Modifier 57 Use: Understand Your Payer’s Definition of Global Period to Avoid Denials

Append modifier 57 only on an E/M code that represents the decision to perform a procedure with a 90-day global. 

 

Correct use of modifier 57 (decision for surgery) seems like a cake walk, but there are unseen rules you need to know before you attach the modifier to one of your claims. Differences in global period definitions and claims edits could invite trouble. Know what need to know to avoid denials:

Variations in Payer’s Definition of Global Period

Global surgical packages describe all services integral to a procedure as described by CPT.

Different payers have different definition of global period. CMS, along with most other payers, assigns a procedure or service to one of the following types of global surgical packages:

·         0-day: Just the day of the surgery is part of the package

·         10-day: The day of surgery and 10 days after the surgery – in total 11-day package

·         90-day: One day prior to the surgery, the day of the surgery, and 90 days after the surgery – in total a 92-day package

According to Medicare, you should append modifier 57 only on an E/M code that represents the decision to perform a procedure with a 90-day global.

What does it mean for your cardiology practice? You will find 90-day globals for procedures such as pacemaker insertion codes 33206 to 33208 or ICD insertion code 33249. Many of the commonly used procedures in cardiology such as catheterizations, normally have a 0-day global. In those cases, modifier 57 is not applicable.

Medicare as well as CPT® include, for their procedures with a 90-day global – the day of or day before surgery. However, there are exceptions as other payers, including some of the Medicaid programs, don’t include a day before surgery; as such the only thing they are worried about is E/M on the same day as the surgery.

Be well-versed with payer rules: If you do not follow their billing rules, you are most likely losing money by not billing for payable services. If you’re in doubt, use CMS/CPT rules. 

Good practice: The American Medical Association (AMA) suggests that you keep a health insurer reference log where you can include the payer’s global period definition. Additionally, you could arm your cardiology practice with the much-needed guidance – code and modifier usage advice, payer rules, global days, and everything you need to stay on the correct side of your cardiology pay by subscribing to Cardiology Coding Alert.

CPT® Update: 92070 Doesnâ??t Allay to Therapeutic Contacts Anymore

New Text module

Novel codes 92071 and 92072 are to be used for lens prescriptions for keratoconus and OSD.

Even though you can't bill Medicare for consistent refractive lenses, savvy ophthalmology coders are aware of the fact that you can anticipate reimbursement for contact lens prescriptions for treating keratoconus (ICD-9 codes 371.60-371.62) as well as ocular surface disorders (OSDs) for example corneal abrasions or dry eye. On the other hand, what coders at present know is changing in 2012, with the removal of one familiar code and the introduction of two novel medical CPT codes. Read on this expert insight on accurate medical Supercoder coding.

92070 no more: The medical CPT 2012 manual scrubs the ophthalmology coder's standby meant for therapeutic contact lenses, 92070 (Fitting of contact lens for treating disease, including supply of lens). As an alternative, you'll find two novel codes:

92071 (Fitting of contact lens for treatment of ocular surface disease)

92072 (Fitting of contact lens for treatment of keratoconus, initial fitting).

Notes in the medical CPT® manual warn you against reporting 92071 with 92072. For the supply of lenses, which was included in the code previous to 2012, CPT® recommends reporting 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or other materials provided), or another suitable supply code.

A note associated with novel code 92072 instructs coders to report an apt 92002-92014 (E/M or General Ophthalmological Services) code for following listed fittings of keratoconic lenses.

Difference in Ophthalmologist's Work Means Difference in RVUs

Why the change? Ophthalmologists were earlier using 92070 to report two very dissimilar kinds of service. Upon assessment of this service, the specialty societies approved that there are two distinct uses for medical CPT® code 92070 that have significantly dissimilar levels of work.

The medical CPT® Editorial Panel decided and removed CPT® code 92070 and then created two novel medical CPT codes (92071 and 92072) to differentiate reporting fitting of contact lens meant for management of ocular surface disease and fitting of contact lens for supervision of keratoconus.

To echo the fact that managing contact lens of keratoconus involves more work for ophthalmologists than treatment of OSD, Medicare has allocated more work RVUs to 92072 (1.97 work RVUs) as compared to 92071 (0.61 work RVUs). The work RVUs for 92071 are alike the work RVUs assigned to 92070 in 2011, sans a small number of adjustments in pre- as well as post-service time.

CPT® : Ascertain Whether A Patient is New With CPT®'s Newest E/M Tweaks

Get acquainted with new thoracoscopy CPT 2012 codes.

It's a long-standing debate--once an established patient visits your practice in order to see a new physician, then should you report a novel patient office visit code? CPT® 2012 tries to make clear when that's possible with a revision to the "New and Established Patient" segment of the CPT® manual. Read this article for accurate medical coding and know what the new CPT 2012 codes are.

The rules: At present, Supercoder CPT® points out that a "new patient" refers to a patient who has not received any professional services, for instance an E/M or another face-to-face service from the physician or physician group practice -- in the similar physician specialty -- in the past three years.

Clarification: CPT® 2012 takes that definition a step ahead, now maintain that a new patient is one who has not obtained any professional services provided by physician or any other physician of the exact similar specialty and subspecialty who is from the same group practice, in the past three years. The parts of the description that are new for 2012 are underlined.

What this means to you: In case your practice employs a variety of subspecialists, CPT® now clarifies that claims for patients who see dissimilar doctors with diverse subspecialties can be billed using a new patient code (such as 99201-99205)

Example: A cardiology practice makes use of a general cardiologist and an electrophysiologist (EP), and then both physicians are categorized as these different specialties with their payers. The cardiologist refers a patient to the EP for consideration of an implantable cardiodefibrillator. In this condition, the visit with the EP must qualify as a new patient visit, supposing the payer accepts these CPT® rules.

CMS Offers Surprise 0-Day Global to New Thoracoscopy CPT2012 Codes

Not only did CPT® 2012 modifies the heading of its "Thoracoscopy" part to cover the term "VATS" (video-assisted thoracic surgery), it also introduced three new diagnostic thoracoscopy CPT 2012 codes (32607, 32608, 32609)

It's an interesting fact that these new CPT 2012 codes were allocated fewer global days than even the CPT® Advisory Committee recommended.

You must keep in mind that Diagnostic thoracoscopies (32607-32609 ) actually have zero-day globals. In fact it's there in a recommendation to modify those to ten-day globals which would reveal the time the patient spends in the hospital which could be up to ten days, but that has not up till now changed. Consequently, physicians can independently report E/M services that they offer to patients all through the related hospital stay, apart from the real day of the procedure itself.

ICD-10: Shift Your Hemorrhoid Diagnosis To 184 From 455

Now that the date for implementation of ICD-10 has been decided, you must start preparing for the transition. Beginning October 1, 2014, when coding for hemorrhoid cases you will need to compare your anesthesiologist’s notes with those of the surgeon even more often. This is because the new ICD-10 code set adds codes for "internal and external" in addition to codes for internal, unspecified, or external hemorrhoids. However, this is not the only change that you’ll notice when you choose a hemorrhoid diagnosis in ICD-10. 

Note the hierarchy

Under the present ICD-9 code set, you have 10, four digit codes under the category 455 (Hemorrhoids). The fourth digit 0-9 separates each code depending on whether the hemorrhoids are internal, external, or unspecified, and also whether the patient exhibits specific complications.

ICD-10, in contrast, provides following three choices (four digit codes) depending on whether the hemorrhoids are thrombosed, have other complications, or have no complications:

•        I84.0—Thrombosed hemorrhoids
•        I84.1—Hemorrhoids with other complications
•       I84.2—Hemorrhoids without complication.

Establish location using a fifth digit

Under ICD-10, you would use the fifth digit to show hemorrhoid location as follows:

• 0—Unspecified
• 1—Internal
• 2—External
• 3—Internal and external.

Specify complication with sixth digit 

After you made your selection to the correct five-digit code, you’ll need to add further specificity to explain if the patient has one of the "other" complications. For subcategory I84.1x, you have the options to choose from the following sixth digits:

• 1—bleeding 
• 2—prolapsed
• 3—strangulated
• 4—ulcerated.

 Consider for example a patient has internal and external ulcerated haemorrhoids. In this case you would report the code I84.134 (Internal and external ulcerated hemorrhoids) in ICD-10. 

Again, for the same condition, you’d have to select a more general code that could represent any number of complications (such as bleeding, prolapsed, strangulated, or ulcerated) under ICD-9. However, ICD-10 allows you to gain specificity by capturing "internal and external" hemorrhoids, and by identifying that the complication is "ulcerated."

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.

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

radiology coding,medical coding resource

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 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.