\Should Assistant Surgeon Billing Each time Match Lead Surgeon's?

Read on the following medical billing question and the expert answer.

Question: You work in a general and laparoscopic surgeon's office. Once he helps other surgeons you get the medical billing information from the other surgeon's coders to bill as the assist.

Occasionally there is inappropriate medical billing relating to the CPT codes as well as ICD-9 codes billed, as per the documentation from the operative report. There is contact made to have them prove and correct, but it is not always followed through with by the lead surgeon's office.

In effort to get the claim submitted in a timely matter you have submitted the claimyou're your doctor as the assist. You have done it in two methods: 1) submitted as billed by the lead surgeon, making notes on the explanation for the errors/problems and 2) submitting the claim with the precise medical billing information.

What is the correct way to handle this problem?

Answer: You must never deliberately send in the wrong codes just to get paid. That is a clear coding and compliance violation.

Your practice of calling the other surgeon's coder and trying to clarify why you will be submitting not the same coding is a good start. In case they don't agree or follow through with the proper coding, though, you must still submit the codes you consider are accurate.

Tip: Send an email to the lead surgeon's practice clarifying the codes you will be submitting and the reason why you are submitting these codes. This makes certain you have your contact with the other coder in writing, and demonstrates you informed them that you planned to submit distinct codes.

You won't probably know what the other surgeon ends up submitting or if they get paid -- but it's not really your area of concern. Given that you are compliant and getting in the reimbursement your surgeon deserves, you're performing your job properly.

Warning: Getting paid might be a bit more challenging when the other surgeon is submitting different codes. You might require appealing a denial that comes from the surgeons submitting dissimilar codes, however in the appeal process if your coding is precise you should get paid.

Bottom line: You should all the times code appropriately and avoid knowledgeably submitting an improper claim just to match the other surgeon's medical billing. In case you think about it, when there is an assistant surgeon, there are three sets of codes the payer gets: the primary surgeon, the assistant surgeon, and the facility as well as not all three are always in sync. Facilities and surgeons don't talk over the coding and work collectively to ensure they have the same result. Each individually codes the case. Why shouldn't the assistant surgeon carry out the same, particularly if they already have a highly qualified coder.

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You Cannot Separately Bill For Starting the IV

Recently, our surgeon carried out an emergency room consult and administered intravenous sedation to perform an incision and drainage of a perirectal abscess. So if I charge for the consult and the procedure, can I code for the IV sedation also?

Well you can only report an intravenous (IV) sedation in addition to an E/M and procedure under certain circumstances. Only a conscious sedation is reportable separately and even that is only in some instances.

If your surgeon carried out conscious sedation, you may be able to bill that with the right documentation and depending on exactly which I&D code you are using. Remember that any code that has the ‘target' symbol in CPT codes includes conscious sedation, which means that you cannot bill the service separately.

If the IV sedation you talked about was conscious sedation for allowable procedure such as 45005 (Incision and drainage of submucosal abscess, rectum), you'll require to document who was monitoring the patient during the case (name and credentials like John Doe, RN). You will also need to document what drug was used and how much as well as the patient's vitals prior to, during, and after the sedation. If you do not have the documentation, you cannot bill for the conscious sedation.

If you cannot bill conscious sedation, you are unlucky for the IV. Beginning an IV is a facility service in the ED; as such you cannot separately bill for starting the IV.

New Insurance Calls for New Verification

A patient has received new coverage but hasn't received an insurance identification card as yet. How should you file a claim on a patient who has new coverage?

Preferably, when patients call to make appointments you should have someone in your office corroborate their insurance coverage and eligibility, more so if you know the patient is going to have new insurance.

The start of the year is the time when benefits verification tends to be most useful. While verification is good practice all year long, January is the time when you will see more insurance charges – including payer, benefit, and deductible/copay changes than at any other time during the year as most employers hold open enrollment in December.

Finding out about insurance changes before the appointment gives you time to check if you're a participating provider with the payer and verify coverage. If the patient does not have an identification number with her new insurance company, ask for the name of the insurer and the policy number from the patient or from the patient's employer. After this, call the insurer and verify the coverage and the date of eligibility, and get the proper information to identify the patient on your claim.

Note of caution: The date of eligibility is an important question to ask the payer as many employees do not make health insurance coverage immediately available to new workers. A patient with a new job and new insurance may be in your office for a visit; however his insurance is not effective for two months.

Option: Even though verifying coverage beforehand is the way to go, many practices have patients corroborate their insurance coverage and note any changes when they check in for their appointments. If you are not able to verify the insurance coverage, or you find the patient's not eligible for coverage on the day of the visit, inform the patient of the problem and ask if he wants to reschedule the appointment (unless it is an emergency visit). Or else, explain to the patient that the visit and services may not be covered, and that he must pay the bill himself. Have the patient sign a waiver stating that the services rendered that day may not be covered by the new insurance, and that he's responsible financially. You should keep the signed waiver in the patient record.

What Diagnosis Code to Use While Billing Medicare For Hiv Screening

If you are confused about which ICD-9 code to use while billing Medicare for HIV screening, read on and get to know the right answer:

Various diagnosis codes would be right here, depending on the patient circumstances. For all Medicare HIV screening billing, you should go for an ICD-9 "V" code as opposed to a code for signs or symptoms of disease.

If the screening is for a patient with no increased risk factors or medical complications such as pregnancy, you should report V73.89 (Special screening for other specified viral diseases).

If the patient reports increased risk factors such as past or present injection drug use, you should list V73.89 as the primary code and additionally report V69.8 (Other problems related to lifestyle) as the secondary diagnosis.

If the patient is pregnant, you can go for an HIV screening at three specific times associated with the pregnancy: when the pregnancy diagnosis is known during the third trimester, and at labor. For these HIV tests screenings during pregnancy, you should go for V73.89; in addition you should choose the proper ICD-9 code from the following list based on the specific patient situation:

V22.0 -- Supervision of normal first pregnancy

V22.1 -- Supervision of other normal pregnancy

V23.9 -- Supervision of unspecified high-risk pregnancy.

Reporting one of these codes as a secondary diagnosis will allow you to bypass the HIV screening frequency restriction of once a year.

Get To Know What Constitutes an Acceptable Signature

You will soon need to ensure physicians and non-physician practitioners (NPP) sign your paper lab requisitions if you want to get paid; however what does that entail exactly?

CMS provides specific guidance on what constitutes an acceptable 'signature' for documents subject to review for Medicare payment or by an audit contractor. See to it that your documents measure up by complying with one of the following choices:

See to it that it is legible

The simplest signature (but toughest to ensure) is a legible full-name signature or a legible signature using first initial and last name.

Unluckily, you will not find many physicians or NPP who have a legible signature and you certainly won't want to stake your payment on it. That is when you will go to the second option.

Accept printed name with scribble

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

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

Do it: There's no denying that getting referring physicians and NPP to comply with Medicare's just-in policy for acceptable paper requisition signatures will be tough; however, compliance is important if pathologists and laboratories are to continue to be paid for their work.

For more on this, stay tuned to a medical coding guide like Supercoder.com .

93922: There Are Special Rules for Unilateral Exams

Puzzled by the 2011 guidelines for 93922-93923? Not sure when to report 93922-52?

Don't be. Read on and know how you should go about it: You should report 93922-52 (Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries … 1-2 levels; Reduced services) when the patient has only one limb accessible for study and the doctor records only one or two levels.

Here's an example: A patient's right leg was amputated. The physician carries out the study on two levels on the patient's left leg. You should use 93922-52 to report unilateral, limited service.

The origin of the confusion may be that CPT guidelines for 93922 and for 93923 (Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, three or more levels … ) guide you to report limited code 93922 when the physician carries out a unilateral exam for three or more levels or using provocative functional maneuvers, on a patient with just one arm or leg available for study.

To put it in other words, this means that 93922 (without modifier 52) is proper for

A bilateral exam on one or two levels

A unilateral exam on three or more levels (i.e, lower and/or upper extremity amputee)

A unilateral exam when performing provocative functional maneuvers

Experts provide the following list to help you count levels:

Lower extremity levels

1. High thigh 2. Low thigh

3. Calf 4. Ankle

5. Metatarsal 6. Toes

Upper Extremity Levels

1. Arm 2. Forearm

3. Wrist 4. Digits

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Dates and Physician Presence Have a Says In 99221 Use

In a particular situation, a physician treated a patient in the office and then admitted her to the hospital later the same day. Here can we bill for the office visit and the first day of admission, or do we just bill for the hospital stay?

Well, the answer depends on whether the physician sees the patient on the same day in the hospital.

First scenario: If the physician sees the patient in the hospital on the same day in the office, you are looking at two face-to-face visits on the same date. Only report the proper initial hospital care code (99221-99223, Initial hospital care, per day, for the E&M of a patient …). As per CPT coding guidelines, all initial hospital care services that start in another place of location (such as the physician's office) should be combined and coded using the proper level of initial hospital care. As the 99221-99223 code will include the evaluation & management provided in the office, you will report an initial hospital care code that includes the work done in both sites of service; this may lead to coding a higher level of initial hospital care than if you were thinking about the hospital services alone.

Second scenario: However, if the physician doesn't see the patient in the hospital until the next day, bill each encounter separately. Select the proper office visit code (99201-99205, Office or other outpatient visit for the E&M guidelines of a new patient …) or 99212-99215(Office or other outpatient visit for the evaluation and management of an established patient …) for the office visit on the first day. After this, add an initial hospital care code from 99221-99223 for day two, when the physician tends to the patient in the hospital for the first time. Note that CPT uses initial hospital care codes to report the first hospital inpatient encounter by the admitting physician. After that, you will report subsequent hospital care codes 99231-99233 (Subsequent hospital care, per day, for the E/M of a patient . . .), until the time of discharge (date of discharge). When the physician discharges the patient, you will submit the proper hospital discharge day code, 99238 or 99239.

Ingrown Toenail Removal Coding Confusions? 11750 Answers Them

In a particular case, a patient presents for a follow-up of an ingrown toe nail. The podiatrist finds that the patient now has two ingrown toenails – one on each foot. He removes both from each toe and also did a silver nitrate cauterization. How should I report this? Should I report 99212-25?

Well, the answer is yes. Besides coding 99212-25, you should bill 11750 (Excision of nail and nail matrix, partial or complete [example, ingrown or deformed nail], for permanent removal) appended by modifier 50 (Bilateral procedure).

Logic for evaluation & management: Since the diagnosis is new to one toe, you could justify 99212 (Office or other outpatient visit for the E/M of an established patient which requires at least two of these three key components: a problem focused history; a problem focused examination, and straightforward medical decision making; Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). The patient presents for follow-up of one ingrown toenail. However, the podiatrist has not examined the other (new) ingrown toenail earlier.

Adding modifier 25 (Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) to 99212 indicates the podiatrist carries out a significant, separate service from the ingrown toenail removal.

Logic for incision: You should report each toenail removal: 11750 for the first complete removal and 11750 for the second removal. Using modifier 50 to the second removal tells the insurer that the podiatrist carries out the toe removal as bilateral procedure.

For more specialty-specific articles to help your podiatry coding, stay tuned to a medical coding resource like CodingInstitute.com .

Code for Splinting Only If No Restorative Treatment Is Administered

Recently, a three-year-old presented to our office with a history of falling off a chair and injuring his right wrist. After carrying out a physical, the pediatrician orders an x-ray which shows a buckle fracture of the right wrist. For the time being, the doctor protects the injury with a forearm splint and refers the established patient to an orthopedic surgeon for restorative treatment. Here, can I code for the splinting?

Since the pediatrician provides only the initial splinting without restorative treatment, you can code for the forearm splinting with 29125 (Application of short arm splint [forearm to hand]; static). As an alternative, if the pediatrician carried out the definitive fracture care, including the pre- and post-operative fracture care, the global fracture code 25600, Closed treatment of distal radial fracture [example., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) would include the initial cast or splint.

In both situations, the pediatrician can still code for the x-ray (73090, Radiologic examination; forearm, two views). Even though the splint is also a separately billable service, some plans may consider the forearm splint (A4590, Special casting material [for instance fiber glass] DME and not pay the physician unless he has obtained DME certification.

In order to report an E/M for the evaluation from the fall, the pediatrician would have to have performed and documented a medically necessary significant and separately identifiable E/M service above and beyond the minor E/M already included in 29125. You would use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the day of the procedure or other service) to the evaluation & management service that you report with 29125.

According to CPT, you can report further significant identifiable services carried out at the time of the cast/splint application. A fall from a chair may engage checking for possible head injury and any other wounds, and will most likely call for an expanded problem focused history and exam, which could support 99213-25

For more specialty-specific articles to assist your pediatric coding and for other medical coding updates, sign up for a medical coding resource like Coding Institute.