Monday, 30 April 2012

Optimize Reimbursement When Assistant Surgeon Takes Over Management of Patient

"Global periods for major procedures apply only to the surgeon who performed the initial surgery, not to other surgeons who may have assisted with the procedure. In the following case study, a general surgeon who assisted with a radical cystectomy and a right nephrectomy nine days earlier has taken over care of the patient, who needs to return to the operating room. Since the assistant surgeon then is the main surgeon, billing for the new procedure(s) will differ from what it would have been had the same surgeon been in charge of both sessions. Our coding experts will discuss which procedure codes and modifiers should be used and the diagnosis codes associated with the procedures.

Note: Before charging for any procedure, office staff need to carefully check both the operative and pathology reports as well as talk with the physician who did the surgery. Coders should never bill for a procedure unless they have read the entire op report.

Operative Report

Preoperative Diagnoses: Perforated hollow viscus. Poor peripheral veins.

Postoperative Diagnoses: Disrupted ileal anastomosis with peritonitis. Poor peripheral veins.

Procedure: Exploratory laparotomy with small bowel resection and functional end-to-end anastomosis.
Estimated blood loss: 400 cc.

History: The 73-year-old man underwent a radical cystectomy and right nephrectomy nine days ago for CA of the bladder. He had a postoperative stroke but had been doing well. Had x-ray done for placement of a Dobhoff tube today, which showed free air into the diaphragm. Examination of the abdomen revealed tenderness and distention, and his white blood count was elevated. He was brought to surgery for exploration. His peripheral veins are pretty well used up, and he requires reliable venous access.

Operative Procedure: Under satisfactory general endotracheal anesthesia and the patient in the trendelenburg position, the chest and neck were prepped and draped. The skin lateral to the junction and clavicle and first rib was incised. A thin-walled needle was passed into the subclavian vein and a guidewire advanced easily. The dilator followed by the quad lumen catheter were passed over the guide wire and sutured. The tip of the catheter was positioned just above the right atrium using fluoroscopy. The catheter was sutured in place and Betadine followed by a gauze dressing applied.

The abdomen was then prepped and draped. The steri-strips had been removed. The previous mid-line incision was opened and the abdomen entered. The abdomen was explored, with a small amount of stool noted in the left lower quadrant. The small bowel was then dissected out with all the adhesions freed up. The bowel was brought up out of the pelvis. The leak was found to be at the end of the previously stapled functional and end anastomosis. There was no............
Article Source : http://www.supercoder.com/coding-newsletters/my-general-surgery-coding-alert/case-study-optimize-reimbursement-when-assistant-surgeon-takes-over-management-of-patient-article

Ileoscopy Payable by Using Small Bowel Endoscopy Code

"General surgeons typically do not perform many endoscopic explorations of the small intestine and may be unfamiliar with the unique coding involved in billing such procedures.

Many coders dont know what to look for in the CPT manual because these codes arent found in the typical spots general surgery coders look, says Kathy Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill.

Unlike colonoscopies, which surgeons perform routinely, these procedures arent performed often, and the codes are tucked away in a section of the CPT manual used more by gastroenterologists or urologists than general surgeons, Mueller says. Its important to be able to identify these codes correctly, based on the information in the op note, she says, because small bowel endoscopies are well-paid procedures.

In the following case study, the surgeon first performs an endoscopy of a previously created ileal conduit to rule out carcinoma. The scope doesnt find anything, so a day later an exploratory laparotomy with biopsy of an abdominal mass adjacent to, but not inside, the ileal conduit is performed. When the pathology report identifies the mass as cancerous, the surgeon excises it.

Operative Report No. 1

Preop diagnosis: Intra-abdominal mass, rule out tumor involving the ileal conduit
Postop Diagnosis: Same
Operations: Panendoscopy of the ileal conduit Loop-o-gram

OP finding/indications for surgery:

Patient has intra-abdominal mass on CT scan. Patient has known carcinoma of the bladder and previously underwent radical cystectomy with ileal conduit urinary diversion in 1994. A surveillance CT scan shows intra-abdominal mass. Repeat CT scan shows a large intra-abdominal mass, with possible tumor involving the ileal conduit. On panendoscopy, no tumor was identified within the ileal conduit. A loop-o-gram shows no filling defects inside the conduit itself, although there appears to be some extrinsic pressure, which would indicate that this tumor is an intra-abdominal mass, but not invading the conduit and incidental reflux of contrast into the right ureter.

Technique of operation:

A #22 french rigid cystoscope was introduced into the conduit. Panendoscopy was then performed. There is no definite tumor identified within the lumen of the ileal conduit. I was able to identify the ureteral orifice and I tried to cannulate it with a glide wire, but I could not advance it beyond the meatus. There was no tumor identified in the meatus or inside the conduit itself. Next, the cystoscope was removed. A #16 french foley catheter was then placed within the conduit, and the balloon was inflated to 5 cc. Fifty cc of contrast material was injected through the catheter and filled the loop. X-rays were taken and showed reflux of the contrast in the right ureter. No effusion into the left............
Article Source : http://www.supercoder.com/coding-newsletters/my-general-surgery-coding-alert/case-study-ileoscopy-payable-by-using-small-bowel-endoscopy-code-article

Clearly Written Op Note Allows Billing for More Procedures

"When a general surgery coder reads the top of a surgeons operative note that lists a left hemicolectomy, along with repairs of umbilical and incisional hernias, insertion of mesh and insertion of right subclavian IV, she knows both hernias normally are bundled into the hemicolectomy. But by reading the entire op note before filling out the HCFA 1500 claim form, she finds that each of the procedures is separately billable.

In the following operative report, the coder finds a carefully documented description of the surgical procedures that allows her to bill for the incisional hernia and the insertion of mesh because the notes clearly document that separate incisions and repairs were performed during the surgery. This highlights the importance both of reading the entire operative note on the part of the coder and clear documentation by the surgeon.

Operative Report

Preoperative Diagnosis: Polyp, descending colon, umbilical hernia and incisional hernia; poor peripheral veins

Postoperative Diagnosis: Polyp at the splenic flexure, umbilical hernia, incisional hernia; poor peripheral veins.

Procedures: Left hemicolectomy, repair of umbilical hernia, repair of incisional hernia with insertion of mesh; incision of right subclavian IV.

Pathology Report: Pathology for the hemicolectomy returned as villous adenoma with atypia.

Estimated Blood Loss: 200 cc.

History: This 83-year-old female presented with an umbilical hernia and incisional hernia from a CABG incision; she also was found to have a rectocele. She subsequently had a colonoscopy that identified a broad-based polyp in the descending colon. She presents now for resection of the colon lesion and repair of the umbilical and incisional hernias.

Operative Procedure: Under satisfactory general endotracheal anesthesia and the patient in the Trendelenburg position, the chest was prepped and draped. The skin lateral to the junction of the clavicle and the first rib on the right side was infiltrated with Xylocaine and a small incision made. A thin wall needle was passed into the subclavian vein and a guidewire advanced. Fluoroscopy showed the wire to be in the chest. The dilator followed by the Arrow triple lumen catheter were threaded over the guidewire and the tip of the catheter positioned at approximately the superior portion of the right atrium. This was then sutured in place at about 14 cm using the attachable hub. Betadine followed by an occlusive dressing was applied.

With the patient in the lithotomy position, the abdomen and perineum were prepped and draped. A midline incision was made and the abdomen entered. Initially, I was trying to keep the colon resection incision separate from the repair of the incisional hernia, but I had to extend the incision up to the very lower aspect of the hernia. There were some adhesions between the colon and the spleen that were............
Article Source : http://www.supercoder.com/coding-newsletters/my-general-surgery-coding-alert/case-study-clearly-written-op-note-allows-billing-for-more-procedures-article

Optimize Billing for Aspiration and Bone or Bone-marrow Biopsy Services

"Some of the confusion regarding appropriate coding for various bone sampling and evaluation procedures is removed when coders understand the difference between bone-marrow aspiration, bone-marrow biopsy and bone biopsy in terms of indications, procedures and types of specimen procured. Additionally, coders need to be familiar with the different codes for specimen collection, manipulation and evaluation, including the technical and professional components of each. With this understanding, pathologists and laboratories can better capture reimbursement for specimen sampling, preparation and pathologic examination. Practices also need to be aware of appropriate coding for adjunct procedures, such as cell blocks and special stains, so they will be reimbursed appropriately for those services as well.

Bone-marrow Biopsy

R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark., explains that bone-marrow biopsy often is used in the diagnosis of a host of diseases involving the bone marrow. The procedure may be ordered for primary neoplasia [cancers] such as myeloblastic leukemia [205.00] or acquired aplastic anemia [284.98] or metastatic disease with secondary bone-marrow involvement, he continues. Overall, it is an excellent tool for assessing cellularity [condition and degree of cells present] of bone marrow, he claims.

Bone-marrow biopsy is carried out through a small incision made over the biopsy site, typically the superior iliac spine. A needle or trocar is inserted through the cortex of the bone, and a core of marrow is removed. A pathologist or hematologist/oncologist often carries out this procedure. The appropriate CPT code for the procedure is 85102 (bone marrow biopsy, needle or trocar).

Following the biopsy, typically, laboratory technicians prepare the bone-marrow tissue for examination by a pathologist. The basic slide preparation services for the bone-marrow specimen are considered bundled in the surgical pathology code used to report the service, 88305 (surgical pathology, gross and microscopic examination, bone marrow, biopsy). Preparing the tissue for examination comprises the technical component of the code and for Medicare and many third-party payers should be reported as 88305-TC (technical component) if the laboratory and the pathologist bill separately, advises Laurie Castillo, MA, CPC, president of the Northern Virginia Chapter of the American Academy of Professional Coders, and owner of Physician Coding & Compliance Consulting in Manassas, Va. You should check with the insurer involved, however, to determine if -TC is the appropriate modifier, she cautions.

In addition to the usual steps of specimen preparation, bone-marrow biopsy specimens typically require a separate step to remove calcium that is not considered a bundled service, Stainton informs. It is reported separately using code 88311 (decalcification procedure). This is an add-on code, meaning that it should be listed separately in addition to the code for surgical pathology examination (in..............
Article Source  :  http://www.supercoder.com/coding-newsletters/my-pathology-lab-coding-alert/bone-sampling-codes-optimize-billing-for-aspiration-and-bone-or-bone-marrow-biopsy-services-article

Friday, 27 April 2012

Billing Tips for Non-Physician Surgical Assists

"As a follow-up to our March article on coding for more than one surgeon, this article will assist the growing number of ob/gyn practices using or contemplating the use of nurse practitioners (NP), certified nurse midwives (CNM) or physician assistants (PA) to provide first assists in surgery. First assist is a term describing the person who provides immediate assistance to a surgeon during a case that requires an extra, trained and qualified set of hands. This article will clarify the issues and direct the ob/gyn coder toward tactics that will maximize reimbursement.

Will Carriers Pay for Mid-level Providers
Who Assist in Surgeries?


In the course of researching this article, we discovered that many ob/gyn practices (including physicians, managers, coders and mid-levels) are confused about whether an NP, PA or CNM can be paid for first assists. Many see the mid-level surgical assistant as part of the physicians cost. But Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management, Inc., says, Yes, in many cases a mid-level provider can be paid in addition to the physician. However, certain conditions must be met.

First, the surgical procedure has to be one that allows for a professional assistant. While there is no national listing of CPT codes that allow for assists, Brink says that Medicare carriers in many states have such lists in their manuals. If no such listing is found, your only choice is to check with the payer ahead of time or bill the service and see what happens, according to Brink. Many commercial carries have a list of procedures that they do not believe merit assists.

Secondly, the mid-level providing the assist must meet the credentialing criteria of the state in which they work. According to Karen S. Fennell, RN, MS, senior policy analyst for the American College of Nurse-Midwives, these laws and regulations vary greatly across the states and among the different kinds of mid-levels. However, Fennell says that in most places nurse-midwives are fully credentialed and allowed to practice and code as physicians. The various local professional associations for the different mid-levels can be a good source of information about regulations and reimbursement. You can check with the local chapter of the American College of Midwives in your area.

Beyond meeting regulatory criteria, Brink points out that the mid-level provider must also have privileges to practice at the hospital or surgical center when the surgery is being performed.

Finally, in order to bill for mid-level services, the mid-level professional must have an individual provider number for the carrier that will be paying. Because these services will be billed as professional services and not incident to, the physicians identification number will not work. Even if the physician and the..........
Article Source : http://www.supercoder.com/coding-newsletters/my-ob-gyn-coding-alert/billing-tips-for-non-physician-surgical-assists-article

Bill US Mammogram After Clip Placement Once in a Blue Moon

Confusion over the guidelines for coding mammograms following breast biopsies creates enough of a ruckus to make you think New Year's bells are still clanging in your ears.

If a breast biopsy was performed with US guidance, many people are unsure whether you will be allowed to code and bill a separate diagnostic mammogram (76090, Mammography; unilateral) with clip placement confirmation (+19295, Image guided placement, metallic localization clip, percutaneous, during breast biopsy). The good news is that there is support for this code combination so if you're careful and provide solid documentation, you may get paid.

However, if a radiologist performs a breast biopsy using stereotactic or mammographic guidance, then the follow-up mammogram is bundled into that procedure. Most coders understand that in this case, you can't code or charge for a diagnostic mammogram. The follow-up mammogram is always bundled into 76095 (Stereotactic localization guidance for breast biopsy or needle placement [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation) and 76096 (Mammographic guidance for needle placement, breast [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation).

We had to do a lot of research before we got the answer" " says Diane Huston CPC RCC a quality-assurance auditor with Lexon Medical Las Vegas a billing service with offices located nationally and in Nevada.
What Medicare Carriers Say Like many other carriers Upstate Medicare Division (UMD) the Medicare carrier in upstate New York does not have specific edits against billing clip placement with a stereotactic biopsy. However it still maintains that if the protocol for the stereotactic biopsy with a clip calls for a postoperative mammography to check placement then you shouldn't bill for the follow-up mammography.

Such a practice would likely fail in a postpayment audit on the grounds of lack of medical necessity. This postprocedure mammogram may be considered a quality-assurance function by this payer.
The reason UMD has not put an edit in place is that it would eliminate legitimate preoperative diagnostic mammograms Huston says.
ACR Has an Opinion The American College of Radiology's (ACR) Committee on Coding & Nomenclature has issued an opinion stating "that it is not appropriate to code for a unilateral diagnostic mammogram for verification of clip placement post-stereotactic breast biopsy since these images are included in the placement of the clip localization code 19295 (provided that the guidance and exam was done by the radiologist)."

The committee goes on to say that "if a stereotactic biopsy with clip placement is done by a surgeon who then requests a radiologist to interpret a two-view mammogram to confirm clip localization it would be appropriate for the radiologist to code a unilateral diagnostic mammogram (76090)."................
Article Source : http://www.supercoder.com/coding-newsletters/my-radiology-coding-alert/bill-us-mammogram-after-clip-placement-once-in-a-blue-moon-article

Bill Fluoroscopy for SI Injections With No Arthrography

Although many insurers argue that fluoroscopy should not be billed separately from injection procedures, there are circumstances when PM&R practices should appeal denials and fight for their rightful fluoroscopy reimbursement.

Fluoroscopic guidance (76000-76005) is a must for many pain management injections, but the Correct Coding Initiative (CCI) bundles fluoroscopy into most injection procedures. Because 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid) includes arthrography in its descriptor, many coders believe that they should not report radiological supervision or fluoroscopic guidance separately. The arthrogram should be billed separately, however, and if the physiatrist does not perform arthrography with the injection, practices can bill fluoroscopy in addition to 27096.

CPT Assistant has clarified the various codes that can be submitted with 27096, advising coders to use 73542 (Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation) for the radiological supervision and interpretation associated with sacroiliac [SI] joint arthrography."" Because fluoroscopic guidance is included in 73542" you should not bill fluoroscopy separately when an arthrogram is performed. Therefore an SI injection with arthrography and fluoroscopy should be billed as follows:

27096
73542.

In some cases the physiatrist does not perform arthrography or issue a formal radiologic report with SI injections but still uses fluoroscopy to identify the appropriate injection site. In these instances you should not report 73542 but you can bill separately for the fluoroscopy using 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural transforaminal epidural subarachnoid paravertebral facet joint paravertebral facet joint nerve or sacroiliac joint] including neurolytic agent destruction). Consequently an SI injection with fluoroscopy but without a formal arthrography should be billed as follows:

27096
76005.

If your carrier denies fluoroscopy claims billed with 27096 appeal the denials with a copy of the CPT reporting guidelines (listed under the 27096 code descriptor in the CPT manual) along with a copy of your chart notes demonstrating medical necessity for the fluoroscopy and as proof that you did not perform an arthrogram with the injection.

Hip Injections Include Fluoroscopy Hip injections often require as much precision as SI injections and therefore physiatrists frequently use fluoroscopy to correctly identify the site. In fact a comment in CPT following 20610* (Arthrocentesis aspiration and/or injection; major joint or bursa [e.g. shoulder hip knee joint subacromial bursa]) advises "If imaging guidance is performed see 76003 76360 76393 76942." Coders report constant denials however when billing 76003 (Fluoroscopic guidance for needle placement [e.g. biopsy aspiration injection localization device]) with 20610.
This occurs because CCI edits bundle 76003 into most injection procedures including joint injections says Trish Buskauskas CPC the chief executive officer of TB Consulting a coding and reimbursement company.........
Article Source : http://www.supercoder.com/coding-newsletters/my-physical-medicine-rehab-coding-alert/bill-fluoroscopy-for-si-injections-with-no-arthrography-article

Bill 76872 With a Different Diagnosis Code When 76942 and 55700 are Performed on Same Day

"Some payers deny full reimbursement when a transrectal ultrasound is performed the same day as ultrasound for a needle biopsy and a biopsy of the prostate. Urologists are discovering that some carriers reject the transrectal ultrasound (76872, echography, transrectal) when billed with the other two procedures. But urology practices can get paid for all three procedures and should appeal denials for these services, explaining why the transrectal ultrasound was performed. Using a different diagnosis code for the transrectal ultrasound than the codes used for the biopsies may also help urologists obtain full reimbursement.

The transrectal ultrasound is necessary to evaluate the prostate if the patient has an elevated prostate specific antigen or an abnormal digital rectal examination. Because the urologist cannot tell from the ultrasound whether there is a benign or a malignant neoplasm, the biopsy is necessary. But some carriers believe that because the biopsy is going to be done anyway, there is no need for the initial transrectal ultrasound.

This is a long-standing problem. In a 1992 memorandum to the American Urological Association (AUA), the Health Care Financing Administration (HCFA) said that the correct codes to report the utilization of transrectal ultrasound of the prostate in guidance for needle biopsy when both are performed by a urologist are: 76942 and 55700. If the urologist and the radiologist perform the procedure together, HCFA said the urologist should report 55700 (biopsy, prostate; needle or punch, single or multiple, any approach) and the radiologist should bill 76942 (ultrasonic guidance for needle biopsy, radiological supervision and interpretation). But the underlying question is: How should the urologist be reimbursed if a diagnostic ultrasound is performed the same day as an ultrasonically guided needle biopsy? In its 1992 memo, HCFA said the scenario should be coded using 76872, 76942, and 55700.

Absence of National Policy Creates Coding Confusion

But HCFA also noted that because there was no national policy on this, the coverage of these services under Medicare is at the discretion of the carriers. The Correct Coding Initiative (CCI), implemented in 1996, allows these three codes to be billed together, according to the AUA. Carriers are not supposed to create their own coding edits in terms of coverage guidelines put in place by HCFA outside of CCI, although they can set their own policies regarding specific ICD-9 codes and frequency edits.

In a coding communication from the May 1996 CPT Assistant, the American Medical Association reported that it is correct to report 76872, 76942 and 55700 for a prostate needle biopsy with ultrasonic guidance and a separate diagnostic transrectal ultrasound. The CPT Assistant also states: Remember, the use of 76872 does not preclude reporting 76942 ... The...........
Article Source : http://www.supercoder.com/coding-newsletters/my-urology-coding-alert/bill-76872-with-a-different-diagnosis-code-when-76942-and-55700-are-performed-on-same-day-article

Thursday, 26 April 2012

Best Ways To Coordinate Benefits From Multiple Insurers

" Practices can maximize reimbursement and reduce the costs of administering claims for patients covered by more than one insurer -- such as those whose employers and spouse's employers both provide health benefits -- if they understand coordination of benefits (COB) and how both insurers are supposed to pay, says Felecia Bernstein, CPC, EMT, a coding and reimbursement consultant in Deal, N.J.

COB is a common clause in most health insurance policies. It specifies how the insurer will reimburse for services when more than one insurance plan is applied to a claim. Although COB rules can be governed by state law, and most insurers have COB rules in their contracts, many payers follow model rules developed by the National Association of Insurance Commissioners (NAIC), says Steve Verno, CMBSI, NREMPT, practice manager with Emergency Medicine Specialists, a 23-physician practice in North Miami Beach, Fla. Under the rules, the plan that pays first is known as the primary plan; the one that pays second is known as the secondary plan. The primary plan must pay benefits as if the secondary insurer did not exist. The secondary plan can only take into account what another plan paid when it is secondary to that plan.

Commercial insurance is generally primary to any public insurance program, such as Medicare and Medicaid, but there are exceptions. For example, federal law states Medicare is the secondary payer when no-fault or liability insurance is available as the primary payer, as in auto accidents. This rule applies even when state law or the insurance policy states that its benefits are secondary to Medicare or otherwise limits payments if the injured person is also entitled to Medicare benefits. Medicare is secondary to employer group health plans under federal law. Medicare beneficiaries age 65 and older who have group health-plan coverage because their spouses are working have Medicare as their secondary payer.

When a provider has a contract with an insurer" the provider must adhere to the terms of the contract and those terms can vary Verno says. A contract may contain COB rules that are different from NAIC rules. Read your contracts on COB and contact the insurer if you have questions.

To ensure your practice collects all the reimbursement it deserves when a patient has primary and secondary insurers it is essential that you obtain the correct health insurance information from the patients Bernstein says. Your front-office staff should ask for insurance information at every patient visit. You could also ask the patient for a copy of each policy Verno says. If a patient reports two insurers verify the coverage and which is primary and which is secondary with both. Getting the correct insurance information can help you submit claims to the payers correctly.......
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Avoid Fraud Fundus Photography and Fluorescein Angiography Need Two Separate Reports

"Many ophthalmologists feel its necessary to perform 92250 (fundus photography with interpretation and report) and 92235 (fluorescein angiography [includes multiframe imaging] with interpretation and report) together. As the descriptors indicate, both codes include an interpretation and report. But some ophthalmologists are asking, if these two procedures are done in connection, why they have to do an interpretation and report of 92250 if they have one for 92235 already in the chart. The short answer is: because CPT says so. Although payers dont always adhere to CPT requirements, in this case they will.

Include Separate Reports

Ophthalmologists should remember these two very important points when documenting reports for both 92250 and 92235:
1. Document medical necessity. If Medicare audits your charts and finds you are performing a fundus photo every time you perform a fluorescein angiogram (FA), they may think you have a standing order in place for the fundus photo, says Raequell Duran, president of Practice Solutions, a coding, compliance and reimbursement consulting firm specializing in ophthalmology, based in Santa Barbara, Calif. A standing order is a request, policy or understanding that certain services are to be performed unless there is a specific order not to for the patient. (See box on page 43.) Without documentation of the specific physicians order for each test performed, you lack medical necessity for the service and will not be reimbursed by Medicare, says Duran. Medicare allows standing orders only in extended-care settings such as lengthy hospitalizations or nursing-home care. Even in those settings, Medicare requires that standing orders be checked with the provider(s) who set them on a regular basis to affirm that quality care is being delivered.

2. Document technical and professional components. In the Medicare program, services that have with interpretation and report in their description have relative value units (RVUs), or payment, allocated separately for the testing or technical component of the service, Duran explains. This usually is included in the global payment for the service (professional and technical) rendered by the same provider. It also can be recognized with a -TC modifier (technical component) if only the technical component is being provided. The physician interpretation, or professional component, can be recognized with the -26 modifier (professional component) if the provider is rendering only the interpretation and not providing or billing for the technical component.

When you report the global servicethe CPT code for the testing service without the -TC or -26 modifier attachedyou are reporting that you have performed both the technical and professional component of the service, Duran says. If you do not have documentation of both services in your medical record and bill the global service, you are billing for services not rendered. Repeated......
Article Source : http://www.supercoder.com/coding-newsletters/my-ophthalmology-coding-alert/avoid-fraud-fundus-photography-and-fluorescein-angiography-need-two-separate-reports-article

Avert Improper Denials for Interpretation of Pap Smears

Some pathologists are getting claim denials for interpretation of abnormal Pap smears (e.g., 88141) when a physician does not bill Pap test (e.g., 88164) as well. Dennis Padget, CPA, FHFMA, president of Padget & Associates, a pathology and laboratory financial consulting firm in Simpsonville, Ky. serving more than 150 clients in 25 states, says clients in many states are reporting denials.

Specifically quite a few insurers including some Medicare Part B carriers are denying 88141 (cytopathology cervical or vaginal [any reporting system]; requiring interpretation by physician) P3001 (screening Papanicolaou smear cervical or vaginal up to three smears requiring interpretation by physician) and G0124 (screening cytopathology cervical or vaginal [any reporting system] collected in preservative fluid automated thin layer preparation requiring interpretation by physician) when billed without a screening Pap test code such as 88142 (cytopathology cervical or vaginal [any reporting system] collected in preservative fluid automated thin layer preparation; manual screening under physician supervision) 88164 (cytopathology slides cervical or vaginal [the Bethesda System]; manual screening under physician supervision) or P3000 (screening Papanicolaou smear cervical or vaginal up to three smears by technician under physician care) " reports Padget.

The confusion evidently stems from the CPT instruction to use 88141 in conjunction with cytopathology codes 88142-88154 and 88164-88167. Padget believes the offending insurers are reading the cited statement too literally" concluding that the American Medical Association (AMA) which authors the CPT always expects two codes to appear on one pathology claim. In other words these insurers and carriers are under the impression that CPT expects code 88141 to be paid only when accompanied by a Pap test code " states Padget.

In correspondence with Padget" however the AMA denied that the two services must be reported together. I have corresponded with the AMA for a definitive answer on what it means by in conjunction with when explaining in CPT how to bill for 88141 interpretation services says Padget. The AMAs response clarifies the meaning: The intent of the parenthetical statements concerning physician interpretation of Pap smears is not to imply that both services must be done by the same provider or facility. In conjunction with means simply that when a pathologist or facility performs both services " both codes are to be reported.

Diagnostic vs. Screening Pap Smears

To understand this scenario" coders must first be familiar with correct coding for Pap smears. Selecting the correct code depends on knowing if the reason for the test is screening or diagnostic as well as the lab methods used states Paula Richburg BS MHA director of laboratory services at QuadraMed Corp a leader in healthcare information technology in Bethlehem " Penn.

Medicare explicitly states that the code..........
Article Source : http://www.supercoder.com/coding-newsletters/my-pathology-lab-coding-alert/avert-improper-denials-for-interpretation-of-pap-smears-article

Auditor’s Worksheet Designed to Help, Not Hamper E/M Coding

The Marshfield Clinic Auditor's Worksheet can help you avoid evaluation and management coding pitfalls, but you have to work around the worksheet's own hidden traps before E/M coding becomes just a walk in the park.

In an effort to curb coding errors, experts designed the Marshfield Clinic Auditor's Worksheet, a tool for simplifying the complex rules for E/M coding. The Marshfield Clinic worksheet is a straight-forward source" " says Kent Moore manager at Health Care Financing and Delivery Systems the American Academy of Family Practices in Leawood Kan. "It is pretty consistent with or faithful to the documentation guidelines for E/M services which it was intended to be as a tool for auditing " he says.

But despite the worksheet's benefits users have expressed difficulties with the point assignments particularly in the number of diagnoses or treatment options portion of the worksheet. Overlooking this portion of the worksheet specifically the "new problem" sections often leads to lost reimbursement for work done by the ED physician or to repetitive denial claims.

The Common 'Complexity'Problem:3 Vs.4 Points
The "new problem" portion of E/M coding is a "frequent discussion among ED coders " says Todd Thomas CPC CCS-P president of Thomas & Associates a company ensuring reimbursement for emergency physicians in Oklahoma City. Almost all ED patients present new problems to an examiner he says.
The two different new problem selections in Grid A of the worksheet's Complexity Section "Number of Diagnoses or Treatment Options" "New Problem (to examiner): no additional workup planned" and "New problem (to examiner): add. workup planned" have different point values. Distinguishing between the two is crucial when it comes to reimbursement for the examining physician.

Deciding whether the service merits three points for "no additional workup planned" or four points for "additional workup planned" is nothing short of a coding challenge Thomas says: "[A]s coders we have to take all the doc's training wisdom and experience and cram it into three points versus four points."

The challenge is whether to assign the ED physician only three points for "no additional workup planned" simply because the ED physician will not do the workup or to give the ED physician four points for examining a patient who will need "additional workup" from someone else
.
The Solution
For example a patient comes in for a fractured metacarpal (815 series) and is given IV morphine for pain control. The emergency physician performs the initial treatment but an orthopedic physician will perform the additional workup.

To find the answer look to the definition Marshfield Clinic gives for a "new problem." "New" means new to the examining physician. Because this definition attributes "new" to the examining physician the point value acknowledges all...........
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Wednesday, 25 April 2012

Are You Confused by Infectious Agent Antigen Coding?

With over 120 infectious agent antigen detection codes to choose from you need some guiding principles to help you select the right one. Listed from 87260 to 87904 of the microbiology section these codes describe lab tests that indicate patient infection with specific organism(s). To find the right code every time your lab performs one of these tests our experts advise that you follow these seven steps:
1. Don't Confuse Antigen With Antibody
Before you choose one of these codes be sure the lab test was for an antigen and not an antibody. "Because many of the same organism names appear under infectious agent antigen tests in the microbiology section and under infectious agent antibody tests in the immunology section [86602-86804] coders can get confused " says Laurie Castillo MA CPC CPC-H CCS-P president of Professional Coding and Compliance Consulting in Manassas Va. Antigen tests identify a portion of the infecting agent such as a specific protein molecule or gene sequence while antibody tests identify a protein the body produces  in response to the antigen.
2. Use for Primary Source Not Culture

To use these codes you should also ensure that the lab performed the antigen test on a primary source such as a blood or urine sample not on a culture. "Although the antigen detection techniques may be similar if the lab performs the test on a culture rather than a direct smear you should report a code from the 87140 family (Culture typing; ...) " Castillo says. These codes include some of the same detection methods such as immunofluorescent technique and nucleic acid probe.
3. Select Lab Method First
Once you know that you're coding antigen detection from a primary source you should first identify the lab method to help you select the proper code. Infectious agent antigen detection codes fall under four basic techniques each of which forms a family of codes. Each family shares a common code portion preceding the semicolon that describes the method as shown in the codes below:

 






  •  87260 - Infectious agent antigen detection by immunofluorescent technique; adenovirus
     Coders may see tests in this family described as "(organism name) by DFA " or "(organism name) by immunofluorescence."
     
  •  87301 - Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative multiple step method; adenovirus enteric types 40/41
    Labs may describe tests from this family as "(organism name) by EIA technique."
     
  •  87470 - Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana direct probe technique 
  •  87471 - ... amplified probe technique
     
  •  87472 - ... quantification
    "Notice that the nucleic acid technique typically lists three codes for each organism - direct probe technique amplified probe technique and quantification " Castillo says...........



  • Answer Five Questions to Determine the Appropriate Trach Code

    To alleviate confusion concerning coding for tracheostomies, answer the following questions to guide you to the correct procedural code.

    (For tips on reporting related post-tracheostomy procedures and services, see Resolve Post-Tracheostomy Billing Issues With Three Questions"" in next month's issue.)
    " 1. Is the Tracheostomy Planned or Is It an Emergency? CPT lists four codes that describe tracheostomy with no additional procedures:


    • 31600 Tracheostomy planned (separate procedure)  
    • 31601 under two years
    • 31603 Tracheostomy emergency procedure; transtracheal
    • 31605 cricothyroid membrane
    • And one code for tracheostomies with skin flaps:
      And one code for tracheostomies with skin flaps:
    • 31610 Tracheostomy fenestration procedure with skin flaps.


    • The key difference between 31600-31601 and 31603-31605 are the terms "planned" and "emergency.   You should choose between these code sets based on the events surrounding the tracheostomy. If the patient may obstruct sometime and the otolaryngologist schedules the procedure assign a planned tracheostomy (31600-31601) says Charles F. Koopmann MD MHSA professor and associate chairman of the department of otolaryngology physician billing director and a member of the faculty group practice at the University of Michigan in Ann Arbor. "If the patient's airway is so tenuous that the physician cannot postpone the tracheostomy report an emergency tracheostomy (31603-31605)."

      The events surrounding the trach can often point you to the correct code set. For instance planned trachs (31600-31601) frequently occur after a patient has been intubated for a long period or requires long-term ventilatory support. The tracheostomy helps to suction secretions and increase air delivery to the lungs. The attending physician usually requests that an otolaryngologist perform the procedure. For these elective planned tracheostomies you should report 31600 or 31601.

      On the other hand doctors perform emergency tracheostomies when a patient's airway is so compromised that he may obstruct at any moment. For example a patient presents with wheezing (786.07) which is quickly progressing to upper-airway obstruction. The otolaryngologist performs a tracheostomy. For emergent situations that require an opening of the windpipe assign 31603-31605.

      Some coders question whether an emergency trach requires a dire situation or if a situation that requires a same-day tracheostomy qualifies as urgent. "Emergency tracheostomy is just what it says it is it is an emergent situation " says Barbara Cobuzzi MBA CPC CPC-H an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions a medical billing firm in Lakewood N.J.
      Stedman's Medical Dictionary defines emergency as "an unexpected development or happening; a sudden need for action." "You cannot describe a set amount of time to define an emergency versus planned trach " Koopmann explains. An emergency trach instead requires a sudden need for action due to the condition of the patient's airway.

    Acceptance of New Endoscopy Codes Will Increase Reimbursement

    CPT 2001 includes 14 new gastrointestinal endoscopy codes and several code revisions. The new code additions primarily reflect current endoscopic ultrasound (EUS) examination procedures, ultrasound-guided intramural or transmural fine needle aspiration (FNA)/biopsy procedures and stent placement procedures in most sections of the gastrointestinal tract. While these codes will be welcomed by gastroenterologists, many questions still surround their appropriate usage.

    The new gastrointestinal endoscopy codes go into effect on Jan. 1, 2001, and will concentrate on the following three medical procedures:

    endoscopic ultrasound examinations (EUS);

    ultrasound-guided intramural or transmural fine needle aspiration (FNA)/biopsy; and

    the transendoscopic placement of stents.

    Coding EUS and FNA/Biopsy

    The new EUS and related EUS FNA/biopsy codes are as follows:

    43231 esophagoscopy, rigid or flexible; with endoscopic ultrasound examination

    43232 ... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

    43242 upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

    45341 sigmoidoscopy, flexible; with endoscopic ultrasound examination

    45342 ... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

    All CPT definitions for these EUS and FNA/biopsy codes contain the phrase fine needle aspiration/biopsy(s). The (s) indicates that this code should be reported once, regardless of the number of fine needle biopsies taken during the session.

    Reimbursement May Drop With New Codes

    Although gastroenterologists have lobbied a long time for these EUS codes, they may be disappointed with the reimbursement, particularly from Medicare. A radiological supervision and interpretation code cannot be billed with these new EUS codes. A cross-reference appears at the end of each new EUS and EUS FNA/biopsy code that instructs gastroenterologists to not report 76975 [gastrointestinal endoscopic ultrasound, supervision and interpretation] in conjunction with the EUS procedures.

    The CPT manual illustrates that the work that goes into the interpretation and supervision of the radiological films is built into the endoscopic ultrasound codes themselves, says Maurits Wiersema, MD, FACP, FACG, a gastroenterologist and associate professor of medicine at the Mayo Clinic in Rochester, Minn., and a member of the American Medical Associations (AMA) CPT editorial advisory panel.

    However, that creates a real paradox because gastroenterologists will get paid less for doing an upper gastrointestinal endoscopy (EGD) with an EUS FNA/biopsy under CPT 2001 than they would if they performed an EGD with only an EUS (43259, upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination) and billed it with the radiological supervision and interpretation code 76975.

    Code 43259, to which Wiersema is referring, was the only gastrointestinal EUS code in CPT 2000. In CPT 2001, it is the only EUS code that has a cross reference.......


    A Surefire Strategy for Male Mammogram Claims

    Hint: Don't rely on your diagnosis codes
    While Medicare often covers diagnostic mammography for male patients with symptoms of breast cancer screening mammograms are another story. Your best bet is to have male patients sign an ABN before you perform a screening mammogram.

    TV announcer Rod Roddy the famous voice of "The Price Is Right " died in October of colon and breast cancer prompting many men to wonder whether breast cancer could happen to them. Because Roddy's death publicized the fact that 1 500 men each year are diagnosed with breast cancer your radiology clinic may soon begin fielding calls from men interested in getting screened for the disease.
    Screening Mammos Are Male-Exempt
    Most local medical review policies (LMRPs) recommend V76.12 (Other screening mammogram) for screening mammograms (76092 Screening mammography bilateral [two view film study of each breast]). The carrier may or may not pay for this service however because CMS covers annual screening mammography for "All women age 40 and over and one baseline screening mammography for women between the ages of 35 and 39."
     
    "Medicare does not cover screening mammography on males by statute " says Jeff Fulkerson BA CPC CMC certified coder for the department of radiology at The Emory Clinic in Atlanta.

    If you perform a mammogram on a male patient in the future you should ask him to sign an advance beneficiary notice (ABN) and append modifier -GA (Waiver of liability statement on file) to 76092 Fulkerson says.

    If you do not obtain an ABN he says you should append modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to 76092. "By adding modifier -GY you are telling the carrier that you know that the service is not covered by statute and do not expect reimbursement " Fulkerson says. "How your local carrier wants the provider to handle claim filing for this type of exam may vary."
    You Can Collect for Diagnostic Mammos
    If you perform a diagnostic mammogram on a male patient (76090 Mammography; unilateral) or 76091      (... bilateral) your practice should document a meticulous patient history because most male patients referred for diagnostic mammography actually have signs and/or symptoms that support the performance of a diagnostic mammogram (for example mass nipple discharge or pain with or without swelling). "History of a mother with breast cancer usually is not sufficient " says Candace Ryan coding supervisor at Radiology Consultants in Denver. "You need a more comprehensive reason for the mammogram than that."

    In such cases you should report the appropriate ICD-9 code(s) for the signs and symptoms. "Most carriers cover diagnostic mammograms for males using the same symptoms conditions and diagnoses that are........


    Tuesday, 24 April 2012

    97014 vs 97032: Make Sure You Know How to Code Electrical Stimulation and Avoid Triggering an Audit

    Tip:  Report G0281-G0283 to Medicare for unattended stimulation

    If your physiatrist performs attended electrical stimulation (97032) but you're reporting unattended electrical stimulation (97014) because you don’t want to attract the OIG’s attention your carrier may notice you bill differently than other PM&R practices which could trigger an audit anyway.
    Know When to Report Electrical Stimulation

    Although this treatment is neuromuscular electrical stimulation you should not report it using 64565 (Percutaneous implantation of neurostimulator electrodes; neuromuscular).

    Electrical stimulation uses an electrical current to cause a single muscle or a group of muscles to contract. By placing electrodes on the skin in various locations the provider can recruit the appropriate muscle fibers to contract and strengthen the affected muscle. The current setting can be changed to allow for a forceful or gentle muscle contraction. Along with increasing muscle strength the contraction of the muscle also promotes blood supply to the area that assists in healing says Marvel Hammer RN CPC CHCO president of MJH Consulting in Denver.

    You should report 97032 (Application of a modality to one or more areas; electrical stimulation [manual] each 15 minutes) for electrical treatments that require "constant attendance" and therefore direct patient-to-provider contact according to CPT. You should not report an electrical stimulation code such as 97014 (... electrical stimulation [unattended]) because it refers to a therapy modality that does not require the presence of a clinician.

    Note: For Medicare you cannot bill 97014 in any case. You've got to use G0281 (Electrical stimulation [unattended] to one or more areas for chronic stage III and stage IV pressure ulcers arterial ulcers diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care) for wound care and G0282 (Electrical stimulation [unattended] to one or more areas for wound care other than described in G0281) and G0283 (Electrical stimulation [unattended] to one or more areas for indication[s] other than wound care as part of a therapy plan of care) for all other unattended stimulation says Paula Franko PT MCSP owner of Encompass Consulting & Education LLC in Tamarac Fla. 
    Differentiate 97014 and 97032
    Key idea: The biggest difference between 97032 and 97014 is that the therapist or physician must stay with the patient during the treatment to report the attended code (97032). When you're reporting 97032 you're saying that your provider promoted muscle function wound stimulation etc. and was directly involved one-on-one throughout the entire treatment. When you report 97014 the provider sets up the electrodes and then can go and treat someone else Franko says.

    Another big difference is that 97014 is not a time-based code so you should only bill it...........
    For more read:-
     http://www.supercoder.com/articles/articles-alerts/pmc/97014-vs-97032-make-sure-you-know-how-to-code-electrical-stimulation-and-avoid-triggering-an-audit/

    7 Tips to Boost ECG Payments

    ICD-9 Codes

    "Getting paid for electrocardiogram (ECG) interpretations can be challenging. Cardiologists should make sure they are using covered diagnosis codes and make separate billing arrangements with hospitals for the interpretations they perform to maximize reimbursement for the services provided, coding experts say.

    Cardiologists often interpret the ECG of a patient whose diagnosis was made by another physician. The patient may have been sent to the cardiologists office by a primary-care physician (PCP), or admitted to the hospital by the PCP, an emergency room physician or a surgeon.

    An ECG may be performed in the office using equipment owned by the cardiologist or his or her practice (Codes 93000, electrocardiogram, routine ECG with at least 12 leads; with interpretation and report); or the cardiologist may do an interpretation (93010, interpretation and report only) at the hospital. Either way, another physician may have diagnosed the patient, and when the bill for the ECG interpretation is submitted by the cardiologist, it will be denied if the diagnosis code isnt covered by the carrier, says Terry Fletcher, BS, CPC, CCS-P, a cardiology coding consultant in Dana Point, Calif.

    Similarly, when a patient is referred to the cardiologist for a pre-operative clearance ECG, the subsequent claim often is denied. Pre-operative clearance is standard procedure at many hospitals, but without an approved diag-nosis, the cardiologists claim will be rejected, Fletcher says.

    Although interpretations are not reimbursed at a high rate93010 has 0.35 relative value units (RVU), paying out at a national average of $12.60ECGs are among the top 50 services provided by cardiologists. That means those $7-$15 fees add up, and now Medicare carriers are scrutinizing ECG interpretations closely to control costs, says Cynthia Swanson, RN, CCS-P, a coding and reimbursement specialist with Seim, Johnson, Sestak & Quist, LLP, in Omaha, Neb.

    Medicare doesnt always want to pay for ECGs done in conjunction with a cataract or orthopedic procedure. The doctors may believe the test is medically necessary, but Medicare wont pay for it, Swanson says. Now, Medicare does not cover tests when diagnosis criteria arent met or when the test is preventive (e.g., screening) and is deemed not medically necessary by the Health Care Financing Administrations (HCFA) definition.

    7 Tips to Improve Pay Up

    The following helpful guidelines can help you optimize reimbursement, minimize denials and stay in compliance while coding with the information you have.

    1. Check Incoming Diagnosis From Referring Doctor. The information in the order form from the primary-care physician requesting the ECG may be incomplete. For example, if the patient is about to have an operation to remove cataracts, the form may not even say cataract. Instead, all it says is patient scheduled for surgery. And the cardiologists may not.............
    For more read:-
     http://www.supercoder.com/articles/articles-alerts/cca/7-tips-to-boost-ecg-payments/

    6 Guidelines Point You to the Correct Complicated Ear Diagnoses

    Report otomycosis' underlying disease, ICD-9 instructions indicate
    When chart notes contain elusive terms, such as ear effusions"" and ""fungal otitis externa" " following ICD-9 Coding Conventions will keep you coding like an otolaryngology expert.

    To submit the correct diagnostic codes for complicated ear diagnoses remember these rules.
    Start With 'A'
    First you should always look up the key terms in ICD-9's Alphabetic Index. "Sometimes you'll find the diagnosis the otolaryngologist listed " says Cindy M. Austin facility manager at Dothan ENT Allergy and Asthma PC in Dothan Ala.
    2 Sources Unlock Possible Diagnoses
    When you're confronted by anatomic or medical terms that don't appear in ICD-9's Alphabetic Index - and you're not familiar with the phrases - you should use your sources. "Look up the key terms in a good medical dictionary " says John F. Bishop PA-C CPC president and CEO of Bishop & Associates Inc. in Tampa Fla. The information may point you to a listed ICD-9 diagnosis.

    Example: An otolaryngologist states that the diagnosis for tubes is "ear effusions." When you look up the key phrase "effusion" in ICD-9's Alphabetic Index you find no listing. A search for "effusion" produces the following information:

    Otitis Media With Effusion 




  • Alternative Names: Glue Ear OME Secretory Otitis Media Serous Otitis Media Silent Ear Infection Silent Otitis Media
     
  • Definition: Otitis media is an inflammation of the middle ear. Otitis media with effusion (OME) refers to fluid in the middle ear space but without the symptoms of an acute infection.

    Therefore you know to look up "otitis media" in ICD-9's Alphabetic Index. When you locate "otitis" you find among the entries one of the above synonyms "serous":

    serous 381.4
    acute or subacute 381.01
    chronic (simple) 381.10.

    The listing points you to nonspecified otitis media code 381.4 (Nonsuppurative otitis media not specified as acute or chronic) which includes "otitis media: serous" and "otitis media: with effusion." If you have further information as to whether the patient has acute or chronic OM you can use the specific diagnosis of 381.01 or 381.10.

    Alternative: If a medical dictionary doesn't give you the information you need to locate an appropriate listed synonym go back to the otolaryngologist for more information. "I ask the physician to explain the unknown term to me so that we can get the right code " Austin says. Slanted Brackets Signal Duel Coding
    ICD-9's Alphabetic Index sometimes includes additional coding directives. For instance if you find slanted brackets following a code you must use these codes together Bishop says. "You should look up the bracketed code to make sure the entry applies " he says.

    Case: After determining that "fungal otitis externa" refers to "otomycosis " you locate the latter phrase in the Alphabetic...........
    For more read:-
     http://www.supercoder.com/articles/articles-alerts/otc/6-guidelines-point-you-to-the-correct-complicated-ear-diagnoses/
  • 5 Examples Tie Diabetes Complications to ICD-9 Codes

    Don't let coding for multiple conditions trip you up
    Each time you choose a fourth digit for diabetes diagnosis code 250.xx you also need to select the appropriate code to identify the specific diabetic manifestation.

    Although the ICD-9 manual lists several possible manifestation code choices below each fourth-digit descriptor you should realize that this is "definitely not an exhaustive list " says Alison Nicklas RHIT CCS director of education and training for Precyse Solutions based in King of Prussia Pa.

    For example the ICD-9 manual lists 583.81 (Nephropathy) and 581.81 (Nephrosis) as possible manifestation codes below 250.4x (Diabetes with renal manifestations). But the manual doesn't list 585 (Chronic renal failure) even though this code is a possible renal manifestation. 

    Avoid coding pitfalls with these tips for five diabetes complications:

    1. Ketoacidosis: Diabetes' most serious acute metabolic complication is diabetic ketoacidosis (DKA) says Shelley Wojtasczyk MS FNP-C a nurse practitioner in a family medicine clinic in Arcade N.Y. The acidosis complication also occurs in patients with chronic and acute alcoholism she says. When coding for diabetic complications be sure the medical chart states whether the patient has diabetic ketoacidosis.

    Only one code: Don't worry about finding an additional code to identify the ketoacidosis as you would with other diabetic complications Nicklas says. Code 250.1x specifies that the patient has diabetic ketoacidosis and "that one code tells the whole story " she says.

    2. Renal failure: Diabetic patients can have nephropathy which leads to kidney failure Wojtasczyk says.

    If the physician's documentation indicates that the patient has chronic renal failure caused by diabetic nephrotic syndrome all you really need to code is 250.4x and 585 (Chronic renal failure) says Nicklas who presented in a March 11 audio seminar titled  "Diagnosis Coding for Diabetes" for the American Health Information Management Association (AHIMA).

    However if you prefer to code all three conditions you can also list 581.81 (Nephrosis) she adds.

    3. Hypertension and renal failure: A diabetic patient may present with hypertension and renal failure as a result. If this is well documented you only need two codes Nicklas says. Assign one code for the diabetes with renal manifestations (250.4x) and one code for the hypertension with renal failure (403.91).

    You don't have to list any other code because the hypertension code includes renal failure she says. You can assign 583.81 (Nephritis and nephropathy) in addition but remember that this is optional.

    4. Cataracts: Internal medicine coders must understand that not all diabetic patients have diabetic cataracts (commonly called snowflake cataracts) Nicklas says. "Studies have shown that most diabetics actually have the more common senile cataracts " she says.

    Snowflake cataracts are rare. Most physicians find them in diabetic patients Wojtasczyk adds.

    To............
    For more read:-
     http://www.supercoder.com/articles/articles-alerts/ica/5-examples-tie-diabetes-complications-to-icd-9-codes/

    Thursday, 19 April 2012

    43235 Is the Key to EGD ‘Family’ Coding Success

    CMS has upped RVUs for several EGD codes
    Do you know how frequently biopsies are performed with upper EGDs? Can you list all of the procedures included in the upper EGD family""? Become familiar with these common gastro codes to set your office up for future success.
    " CMS Sees 43235 'Family' Frequently
    In the most recent list of top-50 procedures reported in gastroenterology offices the Centers for Medicare and Medicaid Service (CMS) included several codes from the 43235 endoscopy family. This is no surprise to Janene Long billing supervisor at Gastroenterology & Hepatology Associates in Reading Penn. She says the 43235 code family would have several entrants in her office's most-performed-procedures list.

    Extra Incentive: These codes were always common in a gastro setting and they're also quite profitable too (see "CMS Grants RVU Increases to 5 Codes in the 43235 'Family' " ). Read on for some expert advice on the 43235 family to ensure you are coding upper diagnostic EGDs the right way every time.
    Learn What Makes Up a Family
    In order to keep things less complicated for coders and gastroenterologists CPT divides endoscopy codes into families.

    Example: Rigid or flexible EGDs are grouped into one endoscopic family: The family code group starts with the base code 43200 (Esophagoscopy rigid or flexible; diagnostic with or without collection of specimen[s] by brushing or washing [separate procedure]) and includes all of the codes between 43200 and 43232 (... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s]).

    Families of codes share the same base procedure. "It's just that you do something else in addition [to the base procedure] " says Amanda Morreale billing supervisor for UCLA's Physician Support Services.
    Use 43235 as the Base Code 
    To best understand the 43235 family start with the base code. The 43235 family's base code is appropriately 43235 (Upper gastrointestinal endoscopy including esophagus stomach and either the duodenum and/or jejunum as appropriate; diagnostic with or without collection of specimen[s] by brushing or washing [separate procedure]) and all codes up to 43259 (... with endoscopic ultrasound examination including the esophagus stomach and either the duodenum and/or jejunum as appropriate) are part of the family.

    The base code includes the diagnostic upper EGD and every other code in the family represents a procedure in which the EGD is performed in addition to something else Morreale says. Let's say the gastroenterologist performs an upper diagnostic EGD with biopsy; you would report 43239 (... with biopsy single or multiple) instead of 43235.

    Some indicators for a diagnostic EGD include:




  •  persistent upper abdominal distress despite trial of therapy
  •  upper abdominal distress with symptoms suggesting a serious organic disease such as anorexia and weight loss
  •  dysphagia or odynophagia
  •  persistent or recurrent esophageal reflux symptoms despite.......... 
  • For more read:-  http://www.supercoder.com/articles/articles-alerts/gac/43235-is-the-key-to-egd-family-coding-success/

    3 Surefire Steps You Need to Avoid Tonsil/Adenoid Removal Miscodes

    Secret: You can use 42820, 42821 as universal T&A codes
    If you don't know when a patient's age and prior surgery status affect tonsillectomy and adenoidectomy coding, you could be choosing the wrong code or even unbundling procedures.
    Step 1: Check the Patient's Age
    When coding for tonsillectomies and/or adenoidectomies, you should choose the appropriate code based on the patient's age.

    CPT contains two tonsillectomy codes, four adenoidectomy codes, and two combination codes - all of which separate at age 12.

    For a child who is under age 12, you will use:
     




  • 42820 - Tonsillectomy and adenoidectomy; under age 12
     
  • 42825 - Tonsillectomy, primary or secondary; under age 12 
  • 42830 - Adenoidectomy, primary; under age 12 
  • 42835 - Adenoidectomy, secondary; under age 12.  When the patient is age 12 or older, you should assign:

  • 42821 - Tonsillectomy and adenoidectomy; age 12 or over 
  • 42826 - Tonsillectomy, primary or secondary; age 12 or over  
  • 42831 - Adenoidectomy, primary; age 12 or over 
  • 42836 - Adenoidectomy, secondary; age 12 or over. Warning: Prompt T&A payment depends on your selecting the right age-specific code. If you use 42820 on a 13-year-old child" the insurance company will deny the claim " says Eileen Antico CPC an otolaryngology coding specialist at Nemours Clinical Management Program (12 otolaryngologists) in Orlando Fla. "Most payers' computer systems have claim edits in place that would drop a mismatched age and code claim from processing."

    Step 2: Look for Primary Secondary Adenoidectomy
    If the otolaryngologist performs an adenoidectomy alone you must also check the operative report to see whether the patient had a secondary adenoidectomy.

    You should use 42830 or 42831 for a primary adenoidectomy. But if the patient has had adenoids previously removed you should code a secondary adenoidectomy with 42835 or 42836. "A secondary adenoidectomy removes the regrowth of the adenoids or any portion missed during the first procedure " Antico says.

    Coding example: An otolaryngologist removes portions of the adenoids that regrew after a 6-year-old patient's primary adenoidectomy. Because the surgeon performs a secondary procedure - and CPT distinguishes between primary and secondary adenoidectomies - you should report this operation with 42835.

    Watch out:
    Even though an otolaryngologist may perform a primary or secondary tonsillectomy CPT lumps both procedures into one code. Although the patient's medical record should reflect whether the patient previously had tonsils removed you still use the same code.

    Step 3: For T&A Report 42820 or 42821
    When coding for a combination T&A you also don't have to distinguish whether the otolaryngologist performed a primary or secondary adenoidectomy.

    "Nowhere is [42820-42821] confined to primary or secondary patient types " says Andrew Borden CCS-P CPC CMA reimbursement manager in the department.....
    For more read:-
     http://www.supercoder.com/articles/articles-alerts/otc/3-surefire-steps-you-need-to-avoid-tonsiladenoid-removal-miscodes/
     
  • 3 Strategies Guide Your ‘Late Effects’ Coding

    If you're overlooking late effects when assigning ICD-9 codes you're providing incomplete information and possibly compromising your surgeon's reimbursement. Fortunately recognizing and reporting late effects can be simple when you know what to look for.
    1. Link the Past and Present
    Late effects are the long-term effects of an injury or illness after the acute phase is over. For example a trauma patient may continue to have pain and other symptoms years after his various wounds and fractures have healed. Some late effects present early while others might become apparent months or years later. "There are no time limits for late effects " says Marcella Bucknam CPC CCS-P CPC-H CCA HIM program coordinator at Clarkson College in Omaha Neb.

    The ICD-9 manual provides a separate subsection (905-909) describing "Late Effects of Injuries Poisonings Toxic Effects and Other External Causes." Late effects that surgeons commonly see can include 906.0-906.9 (Late effects of injuries to skin and subcutaneous tissues) 907.0-907.9 (Late effects of injuries to the nervous system) or 908.6 (Late effects of certain complications of trauma) for example.

    Late effects tell the whole story of a patient's condition and they present a much clearer picture to the carrier of why a physician may treat a patient in a particular way says Terry Fletcher BS CPC CCS-P CCS CMSCS CMC a coding and reimbursement specialist in Laguna Niguel Calif.

    Specifically late effects codes link what is going on with the patient now with what happened in the past. "Like E codes for external causes of injury and poisoning late effects codes provide a more complete picture of the reason for treatment and can become an issue for patients who are injured in an auto accident or in workers' compensation claims '' Fletcher says.

    To determine whether a condition is a late effect you should look for key words in the physician's documentation such as "late " "old " "due to " "caused by" and/or "following." "Paralysis due to stroke " for instance is a clear indication of a late effect of cerebrovascular accident.

    Don't confuse late effects with complications: The two are not the same. "A complication describes a problem arising from a condition that still exits. A late effect on the other hand is caused by a condition no longer in its acute phase " Bucknam says. Certain conditions such as mal- or nonunion of fractures and scarring are inherent late effects regardless of when they occur.
    2. Assign Late Effects as Secondary Diagnoses
     When reporting late effects of an acute injury code the residual problem/condition as the primary diagnosis and record the appropriate late effects code as a secondary diagnosis according to section 1.7 of the Official ICD-9-CM Guidelines for........
    For more read:-
    http://www.supercoder.com/coding-newsletters/my-general-surgery-coding-alert/3-strategies-guide-your-late-effects-coding-article

    1 Tool You Need Before Coding a Skin Lesion Excision

    CPT, ICD-9 force you to withhold suspicious-lesion claims

    Don't be tempted to bill claims for patients' suspicious skin lesions up front. You should instead defer coding until you receive the pathology report.

    We wait for the pathology report to code any lesions that the family physician (FP) has suspicions about" " says Shari Aloway CPC coding specialist at Flowertown Family Physicians in Summerville S.C.

    Why: Waiting for the pathology report allows you to select appropriate CPT and ICD-9 codes says Mary I. Falbo MBA CPC president of Millennium Healthcare Consulting in Landsdale Pa. Until the pathologist determines the skin lesion's nature you don't have enough information to choose either code.
    However you may think making the patient wait for a bill or pay more if the skin lesion is malignant is inappropriate. But coding without a pathology report can prove an insurmountable feat.
    If you still think you can code skin lesion excisions without a pathology report take this challenge: Find a CPT and ICD-9 combination that describes a "suspicious" skin lesion.

    CPT Offers Benign or Malignant Categories No suspicious or uncertain skin lesion excision code exists. CPT contains only benign and malignant lesion removal codes says Susan LeFevre CPC coder at the 10-FP Reedsburg Area Medical Center in Reedsburg Wis.
    Suppose your FP removes a 2-mm suspicious skin lesion from a patient's back using a 1-mm margin. You have to choose between two procedural codes:








  • 11400 - Excision benign lesion including margins except skin tag (unless listed elsewhere) trunk arms or legs; excised diameter 0.5 cm or less
  • 11600 - Excision malignant lesion including margins trunk arms or legs; excised diameter 0.5 cm or less. You could lose about $43 ($151.97 rather than $109.03 based on Medicare's geographically unadjusted rate) if you pre-emptively report a benign skin lesion code. "Reimbursement is higher for malignant lesions " Aloway says.
    Problem: Your patients may question charging based on malignancy. "How can you justify billing a higher price for a cancerous lesion?" LeFevre asks. The FP performs the same procedure regardless of the pathologist's findings.
    A malignancy may contribute more to your bottom line but you shouldn't code according to price. Reporting a malignancy justifies future services Falbo explains. And payers typically won't cover benign skin lesion removal. You won't know if you should charge the patient for the noncovered service until you know the lesion's type.
    Solution: Hold the claim until a pathology report leads you to or confirms your CPT code selection.
    'Suspicious'Doesn't Mean 'Uncertain ''Unspecified'
    In the above suspicious-back-lesion example your diagnostic options include:
  • malignant such as 173.5 -- Other malignant neoplasm of skin; skin of trunk except scrotum
  • benign 216.5...........                                                                                                                           For more read:-                                                                                                                       http://www.supercoder.com/coding-newsletters/my-family-practice-coding-alert/1-tool-you-need-before-coding-a-skin-lesion-excision-article
  • Wednesday, 18 April 2012

    Understand the Building Blocks of Spinal Reconstruction Surgery Coding

    When you comprehend the large number and complexity of terms associated with spinal anatomy, disorders and surgical procedures, coding for spinal reconstruction surgery becomes less daunting. Consequently, you will leave less reimbursement on the table.
    A coder unfamiliar with spine procedures may be baffled by an operative report that reads, laminectomy" L4-5 foraminotomies L4 L5 S1 posterolateral fusion with pedicle fixation L4-5 left iliac crest bone graft." An understanding of these terms can make the spinal coding process a surmountable challenge.
    Coding Spinal Reconstruction Procedures Among the most complicated of an already complex subspecialty spinal reconstruction procedures are used to correct injuries to the spine caused by external factors (falls accidents etc.) and degenerative or deformative diseases such as scoliosis or degenerative disc disease. These procedures involve the use of fusion instrumentation or cages.

    Codes 22548- 22899 describe reconstructive surgeries to the spine. The procedures are often performed in combination with one another which is always the case when instrumentation or cages are inserted. The code descriptions often include the surgical approach either posterior anterior or posterolateral. In posterior approach surgeries the incision is made in the patient's back. In an anterior approach the incision is made in the abdomen or neck and the surgeon moves organs and viscera to reach the operative site on the anterior or front of the spine. In a posterolateral approach the patient lies on his side and the surgeon accesses the operative site from the back.
    When and How to Report Arthrodesis Also referred to as spinal fusion arthrodesis involves removing corrupt vertebra and disk material and replacing it with bone graft or instrumentation to stabilize the spine. It is often performed in combination with other spine procedures and can be approached from the anterior posterior posterolateral or lateral transverse positions. Fusion can be required for several reasons: to treat a vertebral fracture to correct degenerative conditions or to correct deformity from scoliosis or kyphosis.
    Codes 22554-22558 (Arthrodesis anterior interbody technique including minimal diskectomy to prepare interspace [other than for decompression ]) are for anterior fusions or arthrodesis at the cervical level below C2 thoracic and lumbar levels and +22585 ( each additional interspace [list separately in addition to code for primary procedure]) is the add-on code for each additional interspace(s). Code 22548 (Arthrodesis anterior transoral or extraoral technique clivus-C1-C2 [atlas-axis] with or without excision of odontoid process) is different from the other anterior fusion codes in that rather than approach the surgical site through an incision in the neck or trunk the surgeon approaches orally or through the patient's mouth. Obviously this code is only for surgeries to the cervical area.

    Anterior fusions are.............
    For more read:-
     http://www.supercoder.com/coding-newsletters/my-orthopedic-coding-alert/understand-the-building-blocks-of-spinal-reconstruction-surgery-coding-article

    Two Codes Are the Keys to Reporting New Endometrial Ablation Techniques

    New methods for endometrial ablation are here or on the horizon, and although they promise relief for patients, they are bound to bring challenges to ob-gyn coders (see Know the Treatment Options for Endometrial Ablation"" - article 2).
    "What Is Dysfunctional Uterine Bleeding? Physicians often use endometrial ablation to treat dysfunctional uterine bleeding which is also known as menorrhagia the formal name for prolonged or excessive menstrual bleeding. In some patients the bleeding is so severe that it causes anemia. Current ICD-9 codes associated with this condition are 626.2 (Excessive or frequent menstruation) 626.4 (Irregular menstrual cycle) 626.6 (Metrorrhagia) 626.8 (Other) and 626.9 (Unspecified).
    Many things may cause this condition including a hormonal imbalance abnormal ovulation uterine trauma polyps fibroid tumors cancer cervicitis and other infectious conditions. Irritation from an intrauterine device may also cause menorrhagia or it may be a sign of an ectopic pregnancy.
    Coding the Related Services Until CPT 2001 only one procedure code existed for endometrial ablation. That code 58563 describes the use of a hysteroscope to accomplish the endometrial ablation. CPT added a second code 58353 in 2001 to describe the thermal balloon procedure which is accomplished normally without the use of the hysteroscope.

    But how is the coder to know which code to use with the new techniques and what other services can be billed at the time of the procedure? "To begin identify the various types of services provided at the time of the endometrial ablation to see if any can be coded in addition to the procedure " says Melanie Witt RN CPC MA an independent coding consultant and educator based in Fredericksburg Va.
    All of the new techniques for endometrial ablation have cervical dilation in common. Because this is an integral part of the procedure you normally would not code it separately if performed at the time of the procedure. Some physicians however may elect to prepare the cervix in advance using a cervical dilator. You can report this procedure separately using 59200 (Insertion of cervical dilator [e.g. laminaria prostaglandin] [separate procedure]).

    "Because this is a CPT 'separate procedure ' if the ob-gyn performed the cervical dilation on the same date as the ablation but earlier in the day and the physician has met the criteria for using this modifier modifier -59 (Distinct procedural service) should be added " Witt says. If the insertion took place the day before surgery you would not need to add a modifier. "Also note that because 59200 has a zero-day global period you would not need a modifier for the endometrial ablation code performed the next day either " she adds.
    The new methods for performing endometrial ablation may involve the administration of................
    For more vread:-
     http://www.supercoder.com/coding-newsletters/my-ob-gyn-coding-alert/two-codes-are-the-keys-to-reporting-new-endometrial-ablation-techniques-article

    Tube Procedures Are Pipeline to Reimbursement

    Appropriate coding for tube placements and replacements depends on coders distinguishing whether the gastroenterologist performed the procedure manually or endoscopically. Further, understanding the different tube variations and applications can help limit coding problems.   PEG Tube Variations   Percutaneous endoscopic gastrostomy (PEG) tube placement is reported with 43246 (upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube), says Linda Parks, MA, CPC, lead coder with the 22-physician Atlanta Gastroenterology practice. 
    Physician notes sometimes contain references to buttons"" PEG buttons or ""Mickey"" buttons. These are smaller" shorter tubes that are inserted through the tract in the skin of the abdomen that was created by a standard PEG tube explains Michael L. Weinstein MD of Metropolitan Gastroenterology Group in Washington D.C. and previous American Society for Gastrointestinal Endoscopy (ASGE) representative to the CPT Advisory Board. 
    "PEG buttons are used to replace a standard PEG tube after several weeks or months when the original tube tract has matured " Weinstein says. "Therefore you usually code it as a PEG tube replacement (43760 change of gastrostomy tube).
    "You also might see tube descriptions with ports balloons or bumpers " Weinstein adds. "They're all tubes. MIC and Bard are just some of the brand names." Placement of these shorter tubes is still coded with 43246. Changing PEG tubes of any kind should be reported with 43760.

    An Alternative to PEG Tubes   Gastroenterologists also use percutaneous endoscopic jejunostomy (PEJ) tubes explains Thomas M. Deas Jr. MD of Gastroenterology Associates in Fort Worth Texas and chairman of the Practice Management Committee of the ASGE. This is a long tube that is passed through the PEG tube into the small bowel rather than the stomach.  
    There are two ways to code the PEJ tube procedure. The patient may already have a PEG tube in place and the physician has to convert it to a PEJ tube by going beyond the duodenum. This method should be reported with 44373 (small intestinal endoscopy enteroscopy beyond second portion of duodenum not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube). If the patient does not have a PEG tube coders should use 44372 (... with placement of percutaneous jejunostomy tube) for the initial PEJ tube placement. 
    Code 44500 (introduction of long gastrointestinal tube [e.g. Miller-Abbott]) refers specifically to the length of a tube Weinstein explains. Longer tubes are weighted at the end (with mercury for example) and are used when there is a gastrointestinal obstruction. 
    "No other procedure needs to be performed with this " Weinstein says. "The tube position usually requires checking an x-ray -- a separate billable service ................
    For more read:-
    http://www.supercoder.com/coding-newsletters/my-gastroenterology-coding-alert/tube-procedures-are-pipeline-to-reimbursement-article