Two New Codes for Diabetic Food Ulcer Treatment

CPT will come up new codes in 2011. The new codes are G0440 and G0441

As we go into the new year, the talk that's doing the rounds most among the coding community is the Cpt Code changes. CPT will come up with over 200 new codes with the purpose of helping you code more accurately. These changes will have an affect on several categories, and podiatry is no exception.

For podiatry, there are two new codes to report diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity.

The new codes are G0440 (Application of tissue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; first 25 sq cm or less) and G0441 (…each additional 25 sq cm) that'll put an end to the confusion providers put forth the different global periods for two tissue cultured skin substitute codes.

To cite an instance, a patient presents to the office with a history of diabetes and neuropathy. For the past six weeks, he has been treated for an ulcer with minimal results from standard conservative care. An exam shows an ulcer under the fifth metatarsal head. The ulcer measures one cm in diameter and shows necrotic tissue at the base. The podiatrist carried out a debridement, sharply removing it with scalpel and picking up at the skin margins and necrotic tissue. There's no exposure of the muscle or bone. If the podiatrist prepared for an application of Dermagraft or Appligraft, placing the substance in sterile normal fashion and then bandaging in standard fashion, you would use G0440.

For further details on this and to get all updates on how the CPT code changes (http://www.supercoder.com/cpt-codes) are affecting your specialty, sign up for a medical coding guide like Supercoder!

Congress Goes Ahead With One-Year Medicare Pay Fix

President Obama passed a bill that will freeze medical pay at present levels for another 12 months.

The new legislation helps you avoid the scheduled 25 percent drop in Medicare pay for the new year.

The up and down ride of conversion factor changes for 2011 has come to a conclusion thanks to a Senate Finance Committee bill that'll freeze Medicare pay at present levels for another 12 months.

The House of Representatives passed the Medicare and Medicaid Extenders Act of 2010 on December 9 and the Senate voted on it the day before. The bill will do away with the 25 percent cut that medical practices were going to face from January 1. President Obama made it official on December 15, 2010 when he signed the year-long delay into law.

Doctors cheered the news that they will not have to wait for the new Congress and Senate members to take their seats prior to finding out whether a payment fix would take place.

The bill passed as a bipartisan effort, and the Senate Finance Committee noted that it'll cost $14.9 billion over 10 years to implement the physician pay fix. It'll be funded by making minor adjustments to the Affordable Care Act, the health care legislation that President Obama signed into law last March.

Last-minute fix is a welcome sight, however not forever

The US Senate passed a quick, 1-month extension of the present SGR formula on November 18 in a first step to avoid the 23 percent payment cut physicians were facing on December 1. The House of Representatives had already recessed for Thanksgiving at that point and took up the one month fix when they returned on November 29.

While many are pleased that the Senate has acted swiftly on the pending payment cut, one remains sceptical about another round of short term fixes. One hopes that the ultimate result of this Congressional session will be a fix of atleast one year. This extended period must then be followed by a strong bipartisan commitment from Congress to work with the physician community to lastly replace the badly flawed SGR formula with a new update mechanism that works. The frequent disruptions and delayed payments caused by the present formula and Congress' inability to fix it except for short periods are simply not fair to our members who have payrolls and other practice management expenses.

Check whether ACF applies

Some pain management coders also code for anesthesia procedures, which means you have a second CF to consider: the anesthesia conversion factor, or ACF.

The 2011 national ACF will remain at $21.5696. Check your specific area; but then as anesthesia reimbursement changes from state to state and even within regions of the same state.

For more on the latest Medicare updates, sign up for a medical coding guide like Supercoder.com

CPT 2011 Provides Revised Debridement Code Guidelines Latest CPT comes to your rescue with revised debridement code guidelines that explain how to cho

Latest CPT comes to your rescue with revised debridement code guidelines that explain how to choose between the two code groups.

Not sure when to go for a debridement code and an active wound code? Well, the latest CPT comes to your rescue with revised debridement code guidelines that explain how to choose between the two code groups.

According to Chad Rubin, MD, FACS, American College of Surgeons AMA Specialty Society Relative Value Scale Update Committee (RUC) Alternate Member with Albert E. Bothe, Jr. MD, FACS, American College of Surgeons, AMA CPT Editorial Panel Member, ""Depth is the only documentation item you need to determine the proper code."

Active wound care (which has a 0 day global period) is for active wound care of the skin, dermis, or epidermis. For deeper wound care, go for debridement codes in the proper location.

For instance: Codes 11040 and 11041 have been shown the door this time. The parenthetical note under the codes' deletion reads, "For debridement of skin, i.e., epidermis and/or dermis only, see 97597, 97598."

The codes are then revised to mirror the change. For example, 11042 removes "Skin, and" and adds after subcutaneous tissue "includes epidermis and dermis, if performed."

Code 97597's revision involves "mainly rewording to make clear how active wound care is separate from integumentary wound care."

The latest CPT code set includes guidelines that indicate two requirements for active wound care management. These guidelines focus on:

Intent: "Active wound care procedures are performed to remove devitalized and/or necrotic tissue and promote healing."

For further information on when to choose a debridement code and an active wound code as well as on the latest CPT changes (http://www.supercoder.com/cpt-codes), sign up for a medical coding guide like Supercoder!

HCPCS 2011 Brings new Options for Lymph Cancer Drugs

HCPCS 2011: C codes are appropriate only for Hospital Outpatient Prospective Payment System claims.

When all other treatments have failed, take a look at these drugs

You'll have three new J codes for leukemia and lymphoma treatments available for use in January, 2011.

J9302 answers call for Arzerra Code

If you provide Arzerra injections, you should take note of new code J9302 (Injection, ofatumumab, 10 mg). Oncologists normally use the medication to treat chronic lymphocytic leukemia in adults who haven't responded well to fludarabine or alemtuzumab.

As the suffix -mab in ofatumumab points to, this medication is a monoclonal antibody.

Remember: Earlier, hospitals had a C code available for this agent, C9260 (Injection, ofatumumab, 10 mg). However this code makes an exit in the latest HCPCS code sets. (Note that C codes are appropriate only for Hospital Outpatient Prospective Payment System claims.)

Train eyes on J9307 for Folotyn

One more new J code for 2011 is J9307 (Injection, pralatrexate, 1 mg), which is just right for Folotyn.

Oncologists normally use this folate analogue metabolic inhibitor to kill cancer cells in patients with peripher al T-cell lymphoma that hasn't responded to other medications or has returned.

HCPCS 2011 also axes the C code available to hospitals for this drug, C9259 (Injection, pralatrexate, 1 mg).

Flip to J9315 for Romidepsin

If your documentation shows your practice supplied Istodax, you have J9315 (Injection, romidepsin, 1 mg) at your service in the new year. The drug is a histone deacetylase inhibitor that slows the growth of cancer cells. It is intended for use in patients with cutaneous T-cell lymphoma who have been treated earlier with another drug.

In 2010, hospitals use C9265 (Injection, romidepsin, 1 mg) for this drug, however HCPCS 2011 deletes this code.

CPT 2011 Asks for CMS re-Examination of Time as Averages or Thresholds

CPT 2011: The doctor must have spent a time closest to the chosen code, according to CPT Assistant

All that fine green print on time in your E/M CPT 2011 manual comes down to one thing: you can round to the closest time code. However, that advice from CPT contradicts Medicare's threshold time guideline.

CPT treats times as averages

CPT 2011 indicates that you can use the code closest to the documented time. That piece of advice is nothing new. In choosing time, the doctor must have spent a time closest to the chosen code, according to CPT Assistant, Aug. 2004.

Your documented time must be equal to or cross the average time given to bill that level. For a 35-minutes spent on a medically necessary counseling-dominated visit is a 99214, according to CPT you could report 99215.

Medicare has considered times thresholds

Medicare has always considered the times indicated in CPT's code descriptors to represent minimums. The doctor would choose the lower code (for example 99214… physicians typically spend 25 minutes face-to-face with the patient and/or family …) unless the time was greater or equal to the higher-level code's required time (such as 40 minutes for 99215).

Will Medicare alter its position?

When questioned on whether Medicare would change the allotments from thresholds to averages at the CPT® and RBRVS 2011 Annual Symposium, medical directors were hesitant to give a definitive answer. "I do not want to say one way either 'yes' or 'no' at this juncture," said E/M expert Deborah Patterson, MD, clinical medical director for Trailblazer Health Enterprises, LLC in Dallas.

For more on CPT 2011 , sign up for a medical coding guide like Supercoder!

Maneuver the Medicare Opt-Out Process in Three Easy Steps

Medicare: You can find samples of the form online at specialty association Websites and even some Medicare carrier Websites.

If you've decided that 2011 is the year your practice's going to scrap Medicare, follow this plan to see to it that you do not miss any important components when you are boosting your no-Medicare plan.

Notify Medicare that you are opting out

First, file an affidavit with your Medicare contractors informing them that your physician is opting out. If you're already a participating provider, states CMS, “To opt out of Medicare, a participating doctor must first terminate his or her Medicare Part B participation pact."

Tool: You can find samples of the form online at specialty association Websites and even some Medicare carrier Websites. For example, you can get National Government Service's form at www.ngsmedicare.com/pdf/medicareoptoutaffidavit.pdf.

Create a patient contract

If your practice decided to opt out of Medicare, however your providers plan to see Medicare patients, you will need solid patient contracts. “The provider has to have a written ‘private contract' with each Medicare beneficiary to whom the provider provides any service, except in a life-threatening emergency.

This contract, among other things, inform your patients that you're no longer part of Medicare and therefore, neither they nor the provider will get any reimbursement from Medicare. You'll be able to treat patients with Medicare coverage just like before, however you won't bill Medicare for the services. In its place, you'll bill any secondary or supplementary insurance the patient may have, or bill the patient directly. For instance, Medigap insurance will not pay you money if you're opted out since Medigap pays only secondary to Medicare payment.

Point to remember: Medicare has various requirements for what it considers an acceptable private contract. Be wary that the contracts have to be made available to CMS upon request, even long after the two-year opt-out period expires.

Set up internal processes to avoid claim errors

Finally, implement procedures within your office to ensure that:

You never file a Medicare claim

You don't provide the info to your patient to file a Medicare claim

Rule breaker: Two exceptions to this are emergency or urgent care, and providing covered services that Medicare would consider unnecessary.

Do not miss: Set up reminder notices either electronically or on a paper calendar so that you know when the two-year optout period expires. If you decide to opt out again, you will need to fill out another affidavit.

For more on this, and for more medical coding updates, sign up for a medical coding guide like Supercoder!

Axe 90658 for Medicare Patients In Favor Of Just-In Q Codes

Medical Coding: Medicare will no longer pay you money for 90658 with effect from January 1, 2011.

The new year brings changes to flu vaccines and counseling codes.

Your vaccine coding in 2011 will be on its toes, thanks to changes in codes and administration reporting. Two more updates every family physician should know involve new Q codes for some Medicare flu vaccines and expanded ages for adolescent vaccine counseling.

Nix 90658 for Medicare patients

CMS has come up with New HCPCS codes and payment allowances to replace 90658. Medicare will no longer pay you money for 90658 with effect from January 1, 2011. As such, select from the new codes instead, based on the specific product: Q2035, Q2036, Q2037, Q2038, Q2039.

Timing: Codes Q2035-Q2039 went into effect on October 1, 2010. When filing claims for DOS from October 1 until December 31, 2010: bill Medicare immediately with 90658, or hold the claim until January 1, 2011 and file with the proper Q code.

Explanation: Medicare pays for influenza vaccine based on 95 percent of the average wholesale price. The products normally classifiable to 90658 have widely varying AWPs. If Medicare continued paying for all of them under a single code, they could be overpaying some and underpaying others, relatively.

Consequence: Medicare assigns different Q codes to each individual product starting January 1, 2011 to account for variances in manufacturing prices. "This should actually ensure that physicians are paid well for products that might have significant differences.

Report 90460, +90461 through age 18

You will be able to use medicine series vaccine administration with counseling codes on older patients and when a nurse provides the counseling, thanks to CPT 2011.

As counseling for adolescents can involve as much as counseling on vaccine for younger children, the American Academy of Pediatrics recommended that the age limitation on the vaccine administration with counseling codes be raised. New codes extend vaccine administration with counseling to patients through 18 years of age.

Benefit from RN/LPN counseling and still get the reimbursements

Busy practices will be excited at being able to use their registered nurses (RN) or licensed practicing nurses (LPN) to capture the higher RVUs some private payers associate with the vaccine administration with counseling codes. The just-in vaccine administation code with counseling code descriptor expands who can provide the vaccine counseling described in the deleted immunization administration with vaccine counseling codes (90465-90468). CPT 2010 vaccine administration with counseling codes 90465-90468 limited the counselor role to a doctor and, subject to state scope of practice laws, nurse practitioner (NP) or physician assistant (PA).

Final say: Remember the just-in administration codes 90460 and 90461 are per vaccine/toxoid component. That means if your doctor provides counseling and administration for a combination, you will report 90460 for the first component and 90461 for each additional component. In the MMR example, you would use 90460 once and 90461 twice. Before 2011, you'd report only a single vaccine administration code for a combination vaccine, irresespective of the number of components in the vaccine.

Cisplatin, Cyclophosphamide, and Vincristine Most Affected

HCPCS 2011 code-set has a number of deletions, streamling your drug coding choices. Most affected are cisplatin, cyclophosphamide, and vincristine.

The just-released HCPCS 2011 code-set has a number of deletions, streamling your drug coding choices. Among the most affected are cisplatin, cyclophosphamide, and vincristine.

The good news is that this change should simplify billing, more so if the system your practice or facility uses like Pyxis or Lynx, limits you to a single code and billable unit for a drug.

Watch out: These HCPCS (http://www.supercoder.com/hcpcs-codes) changes have a positive side, however there are always considerations that'll arise. For instance, if your practice uses different sizes, you'll need to be alert for the different and specific national drug code (NDC) numbers for the agent dispensed to the patient when you send a claim to a payer who needs NDC information.

For cisplatin, stick to J9060

Cisplatin, ordered particularly for patients with metastatic testicular or ovarian neoplasms, or advanced bladder cancers, is one of the many agents impacted by the HCPCS 2011 shake-up.

Revision work: HCPCS 2011 will make a small wording revision to J9060.

2010: J9060 -- Injection, cisplatin, powder or solution, per 10 mg

2011: J9060 -- Injection, cisplatin, powder or solution, 10 mg.

Code J9062 (Cisplatin, 50 mg) will no longer be available for use in the new year. You should go for J9060 to report cisplatin, brand name Platinol, when supplied for 2011 dates of service.

For cyclophosphamide, J9070 comes out on top

At 1 unit per 100 mg, J9070 (Cyclophosphamide, 100 mg) won the role of the single option for coding cyclophosphamide injection supply.

J9080-J9097 go to the chopping block in 2011.

Vincristine Codes J9375 and J9380 feature in deleted list

Oncologists may order vincristine (Vincasar PFS) for patients with leukemia, Hodgkin's disease, non-Hodgkin's lymphoma, soft-tissue tumors, and neuroblastoma, among others. You will be reporting vincristine per milligram in the new year.

Steps to Pave the Way to Audit-Hardy Coding

ICD-9 coding: 6 steps to pave the way to audit-hardy coding. But remember what not to do.

An ICD-9 coding policy can keep your claims flowing smoothly; however you cannot just set it up and forget about it. Here's how to establish a policy that'll remain current and help you avoid headaches when auditors come calling.

Step 1: The first building block of a well-designed coding policy is to indicate that you adhere to the ICD-9-CM official guidelines for coding and reporting. If you don't stay up to date with these standard rules, you could be in for trouble.

For details: The official guidelines are updated each year and are normally available shortly after the annual ICD-9 updates go public.

If you keep up on the rules in the official guidelines, you will not have to worry about being blindsided by any across-the-board ICD-9 coding changes.

Step 2: Establish your coding process, including who does the coding and how you make corrections.

Step 3: Describe how your coding staff will stay up to date and keep up their coding competencies. Staying on top of changes can be especially vital, whether to the official guidelines, payer requirements or the transition to ICD-10.

Important issue: Right sequencing is always a concern for medical coders. Selecting the most proper diagnosis helps ensure not only that your practice gets its proper payments but that your coding will stand up under scrutiny from auditors. The assessing clinician and the expert coder must work together to ensure the ICD 9 codes are listed as per the seriousness of the patient's condition.

Step 4: Documenting your auditing process – including the percentage of charts you will audit for accuracy and how often you will conduct those audits. Internal auditing can help ensure your dermatology coding is spot on before your mistakes are traced in a costly audit from a ZPIC, RAC, or one of the other auditing entities.

Step 5: Weigh the accuracy of your dermatology coders. Paired with auditing, establishing an accuracy rate for your coders can help set the bar for your commitment for precise coding. If you want your coders to maintain a 95 percent accuracy rate with their coding, include this information in your policy.

Step 6: Keep polices up to date. Do not let your coding policy sit on the shelf and grow dusty. Ensure the effort to check your policy periodically to make sure it's up to date.

Mistake: Do not write policies that attempt to address how you are going to code each particular diagnosis. General policies that address the methods you use to keep your coding spot on are more useful and workable.

Source URL :- http://www.supercoder.com/coding-newsletters/my-ophthalmology-coding-alert/diagnosis-coding-6-steps-pave-the-way-to-audit-hardy-coding-104080-article

Follow up: If you get downcoded in an audit related to your diagnosis codes, gear up to ask for a redetermination. If your coding is supported by clear clinical documentation and you have followed the proper guidance, be prepared to write an appeal stating why the coding is right and quote official guidance in that appeal.

Auditors are not necessarily coders and may not be aware of the rules that govern the practice of coding. Quoting specific sections of the official coding guidelines helps to show that you are knowledgeable and have coded right.

Question and Answers to Help Code Unna Boot Application

Medically necessary Unna boots, not applied as post-op dressings make use of the CPT 29580

Find out why E/M and strapping cannot go together as separate codes

Are you aware that CCI bundles Unna boot application to many other complete surgeries (for instance tendon sheath injections, joint aspiration/injection, and the like)? If you are confused about this and many other questions about coding Unna boot application, the following questions and answers should throw some light.

Question 1: What's the purpose of Unna Boot?

Answer: The New York Medicare carrier National Government Services LCD L6979 Unna boot as a dressing used to treat varicose ulcers of the lower extremities, which are owing to increased venous pressure, venous insufficiency or capillary dysfunction. It comprises a bandage impregnated with a gelatin, zinc oxide, and glycerin paste that the provider layers on the leg ulcer until the bandage becomes rigid.

According to the LCD, the resulting pressure and bacteriostatic properties aid in healing.

Question 2: Do you get the payments for the supplies with Unna Boot?

Answer: You should not think about Unna boots applied as dressings a separately reimbursable service apart from surgical procedure.

As per CCI, payment for surgical dressings applied by the doctor during his/her encounter with the patient is included in the fee schedule payment for the doctor's service.

Medically necessary Unna boots, not applied as post-op dressings make use of the CPT 29580 (Strapping; Unna boot). Just like that, you should never code for any supplies. Payers include the cost of all Unna boot bandages, straps and paste in their payment for 29580.

But then you should report change in dressings every few days, while the patient is in Unna boot, with 29580, which has a global period of zero days.

Question 3: Can I bill an Evaluation/Management with 29580?

Answer: You may report an Unna boot application with 29580 apart from the proper E/M code only under this situation: The boot application is provided as an initial service with no expectation that the doctor who rendered only the original care will carry out another treatment or procedure.

To put it in other words, if the patient has a new or different complaint that requires a separate and significant E/M service, you may bill a proper E/M code. Do not forget to append with modifier 25.

Reminder: You'd need to attach a separate diagnosis to the E/M service to further distinguish it from the inherent E/M service included in the Unna boot application.

Question 4: What if Doc carried out a debridement also?

Answer: Debridement before applying the Unna boot is a typical procedure that podiatrist performs. You can report debridement during the same session as 29580 only if the services apply to separate anatomical areas (separate feet).

Fact: CCI has bundled column-2 code 29580 into column-1 codes 11040-11044 as a standard of medical/surgical practice. The modifier indicator of 1 allows you to report both procedures separately using modifier 59. For instance, the physician carries out a debridement on the patient's right foot and applies an Unna boot to the left foot.

Question 5: What ICD-9 codes should you use with 29580?

Answer: Depending on the payer, 29580 links to diseases like varicose veins of lower extremities (454.0-454.2) and lower limb ulcers, except decubitus (707.10, 707.12-707.19). Some payers will take additional diagnoses, such as atherosclerosis of extremity with ulceration (440.23) or sprains and strains of the ankle and foot (845.00-845.19). Like always, you should report the diagnosis as per your physician's documentation.

Do: Ensure you check with your payer on current policy or update for the different diagnoses.

Choose 43255 for control-of-bleeding situations

43255 is a good choice for control-of-bleeding situations

When coding for excessive blood loss, modifier 22 may not be that ally you are looking for. The answer may lie on more proper CPTs such as 43255 and critical care codes. Take cue from these two scenarios:

Think about endoscopy with injection as option

First Scenario: The doctor injects epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy.

Code it: Earlier, you may opt to use 43239 appended with modifier 22 if the physician required significant effort to control the patient's bleeding.

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

As evident from 43255's descriptor, this procedure describes control of bleeding by any method, including injection.

Requirement: On your claim, you should append modifier 59 to 43255, and then report 43239. Omitting the modifier would give payers the feeling that the biopsy (or physician) caused the bleeding and bundle 43255 into 43239.

Extraordinary bleeding will require critical care coding

Second scenario: When the gastroenterologist is about to carry out an upper GI endoscopy, the patient experiences gastrointestinal bleeding so severe that the physician must suspend the endoscopy and spend 40 minutes lavaging blood from gastro-intestinal tract before continuing.

Code it: Here, the critical code 99291 is your best choice.

Here's why? If the gastroenterologist caused the bleeding, you can't bill for the control of bleeding procedure. You should call on control-of- bleeding codes only when treatment is required to control bleeding that takes place spontaneously or as a consequence of traumatic injury (noniatrogenic), and not as a result of another type of operative intervention," states CPT Assistant.

Remember, the time spent at the bedside carrying out services including lavage of gastric blood is not included in the performance of a subsequent endoscopic procedure and is not part of the E&M service that might be carried out on the same day.

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

22551, 22552 Boost Your Arthrodesis Accuracy

CPT 2011 will come up with 200 plus new codes. 22551, 22552 Boost Your Arthrodesis Accuracy

Additional neurostimulator and arthrodesis codes are two of the plusses in the new and revised codes your orthopedic practice will have in the coming year.

As a matter of fact, CPT will come up with 200 plus new codes in 2011 and revise over 90 codes to help keep your coding more specific than ever, spanning a number of specialties, from dermatology to orthopedics to cardiology and beyond.

Make room for extra arthrodesis specificity

Beginning January 1, you'll be required to report arthrodesis procedures that include discectomy, osteophytectomy and spinal cord decompression with two new bundled codes:

22551

22552

Code 22552 is an add-on code; as such, you would report it with 22551 to reflect any additional interspace the neurosurgeon treats below C2. Earlier, this bundled procedure would have been reported as 63075, for the discectomy,osteophytectomy and spinal cord/nerve decompression and 22554-51. This is one of several code pairs which were used together more than 90 percent of the time, prompting CMS to request a bundled code from CPT.

Add more neurostimulator codes

Beginning January 1, you will be able to describe more fully tibial and cranial neurostimulator services with four new codes:

64566, 64568, 64569, 64570

And if your neurosurgeon carries out chemodenervation, you will have a new code to report for work on the salivary glands: 64611

Watch halo, allograft, and vertebral fracture revisions

Do not let code descriptor changes trip you up when you turn to 20664 for halo application as the latest revision removes the phrase “requiring general anesthesia:"

20664 (Revised)

Add-on allograft codes 20930 and 20931 received changes, which will be for the coming year:

20930 (Revised), 20931 (Revised)

The development of many bone graft extenders including demineralized bone matrix and bone morphogenic protein led to frequent questions regarding the right coding for these materials.

The revision of 20930 places these materials in the same category as other non-structural bone extenders that aren't obtained directly from the patient being treated.

Closed vertebral facture code 22315 now omits the phrase “with or without anesthesia": 22315 (Revised).

And code 22851 for application of intervertebral biomechanical devices deletes “threaded bone dowels" from the definition:22851 (Revised).

The rationale: The production of machined allografts led to frequent questions regarding the proper coding for placing these materials. As the machined allografts are bone allograft materials, the right code to describe their use was 20931. But the example of threaded bone dowel in code 22851 led to confusion that prompted removal of this example from 22851, which was intended to describe placement of structural devices composed of non-bony prosthetic material.

Source URL :- http://isupercoder.blogspot.in/2010/12/22551-22552-boost-your-arthrodesis.html

Comparison of 2010 and 2011 definitions for 93922-93924

CPT 2011 revises the definitions for 93922-93924. Look how the 2010 and 2011 definitions compare for 93922-93924.

If you have been longing for more details in your noninvasive physiologic code definitions, your wish will be fulfilled in 2011.

CPT 2011 revises the definitions for 93922-93924. Take a look at how the 2010 and 2011 definitions compare for 93922-93924.

93922: Watch changes to number of levels

When looking at the 93922 definitions, notice that the 2010 version refers to ‘single level, while the 2011 version offers several examples that refer to "1-2 levels":

This year: 93922 -- Noninvasive physiologic studies of upper or lower extremity arteries, single level, bilateral (example, ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement).

In the coming year: 93922 -- Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (example, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 1-2 levels).

93923: Number of levels are the key change once again

One of the changes to watch for 93923 is the switch from "multiple levels" in this year to "3 or more levels" in the coming year:

This year: 93923 -- Noninvasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (example, segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia)

In the coming year: 93923 -- Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, three or more levels (example for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/ dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at three or more levels, or ankle/ brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at three or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at three or more level(s), or single level study with provocative functional maneuvers (example, measurements with postural provocative tests, or measurements with reactive hyperemia).

93924: Improve your understanding of this service

The change to 93924 is the addition of a lot more detail to explain what CPT intends the code to describe:

This year: 93924 -- Non-invasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study.

In the coming year: 93924 -- Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (i.e., bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/ brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study.

Will CMS slash 2011 conversion factor 30 percent?

A long-term solution is the need of the hour, the Fee Schedule notes.

Whether your Medicare payments will be slashed is a question on everyone's mind as we get ready to step into the New Year.

What to expect: There's a possible cut to 2011 payments beginning January 1. There are rumblings that another one-year path to keep rates up is under consideration by Congress. Some newly-elected Senators and House members will be in place in 2011, and it is not clear whether the current Congress will make changes affecting 2011 pay before January or whether they will leave the issues for the new Congress to handle.

The conversion factor for the calendar year 2011 PhysicianFee Schedule(Source "") is $25.5217. This amounts to a dismal 30 percent compared to the present rate of $36.8729.

All of this leaves Part B practices in the dark about the future of payments once again. While Congress has provided temporary relief from these reductions every year since 2003, a long-term solution is the need of the hour, the Fee Schedule notes.

Radiology hit hard by RVU cuts as well

Apart from dealing with conversion factor fluctuations, radiology will be among the hardest hit by additional cuts to RVUs and other factors affecting payment. These cuts will have a significant impact on specialty practices that are already stretched financially:

Diagnostic testing facility: 15 percent cut

Radiology: 10 percent cut

Interventional radiology: 5 percent cut

Nuclear medicine: 4 percent cut

Radiation oncology: 1 percent cut.

For more on this and for the latest on the 2011 Fee Schedule, sign up for a medical coding guide like Supercoder!

Cms Plays Spoiltsport on Your Pay

CMS doesn't make payments for preventive medicine services billed under 99381-99397.

Owing to the flawed Sustainable Growth Rate (SGR) formula to calculate Medicare fees, Medicare payments to doctors are also due to fall, and medical practices will face a perfect storm of payment nightmares.

Practices are not sure what will transpire on January 1, 2011. Some newly-elected Senators and House members will be in place in the new year, and it's not clear whether the present Congress will make changes affecting 2011 pay prior to January or whether they'll leave these issues for the new Congress to solve.

Some specialties will face additional cuts apart from dealing with conversion factor fluctuations.While the most affected practices will be those that specialize in radiology, the cuts will most certainly have a significant impact on specialty practices that are already financially stretched.

The Fee Schedule also incorporates several provisions of the Affordable Care Act of 2010 that was passed last March. Firstly, you will see that coverage has been established for annual wellness visits for Medicare patients. The rule that was issued on November is a major step toward improving the health status of Medicare beneficiaries by providing coverage for an annual wellness visit that will allow a physician and patient to forge closer ties to improve the patient's long term health.

"If you carry out a procedure that meets CMS's description of an annual wellness visit, you shouldn't report a code from CPT's preventive medicine section to your Medicare carrier," indicates the Final Rule.

CMS doesn't make payments for preventive medicine services billed under 99381-99397. Instead, you should report one of the following newly-established HCPCS codes(http://www.supercoder.com/hcpcs-codes/):

G0438 -- Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit

G0439 -- subsequent visit.

Even though most of these wellness examinations are normally carried out by the patient's internist or family physician, occasionally a urologist will carry out this service. If so, think about the above codes and information to help you bill properly and be paid for this service.

CMS has assigned 2.43 physician work RVUs to G0438 and 1.50 RVUs to G0439, and these codes will be effective on January 1, 2011. Beneficiaries who have been enrolled in Part B for a year will be eligible for an initial preventive physical exam, (also known as an IPPE, which is billed with G0402).

Post the first 12 months of Part B coverage on or after January 1, 2011, beneficiaries would be eligible for an initial preventive physical exam. After the first 12 months of Part B coverage on or after January 1, 2011, beneficiaries would be eligible for an annual wellness visit as described by the new G codes, thinking that the patient has had an IPPE within the preceding 12 month period, states the Fee Schedule.

43255 Good Bet for Coding for Excessive Blood Loss

Coding for Excessive blood loss, modifier 22 may not be what you are looking for. The answer may depend on more appropriate CPTs such as 43255 and critical care codes.

When you are coding for excessive blood loss, modifier 22 may not be what you are looking for. The answer may depend on more appropriate CPTs such as 43255 and critical care codes.

Think about endoscopy with injection as option

Scenario 1:

The physician injects epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy. 43239, Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as apt; with biopsy, single or multiple).

Previously, you may opt to use 43239 appended with modifier 22 (Increased procedural services) if the doctor required effort to control the patient's bleeding.

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

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

Requirement: On your claim, you should append modifier 59 to 43255, and then report 43239. Omitting the modifier would give payers the impression that the biopsy (or physician) caused the bleeding and bundle 43255 into 43239.

Extraordinary bleeding requires critical care coding

Scenario 2: When the gastroenterologist is about to carry out an upper GI endoscopy, the patient experiences gastrointestinal bleeding so severe that the doctor must suspend the endoscopy and spend 40 minutes lavaging blood from the gastro-intestinal tract before continuing.

Code it: This time, the critical code 99291 is your best choice.

Here's why" If the gastroenterologist caused the bleeding, you cannot bill for the control of bleeding procedure. You should call on control-of- bleeding codes only when treatment is required to control bleeding that occurs spontaneously, or as a consequence of traumatic injury (noniatrogenic), and not as a result of another type of operative intervention, the CPT Assistant states.

Remember that the time spent at the bedside carrying out services including lavage of gastric blood isn't included in the performance of a subsequent endoscopic procedure and is not part of the E&M service that might be carried out on the same day.

Nevertheless, you should not report a critical care code carelessly for an excessive bleeding situation that's not out of the ordinary. Additional time for emergency bedside services less than 30 minutes does not count as billable critical care service. For prolonged critical care services, the physician should specifically note the amount of time in his notes.

Four Question to Guide your Ucler Reporting

Ask yourself few questions about the excision and debridement services, you will have an easier time selecting the right code.

When your dermatologist carries out a decubitus ulcer excision or debridement, you will have to choose from about 25 possible codes. If you ask yourself the following four questions about the excision and debridement services, you will have an easier time selecting the right code.

Was the wound closed? If yes, by what method?

In some instances, the dermatologist may debride the ulcer and allow the wound to stay open to heal.

On the other hand, the dermatologist may excise the ulcer, clear all infection, and close the wound.

The difference: You shouldn’t distinguish debridement from excision by the ulcer’s removal but, rather, by what the documentation specifies. For instance, documentation for an ulcer removal may read, “The skin was cut in elliptical fashion around the lesion, and the dermatologist excised and sent the lesion to pathology. The dermatolgist closed the wound with 4-0 sutures in a layered fashion (or packed open to drain and heal by secondary intention)." It’s difficult to tell the difference sometimes (both methods are ways of clearing infection); as such you should determine your coding on what the dermatologist describes in the documentation.

Where was the ulcer?

With the nine ICD-9 codes for decubitus ulcers (707.00-707.09), you may have many codes to select from, specific to the ulcer’s location on the body:

707.00 -- Pressure ulcer; unspecified site

707.01 -- elbow

707.02 -- upper back

707.03 -- lower back

707.04 -- hip

707.05 -- buttock

707.06 -- ankle

707.07 -- heel

707.09 -- other site.

How deep was the debridement?

You can report debridement (11040-11044) based on three different skin levels, which are partial thickness, full thickness or subcutaneous – or as deep as muscle or even bone. For instance, 11044 (Debridement; skin, subcutaneous tissue, muscle, and bone) describes a debridement that involves chipping off pieces of diseased bone to help rid the wound of infection.

A partial thickness debridement includes the epidermis and part of the dermis; however some dermal cells are left. The physician normally carries out these procedures using a scalpel or scissors, depending on the situation.

Besides the ulcer, was anything else excised?

In some cases, with coccygeal pressure sores the dermatologist may remove the coccyx to do away with irritation and prevent the ulcer from recurring. The dermatologist may also excise bony prominences as a pressure sore at the same time.

Was anything else excised besides the ulcer?

In some instances, with coccygeal pressure sores the dermatologist may remove the coccyx to eliminate irritation and prevent the ulcer from recurring. The dermatologist may also excise bony prominences at the same time as a pressure sore.

Source URL :- http://www.supercoder.com/coding-newsletters/my-dermatology-coding-alert/ulcer-treatments-70700-70709-basics-4-questions-guide-your-ulcer-reporting-article

Fee Schedule Establishes Coverage for Annual Wellness Visits for Medicare Patients

The Fee Schedule establishes coverage for annual wellness visits for Medicare patients.

The new Fee Schedule incorporates several provisions of the Affordable Care Act of 2010 that was passed in March.

New coverage: The Fee Schedule(http://www.supercoder.com/coding-tools/fee-schedules) establishes coverage for annual wellness visits for Medicare patients.

The rule that was issued on November 3 is a key step toward improving the health status of Medicare beneficiaries by providing coverage for annual wellness visit that'll allow a physician and patient to develop closer ties to improve the patient's long term health.

Change: If your doctor carries out a procedure that meets CMS's description of an annual wellness visit, don't report a code from CPT's preventive medicine section to your Part B carrier, the Final Rule indicates. CMS doesn't pay for preventive medicine services billed under 99381-99397. Instead, report one of the following newly-established HCPCS codes that'll be effective from January 1, 2011:

G0438 -- Annual wellness visit; includes a personalized prevention plan of service, first visit

G0439 -- Annual wellness visit; includes a personalized prevention plan of service, subsequent visit

CMS has assigned 2.43 physician work RVUs to G0438 and 1.50 work RVUs to G0439. Beneficiaries who have been enrolled in Part B for 12 months will be eligible for an initial preventive physical exam (also known as an IPPE, which is billed with G0402). After the 12 months of Part B coverage on or after January 1, 2011 beneficiaries would be eligible for an annual wellness visit as described by the new G codes, assuming that patient has not had an IPPE within the preceding 12-month period, states the Fee Schedule.

Take a Look at Your Cardiac Cath Injection Coding Options In 2011

Start easing your practice into the CPT 2011 changes that'll be in effect on the first day of the year.

As you gear up to step into the New Year, you should start easing your practice into the CPT 2011 changes that'll be in effect on the first day of the year. Begin your preparations with this preview of some of the new and revised descriptors that may have an impact on your cardiology coding.

Gear up for cardiac cath coding overhaul

CPT 2011 brings major code changes for cardiac catheterization codes. One aspect of that change is that many of the new injection codes appear to be add-on codes. It'll be interesting to see what the fee schedule has allowed for these services to really get a hang of how it'll affect the cardiology practices in the coming year.

We will go into more details on the correct use of the new codes once the AMA has released details; however you can get a hint of what's to come by looking at the new injection procedure codes. Note that these codes include both (1) the injection procedure during cardiac cath and (2) imaging supervision, interpretation, and report:

93563

93564

93565

93566

93567

93568

Deletion alert: As a result of these additions, reports indicate that CPT 2011 will delete 2010 codes 93539-93545 and 93555-93556.

Rely on more to come for coronary angiography options

You may also think why the just-in injection procedure codes for coronary angiography (93563-93564) specify "congenital heart catheterization". It appears you will have other options for non-congenital cases.

This is because another one of the major changes you can expect is the addition of a new, eight-code family, 93454-93461. The codes in the family differ based on whether you are reporting additional imaging or heart catheterization services carried out at the same session.

For other cardiac cath codes and the entire CPT code list(http://www.supercoder.com/cpt-codes), sign up for a medical coding guide like Supercoder!

Family Physicians likely to See Some Gains

Family Physicians: Congress voted to not only stave off a 21 percent cut to your Medicare pay, but to increase the conversion factor by 2.2 percent.

As everyone knows, the Congress voted to not only stave off a 21 percent cut to your Medicare pay, but to increase the conversion factor by 2.2 percent. However that vote only kept the cuts at bay through November 30.

With effect from December 1, your Medicare pay is likely to come down by over 23 percent, unless Congress intervenes to reverse the cuts. To add to it all, the 2011 payments are due to drop even further with effect from January 1, and medical practices are facing a perfect storm of payment nightmares.

Some practices will bear the brunt and face additional cuts. Affected groups include radiology, urology, oncology/hematology, pathology, and emergency medicine. But family physicians have better news to face thanks to the government seeking to give primary care practices boosts in the coming year.

Family medicine practices expect a two percent gain in Medicare allowed charges next year based on an ongoing transition in Medicare's practice expense RVUs, according to one impact table in the final rule. Internists and pediatricians should anticipate a one percent boost in their Medicare allowed charges, as per the same table.

Other practices that'll see their pay go up will be hand surgeons, who will watch their Medicare allowed charges increase on average by four percent. The following specialists will also see gains in the coming year: neurologists (2 percent), otolaryngologists (3 percent), dermatologists (4 percent), plastic surgeons (3percent), and colorectal surgeons (3 percent).

For more on the Fee Schedule, sign up for a medical coding guide like Supercoder!

Supercoder give you ways to boost your Hemoccult Test Coding.

If you want to keep the money coming for in-office examination of fecal occult blood test (FOBT), you should train eyes on the difference between three hemoccult codes and their purpose.

Here's a scenario:

A 60-year old patient presented in the office complaining of diarrhea preceded by intestinal cramping, which lasted two weeks. The patient has no history of cancer in the family. He also did not feel nauseous at all. The physician took a stool sample to test for both parasites and blood. How should you approach this situation?

Assign the right code for each type of collection

Since the year 2007, CPT has assigned two codes that you can use for post digital rectal exam (DREs) and consecutive specimen collection:

82270

82272

Update: With effect from January 1, 2007, CPT has terminated HCPCS code G0107 and replaced by 82270 even for routine Medicare screening FOBT.

Remember: In the above scenario, it is not clear whether the doctor examined the samples herself or sent them to the lab. But as a general rule, parasite exams almost always take place in the lab. Here, the lab would be paid for the test directly.

Do not forget: There are interval limitations for screenings established by Medicare and most commercial carriers.

On the other hand, if a patient presents to the office with symptoms, the gastroenterologist would carry out a diagnostic FOBT, and you should bill it with 82272. One can bill CPT 82272 if 1 to 3 specimens are obtained. The diagnosis code for the test would be related to the patient's presenting symptoms.

Count number of tests

If you are still not sure whether you have got the right code by differentiating screening from diagnostic, you can look further into the test's details. Identify how many tests the gastroenterologist or lab performs. For a three-specimen collection, you would go for 82270. Use a single-specimen collection with 82272.

Red flag: Even though 82270 involves analysis of three specimens, you should always assign 82270 with a “1" in the units field. Some coders incorrectly interpret 82270's descriptor of “one to three simultaneous determinations" to mean they should bill “each of the three determinations with one unit of CPT 82270 (82270 x 3)." The revised description more clearly reminds providers that the code identifies as many as three consecutive determinations.

What if: The patient fails to collect all three samples. You may still bill 82270. If this happens, the laboratory should carry out analysis of the one or two collected specimen, report the results accordingly and record one unit of 82270.

Determine who obtains the sample

Where the sample is collected and who performs it can also include you in to the right FOBT code. CPT Code 82270 will always be billed as a separate service when the developer has been placed on the cards after the three completed cards (or one completed triple card) have been returned to the office. In a nutshell, the doctor should not collect the specimen in the office.

Instead you should use 82272 when the doctor carries out a digital rectal exam in the office and obtains a sample at that time.

How to Code Cosmetic Ptosis Repair

Having issue how to code Cosmetic Ptosis repair. For more on this and all 2011 CPT updates visit a medical coding guide like Supercoder.

There is this Medicare patient of ours who'll be having a leva to resection on his right eye for ptosis. The ophthalmologist wants to do this as a bilateral procedure; however the patient's left eye is a non-seeing eye. As the operation on the right side may be medically necessary, but the left side would likely be considered cosmetic, how should I go about coding this surgery?

Well, you should report each side of the bilateral procedure on a separate line, appending modifiers LT (left side) and RT (Right side), linking each side to the appropriate diagnosis code explaining the necessity for the surgery.

In this situation, one side will be medically necessary, while the other will be cosmetic – the procedure will not benefit the vision on the non-seeing eye.

Here's what you need to do: Before the surgery, have the patient sign an advance beneficiary notice of non-coverage (ABN) prior to surgery, stating that he's aware that Medicare will not cover the procedure carried out on the left eye. Ensure your ABN is in layman's terms and specifies the specific reasons for non-coverage. (you shouldn't use CPT Code, ICD 9 codes on the ABN form).

Source URL :- http://www.supercoder.com/coding-newsletters/my-ophthalmology-coding-alert/reader-questions-report-cosmetic-ptosis-repair-separately-15819-article

You must also specify the estimated cost of the service on the ABN. The original signed ABN indicating the patients decision ( be sure the patient has chosen one of the options) to accept financial responsibility, is maintained by the practice and a fully executed copy must be provided to the patient. Append modifier (Waiver of liability statement on file) to the procedure done on the non-seeing eye to indicate that the patient was informed before and has selected the option to be responsible for the non-covered service and unpaid amount.

For instance: The patient has congenital ptosis (743.61), and his left eye is non-seeing. The ophthalmologist carries out levator resection (67904, Repair of blepharoptosis; [tarso] levator resection or advancement, external approach) bilaterally. Code as follows:

Line 1: 67904-RT linked to 743.61

Line 2: 67904-LT-GA linked to V50.1 (Elective surgery for purposes other than remedying health states; other plastic surgery for unacceptable cosmetic appearance).

If your documentation shows that the procedure was medically necessary on the right side, Medicare will reimburse the full amount for 67904-RT. The cosmetic diagnosis linked to 67904-LT-GA will prompt the carrier to deny the specific service due to the diagnosis and non-coverage of cosmetic services, and the explanation of benefits (EOB) received by the patient will confirm that the patient is responsible for payment.

Wrong Answer Could Weigh Heavily on your Medical Coding Practice

In Medical Coding a mistake can also impact on your practice’s reimbursements.

Your ophthalmologist provides a new patient with a standard office-visit E/M. You use an established patient E/M to report the encounter. And if you thought it’s no big deal, you are wrong.

Not only is the coding wrong, this mistake will also have an impact on your practice’s reimbursements. To add to it, Medicare’s non-payment of consultation codes means that medical coders will have to answer the new versus established question more often than before.

For Medicare and payers that follow their lead, medical coders will now have to choose the correct code, new or established, to bill for what used to be consults and didn’t have a new versus established component concept.

Here’s an expert advice on new and established patients.

If you ignore new patient E/Ms, you could be losing your deserved money

For physician practices, the difference between new and established patient codes is the payment rate. Think about this comparison of average national payouts for new and established level-two E/m codes respectively:

99202 pays about $68 per encounter (1.86 transitioned nonfacility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.8729)

99212 pays about $40 per encounter (1.08 transitioned nonfacility RVUs multiplied by the temporary 2010 Medicare conversion rate of 36.8729).

That is almost $30 lost if you report 99212 instead of 99202 mistakenly. The main difference between a new and established patient visit, service-wise, can be minimal: Often it includes simple tasks like setting up a new chart and quizzing the patient a little closer to get familiar with him.
First ask 3-year question

If your patient has had a face-to-face service with the ophthalmologist within the last three years, then the patient is considered established. So let us say a patient reports to your ophthalmologist and gets a level-three E/M service on April 20, 2010. The patient’s record points to the fact that she received a previous face-to-face E/M service from another ophthalmologist within the group on Dec. 14, 2008. Since this is an established patient, you should report 99213.

For established patients, Face Time is a must

As a coder, what would you do when the patient has received treatment from your ophthalmologist within the last three years, however the doctor didn’t actually lay eyes on the patient? This is a different coding situation; here’s what you need to do: ‘Interpret the phrase ‘new patient’ to mean a patient who hasn’t received any personal services – to put it separately, an E/M service or other face-to-face service from the physician or physician group practice within the last three years.

This means that you might be able to report a patient as new if your ophthalmologist provided services for the patient less than three years ago, provided it wasn’t a face-to-face service.

Check specialty when deciding status

Coders who work in multispecialty practices will have to pay attention to one more new/established patient status rule.

For more on this, and other evaluation & management coding guidelines, stay tuned to a medical coding guide like Supercoder

New Choice to Boost your Diagnosis Coding

ICD-9 Codes 2011 going to effect in October, and here new ‘attention deficit’ to boost your Diagnosis Coding

The 2011 ICD-9 codes going into effect on October 1 have a few welcome additions for younger patients. Here are some examples of new diagnoses you could find yourself reporting on a regular basis.

Attention deficit options provide a better starting point ICD-9 2011 adds the 799.5x family to the ‘I’ll defined and unknown causes of morbidity and mortality’ section. The just-arrived codes include:

799.51 -- Attention or concentration deficit

799.52 -- Cognitive communication deficit

799.53 -- Visuospatial deficit

799.54 -- Psychomotor deficit

799.55 -- Frontal lobe and executive function deficit

799.59 -- Other signs and symptoms involving cognition.

This new series will be useful for symptoms and signs as a diagnosis before the doctor establishes a definitive diagnosis. Physicians treat children with concerns regarding attention or activity. You do not have sufficinet information after the first visit for an official diagnosis; but then you still need something to report.

V codes address retained fragments

ICD-9 2011 also comes up with a series of specific V codes for diferent types of retained fragments. The series (V90.01- V90.9) address objects ranging from metal, plastic or wood to animal quills or spines, glass, teeth, and other specified foreign bodies, including radioactive fragments.

Remember that you won’t report a code for foreign body removal in conjunction with V90.x. These foreign bodies are retained. You will deal with it in terms of the patient’s history and physical, however not an actual procedure to remove the object.

Want to know more about these attention deficit choices and other 2011 ICD-9 code(http://www.supercoder.com/icd9-codes/) changes? Just stay tuned to a medical coding guide like Supercoder.

Three ways to add an Additional $293 in Minor Procedure Pay

You could be missing out on opportunities to capture higher-paying procedure codes if you are overlooking reporting these splinting and foreign body removal codes.

Procedure 1: Gather $38 for sport injury splinting

Pee-wee football has started up and with it the chance you will see an increased number of patients with jammed fingers. For a non-angulated finger, the pediatrician might fix the sprain, splint the finger and send the patient home.

For the finger splint application, you could report 29130, which contains 1.02 RVUs, using the Resource Based Relative Value Scale. Even though global fracture care codes include the initial cast or application, you may use the casting and splinting codes in addition to an appropriate E/M code with modifier 25 when you don't report a fracture treatment code.

Do not miss: For the history, exam, and medical decision making that led to the decision to splint the finger, you'd report a significant separate E/M service appended with modifier 25. As you are not reporting a global fracture care code, you may also code the x-ray.

Procedure 2: Use tapping procedure code to add on $38

If a toe is broken, the pediatrician might buddy tape it to the adjacent toe and refer the patient to an orthopedist. For the buddy tapping, you could code 29550 (Strapping toes). The Medicare Physician Fee Schedule, which many payers adopt, assigns the code 1.04 RVUs. Report the history, examination and medical decision making preceding the decision to buddy tape the toe with 99201-99215 appended with modifier 25.

For the x-ray, go for 73600.

Procedure 3: Capture $227 on splinter removal

Removing a splinter from a patient's foot can net you around $227. For example, a pediatrician removes a 3 mm wooden splinter from a child's foot. Rather than including the work in an E/M code, you can use 28190, which has 6.15 RVUs.

Tip: Prior to using 28190, check that the documentation includes two details. The code need excising or opening to remove the foreign body. You have to say how and what you removed. Proper documentation could read: “1 mm incision made with X, removed splinter. This entry meets 28190's requirements of incision and removal.

Source URL :- http://www.supercoder.com/coding-newsletters/my-pediatric-coding-alert/revenue-boosting-procedures-29130-29550-28190-3-ways-you-can-add-an-additional-293-in-minor-procedure-pay-article

CPT 2011 Bids Goodbye to 90465-90474, Welcomes Hello Vaccine

For combination vaccines that may involve counseling on as many as five different diseases, getting paid as though you counseled on one never seemed right, however CPT 2011 lets you capture that extra counseling work.

Multiple component vaccines (Pentacel, Kinrix, MMRV) have had an economic disincentive related to the loss of immunization administration codes with these vaccines.

As the present CPT vaccine administration codes (90465-90467) are coded per vaccine, the codes capture payment for only one counseling administration code.

CPT 2011 will delete 90465-90468. The 90471-90474 (Immunization administration ...) codes will remain.

Good news: In the coming year, you will report the immunization administration with counseling codes per component. Here's how:

Step 1: Report 90460 as vaccine adminstration W/ counseling base code

You shouldn't look at administration route when selecting which immunization adminstration with counseling code. For vaccine administration except for H1N1, you'll assign one code for each vaccine's initial component: 90460.

Step 2: Use second vaccine component with +90461

Pediatric coders can heave a sigh of relief as the complexities over deciding which 90465-90468 code to use as the base code will soon end. The CPT codes 2011 for the coming year give you only one vaccine administration with counseling base code (90460). You will report the same add on code for each additional vaccine component: +90461.

If the physician, nonphysician practitioner (NP), physician assistant (PA), or other healthcare qualified professional provides vaccine counseling to a patient less than 19 years old for a second disease/component, you will assign +90461 for the second vaccine component. You will always report +90461 in addition to 90460.

Step 3: Use units to report 3+ Administrations

You will keep using the same add-on code, +90461, for each additional vaccine component. Bill the add-on code, in addition to the number of units that represents the number of components.

For more information on CPT 2011 and the entire CPT code list, sign up for a medical coding guide like Supercoder.com

Do Not Miss Out On Ancillary Procedures with Kyphoplasty, Vertebroplasty

Report radiologic supervision and interpretation, however leave out bone biopsies.

When your orthopedist carries out a vertebroplasty or kyphoplasty procedure, you will need to decide if there are additional services you could be coding and reporting. Get the low down on what you can and cannot report separately.

Modifier 26 brings you radiology pay

You can report the operating surgeon's imaging for needle positioning and injection assessment during a kyphoplasty or vertebroplasty procedure. You will use either 72291 or 72292 in addition to fluoroscopic guidance.

CPT revised these codes for 2006 to use with either vertebroplasty or kyphoplasty. You should be sure to append modifier 26 (PC) to the appropriate radiology service code to show that the surgeon provided only the physician component of the service and didn't supply the equipment, etc.

Caution: If your surgeon doesn't personally carry out the guidance, you can't bill for it. Rather, the healthcare professional who provides the service (often the facility radiologist) will bill for it.

Include bone biopsy with main procedure

When you are reporting 22520-+22522 or 22523-+22525, you won't code separately for a bone biopsy. You shouldn't report 20225 if the biopsy occurs at any of the same spinal levels as the primary procedure.

Here is the reason: The CPT code descriptors stimulate this limitation as do many payer local coverage determinations (LCDs). To add to it, CCI edits(http://www.supercoder.com/coding-tools/cci-edits-checker/) bundle bone biopsy to vertebroplasty and kyphoplasty codes. As there's boney tissue removed during the process anyway, it wouldn't be right to charge for taking some specifically for a biopsy.

Alternative: If your surgeon carries out bone biopsy at a level not addressed by the vertebroplasty or kyphoplasty, but you may report the biopsy separated with modifier 59 (distinct procedural service) to indicate the unrelated nature and separate locations of the two procedures.

Increase your Coding Options for Patients Refusing Dilation

A patient shows up for an exam, however he won’t let the ophthalmologist dilate his pupils that day. Whatever the reason – time, the drive home, etc, you are stuck trying to find the best way to report a dilation at a separate visit.
Most Medicare carriers assume that a dilated fundus exam will be part of any comprehensive eye exam you carry out and bill with 92004 or 92014.

Without dilation, you cannot carry out the fundus exam and without the fundus exam, you don’t have a comprehensive service.

Count two visits as one service

According to CPT, a comprehensive ophthalmological service “often includes" examination with dilation, therefore dilation is not necessarily required to bill 92004 or 92014. But some payers and state specific guidelines may have their own dilation requirements. For instance, according to Trailblazer, the 92004/92014 exams should be done under dilation unless “medically contraindicated. Check with your carrier if you get a denial you think is unfounded.

Do not submit bill until second appointment

The real challenge comes into play when you are expecting the patient to come back for the dilated exam and he never shows up. This’s a difficult situation as you do not want to bill for services not rendered, nor do you want to undercode a visit.

If you bill the insurance company for the initial visit before the time of the second visit, and the patient does not show up, document carefully that the patient refused dilation on the first visit, scheduled a return visit and then refused to keep the appointment. But then it is not recommended to bill for services that have not been rendered or refused by patients under any circumstances.

Better idea: Do not file the claim until the second appointment. You could downcode to a 92002/92012 (intermediate service) if the patient failed to show up and you wouldn’t have to pursue the patient to return. You couldn’t bill the comprehensive codes in this case as the first visit didn’t include a dilated fundus examination.

For more on this and other CPT coding updates, sign up for a medical coding guide like Supercoder!

Do and Don't of Unlisted Procedure Coding

Keep this CPT instruction in mind: "Don't choose a CPT code that merely approximates the service provided." This rule is key for compliant coding, however it leaves you with tough job of submitting a claim without a procedure-specific code. Here are some do's and don'ts to increase your chances of getting the payment your practice earned.

Explain the procedure in Layman's Terms

If CPT does not offer a code specific to the service provided, then you should report the appropriate unlisted-procedure code like 37799 (Unlisted procedure, vascular surgery) for vascular sclerotherapy.

When you file a claim using an unlisted procedure code you should include a cover letter stating why you are using the unlisted code. This separate report should explain in simple straightforward language exactly what the physician did.

According to CPT Assistant (http://www.supercoder.com/coding-references/code-connect)(April 2001), you need to submit reporting documentation identifying the specifics of the procedure such as the procedure report when you file the claim. The supplemental documentation should define the service (nature, extent, need) and the time, effort and equipment required. According to CPT Assistant, you may also include the following factors:

Whether the doctor required help to carry out the service

Whether the procedure was independent of other services

Whether the doctor carried out additional procedures at the same site

Number of times the doctor carried out the service at the encounter

Extenuating circumstances that complicated the service.

You may even want to include diagrams or photographs to facilitate the person reviewing your claim better understand the procedure.

Do not try to use modifiers or multiple units

You shouldn't append modifiers to unlisted-procedure codes or try to report them more than once per encounter.

Suggest an appropriate fee for the service

Unlisted procedure codes don't appear in the Medicare Physician fee Schedule, so they don't have assigned fees or global periods. Your payers will generally determine payment for unlisted procedure claims based on the documentation you provide.

You can suggest a fee by comparing the unlisted procedure to a similar listed procedure with an established reimbursement value.

New Codes for Peritoneal Cavity Chemo and Interstitial Device Placement

If your oncology practice provides chemotherapy into the peritoneal cavity using an indwelling port or catheter, your task will get a lot easier with effect from January 1 next year.

Here's why?

The American Medical Association (AMA) has announced the CPT 2011 codes, and they include a code specific to that service: 96446 (Chemotherapy administration into the peritoneal cavity through indwelling port or catheter).

You will also have new codes describing placement of interstitial devices for radiation therapy guidance, such as the following:

+49327 -- Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (for instance, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if carried out, single or multiple (List separately in addition to code for primary procedure)

+49412 -- Placement of interstitial device(s) for radiation therapy guidance (for instance fiducial markers, dosimeter), open, intra-abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if carried out, single or multiple (List separately in addition to code for primary procedure)

57156 -- Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy.

Evaluation /Management (E/M) service: Subsequent day observation care will also get new codes (99224-99226), reportable per day. Pay special attention to these codes as they will change the way you code an observation stay longer than forty eight hours.

Source Code:- www.supercoder.com/coding-newsletters/my-oncology-hematology-coding-alert/cpt-2011-update-expect-new-codes-for-peritoneal-cavity-chemo-and-interstitial-device-placement-article

Coding Life Becomes Easier With This Denial Busting Tool

Is the CPT-ICD 9 code linkage pushing you towards denials? Well, ICD Cross-Ref tool lets you know whether you are safe.

To get this Cross-Ref tool and stay away from denials, sign up for Supercoder as the site has come up with this denial busting tool with effect from November 2. This CrossRef allows a coder to look up a surgical CPT procedure code and see which diagnosis codes Medicare and private payers allow.

So the next time you need to take a look at the ICD-9-CM codes that Medicare and private payers accept for a given surgical procedure rightaway, all you need to do is become an Advantage Plus member of the site and look under 'Tools' section. When you do so, you can have access to surgical (series 10000-60000) CPT procedure code to ICD-9-CM CrossRef under Tools.

What's more, come December 1 and you will get common diagnoses associated with radiology (70000 series), pathology (80000 series) and medicine (90000 series) codes.

Not just this, there are more reasons now to become members of Supercoder as it puts more spot on coding with Lay Terms for every CPT code (http://www.supercoder.com/cpt-codes) for major specialties. And to add to it all, SuperCoder Codesets & Tools and Advantage members should look for this feature in addition to visually helpful anatomical illustrations under Code Details.

What's more, onboard Supercoder, you can even have access to ICD-9-CM codes 2011 as well as the CCI Tool, CCI Alert feature, Fee Schedule and lots more!

So get onboard Supercoder today and stay away from denials!

FAQ to Boost Your Pain Management ICD-9 Coding

FAQ to boost your pain management ICD-9 coding

If you do not know how many diagnosis codes you can report, you could find yourself assigning the wrong code. Here's a question followed by the answer that'll help you get quick tips to help your pain management ICD-9 coding:

How many diagnosis codes are 'too many'?

Question: Our pain management specialist treated a patient with diabetes, however he was actually seeing the patient to treat a complication of the diabetic polyneuropathy. During his evaluation, the doctor also noted that the patient has shoulder joint inflammation. Should we use the neuropathy complication only or several ICD-9 codes to represent various conditions of the patient?

Answer: Normally, the primary diagnosis code that you list on your claim should represent the main reason for the encounter, or the condition with the highest risk of morbidity/mortality that the physician tends to during the visit. However, when you deal with a condition like diabetes, the situation changes.

Section 1.A.6 of the ICD-9-CM official

Guidelines for coding and reporting certain conditions have both an underlying etiology and multiple body system manifestations owing to the underlying etiology. For conditions such as this, the ICD-9-CM(http://www.supercoder.com/icd9-codes/) has a coding convention that requires that the underlying condition be sequenced first after the manifestation.

If a patient has more than one manifestation of diabetes, more than one code from category 250 may be used with as many manifestation codes as are needed to describe the patient's diabetic condition fully.

As such, you should first use 250.6x (Diabetes with neurological manifestations). Remember to add a fifth digit to reflect the patient's type of diabetes and status of control. Your secondary code should represent the specific pain manifestation being treated. In this case, you should report 357.2 (Polyneuropathy in diabetes) as the secondary diagnosis. As because your pain practitioner documented joint inflammation, you should also report the right code describing that condition (716.91, Arthropathy, unspecified; shoulder region).

Why so many codes: Even though many payers will link only the first, main diagnosis code that you list to support the provided service's medical necessity, reporting all the diagnoses that follow the HIPAA-mandated guidelines is compliant coding. As of July 2007, Medicare must accept up to eight diagnoses for each electronic claim reported. The additional diagnoses might indicate more complex presenting problems and can provide the help you might need for a higher-level E/M service.

Review Billed Service Levels with These Tips

You cannot get inside your ENT's head to know whether his MDM requires the E/M service code that he reported – however Medicare auditors are training eyes on this area while examining E/M claims, so you need to stay alert.

Auditors are not scrutinizing the exam or history as much as they weigh toward medical decision-making. However you can be your otolaryngologist's front line of defense and ensure his notes withstand scrutiny if you follow these tips:

Tip 1: Take this strategy's help to identify a mismatch

When your staff gets together for an education meet next time, remind your ENTs that medical necessity should be the overarching factor they use to choose the E/M service level. Just because a physician does a comprehensive history and examination does not mean he should report 99215. Medical necessity should drive the components that he carries out. This is of particular importance with the implementation of EHR systems, which automatically code encounters without regard to medical necessity. It's very easy to document high levels of history and exams, particularly for established patients, which'll result in level four services when the medical necessity may dictate only level two or three services.

You can help ensure your doctors are choosing the proper codes by occasionally pulling a sample of their charts. Take a look at the patient's chief complaint and the encounter's outcome or its final diagnosis. If the main ICD-9 code doesn't support a billed upper level of service, you should really read the chart notes.

Tip 2: Look for potential MBM-boosting factors

However, complimenting factors could make 99214 and 461.x a match. The patient may have comorbidities or other chronic conditions. And medications that the patient is already taking or or adverse reactions the patient had to previous medications could up the level of MDM. Comorbidities, frequency of episodes of sinusitis, the plan of care, and the like may complicate the medical decision making also.

To add to it, evaluation of symptoms possibly related to sinusitis like fatigue, headache, fever and cough can boost the MDM. When you work up a sinusitis, if a patient has these other symptoms also, then you ensure he does not have any problems that could be more serious.

Source URL :-  http://www.supercoder.com/coding-newsletters/my-otolaryngology-coding-alert/em-services-5-tips-help-you-review-billed-service-levels-article

Tip 3: Uncover extra complexity in these places

Medication can lead to a higher-level MDM another way. Take a look at the tests and medications the otolaryngologist ordered for clues to the extra complexity the doctor may not be explaining. Here are a couple of tips to make identifying increased complexity easier:

See the history of present illness and review of systems to determine what the ENT is trying to rule out.

Encourage your ENTs to state what diagnoses they hope to rule out or confirm.

Be wary: Do not put such ‘rule out' diagnoses on your claims. Doing so would not be right coding.

Tip 4: Give due credit for clear management options

Intimate your doctors that they should indicate clearly when they are taking an immediate step that they do not believe will solve the patient's problem. For instance, they may try antibiotics before a more aggressive treatment, however that the patient may need a more aggressive approach can boost the level of MDM. Documenting the extra step shows that the physician considered more management options (one element of MDM).

Tip 5: Look at patient's complexity

Sometimes a low level of MDM can support a 99214. You cannot just look at the MDM; you also have to look at the complexity of the patient.

Make Perfect your ICD-9 Coding Skills

OB-Gyn - ensure you have coded high-risk or complicated obstetrical care correctly - and that means perfecting your ICD-9 coding skills.

You can get increased payments when your ob-gyn provides additional visits outside of the normal global ob package; however you'll have to ensure you have coded high-risk or complicated obstetrical care correctly – and that means perfecting your ICD-9 coding (http://www.supercoder.com/icd9-codes/) skills.

Be firm on perfect ICD-9s

To demonstrate the reason for the additional service, you have to link the ICD-9 code on the CMS-1500 claim form (boxes 21 and 24E) to an E/M code. You can add this to the claim that includes the global service or you can submit it as an additional claim.

Here's an example: A 33-year-old patient, gravida 3, para 2 (both normal spontaneous vaginal delivery [NSVD] full term), is tended to 19 times due to developing pre-eclampsia. Post delivery, you review the case and find that the patient required six additional visits (beyond the usual 13) for this care. The documentation for three of these visits supports reporting 99212 while three of the visits have more extensive documentation that supports reporting 99213.

To add to it, post delivery, the patient experiences prolonged pain and irritation owing to a hemorrhoid. The ob-gyn tends to her for a thrombosed hemorrhoid, which he incises in the office two weeks post-delivery. In the end, the ob-gyn rechecks the patient at her six weeks postpartum visit.

Break it down: When coding for this patient, remember the claim form must note both the CPT codes describing the additional services as well as the diagnoses that depict why the patient required the additional services.

Heads up: Observe the fifth digits of these ICD-9-codes. The digit ‘3' that takes place in most of these codes has become a ‘4' in the last ICD-9 code to indicate a postpartum condition rather than an antepartum one. In other words, the patient has been discharged from the hospital after giving birth. Using ‘3' indicates she did not deliver during the hospital stay.

To add to it, after delivery, the patient experiences prolonged pain and irritation owing to a hemorrhoid. The ob-gyn sees her for a thrombosed hemorrhoid, which he incises in the office two weeks post delivery. In the end, the ob-gyn rechecks the patient at her six weeks postpartum visit.

CPT 2010 adds More Options to Your Vaccine Administration Coding

Earlier Editions of CPT include vaccine administration codes (90465-90468) for children younger than eight years of age. Now CPT 2011adding more options to your Vaccine Administration.

As winter sets in, CPT 2011 will bring some welcome additions to your observation care and vaccine administration coding options. These vaccine administration codes are expected to help boost physicians' bottomlines.

Earlier editions of CPT included vaccine administration codes (90465-90468) for children younger than eight years of age when the physician counseled the patient/family. This time, CPT introduces two administration codes that expand the concept to include adolescents and teens and does away with the distinction based on route administration:

90460 -- Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component

90461 -- each additional vaccine/toxoid component (List separately in addition to code for primary procedure).
You could find yourself relying frequently on 90460 and 90461 if your physician often provides counseling with vaccinations for patients 18 or under. Perhaps part of the supposed need for these codes was the increasing prevalence of multicomponent vaccines. The physician needs to counsel regarding each component; but the coding did not distinguish that higher amount of counseling from counseling for a single component. The switch allows physicians to get credit for each component on which they counsel, and not the number of shots given.

Note: Components drive vaccine descriptors

The new immunization administration codes this time are based on the number of components in the vaccine.

Get a sneak peek on these vaccine administration codes as well the entire CPT code list (http://www.supercoder.com/cpt-codes) for the coming year by signing up for a medical coding guide like Supercoder!

Correct Date of Service is Imperative

OIG released the results of its audit 'Review of Medicare Parts A and B Services Billed With Dates of Service After Beneficiaries' Deaths

On September 23 this year, the OIG released the results of its audit 'Review of Medicare Parts A and B Services Billed With Dates of Service After Beneficiaries' Deaths', which revealed that CMS paid approximately $8.2 million in benefits for claims with dates of service after the beneficiaries' deaths.

The OIG noted that Medicare will only shell out money for expenses 'reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member as medically necessary items or services can't be provided after beneficiaries'deaths, no items or services are allowable' thereafter.

Since the OIG is tracking dates of service by investigating the date the patient passed away, you should make it a point to ensure your ob-gyn practice records the correct date of service (DOS) on your Medicare claims. In many instances, some practices are still charging for services long after their patients died, and it is costing the Medicare system big money.

Correct date of service is very important : Even though many practices might be surprised to find that they've made a mistake like this, the OIG found some problems with claims for over 69,000 deceased beneficiaries between Parts A and B over a two-year period.

Safeguard your practice by following this advice

Watch your date protocol: Sometimes there are errors where practice employees misinterpret the dates that the physician writes down. If the physician notes down '06-04-10,' he might mean June 4, 2010, while someone else might interpret that as April 6, 2010 as the date is written differently by different people."

Advice: If you enter the DOS into the patient's claim form manually, be sure and have a uniform way of writing the date at your practice, between all providers and back office staff members. To add to it, you should cross-reference the DOS against the records for all deceased patients to ensure that you have recorded all dates correctly.

Follow through with other data: If you are making errors on deceased patients' records, it is likely that you have also applied the wrong date on other patients' claims as well. Ensure that everyone in your practice is using the same criteria to apply DOS. If some doctors still write the date with the numbers for the month and year transposed, it might be a good idea to ask all the practitioners to begin writing out the month instead. For example, instead of 06-04-10, you might have to ask everyone to start writing out June 4, 2010.

For more tips on ways to write the correct DOS and for other medical coding news pertaining to this, sign up for a medical coding guide like http://www.supercoder.com/

93270 Calls for Minimum Transimission

As per CPT Assistant if you going to report 93270 you should have check some conditions.


Often, you may be confused over questions such as this: Question: Should you report 93270 even when the only transmission was the test transmission?


The answer is that you should be able to report 93270 in the situation you describe, assuming you meet certain conditions.



As per CPT Assistant (August 2010), prior to reporting 93270, you should check for the following:

The patient got the monitor from the office or facility, or through mail, such as from a monitoring center.

The doctor or facility instructed the patient on proper monitor use (including hookup, recording, and transmission).

The patient sent at least one transmission; the reason being: Patients must send a test transmission when the monitoring period starts to ensure the device is working.
Lesson learned: According to CPT Assistant, when the patient (1) gets both the device and instructions in the mail and (2) the physician or facility staff never instructed the patient directly, you shouldn't report 93270.


You also shouldn't report 93270 if the patient sends no transmissions. CPT Assistant states, “If no tracing is sent, then there can be no report and no reportable service has been provided although the patient received a monitor for a month.

For more updates on this, sign up for a one-stop medical coding website. Onboard such a site, you can even subscribe to a CPT Assistant to get hands on information that can help you bring in the reimbursements. Here, you'll get the annual CPT Assistant newsletter, along with access to CPT assistant back issues (1990 to 2009), at a good discount.