Tuesday, May 31, 2011

Late or no-show patients? Take a look at these options

Take a look at this ophthalmology coding scenario:

There are some patients who regularly miss appointments or show up late. We would like to focus on the importance of keeping appointments without alienating the patients. As such, can you bill for no-show visits and/or charge a fee for being late?

Well, whether you can bill for no-show visits or charge a late fee will depend on your payer contracts and the laws in your state. Some contracts bar no-show charges or fees not related to patient services. Take a look at your contract and state laws and if both allow such charges, go ahead and bill the patient for this difficulty.

There are many practices that charge a fee for missed appointments; however there are other choices to consider. Take a look at these suggestions from other practices: if you charge for missed appointments or a certain number of late arrivals, post that information so that patients know about the policy. Cover notices on the registration form, in the registration area and in the waiting room. Some practice writes off the first occurrence and take it as part of patient education.

You should have a financial policy that mentions the fee in writing. You should also have the patient sign a copy of the policy, which he keeps, in addition to one you will keep. This way, he can't claim he was never told or didn't see the notification.

You should tell late arrivals that your staff will fit them in as best you can; however that patients who are on time for appointments will get preference. Give the patient the choice of rescheduling later.

If the patient happens to miss an appointment, you need to send a follow-up letter. Set guidelines for the practice and send a stronger letter every time until you reach the predetermined point of dismissing the patient (normally three missed or late arrival appointments).

Remember: You should be sure to note the missed or late arrival appointment in the patient chart especially when the patient is coming in for diagnostic tests like visual fields or optical coherence tomography (OCT). This may be helpful in safeguarding the practice from abandoned patient lawsuits. Going through how your practice handles this issue is a good opportunity to assess scheduling and other issues from an internal perspective. If you are in a larger multispecialty clinic or in an area where traffic and parking are a recurring problem, realize that these issues might be impacting your patient's ability to be on time. What's more, take a look at how you schedule sick visits; many will be ‘no shows' of you book them a day or two ahead because the patient encourage your physicians to be on time. Some patients think that if the doctor is getting late, it will not matter or will not be noticed if they are late for the scheduled time.

Cpt 2011 Brings Two New Codes For Home Study Among Other Key Changes

If you perform sleep studies, you need to upgrade your coding style this year.

This time, CPT brought some big changes as far as pulmonology coding is concerned. Here are some codes you will have know this year. As such, if you have been using inactive or unrevised codes, you are risking denials for sure.

Two new codes for Sleep Study

The good news is home sleep studies type II had made a straight transition from Code G0398 to 95806 in last year's CPT. Now the codes for home sleep studies type III and IV now have their own category I codes for this year: 95800 and 95801.

These sleep study codes have been established for reporting unattended sleep study testing services. These codes appear with a number (#) symbol to indicate that they are out of numerical sequence.

Other new pulmonology codes on focus

For trachea and bronchi, a new code has been created to report bronchoscopy with balloon occlusion, with assessment of air leak, with the administration of occlusive substance, if performed. Other codes that have been included this year are: 90470, 0250T -, 0251T and 0252T.

CPT codes 0250T, 0251T, 0252T have not been assigned any physician work relative value units. This means that payment is only received by the facility for these services.

There are revisions to Photodynamic Therapy Guidelines and Others

CPT has also revised photodynamic therapy coding. So from January 1 this year, you need to pay attention to the documented time in case a modifier is necessary. CPT also adds various parenthetical guidelines after codes 96570 and 96571. If the pulmonologist carries out 96570 for less than 23 minutes, you should report modifier 52. For each increment after the first 30, you have to get to the eighth minute for each interval. Other CPT 2011 revised codes include 90662, 90663 , and 90670.

Evaluation and management changes offer a sneak peak.

This year, CPT has made significant revisions to the hospital observation services section, including the addition of three new resequenced codes in the subsequent hospital observation subsection. More revisions have also been made in the hospital inpatient services, pediatric critical care patient transport, and inpatient neonatal and pediatric critical care subsections.

Here are three new evaluation and management codes that can impact your pulmonology practice's coding success: 99224, 99225 and 99226.

Monday, May 30, 2011

Backache example to help your ICD-9 coding

With not much time to go for October 1, 2013, there is no denying that now everyone is training eyes on ICD-10. However, in doing so, you should not ignore your ICD-9 coding options. Here's a scenario to help your understanding of ICD-9 codes:

Patient A comes to your office for treatment of severe, chronic pain in the right side of his back. The pain had started about 10 months ago. In the right lumbar multifidus muscle for pain relief, your interventional radiologist uses ultrasound guidance to administer two trigger point injections (TPIs). But then his chart notes only say that the patient had 'pack pain'.

You get the chart and also get to see your radiologist performed trigger point injections on other patients in the past, using 20552 and 76942. The most recent injections carried out on the other patients' backs were for myofascial pain.

Minus more specific diagnosis, you should assume that Patient A also has myofascial pain, and report one unit of 20552 with a diagnosis of 729.1?

Well, the answer here is no. Making assumptions does not support compliant coding. From a clinical standpoint, pain can be caused by various reasons. Even if the diagnosis seems obvious, coders are not clinicians and should never make presumptions.

If your radiologist did not specifically document myofascial pain or myalgia and you use one of those codes, you could land in trouble in case of a payer audit. Such mistakes are just the kind of thing that auditors watch out for. In its place, you may be required to report an unspecified code, such as 724.5.

Remember payers may not always accept 'unspecified' codes in assistance of a service; however some payers will reimburse for 724.5 for trigger point injections. As such, be sure to study your payer coverage policies well prior to determining if the diagnosis fits the payer's rules. As a coder, you should be aware of payer policies and LCDs to be able to convey that information to the physician.

Bear in mind that spot on medical coding requires that you select code based on the documentation you must never report a diagnosis code just because you are aware the payer will pay the service if you report that diagnosis.
Link

Friday, May 27, 2011

Pediatric Coding: Key Things You Need To Consider While Using 2011 Icd-9

While choosing the proper influenza diagnosis, two details are key.

Do not let rumors of some ICD-9 changes in preparation for ICD-10 make you blind to the top pediatric diagnosis code change . Minus the scoop on expansion to the 488 category, denials for invalid codes will disrupt your claims delaying your payments.

ICD-9 2011 codes continue to become more and more specific requiring a provider to document clearly and thoroughly to allow for selection of the most specific and spot on code.

Here are some key points you need to consider while using ICD-9 2011 codes.

a) While assigning ‘swine flu' DX, look at manifestation. When a patient has H1N1 (swine flu), you need to pay attention to a couple of details. The medical record will have to identify the proper influenza and you'll have to capture the proper manifestation to choose the codes to the degree of specificity now called for. With the change, category 488 mirrors the structure of category 487.

There has been a tremendous expansion of the H1N1 category. Now you will no longer be able to use 488.0 and 488.1 as ICD-9 2011 has deleted these codes. Instead it has come up with six new five-digit codes. This year's ICD-9 codes 488.0x (Influenza due to identified avian influenza virus) and 488.1x (Influenza due to identified novel H1N1 influenza virus) allow you to uniquely capture pneumonia, other respiratory manifestations and manifestations taking place with these types of influenza. Now you need to assign the proper code 488.xx code based on the type of comorbid manifestation the avian or H1N1 influenza involves.

Remember: When you report 488.01 or 488.11, as with 487.0, you will report an additional code to identify the type of pneumonia.


Otolaryngology Coding: Physicians Will Finally Get Paid For Crp Coding

This year, CPT brought good news for ENT coders. Finally, physicians will get paid for canalith repositioning procedure (CRP) coding after a two-year struggle.

When we look back, CPT 2009 excited ENT coders with new CPT code 95992. However the 2009 Medicare Physician Fee Schedule played spoilsport. CMS assigned the codes ‘B' status or bundled it always, making payment for CRP or the Epley maneuver using the new code impossible to get.

However the fight for payment of CRP came to an end because of the 2011 Medicare Physician Fee Schedule.

Note: If the ENT carries out and documents a medically necessary E/M that's significant and separately identifiable from the CRP, add modifier 25 to the evaluation & management service. What's more, Medicare doesn't allow payment for audiologists performing therapeutic procedures, such as CRP.

2011 CPT dictates you can use the code closet to the documented time. And this advice is nothing new. Your documented time must be equal to or exceed the average time given to bill that level. Your documented time must be equal to or get past the average time provided to bill that level. For a 35 minutes spent on a medically necessary counseling-dominated visit is a 99214, per CPT you could report 99215.

If the ENT carries out and documents a medically necessary E/M that's significant and separately identifiable from the CRP, add modifier 25 to the evaluation & management service. What's more, Medicare doesn't allow payment for audiologists carrying out therapeutic procedures, such as CRP.

Always Medicare has taken the times indicated in CPT's code descriptors to represent minimums. The doctor would opt for the lower code unless the time was greater than or equal to the higher-level code's required time.

So will Medicare change its position? At this juncture, it's not sure.

Thursday, May 26, 2011

Gastroenterology Coding: 43255 And Control-Of-Bleeding Situations

Gastroenterology coding: 43255 and control-of-bleeding situations

Coding for excessive blood loss? If so, modifier 22 may not be the ally you are looking for. Your answer may lie on more spot on CPTs such as 43255 and critical care codes.

In the first scenario, the doctor injects epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy (43239). Earlier, you may opt to use 43239 added with modifier 22 if the physician required significant effort to control the patient's bleeding.

However this option would need you to submit additional paper documentation to support your modifier 22 claim. So instead if submitting yourself to potential hassles, you can correctly describe this session by reporting 43239 for the biopsy and 43255 for the control of bleeding provided that the bleeding was not caused by the biopsy.

As is obvious from 43255's descriptor, this procedure describes control of bleeding by “any method," including injection.

Necessity: On your claim, you should add modifier 59 to 43255, and then report 43239. If you leave out the modifier, it would give payers the impression that the biopsy (or physician) caused the bleeding and bundle 43255 into 43239.

In the second scenario, when the gastroenterologist is about to carry out an upper GI endoscopy, the patient undergoes very severe gastrointestinal bleeding; so much so that the physician must suspend the endoscopy and spend 40 minutes lavaging blood from the gastro-intestinal tract before continuing.

Report it: This time round, the critical care code 99291 is your best choice.

Here's why: if the gastroenterologist caused the bleeding, you can't bill for the control of bleeding procedure. You should ask control-of-bleeding codes only when treatment is required to control bleeding that takes place spontaneously or as a consequence of traumatic injury (noniatrogenic), and not as a consequence of another type of operative intervention.

You should bear in mind that the time spent at the bedside carrying out services including lavage of gastric blood isn't included in the performance of a subsequent endoscopic procedure and isn't part of the evaluation & management service that might be carried out on the same day.

Nonetheless, you should not report a critical care code carelessly for an excessive bleeding situation that is not out of the ordinary. Extra time for emergency bedside services less than 30 minutes does not count as billable critical care service. For prolonged critical care services, the doctor should exclusively note the amount of time in his notes.

Cardiology Coding: Femoral/Popliteal Coding Options

We are almost mid way through the year, and by now you should be well-versed with all the CPT changes affecting your cardiology practice this year. However, if you're not up to speed with these changes, read on and get more insight.

This time CPT has added new codes for lower extremity endovascular revascularization covering angioplasty, atherectomy, and stenting.

Here we take a look at femoral/popliteal codes 37224-37227. The new femoral/ popliteal service codes are angioplasty: 37224, Atherectomy (and angioplasty): 37225, Stent and atherectomy (and angioplasty): 37227.

The general rule for 37224-37227 is that you should report the one code that represents the most intensive service carried out in a single lower extremity vessel. In that one code, all lesser services are covered. When the cardiologist carried out a stent placement, atherectomy, and angioplasty in the left popliteal vessel, you should use only 37227. That code covers stent placement, atherectomy, and angioplasty. You should code 37224, 37225 or 37226 separately or in addition to 37227 in this situation.

Last year, you reported a superficial femoral artery angioplasty via antegrade puncture using just-deleted code 35474 and 75962. This year you need to report only 37224 to cover all of the services.

If the doctor performs mechanical thrombectomy, thrombolysis or both to help restore blood flow to the occluded area, according to CPT, you may report those services separately. If the physician carries out mechanical thrombectomy, thrombolysis or both to help restore blood flow to the occluded area, you should report those services separately, says CPT. Codes 37220-+37235 apply to different territories and each territory has its own specific set of guidelines. Codes 37224-37227 fall under the femoral/popliteal vascular territory.

According to CPT, the entire femoral/popliteal territory in 1 lower extremity is considered a single vessel for CPT reporting. Therefore, you should report a single code even if the cardiologist carried out various interventions for various lesions in the popliteal artery and in the common, deep, and superficial femoral arteries in the same leg at the same session. In situations such as these, you should use the code for the most complex service. If the cardiologist carries out angioplasty in the left popliteal artery and atherectomy in the left common femoral, you should report atherectomy code 37225 only.

Wednesday, May 25, 2011

Twin deliver coding? Here's how you should go about it

Ob-gyn coding presents a lot of coding challenges before you. Sometimes you may find yourself in a fix trying to report twin cesarean delivery.

If so, you should take a dig at 59510 with modifier 22 attached. However, that may not always be the case. You will need to adjust your twin delivery reporting depending on an insurance company's preference.

So how should you report twin delivery?

Whenever a patient has twins, most ob-gyns first make an attempt at a vaginal delivery as long as the physician has not figured out any complications. Here in this situation, you should go for 59400 for the first baby and 59409-51 for the second.

Keep this in Remember: Both CPT and the American Congress of Obstetricians and Gynecologists (ACOG) recommend you use modifier 51 (Multiple procedures) for the second delivery. But then you may come face to face with some payers who want to see modifier 59 instead. Other coders report appending modifier 22 to the global delivery (59400) if the patient had more than the average of 13 visits and to account for the second delivery in instances where the payer does not permit separate billing for the additional delivery. When this piece of guidance is in writing, you should follow it.

Best option: Send a letter of explanation with the claim to stay away from immediate denial by the claim processor. A simple form letter talking about the high-risk nature of multiple-gestation pregnancies will routinely go straight to medical review and save the hassle of denial resubmissions or lost reimbursement through write-offs.


Otolaryngology Coding: How To Report Fungal Sinusitis

Your otolaryngology coding practice throws open many challenges and presents a lot of questions. Say for instance you may be asking yourself questions like "Is there a specific diagnosis code for fungal sinusitis?"

Well, even though looking up "Sinusitis: due to: fungus, any sinus" in the Alphabet Index, Volume 2 of ICD-9-CM directs you to "117.9," a single code does not describe fungal sinusitis. You should instead use a combination of ICD-9 codes to represent the condition.

According to the initial instruction for category 110-118, Mycoses, you should use additional code to identify manifestation. List the chronic or acute sinusitis for the primary diagnosis. After this code the underlying fungal infection as the secondary diagnosis.

The following steps will tell you how:

One: Report the proper sinusitis code for sinus membrane lining inflammation. Code 461.x for acute sinusitis. For chronic sinusitis (frequent or persistent infections lasting more than three months) report 473.x. select the fifth-digit code based on where the sinusitis takes place.

For instance, for ethmoidal chronic sinusitis, you should choose Code 473.2 (Chronic sinusitis; ethmoidal).Most likely, your otolaryngologist will prescribe a decongestant, pain reliever or antibiotics to treat sinusitis.

Two: Report the ICD-9 code that represents the fungal infection. Category 117 lists various types of mycoses that offer a more specific diagnosis than 117.9 (Other and unspecified mycoses).For example, think that a patient has chronic ethmoidal sinusitis due to aspergillosis (117.3), an infection that can affect the sinuses and is caused by inhaling the fungus aspergillus, which is found in compost heaps, air vents and airborne dust. You need to enter 473.2 as diagnosis 1 and 117.3 as diagnosis 2 in Box 21 of the CMS-1500 form.

Even though the otolaryngologist may treat aspergillosis with antifungal drugs, such as amphotericin, itraconazole or voriconazole, some forms of aspergillus oppose these drugs. Therefore the physician may need to treat the patient with caspofungin, a newer antifungal drug. Your otolaryngologist can tend to more serious aspergillosis cases in the sinuses by scraping out the fungus and applying antifungal drug drops.

Tuesday, May 24, 2011

Anesthesia coding and modifier 23 use

Here are some tips to help you get rid of modifier 23 confusions.

First, you need to know where the service took place. You can add modifier 23 to many procedures that take place outside the OR if your physician provides sufficient documentation. Radiologists carry out an ever-growing range of procedures, many of which require anesthesia because of their invasive nature. But then they might also require anesthesia for MRI procedures, which cross to 01922.

Even though technically part of the radiology department, the cath lab staff carries out many involved procedures that could require anesthesia.

Anesthesia during a cast change or removal is an exception more than the rule; however it could be important for small children. You should choose the anesthesia code based on the cast site, such as 01490 or 01680.

Second, you should know which special circumstances existed. Many procedures that qualify for modifier 23 doesn't normally need anesthesia. Documentation of medical necessity will help justify modifier 23. You should keep a watch for circumstances such as this:

Parkinson's disease, mental retardation, claustrophobia and cerebral palsy are all valid diagnoses for anesthesia during MRIs, line removals, or other seemingly simple procedures.

For anesthesia services during non-invasive or invasive radiological procedures and pain management services, children are often considered as special circumstances. Even though the procedure may be relatively painless from an adult perspective, a young child may not be able to remain still or may have been poked and prodded so many times they must be sedated for the procedure.

Third, you should be aware of what payer guidelines apply. Just like in all cases, you need to check your payer guidelines prior to submitting claims with modifier 23 to see to it that you file right. Modifier 23 definition indicates a procedure which normally requires no anesthesia or local anesthesia, however because of unusual circumstances must be done under  general anesthesia coding. The physician or CRNA must administer general anesthesia and not monitored anesthesia care (MAC) – for the procedure prior to qualifying for modifier 23.

Remember: It's not enough to know the rules. It does not lead to automatic acceptance. Gear up to appeal any claims with modifier 23 with documentation of medical necessity. What's more include a letter of medical necessity from the patient's primary care physician or surgeon to help boost your position.

Cpt 2011 And Pediatric Critical Care Bundles

This year, we saw a whole new crop of bundles with pediatric critical care and transport services. From January 1 this year, CPT changed ( Source cpt http://www.supercoder.com/cpt-codes/ ) which services are bundled into critical care codes 99291-99292 based on whether a facility or professional reports the services. What's more, now CPT returns the list of services bundled into 99466-99467 to the bundles that were in effect as of 2007.

This year, pediatricians from your practice will still face the following services as being bundled into critical care:




  • Interpretations of cardiac output measurements





  • Chest X-rays
  • Pulse oximetry
  • Blood gases
  • Information data stored in computers
  • Gastric intubation
  • Temporary transcutaneous pacing
  • Vent management
  • Vascular access

    But then, facilities will be able to report these services separately from critical care and will not face the bundles.

    Note: This says that you can use the critical care code only, even if the facility is reporting the critical care codes as well as the separate x-rays, intubation, and other services for that matter separately.

    You should now also stay away from reporting new observation care codes with other evaluation & management. This year CPT has added 99224-99226. Even though confusion surrounded these new codes when CPT first debuted them, some rules have recently come to light on ways you can report them.

    Subsequent observation care: Subsequent observation care starts on the same date as initial observation care codes (99218-99220); nor can you report observation services on the same date as office or emergency department services. What's more, you cannot report the new subsequent observation codes on the same date as observation care discharge (99217).

  • Monday, May 23, 2011

    Family Practice Coding: Foot Claims Success Tips

    So your anatomic terminology tripping up your foot and ankle claims? If so read on for more about some of the more common foot procedures your family physician might face and you will be coding those services like a pro.

    You should build coding foundations with basic knowledge. Sudden impacts, say for instance those from jumping during sports) or simple wear-and-tear can lead to toe, foot and ankle problems. You should know the differences between these diagnoses or you may miss a subtle difference and report the wrong code.

    Medical coding tip: You might need modifiers to help differentiate work on different areas of the feet or toes. These modifiers include LT, RT, TA-T9 and sometimes 59, depending on the service your physician provides. These modifiers become all the more important if the FP performs the same procedure on more than one foot or toe.

    You should check differences between bunions and hallux valgus. A bunion happens to be an enlargement of bone or tissue around the metatarsophalangeal (MTP) joint of the great toe. It's often caused by patients wearing shoes that are too narrow around the toe box and can lead to pain and deformity of the toes.

    You should verify injection rules for Morton's Neuroma, TTS

    Morton's neuroma (355.6) is a thickening of the plantar nerve lying between the heads of the metatarsals. Normally, symptoms include pain, tingling, burning or numbness in the area. This can be caused by wearing shoes with a narrow toe or box or due to sports.

    Doctors conduct a physical exam and many a time use x-rays to diagnose a Morton's neuroma. Rest, orthotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and changing shoes will normally help lessen the patient's pain, however corticosteroid injections may be necessary. In some instances, the family physician might refer the patient to a surgeon for excising the neuroma surgically.

    Compression or entrapment of the posterior tibial nerve causes tarsal tunnel syndrome (TTS, 355.5). This condition is similar to carpal tunnel syndrome in the wrist, however causes pain and numbness at the bottom of the foot. Extreme standing on the feet, varicose veins, bone spurs, athletic injuries, and other issues can lead to tarsal tunnel syndrome.

    Physicians depend on a physical exam to diagnose TTS, normally along with studies including electromyography (95860- 95872) or nerve conduction studies (95900-95905). Once the physician confirms the diagnosis, she'll usually begin conservative treatments such as injections, NSAIDs, rest, and footwear changes. However in some cases, the patient may need surgery. The most common surgical treatment happens to be a tarsal tunnel release (28035).

    PTTD, Plantar Fasciitis may need surgery. Posterior tibial tendon dysfunction (PTTD) takes place when the posterior tibial tendon becomes inflamed, stretched out, or torn because of wear-and-tear or a sudden injury. Normally physicians can diagnose this condition using a physical exam, x-ray, or MRI.


    Family Practice Coding: What Should You Report For Emphysema Visit

    Code 94640 to cover the comprehensive service the physician provided.

    An established patient with emphysema presents complaining of shortness of breath. The doctor provides inhalation treatment, trains the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity. Considering this, which CPT code should you report here?

    Well, one CPT code will not suffice. You will need more than CPT code for this encounter. You should use 94640 to cover the comprehensive service the physician provided. Since the physician also carried out an office visit, go for 99213 based on your documentation of an expanded problem-focused exam with low-complexity decision-making. You might be required to add modifier 25 to 99213 to indicate that the evaluation & management service was significant and separately identifiable from 94640.

    You should use 94640 in place of 94664 since the physician's primary intent was to treat the obstruction.

    Word of caution: If you bill 94664 along with 94640 on the same day to Medicare, see to it that you justify that the physician provided the 94664 service distinctly separate from the treatment. In this instance, add modifier 59 to 94664 to notify the payer that the family physician performed 94664 separate from 94640. The documentation should cover details on the medical necessity for separately providing this service.

    Here's an instance: The physician determined that the patient's plan of care should cover inhalation therapy, or the patient is new to this therapy and doesn't know the administration techniques involved in the procedure.

    The note should clearly make out that the physician demonstrated the inhaler to the patient separate from the administration for treatment. Or else, the insurer may think you're trying to report a service twice.

    Here's a tip that'll stand you in good stead: Even though technically not called for it may help to link separate diagnosis codes to the E/M and the nebulizer treatment. For example, you could link 786.05 to 99213, and link the emphysema code to 94640.



    Monday, May 9, 2011

    Lesion Removal Coding In The Ed

    You should never label a lesion malignant on your own.

    Patients who report to the emergency department for lesion removal present for special challenges for the coder who normally does not have time to wait on pathology reports prior to choosing a CPT code for the procedure. You should also know how CPT breaks the body down when a patient reports with an oozing scab or some other sort of lesion.

    Here are some expert guidance to help you in your lesion removal coding.

    The starting point: As a coder, you need various pieces of information before you can choose a proper lesion excision. First, find out the anatomical area of the lesion. For coding, CPT (Source CPT http://www.supercoder.com/ )breaks down lesion removals into various categories:

    Lesion is benign or malignant: You should never have to choose between a benign and malignant lesion. It’s unethical and illegal to diagnose any patient with any condition minus the burden of proof. The only way to be sure a lesion is malignant is to wait for a path report. This isn’t a problem in a dermatologist’s or plastic surgeon’s office. However, ED charts are normally sent for billing within a day or two, so you have to default to the benign (removal) codes, unless you have pathology confirmation that the lesion is malignant.

    You should ensure that the physician signs off on the pathology of the lesion, even if it is benign. The physician needs to be the one to document the findings.

    Measuring total removal size: If you are reporting only the length of the lesion while choosing a removal code, you are selling the ED short. When determining the proper size of the excised lesion, the provider should add together the (greatest clinical) diameter of the lesion in addition to the size of the margins (required).


    Cpt 2011 Changes Affecting Your Podiatry Coding

    This year, CPT introduced over 200 new codes to help you code more accurately. The changes have affected several practices and your podiatry practice is no exception. For this practice, the big change focuses on two new codes to report diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity.

    Also, you will use various G codes while reporting diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity for a Medicare beneficiary this year.

    This time CPT introduces Code G0440 and G0441 which will put an end to the confusion providers put forth the different global periods for two tissue cultured skin substitute codes.

    This year, for your ultrasound coding, you will not use 76880 as this code has made way to two new codes - 76881 and 76882.

    A complete procedure (76881) includes real time scans of a specific joint that includes examination of the muscles, tendons, joint, other soft-tissue structures, and any identifiable abnormality. A limited study (76882) involves examining the extremity where a specific anatomic structure such as a tendon or muscle is assessed.

    Bear in mind that when the podiatrist carries out spectral and color Doppler evaluation of the extremities, you should use the proper code with 76881 or 76882. In the meantime, CPT has also revised and revalued codes for noninvasive physiologic studies of the upper or lower extremity arteries: 93922, 93923, 93923, 93924.

    And if you were confused about choosing between a debridement code and an active wound code, this year’s CPT saves the day by revising debridement code guidelines.

    Thursday, May 5, 2011

    CPT & ICD-9 guidelines to help your dysphagia evaluation and treatment

    With so many coding changes taking place at regular intervals, coding for your gastroenterology coding practice is never easy.

    You are constantly surrounded by tough coding situations and tough questions and answers. If you have queries on coding and reimbursement of dysphagia evaluation and treatment, here are some common concerns to help your understanding.

    There are six ICD-9 codes that you should use to diagnose dysphagia. ICD-9 codes that are commonly used by practices to provide an appropriate dysphagia diagnosis are 787.20, 787.21, 787.22, 787.23, 787.24, 787.29.

    Gastroenterologists should report 438.82 coupled with an additional code from the 787.20, "787.29 series for dysphagia due to the late effects of cerebrovascular disease. Reporting the combined ICD-9 codes should identify the specific type of dysphagia, if proper.

    As far as CPT codes for dysphagia-related services are concerned, you should report these codes: 92526, 92610, 92611, 92612, 92614, and 92616. But then for most gastroenterology practices, 92526 is the only choice while reporting treatments associated with dysphagia related to any of the upper throat mechanics, as per the National Government Services LCD.

    What’s more, the CCI prohibits combining 92526 with other CPTs when the focus of the treatment is for swallowing. For example, you should never use the 97xxx series of codes while billing for dysphagia treatment. Other codes that you will not be able to use with 92526 are 92511, 92520, 97032, 97110, 97112, 97150, 97530, 97532, among others.

    And what about restrictions CCI has imposed on dysphagia treatment codes? CCI edits on dysphagia-related services prevents billing the codes together or requires using modifier 59 to indicate that they are distinctly separate procedures.


    Details About Procedure And Location Can Help You Use Modifier 23 Right


    For Medicare purposes, modifiers are 2-digit codes added to procedure codes and/or HCPCS codes in order to provide additional information about the billed procedure. If you are thinking about appending modifier 23, you need to remember these key rules:

    Where did the service take place: You can add modifier 23 to many procedures that take place outside the OR if your doctor provides sufficient documentation.

    Radiology coding: Radiologists carry out an ever-growing range of procedures, many of which require anesthesia because of their invasive nature. But then they might also need anesthesia for MRI procedures, which cross to 01922.

    Cath lab: Even though technically part of the radiology department, the cath lab staff performs many involved procedures that could require anesthesia.

    Which special circumstances existed: Many procedures that qualify for modifier 23 do not require anesthesia normally. Documentation of medical necessity – by the anesthesia provider and requesting doctor will help justify modifier 23.

    What payer guidelines apply here: Take a look at your payer guidelines prior to submitting claims with modifier 23 to ensure you file right. Modifier 23 indicates a procedure which normally requires no anesthesia or local anesthesia, however because of unusual circumstances must be carried out under general anesthesia. The physician or CRNA must administer general anesthesia – not monitored anesthesia care (MAC) – for the procedure prior to qualifying for modifier 23.

    However remember that knowing the rules does not lead to automatic acceptance. Be ready to appeal any claims with modifier 23 with documentation of medical necessity. What’s more, include a letter of medical necessity from the patient’s primary care physician or surgeon to help boost your position.

    Dermatology Coding & Modifier 25

    Modifier 25 plays a vital role in your dermatology coding practice; as such you need to know the right way to wield this modifier.

    Many a time, you find yourself confused while using this modifier with modifier 57; it's a common point of confusion since both involve your dermatologist carrying out a procedure and distinct evaluation & management service for the same patient on the same day.

    The most noticeable distinction is that you would use modifier 25 for a distinct E/M with a minor procedure, and 57 for a distinct evaluation & management with a major follow-up procedure.

    You should only use modifier 25 with procedures that have a 0- or 10-day global period. These types of procedures are what Medicare defines as ‘minor'. In comparison, you will use modifier 57 for procedures with a 90-day global period. However note that some payers are now requesting modifier 57 on 10-day globals.

    Some coders look at modifier 25 as a magic wand and they always add a modifier 25 to evaluation & managements performed on the same day as a procedure since that's the only way they can get them paid. Don't follow this tip blindly and fall into that trap though! Any practice that applies modifier 25 indiscriminately to their E/Ms will be an outlier to other practices in the volume of claims billed with modifier 25 and will be sending up red flags.

    Also remember that proper modifier 25 does not call for a different diagnosis code. As a matter of fact, the presence of different diagnosis codes attached to the evaluation & management and the procedure doesn't support a reportable evaluation & management service.

    If you go to the CPT manual (Source CPT manual http://www.supercoder.com/cpt-codes/), you will find that the information about modifier 25 indicates that you don't have to have two different diagnoses codes to use this modifier.

    How it functions: The proof is in the documentation of the E/M coding. Your dermatologist's documentation should clearly establish that the visit's purpose was not to perform the procedure. If you meet denials on modifier 25 claims simply because you use the same diagnosis code for the evaluation & management and the procedure, you should appeal taking that your dermatologist's documentation supports reporting separate services.

    Wednesday, May 4, 2011

    What type of encounter qualifies for shared visit?

    Emergency medicine coding department that do not recognize every shared visit that the physician and qualified non-physician practitioner (NPP) provide are costing their emergency department a lot of money. If you are wondering what type of encounter qualifies for shared visit, read on and figure it out for yourself:

    In order to bill a visit as shared, the doctor has to carry out and document that he performed, a substantial part of the service. For instance, with an emergency department, evaluation & management service the physician needs to carry out and document that he had a clinically meaningful face to face encounter with the patient. If the doctor documents “that he was in the presence of the non-physician practitioner and agrees with his assessment, you cannot report a shared visit.

    Most importantly, a shared visit must include a documented face-to-face physician service. General oversight such as reviewing the medical record is not sufficient.

    What constitutes a face to face encounter has always been that the [physician] should do more than throwing back the curtain and asking if the patient is OK,'; nevertheless not to the extent of a resident /teaching physician note. The physician's comment on an element of the history, exam, decision making or course of treatment would be enough."

    Medicare Transmittal 1776 also incorporates state law in terms of the degree and extent of “supervision" that's required for the non physician practitioner.

    As such if you don't know what types of supervision rules your state has for doctors, be sure to check prior to coding shared visits.

    States differ widely in terms of whether the supervising doctor must be 'present' or 'sign' the record, it's believed that Medicare is stating that in addition to their specific requirements that the NPP must be supervised to the level required by the state.

    Strategies to Wrap up Your Orthopedic Coding Payments Every Time

    An orthopedist carries out several procedures during a knee arthroscopy on the same patient on the same day. Here, you will need to understand the multiple-scope rule to determine which procedures you can actually claim -- and get the payments for.

    Remember:

    In the orthopedic practice, the multiple-scope rule applies mainly to shoulder and knee procedures. But then it also affects those of the elbow, wrist and hip. In contrast, it does not apply to ankle or metacarpophalangeal (MCP) arthroscopy; and it doesn't have a say on arthroscopically-aided procedures. That apart, some surgical knee arthroscopies are excluded from the family.

    Here are some sure-success tips to seal your coding every time.




  • You must first know why and when the multiple-endoscopy rule applies before thinking about how to apply it. This rule is Medicare's method to avoid paying twice (or for that matter more for 'inclusive services by reimbursing only a part of any scope carried out at the same time as another scope of the same basic type.

    You should also include the 'base' procedure. For example, the physician has carried out a diagnostic shoulder arthroscopy (29805) in addition to shoulder arthroscopy for repair of SLAP lesion (29807). As such, how does the multiple-scope rule apply? Family codes always include the work involved in the base code while a surgical scope always includes the diagnostic scope of the same type. Here you would go for only 29807. And as far as diagnostic shoulder arthroscopy followed by arthroscopic limited debridement is concerned, you should once again report only the most extensive procedure. Here you should go for 29822.




  • Say for instance the surgeon carries out two scopes in the family, neither of which is the base procedure. Here you should go for both codes. Therefore, if your orthopedist carries out shoulder arthroscopy with foreign-body removal (29819) followed by shoulder arthroscopy for complete synovectomy, you would report both 29819 as well as 29821.

    Under the multiple-scope rule, Medicare will shell out the entire fee schedule amount only for the highest-valued scope in a given code family during the same operative session. Medicare carriers will pay for any additional scopes in the same family by subtracting the value of the base scope in that family and paying the difference.


  • Tuesday, May 3, 2011

    Separate education? Wind it off with modifier 59

    Here's a scenario: During an outpatient visit, an asthmatic patient is wheezing and having difficulty breathing, which requires one or more bronchodilator treatments for intervention: 493.01, 493.02, 493.21 or 493.22. The patient did not use his MDI devide, nebulizer and the like properly prior to the visit; as such he was given an education about the use if these devices post the treatment.

    Report it: At the outset, report 94640 apart from the proper evaluation & management code with a modifier, unless the payer calls for modifier 25 with the evaluation & management. After this code 94664 with modifier 59 (Distinct procedural service) as the patient needed additional instruction for his daily maintenance medication.

    This is contrary to the medication provided for immediate intervention – 94640.

    To put it in a nutshell, if the patient required separate education post getting an inhalation treatment on the same day, you'd bill both services – treatment as well as education – adding modifier 59 to 94664.

    Reasoning: The CCI places a level-one edit on 94640 and 94664.As such Medicare and payers that follow CCI edits may need modifier 59 on the component code (94664) to show that the teaching is a distinct procedural service from the inhalation treatment. It's key that the teaching was not part of the treatment for the patient, which would be one parallel encounter. It's key that the teaching wasn't part of the treatment for the patient, which would be one parallel encounter – teaching while treating. Remember in the example, the teaching took place separately after the patient got the treatment. You should break these services into two separate serial encounters, one after another.

    Easy dollars

    If payers wouldn't pay your 94664 claim, you'd require to support it with documentation indicating medical necessity to reimburse the approximately $16 national rate (0.47 relative value units multiplied by 2011 conversion factor of 33.9764). For example, you may need to state in the Plan of Treatment portion of the written record that the patient needs an educational session on the use of his MDI, diskus, nebulizer, etc. Apart from this, do not forget to note why the session is called for.

    Faqs to Bring You the Rightful Reimbursements for Your Hammertoe Coding

    Question: My payer does not recognize modifiers. What can I use in its place?

    You might require modifiers to help differentiate work on different areas of the feet or toes. But then it is not normal to have a carrier prohibit the use of toe modifiers, which run sequentially from TA (Left foot, great toe) and T1 (Left foot, second digit) to T9 (Right foot, fifth digit). To differentiate between toes operated on try using modifier 59. Also, you can go for modifier 59 in combination with the toe modifiers: Say for instance 28899-59-T3.

    Question: My patient broke his toe (a closed fracture) three days after I carried out a hammertoe correction on that toe (T7) and another toe on the same foot (T8). How should I report this?

    As there's no treatment for a broken toe, you could bill the office visit 9921x-24 (Unrelated E&M service by the same doctor during a post-operative period) and cover the ICD-9 code for a fractured toe, 826.0 (Fracture of one or more phalanges of foot, closed).

    Since I do not want to use the unlisted-procedure code, what other procedures are close enough to hammertoe to be billed as a hammertoe?

    You should think about reporting hammertoe code 28285 for the correction of claw toe or mallet toe.

    Question: So can I bill for removal of a K-wire?

    The answer is no. you may not bill the removal of a K-wire separately. It's bundled into the procedure. Reporting 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) wouldn't be proper too. If the pin is outside the skin, you cannot bill for it. But then if it needs to be removed because it has been cut and buried beneath the skin, go for 20680 and add modifier 78 which tells the insurance company it was necessary to do a second procedure on the patient.

    Is a tenotomy included in the hammertoe procedure?

    Well, yes, the tenotomy is included and it should not be billed for separately. But then if you look closely, at the present National Correct Coding Initiative edits only 28234 is listed as bundled into the procedure, not 28232. The flexor tenotomy procedure may be billed differently if a separate incision is used.

    Monday, May 2, 2011

    Easy bruising with no identifiable cause? Report 782.7

    If you are wondering what the ICD-9 code for easy bruising is, read on and find out for yourself.

    What's easy bruising?

    Easy bruising is a symptom of another condition rather than a standalone diagnosis. As such, the ICD-9 code depends on whether or not the family physician identified a cause. If you identify the cause, then code for the specific disease. But again if no cause is pinpointed, then report for the symptoms.

    How to report easy bruising?

    For easy bruising with no identifiable cause, report 782.7 (Spontaneous ecchymoses). An individual may be ailing from other diseases that predispose him to develop bruises even with minimal trauma (say for instance a light rap on the hands), which normally will not happen to normal people, thus resulting in "easy bruising." Diseases that could result in this include platelet or coagulation disorders (thrombocytopenias), bone marrow disorders, hemophilias, liver diseases, and Marfan's syndrome. Aging and medications (for instance aspirin, prednisone, and other nonsteroidal anti-inflammatory drugs) can also lead to easy bruising. For patients suffering from these conditions, bruises seem to appear spontaneously without any identifiable reason.

    What is ecchymosis, purpura and petechiae?

    An ecchymosis is a bruise larger than 1 cm. A bruise less than 1cm but not less than 3 mm is said to be a purpura. A bruise less than 3 mm is a petechiae. Code 782.7 applies also to petechia but not purpura, which has various other codes (287.0-287.9) depending on the etiology.

    Bruises from trauma can take place owing to a variety of reasons, including falls, accidents and post-surgeries. Normally, report codes 920-924 for bruises secondary to trauma. Say for instance a soccer player who was seen by a family pactice coding for bruises in the heel, report 924.20. Remember that as per ICD-9, these codes exclude contusions that are incidental to specific categories of injuries, like crushing injury, dislocation, fracture, internal injury, intracranial injury, nerve injury, and open wound.

    Learn Constitutes an Acceptable Signature

    If you want to get paid correctly, you'll need to ensure physicians and non-physician practitioners (NPP) sign your paper lab requisitions. But what exactly what does that require?

    The agency 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 match by complying with one of the following options:

    You need to ensure it's legible

    The simplest signature and most difficult 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 non-physician practitioners who have a legible signature and you most certainly won't want to stake your payment on it. This is when you need to turn to option 2.

    You should accept printed name with scribble

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

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

    Don't wait. Just do it. There's no doubt that getting referring physicians and non physician practitioners to comply with Medicare's new 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.