Thursday, June 30, 2011

Coding Corner: Overcome Modifier 22 Mishaps With 3 Mythbusters

Making assumptions about automatically applying 22 will land you in OIG hot water.

If you overuse modifier 22 (Increased procedural services) you'll wind up facing scrutiny -- or worse -- from your payers or even the Office of Inspector General (OIG). But if you avoid the modifier entirely, you're likely missing out on reimbursement your physician deserves.

How it works: When a procedure requires significant additional time or effort that falls outside the range of services described by a particular CPT code -- and no other CPT code better describes the work involved in the procedure" you should look to modifier 22. Modifier 22 represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code but instead raise the reimbursement for a given procedure.

Take a look at these three myths -- and the realities -- to ensure you don't fall victim to the modifier 22 catch-22.

Myth #1: Morbid Obesity Means Automatic 22

While morbid obesity is sometimes an appropriate reason to use modifier 22, it's not appropriate to assume that just because the patient is morbidly obese you can append modifier 22.

"Modifier 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

"Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifier 22 should not be appended," warns Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, director of best practices -- network operations at Mount Sinai Hospital in New York City.

There are some scenarios where you usually be considering whether modifier 22 is appropriate -- such as reoperations, unusual body habitus (obesity, unusually thin, tall, short, etc.), altered anatomy (congenital or due to trauma or previous surgery), and very extensive injury or disease -- but do not automatically append modifier 22 without the documentation to back it up. You'll only be able to append modifier 22 when a procedure requires substantially greater additional time or effort because of the patient's obesity.

Check the notes: To support appending the modifier, your physician should document how the patient's obesity increased the complexity of that particular case. CPT specifically recommends that surgeons document the reason for the additional effort, such as "increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required."

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Tuesday, June 28, 2011

ICD-10 Preparation: Not Planning to Transition to ICD-10 as of Oct. 1, 2013? You Might Be Liable to Face Millions in Fines, CMS Reps Say

Plus: CMS officials are considering how to handle dates of service that span the pre- and post-ICD-10 implementation dates.

If you think the ICD-10 codes won't apply to your Medicare claims as of Oct. 1, 2013, CMS has news for you--not only will your claims be denied if you continue to submit ICD-9 codes to Medicare after that date, but you could face fines. CMS representatives shed light on this and several other issues during the agency's May 18 "ICD-10 National Provider Teleconference," and we've broken down the five FAQs that best apply to Part B practices.

Question 1: How will CMS handle claims that span from before Oct. 1, 2013 through dates after Oct. 1, 2013? Should the practitioner use ICD-9 or ICD-10 codes for these claims?

Answer: CMS is mulling how to handle this situation, but hasn't yet arrived at a firm decision. "We are getting very close to finalizing our decision for all claim types, including professional claims, supplier claims, and the various types of institutional claims," said CMS's Sarah Shirey-Losso during the call. "Some claims will continue to use the discharge date, some will use the ‘from' date, and some may be required to be split," she said.

Stay tuned: CMS is currently working on a final decision, which the agency will issue in a "Change Request" document this summer.

Date of service issue: If, however, you submit a claim for a single date of service, you'll submit ICD-9 codes for dates of service through Sept. 30, 2013, and ICD-10 codes for dates of service Oct. 1, 2013 and thereafter. For instance: If you send in a claim on Oct. 15, 2013, but the date of service is Sept. 1, 2013, you'll still use ICD-9 codes.

Question 2: Will workers' compensation insurers still use ICD-9, even after the rest of the industry transitions to ICD-10 after Oct. 1, 2013?

Answer: The answer to that is unclear, but CMS has heard murmurs that workers' comp. insurers will switch over to ICD-10.

"We've heard anecdotally that even though they're not required to transition to ICD-10, that many of them are planning to, just because it's more practical to do so and they see that it's the way the rest of the industry is going," said CMS's Denise Buenning, MsM, during the call.

What about Medicaid? You can rest assured that Medicaid insurers will be transitioning to ICD-10 as of the Oct. 1, 2013 date, Buenning said. CMS is working with Medicaid administrators to ensure that they are compliant by the implementation date, she noted.

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Tuesday, June 14, 2011

Be Well-Versed With the Multiple Scope Rule

Here are four medical coding strategies every ortho coder needs to know.

If your orthopedist carries out several procedures during a knee arthroscopy on the same patient on the same day, you will need to understand the multiple-scope rule to figure out which procedures you can claim in reality and get paid for.

Exception: Remember that the multiple-scope rule applies mainly to shoulder and knee procedures in the orthopedic practice. However it also affects those of the elbow, wrist and hip. On the other hand, it doesn't apply to ankle or metacarpophalangeal (MCP) arthroscopy, and it does not impact arthroscopically aided procedures. What's more, some surgical knee arthroscopies are excluded from the family -- specifically, 29866-29868.

Here are some sure success medical coding tips:

For scope families, look to CPT

Prior to worrying about how to apply the multiple-endoscopy rule, you must first know why and when it applies. The multiple-endoscopy rule is Medicare's method to avoid double payment (or more) for inclusive services by paying back only a portion of any scope carried out at the same time as another scope of the same basic type.

Here's how the rule functions: CPT divides groups of similar codes into so-called families. The first code describes the basic procedure. Following the base code, CPT lists any variants that go beyond the base code. For instance take this partial code family: 29805, 29806, 29807, and 29819.

Always include the 'base' procedure

Let the say that the doctor has carried out a diagnostic shoulder arthroscopy (29805) plus shoulder arthroscopy for repair of SLAP lesion (29807). How does the multiple-scope rule apply here?

Bear in mind: Family codes always include the work involved in the base code and a surgical scope always includes the diagnostic scope of the same type. As such, you would only code 29807 in this case.

And what about diagnostic shoulder arthroscopy followed by arthroscopic limited debridement? Again, you should code only the more extensive procedure – in this instance 29822.

If there is no base procedure, you should bill both scopes

If the surgeon carries out two scopes in the same family, neither of which happens to be the base procedure, you should report both codes. Therefore, if your orthopedist carries out shoulder arthroscopy with foreign-body removal (29819) followed by shoulder arthroscopy for thorough synovectomy, you'd go for both 29819 and 29821.

Keep a watch on your reimbursement

Medicare will shell out money for the entire fee schedule amount only for the highest-valued scope in a given code family during the same operative session. Medicare carriers will pay any additional scopes in the same family by subtracting the value of the base scope in that family and paying the difference.

Which Nerve Conduction Study Code Is Right for you?

Selecting the proper code to describe your nerve conduction test can prove to be a demanding proposition; but that need not be the case if you learn three important areas:

Here are some steps to boost your medical coding and billing know how and to make the proper choice every time.

Physicians make use of nerve conduction studies (NCS) to assess the function and electrical conduction of motor and sensory nerves in the body. CPT provides you with three options when you face nerve conduction studies coding: 95900, 95903, and 95904.

First step: Review carefully the physician's documentation for the individual nerves stimulated. Bear in mind that you can report only one unit of service of the corresponding NCS code when the neurologist carries out a diagnostic study on the same nerve at multiple sites.

Use codes 95900, 95903, and 95904 by "each nerve and ensure you follow this guide and are not reporting multiple units of service for NCS testing at multiple sites on the same nerve as "separate nerves".

Go for 95900, 95903 and/or 95904 only once when the provider stimulates or records multiple sites on the same nerve. Code 95903 includes both the F-wave study and the underlying motor nerve conduction study. As per NCCI edits, you cannot bill both 95900 and 95903 for motor NCS testing on the same nerve. CCI takes the Column 2 code, 95900 as a component of the more comprehensive Column 1 code 95903.

You should know when to add modifiers

While coding nerve conduction studies, modifiers can certainly come in handy especially when the doctor tests different nerves or nerve braches or carries out different diagnostic NCS.

Here's an example: The physician carries out a motor NCS without F-wave on the right motor ulnar nerve to the abductor digit minimi (ADM) muscles. During the same procedure, he also carries out a motor nerve conduction study with F-wave on the right radial motor nerve to the extensor digitorum communis (EDC) muscle.

You should report 95900 for the first motor NCS and 95903 for the second owing to the fact that the doctor carried out the diagnostic studies on different nerves. Add modifier 59 to the 95900 code to indicate that the physician performed a separate motor NCS on a different nerve.

You should establish medical necessity

The patient's signs and/or symptoms or a confirmed diagnosis support medical necessity while ordering a diagnostic procedure. The doctor must document the information in the order and note for the procedure. Information aiding medical necessity should also be in the professional interpretation report for the diagnostic study.

Caution: NCS studies look for underlying conditions or injuries that could cause compromised nerve function. Owing to this, numbness, tingling, weakness, and loss of sensation are all symptoms that can help support medical necessity for the diagnostic study, particularly when the final interpretation points to normal NCS.

For further details on this and for other medical coding and billing updates, sign up for a one-stop medical coding guide like Supercoder.

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Monday, June 13, 2011

Know Your Cirrhosis Diagnosis Options

Staying tuned to specialty coding libraries will help you stand in good stead as far as cirrhosis diagnosis options and other coding know how is concerned.

Here's a scenario: According to medical records, your gastroenterologist treats a patient for "cirrhosis likely secondary to alcohol dependency complicated by varices with GI bleeding." In this situation, what cirrhosis diagnosis code should you report?

Well, none between alchoholic cirrhosis (571.2) and 571.5 could describe the condition more properly. Depending on what (if any) procedures the doctor carried out during this encounter, you should code it with gastrointestinal bleeding as the diagnosis (578.9, Hemorrhage of gastrointestinal tract, unspecified).

You should think about 456.20 as an option in the name of specificity. According to a note in the description of this code in the ICD-9 manual, you must code the underlying cause (either cirrhosis of the liver or portal hypertension) as the primary diagnosis, which forces you to select between alcoholic and non-alcoholic cirrhosis.

Reminder: Don't code for suspect, rule-out or probable diagnoses. In this instance, the gastroenterologist isn't sure this is alcoholic cirrhosis; as such you shouldn't code it as such. This practice protects the patient as well. If it turns out that it's not alcoholic cirrhosis, you have incorrectly labeled the patient as alcohol-dependent with his insurance company.

For further details on this and for other specialty-specific articles to assist your coding, sign up for a one-stop medical coding guide like Supercoder. Such a site comes with a Specialty Coding Library to assist you in your everyday coding. The library will help you get every dollar your practice deserves. A lot of people rely on this specialty library which offers 12 monthly issues of the Specialty Coding Alert of your choice, reader questions answered by experts, CPC moderated forums, 14 Specialty-specific SuperCoder Survival Guides, and you just name it.

Whether it's a powerful code reference tool, a real-time claims auditor to help you reduce denials or step-by-step guidance from CPC certified experts, we've got you covered. Some of our products like Physician Coding Bundle, Ambulatory Surgery Center (ASC) Authority, etc provide you with just the ammunition you need to get instant success.

Code the More Complex Procedure With 69610-RT

In a particular situation, a physician assessed the patient's right ear and cleared the canal of all cerumen. The tympanic membrane was visualized, which had retained a tube. He removed a tube in the anterior superior aspect of the eardrum with a Rosen needle while ciprodex was applied. Post this, a paper patch was placed in an overlay technique and positioned using the operative microscope. After this, the physician went to the left ear and got rid of some dry debris. He also got rid of an extruded tube. There wasn't any perforation in situ; he debrided the canal and applied Ciprodex. As such, how do you report this?

Well, first of all you need to code the more complex procedure with 69610-RT.

Call off these choices: You can't code for the binocular microscope since it's a separate procedure and inclusive minus any other ear procedure carried out. Likewise, the removal of impacted cerumen is also a separate procedure, and insurers take it as inclusive with any other ear procedure. What's more, if the physician carried out this service in the operating room, you can't code 69990 because even though the physician used the operating microscope, coding 69990 requires the use of microsurgical technique. These procedures show no proof of microsurgery.

Next, you should code 69424-59-LT if the doctor carried out this procedure in the operating room under general anesthesia. If the doctor carried out this service under local anesthesia in the OR or in the office, you can code it 92504-59-LT for the use of the binocular microscope as you won't find any code for tube removal when the physician does not use general anesthesia.

Typically, if an otologic procedure requires a transcanal or endaural approach with incision of the tympanic membrane and access through the middle ear, you shouldn't report it separately. But then your physician carried out these services on two ears and should be paid for them as separate procedures. Your claim should look like this: 69610-RT, 69424-59-LT or 92504-59-LT depending on the type of anesthesia the physician used.

For further details on this and for other physician medical billing and coding tips, sign up for a one-stop medical coding guide like Supercoder. Such a site comes stocked with a physician coder's Powerpack that offers powerful physician medical billing and coding tools to provide you everything you need for denial-proof claims. It comes with codesets and tools, specialty coding library, SuperScrubber for physicians, CPT Assistant, and the like.

Thursday, June 9, 2011

Hyaluronic Acid Injections: 'Count Correctly' to get your Rightful Reimbursements

For some time, Hyaluronate injections have had its own J code. However it has been changed from 'unspecified' to its own assigned code, back to 'unspecified' and then back to an assigned HCPCS code. Now that all hyaluronate injections fall under the same code, here are three medical coding tips to remember and help you calculate the right way.

Validate the type of medication

Physicians make use of hyaluronate injections to lessen the patient's pain owing to osteoarthritis of the knee. The medications achieve the same purpose and you report both types of injections with J7325. Correct coding depends on the medication used and the number of units you report. Synvisc-One is a one-shot injection equaling 6 cc of the medication. The patient sees your physician once for the full injection, which you report as 48 units of J7325 (2 cc = 16 g, so 6 cc = 48 mg). Physicians administer the other forms of hyaluronate as a series of injections instead of one shot at a single patient visit. Watch the dosage amounts closely so that you will report the correct number of J7325 units for each administration.

Chart note: Owing to the difference in calculations and unit reporting, the doctor must clearly document the medication used and number of units administered. Medication reimbursement can be low; as such wrong or unclear documentation could mean the difference between some payment versus virtually none. Some providers give patients a prescription for hyaluronate (depending on the insurer) and ask them to get the medication and return to the physician's office for the injection.

Injection: Code J7325 represents the medication only; as such you still need to report the injection procedure. Submit 20610; take a look at the diagnosis code. Medicare will only pay for hyaluronate injections to treat osteoarthritis of the knee. You have several diagnosis choices; as such be sure one of these applies to help smooth your claims processing: 715.16, 715.26, 715.36, and 715.96.

Anatomy note: Your 'additional digit' choices for the 715. xx code family do not include a specific option for knee. While selecting the best anatomic choice, take the knee part of the lower leg in place of pelvic region and thigh.

Figure out whether evaluation & management and modifiers apply

Some visits for hyaluronate injections qualify for an evaluation & management code or modifiers; however others do not. If the patient comes to your office specifically for a scheduled Synvisc-One injection, you will only report the injection code. However, if the physician completes another service during the visit, an E/M code might apply.

For more on this and for other medical coding articles to assist your orthopedic coding, sign up for a one-stop medical coding guide like Supercoder.

Make Your Doctors ICD-10 Ready

Where have you reached as far as your ICD-10 preparation is concerned? If you're still lagging behind, it's time you geared yourself up for it because irrespective of where you work (hospital, ambulatory surgical center, physician practice, clinic, etc), the ICD-10 deadline applies to you.

D-Day: Oct. 1, 2013 will be the date that everyone will begin to use ICD-10. After this date, CMS will not accept ICD-9 codes for any dates of service on or after Oct. 1, 2013; however the agency will continue to process claims for services prior to that date for a still-unannounced period of time.

Transition: The more familiar you are with the changes, the easier the transition will be. Even though you should not start your intensive, in-depth ICD-10 training until six to nine months prior to implementation, you can gear yourself up in other ways now. Obtain education and understand early on so that you will be well equipped.

Gear up your doctors:

Popular thinking: One of the major worries pertaining to ICD-10 is the increased number of codes making the new system impossible to use. However, the truth that it should not be the case. While your physician's documentation will need to be detailed and clear, the diagnosis code set will not be more difficult to use. Presently, the agency publishes about 14,000 ICD-9 codes, but there will be over 69,000 ICD-10 codes. The additional codes will allow you to give more detail in describing diagnoses and procedures. Since ICD-10 codes will often be more detailed and specific than the ICD-9 codes you and your surgeon are used to, you may need to persuade your physician to start being more detailed in his documentation.

ICD-10 will need some improvement in physician documentation; the higher the quality of your documentation now, the easier it'll be to stay away from unspecified codes, and the quicker you will find the accurate ICD-10 code. Begin by speaking with your doctors now about improving their clinical documentation detail which will be the most important aspect for them and should be started prior to the change. With the increased granularity of ICD-10 code descriptions, payers may make use of this opportunity to develop increased pay for performance incentives and more specific medical necessity requirements that were not possible earlier. In this direction, accurate and specific code selections will be required however only possible if physicians have improved their ability to pain a clear and more detailed picture of the patient's clinical conditions.

Tuesday, June 7, 2011

Medicare reimbursement: Is the Physician Responsible for Certain Parts of the E/M Visit?

For an evaluation & management visit, the doctor is responsible for certain parts of that visit, I have heard. So does Medicare state this openly?
Well, in the evaluation and management service documentation guidelines, the agency states that ancillary staff or even the patient (via questionnaire) may record the review of systems (ROS) and past, family, and/ or social history (PFSH) portions of the history component.

Watch out: To get credit for these history elements, your doctor should date and sign the patient's chart to point to the fact that he reviewed the whole history note.

Source: According to the 1995 evaluation and management guidelines, "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. In order to document that the doctor reviewed the information, there must be a notation supplementing or corroborating the information recorded by others."

As a matter of fact, the 1997 guidelines include the same wording as the 1995 Evaluation & management guidelines. What's more, the 1997 guidelines refer to documentation by ancillary staff in yet another section, which describes requirements for the "constitutional" element of the exam: Measurements of any three of the following s even key signs: Sitting or standing blood pressure, supine blood pressure, pulse rate and regularity, respiration, temperature, height, weight.

Word of caution: You should take a look at your state requirements. For example, some states require the physician to sign off on any incident-to services, say for instance 99211 as well as higher-level E/M services such as 99212-99215, provided by mid-level providers. Other states don't require the physician to sign off on incident-to services, however the physician does have to create the plan of care.

For more on this and for other Medicare reimbursement updates, sign up for a one-stop medical coding guide like

Four Tips to Overcome MUE Denials

So are your receiving denials from Medicare? One possibility could be you are running up against medically unlikely edits (MUEs).

Medical claims billing: The MUEs, which are designed to prevent overpayments, caused by gross billing mistakes, normally a result of result of clerical or billing systems' mistakes, many a time confuse veteran coders too.

Here are four aspects of these edits to see to it that you are not letting MUEs wreak havoc on your practice's coding and payments.

First, understand what MUEs are and how they work.

Some practices are of the opinion that they don't need to worry much about MUEs. The reality is any practice filing a claim with Medicare should know what MUEs are and how they function. One needs to be aware of MUEs as they occur. The MUE list covers specific CPT or HCPCS codes, followed by the number of units that CMS will pay. In fact, the agency had developed the MUEs to bring down paid claims error rates in the Medicare program. While some MUEs deal with anatomical impossibilities, others limit codes as per the CMS policy.

Second, you can't use ABNs to transfer responsibility for payment to the beneficiary.

The agency makes this rule very clear in its FAQs. What's more, if services are denied claim based on an MUE, an ABN can't be used to shift liability and bill the beneficiary for the denied services. It's a provider/supplier liability.

Third, you can certainly override an MUE contrary to popular belief that you can never override an MUE.

According to the agency, MUEs reflect the maximum number of units the vast majority of properly reported claims for a particular code would have; as such you don't need to override them. However, you can override an MUE when your doctor carries out and documents a medically necessary number of services that cross the limit.

Fourth, you can appeal if you receive a claim denial owing to MUEs

Yes, you can certainly appeal the claims and you can address inquiries regarding the rationale for an MUE. However, the warning is that you may not get the answer you want, and it'll take some time to receive your response.

For further details on this and for other medical claims billing and coding updates, sign up for a good coding resource like Supercoder. Such a site comes with SuperScrubber for Batch Processing to save you both the time and money lost re-working denied claims.

Thursday, June 2, 2011

Emergency Department Coding: Know the NOPP Levels Well to Be Bang on Target

While going about your Emergency department coding , you need to be well-versed with some key topics such as NOPP levels so that you bag the rightful reimbursements for your practice.

Without a good understanding on nature of presenting problems (NOPP) levels, you will not be able to choose the most spot on emergency coding E&M code possible for each claim. Without NOPP level, you can't decide on medical necessity for the encounter. And the important thing is Medicare and insurers will only pay for care that is 'medically necessary'. In fact, CPT defines medical necessity by the nature of presenting problem.

Get a better understanding of the five NOPP levels

According to the CPT manual, NOPP is a contributing E/M component, however not one of the vital elements. Discerning NOPP level is important; but while selecting the level of medical decision making.

The five NOPP levels are:

a) Minimal NOPP: This might not require the presence of a physician, however is provided under the physician's supervision.

b) Minor or self limited NOPP: This is not likely to change the patient's health for good; problems in this NOPP level run a proscribed course and then fade. Patients with minor or self-limited NOPP have a very low risk of morbidity minus treatment.

c) Moderate NOPP: Here, patients have a moderate risk of morbidity minus treatment, or at least an increased probability of prolonged functional impairment.

d) High NOPP: Here, patients have a big risk to extreme risk morbidity minus medical attention; a high NOPP might also involve the likelihood of severe functional impairment minus treatment.

Prior to choosing NOPP level, take a look at comorbidities

You must take a look at the condition the patient presents with along with any comorbidities so that you reach the proper NOPP level. Say for instance a patient has an NOPP of mild hypertension with slight elevation. He also suffers from lupus, a comorbidity that sends the NOPP level up. In this instance, the NOPP will be much higher because of preexisting conditions and medical history.

High NOPP doesn't always mean 99285

With five levels of NOPP at hand, it might be enticing to assume each one coincides with an emergency department E/M code; minimal NOPP equals 99281, self-limited NOPP equals 99282 and the like. However this is a dangerous coding practice.

Perfect your Twin Delivery Claims

You need to be well-versed with procedure and diagnosis codes if you are to code right for your ob-gyn practice.

Do you know how to report a twin cesarean delivery? A simple answer would be 59510 with modifier 22 attached. But this may not as simple as that. The fact is you will need to adjust your twin delivery reporting depending on an insurance company's preference. Here are two tricky twin situations to help your understanding so that you submit picture perfect claims in no time.

First Scenario:

Cesarean deliveries and what should be done in such instances

A doctor delivers twin deliveries (the same will be the case if the doctor carries out triplets by cesarean; in this situation, you should report 59510 with modifier 22 added. Since the ob-gyn made only one incision, he carried out only one cesarean. However the modifier shows that the doctor carried out a significantly more difficult delivery owing to the presence of multiple babies.

This can also depend on the carrier. For example, Colorado Medicaid allows you to bill for both babies, even though the physician makes only one incision. See to it that you include a letter with the claim that outlines the added work that the ob-gyn carried out to give the carrier a clear picture of why you are asking for more reimbursement.

Second scenario: The babies come out on different days.

Once in a while, multiple-gestation babies will be born of different days. Say for instance, a patient is at 38 weeks gestation and carrying twins in two sacs. One membrane ruptures and the ob-gyn delivers the baby vaginally. A couple of days later, the second ruptures and the second baby delivers vaginally too.

In this situation, you should report the first baby as a delivery only (59409) on that date of service (DOS). For the second one, you should go for the global code (59400), taking that the physician provided prenatal care, on that date of service. The reason why you should not bill the global first is that you're still offering prenatal care owing to the retained twin. You need to attach a letter explaining the situation to the insurance company. ICD-9 diagnosis codes will be important to the payment. See to it that you make use of the outcome codes (say for instance V27.2).

And when the ICD-10 system comes into effect in 2013, you will have to change how your report some of the codes like V27.2, 651.01, O30.001, O30.002, among others.