Be Cautious Before Reporting Neonatal Hypothermia During Heart Procedures

Latest CCI edits have a say on hypothermia

In case your anesthesiologist carries out controlled hypothermia in neonatal heart surgery cases, you must only report the anesthesia code, and never the "T" code as far as hypothermia is concerned. The latest Correct Coding Initiative (CCI) edits brought changes in the hypothermia(plus edits related to injection procedures). Read on this expert anesthesia coding and billing advice for cleaner claims.

Anesthesia Outweighs Hypothermia

Every single edit pair linked to anesthesia concentrates on codes 0260T (Total body systemic hypothermia, per day, in the neonate 28 days of age or younger) as well as 0261T (Selective head hypothermia, per day, in the neonate 28 days of age or younger).

The edits associated with 0260T and 0261T use the description "Misuse of column two code with column one code." CCI 17.2 specifies that you should not report neonatal hypothermia codes using the cardiac anesthesia codes:

00560 -– i.e. Anesthesia used for procedures on heart, pericardial sac, as well as great vessels of chest; excluding pump oxygenator

00561 -- i.e Anesthesia used for procedures on heart, pericardial sac, as well as great vessels of chest; including pump oxygenator, younger than 1 year of age

00562 -- i.e Anesthesia used for procedures on heart, pericardial sac, as well as great vessels of chest; including pump oxygenator, age 1 year or older, meant for all non-coronary bypass procedures (for instance., valve procedures) or for re-operation for coronary bypass more than 1 month following original operation

00563 -- i.e Anesthesia used for procedures on heart, pericardial sac, as well as great vessels of chest; including pump oxygenator by means of hypothermic circulatory arrest

00566 -- i.e Anesthesia used for direct coronary artery bypass grafting; excluding pump oxygenator

00567 -- i.e Anesthesia used for direct coronary artery bypass grafting; including pump oxygenator

00580 -- i.e Anesthesia used for heart transplant or heart/lung transplant.

Note: CPT® consists of a qualifying circumstances code you can occasionally report once your anesthesiologist treats patients of extreme age: +99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70 [List separately in addition to code for primary anesthesia procedure]). For anesthesia coding, never use +99100 in combination with codes that specify patient ages, though, such as 00561.

Caution: Cardiac anesthesia codes that are not age specific and do not specify that the service involves hypothermia might be qualified for circumstances codes.

Plus: Each of the hypothermia edits has a modifier indicator of 1, implying you can use a modifier to isolate these bundles when both services were medically essential and conducted as separate procedures. Look out for notations in the patient record maintaining that anesthesia was complex by utilization of total body hypothermia or a description of the procedure used to lower the patient's body temperature lower than 35C/95F.

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784.0 or 723.8? Headache Choice Depends on Provider Notes

Know the best diagnosis and injection codes.

In case your neurologist or pain specialist administers greater occipital nerve blocks, don't allow coding turn into a headache. Confirm specifics about the patient's headache as well as the service your provider provided to pin down the accurate diagnosis and procedure codes each time. Read this neurology billing and coding expert insight and know what neurology CPT codes apply in such a scenario.

Location of the Occipital Nerve

The greater occipital nerve (GON) starts from the subsequent medial branch of the C2 spinal nerve and supplies sensory innervations to the posterior area of the scalp going to the top of the head. Physicians normally inject the GON at the point of the superior nuchal line which exists just above the bottom of the skull for occipital headaches or neck pain.

Tip: Some physician practices have a little illustration in the chart that the physician can mark with a range of injection sites. Counting this type of tool helps your physician unmistakably document the injection location, which further helps you select the correct nerve injection neurology CPT code as well as submit more accurate claims.

Kind of Headache

Your physician's documentation may have notes covering "occipital headache" to "occipital neuralgia" to "cervicogenic headache." Your job is to make certain that you interpret the notes and then assign the most precise diagnosis.

Occipital headache: ICD-9's alphabetic index does not contain a definite listing meant for occipital headache. Owing to this, you should report the general code 784.0 (Headache), which involves "Pain in head NOS." Further details in your provider's notes may result in diagnoses like 307.81 (Tension headache), 339.00 (Cluster headaches), 339.1x (Tension type headache), or 346.xx (Migraine).

Occipital neuralgia: You have certainly a more definite diagnosis to code when your provider documents occipital neuralgia. Greater occipital neuralgia lead to an aching, burning, or hammering pain or sensation a tingling or numbness all along the back of the head. You'll, in such a case, report diagnosis 723.8 (Other syndromes affecting cervical region).

Cervicogenic headache: The alphabetic index doesn't involve a listing requiring coders to reassess a definite ICD-9 code . A lot of coders report 784.0 (Headache) because of lack of a better option.

Handling Bilateral Injections

Once your provider administers bilateral GON injections, confirm the patient's insurance company prior to completing your claim.

Reason: A lot of Medicare contractors need you to report bilateral procedures as simply a single line item along with a single unit of service as well as modifier 50 (Bilateral procedure) appended. Private payers, though, regularly need two lines for bilateral claims:

Line 1 including the neurology procedure code, modifier RT (Right side), as well as one unit of service

Line 2 including the neurology procedure code, modifier LT (Left side), as well as one unit of service.

Want to have more neurology Medical billing and coding expert tips and know everything about neurology CPT codes ? Click here to read the entire article and to get access to our monthly Neurology and Pain Management Coding Alert: Your practical adviser for ethically optimizing neurology billing and coding, payment, and efficiency in neurology and pain management practice

About the Editor: Leigh DeLozier, BS, CPC, moved from the world of hospital public relations to writing Specialty Alerts in the year 1999. She launched the Anesthesia Coding Specialty Alert and is presently the editor for three other publications including Neurology and Pain Management Coding Alert, Family Practice Coding Alert, and Anesthesia Coding Alert. She has written for pain management, pulmonology, oncology, and other specialties along the way. Leigh re-launched newsletters for podiatry and dermatology in 2009.
She became a Certified Professional Coder® (CPC®) through the American Academy of Professional Coders (AAPC) in 2002.

Pin down Common Acronyms to Code More Precisely

Make out how well you understand these abbreviations.

In case the charts you code occasionally seem like alphabet soup owing to specialized acronyms or abbreviations your providers use, it's time to re-acquaint yourself with some common terms to help improve your coding. Read on this expert anesthesia billing service insight and for perfect anesthesia claims and maximized reimbursements.

Here's why: When the physician documents a chart, he doesn't at all times have time to elucidate phrases like "past history" (PH) and "present illness" (PI), however knowing which is which can make a remarkable difference in the correctness of your charts. In case you code a chart thinking that the patient presently suffers from every condition listed as "PH," you'll be certainly coding the wrong diagnoses for the present illness.

Does 'TKA' Mean Visualizing or Replacing?

The physician documents "TKA" in the patient' chart, which could mean "total knee arthroplasty" or "total knee arthroscopy." In arthroplasty, the surgeon repairs or replaces a joint. Through arthroscopy, on the other hand, the surgeon utilizes minimally invasive techniques to look inside the patient's joint to better diagnose problems and probably provide some treatment.

Possibility 1: The right CPT® surgical code meant for total knee arthroplasty is 27447 (Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing [total knee arthroplasty]). Code 27447 crosses to anesthesia CPT code 01402 (Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty), which has a base value of 7 units.

Possibility 2: CPT® covers a variety of codes meant for total knee arthroscopy, resting on the detailed procedure. Each choice crosses to anesthesia CPT code 01400 (Anesthesia for open or surgical arthroscopic procedures on knee joint; not otherwise specified), which is valued at 4 base units.

Does 'I&D' Point to Clean Up or Incision?

Assume the doctor documents "I and D" on the chart that means he has documented this for both 'irrigation and debridement' as well as 'incision and drainage, This is a different example of two dissimilar types of procedures with two seperate surgical codes, so make certain that you know what your provider means.

Possibility 1: You code irrigation and debridement along with the suitable selection from a huge range of codes, dependent on which level of skin the surgeon reaches. A number of of the options meant for surgical codes cross to either 00300 (Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified) with 5 base units or 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) with 3 base unit value. Though, other options send coders to more detailed anatomical codes, so ensure that you do understand which code selection is suitable.

Possibility 2: You code incision and drainage, though, with a choice from 10060-10180. The code descriptors differ in accordance with what the surgeon incised as well sd the level of complexity. Each code crosses to anesthesia CPT codes 00300 or 00400, as the irrigation and debridement procedures.

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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.

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.

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.

Rid Your Invasive Lines Documentation Challenges with These Tips

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

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

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

Support medical necessity

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

Watch the clock

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

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

Identify the location

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

Validate barrier method/technique

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

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

Include the provider's name and signature

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

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

Medicare guidelines allow a handwritten or electronic signature on orders or other medical record documentation for review. Stamped signatures aren't acceptable; however the provider can sign her initials over her printed or typed name.