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.

99360 Is Certainly Payable If You Follow The Rules

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

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

You should code based on availability and not care

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

You should document three key factors

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

Another doctor must request that your anesthesiologist make himself available for standby time. You need this request in writing along with justification for why the other physician requests anesthesia standby.

The chart should cover a note by the anesthesiologist documenting that his service might be necessary.

Know how about the anesthesiologist's involvement in the case.

Check times and locations twice

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

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

Pay no attention to 99464 for your claims

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

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

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

Family practice coding: Which code for emphysema visit?

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

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

Since the doctor also carried out an office visit, go for 99213 based on your documentation of an expanded problem-focused exam with low-complexity decision-making. You might require to add modifier 25 to 99213 to indicate that the evaluation & management service was significant and separately identifiable from 94640.

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

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

Here's an instance: The doctor determined that the patient's plan of care should include inhalation therapy or the patient is new to this therapy and doesn't know the administration techniques involved in the procedure. The note should clearly show that the doctor demonstrated the inhaler to the patient separate from the administration for treatment. Or else, the insurer may think you're trying to report one service twice.

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

Pain management coding: does injury codes apply to pain?

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

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

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

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

Pain management coding: Do injury codes apply to pain?

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

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

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

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

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

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

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

00918 is primary anesthesia code for procedures 52352-52355

However don't make it your automatic choice.

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

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

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

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

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

Late or no-show patients? Take a look at these options

Take a look at this ophthalmology coding scenario:

There are some patients who regularly miss appointments or show up late. We would like to focus on the importance of keeping appointments without alienating the patients. As such, can you bill for no-show visits and/or charge a fee for being late?

Well, whether you can bill for no-show visits or charge a late fee will depend on your payer contracts and the laws in your state. Some contracts bar no-show charges or fees not related to patient services. Take a look at your contract and state laws and if both allow such charges, go ahead and bill the patient for this difficulty.

There are many practices that charge a fee for missed appointments; however there are other choices to consider. Take a look at these suggestions from other practices: if you charge for missed appointments or a certain number of late arrivals, post that information so that patients know about the policy. Cover notices on the registration form, in the registration area and in the waiting room. Some practice writes off the first occurrence and take it as part of patient education.

You should have a financial policy that mentions the fee in writing. You should also have the patient sign a copy of the policy, which he keeps, in addition to one you will keep. This way, he can't claim he was never told or didn't see the notification.

You should tell late arrivals that your staff will fit them in as best you can; however that patients who are on time for appointments will get preference. Give the patient the choice of rescheduling later.

If the patient happens to miss an appointment, you need to send a follow-up letter. Set guidelines for the practice and send a stronger letter every time until you reach the predetermined point of dismissing the patient (normally three missed or late arrival appointments).

Remember: You should be sure to note the missed or late arrival appointment in the patient chart especially when the patient is coming in for diagnostic tests like visual fields or optical coherence tomography (OCT). This may be helpful in safeguarding the practice from abandoned patient lawsuits. Going through how your practice handles this issue is a good opportunity to assess scheduling and other issues from an internal perspective. If you are in a larger multispecialty clinic or in an area where traffic and parking are a recurring problem, realize that these issues might be impacting your patient's ability to be on time. What's more, take a look at how you schedule sick visits; many will be ‘no shows' of you book them a day or two ahead because the patient encourage your physicians to be on time. Some patients think that if the doctor is getting late, it will not matter or will not be noticed if they are late for the scheduled time.

Backache example to help your ICD-9 coding

With not much time to go for October 1, 2013, there is no denying that now everyone is training eyes on ICD-10. However, in doing so, you should not ignore your ICD-9 coding options. Here's a scenario to help your understanding of ICD-9 codes:

Patient A comes to your office for treatment of severe, chronic pain in the right side of his back. The pain had started about 10 months ago. In the right lumbar multifidus muscle for pain relief, your interventional radiologist uses ultrasound guidance to administer two trigger point injections (TPIs). But then his chart notes only say that the patient had 'pack pain'.

You get the chart and also get to see your radiologist performed trigger point injections on other patients in the past, using 20552 and 76942. The most recent injections carried out on the other patients' backs were for myofascial pain.

Minus more specific diagnosis, you should assume that Patient A also has myofascial pain, and report one unit of 20552 with a diagnosis of 729.1?

Well, the answer here is no. Making assumptions does not support compliant coding. From a clinical standpoint, pain can be caused by various reasons. Even if the diagnosis seems obvious, coders are not clinicians and should never make presumptions.

If your radiologist did not specifically document myofascial pain or myalgia and you use one of those codes, you could land in trouble in case of a payer audit. Such mistakes are just the kind of thing that auditors watch out for. In its place, you may be required to report an unspecified code, such as 724.5.

Remember payers may not always accept 'unspecified' codes in assistance of a service; however some payers will reimburse for 724.5 for trigger point injections. As such, be sure to study your payer coverage policies well prior to determining if the diagnosis fits the payer's rules. As a coder, you should be aware of payer policies and LCDs to be able to convey that information to the physician.

Bear in mind that spot on medical coding requires that you select code based on the documentation you must never report a diagnosis code just because you are aware the payer will pay the service if you report that diagnosis.

Pediatric Coding: Key Things You Need To Consider While Using 2011 Icd-9

While choosing the proper influenza diagnosis, two details are key.

Do not let rumors of some ICD-9 changes in preparation for ICD-10 make you blind to the top pediatric diagnosis code change . Minus the scoop on expansion to the 488 category, denials for invalid codes will disrupt your claims delaying your payments.

ICD-9 2011 codes continue to become more and more specific requiring a provider to document clearly and thoroughly to allow for selection of the most specific and spot on code.

Here are some key points you need to consider while using ICD-9 2011 codes.

a) While assigning ‘swine flu' DX, look at manifestation. When a patient has H1N1 (swine flu), you need to pay attention to a couple of details. The medical record will have to identify the proper influenza and you'll have to capture the proper manifestation to choose the codes to the degree of specificity now called for. With the change, category 488 mirrors the structure of category 487.

There has been a tremendous expansion of the H1N1 category. Now you will no longer be able to use 488.0 and 488.1 as ICD-9 2011 has deleted these codes. Instead it has come up with six new five-digit codes. This year's ICD-9 codes 488.0x (Influenza due to identified avian influenza virus) and 488.1x (Influenza due to identified novel H1N1 influenza virus) allow you to uniquely capture pneumonia, other respiratory manifestations and manifestations taking place with these types of influenza. Now you need to assign the proper code 488.xx code based on the type of comorbid manifestation the avian or H1N1 influenza involves.

Remember: When you report 488.01 or 488.11, as with 487.0, you will report an additional code to identify the type of pneumonia.

Otolaryngology Coding: Physicians Will Finally Get Paid For Crp Coding

This year, CPT brought good news for ENT coders. Finally, physicians will get paid for canalith repositioning procedure (CRP) coding after a two-year struggle.

When we look back, CPT 2009 excited ENT coders with new CPT code 95992. However the 2009 Medicare Physician Fee Schedule played spoilsport. CMS assigned the codes ‘B' status or bundled it always, making payment for CRP or the Epley maneuver using the new code impossible to get.

However the fight for payment of CRP came to an end because of the 2011 Medicare Physician Fee Schedule.

Note: If the ENT carries out and documents a medically necessary E/M that's significant and separately identifiable from the CRP, add modifier 25 to the evaluation & management service. What's more, Medicare doesn't allow payment for audiologists performing therapeutic procedures, such as CRP.

2011 CPT dictates you can use the code closet to the documented time. And this advice is nothing new. Your documented time must be equal to or exceed the average time given to bill that level. Your documented time must be equal to or get past the average time provided to bill that level. For a 35 minutes spent on a medically necessary counseling-dominated visit is a 99214, per CPT you could report 99215.

If the ENT carries out and documents a medically necessary E/M that's significant and separately identifiable from the CRP, add modifier 25 to the evaluation & management service. What's more, Medicare doesn't allow payment for audiologists carrying out therapeutic procedures, such as CRP.

Always Medicare has taken the times indicated in CPT's code descriptors to represent minimums. The doctor would opt for the lower code unless the time was greater than or equal to the higher-level code's required time.

So will Medicare change its position? At this juncture, it's not sure.

Gastroenterology Coding: 43255 And Control-Of-Bleeding Situations

Gastroenterology coding: 43255 and control-of-bleeding situations

Coding for excessive blood loss? If so, modifier 22 may not be the ally you are looking for. Your answer may lie on more spot on CPTs such as 43255 and critical care codes.

In the first scenario, the doctor injects epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy (43239). Earlier, you may opt to use 43239 added with modifier 22 if the physician required significant effort to control the patient's bleeding.

However this option would need you to submit additional paper documentation to support your modifier 22 claim. So instead if submitting yourself to potential hassles, you can correctly describe this session by reporting 43239 for the biopsy and 43255 for the control of bleeding provided that the bleeding was not caused by the biopsy.

As is obvious from 43255's descriptor, this procedure describes control of bleeding by “any method," including injection.

Necessity: On your claim, you should add modifier 59 to 43255, and then report 43239. If you leave out the modifier, it would give payers the impression that the biopsy (or physician) caused the bleeding and bundle 43255 into 43239.

In the second scenario, when the gastroenterologist is about to carry out an upper GI endoscopy, the patient undergoes very severe gastrointestinal bleeding; so much so that the physician must suspend the endoscopy and spend 40 minutes lavaging blood from the gastro-intestinal tract before continuing.

Report it: This time round, the critical care code 99291 is your best choice.

Here's why: if the gastroenterologist caused the bleeding, you can't bill for the control of bleeding procedure. You should ask control-of-bleeding codes only when treatment is required to control bleeding that takes place spontaneously or as a consequence of traumatic injury (noniatrogenic), and not as a consequence of another type of operative intervention.

You should bear in mind that the time spent at the bedside carrying out services including lavage of gastric blood isn't included in the performance of a subsequent endoscopic procedure and isn't part of the evaluation & management service that might be carried out on the same day.

Nonetheless, you should not report a critical care code carelessly for an excessive bleeding situation that is not out of the ordinary. Extra time for emergency bedside services less than 30 minutes does not count as billable critical care service. For prolonged critical care services, the doctor should exclusively note the amount of time in his notes.

Twin deliver coding? Here's how you should go about it

Ob-gyn coding presents a lot of coding challenges before you. Sometimes you may find yourself in a fix trying to report twin cesarean delivery.

If so, you should take a dig at 59510 with modifier 22 attached. However, that may not always be the case. You will need to adjust your twin delivery reporting depending on an insurance company's preference.

So how should you report twin delivery?

Whenever a patient has twins, most ob-gyns first make an attempt at a vaginal delivery as long as the physician has not figured out any complications. Here in this situation, you should go for 59400 for the first baby and 59409-51 for the second.

Keep this in Remember: Both CPT and the American Congress of Obstetricians and Gynecologists (ACOG) recommend you use modifier 51 (Multiple procedures) for the second delivery. But then you may come face to face with some payers who want to see modifier 59 instead. Other coders report appending modifier 22 to the global delivery (59400) if the patient had more than the average of 13 visits and to account for the second delivery in instances where the payer does not permit separate billing for the additional delivery. When this piece of guidance is in writing, you should follow it.

Best option: Send a letter of explanation with the claim to stay away from immediate denial by the claim processor. A simple form letter talking about the high-risk nature of multiple-gestation pregnancies will routinely go straight to medical review and save the hassle of denial resubmissions or lost reimbursement through write-offs.

Otolaryngology Coding: How To Report Fungal Sinusitis

Your otolaryngology coding practice throws open many challenges and presents a lot of questions. Say for instance you may be asking yourself questions like "Is there a specific diagnosis code for fungal sinusitis?"

Well, even though looking up "Sinusitis: due to: fungus, any sinus" in the Alphabet Index, Volume 2 of ICD-9-CM directs you to "117.9," a single code does not describe fungal sinusitis. You should instead use a combination of ICD-9 codes to represent the condition.

According to the initial instruction for category 110-118, Mycoses, you should use additional code to identify manifestation. List the chronic or acute sinusitis for the primary diagnosis. After this code the underlying fungal infection as the secondary diagnosis.

The following steps will tell you how:

One: Report the proper sinusitis code for sinus membrane lining inflammation. Code 461.x for acute sinusitis. For chronic sinusitis (frequent or persistent infections lasting more than three months) report 473.x. select the fifth-digit code based on where the sinusitis takes place.

For instance, for ethmoidal chronic sinusitis, you should choose Code 473.2 (Chronic sinusitis; ethmoidal).Most likely, your otolaryngologist will prescribe a decongestant, pain reliever or antibiotics to treat sinusitis.

Two: Report the ICD-9 code that represents the fungal infection. Category 117 lists various types of mycoses that offer a more specific diagnosis than 117.9 (Other and unspecified mycoses).For example, think that a patient has chronic ethmoidal sinusitis due to aspergillosis (117.3), an infection that can affect the sinuses and is caused by inhaling the fungus aspergillus, which is found in compost heaps, air vents and airborne dust. You need to enter 473.2 as diagnosis 1 and 117.3 as diagnosis 2 in Box 21 of the CMS-1500 form.

Even though the otolaryngologist may treat aspergillosis with antifungal drugs, such as amphotericin, itraconazole or voriconazole, some forms of aspergillus oppose these drugs. Therefore the physician may need to treat the patient with caspofungin, a newer antifungal drug. Your otolaryngologist can tend to more serious aspergillosis cases in the sinuses by scraping out the fungus and applying antifungal drug drops.

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.

Cpt 2011 And Pediatric Critical Care Bundles

This year, we saw a whole new crop of bundles with pediatric critical care and transport services. From January 1 this year, CPT changed ( Source cpt http://www.supercoder.com/cpt-codes/ ) which services are bundled into critical care codes 99291-99292 based on whether a facility or professional reports the services. What's more, now CPT returns the list of services bundled into 99466-99467 to the bundles that were in effect as of 2007.

This year, pediatricians from your practice will still face the following services as being bundled into critical care:

Interpretations of cardiac output measurements

Chest X-rays

Pulse oximetry

Blood gases

Information data stored in computers

Gastric intubation

Temporary transcutaneous pacing

Vent management

Vascular access

But then, facilities will be able to report these services separately from critical care and will not face the bundles.

Note: This says that you can use the critical care code only, even if the facility is reporting the critical care codes as well as the separate x-rays, intubation, and other services for that matter separately.

You should now also stay away from reporting new observation care codes with other evaluation & management. This year CPT has added 99224-99226. Even though confusion surrounded these new codes when CPT first debuted them, some rules have recently come to light on ways you can report them.

Subsequent observation care: Subsequent observation care starts on the same date as initial observation care codes (99218-99220); nor can you report observation services on the same date as office or emergency department services. What's more, you cannot report the new subsequent observation codes on the same date as observation care discharge (99217).

Family Practice Coding: Foot Claims Success Tips

So your anatomic terminology tripping up your foot and ankle claims? If so read on for more about some of the more common foot procedures your family physician might face and you will be coding those services like a pro.

You should build coding foundations with basic knowledge. Sudden impacts, say for instance those from jumping during sports) or simple wear-and-tear can lead to toe, foot and ankle problems. You should know the differences between these diagnoses or you may miss a subtle difference and report the wrong code.

Medical coding tip: You might need modifiers to help differentiate work on different areas of the feet or toes. These modifiers include LT, RT, TA-T9 and sometimes 59, depending on the service your physician provides. These modifiers become all the more important if the FP performs the same procedure on more than one foot or toe.

You should check differences between bunions and hallux valgus. A bunion happens to be an enlargement of bone or tissue around the metatarsophalangeal (MTP) joint of the great toe. It's often caused by patients wearing shoes that are too narrow around the toe box and can lead to pain and deformity of the toes.

You should verify injection rules for Morton's Neuroma, TTS

Morton's neuroma (355.6) is a thickening of the plantar nerve lying between the heads of the metatarsals. Normally, symptoms include pain, tingling, burning or numbness in the area. This can be caused by wearing shoes with a narrow toe or box or due to sports.

Doctors conduct a physical exam and many a time use x-rays to diagnose a Morton's neuroma. Rest, orthotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and changing shoes will normally help lessen the patient's pain, however corticosteroid injections may be necessary. In some instances, the family physician might refer the patient to a surgeon for excising the neuroma surgically.

Compression or entrapment of the posterior tibial nerve causes tarsal tunnel syndrome (TTS, 355.5). This condition is similar to carpal tunnel syndrome in the wrist, however causes pain and numbness at the bottom of the foot. Extreme standing on the feet, varicose veins, bone spurs, athletic injuries, and other issues can lead to tarsal tunnel syndrome.

Physicians depend on a physical exam to diagnose TTS, normally along with studies including electromyography (95860- 95872) or nerve conduction studies (95900-95905). Once the physician confirms the diagnosis, she'll usually begin conservative treatments such as injections, NSAIDs, rest, and footwear changes. However in some cases, the patient may need surgery. The most common surgical treatment happens to be a tarsal tunnel release (28035).

PTTD, Plantar Fasciitis may need surgery. Posterior tibial tendon dysfunction (PTTD) takes place when the posterior tibial tendon becomes inflamed, stretched out, or torn because of wear-and-tear or a sudden injury. Normally physicians can diagnose this condition using a physical exam, x-ray, or MRI.

Family Practice Coding: What Should You Report For Emphysema Visit

Code 94640 to cover the comprehensive service the physician provided.

An established patient with emphysema presents complaining of shortness of breath. The doctor provides inhalation treatment, trains the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity. Considering this, which CPT code should you report here?

Well, one CPT code will not suffice. You will need more than CPT code for this encounter. You should use 94640 to cover the comprehensive service the physician provided. Since the physician also carried out an office visit, go for 99213 based on your documentation of an expanded problem-focused exam with low-complexity decision-making. You might be required to add modifier 25 to 99213 to indicate that the evaluation & management service was significant and separately identifiable from 94640.

You should use 94640 in place of 94664 since the physician's primary intent was to treat the obstruction.

Word of caution: If you bill 94664 along with 94640 on the same day to Medicare, see to it that you justify that the physician provided the 94664 service distinctly separate from the treatment. In this instance, add modifier 59 to 94664 to notify the payer that the family physician performed 94664 separate from 94640. The documentation should cover details on the medical necessity for separately providing this service.

Here's an instance: The physician determined that the patient's plan of care should cover inhalation therapy, or the patient is new to this therapy and doesn't know the administration techniques involved in the procedure.

The note should clearly make out that the physician demonstrated the inhaler to the patient separate from the administration for treatment. Or else, the insurer may think you're trying to report a service twice.

Here's a tip that'll stand you in good stead: Even though technically not called for it may help to link separate diagnosis codes to the E/M and the nebulizer treatment. For example, you could link 786.05 to 99213, and link the emphysema code to 94640.

Lesion Removal Coding In The Ed

You should never label a lesion malignant on your own.

Patients who report to the emergency department for lesion removal present for special challenges for the coder who normally does not have time to wait on pathology reports prior to choosing a CPT code for the procedure. You should also know how CPT breaks the body down when a patient reports with an oozing scab or some other sort of lesion.

Here are some expert guidance to help you in your lesion removal coding.

The starting point: As a coder, you need various pieces of information before you can choose a proper lesion excision. First, find out the anatomical area of the lesion. For coding, CPT (Source CPT http://www.supercoder.com/ )breaks down lesion removals into various categories:

Lesion is benign or malignant: You should never have to choose between a benign and malignant lesion. It’s unethical and illegal to diagnose any patient with any condition minus the burden of proof. The only way to be sure a lesion is malignant is to wait for a path report. This isn’t a problem in a dermatologist’s or plastic surgeon’s office. However, ED charts are normally sent for billing within a day or two, so you have to default to the benign (removal) codes, unless you have pathology confirmation that the lesion is malignant.

You should ensure that the physician signs off on the pathology of the lesion, even if it is benign. The physician needs to be the one to document the findings.

Measuring total removal size: If you are reporting only the length of the lesion while choosing a removal code, you are selling the ED short. When determining the proper size of the excised lesion, the provider should add together the (greatest clinical) diameter of the lesion in addition to the size of the margins (required).

Cpt 2011 Changes Affecting Your Podiatry Coding

This year, CPT introduced over 200 new codes to help you code more accurately. The changes have affected several practices and your podiatry practice is no exception. For this practice, the big change focuses on two new codes to report diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity.

Also, you will use various G codes while reporting diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity for a Medicare beneficiary this year.

This time CPT introduces Code G0440 and G0441 which will put an end to the confusion providers put forth the different global periods for two tissue cultured skin substitute codes.

This year, for your ultrasound coding, you will not use 76880 as this code has made way to two new codes - 76881 and 76882.

A complete procedure (76881) includes real time scans of a specific joint that includes examination of the muscles, tendons, joint, other soft-tissue structures, and any identifiable abnormality. A limited study (76882) involves examining the extremity where a specific anatomic structure such as a tendon or muscle is assessed.

Bear in mind that when the podiatrist carries out spectral and color Doppler evaluation of the extremities, you should use the proper code with 76881 or 76882. In the meantime, CPT has also revised and revalued codes for noninvasive physiologic studies of the upper or lower extremity arteries: 93922, 93923, 93923, 93924.

And if you were confused about choosing between a debridement code and an active wound code, this year’s CPT saves the day by revising debridement code guidelines.