Wednesday, June 29, 2011

ASC Payments: These 5 Tips Will Make Your Derm ASC Coding A Snap

Check out the new 2011 payment rates for dermatology procedures performed in an ambulatory setting.

True or false: Modifier SG is required for all ambulatory surgical center (ASC) claims.

The answer is false for claims with dates of service after Jan. 1, 2008 -- and if you got that one right, you're on your way to ASC reimbursement bliss.

CMS has issued its latest quarterly update to the ASC Payment System, which includes HCPCS codes , modifiers, drugs and supplies that are payable for ASCs effective April 1.

With so many changes affecting ASCs every year, it's enough to make your head spin -- but despite all of the changes, some aspects of ASC reimbursement have remained the same. We've got the lowdown on how the ASC rules affect you.

1. Know where to find ASC-allowed services. CMS maintains a very specific list of codes payable for ASCs, but if you don't know how to access the list, you could be flying blind when it comes to reimbursement.

Resource: You can download the most recent ASC-allowable codes at www.cms.gov/ASCPayment/11_Addenda_Updates.asp, which includes not only the current quarter (which began on Jan. 1), but also any previous quarters in case you're battling older claims.

2. Remember the 'same-day global' rule. Every procedure the ASC bills has a "same-day" global period. This makes sense because the ASC is not reporting physician work services -- only facility fees. This applies to the coder working for the ASC, but not the physician who performed the service.

For instance, if a patient experiences postoperative bleeding after the repair of a superficial wound (12001-12018, Simple repair of superficial wounds …) and the physician must return the patient to the ASC for control of bleeding on the same day, both the physician's coder and the ASC's coder should report the appropriate control-of-bleeding code appended with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period) because the procedure occurred within the "same-day" global period for the ASC.

If, however, the physician returned the patient to the ASC the day after the initial surgery, the ASC coder would report the appropriate control-of-bleeding code with no modifier. For the ASC's purposes, the initial surgery's global period has expired, even though the surgery includes a 90-day global period for physician services. On the other hand, the surgeon's coder would report the bleeding-control code with modifier 78 appended because the physician's services follow the standard global rule.


Tuesday, June 14, 2011

99360 Is Certainly Payable If You Follow The Rules

Take a look at documentation of four areas prior to submitting claims. Also keep an anesthesia code crosswalk handy to assist you in your coding.

CPT's evaluation & management section includes only one code for standby time, however limited choices do not ensure payment. Here are four areas our experts suggest and do not leave your claims hanging in the wings.

You should code based on availability and not care

Your first step in gearing up to submit a claim for standby service is to know what you are reporting and what you are not. Code 99360 doesn't represent patient care, rather it represents availability.

You should document three key factors

Even though CPT includes a standby code, many payers don't reimburse for the service. Comprehensive documentation of your provider's service is key as you might be faced with an appeal. Here are three documentation tips you should heed to when coding 99360 for standby care.




  • Another doctor must request that your anesthesiologist make himself available for standby time. You need this request in writing along with justification for why the other physician requests anesthesia standby.
  • The chart should cover a note by the anesthesiologist documenting that his service might be necessary.
  • Know how about the anesthesiologist's involvement in the case.

    Check times and locations twice

    Being able to report standby service hinges on two more important factors: time and location.

    Your anesthesiologist must be in attendance for standby for at least 30 minutes - and he must document that time. According to CPT, if the time is less than half an hour, you do not report it separately. However, it is always a good idea to document patient care whether it is billable or not.

    Pay no attention to 99464 for your claims

    Some materials that teach about standby coding for labor and delivery (L&D) patients also mention 99464. Even though 99464 goes hand-in-hand with 99360, since it represents newborn care, you will not report 99464 as an anesthesia coder.

    Rationale: Anesthesia providers care for the mother and not the baby. The American Society of Anesthesiologists even has policies to this effect. One more provider should be available to offer neonate care, so 99464 applies to that professional.

    For further details on this and for other specialty-specific articles to assist your anesthesia coding, sign up for a good medical coding resource like TCI. Such a site comes with products like Anesthesia Analyst that comes with anesthesia code crosswalk to assist your coding.


  • Family practice coding & proper modifier 25 use

    You should stop omitting modifier 25 because of same day diagnosis.

    Recently, someone told me that we do not require different diagnosis codes to use modifier 25 for reporting an Evaluation & management service on the same date as a procedure. However, I have been told many times in the past by certified coders that when I bill more than a procedure that I need to add modifier 25 to the evaluation & management and point the primary diagnosis to the evaluation & management and point a secondary diagnosis to the other procedure. Can you help clear up my doubt?

    Answer: Proper modifier 25 use doesn't need a different diagnosis code. As a matter of fact, the presence of different diagnosis codes attached to the E/M and the procedure doesn't support a separately reportable E/M service.Your key to reporting the E/M service lies in whether your doctor carried out and documented work beyond what's considered to be part of the procedure.

    How if functions: The information about modifier 25 in the CPT manual distinctly indicates that you don't need to have two different diagnosis codes to use the modifier. As per the CPT manual description of modifier 25, the evaluation & management service may be prompted by the symptom or condition for which the procedure and/or service was provided. Therefore, different diagnoses are not required for reporting of the E/M services on the same date."

    Both CPT and Medicare rules will allow the same diagnosis for the evaluation & management service with modifier 25 and the procedure on the same day, and Medicare will pay for both with the same diagnosis, assuming both are reasonable and necessary and otherwise meet Medicare coverage criteria. The catch is that your physician's documentation should establish clearly that the evaluation & management involved work over and above that typically associated with the procedure done at the same encounter and that the encounter's sole intention was not to carry out the procedure. So if you get denials on modifier 25 claims just because you use the same diagnosis code for the Evaluation & management and the procedure, you should appeal, assuming your physician's documentation supports reporting separate services.

    Monday, June 13, 2011

    Ob-Gyn Coding: Ensure You've Got Well-Documented Adhesions Ob-Gyn Coding: Ensure You've Got Well-Documented Adhesions

    In a particular scenario, my ob-gyn carried out an "operative laparoscopy adhesiolysis, abdominal myomectomy." How should you report this?

    Well, to put it in other words, your ob-gyn carried out laparoscopic lysis of adhesions, then converted to an open myomectomy. For the laparoscopic lysis of adhesions, you should code 58660. In order to report this code, you should ensure that the type of adhesions your ob-gyn addressed is the kind that payers normally pay. If your ob-gyn doesn't describe the adhesions in the op report thoroughly, trying to report the lysis is a waste of your time and a line item on the claim form.

    You should either report 58140 or 58146 for the abdominal myomectomy.

    While listing the codes on your claim, list 58140 or 58146 first followed by the lysis code (58660). You do not require a separate procedure modifier since you will not find this code combination bundled in the National Correct Coding Initiative (NCCI).

    Heads up: See to it that you include V64.41 as a diagnosis for the open procedure in addition to the diagnosis for the surgery itself.

    Remember: If the ob-gyn intended to do a laparoscopic myomectomy and found adhesions but did not remove them laparoscopically, then converted to carry out the abdominal myomectomy, you should bill the myomectomy code (Increased procedural services) with modifier 22 (Increased procedural services) only. Payers will bundle the lysis in this situation.


    Tuesday, June 7, 2011

    Family practice coding: Which code for emphysema visit?

    Here's a family practice coding scenario: When an established patient with emphysema presents complaining of shortness of breath, which CPT code should you go for? The physician provides inhalation treatment, teaches the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity.

    Well, you'll require more than one CPT code for this encounter. Use 94640 to cover the all-encompassing service the physician provided.

    Since the doctor 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 require to add modifier 25 to 99213 to indicate that the evaluation & management service was significant and separately identifiable from 94640.

    Go for 94640 in place of 94664 as the physician's main intent was to treat the obstruction.

    A word of caution: If you bill 94664 with 94640 on the same day to Medicare, see to it that you justify that the doctor provided the 94664 service distinctly separate from the treatment. In this instance, add modifier 59 to 94664 to notify the payer that the FP carried out 94664 separate from 94640. The documentation should include details on the medical necessity for separately providing this service.

    Here's an instance: The doctor determined that the patient's plan of care should include 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 show that the doctor demonstrated the inhaler to the patient separate from the administration for treatment. Or else, the insurer may think you're trying to report one service twice.

    Note: even though it's technically not required, it may link separate diagnosis codes to the E/M and the nebulizer treatment. Say for instance, you could link 786.05 to 99213, and link the emphysema code (492.8, Other emphysema) to 94640.


    Pain management coding: does injury codes apply to pain?

    Here's pain management coding scenario to help your understanding: When can you report an acute injury ICD-9 code rather than a chronic injury code? We treat patients for generalized pain (not necessarily a recent injury) and are not sure what to code.

    Answer: When coding some conditions such as kidney disease (584.x and 585.x), you can many a time easily figure out when the patient's condition is chronic as the diagnosis codes differ based on the patient's lab results. However, coding for pain can be trickier.

    Say for instance your patient presents with shoulder pain, which came on slowly; that she says she had for some time. You think about 840.4; however it's from ICD-9's ‘injury' chapter. In this instance, the patient did not have an injury – in its place she had nine months of pain. As such, you should avoid 840.4 and choose another code based on the rest of your physician's documentation. You'd most likely look for notes pertaining to the patient's signs and/or symptoms, such as 719.41 of your provider has not determined what is causing the patient's shoulder pain and hasn't given a definitive diagnosis. And once a definitive diagnosis has been reached, you no longer code the symptoms.

    Here's why: Acute pain normally results from disease, surgery, inflammation or injury. The pain is immediate and normally of a short duration. By contrast, chronic pain typically persists beyond three to six months and can last from weeks to a lifetime. Chronic pain can originate with an initial trauma or injury; however continues beyond the time of normal healing. Many practices use the ‘three months or longer' guideline for coding chronic pain conditions versus acute problems. A definitive guideline hasn't been addressed by CMS, even though it has identified coverage of electrical stimulation for chronic wounds as longer than a month.

    Friday, June 3, 2011

    Pain management coding: Do injury codes apply to pain?

    You could be using the wrong code if you are not aware what differentiates an acute condition from a chronic one, or how many diagnosis codes you can report. Here's a common question to help your pain management coding (ICD-9).

    When can you report an acute injury ICD-9 code rather than a chronic injury code? We tend to patients for generalized pain (not necessarily a recent injury) and are not sure what to code.

    Answer: While coding some conditions like kidney disease (584.x and 585.x), often you can easily figure out when the patient's condition is chronic since the diagnosis codes differ based on the patient's lab results. However, coding for pain can be trickier.

    Here's an instance: Think that your patient presents with shoulder pain, which came on slowly, that she says she has had for the last nine months. You can think about 840.4; however it is from ICD-9's "injury" chapter. In this instance, the patient did not have an injury; in its place she had nine months of pain. As such, you should stay away from 840.4 and choose another code based on the rest of your physician's documentation. Most likely you'd look for notes pertaining to the patient's signs and/or symptoms, such as 719.41 if your provider hasn't determined what is causing the patient's shoulder pain and hasn't given a definitive diagnosis. Once a definitive diagnosis has been reached, you no longer need to code the symptoms.

    Here's why: Generally acute pain results from disease, surgery, inflammation, or injury. The pain happens to be immediate and normally short-lived. By comparison, chronic pain can originate with an initial trauma or injury however continues beyond the time for normal healing. Many practices use the ‘three months or longer' guideline for coding chronic pain conditions in comparison to acute problems. "A definitive guideline has not been addressed by Centers for Medicare & Medicaid; but it has identified coverage of electrical stimulation for chronic wounds as ‘longer than one month'.

    Bottom line: You should leave the determination of acute versus chronic to the physician. If an ICD-9 or CPT code compels you to differentiate between whether the patient's condition is acute or chronic, show both descriptors to the pain specialist and ask him to take a stance.

    ICD-9 includes code family 338.xx for acute and chronic pain diagnoses. However, as per Section 1.B.6 of the ICD-9 Guidelines, do not assign codes from category 338.xx if you don't have an "acute" or "chronic" distinction. The sole exception to this guideline lie with post-thoracotomy pain, postoperative pain, neoplasm related pain, or central pain syndrome. If acute or chronic is not specified, you need to look elsewhere for the code.




    00918 is primary anesthesia code for procedures 52352-52355


    However don't make it your automatic choice.

    While coding for your anesthesia practice, you may find yourself in various tight situations such as this: Say for instance you may find yourself asking: How should I code for anesthesia during a cystourethroscopy with lithotripsy for a diagnosis of kidney or ureteral stones?

    Answer: Well, the anesthesia code crosswal lists   00918 (anesthesia for transurethral procedures [including urethrocystoscopy]; with fragmentation, manipulation and/or removal of ureteral calculus) as the primary anesthesia code for procedures 52352-52355 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy …) however you should not make that your automatic choice.

    Notes below each code from 52352-52355 state that you should report 00862 (Anesthesia for extraperitoneal procedures in lower abdomen, inclusive of urinary tract; renal procedures, including upper one-third of ureter, or donor nephrectomy) when lithotripsy involves the kidney or upper one-third of the ureter. Owing to this ‘upper one-third' distinction, you will need a copy of the operative report to code properly.

    Many a medical coder gauge their condition by the stone's location. They submit 00910 (Anesthesia for transurethral procedures [including urethrocystoscopy]; not otherwise specified) for a bladder stone, 00918 for a ureter stone, and 00862 for a kidney stone.

    For more on this and for other specialty-specific articles to assist your anesthesia coding, sign up for a good coding resource like TCI. Onboard such a site, you can have access to the anesthesia analyst that provides you with anesthesia codes, tools, and resources you need for successful coding. It also comes with an anesthesia code crosswalk to help you choose the proper anesthesia code for each CPT procedure code in the record. Basically, the anesthesia crosswalk is a listing of CPT procedure codes and their corresponding anesthesia codes.