duct, then only the 43269 would be reported. If a stent is removed from the pancreatic duct but then a stent was placed in the common bile duct, you would report 43268 with a -59 modifier," says Copen. She further shares what she does. "I put a note on the claim that states that the 43269 was the pancreatic duct and the 43268 was the common bile duct. If one stent is placed in the common bile duct and one placed in the pancreatic duct, I report the 43268 twice. The second 43268 gets a -59 modifier and again I note that one is the common bile duct and the other is the pancreatic duct. This is allowable because the wording for the CPT® codes states bile or pancreatic duct, not both, so when a physician does both stents, then they are billable separately."
Know the Method in Stone Removal
When your gastroenterologist is performing a stone removal through ERCP, you report the procedure with 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts). The code remains the same irrespective of whether a balloon or a basket is used to remove the stone. "The CPT® code 43264 states that it is a removal of calculus/calculi from bilary and/or pancreatic duct. The code is also used for stone removal with balloon because a removal is a removal, no matter how it is removed," says Copen.
Warning: Stone removal with balloons should not be confused with dilation using balloons to relieve strictures that are reported with 43271 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct[s]). A stone removal with balloon should be reported with 43264. "The CPT® code 43271 specifies that it is a balloon dilation of the ampulla, biliary, and/or pancreatic duct(s) which would make this code unsuitable to use for removal of a stone with a balloon. The balloon dilation would be used if there was a stricture or stenosis of the ampulla, biliary, and/or pancreatic duct," says Copen.
If your gastroenterologist destroys the stone with lithotripsy, you report the procedure with 43265 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method).
Coding Tips: If your gastroenterologist performs a removal procedure with a basket or balloon and a lithotripsy in the same session, it is quite common to assume that these two procedures are mutually exclusive and cannot be reported together.
However, you should note that CPT® allows you to report both the procedures. As per multiple procedure payment reduction policy, you need to report 43265 first as this is of higher RVU value and you get a total claim. 43264 should be reported with modifier 51 (Multiple procedures), depending on payer’s preference, for consideration of both the claims.
Don’t Forget These Additional Procedures
Your gastroenterologist might also perform additional procedures such as a sphincterotomy along with stone removal. When your gastroenterologist needs to gain access to the bile duct or pancreatic duct, it is often necessary to cut the major papilla orifice with a wire. This is sphincterotomy or papillotomy and is a separate service not included in the other ERCP therapeutic codes.
In such a case, you need to report the primary procedure of the removal and then report sphincterotomy as a separate procedure with 43262 (Endoscopic retrograde cholangiopancreatography [ERCP]; with sphincterotomy/papillotomy). "If a sphincterotomy is performed with a stone removal and a stent placement then the three different codes are billable," says Copen. "When multiple sphincterotomies are performed at the same session than only one code would be allowed." This can occur when your gastroenterologist needs to gain access to both the major papilla and the nearby minor papilla.
If multiple sphincterotomies have been performed, you report the procedures using 43262 with modifier 59 (Distinct procedural service). Additionally, if your gastroenterologist took long at a difficult procedure which required multiple sphincterotomies in a single session, you append modifier 22 (Increased procedural service). "If the sphincterotomy is performed multiple times during the same session, then I would suggest putting a -22 modifier with the stipulation that the doctor documented the difficult procedure and the need to perform it multiple times," says Copen.
During the ERCP, your gastroenterologist might use a camera to visualize the bile duct or the pancreatic ducts. In such a circumstance, CPT® allows the use of an additional code and you report it with +43273 (Endoscopic cannulation of papilla with direct visualization of common bile duct[s] and/or pancreatic duct[s] [List separately in addition to code[s] for primary procedure]). You need to use this code if you see that your gastroenterologist performed a cannulation to view the ducts. The tiny camera device will often be referred to as a "Spyglass™" catheter.
CPT® Assistant Holds the Key to 2014’s Vascular Embolization Code Changes
Four new vascular embolization codes debuted in January, and the latest CPT® Assistant
has a must-read article for anyone who performs these services. You’ll
benefit from five separate examples that will help you identify and
count surgical fields. The article also reveals at-a-glance lists of
which services are included and which services you may report
separately. A bonus Q&A section addresses confusing scenarios, such
as how to code when there are multiple indications for embolization or
when stent placement is performed at the same session.
The newest CPT® Assistant also has you covered whether you need more information on using complex chronic care E/M codes or you’re searching for clues on 2014’s radiation oncology changes. Search SuperCoder.com’s Code Connect by code or keyword to get the latest on these topics.
If you want advice targeted at overcoming common coding hurdles, you’ll find what you need in the CPT® Assistant FAQs. Search for these codes and keywords on Code Connect:
The newest CPT® Assistant also has you covered whether you need more information on using complex chronic care E/M codes or you’re searching for clues on 2014’s radiation oncology changes. Search SuperCoder.com’s Code Connect by code or keyword to get the latest on these topics.
- Complex chronic care: 98960, 98961, 98962, 98966-98968, 99071, 99075, 99078, 99339, 99340, 99358, 99359, 99363, 99364, 99374, 99375, 99377-99380, 99487-99489, 99495, 99496
- Fluid collection drainage, catheter: 10030, 32201, 44901, 47011, 48511, 49021, 49041, 49061, 49405, 49406, 49407, 50021, 58823
- Radiology simulation: 77280, 77285, 77293, 77295
- Vascular embolization and occlusion: 37204, 37210, 37241, 37242, 37243, 37243, 37244, 75894, 75898.
If you want advice targeted at overcoming common coding hurdles, you’ll find what you need in the CPT® Assistant FAQs. Search for these codes and keywords on Code Connect:
- Angiography: 36216, 36222, 36225, 36245-36247, 36253, 37241-37244, 37799, 75894, 75898
- Integumentary services: 15273, 15274, 15277, 15278, 19301, 19499
- Neuroma injection: 11900, 64455, 64632, 64999.
Source: http://codingnews.inhealthcare.com/hot-coding-topics/news-cpt-assistant-holds-the-key-to-2014s-vascular-embolization-code-changes/
36 Options Replace 996.01 in October 2014
When a pacemaker battery wears down unexpectedly or a lead becomes
damaged, the patient may experience shortness of breath, fatigue, and
other symptoms of arrhythmia or decreased heart function. ICD-9-CM
categorizes these problems as “Mechanical complication of cardiac
device.” ICD-10-CM says one big category just won’t do. Here’s how the
new codeset splits your choices.
ICD-9-CM Code:
996.01, Mechanical complication of cardiac device, implant, and graft; due to cardiac pacemaker (electrode)
ICD-10-CM Codes:
T82.110-, Breakdown (mechanical) of cardiac electrode
T82.111-, Breakdown (mechanical) of cardiac pulse generator (battery)
T82.118-, Breakdown (mechanical) of other cardiac electronic device
T82.119-, Breakdown (mechanical) of unspecified cardiac electronic device
T82.120-, Displacement of cardiac electrode
T82.121-, Displacement of cardiac pulse generator (battery)
T82.128-, Displacement of other cardiac electronic device
T82.129-, Displacement of unspecified cardiac electronic device
T82.190-, Other mechanical complication of cardiac electrode
T82.191-, Other mechanical complication of cardiac pulse generator (battery)
T82.198-, Other mechanical complication of other cardiac electronic device
T82.199-, Other mechanical complication of unspecified cardiac device
The appropriate 7th character is to be added to each code from category T82.-:
A, initial encounter
D, subsequent encounter
S, sequela
ICD-9 coding rules: ICD-9 offers an inclusion note under 996.0x showing the codes apply to breakdown (mechanical); displacement; leakage; obstruction, mechanical; perforation; and protrusion. If you need to code these complications for an automatic implantable cardiac defibrillator (AICD), you would use 996.04 (Mechanical complication of automatic implantable cardiac defibrillator) instead of 996.01.
ICD-10 changes: ICD-10 offers a long list of codes that cross to both 996.01 and 996.04. The codes differ based on whether the complication is a breakdown, a displacement, or “other.” Within each of those divisions, you’ll have to choose codes based on whether the problem relates to the electrode, generator, other, or unspecified device. You’ll also have to choose a seventh character based on the encounter.
Documentation: Ensure that your providers document all the information you need to choose among the long list of new codes: the nature of the complication (breakdown, displacement, etc.), the part of the device involved (electrode, generator, etc.), which encounter it is (initial, subsequent, sequela).
Coder tips: ICD-10 Official Guidelines explain proper use of the seventh characters:
Use A, initial encounter, while the patient is receiving active treatment for the injury. “Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.”
Use D, subsequent encounter, “for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following injury treatment.”
Use S, sequela, “for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn.” When you use S, “use both the injury code that precipitated the sequela and the code for the sequela itself. The ‘S’ is added only to the injury code, not the sequela code. The ‘S’ extension identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.”
Remember: CMS has finalized the ICD-10 compliance date of Oct. 1, 2014. When ICD-10 is implemented, you should apply the code set and official guidelines in effect for the date of service reported. Learn more at www.cms.gov/ICD10/ and www.cdc.gov/nchs/icd/icd10cm.htm#10update.
Source: http://codingnews.inhealthcare.com/icd-10/36-options-replace-996-01-in-october-2014/
ICD-9-CM Code:
996.01, Mechanical complication of cardiac device, implant, and graft; due to cardiac pacemaker (electrode)
ICD-10-CM Codes:
T82.110-, Breakdown (mechanical) of cardiac electrode
T82.111-, Breakdown (mechanical) of cardiac pulse generator (battery)
T82.118-, Breakdown (mechanical) of other cardiac electronic device
T82.119-, Breakdown (mechanical) of unspecified cardiac electronic device
T82.120-, Displacement of cardiac electrode
T82.121-, Displacement of cardiac pulse generator (battery)
T82.128-, Displacement of other cardiac electronic device
T82.129-, Displacement of unspecified cardiac electronic device
T82.190-, Other mechanical complication of cardiac electrode
T82.191-, Other mechanical complication of cardiac pulse generator (battery)
T82.198-, Other mechanical complication of other cardiac electronic device
T82.199-, Other mechanical complication of unspecified cardiac device
The appropriate 7th character is to be added to each code from category T82.-:
A, initial encounter
D, subsequent encounter
S, sequela
ICD-9 coding rules: ICD-9 offers an inclusion note under 996.0x showing the codes apply to breakdown (mechanical); displacement; leakage; obstruction, mechanical; perforation; and protrusion. If you need to code these complications for an automatic implantable cardiac defibrillator (AICD), you would use 996.04 (Mechanical complication of automatic implantable cardiac defibrillator) instead of 996.01.
ICD-10 changes: ICD-10 offers a long list of codes that cross to both 996.01 and 996.04. The codes differ based on whether the complication is a breakdown, a displacement, or “other.” Within each of those divisions, you’ll have to choose codes based on whether the problem relates to the electrode, generator, other, or unspecified device. You’ll also have to choose a seventh character based on the encounter.
Documentation: Ensure that your providers document all the information you need to choose among the long list of new codes: the nature of the complication (breakdown, displacement, etc.), the part of the device involved (electrode, generator, etc.), which encounter it is (initial, subsequent, sequela).
Coder tips: ICD-10 Official Guidelines explain proper use of the seventh characters:
Use A, initial encounter, while the patient is receiving active treatment for the injury. “Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.”
Use D, subsequent encounter, “for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following injury treatment.”
Use S, sequela, “for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn.” When you use S, “use both the injury code that precipitated the sequela and the code for the sequela itself. The ‘S’ is added only to the injury code, not the sequela code. The ‘S’ extension identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.”
Remember: CMS has finalized the ICD-10 compliance date of Oct. 1, 2014. When ICD-10 is implemented, you should apply the code set and official guidelines in effect for the date of service reported. Learn more at www.cms.gov/ICD10/ and www.cdc.gov/nchs/icd/icd10cm.htm#10update.
Source: http://codingnews.inhealthcare.com/icd-10/36-options-replace-996-01-in-october-2014/
Check Bundling Between Epidurals and E/M Depending on DOS
Question: I have done
continuous epidural for my patient and injected different concentrations
of Marcaine and normal saline to evaluate the response and identify
psychosomatic disorder. Total time spent was 3 hours during which the
patient was evaluated for response and monitoring vital signs. How
should I bill for this procedure?
Chicago Subscriber
Answer: First and foremost, you have not made it clear as to what other services were provided. If the evaluation only included using the epidural to assess the patient, again depending on how (needle or indwelling catheter) and where the epidural was given, codes 62310 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic), 62311 (…lumbar or sacral [caudal]), 62318 (Injection[s], including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic) or 62319 (…lumbar or sacral [caudal]) can be reported.
Also, an appropriate E/M code can be selected to report the evaluation of the patient. Depending on the typical time of the E/M code selected and how much of the three hours was spent in evaluation and management, you may also be able to report a prolonged services code (or two) from the range 99354-99357.
However, if the date of service was after July 1, it is important to note that there is a CCI edit that bundles these services along with E/M codes wherein you cannot report the E/M service separately with these codes. But the edit carries the modifier indicator ‘1,’ which means that if the E/M service was separate and distinct, a modifier such as 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) can be appended to the E/M code to unbundle the edits.
Finally, there is a HCPCS code for Marcaine HCL (S0020, Injection, bupivicaine hydrochloride, 30 ml) and one for saline (A4217, Sterile water/saline, 500 ml), which may or may not be reportable, depending on the payer and the circumstances.
Chicago Subscriber
Answer: First and foremost, you have not made it clear as to what other services were provided. If the evaluation only included using the epidural to assess the patient, again depending on how (needle or indwelling catheter) and where the epidural was given, codes 62310 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic), 62311 (…lumbar or sacral [caudal]), 62318 (Injection[s], including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic) or 62319 (…lumbar or sacral [caudal]) can be reported.
Also, an appropriate E/M code can be selected to report the evaluation of the patient. Depending on the typical time of the E/M code selected and how much of the three hours was spent in evaluation and management, you may also be able to report a prolonged services code (or two) from the range 99354-99357.
However, if the date of service was after July 1, it is important to note that there is a CCI edit that bundles these services along with E/M codes wherein you cannot report the E/M service separately with these codes. But the edit carries the modifier indicator ‘1,’ which means that if the E/M service was separate and distinct, a modifier such as 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) can be appended to the E/M code to unbundle the edits.
Finally, there is a HCPCS code for Marcaine HCL (S0020, Injection, bupivicaine hydrochloride, 30 ml) and one for saline (A4217, Sterile water/saline, 500 ml), which may or may not be reportable, depending on the payer and the circumstances.
Tuesday, January 14, 2014
should we charge 75989 or 77012 for the CT guidance along with 32551?
You should report 75989 (Radiological guidance
[i.e., fluoroscopy, ultrasound, or computed tomography], for
percutaneous drainage [e.g., abscess, specimen collection], with
placement of catheter, radiological supervision and interpretation) for CT guidance performed with chest tube insertion code 32551 (Tube thoracostomy, includes water seal [e.g., for abscess, hemothorax, empyema], when performed [separate procedure]).
A note with 32551 specifically points you to 75989 for related guidance, including CT guidance.
Although 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation) does describe CT guidance, it is specific to needle placement guidance.
A note with 32551 specifically points you to 75989 for related guidance, including CT guidance.
Although 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation) does describe CT guidance, it is specific to needle placement guidance.
Which code applies to a KUB interpretation following ESWL
Code 74000 (Radiological examination, abdomen; single anteroposterior view)
typically applies to a KUB (which stands for, but does not require
imaging of, kidney, ureters, and bladder). Documentation should drive
your final code choice, however. Append modifier 26 (Professional component) to 74000 if you need to indicate that the radiologist performed only the interpretation and report.
The physician who performs the ESWL to break up kidney stones should report 50590 (Lithotripsy, extracorporeal shock wave).
The physician who performs the ESWL to break up kidney stones should report 50590 (Lithotripsy, extracorporeal shock wave).
Maximize Payment for A-Scans by Understanding Medicare vs. Commercial Payers
Ophthalmologists should bill for both eyes together when performing the
technical component of an A-scan for reimbursement from Medicare. But
for reimbursement from commercial payers, code each eye separately.
Correctly Code for Medicare Reimbursement
Medicares payment policy for 76519 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) is one of the most confusing policies in existence. This procedure must be done before cataract surgery, and both A-scans and cataract surgery constitute a large part of a general ophthalmologists practice, so it is important for coders to know how to bill for 76519.
Medicare breaks down 76519 into technical and professional components. The technical portion is the actual measuring, which is done with equipment that takes two measurementsthe axial length of the eye and the shape of the corneaand turns them into a calculation for the power of the intraocular lens implant.
Note: Not all offices can do both with one piece of equipment. In fact many offices have to do the keratometry separately and feed the readings into the A-scan equipment for use in the IOL calculation.
Medicare will only allow one technical component in a 12-month period. If it has been more than 12 months since the last measurement was performed, then another technical component may be billed. The professional component takes place when the ophthalmologist actually selects the power and style of the lens to insert. Both eyes need to be synchronized to work together, so that perfect vision may not be the best power for an IOL. Medicare allows the professional component to be billed once for each cataract surgery, even if the professional component for the other eye (and technical component for both eyes) was done recently. Here are some Medicare billing scenarios, courtesy of Lise Roberts, vice president of Health Care Strategies of Syosset, N.Y.
Scenario 1: The patient has cataracts in both eyes that impair vision by approximately the same amount. The physician does the dominant eye (right eye in this example) first and plans to do the other eye soon after the first eye is healed. The A-scan and keratometry are performed to measure both eyes and the physician selects the power and style to implant into the dominant eye. The first claim will reflect 76519-RT. The Medicare Physicians Fee Schedule (MPFS) for 76519 includes payment for measuring both eyes and interpreting one eye. Later, when the physician selects the power and style of the IOL for the other eye the second claim will reflect 76519-26-LT. The MPFS for 76519-26 includes payment for the interpretation only, resulting in the selection of the power and style of the IOL.
Correctly Code for Medicare Reimbursement
Medicares payment policy for 76519 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) is one of the most confusing policies in existence. This procedure must be done before cataract surgery, and both A-scans and cataract surgery constitute a large part of a general ophthalmologists practice, so it is important for coders to know how to bill for 76519.
Medicare breaks down 76519 into technical and professional components. The technical portion is the actual measuring, which is done with equipment that takes two measurementsthe axial length of the eye and the shape of the corneaand turns them into a calculation for the power of the intraocular lens implant.
Note: Not all offices can do both with one piece of equipment. In fact many offices have to do the keratometry separately and feed the readings into the A-scan equipment for use in the IOL calculation.
Medicare will only allow one technical component in a 12-month period. If it has been more than 12 months since the last measurement was performed, then another technical component may be billed. The professional component takes place when the ophthalmologist actually selects the power and style of the lens to insert. Both eyes need to be synchronized to work together, so that perfect vision may not be the best power for an IOL. Medicare allows the professional component to be billed once for each cataract surgery, even if the professional component for the other eye (and technical component for both eyes) was done recently. Here are some Medicare billing scenarios, courtesy of Lise Roberts, vice president of Health Care Strategies of Syosset, N.Y.
Scenario 1: The patient has cataracts in both eyes that impair vision by approximately the same amount. The physician does the dominant eye (right eye in this example) first and plans to do the other eye soon after the first eye is healed. The A-scan and keratometry are performed to measure both eyes and the physician selects the power and style to implant into the dominant eye. The first claim will reflect 76519-RT. The Medicare Physicians Fee Schedule (MPFS) for 76519 includes payment for measuring both eyes and interpreting one eye. Later, when the physician selects the power and style of the IOL for the other eye the second claim will reflect 76519-26-LT. The MPFS for 76519-26 includes payment for the interpretation only, resulting in the selection of the power and style of the IOL.
News Brief: Look for Corrections to National CCI Version 6.1
Due to a large number of errors, the implementation of the national
Correct Coding Initiative (CCI) version 6.1 has been delayed from April 1
to May 1, 2000. Users of any CCI edit products should make certain that
they have a corrected copy of version 6.1 before its implementation on
May 1, either in the form of an errata sheet or, in some cases, an
updated book, says Laurie Castillo, MA, CPC, president of
American Association of Professional Coders Northern Virginia Chapter
and owner of Physician Coding & Compliance Consulting in Manassas,
Va.
The National Technical Information Service (NTIS) publishes the CCI Edits , along with several other commercial resellers who purchase the raw data from NTIS. According to NTIS, all of its customers received an errata sheet soon after NTIS was made aware of the errors by the Health Care Financing Administration (HCFA).
We received 37 pages of changes from NTIS, confirms Tony Mistretta of the Medical Management Institute, one of the licensed resellers of the CCI edits. We have committed to making all the changes to the book by hand and sending out corrected manuals to our subscribers, he said.
Those who purchased CCI edits from a source other than NTIS and the Medical Management Institute also should look for corrections to version 6.1 in time for the May 1 implementation. For NTIS customers, this has been sent out in the form of an appendix, which must be cross-referenced to the version 6.1 product. Other resellers should have received the errata sheet from NTIS and made arrangements to get that information to their customers.
In response to direction from Congress, CCI edits were initiated in 1996 to reduce Medicare program expenditures by detecting inappropriate coding on claims, and denying payment. The CCI edits are basically a list of code pairs that Medicare will not reimburse together for the same patient on the same day, because they represent services that are bundled or would not ordinarily be performed together, states Castillo. Reporting two of these codes together for the same service represents fraudulent unbundling, which is the practice of breaking down a single procedure into its component parts, and billing for additional services, Castillo warns.
There are times, however, when two of these codes might legitimately be coded together, if they represent two services that are distinct and independent from each other, declares Castillo. In order to indicate that the codes represent separate services as opposed to unbundling of a single service, coders should use appropriate modifiers, such as CPT modifier -59 (distinct procedural service), she advises.
The National Technical Information Service (NTIS) publishes the CCI Edits , along with several other commercial resellers who purchase the raw data from NTIS. According to NTIS, all of its customers received an errata sheet soon after NTIS was made aware of the errors by the Health Care Financing Administration (HCFA).
We received 37 pages of changes from NTIS, confirms Tony Mistretta of the Medical Management Institute, one of the licensed resellers of the CCI edits. We have committed to making all the changes to the book by hand and sending out corrected manuals to our subscribers, he said.
Those who purchased CCI edits from a source other than NTIS and the Medical Management Institute also should look for corrections to version 6.1 in time for the May 1 implementation. For NTIS customers, this has been sent out in the form of an appendix, which must be cross-referenced to the version 6.1 product. Other resellers should have received the errata sheet from NTIS and made arrangements to get that information to their customers.
In response to direction from Congress, CCI edits were initiated in 1996 to reduce Medicare program expenditures by detecting inappropriate coding on claims, and denying payment. The CCI edits are basically a list of code pairs that Medicare will not reimburse together for the same patient on the same day, because they represent services that are bundled or would not ordinarily be performed together, states Castillo. Reporting two of these codes together for the same service represents fraudulent unbundling, which is the practice of breaking down a single procedure into its component parts, and billing for additional services, Castillo warns.
There are times, however, when two of these codes might legitimately be coded together, if they represent two services that are distinct and independent from each other, declares Castillo. In order to indicate that the codes represent separate services as opposed to unbundling of a single service, coders should use appropriate modifiers, such as CPT modifier -59 (distinct procedural service), she advises.
Thursday, January 9, 2014
Failure to Thrive 779.34 or 783.41 Depends on Exact Age
Question: What diagnosis should we submit for a newborn who is not gaining enough weight?
Florida Subscriber
Answer: The correct choice depends on the child's age. For an infant 28 days of age or younger, report 779.34 (Failure to thrive in newborn). If the infant is older than 28 days, select 783.41 (Failure to thrive).
Florida Subscriber
Answer: The correct choice depends on the child's age. For an infant 28 days of age or younger, report 779.34 (Failure to thrive in newborn). If the infant is older than 28 days, select 783.41 (Failure to thrive).
More partnerships between doctors and hospitals strengthen coordinated care for Medicare beneficiaries
Doctors, hospitals and other health care
providers have formed 123 new Accountable Care Organizations (ACOs) in
Medicare, providing approximately 1.5 million more Medicare
beneficiaries with access to high-quality coordinated care across the
United States, Health and Human Services Secretary Kathleen Sebelius
announced today.
Doctors, hospitals and health care providers establish ACOs in order to work together to provide higher-quality coordinated care to their patients, while helping to slow health care cost growth. Since passage of the Affordable Care Act, more than 360 ACOs have been established, serving over 5.3 million Americans with Medicare. Beneficiaries seeing health care providers in ACOs always have the freedom to choose doctors inside or outside of the ACO. ACOs share with Medicare any savings generated from lowering the growth in health care costs when they meet standards for high quality care.
“Accountable Care Organizations are delivering higher-quality care to Medicare beneficiaries and are using Medicare dollars more efficiently,” Secretary Sebelius said. “This is a great example of the Affordable Care Act rewarding hospitals and doctors that work together to help our beneficiaries get the best possible care.”
“This program puts the control in the hands of physicians and allows them to take the lead in an innovative way to deliver the right care to the right patient at the right time,” said Kelly A. Conroy, executive director of the Palm Beach ACO and South Florida ACO. “We are honored to be a Medicare Shared Savings Program Accountable Care Organization, and after 18 months in the program, can proudly say that we have seen measurable success. We are so impressed with our participating physicians’ enthusiasm towards the cultural shift, and it demonstrates that physicians are primed for the future of medicine.”
The ACOs must meet quality standards to ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely. The Centers for Medicare & Medicaid Services (CMS) evaluates ACO quality performance using 33 quality measures on patient and caregiver experience of care, care coordination and patient safety, appropriate use of preventive health services, and improved care for at-risk populations.
The new ACOs include a diverse cross-section of health care providers across the country, including providers delivering care in underserved areas. More than half of ACOs are physician-led organizations that serve fewer than 10,000 beneficiaries. Approximately 1 in 5 ACOs include community health centers, rural health clinics, and critical access hospitals that serve low-income and rural communities.
Affordable Care Act provisions have a substantial effect on reducing the growth rate of Medicare spending. Growth in Medicare spending per beneficiary hit historic lows during the 2010-2012 period, and this trend has continued into 2013. Projections by both the Office of the Actuary at CMS and the Congressional Budget Office estimate that Medicare spending per beneficiary will grow at approximately the rate of growth of the economy for the next decade, breaking a decades-old pattern of spending growth outstripping economic growth.
The next application period for organizations interested in participating in the Shared Savings Program beginning January 2015 will be in summer 2014.
More information about the Shared Savings Program, including previously announced ACOs, is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/News.html.
For a list of the 123 new ACOs announced today, visit: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2014-ACO-Contacts-Directory.pdf.
Source:http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-12-23.html
Doctors, hospitals and health care providers establish ACOs in order to work together to provide higher-quality coordinated care to their patients, while helping to slow health care cost growth. Since passage of the Affordable Care Act, more than 360 ACOs have been established, serving over 5.3 million Americans with Medicare. Beneficiaries seeing health care providers in ACOs always have the freedom to choose doctors inside or outside of the ACO. ACOs share with Medicare any savings generated from lowering the growth in health care costs when they meet standards for high quality care.
“Accountable Care Organizations are delivering higher-quality care to Medicare beneficiaries and are using Medicare dollars more efficiently,” Secretary Sebelius said. “This is a great example of the Affordable Care Act rewarding hospitals and doctors that work together to help our beneficiaries get the best possible care.”
“This program puts the control in the hands of physicians and allows them to take the lead in an innovative way to deliver the right care to the right patient at the right time,” said Kelly A. Conroy, executive director of the Palm Beach ACO and South Florida ACO. “We are honored to be a Medicare Shared Savings Program Accountable Care Organization, and after 18 months in the program, can proudly say that we have seen measurable success. We are so impressed with our participating physicians’ enthusiasm towards the cultural shift, and it demonstrates that physicians are primed for the future of medicine.”
The ACOs must meet quality standards to ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely. The Centers for Medicare & Medicaid Services (CMS) evaluates ACO quality performance using 33 quality measures on patient and caregiver experience of care, care coordination and patient safety, appropriate use of preventive health services, and improved care for at-risk populations.
The new ACOs include a diverse cross-section of health care providers across the country, including providers delivering care in underserved areas. More than half of ACOs are physician-led organizations that serve fewer than 10,000 beneficiaries. Approximately 1 in 5 ACOs include community health centers, rural health clinics, and critical access hospitals that serve low-income and rural communities.
Affordable Care Act provisions have a substantial effect on reducing the growth rate of Medicare spending. Growth in Medicare spending per beneficiary hit historic lows during the 2010-2012 period, and this trend has continued into 2013. Projections by both the Office of the Actuary at CMS and the Congressional Budget Office estimate that Medicare spending per beneficiary will grow at approximately the rate of growth of the economy for the next decade, breaking a decades-old pattern of spending growth outstripping economic growth.
The next application period for organizations interested in participating in the Shared Savings Program beginning January 2015 will be in summer 2014.
More information about the Shared Savings Program, including previously announced ACOs, is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/News.html.
For a list of the 123 new ACOs announced today, visit: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2014-ACO-Contacts-Directory.pdf.
Source:http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-12-23.html
Use 250.8x to Represent Diabetic Hypoglycemia
Question: Our physician saw a hypoglycemic patient,
but we aren't sure which hypoglycemia code applies. Do you have any
advice on selecting an ICD-9 code?
Nevada Subscriber
Answer: If the patient has diabetic hypoglycemia, you should report 250.8x (Diabetic hypoglycemia).
If not, you should probably select one of the following codes, based on the physician's documentation:
- 250.3x -- Diabetes with other coma (diabetic hypoglycemic coma)
- 251.0 -- Hypoglycemic coma
- 251.1 -- Other specified hypoglycemia
- 251.2 -- Hypoglycemia, unspecified.
- 579.3 -- Other and unspecified postsurgical nonabsorption
- 775.6 -- Neonatal hypoglycemia.
Nevada Subscriber
Answer: If the patient has diabetic hypoglycemia, you should report 250.8x (Diabetic hypoglycemia).
If not, you should probably select one of the following codes, based on the physician's documentation:
- 250.3x -- Diabetes with other coma (diabetic hypoglycemic coma)
- 251.0 -- Hypoglycemic coma
- 251.1 -- Other specified hypoglycemia
- 251.2 -- Hypoglycemia, unspecified.
- 579.3 -- Other and unspecified postsurgical nonabsorption
- 775.6 -- Neonatal hypoglycemia.
CPT® 2014 Introduces 4 New Consultation Codes
Interestingly, four new codes have been added
that describe the work of two medical professionals who discuss a
patient’s condition over phone or Internet.
So from the first day of the New Year, if two medical professionals discuss a patient’s condition via phone or internet, you’ll report the following codes:
- 99446 – Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
- 99447 – … 11-20 minutes of medical consultative discussion and review
- 99448 – … 21-30 minutes of medical consultative discussion and review
- 99449 – … 31 minutes or more of medical consultative discussion and review.
Questions related to time
Coders need to be alert to:
- Why these codes are broken into time
- How that time will be measured (reading, discussing, interpreting, further research, etc.).
- How will the time be documented
- Will it be documented
- For consultations less than 5 minutes, avoid using these codes
- Major part of the service time reported (more than half) must be devoted to the medical consultative verbal/Internet discussion.
- The consult includes review of related medical records, path/lab studies, imaging, medications, and similar date.
- A single code covers all contact time and review time, so add together and calculate the total time spent when multiple calls/internet contacts are performed for a single consult.
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