Check out the new 2011 payment rates for dermatology procedures performed in an ambulatory setting.
True or false: Modifier SG is required for all ambulatory surgical center (ASC) claims.
The answer is false for claims with dates of service after Jan. 1, 2008 -- and if you got that one right, you're on your way to ASC reimbursement bliss.
CMS has issued its latest quarterly update to the ASC Payment System, which includes HCPCS codes , modifiers, drugs and supplies that are payable for ASCs effective April 1.
With so many changes affecting ASCs every year, it's enough to make your head spin -- but despite all of the changes, some aspects of ASC reimbursement have remained the same. We've got the lowdown on how the ASC rules affect you.
1. Know where to find ASC-allowed services. CMS maintains a very specific list of codes payable for ASCs, but if you don't know how to access the list, you could be flying blind when it comes to reimbursement.
Resource: You can download the most recent ASC-allowable codes at www.cms.gov/ASCPayment/11_Addenda_Updates.asp, which includes not only the current quarter (which began on Jan. 1), but also any previous quarters in case you're battling older claims.
2. Remember the 'same-day global' rule. Every procedure the ASC bills has a "same-day" global period. This makes sense because the ASC is not reporting physician work services -- only facility fees. This applies to the coder working for the ASC, but not the physician who performed the service.
For instance, if a patient experiences postoperative bleeding after the repair of a superficial wound (12001-12018, Simple repair of superficial wounds …) and the physician must return the patient to the ASC for control of bleeding on the same day, both the physician's coder and the ASC's coder should report the appropriate control-of-bleeding code appended with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period) because the procedure occurred within the "same-day" global period for the ASC.
If, however, the physician returned the patient to the ASC the day after the initial surgery, the ASC coder would report the appropriate control-of-bleeding code with no modifier. For the ASC's purposes, the initial surgery's global period has expired, even though the surgery includes a 90-day global period for physician services. On the other hand, the surgeon's coder would report the bleeding-control code with modifier 78 appended because the physician's services follow the standard global rule.
medical diagnosis codes, medical procedure codes, medical procedure, medical coding publications, medical coding, medical billing, medical collection, medical receptionist
Wednesday, June 29, 2011
Tuesday, June 14, 2011
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.
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.
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.
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 & proper modifier 25 use
You should stop omitting modifier 25 because of same day diagnosis.
Recently, someone told me that we do not require different diagnosis codes to use modifier 25 for reporting an Evaluation & management service on the same date as a procedure. However, I have been told many times in the past by certified coders that when I bill more than a procedure that I need to add modifier 25 to the evaluation & management and point the primary diagnosis to the evaluation & management and point a secondary diagnosis to the other procedure. Can you help clear up my doubt?
Answer: Proper modifier 25 use doesn't need a different diagnosis code. As a matter of fact, the presence of different diagnosis codes attached to the E/M and the procedure doesn't support a separately reportable E/M service.Your key to reporting the E/M service lies in whether your doctor carried out and documented work beyond what's considered to be part of the procedure.
How if functions: The information about modifier 25 in the CPT manual distinctly indicates that you don't need to have two different diagnosis codes to use the modifier. As per the CPT manual description of modifier 25, the evaluation & management service may be prompted by the symptom or condition for which the procedure and/or service was provided. Therefore, different diagnoses are not required for reporting of the E/M services on the same date."
Both CPT and Medicare rules will allow the same diagnosis for the evaluation & management service with modifier 25 and the procedure on the same day, and Medicare will pay for both with the same diagnosis, assuming both are reasonable and necessary and otherwise meet Medicare coverage criteria. The catch is that your physician's documentation should establish clearly that the evaluation & management involved work over and above that typically associated with the procedure done at the same encounter and that the encounter's sole intention was not to carry out the procedure. So if you get denials on modifier 25 claims just because you use the same diagnosis code for the Evaluation & management and the procedure, you should appeal, assuming your physician's documentation supports reporting separate services.
Recently, someone told me that we do not require different diagnosis codes to use modifier 25 for reporting an Evaluation & management service on the same date as a procedure. However, I have been told many times in the past by certified coders that when I bill more than a procedure that I need to add modifier 25 to the evaluation & management and point the primary diagnosis to the evaluation & management and point a secondary diagnosis to the other procedure. Can you help clear up my doubt?
Answer: Proper modifier 25 use doesn't need a different diagnosis code. As a matter of fact, the presence of different diagnosis codes attached to the E/M and the procedure doesn't support a separately reportable E/M service.Your key to reporting the E/M service lies in whether your doctor carried out and documented work beyond what's considered to be part of the procedure.
How if functions: The information about modifier 25 in the CPT manual distinctly indicates that you don't need to have two different diagnosis codes to use the modifier. As per the CPT manual description of modifier 25, the evaluation & management service may be prompted by the symptom or condition for which the procedure and/or service was provided. Therefore, different diagnoses are not required for reporting of the E/M services on the same date."
Both CPT and Medicare rules will allow the same diagnosis for the evaluation & management service with modifier 25 and the procedure on the same day, and Medicare will pay for both with the same diagnosis, assuming both are reasonable and necessary and otherwise meet Medicare coverage criteria. The catch is that your physician's documentation should establish clearly that the evaluation & management involved work over and above that typically associated with the procedure done at the same encounter and that the encounter's sole intention was not to carry out the procedure. So if you get denials on modifier 25 claims just because you use the same diagnosis code for the Evaluation & management and the procedure, you should appeal, assuming your physician's documentation supports reporting separate services.
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