Accurately Report Pouchoscopy and Overcome Keofeed Reporting Confusion

Know How to Appropriately Report Pouchoscopy With Additional Procedures

Question: Your gastroenterologist recently carried out a pouchoscopy. (The operative report read like this: The patient was turned around and the scope was changed to an Olympus P CF-180 pediatric video colonoscope. There was an anal stricture but I was able to get the scope beyond this. There was inflamed tissue at 40 cm. I bypassed this. There was a stricture at 100 cm and I was unable to bypass it with the scope. I dilated that with a 20 mm balloon. Then I was able to bypass the stricture and the ileum proximal to it appeared normal. The colonoscope was slowly withdrawn and the ileum and pouch were decompressed. The anus was dilated with a 50 French Maloney dilator. The procedure was then terminated. He tolerated it well. There were no immediate complications.)

Should you use a colonoscopy CPT® code to describe the procedure that was carried out?

Answer: Colonoscopy is a diagnostic procedure used to discover problems in the colon or the rectum. A pouchoscopy is carried out on the small intestinal (abdominal or pelvic) pouch. Thus, a colonoscopy CPT® code cannot be used in case pouchoscopy is the procedure your gastorenteroloist is carrying out. If pouchoscopy was the only procedure that your gastroenterologist carried out, then you have to report the procedure using medical billing code 44385 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). However, since your gastroenterologist also used dilators to overcome the strictures, if you simply report the procedure with medical billing code 44385, your reporting will only be half-correct.

CPT® does not cover a lot of endoscopy procedures with separate medical billing codes. One such code that is not covered includes pouchoscopy together with dilation to overcome strictures using a balloon, bougie or a guidewire. As, CPT® does not have a distinct code for pouchoscopy with dilation you will have to report the pouchoscopy with 44385 and the dilation with 44799 (Unlisted procedure, intestine).

As you are reporting an unlisted procedure code, you will be required to submit a copy of the operative report together with documentation defining what additional procedures have been carried out by your gastroenterologist. The documentation must also include the time that was taken by your gastroenterologist to carry out the procedure.

Address the Keofeed Reporting Confusion

Question: Your gastroenterologist recently carried out a Keofeed feeding tube placement at our facility. How do you report this?

Answer: The placement procedures for feeding tubes is essentially reported based on the type and method that was used. A Keofeed feeding tube is a kind of nasogastric tube. Nasogastric tubes, as the name specifies, are inserted via the nose into the stomach. The tube insertion is carried out largely for feeding purposes and also for the administration of drugs and other agents for instance activated charcoal. You must report the placement of a nasogastric tube with medical billing  Codes 43752 (Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance [includes fluoroscopy, image documentation and report]).

No History and RVU Order

Don't Assume Comprehensive Level If There is No History

Question: Your physician admitted someone as an initial inpatient, however couldn't get all her information. He carried out a comprehensive exam as well as complex medical decision making based on the patient's present condition. Can you give credit for a comprehensive history despite the fact he couldn't obtain a comprehensive ROS (review of systems) because of the patient being mentally confused?

Answer: There is no written rule that you can automatically provide credit for a comprehensive level when all or part (e.g., ROS) of a patient's history is unattainable. Generally, you can only give credit for the level of history that is documented. Remember that the viewpoint may be payer specific, so you must check with your local payer to have clean medical coding and billing claims.

Medical Coding and Billing Tip: Though, in a lot of cases you are permitted to count history toward the level of E/M service you bill even though you are not able to obtain it directly from the patient. However you should document that you made an effort to obtain information about the patient from other sources.

Action: The "Documentation Guidelines for E/M Services" states, "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstances which precludes obtaining a history." Consequently, verify that your physician evidently documents the reason the patient is unable to provide a history, and also document his efforts to obtain the patient's history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) as well as using information from the records to document some of the history components (past medical, family, social).

Base Your Billing Order on RVU Order

Question: You know that as a general rule the highest RVU has essentially a higher billed amount and that while billing you must always put the highest amount first. However when it comes to bilateral surgeries is it right that you would sometimes be wise to put another procedure first as a bilateral code that was done bilateral/unilateral would still be paid at a reduced allowable?

Answer: Yes, you must sometimes put another procedure first. In case the 150 percent amount of the relative value units (RVUs) for a bilateral procedure is the highest, you must put that code first.

Here's why: As the insurer will discount the second and subsequent procedures based on multiple procedure discounts, it's by far the best to list the codes in RVU order, with the highest-paying code listed first. Remember that you should follow this rule of thumb even though your insurer wants you to append modifier 51 (Multiple procedures) before you submit the medical coding and billing claim.

Payers will decide your primary and secondary procedures in one of following listed three ways:

• As per the relative value unit (RVU) order based on the Medicare fee schedule
• As per the insurer's own fee schedule
• In the order in which you listed the codes on your medical coding and billing claim.

Refresh Your E-Prescribing Knowledge With This Advice

Medical Billing and Coding

Explore these incentives for adopting eRx.

In case your gastroenterologist's practice hasn't by now adopted electronic prescribing (ePrescribing or eRx) system in 2011, then you may be bound by a payment adjustment for Medicare Part B claims in 2012 and the future years. Read on this expert medical billing and coding article to know more about what these adjustments actually are and how you can circumvent them in the coming years and also take advantage from incentives CMS offers for e-prescribing.

If you have not by now implemented the e-prescribing system in 2011 (between Jan.1, 2011 and June 30, 2011) and not claimed for hardship exemptions by the prescribed deadline, then your practice will have to face a 1 percent adjustment in 2012 for all Medicare Part B claims. Your practice will evade the payment adjustments of 1 percent and will be entitled for an incentive of 1 percent of all Medicare Part B payments in case you have filed claims using the electronic prescription code G8553 (Prescription(s) generated and transmitted via a qualified eRx system or a certified EHR system) no less than ten times in the period between Jan.1, 2011 and June 30, 2011.

If you still fail to implement the electronic prescribing system in 2012, your practice might have to face additional payment adjustments of 1.5 percent in the year 2013 and 2 percent in the year 2014.

Medical Billing and Coding Update: You are also eligible for evading payment adjustments for 2013 in case you have made 25 claims using the e-prescribing code G8553 in the above-mentioned period in 2012.

Medical Billing and Coding Tip: Note These Enrollment Guidelines

The list of qualified professionals (EP) involve physicians and other recognized practitioners who fall under the purview of the Medicare Act who have prescribing authority in their scope of practice. Any EP can enroll for the eRx prescribing incentive program for their Medicare Part B claims. You are not required to pre-register to take part in the program. You are required to observe that 10 percent of your Medicare Part B covered claims should make up for codes in the denominator of the eRx measure.

Providers can report the eRx G-code with office visits, eye exams, psychotherapy or certain other services listed in the CMS e-prescribing measure conditions.

To ensure accurate medical coding and billing, you will be required to have a certified eRx system ready to enroll for the eRx prescribing incentive program. You can further check with your system vendor to make certain that the system meets all the requirements for e-prescribing. To meet the requirements for the incentive program, you will need to convey your involvement to CMS through one of the following methods:

• By submitting G8553 together with the service code on Medicare Part B claims. Keep in mind that the G code on the claim form must be charged $0.00 or if the system does not permit you to place $0.00, you must assign a very small value to it, for instance, $0.01 (this claim will not be paid out).
• On the other hand, you can submit your claims to a CMS qualified registry that is also partaking in the 2012 Physician Quality Reporting System (PQRS). Though, you must keep in mind that you must also be participating in the PQRS program to select for this system of submitting your claims.
• In case your practice has a certified electronic health record (EHR) system in place, you can submit your claims right to CMS using the system. Though, you will also have to be participating in the PQRS program to use this system for eRx prescribing.

Flu, BMI, Jaw Pain Diagnosis Codes Are More Direct

Think through: Where do BMI codes exist in pulmonology?

Proficient billing is not only about getting your CPTs right. You are required to have an in-depth knowledge and use of modifiers as well as diagnosis codes prior to you can come full circle on competent billing and reimbursement.

While latest additions on influenza ICD-9 codes seem to be confusing, it's not what it seems to be. Catch up with these newest flu codes, together with some other pulmonology-related diagnosis codes with these beneficial tips.

Choose From 6 Extra Flu Codes

As the introduction of six new ICD-9 codes on influenza in October 2010, you should have been using the more detailed codes in the 488.0x (Influenza due to identified avian influenza virus) as well as 488.1x (Influenza due to identified novel H1N1 influenza virus) subcategories.

In case you used to satisfy yourself with the old code category 487 (Influenza) which didn't deliver the detail you required for more kinds of the flu, now you must be using six new ICD-9 codes growing from the 488.0 and 488.1 subcategories:

488.01: i.e. Influenza owing to identified avian influenza virus including pneumonia

488.02: i.e. Influenza owing to identified avian influenza virus including further respiratory manifestations

488.09: i.e. Influenza owing to identified avian influenza virus including further manifestations

488.11: Influenza owing to identified novel H1N1 influenza virus including pneumonia

488.12: i.e. Influenza owing to identified novel H1N1 influenza virus including further respiratory manifestations

488.19: i.e. Influenza owing to identified novel H1N1 influenza virus including further manifestations.

Remember: With 487.0 (Influenza with pneumonia), when you code 488.01 or 488.11, you should be using an added code to categorize the type of pneumonia (480.0-480.9, 481, 482.0-482.9, 483.0-483.8, 485)

Caveat: You must not use one of these new ICD9 codes except the cause of the pneumonia is established. Influenza symptoms may rest on which virus lead to the infection however regularly is alike those connected with seasonal influenza. Laboratory tests can be carried out to approve influenza infection. Prescription antiviral drugs confirmed for influenza (based on seasonal outbreak data) may be of some advantage in treating avian or H1N1 flu infection.

Search for Jaw Pain Codes

How are you presently addressing to report a patient's jaw pain? You must be coding 784.92 (Jaw pain) to define this symptom.

Jaw pain may be an indication of a pulmonary embolism (415.19), or additional conditions not related with TMJ. ICD-9 code 784.92 was created to categorize the patient, and validate the essential testing/evaluation for patients who come with this complaint.

For More Info :- http://www.supercoder.com/coding-newsletters/my-pulmonology-coding-alert/icd-9-coding-flu-bmi-jaw-pain-diagnosis-codes-become-more-straightforward-106140-article

Dermatology Coding Alert: Master Your Derm ASC Coding

Numerous changes affecting ASCs every year are enough to confuse you. Still, few aspects of ASC reimbursement continue to be the same. Read further to know how the ASC rules affect you and what dermatology codes you should choose in such a case. These expert tips will surely take you a step ahead in perfecting your dermatology medical billing and coding.

1. ASC-allowed services: Know where to find them. CMS has a very specific list of codes payable for ASCs, but if you don't know how to access the list, you could be losing your reimbursement.

You can download the most recent ASC-allowable codes from the CMS website. It includes both the current quarter as well as previous quarters in case you're battling older claims.

2. 'Same-day global' rule. Each procedure the ASC bills takes a "same-day" global period as the ASC is only reporting facility fees and not physician work services. This is applicable to the coder working for the ASC and not the physician who performed the service.

In case the physician returned the patient to the ASC the day after the initial surgery, the ASC coder is supposed to report the suitable control-of-bleeding code with no modifier. On the other hand, the surgeon's coder would report the bleeding-control code with modifier 78 appended because the physician's services follow the standard global rule.

The ASC coder should go by the "same-day" global rule, but the physician's coder should follow standard global period rules from the fee schedule.

3. You Can Avoid modifier SG. In the past, the ASC coder had to list modifier SG (ASC facility service) as the first modifier on the claim in case he billed Medicare for any service performed in the ASC. However, that all changed with the CMS Transmittal 1410, which stated that the SG modifier is no longer applicable for Medicare services for services on or after January 1, 2008.

4. Discontinued surgery modifiers may differ. ASC coders may sometimes use modifier 52 (Reduced services) but would not use modifier 53 (Discontinued procedure). Instead, insurers generally want ASC coders to call on modifiers 73 (Discontinued outpatient hospital/ASC procedure before administration of anesthesia) or 74 (Discontinued outpatient hospital/ASC procedure after the administration of anesthesia), as appropriate.

When the physician gets back to the ASC with the patient to perform the aborted procedure at a later date or time, the ASC will get full reimbursement for the completed procedure.

5. Keep in contact with the surgeon's coder. You could lose your reimbursements when the physician and the ASC report separate codes for the same procedure. Remember, the physician and ASC should report the same codes for each surgery, any coding differences should be fixed before the claim is submitted.

Want to get more tips like these to master dermatology medical billing and coding? Click here to read the entire article and to get access to our monthly Dermatology Coding Alert: Your practical adviser for ethically optimizing dermatology medical billing and coding , payment, and efficiency for dermatology practices

Medical Coding & Billing: Tips to Improve Your Appeals Process

A particular practice after ensuring it has not made any medical coding and billing entry error automatically appeals payer denials using a standard letter. However this wasn't working in getting them their payments. The question is: How can it boost its appeals process?

Well, before starting the appeal process, one needs to check the payer's policies first. Say for instance if the payer has a policy that bundles dipstick urinalysis (81002) into any evaluation & management services carried out on the same day and will not be reimbursed separately, one should not appeal these. Writing appeals takes up a lot of time. As such you wouldn't want to waste time on appeals you cannot win since already there is a specific policy in place.

What you should do:

Next time, you should follow the payer's appeal procedure just as it is. Many a time, the address to submit appeals is different from the claims address and some payers require you to send a special form with the appeal.

Being specific is the key:

In place of sending a generic appeal letter for every denial, you can customize your letter with the proper key words for each situation. Say for instance you submitted a claim for an evaluation and management service and injection on the same date. You added modifier 25 to the evaluation & management service code, however the payer still denied it.

Here's what you can do: Instead of sending a letter saying 'the claim was submitted correctly', send a letter that addresses the specific claim and the specific reason why modifier 25 was spot on. What's more, you should quote industry guidelines (say for instance CPT and/or CMS guidelines) and if likely the insurance company's own guidelines.

Appeal letter tips: Writing an appeals letter can take up a lot of your time. However you can save time by figuring out your most frequent denials and creating fill-up-the-gap appeal letters for each of these situations.

Say for instance you may find that you get many denials for bundling issues even when you use modifier 59 correctly. Most probably the letters you put together will begin and end basically the same. By creating a base template you can focus on filling in the details for each claim instead of writing each one from scrape.

Medical Billing & Coding: AMA Report Shows 19.3 Percent Claims-Processing Error Rate

Here are some payer updates that will stand your medical coding & billing in good stead.

The findings of the American Medical Association’s (AMA) fourth annual National Health Insurer Report Card (NHIRC) do not paint a rosy picture. As per the association, commercial payers show an average claims processing error rate of 19.3 percent, notes an AMA press release. This is a two percent increase over last year.

Errors galore

According to the release, 20 percent error rate among health insurers talks of a great deal of incompetence that leads to a wastage of $17 billion annually.

Need of the hour

Keeping this huge inefficiency in mind, health insurers must put in more effort into paying claims correctly the first time to save money and bring down needless administrative tasks that take time and resources away from the patient, the release cites.

Payer rankings

As far as claims-processing accuracy is concerned, UnitedHealthcare was the only payer that showed a boost. The firm was ranked first in the list of seven leading commercial payers with an accuracy rate of 90.23 percent while Anthem Blue Cross Blue Shield figured in the bottom with an accuracy rate of 61.05 percent.

Legitimate pay may go unpaid by an insurer

What’s more, the report card also showed that you got no payment at all on around 23 percent of claims you submitted to commercial payers.

There are many reasons a rightful claim may go unpaid by an insurer, the release indicates. It may be denied, edited or deferred to patients. During February and March of this year, the most common reason insurers did not issue a payment was owing to deductible requirements that shift payment responsibility to patients until a dollar limit is surpassed.

Healthcare billing news: For many of the payers included in the report - Aetna, Anthem Blue Cross Blue Shield, Health Care Service Corporation and UnitedHealthcare - there were lower denial rates.

In addition, the report card indicates that Cigna and Humana cut their medical claims response time in half during the last four years.

Resource: More information is available at http://www.ama-assn.org/ama/pub/advocacy/topics/administrative-simplification-initiatives/national-health-insurer-report-card.page.