New modifiers? Stay alert!

Modifiers play a key role in your day to day coding life. As such, you stand a better chance of getting the payments if you are well-versed with everything relating to modifiers. As an orthopedic coder, you need to stay on top of all modifier changes which in turn will have an impact on your orthopedic coding practice.

In 2011, it's important that you are aware of a few just-in modifiers as well as some changes to the present CPT modifiers.

This year add several just-in modifiers to your coding armory and update the descriptors for various others you might use regularly. Say for instance, you can use modifier GU (Waiver of liability statement issued as required by payer policy, routine notice) for dates of service (DOS) January 1, 2011 and after that.

There may be times when it's proper to report modifier GU in place of the revised stamdby modifier GA (Waiver of liability statement on file; individual).

In addition, three existing CPT modifiers (Source CPT http://www.supercoder.com/cpt-codes) now cover non-physician providers in the descriptors, as follows:

Modifier 76 -- Repeat procedure or service by same physician or non-physician provider

Modifier 77 -- Repeat procedure or service by another physician or NPP

Modifier 78 -- Unplanned return to the operating/procedure room by the same doctor or NPP following initial procedure for a related procedure during the postoperative period).

Modifier 78 -- Unplanned return to the operating/procedure room by the same physician or NPP following initial procedure for a related procedure during the postoperative period).

In earlier years, some payers did not allow non-physician providers to report their services with these modifiers as they purposely addressed “physician" care. If you update the descriptors, it should be much easier for you to report situations represented by modifiers 76, 77, or 78 to your payers.

Report Appendectomy Separately Depending On What The Situation Demands

So you think appendectomy always comes bundled with other procedures. If so, you need to think again. You can report appendectomy separately depending on what the situation demands. If you miss your appendectomy codes, you could be losing your deserved payments.


Many people are of the false notion that skipping appendectomy codes has no bearing. Whereas the fact is if you fail to report 44955 when the situation demands, you would be costing your practice $83.58 (2.46 relative value unit times the 2011 conversion factor of $33.9764).


Familiarize yourself with these two requirements for separate appendectomy:


a) Your surgeon clearly documented a problem with the appendix


b) Other procedures during the same session do not relate directly to the right colon. When your gastroenterologist carries out a medically necessary appendectomy at the same time as another procedure, you would use +44955 (reported in addition to the primary procedure performed).



Using 44955 follows that you code a diagnosis to prove that the procedure was medically necessary.


Clue: If you cannot find an appropriate diagnosis code to support 44955, there are chances that the removal wasn't required because of immediate health concerns, and you shouldn't be separately reporting the appendectomy after all. Your answer to supplying a separate ICD-9 for 44955 lies in the CPT's descriptor, which includes the phrase “indicated purpose. This means that there must be a separate, medically necessary diagnosis or signs and symptoms to justify the appendectomy.


Here's an example: The patient has a gallbladder problem, and while carrying out the gallbladder removal, the surgeon finds acute appendicitis as well; as such he carries out an appendectomy. In this instance, you should use 44955 as well as the cholecystectomy. (for instance 47562, Laparoscopy, surgical; cholecystectomy). Also, you should bill 540.9 (Acute appendicitis without mention of peritonitis) to support your claim.


Physician's notes suggest you should scoop up info from path report


Also, you can take a look at the applicable signs and symptoms or the pathology report to verify your diagnosis code(s). See to it that your codes are supported by both your physician's documentation and your path report.


Even if the pathology report turns out to be negative for appendicitis, you can still report 44955 as long as the physician's documentation clearly states the reason he is removing the appendix.

93970: Global Period A Factor for Evaluation & Management Coding

The question here is whether you can bill a bilateral scan (93970) along with an office visit and get paid for both. Also, would you need to use modifier 25 on the office visit?

Well, you may report an evaluation & management service and 93970 (Duplex scan of extremity veins together with responses to compression and other maneuvers; entire bilateral study) on the same claim. Whether you need to add modifier 25 (Significant, separately identifiable evaluation & management service by the same doctor on the same day of the procedure or other service) may depend on your payer.

Details: As per the Medicare physician fee schedule, the global period for 93970 is XXX. According to Medicare's Correct Coding Initiative (CCI) manual, chapter 1, section D, if you have a truly separate evaluation & management, you may report it on the same day as a XXX procedure. The manual further says that you should add modifier 25 to the evaluation & management code. (As we said above, different payers may have different requirements for use of modifier 25, more so since you won't find evaluation & management codes bundled with 93970 in the listed CCI edit pairs.)

Note of caution: The CCI manual sets out the following rules:

You shouldn't report a separate evaluation & management code for the usual pre-, intra-, and post-procedure work expected from a physician for the given XXX procedure.

You shouldn't report a separate evaluation & management code to represent physician supervisor or interpretation of another provider's performance of a XXX procedure that has no physician work relative value units (RVUs).


Bonus tip: If both bilateral upper and lower studies are carried out on the same date and/or session, report 93970 twice and modifier 59 (Distinct procedural service) to one of the codes.

Resource: Take a look at the CCI manual online at www.cms.gov/NationalCorrectCodInitEd/.

77071: A Small Status-Indicator Change Could Cost You $46 Per Claim

You never know what every new quarter will unfold as far as Medicare updates are concerned. This month you need to ensure your practice is up to speed on physician fee schedule news.

New: The bilateral surgery indicator for 77071 (Manual application of stress carried out by doctor for joint radiography, including contralateral joint if indicated) has changed from three (The usual payment adjustment for bilateral procedures does not apply) to 2 (150 percent payment adjustment does not apply).

While the effective date is January 1, the implementation date is April 4, 2011. This means that the changes are retroactive to January 1 this year. But then your carrier's deadline for implementing the changes is April 4.

Previous way: '3'offered payment for two sides

77071 used to have a bilateral indicator of 3. As per the Medicare Physician Fee schedule, a bilateral surgery indicator of three basically means that when you code the procedure as bilateral, the carrier will pay you separately for each side.

Indicator three rule: When you code both sides on the same date, Medicare will base the payment for each side on whichever is lower -- the actual charge for each side or 100 percent of the fee schedule sum for each side. The rule holds true regardless of how you report the bilateral service. (say for instance using modifier 50 (Bilateral procedure), modifiers RT and LT or two units.

What's more, Medicare's policy for the three indicator is: "If the procedure is reported as a bilateral procedure and with other procedure codes on the same day, figure out the fee schedule amount for a bilateral procedure prior to applying any multiple rules.

Just-in way: '2'tells you 1 code includes Bilateral Service

Since code 77071 now has a 2 bilateral indicator, you will need to be sure your reimbursement expectations are in line with the official fee schedule.

Indicator 2 rule: When the agency labels a code with a 2 bilateral indicator, relative value units are already based on the procedure being carried out as a bilateral procedure, as per fee schedule documentation.

Consequently, if you report the procedure a couple of times on the same date, Medicare will base payment on the lower of:

The actual fee for both sides

Or 100 percent of the fee schedule (source for fee schedule http://www.supercoder.com/coding-tools/fee-schedules ) amount for a single code.

Impact of the change: This could be a big drop for practices that were collecting twice the reimbursement and now will get no payment adjustment. But then since the descriptor refers to inclusion of the contralateral joint, it would be difficult to dispute the fact that the code is inherently bilateral.

Good tidings: Although the change is retroactive to January 1, Medicare is not requiring contractors to search their files to adjust claims they have paid already. But then contractors will adjust claims if you bring them to their notice.

Internal Medicine Coding: Friction Burns Are Still Considered Burns

In a particular scenario, a patient presented with multiple friction burns from a treadmill. He had partial thickness friction burns on one hand, both ankles, and one foot. He had a full thickness friction burn to down to the fascia on two of his fingers. The internist cleaned all burns with surclens and debrided the loose skin, applied silvadene, and used gauze and dressings to all burn areas.

Here you will need to calculate the total body surface area (TBSA) affected by the burns (based on the documentation) to code properly. The two possibilities for for the partial thickness burns are 16020 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; small [less than 5 percent total body surface area]) or 16025 (… medium {example whole face or whole extremity, or five percent to 10 percent total body surface area]).


Often full-thickness burns require skin grafting. If that is the situation with this patient, the intern will refer the patient to a surgeon for definitive treatment. In the meantime, he might complete temporary debridement and dressing, however 16020 and 16025 include that care. If the burns weren't serious enough to call for grafting, however, include the burns to the fingers in your calculations with 16020 or 16025.

Here's what you need to do: When the patient returns for a check-up, you will turn to the same group of codes. Remember that the specific codes might change owing to TBSA, depending on how much healing has occurred. These codes have a zero day global period associated with them, allowing for repeat billing of the services for follow-up visits.

CCI 17.1: Include injections in DLEK & DSEK coding

So does your ophthalmology practice bill for anesthesia injections along with endothelial keratoplasty (EK) procedures? If so, with effect from April 1 this year, you need to think before you code, as per CCI 17.1.

Non-mutually exclusive (NME) edits apply to services that a doctor might carry out during the same care session however that are not billable together. This is because one of the codes (the Column 2 or component code) is included in the services represented by the Column 1 (comprehensive) code of the pairing. You can bill individual components if the doctor doesn't carry out the whole comprehensive procedure.

However if the doctor carries out the entire (comprehensive) procedure, you need to bill the comprehensive code in place of the individual parts or components.

Bundle anesthetic agent injections into EK code

CCI adds several new bundled codes. Now code 65756 (Keratoplasty [corneal transplant]; endothelial?) includes almost all of the “Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic" codes (64400-64530). CCI marks most of these bundles with modifier indicator “0', which prevents you from reporting the bundled codes separately under any circumstances, even with a proper modifier.

Apart from these, the latest CCI also bundles codes such as 36400-36406, 36420-36425 into 65756:

Watch for Aqueous Drainage Bundles

The latest edits also declares CPT codes 66170, 66172, and 66180 mutually exclusive with 0253T. CCI had already declared 66170, 66172, and 66180 to be mutually exclusive with similar CPT Category III (temporary) codes 0191T and 0192T.

Anterior segment aqueous drainage devices (say for instance the iStent Trabecular Micro-Bypass Stent) inserted internally or externally without an extraocular reservoir are a new treatment many ophthalmologists are utilizing as a method to reduce intraocular pressure for the treatment of glaucoma. But then many insurers take these devices investigational and not medically necessary.

For your information: According to Frank Cohen, MPA, MBB, senior analyst for The Frank Cohen Group in Clearwater, Fla., CCI 17. 1 has 709,527 active edit pairs. For the latest on this, go to www.cms.gov to ensure you correctly report procedures.

ICD-10: For Sensorineural Hearing Loss, exercise H code use

How would you go about second-time diagnostic analysis?

The most frequent diagnosis for cochlear implant patients is 389.10 (Sensorineural hearing loss, unspecified). This condition is normally due to lesions of the cochlea and the auditory division of the eighth cranial nerve. When ICD-9 switches to ICD-10 in October 1, 2013, you will have to shift to coding sensorineural hearing loss using the code H90.5 (Unspecified sensorineural hearing loss).

ICD-10 difference: You would not have to make any adjustment to change to the ICD-10 code as the conversion will offer no difference in the code's function. Also, you should notice that 389.10 and H90.5 have the same descriptors.

Otolaryngology coding tips: Think that a patient had cochlear implant surgery, and your otolaryngologist carried out diagnostic analysis. But then this first surgery failed, and the patient underwent a second surgery. You should go for the second round of diagnostic analysis with the same CPT codes you must have used to report the first one: 92601-92604 (Diagnostic analysis of cochlear implant ...).

You can either attach 389.10 or 389.18 (Sensorineural hearing loss of combined types) to the procedure code to describe the fitting diagnosis for bilateral sensorineural hearing impairment.

CI patients normally require analysis within six weeks postoperatively for the initial fitting. The patient goes back periodically during the first year for adjustments to the processor's stimulus parameters to figure out the signals going to surgically implanted electrodes in the cochlea.

E/M Coding: Learn The Importance Of The Eight-Hour Rule

Clue: Don't use discharge code 99217 in all observation situations.

Oftentimes, deciding on what observation code to use can be a challenge, more so because you have to look into two sets of this type. While one set (99234-99236) pertains to the care provided on a single calendar date, another set concerns care that spans two calendar dates (99218-99220).

Figure out the criteria for observation codes' use for physician services by looking closely into these three fallacies.

Fallacy 1: Observation services support extended inpatient care

You'd want to ensure –first and foremost – that the service is carried out by your gastroenterology qualifies as an observation. The doctor should opt for observation services to potentially prevent a lengthy inpatient admission. For example, an observation status is proper when:

The encounter lacks diagnostic certainty, where a more spot on diagnosis could decide admission or discharge.

The patient's condition calls for extensive therapy in order to possibly be abated.

Fallacy 2: Document, one more paperwork

The doctor's notes on the encounter would tell you how many calendar days the observation service lasted.

Consider the previous scenario: Say for instance the gastroenterologist admits the patient to observation at 9 p.m. on Wednesday. The doctor orders blood tests to check the patient's enzyme levels and performs a hydrogen breath test (91065, Breath hydrogen test [e.g., for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit]) in order to check for any traces of bacterial overgrowth. The consequences of both tests turn out normal. For monitoring, the doctor keeps the patient overnight. Her notes point to a level two observation.

You would report the Wednesday services with 99219. 99219. What's more, another key component of coding multi-calendar date observation codes is reporting 99217 on the date of discharge service. Connect 789.00 and 787.01 to both CPTs to describe the patient's symptoms.

Report 99218-99220 for all the care rendered by the admitting physician on the date the patient was admitted to observation.

For the documentation requirements, the CMS Claims Processing Manual points out that a doctor can bill the initial observation care codes, provided he completes a medical observation record for the patient. This record should have dated and timed admitting orders of the physician, and reflect the care the patient gets while in observation, nursing notes, and progress notes arranged by the physician while the patient was in observation status.


Fallacy 3: Same-day observation codes require a discharge code

How about your gastroenterologist admits a patient to observation status and discharges him on the same calendar date? Then you would code 99234-99236. In this case, you would not have to code the 99217 discharge code. CPT allows the use of 99217 “if the discharge is on other than the initial date of ‘observation status'," as mentioned on the code's descriptor.

Same-day observation services 99234-99236 include documenting the time of the visit in hours (with a minimum of eight hours documented on the same calendar date, also referred to as the eight-hour rule).

Otolaryngolology coding : Four FAQs to help your Cochlear Implant Coding

Find out why physicians have limited use of available CPT codes

While reporting for audiologist's services, do not forget that Medicare prohibits audiologists from billing for treatment services. They're allowed to bill for diagnostic services only. But then otolaryngologists may bill for therapeutic services. For cochlear implant services, CPT manual lists 10 codes.

Do not rack your brains as yet. Thankfully you have ways to work within this guideline. Take a look at these FAQs and get to know how you should tackle that claim for hearing loss treatment.

What CPT codes do I have in my cache?

CPT lists 10 codes which you may use for cochlear implant services: 92506, 92507, 92601, 92602, 92603, 92604, 92626, 92627, 92630, 92633.

Once more, Medicare limits coverage of an audiologist's services to diagnostic testing only. What's more, speech language pathologists (SLPs) may only use 92506, 92507 and 92508 (Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals) for treatment services, including auditory rehabilitation, according to Medicare. This means that Medicare will not pay audiologists when they code 92506, 92507, or 92508. On the contrary, think of 92507 as an "umbrella" code that covers everything SLPs do. The otolaryngologist can report any of these codes.

What choices do I have besides 92507?

Depending on the type of cochlear implant service rendered by your doctor, you can check out using any of the 10 codes listed previously. For example, if the service involves cochlear implant fitting and programming, you would bill 92603 for patients older than seven years; 92601 for patients seven years and younger.

HCPCS' L codes (source for HCPCS Codes http://www.supercoder.com/hcpcs-codes-range ) too have a role to play for cochlear implant supplies. You'd report L8619 (Cochlear implant external speech processor and controller, integrated system, replacement) to code replacement, and L7500 (Repair of prosthetic device, hourly rate [excludes V5335 repair of oral or laryngeal prosthesis or artificial larynx]) to report repair services.

Key: Ensure you contact he payers to check which CPTs/HCPCS they will accept. Doing so could save you time in waiting for your payment.

What Medicare official directive should I refer to?

Medicare's specific policy on cochlear implant services appears on an article in MLN Matters, a publication of the CMS Medicare Learning Network, and describes Medicare coverage for CI services that became effective April 4, 2005.

As per the article, CMS will cover treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss for individuals with hearing test scores equal to or less than 40 percent correct in the best aided listening condition on tape-recorded tests of open-set sentence recognition...in addition, the agency will cover cochlear implants of individuals with open-set sentence recognition test scores of greater than 40 percent to less than or equal to 60 percent correct, where the device was implanted in an acceptable clinical trial/study."

Do private payers follow Medicare rule?

Well some do, while others don't. Nevertheless, each patient's health plan has a specific policy regarding coverage that may differ from the others. Irrespective of the general policy of the health insurance carrier, you should check out the patient's contract to determine coverage.

You should also note that some states mandate cochlear implant (CI) coverage.

Anesthesia Coding: Convert To Units for Reporting More Minutes

While billing for code 01967, sometimes the time is over 999 minutes. In one instance, the time was 1,080 minutes. As such, may I bill the anesthesia as: 01967 (900 minutes in the units field) plus 01967 (180 minutes in the units field), or should I report it some other way?

Answer: Well, knowing how to handle multiple-digit units can be tough. Most payers that accept claims electronically can accept a maximum of three digits in the time field. By comparison, some payers that only accept paper claims and do not accept electronic claims (such as some workers comp or auto injury payers) scan in only two digits in the units field on your claim.

However this limitation shouldn't present a problem in your case.

Here's why: For 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery [this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]), you should fill the units field with time units, and not minutes. Your listed units should show how many minutes is equal to one unit.

Taking in your case 15 minutes equals one time unit, 900 minutes is equivalent to 60 time units (or 15 hours multiplied by four time units per hour). Just the same, the 180 minutes would equal 12 time units. That is a total of 72 minutes time units which will fit into your two- or three-digit field.

Bonus tip: Some insurance companies may need you to report time. If software limitations keep you from reporting the proper time rather than report 01967 twice with the time divided between two lines, you could drop the claim to paper and hand-correct it, attaching a copy of the report to validate the time.

For your information: Keep an eye on your carriers. Many cap the anesthesiologist's labor at a level provided. You can find that information in their anesthesia policies by either looking online or contacting them directly.

For post-op disease counseling, consider V58.42

There is this patient with a prostate cancer diagnosis who had an office visit during the post op period to discuss treatment options (not for surgical follow up). So can I bill for this office visit during the global period, and what diagnosis code should I use to indicate that the service was unrelated to surgery?

Well, yes you can separately bill an office visit for treatment counseling during the post-op period. You should report the underlying diagnosis -- 185 (Malignant neoplasm of prostate).

The global package doesn't not include treatment directed at the underlying disease process even for the most conservative payers such as Medicare.

The Claims Processing Manual (Internet only manual 100-04) section 40.1B lists "treatment for the underlying condition or an added course of treatment which isn't part of normal recovery from surgery" as a service not covered in the global surgical package.

Keep in mind: Add modifier 24 (Unrelated E&M service by the same doctor during a postoperative period) to your evaluation & management visit to indicate that this visit is unrelated to the surgical procedure. This'll guarantee payment for the office visit within the global period of the surgery.

Counseling on treatment choices and prognosis is not normal recovery from surgery, however is care directed at the underlying disease process.

Check diagnosis: Some payers might warrant an additional diagnosis to further support the reason for the encounter. For example, V58.42 (Aftercare following surgery for neoplasm), V58.76 (Aftercare following surgery of the genitourinary system, NEC), or V65.8 (Other reasons for seeking consultation) might help establish the separate nature of the encounter. Get in touch with your major payers and see how they want you to report these services so that you can get paid for proper additional services during the global period.

Differentiate facility's documentation rules from surgeon's report

You should concentrate on your physician's thorough note.

Here's a myth: When your surgeon carries out surgery in a hospital, you should make it a point to coordinate your coding with the hospital's records.

Reality check: Even though that rule is smart for surgeries carried out in ambulatory surgical centers (ASCs), it is not true for facility-based surgeries. When it  comes to surgery coding for your surgeon's work, remain glued to your to your physician's documentation as a guide regarding what to report, and do not stress about what the facility documents.

A lowdown: The facility is governed by a different set of rules than the office-based surgical coder.

Facility regs: The Joint Commission wants an immediate post-op note written after the surgery. The facility can bill from this as they are billing a different ‘type' of service. They're billing for essentially the room, the staff, the equipment, and the like. In fact, you can get the Joint Commission's documentation rules right here: http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=215&StandardsFAQChapterId=13.

What constitutes immediate: As per the Joint Commission, the operative report must be written or dictated "immediately after an operative or other high risk procedure," and defines "immediately after surgery" as "upon completion of surgery, prior to the patient is transferred to the next level of care."

Physician regs: The surgeon's chart will cover detailed documentation based on the specifics of the surgery that she carried out and documented. It must be thorough and contain all the required elements about equipment count, sedation, pre- and post-op diagnoses, indications, description of the procedure, attestations, signature, and the like. The coder can then assign a proper service code to the description the doctor provides.

Bottom line: You should choose the proper code from the surgeon's documentation instead of waiting to coordinate with the hospital. If the notes are not thorough, take it up with the physician directly.

Updated your 2011 CPT Modifier Options? If not, do it now!

A general surgery coder asked, "We read lots of information about CPT 2011 code changes, however are there any modifier changes we should be aware of?

In 2011, it is important to know about a few new modifiers, as well as some revisions to existing CPT modifiers. For instance, three existing CPT modifiers now include non-physician providers in the descriptors as here:

76 -- Repeat procedure or service by same physician or non-physician provider

77 -- Repeat procedure or service by another physician or non-physician provider

78 -- Unplanned return to the operating/procedure room by the same physician or non-physician provider following initial procedure for a related procedure during the postoperative period).

Earlier, some payers did not allow non-physician providers to report their services with these modifiers because they specifically addressed "physician" care. Updating the descriptors should make it easier for you to code situations represented by modifiers 76, 77, or 78 to your payers.

Apart from this, CPT introduced modifier 33 (Preventive service), which allows you to tell your payer that you performed a preventive service and that the patient's deductible and coinsurance do not apply under the new PPACA (Patient Protection and Affordable Care Act) rules.

Surgical practices that carry out colonoscopies should know about new modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure). Make use of this modifier when the surgeon converts a screening test to a diagnostic service.

Just-in ABN modifier: You have a just-in modifier GU (Waiver of liability statement issued as required by payer policy, routine notice) to use in some instances when you shouldn't use the revised modifier GA (Waiver of liability statement on file; individual) for ABNs. Medicare has not yet provided instructions for correctly reporting modifier GU; however look out for updates and other specialty-specific articles to assist your general surgery coding. , sign up for a good medical coding resource like Coding Institute.

Gasteroenterology coding:74270 is for barium enema as well as water-soluble contrast

Recently, my gastroenterologist ordered barium enema for a four-year old male patient with a history of encopresis and constipation. Therefore, I am billing the procedure for my radiologist. How should you report the procedure if the radiologist writes the following text in her notes:

Technique: A single frontal scout radiograph of the abdomen was carried out. A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed through spot fluoroscopic images. A post-evacuation overhead radiograph of the abdomen was carried out.

Findings: The scout radiograph demonstrates a non-obstructive gastrointestinal pattern. There're no suspicious calcifications seen or evidence of gross free intraperitoneal air. The visualized lung bases and osseous structures are within normal limits.

Throughout its course, the rectum and colon is of normal caliber. There's no evidence of obstruction, as contrast is seen to flow without trouble into the right colon and cecum. A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image. There is also opacification of a normal-appearing appendix documented.

Answer: You should report this as a commonly performed barium enema: 74270 (Radiologic examination, colon; contrast [example, barium enema, with or without KUB]).

Medical coding tip: Even though you will normally see barium or barium and air enemas, some doctors may instead choose a water-soluble solution that includes iodine. For instance if the physician suspects perforation of the colon, he will choose a water-soluble contrast solution. For instance, if the physician suspects perforation of the colon, he will choose a water-soluble contrast solution. Do not limit your 74270 coding to barium; you'll use this code for a different kind of contrast agent that your gastroenterologist may use.

That apart, you should bill 99212(Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:

A problem focused history, A problem focused exam, Straightforward medical decision making(MDE). Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's requirements. Normally, the presenting problem[s] are self limited or minor. Doctors normally spend 10 minutes in person with the patient and/or family.) to report the evaluation & management service that your gastroenterologist carried out.

For ICD-9, you would have to report the following:

787.6 -- Incontinence of feces

564.00 -- Unspecified constipation.

Cardiology coding: No Medicare pay for 99360

My physicians stand by for the cardiologist during a pacemaker placement case they need to place epicardial leads. They want to code for their time, and I’ve found code 99360 for this. Is it necessary that they dictate something so that I can charge for this?

CMS and many other payers do not pay for 99360 (Physician standby service, requiring prolonged physician attendance [face-to face] without direct patient contact, each 30 minutes [example., operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG]), so that the doctor may not be able to charge for standby time.

If a third party payer does reimburse for 99360, then see to it that the doctor has documented the standby service with something like: I was requested by [DOCTOR’S NAME] to be on standby for the pacemaker implant performed on [PATIENT’S NAME] on [DATE]. I reached the operating room at [ARRIVAL TIME] and departed at [DEPARTURE TIME].

Remember: When standby care is requested, both the requesting physician and providing physician must document the need for standby care irrespective of whether a claim for reimbursement is submitted.

If you submit a claim, see to it that you follow the CPT guidelines for 99360 , which include:

One more doctor must document in writing the request for the standby service.

The standby doctor must not provide care to other patients during the standby period.

The standby doctor shouldn’t submit 99360 for any service of less than 30 minutes total on that DOS. You may report an additional unit of 99360 for each additional 30 minutes, which means another full 30 minutes of standby service.

Tip: If the doctor is called upon during the procedure to place epicardial leads, you should report the code for the service provided rather than reporting 99360.

Report 44180 with unlisted code 58999

Here's a procedure that my ob-gyn documented: Excision granulation tissue vaginal cuff. Laparoscopy, extensive lysis of adhesions of the sigmoid colon to posterior cul-de-sac. Scissors used to cut it. Uterosacral stitch (out of peritoneum). Inspection pointed to connection of the granulation tissue through the vagina into peritoneum. All granulation tissue was removed from vagina along with inflammation and what appeared to be reaction to stitch. As such, how should I go about this particular ob-gyn coding scenario?

Well, you should report the lysis of adhesions with 44180 (Laparoscopy, surgical, enterolysis [freeing of intestinal adhesion] [separate procedure]) and the removal of the granulation from the vaginal cuff (performed vaginally) as 58999 (Unlisted procedure, female genital system [nonobstetrical]).

While reporting an unlisted procedure code, you have to let the payer know how to judge that your charge is reasonable based on the physician work.

Better still: In order to set your fee, check with your surgeon to see what procedure he would like to compare this work to. Also, you should let the payer know an equivalent of the approximate amount of work. In order to do this, review your physician's to note how the ob-gyn removed the granulation tissue.

If done by chemical cautery, you might compare the work to 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]). If done by destruction, say for instance by using a laser, by cryocautery you might compare the work to 57061 (Destruction of vaginal lesions[s]; simple [for instance, laser surgery, electrosurgery, cryosurgery, chemosurgery]) or 57065 (Destruction of vaginal lesion[s]; extensive [for instance, laser surgery, electrosurgery, cryosurgery, chemosurgery]). If he debrided the area, you might look to 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if carried out]; first 20 sq cm or less), and if he excised the tissue, you would have to know the level of the area removed and take a look at 11440-11446 (Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane ...) as a contrast, as the vaginal canal would be consistent with a mucus membrane.

Do not bother trying to code for the stitch removal as since this service seems to be part of the adhesions involvement.

66984: Coordinate with surgeon to ensure proper payments

Clue: Take a look at the original coding before you report 366.10 every time.

When more than one physician is involved in a patient's cataract care, see to it that diagnosis and procedure codes match up or you will land a denial. Here are two pointers to help you get your payments for cataract comanagement on time.

Tip 1: Match codes to stay away from denials

The number one reason for cataract co-management denials is the OD reporting a different diagnosis code than the ophthalmologist. According to experts, if the code does match up, one of those physicians is going to be denied.


Here's what to do: Stay away from across-the-board use of 366.10 (Senile cataract, unspecified) and retrieve the precise diagnosis code from the ophthalmologist prior to sending out a claim.

Here's an instance: If the ophthalmologist makes use of 366.13 (Anterior subcapsular polar senile cataract), the optometrist should use 366.13.

Try this: The same applies to matching the surgical CPT code you both are reporting. While 66984 applies to the majority of cataract patients, once in a while the procedure will be difficult and the surgeon will report 66982.

Good news: Since 66982 has a higher relative value than 66984, the postoperative care also will reimburse the OD at a higher level.

See to it that you append modifier 55 (Postoperative management only) to either 66984 (source 66984 http://www.supercoder.com/cpt-codes/66984 ) or 66982 to represent the post-op services you have provided accurately.

Good idea: Insert a note on the claim form explaining that any documentation required is available upon request. Many practices have used this technique successfully to stay away from denials.

Tip 2: Gather accurate fees with surgeon's input

Yet another common co-management billing error is turning a blind eye to changes in the surgeon's fee structure. It is important to stay in the loop when the ophthalmologist increases her fees so you can earn the entire 20 percent of the Medicare allowable to which you're entitled for postoperative care.

However: That would only apply if the surgeon was charging less than the Medicare allowable, which is not likely.

Remember: Many a time, the surgeon will provide initial postoperative care prior to transferring the patient to the OD. In this situation, it is important to coordinate on the number of days each physician is providing care and enter those numbers on separate claim forms.

Keep a look out for: Does the surgeon keep each patient the same number of days prior to referring back to you? That may bring the attention from insurers. If the surgeon always sends the patient back to you after the one-week visit, payers may suspect you have a deal with that surgeon.

In order to figure the split, first calculate 20 percent of the overall charge for the service. After this, divide that total by 90, which is the cataract postoperative global period. This provides you the per-day value of the postoperative management service. In the units field, write in the number of days of service your OD provides, which, multiplied by the per-day rate described above, will yield your total charge for the service.

Tip: The OD can suppose care on the day after the patient is last seen by the surgeon.

Find your share: Call the surgeon after you see the patient to find out if she's filing for postoperative care and, if so, how many days she'll report, so you can bill for the balance. This is also a good time to remind that office to include modifier 54 on its claim form – or else you run the risk of the payer denying your co-management claim.

Try this: If the surgeon is not already using a postoperative form that covers all the bases, offer to help design one. A good form could show the surgery date, which eye the surgeon treated (if not both), the surgeon's postoperative care dates, as well as the number of days that represents. What's more, the form could indicate the date the OD assumed care, the initial refraction, and the resultant acuities. E-mail or fax this completed form back to the surgeon to share the record of the patient's continuing care.

Pathology coding: Do not miss pay for second flu testing

So which code for influenza – A or B? If your lab test aids you in answering the A/B question, you might be able to report two units of the test code. Watch out: Missing the second test could cost your lab up to $27 in lost revenue.

Here are some tips that can help you get your flu coding on course to get all the pay you deserve:

Code 87400 for 'Each'

If your lab carries out a test that looks for influenza A or B antigens using enzyme immunoassay (EIA) technique, you should report 87400. The specimen source for this test may include blood, nasopharyngeal wash, throat swab, or sputum for that matter.

Irrespective of whether positive or negative, if the EIA antigen test involves results for A and for B, you should list 87400 x 2.

Word of caution: If the EIA provides a qualitative determination for influenza A and B however does not differentiate between the two strains, you should not code 87400. For example, ZymeTx Zstatflu gives a positive reading in the presence of A or B antigens, with no distinction.

Try this: In its place, you should report the test using unspecified code 87449.

87804 Warrants two

For an influenza test that uses an immunoassay leading to an observable result, say for instance a color change, you should report 87804. For a test that doesn't identify the influenza strain -- one that involves a single positive or negative result for influenza -- report one unit of 87804.

Opportunity: The 87804 definition does not specify 'each' for influenza A and B; however you may be able to bill for both.


If you use a test differentiates between influenza A and B and you document both results, you should code 87804 twice.

You may figure out differences in how payers want you to report multiple units of 87804. Take a look at how to decide which method to use:


Best practice: If the payer allows it, report two units of 87804. Many MACs allow you to report 87804 x 2, since the MUEs limits you to two units of 87804.

For payers that deny the second 87804 charge as a duplicate, add modifier 59 on the second 87804 entry. According to the May 2009 CPT Assistant, you should use modifier 59 when separate results are reported for different species or strains that are described by the same CPT code.

Fallback technique: In some rare instances, such as certain state Medicaid providers, your payer may tell you to use modifier 91 on the second listing of 87804.

Report 87254 per virus strain

Labs may carry out a rapid culture and direct antigen test to distinguish type A and B influenza. Often doctors order this test since it provides a quick response and high sensitivity.

The right code for this test method is 87254. A negative test result indicates no influenza infection, whereas a positive result indicates the presence of influenza A or B, as specified. Since the test is for influenza A and B, you should report two units of 87254 for the test.

86710 depends on antibody

Doctors may order influenza antibody test(s) on a blood sample to help figure out influenza A or B infection. The presence of IgG antibody shows prior exposure to the virus, while IgM antibody presence shows present acute infection. The method may be enzyme-linked immunosorbent assay (ELISA) or other methods. The key is that this is an antibody test, and not an antigen test. Code this service as 86710 (Antibody; influenza virus).

Capture two or four: Just like the other test codes, if the lab tests for influenza A and B, you can list the code twice (86710 x 2). However that is not all for the antibody test. Since the lab may test for IgG and IgM, you can use a separate code for each of those antibodies. If you test for each antibody for each influenza strain, you will have four units of 86710.

BMI: New code choices could support higher coding, but don't assume you need -22

This year's just-in fifth-digit diagnosis codes for BMI help you document a patient's condition better, especially when the patient's BMI might lead to more complex risk factors for the anesthesiologist to handle. However, having documentation of a high BMI does not automatically lead to more payments. Watch two areas prior to assuming you can automatically add modifier 22 (Increased procedural services) owing to BMI and potentially score a 20-30 percent higher pay for the procedure.

Not all morbid obesity means modifier 22

A patient is taken to be morbidly obese when his or her BMI is 40 or more. Just-in BMI codes for this year include:

V85.41 -- BMI 40.0-44.9, adult

V85.42 BMI 45.0-49.9, adult

V85.43 -- BMI 50.0-59.9, adult

V85.44 -- BMI 60.0-69.9, adult

V85.45 -- BMI 70 and over, adult

While morbid obesity can be a proper reason to report modifier 22, do not assume that you should always add the modifier just because the patient is morbidly obese.

Extra time does not always mean more money

Modifier 22 is about extra procedural work and even though morbid obesity might lead to extra work, it's not enough in itself.

Unless time is significant or the intensity of the procedure is increased owing to obesity, then modifier 22 shouldn't be added.

Here's the catch: CPT doesn't provide specific direction on how much time and/or percentage of increased time or work the provider must document to merit modifier 22. However, the rule of the thumb is your provider must spend at least 50 percent more time and/or put in at least 50 percent more effort than normal for you to add modifier 22.

There should be documentation of at least a 50 percent increase in work and/or time to justify tge use of modifier 22.

Document: One sure-shot way to demonstrate a procedure's increased nature is to compare the actual time, effort or circumstances to your anesthesiologist's typical time and effort for that particular procedure. A note like “The procedure required 90 minutes to complete, instead of the usual 35-45 minutes" can be useful. Remind your anesthesia providers to clearly document the reason for the increased time and effort in the patient's record.

As these claims normally require manual review or an appeal in order to get additional payment, be sure the operative note is detailed and specific to support the medical necessity and reasons for the use of modifier 22. An additional letter from the doctor to present the case and the reasons for requesting more payment that is written in layman's terms will help to appeal the claim.

96402 Is No More An Option For Lupron Depot Admin

Does your practice sees patients with Part B coverage through Noridian? If so, you will need to take note of a new drug administration rule from this Medicare Administrative Contractor (MAC). Being well-versed with all the recent happenings will help you report gonadotropinreleasing hormone (GnRH) injections the right way.

This rule will have an impact on practices in Arizona, Utah, North Dakota, South Dakota, Wyoming, and Montana, with Noridian Administrative Services as their MAC, along with practices in Alaska, Oregon, and Washington, which Noridian covers under a legacy contract.

Reason for the change

From March 1, you cannot use administration code 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic) or any other chemotherapy administration code with some agents as you have done in previous occasions.

The administration of GnRH (also known as luteinizinghormone releasing hormones -LHRH, or its analogs) doesn't meet the CPT manual requirements for the use of the chemotherapy administration codes.

The announcement of Nordian doesn't allow any additional rationale to explain why the MAC is treating Lupron Depot, a biological response modifier, as a less complex therapeutic administration. Abbott's package insert for dosage and administration of Lupron Depot talks about the great instability of the medication and the particular care needed to administer it properly.

Official version: The information below was published by Nordian in the March 2, 2011, Medicare B News, Issue 268, and posted it as news on Jan. 21, this year: Medicare takes the use of the chemotherapy administration codes to properly describe the parenteral administration of the only following drugs - J1745 Injection Infliximab, Any non-GnRH drug/compound listed in the present HCPCS section – chemotherapy drugs J9000-J9999, instances of GnRH and analogs include however are not confined to J9217 and J9218.

From April 2010, follow the timeline

The March 2, 2011, announcement points to it updates of the June 2, 2010, Medicare B News, Issue 262. Remember that this version does not reference GnRH coding:

Any drug listed in the present HCPCS section - 'CHEMOTHERAPEUTIC DRUGS J9000-J9999' and the biologic response modifier, J1745 Injection Infliximab, 10 mg.

However hold on, there's more: On May 6, last year, Nordian posted an update effective as of June 15, last year, specifically referencing J9217 and J9218: Medicare takes the use of the chemotherapy administration codes to properly describe the parenteral administration of only the following drugs: J1745 Injection Infliximab.

Medicare Fee schedule: Bilateral surgery indicator for 77071 changes from 3 to 2

A small status-indicator change could cost you $46 per claim.

It's difficult to fathom what each quarter will unravel in the form of Medicare updates. As such, this month (April) you need to stay in tune with the latest on physician fee schedule news.

New: The bilateral surgery indicator for 77071 has changed from 3 to 2.

While the effective date is January 1, the implementation date is April 4 this year. This means that the changes are retroactive to January 1 but the deadline for your carrier to implement the changes is April 4.

Previous way: 3' Offered Payment for 2 Sides

Earlier, 77071 used to have a bilateral indicator of 3. Under the Medicare fee schedule, a bilateral surgery indicator of 3 in essence means that when you code the procedure as bilateral, the carrier will reimburse you separately for each side.

Indicator 3 rule: When you report both sides on the same date, Medicare'll base the payment for each side on whichever is less -- the actual charge for each side or 100 percent of the fee schedule amount for each side. The rule holds true irrespective of how you report the bilateral service, such as using modifier 50 (Bilateral procedure), modifiers RT and LT or two units.

What's more, Medicare's policy for the 3 indicator is if the procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure prior to applying any multiple procedure rules."

New way: '2' says 1 code covers bilateral service

Since code 77071 now has a 2 bilateral indicator, you will need to be sure your payment expectations are in line with the official fee schedule.

Indicator 2 rule: When CMS labels a code with a 2 bilateral indicator, relative value units are already based on the procedure being carried out as a bilateral procedure.

Therefore, if you report the procedure two times on the same date (using modifier 50 or any other means), Medicare will base payment on the lower of:

The actual charge for both sides, or

100 percent of the fee schedule amount for a single code

Change's impact: This could be a big drop for practices that were collecting twice the reimbursement and now will get no payment adjustment. But again as the descriptor refers to inclusion of the contralateral joint, it would be difficult to argue the fact that the code is inherently bilateral.

Good tidings: The change is retroactive to January 1; however Medicare is not requiring contractors to search their files to adjust claims they have already paid. However contractors will adjust claims if you bring them to their attention.