Sunday, February 27, 2011

Get To Know What Constitutes an Acceptable Signature

You will soon need to ensure physicians and non-physician practitioners (NPP) sign your paper lab requisitions if you want to get paid; however what does that entail exactly?

CMS provides specific guidance on what constitutes an acceptable 'signature' for documents subject to review for Medicare payment or by an audit contractor. See to it that your documents measure up by complying with one of the following choices:


  • See to it that it is legible

    The simplest signature (but toughest to ensure) is a legible full-name signature or a legible signature using first initial and last name.

    Unluckily, you will not find many physicians or NPP who have a legible signature and you certainly won't want to stake your payment on it. That is when you will go to the second option.




  • Accept printed name with scribble

    If you cannot count on ordering physicians and NPP to legibly sign requisitions, you certainly have an alternative. Other personnel such as a circulating nurse can print the full name of the ordering physician/NPP on the requisition. After that the physician/NPP can initial next to or above the full printed name. In this situation, the initials don't have to be legible to count as a legitimate signature.

    On the other hand, if you submit a signature log or attestation statement that identifies the signer of an illegible signature, you can meet the signature requirement that way.

    Do it: There's no denying that getting referring physicians and NPP to comply with Medicare's just-in policy for acceptable paper requisition signatures will be tough; however, compliance is important if pathologists and laboratories are to continue to be paid for their work.

    For more on this, stay tuned to a medical coding guide like Supercoder.com .
  • 93922: There Are Special Rules for Unilateral Exams

    Puzzled by the 2011 guidelines for 93922-93923? Not sure when to report 93922-52?

    Don't be. Read on and know how you should go about it: You should report 93922-52 (Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries … 1-2 levels; Reduced services) when the patient has only one limb accessible for study and the doctor records only one or two levels.

    Here's an example: A patient's right leg was amputated. The physician carries out the study on two levels on the patient's left leg. You should use 93922-52 to report unilateral, limited service.

    The origin of the confusion may be that CPT guidelines for 93922 and for 93923 (Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, three or more levels … ) guide you to report limited code 93922 when the physician carries out a unilateral exam for three or more levels or using provocative functional maneuvers, on a patient with just one arm or leg available for study.

    To put it in other words, this means that 93922 (without modifier 52) is proper for




  • A bilateral exam on one or two levels
  • A unilateral exam on three or more levels (i.e, lower and/or upper extremity amputee)
  • A unilateral exam when performing provocative functional maneuvers

    Experts provide the following list to help you count levels:

    Lower extremity levels

    1. High thigh 2. Low thigh

    3. Calf 4. Ankle

    5. Metatarsal 6. Toes

    Upper Extremity Levels

    1. Arm 2. Forearm

    3. Wrist 4. Digits

    For more answers to your coding confusions, sign up for a one-stop medical coding guide.
  • Dates and Physician Presence Have a Says In 99221 Use

    In a particular situation, a physician treated a patient in the office and then admitted her to the hospital later the same day. Here can we bill for the office visit and the first day of admission, or do we just bill for the hospital stay?

    Well, the answer depends on whether the physician sees the patient on the same day in the hospital.

    First scenario: If the physician sees the patient in the hospital on the same day in the office, you are looking at two face-to-face visits on the same date. Only report the proper initial hospital care code (99221-99223, Initial hospital care, per day, for the E&M of a patient …). As per CPT coding guidelines, all initial hospital care services that start in another place of location (such as the physician's office) should be combined and coded using the proper level of initial hospital care. As the 99221-99223 code will include the evaluation & management provided in the office, you will report an initial hospital care code that includes the work done in both sites of service; this may lead to coding a higher level of initial hospital care than if you were thinking about the hospital services alone.

    Second scenario: However, if the physician doesn't see the patient in the hospital until the next day, bill each encounter separately. Select the proper office visit code (99201-99205, Office or other outpatient visit for the E&M guidelines of a new patient …) or 99212-99215(Office or other outpatient visit for the evaluation and management of an established patient …) for the office visit on the first day. After this, add an initial hospital care code from 99221-99223 for day two, when the physician tends to the patient in the hospital for the first time. Note that CPT uses initial hospital care codes to report the first hospital inpatient encounter by the admitting physician. After that, you will report subsequent hospital care codes 99231-99233 (Subsequent hospital care, per day, for the E/M of a patient . . .), until the time of discharge (date of discharge). When the physician discharges the patient, you will submit the proper hospital discharge day code, 99238 or 99239.

    Tuesday, February 22, 2011

    Do 569.3 and 578.1 function the same way?

    As a just-in gastroenterologist coder, sometimes you may run into rough weather or be confused about which code to use for a particular service.

    For instance, a just-in coder was confused about when to use 569.3 and 578.1 for bloody stool? She was trying to figure out if they are one and the same.

    Well, the answer is no. When you examine the stool, you would be able to decide on the original source of the bleeding. After that you would be able to select the proper ICD-9 code.

    Blood in the stool originates from somewhere up the gastrointestinal tract. In this situation, you would use 578.1 (Blood in stool). On the contrary, traces of bright red blood on the outside of the stool or on the toilet tissue normally takes place from a source within the rectum or anus (569.3, Hemorrhage of rectum and anus).

    While coding for a colonoscopy (45378), you would normally report 578.1 with 792.1 (Nonspecific abnormal findings in stool contents). A number of carriers do not accept rectal bleeding as a justifiable diagnosis for colonoscopy as they presume that the source of the bleeding is the rectum or anus, not the colon. But then, they accept rectal bleeding as an acceptable diagnosis for a flexible sigmoidoscopy (45330, Sigmoidoscopy, flexible; diagnostic, with or with no collection of specimen[s] by brushing or washing [separate procedure]).

    Here's a hint: The gastroenterologist would opt for a colonoscopy if the flexible sigmoidoscopy does not reveal a source of the bleeding. The source could lie past the splenic flexure, which is only visible through a colonoscopy.

    For more specialty-specific articles to assist your gastroenterology coding, sign up for a medical coding resource like CodingInstitute.com.

    Medical Coding - Office Visit With Vision Training?

    Can you submit 99213 for an office visit and 92065 for vision training on the same date of service (DOS)?

    Well, vision training code 92065 (Orthoptic and/or pleoptic training, with continuing medical direction and evaluation) is not bundled with E/M code 99213 (Office or other outpatient visit for the evaluation and management of an established patient …).

    Remember: There must be medical necessity for providing the E/M service and documentation should be separately identifiable in the medical record to support the need and level of service. Some carriers or private payers may require the use of modifier 25 (Significant, separately identifiable E&M service. The office must be able to stand alone as a procedure without the vision training session; as such ask yourself: “Would 99213 have been required even if the 92065 procedure had not been done?"

    But then note that 92065 is bundled with 99211 (Office or other outpatient visit for the E&M of an established patient, that may not require the presence of a physician …).

    What's more, include the recommendations or prescription from the referring physician for the vision training (92065) in addition to documentation in the medical record to support the medical necessity for the office visit (99213). The vision training can be done under general supervision by a technician; however the physician must perform the OV.

    Documentation of the training by a technician must also support direction and oversight by the physician. The claim should also show the referring physician's name (which may be the actual physician submitting the charge.)

    For specialty-specific articles to assist your optometry coding, sign up for a medical coding resource like CodingInstitute.com

    Therapy Progression for Proper Whiplash Coding

    Coding for whiplash diagnosis might be a cakewalk, however don't take it too easy. Keep looking for situations when the patient's symptoms persist in spite of conservative therapy and demand more extensive treatment. Not paying heed to these diagnoses can mean missed pay.

    Watch for move from therapy to scans

    When a patient presents with whiplash symptoms, your pain management coding  and specialist will carry out a thorough exam and will carry out a comprehensive exam and will often order neck x-rays to rule out fractures.

    Initial steps: Once the pain specialist diagnoses whiplash (847.0, Sprains and strains of other and unspecified parts of back; neck sprain), he normally will prescribe conservative treatment. Common options cover physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. Some patients may also stand to gain from wearing a soft cervical collar or by using a portable traction device.

    If conservative treatment fails to make an impact, the physician might order additional diagnostic imaging tests.

    Count trigger point injections the right way

    Your physician might also administer trigger point injections to relieve the patient's pain and muscle tenderness. Report these procedures with 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) or 20553 (...three or more muscles).

    Note of caution: The difference between the two codes is the number of muscles the physician injects, and not the number of trigger points or the number of injections he administers.

    The descriptors clarify that if your provider documents a different muscle, you can count the number of muscles to determine the difference between 20552 and 20553. However if the provider injects multiple trigger points within the same muscle, you only count one muscle, irrespective of the amount of injections.

    Watch out: Owing to the 'one or two muscles' and 'three or more muscles' distinction between codes, you will report a maximum of one unit for either 20552 or 20553 for an encounter - not both codes. For instance, if your pain management physician injects trigger points in a total of four separate muscles, compliant coding would be one unit of 20553.

    For more pain relief, move to nerve blocks

    When more conservative treatments for whiplash fail to help the patient, your physician might administer nerve blocks to help diagnose a patient's condition and/or provide therapeutic pain relief. Common options include lidocaine and/or steroids such as methylprednisolone acetate (J1020) into cervical facet joints (such as C3-4 and C4-5).

    Report it: Code the block at the first facet joint level with 64490 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; single level). Submit blocks at additional facet joint levels on the following lines of your claim with +64491 (… second level [List separately in addition to code for primary procedure]) and +64492 (... third and any additional level[s] [List separately in addition to code for primary procedure]) as proper.

    Guidance: Physicians go for fluoroscopic guidance to help ensure they inject the proper site. Earlier, you reported fluoroscopic guidance in addition to the injection procedure code. Last year, CPT introduced codes 64490-+64492, which include fluoroscopic or CT guidance. Now you can simply code the injection.

    Bilateral question: Often, providers administer facet joint injections unilaterally. If your doctor administers bilateral injections, remember to add modifier 50 (bilateral procedure) to the injection codes.

    Be on the lookout for add-on diagnoses

    Some factors (age, gender, and pre-existing conditions like arthritis) can have an impact on the severity and prognosis of whiplash injuries. When the patient doesn't respond to more conservative treatments or if her symptoms get worse, your physician may re-evaluate her for other disorders.

    In these instances, report the additional diagnoses along with whiplash.

    Depend on nerve destruction as last recourse

    If nerve blocks don't bring the patient long-lasting relief, your pain specialist may consider paravertebral facet joint denervation.

    Document it: Prior to taking the patient's treatment to this level, your physician should have thorough documentation of other treatments. The patient's chart should cover two important details:



  • The proper diagnostic paravertebral facet joint block or medial branch nerve block studies that identify the specific joint level
  • Documentation that the patient had significant – however not long-lasting -- pain relief from the facet joint blocks. Some payers are beginning to need actual documentation and quantification of the patient's status. For instance, the payer might want details regarding the percentage of change in pain, duration of pain relief, and changes in the patient's functional status during relief from the diagnostic blocks.

    If the patient meets these criteria, your physician may use paravertebral facet joint denervation to treat back or neck pain following whiplash/post-traumatic injury and to relieve the pain of associated cervicogenic headache.

    In these cases, CPT includes two codes for denervation:
  • 64626 -- Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level
  • +64627 -- each additional level [list separately in addition to code for primary procedure].

    Just like nerve blocks, physicians often carry out the therapeutic destructive procedures as unilateral procedures. If your specialist carries out a bilateral procedure, add modifier 50 and document which joint levels he treated.

    Bottom line: With the prevalence of whiplash injury and range of treatment choices for whiplash and related disorders, physicians and codes need to know what payers cover and what they do not.
  • Ingrown Toenail Removal Coding Confusions? 11750 Answers Them


    In a particular case, a patient presents for a follow-up of an ingrown toe nail. The podiatrist finds that the patient now has two ingrown toenails – one on each foot. He removes both from each toe and also did a silver nitrate cauterization. How should I report this? Should I report 99212-25?

    Well, the answer is yes. Besides coding 99212-25, you should bill 11750 (Excision of nail and nail matrix, partial or complete [example, ingrown or deformed nail], for permanent removal) appended by modifier 50 (Bilateral procedure).

    Logic for evaluation & management: Since the diagnosis is new to one toe, you could justify 99212 (Office or other outpatient visit for the E/M of an established patient which requires at least two of these three key components: a problem focused history; a problem focused examination, and straightforward medical decision making; Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). The patient presents for follow-up of one ingrown toenail. However, the podiatrist has not examined the other (new) ingrown toenail earlier.

    Adding modifier 25 (Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) to 99212 indicates the podiatrist carries out a significant, separate service from the ingrown toenail removal.

    Logic for incision: You should report each toenail removal: 11750 for the first complete removal and 11750 for the second removal. Using modifier 50 to the second removal tells the insurer that the podiatrist carries out the toe removal as bilateral procedure.

    For more specialty-specific articles to help your podiatry coding, stay tuned to a medical coding resource like CodingInstitute.com .

    Code for Splinting Only If No Restorative Treatment Is Administered


    Recently, a three-year-old presented to our office with a history of falling off a chair and injuring his right wrist. After carrying out a physical, the pediatrician orders an x-ray which shows a buckle fracture of the right wrist. For the time being, the doctor protects the injury with a forearm splint and refers the established patient to an orthopedic surgeon for restorative treatment. Here, can I code for the splinting?

    Since the pediatrician provides only the initial splinting without restorative treatment, you can code for the forearm splinting with 29125 (Application of short arm splint [forearm to hand]; static). As an alternative, if the pediatrician carried out the definitive fracture care, including the pre- and post-operative fracture care, the global fracture code 25600, Closed treatment of distal radial fracture [example., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) would include the initial cast or splint.

    In both situations, the pediatrician can still code for the x-ray (73090, Radiologic examination; forearm, two views). Even though the splint is also a separately billable service, some plans may consider the forearm splint (A4590, Special casting material [for instance fiber glass] DME and not pay the physician unless he has obtained DME certification.

    In order to report an E/M for the evaluation from the fall, the pediatrician would have to have performed and documented a medically necessary significant and separately identifiable E/M service above and beyond the minor E/M already included in 29125. You would use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the day of the procedure or other service) to the evaluation & management service that you report with 29125.

    According to CPT, you can report further significant identifiable services carried out at the time of the cast/splint application. A fall from a chair may engage checking for possible head injury and any other wounds, and will most likely call for an expanded problem focused history and exam, which could support 99213-25

    For more specialty-specific articles to assist your pediatric coding and for other medical coding updates, sign up for a medical coding resource like Coding Institute.

    Rid Your Invasive Lines Documentation Challenges with These Tips


    Every detail matters when your anesthesia providers place invasive lines that are separately reportable from the standard anesthesia service.

    Remember that line placement is a surgical procedure; as such, the service must be documented before a payer will reimburse.

    Stay away from denials by training your anesthesia providers to document these five components of line insertion without fail.



  • Support medical necessity

    As standard anesthesia coding (source for anesthesia coding http://www.supercoder.com/coding-newsletters/anesthesia-coding-alert ) includes so many services, documenting medical necessity for additional lines is important. For instance, the patient might have coarctation (747.10, Coarctation of aorta [preductal] [postductal]), a narrowing of the aorta between the upper and lower body branches. That type of condition or more common issues such as circulatory problems might also need an additional arterial line for the anesthesiologist's monitoring purposes.
  • Watch the clock

    Your providers should by now be familiar to documenting their start and stop times for any anesthesia case. If they place lines during a case they expect to bill separately, remind them to document each line's start and stop time by yourself.

    Tip: If your provider places the line intraoperatively, you do not normally need to deduct the placement time from the anesthesia time. If your provider places the lines before the anesthesia time begins, be sure the case start time is after the line placement time to avoid ‘double dipping'.
  • Identify the location

    The operative note should document where the provider placed the line, like the “right radial artery" or “right intrajugular." The note does not make a difference in your code selection; however is good documentation of the line placement.
  • Validate barrier method/technique

    If your physicians submit data for PQRS, they should be on the look-out for ways their documentation can support reporting the anesthesia measures. Documenting sterile technique or maximal barrier sterile technique (MSBT) helps support reporting PQRS (Physician Quality Reporting System) measure 76 (Prevention of catheter-related bloodstream infections [CRBSI): Central venous catheter [CVC] insertion protocol).

    Measure 76 tracks the percentage of patients who undergo CVC insertion when the provider uses all elements of maximal sterile barrier technique. Requirements say that providers use cap, mask, sterile gown, sterile gloves, a large sterile sheet, hand hygiene, and 2 percent chlorhexidine for cutaneous antisepsis.
  • Include the provider's name and signature

    Even if you have every other detail noted, you will only be reimbursed when the chart includes the provider's name and signature.

    Definition of a handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation.

    Medicare guidelines allow a handwritten or electronic signature on orders or other medical record documentation for review. Stamped signatures aren't acceptable; however the provider can sign her initials over her printed or typed name.
  • Anesthesia Coding: Two New H Codes Will Replace 366.16 Post ICD-10


    October 1, 2013 is fast approaching. But all you anesthesia coders out there, are you geared up for the changes that will have a say in your anesthesia practice?

    So when ICD-9 becomes ICD-10 in a couple of years time, the diagnosis codes you are used to reporting will no longer be there. Many diagnosis codes will include more details than their present counterparts, and some sub-codes of the family will even move to different locations.

    Here are two commonly used options for nuclear nuclear sclerosis, or nuclear cataract (366.16, Senile nuclear sclerosis).

    The difference when ICD-10 goes into effect on October 1, 2013: Diagnosis 366.16 will change to H25.10 (Age-related nuclear cataract, unspecified eye) as the descriptor does not specify which eye the surgeon treated, your physician's notes should include details to help you code right. The anesthesiologist might not include modifier LT (Left side) or RT (Right side), however will often note whether the surgeon treated a right or left cataract.

    Word of caution: Some coders presently submit 366.9 (Unspecified cataract) in place of gleaning the details required for more spot on reporting. ICD-10 will also change that diagnosis to H26.9 (Unspecified cataract). Take note that the 'unspecified' option will be in a different code family (H26.x versus H25x); as such be prepared to dig deeper for the best choice. Always urge your anesthesia coding alerts providers to document clearly whatever procedure the surgeon carries out, however, so you can code right and hopefully avoid 'unspecified' diagnoses.