If you have come face to face with a transnasal turbinate surgery claim, see to it that you put your clinical judgment on high alert considering the diversity of anatomic sites, surgical techniques, and types of instrumentation involved in this type of service.
Here are three FAQs to help master your turbinate surgery coding skills:
Should 30130 and 30140 go in tandem?
Imagine the documentation states that the doctor entered or excised mucosa and subsequently preserved it. This indicates to you that you should use 30140 to report this service. But then simply reporting that the turbinate was excised is most likely not enough documentation for this code. Do not forget to bill 30130 (Excision inferior turbinate, partial or complete, any method) if there is no evidence of the preservation of the mucosa and the op note just indicates that the inferior turbinate was excised or resected.
You shouldn't bill 30140 with 30130 - you'd bill one or other for a single side. But then if a submucousal resection (preservation of the mucosa) is performed on one side and a straight excision is performed on the other side (no preservation of mucosa), you would code 30140-RT and 30130-59-LT, for instance. The RT and LT would represent which side each procedure was carried out.
Facts: Normally, you'd code 30130 or 30140 separately with septoplasty or a functional endoscopic sinus surgery is carried out along with an inferior turbinate removal, either excision (30130) or submucous resection (30140), preserving the mucosa.
CPT 31240 describes the removal of a middle turbinate endoscopically. You'd code this when the concha bullosa is removed during endoscopic sinus surgery. CPTs 30130 and 30140 shouldn't be used if the turbinates excised non-endoscopically were middle turbinates. If the doctor removed the middle turbinates through excision or resection, as in a middle turbinectomy and septoplasty, you'd use the unlisted nasal code for the middle turbinectomy, 30999.
Important: You should always take 30130 and 30140, along with 30930 and 31240 as unilateral codes. This means that you add the modifier 50 if the doctor carried out the procedure bilaterally. CPT 30140 is “modifier 50-allowed.
How much can we get from uni turbinate claims?
You should note the different RVUs that unilateral turbinate codes carry so you can have an idea how much you'd be paid.
Remember that when the turbinate procedure is part of a multiple procedure surgery, it'll be divided in half when adjusted for the multiple-surgery reimbursement.
Does inferior and middle turbinates point to the same thing?
While billing 30130 or 30140 (inferior turbinates), the payer should not confuse your billing for it with the middle turbinates. Since year 2006, 30130's definition has been changed from “any turbinate" to “inferior turbinate." This was done since so many payers denied 30130 and 30140 when coded for inferior turbinates and endoscopic sinus surgeries thinking that the resection was performed on the middle turbinates which are considered access to the sinuses. By changing the wording and definition of the codes, there can be no question by the payer as to whether the procedure was carried out on the inferior turbinates.
If you're still puzzled, consult a good one-stop medical coding guide like Supercoder.
Thursday, March 31, 2011
Settle On Which Primary Code This Case Suggests: +33225
Start by analyzing the report excerpt An incision was made along the left deltopectoral groove, and an ICD pocket was dissected out, was geared up with extensive dissection. Three different guidewires were advanced into the left subclavian vein using the Seldinger technique across the open pocket.
The middle of these wires were then used to further a coronary sinus sheath for placement of the left ventricular lead. With some complexity, we were in the end able to advance the coronary sinus sheath in the mid coronary sinus and an angiogram was obtained. After this a left ventricular lead was advanced in the lateral cardiac vein and the tip was advanced to the near LV apex. Electrical testing was done at three separate locations and the rest of these noted a lead impedance of 840 ohms and an R wave value of 17.1 mV. After this, the bipolar right ventricular defibrillator active fixation lead was advanced to the right ventricle, various areas were checked and the lead was lastly fixated along the RV. Next the bipolar right ventricular defibrillator active fixation lead was advanced to the right atrium. Various areas checked and the lead was in the end fixated along the RV septum and tested. Post this, a bipolar screw in type right atrial lead was advanced to the right atrium and the lead was fixated to the right atrial wall. Then the coronary sinus sheath was removed with the cutting device maintaining a good lead position of the LV lead. All three leads were then sutured to the pectoral fascia over the Silastic sleeves; the pocket was then irrigated. Pretty soon the leads were attached to the ICD/BiV device.
Then the ICD was placed in the pacer pocket after a standard dose of thrombin material in the pocket. Pocket was then sutured closed. The patient was given propofol and the following establishment of adequate general anesthesia. Ventricular fibrillation was induced; the advice analyzed and delivered three different DC counter shocks, at last at 36V and the patient converted back to normal sinus rhythm. Patient was awakened from sedation minus obvious side effects. Find your first stop at an add-on code The case study appears to be a new implant of a Biventricular Defibrillator with follow-up testing at implant. While making your way through the first two paragraphs, you should train eyes on the terms describing placement of the left ventricular lead through the coronary sinus. The proper code for this portion is +33225. Documentation tip: You may see this lead referred to as either a left ventricular (LV) lead or coronary sinus lead.
Add the primary code for that add-on code The next few paragraphs of the documentation describe lead fixation for the right ventricle (RV) and the right atrium (RA). Also the cardiologist attaches the leads to the device, places the device in the pacer pocket, and sutures the pocket closed. All of this is covered by one code: 33249. Add-on note: CPT code lists 33249 as a proper primary code for add-on code +33225. Remember that ‘add-on' codes are always carried out in addition to the primary service or procedure and must never be reported as a stand-alone code.
Defib testing earns the final code The last paragraph of the case study excerpt describes 93641. With defib testing, you want to see impedance in the documentation. Generally physicians will state something like ‘Ventricular fibrillation was induced. The device analyzed and delivered 3 separate DC countershocks, at last at 36V and the patient converted back to normal sinus rhythm. The high-voltage impedance was 45 ohms. Term tip: The defibrillation threshold (DFT) is the minimum energy amount required during ventricular arrhythmia to defibrillate the heart reliably. Knowing the patient's DFT aids the cardiologist confirm that the cardioverter-defibrillator (ICD) programming will provide enough of a surprise to defibrillate the patient's heart.
Ensure your practice hits these points In a situation like this, the doctor would typically use fluoroscopy, as well; however, it is not documented in this case. No documentation of fluoroscopy means you should not bill fluoroscopy. When fluoroscopy is documented, you should go for 71090-26. ICD-9: What's more, the case study does not mention indications for you to select ICD-9 diagnosis codes. Minus a VT [ventricular tachycardia] diagnosis or information relating to primary prevention criteria, this cannot be coded. Either you have to have a payable diagnosis for the ICD or data to support adding a Q0 modifier to 33249. What's more, check your local requirements for diagnosis codes that support medical necessity for 33225.
The middle of these wires were then used to further a coronary sinus sheath for placement of the left ventricular lead. With some complexity, we were in the end able to advance the coronary sinus sheath in the mid coronary sinus and an angiogram was obtained. After this a left ventricular lead was advanced in the lateral cardiac vein and the tip was advanced to the near LV apex. Electrical testing was done at three separate locations and the rest of these noted a lead impedance of 840 ohms and an R wave value of 17.1 mV. After this, the bipolar right ventricular defibrillator active fixation lead was advanced to the right ventricle, various areas were checked and the lead was lastly fixated along the RV. Next the bipolar right ventricular defibrillator active fixation lead was advanced to the right atrium. Various areas checked and the lead was in the end fixated along the RV septum and tested. Post this, a bipolar screw in type right atrial lead was advanced to the right atrium and the lead was fixated to the right atrial wall. Then the coronary sinus sheath was removed with the cutting device maintaining a good lead position of the LV lead. All three leads were then sutured to the pectoral fascia over the Silastic sleeves; the pocket was then irrigated. Pretty soon the leads were attached to the ICD/BiV device.
Then the ICD was placed in the pacer pocket after a standard dose of thrombin material in the pocket. Pocket was then sutured closed. The patient was given propofol and the following establishment of adequate general anesthesia. Ventricular fibrillation was induced; the advice analyzed and delivered three different DC counter shocks, at last at 36V and the patient converted back to normal sinus rhythm. Patient was awakened from sedation minus obvious side effects. Find your first stop at an add-on code The case study appears to be a new implant of a Biventricular Defibrillator with follow-up testing at implant. While making your way through the first two paragraphs, you should train eyes on the terms describing placement of the left ventricular lead through the coronary sinus. The proper code for this portion is +33225. Documentation tip: You may see this lead referred to as either a left ventricular (LV) lead or coronary sinus lead.
Add the primary code for that add-on code The next few paragraphs of the documentation describe lead fixation for the right ventricle (RV) and the right atrium (RA). Also the cardiologist attaches the leads to the device, places the device in the pacer pocket, and sutures the pocket closed. All of this is covered by one code: 33249. Add-on note: CPT code lists 33249 as a proper primary code for add-on code +33225. Remember that ‘add-on' codes are always carried out in addition to the primary service or procedure and must never be reported as a stand-alone code.
Defib testing earns the final code The last paragraph of the case study excerpt describes 93641. With defib testing, you want to see impedance in the documentation. Generally physicians will state something like ‘Ventricular fibrillation was induced. The device analyzed and delivered 3 separate DC countershocks, at last at 36V and the patient converted back to normal sinus rhythm. The high-voltage impedance was 45 ohms. Term tip: The defibrillation threshold (DFT) is the minimum energy amount required during ventricular arrhythmia to defibrillate the heart reliably. Knowing the patient's DFT aids the cardiologist confirm that the cardioverter-defibrillator (ICD) programming will provide enough of a surprise to defibrillate the patient's heart.
Ensure your practice hits these points In a situation like this, the doctor would typically use fluoroscopy, as well; however, it is not documented in this case. No documentation of fluoroscopy means you should not bill fluoroscopy. When fluoroscopy is documented, you should go for 71090-26. ICD-9: What's more, the case study does not mention indications for you to select ICD-9 diagnosis codes. Minus a VT [ventricular tachycardia] diagnosis or information relating to primary prevention criteria, this cannot be coded. Either you have to have a payable diagnosis for the ICD or data to support adding a Q0 modifier to 33249. What's more, check your local requirements for diagnosis codes that support medical necessity for 33225.
Sunday, March 27, 2011
CPT Provides you An Assist on Multi-arthroscopy Encounters
In a particular situation, my orthopedist carried out a medial and lateral meniscectomy on a patient, and also performed a synovectomy in the patellofemoral compartment. Because the arthroscopic procedures were carried out in separate knee compartments, is it possible to code for their procedures or do I have to select one? Well, you should be able to report both procedures. You should report the following on the claim:
29880 (Arthroscopy, knee, surgical; with meniscectomy [medial AND lateral, including any meniscal shaving])
29875 (… synovectomy, limited [example, plica or shelf resection [separate procedure]]) for the synovectomy
modifier 59 (Distinct procedural service) added to 29875 to show that the synovectomy and meniscectomy were different services. Explanation: In case the payer challenges the appropriateness of this coding, note this guidance from the August 2001 CPT Assistant: Arthroscopic synovectomy is reported using 29875 and 29876. Limited synovectomy (29875) involves resection of the synovium and may cover partial resection of the plica of one knee compartment… 29875 is designated as a "separate procedure". Normally, codes with the 'separate procedure' designation would not be additionally reported when the procedure or service is carried out as an integral component of another procedure or service. But then when a procedure or service designated as a separate procedure is carried out independently or is thought of as unrelated or distinct from the other procedure(s) or service(s) provided at the time, then it would be proper to report the code in combination with the other procedure(s) or service(s). Modifier -59, Distinct Procedural Service should be added to the separate procedure code to indicate that the procedure was distinct from the overall procedure. For instance, if the knee arthroscopy with limited synovectomy were carried out in a different knee compartment than another knee procedure, modifier 59 would be added to code 29875 to show that a different compartment was involved. For more on this and for other medical coding updates regarding orthopedic coding, sign up for a one-stop medical coding guide like Supercoder.
Article Source :- http://www.supercoder.com/coding-newsletters/my-orthopedic-coding-alert/you-be-the-coder-cpt-gives-you-an-assist-on-multi-arthroscopy-encounters-article
Article Source :- http://www.supercoder.com/coding-newsletters/my-orthopedic-coding-alert/you-be-the-coder-cpt-gives-you-an-assist-on-multi-arthroscopy-encounters-article
Same-Polyp Intervention? Turn to 45383 & 45381
As a gastroenterology coder, you may find yourself bowled over by coding situations such as these: The olympus scope was passed in the transverse colon. Outstanding prep. The lesion itself was at about 9 centimeter in the rectosigmoid or upper one third of the rectum really. With the rotatable snare, the base was encircled, and the polyp removed, and then one more small piece that was still on the wall was removed, thus, removing the entire lesion. This was retrieved, and put in a pathology bottle. After this, the area was re-examined. Since there was a diagnosis of dysplasia, it was elected to use the APC with 360 head post polypectomy setting which was done, and the entire area was APC'd under narrow band light. This was removed, the Argon removed, and then a tattoo was a SPOT material was used and photographs were clicked. As such, what codes should you use to report this procedure? Well, it appears the snare and APC intervention are on the same polyp/lesion. According to the report, the scope was passed only to the transverse colon; as such, if the procedure was planned as a sigmoidoscopy then you would use CPT codes from the flexible sigmoidoscopy family of codes even if the scope went beyond the splenic flexure. If the procedure was planned as a colonoscopy, then you should bill these codes on your claim:
For code 45383 - Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique.
For code 45381 -Colonoscopy, flexible, proximal to splenic flexture, with directed submucosal injection[s], any substance. You should not go for 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) as correct coding initiative edits bundle this code into 45383. The relative value units for 45385 (15.69 relative value units for non-facility) are lower than that for 45383 (16.72 relative value units for nonfacility); as such using the latter code will bring you more reimbursement: $568.09 (relative value units) multiplied by 2011 conversion factor of 33.9764). In this situation, you cannot unbundle the edit by using modifier 59 since interventions are on the same polyp. You'd bill the tattooing with 45381. For more on this and for other medical coding updates pertaining to gastroenterology coding, sign up for a good medical coding guide like http://supercoder.com/
Wednesday, March 23, 2011
Seven Key Billing Practices to Get the Payments You Deserve
When your practice is feeling pinched, it is important to ensure that you are not forgetting to bill for everything your practitioner performs and documents.
It's known to all that Medicare coding rules are tough and challenging; and sometimes it's difficult to gather which services you can bill rightfully. However if you remember these seven key billing practices, you will be collecting all of the pay you rightfully deserve.
Bear modifier 50 in mind: Many procedures are inherently unilateral and you will not get full reimbursement for bilateral versions of those procedures unless you add modifier 50 (Bilateral procedure).
Be careful: Often medical coders forget the modifier 50, and if your doctor performs and documents a bilateral procedure for one of those services, see to it that you submit your claim for a bilateral service.
Gather copays at the visit: You will save yourself time and money later on if you calculate copays following a patient's service and collect that money before they leave your office.
Bear in mind: If it is not a copay, you can gather it before the patient sees the doctor. Just because a doctor plans to carry out a service does not mean he will perform and document it properly. As such, it is a good idea to gather after the patient has already seen the practitioner.
Some coders are of the opinion that if the correct coding initiative (CCI) forbids billing two codes on the same date, that is the end of the story. However in fact, you may be missing out on some legitimate cases where CCI allows you to use a modifier like 59 (Distinct procedural service) to override an edit.
Always scan the CCI edits ( Source "" ) for the procedures you carried out to see which code pairs a modifier can override. You should of course only use the modifier 59 when the services are separate, distinct, and medically necessary, and the doctor has thoroughly documented the distinct nature of both services.
Keep a watch for supervision and interpretation: You need two codes – the S&I code plus a surgical code for many invasive/ diagnostic radiology codes. Regularly, coders forget to add the surgical code, moreso on the outpatient hospital claims.
For instance: You may keep in mind to report CT guided needle biopsy code 77012; however leave out the associated site-specific percutaneous needle biopsy code.
When you feel you've been wronged, appeal: As many practices fear being labeled "troublemakers" or even worse yet, non-compliant with the FCA's regulations, they accept Medicare payers at their word and this is not always a good idea.
If your MAC denies your claim or requests a refund, investigate the issue before you take the payer's word for it. You should make an appeal any time you feel your payer has denied your claim wrongly or erroneously requested a refund.
Ensure you have up to date coding guidelines
In some practices, coders have not updated their CPT, ICD-9-CM, or HCPCS coding manuals in years as they do not think that changes are enacted often enough to warrant purchasing new books. But then outdated codes can lead to claim rejections. What's more, the modifiers, coding rules, and parenthetical notes also change from year to year, and it is tough to understand which regulations apply if you do not have present resources. If you use a computer-based program for these resources, you can normally get all the updates through there; however paper manuals should be annually replaced.
Join outpatient E/M with initial hospital care record for same-day admits
If you witness a patient in your office and then perform initial inpatient care for the same patient on the same date, you should report one E/M code only.
When the doctor provides both services on the same date, combine the work documented in the office with the work documented in the hospital to figure out the proper level of initial inpatient care (99221-99223).
Bear modifier 50 in mind: Many procedures are inherently unilateral and you will not get full reimbursement for bilateral versions of those procedures unless you add modifier 50 (Bilateral procedure).
Be careful: Often medical coders forget the modifier 50, and if your doctor performs and documents a bilateral procedure for one of those services, see to it that you submit your claim for a bilateral service.
Gather copays at the visit: You will save yourself time and money later on if you calculate copays following a patient's service and collect that money before they leave your office.
Bear in mind: If it is not a copay, you can gather it before the patient sees the doctor. Just because a doctor plans to carry out a service does not mean he will perform and document it properly. As such, it is a good idea to gather after the patient has already seen the practitioner.
Some coders are of the opinion that if the correct coding initiative (CCI) forbids billing two codes on the same date, that is the end of the story. However in fact, you may be missing out on some legitimate cases where CCI allows you to use a modifier like 59 (Distinct procedural service) to override an edit.
Always scan the CCI edits ( Source "" ) for the procedures you carried out to see which code pairs a modifier can override. You should of course only use the modifier 59 when the services are separate, distinct, and medically necessary, and the doctor has thoroughly documented the distinct nature of both services.
Keep a watch for supervision and interpretation: You need two codes – the S&I code plus a surgical code for many invasive/ diagnostic radiology codes. Regularly, coders forget to add the surgical code, moreso on the outpatient hospital claims.
For instance: You may keep in mind to report CT guided needle biopsy code 77012; however leave out the associated site-specific percutaneous needle biopsy code.
When you feel you've been wronged, appeal: As many practices fear being labeled "troublemakers" or even worse yet, non-compliant with the FCA's regulations, they accept Medicare payers at their word and this is not always a good idea.
If your MAC denies your claim or requests a refund, investigate the issue before you take the payer's word for it. You should make an appeal any time you feel your payer has denied your claim wrongly or erroneously requested a refund.
Ensure you have up to date coding guidelines
In some practices, coders have not updated their CPT, ICD-9-CM, or HCPCS coding manuals in years as they do not think that changes are enacted often enough to warrant purchasing new books. But then outdated codes can lead to claim rejections. What's more, the modifiers, coding rules, and parenthetical notes also change from year to year, and it is tough to understand which regulations apply if you do not have present resources. If you use a computer-based program for these resources, you can normally get all the updates through there; however paper manuals should be annually replaced.
Join outpatient E/M with initial hospital care record for same-day admits
If you witness a patient in your office and then perform initial inpatient care for the same patient on the same date, you should report one E/M code only.
When the doctor provides both services on the same date, combine the work documented in the office with the work documented in the hospital to figure out the proper level of initial inpatient care (99221-99223).
CPT 2011 Freshens Up Your IP Catheter Coding Choices
For intraperitoneal (IP) catheter coding, confusing terms such as 'temporary' and 'permanent' are archaic now. Read on and find out how CPT 2011 freshens up your options:
Just-in code 49418 begins the IP catheter code changes
Defined as a 'complete' procedure, you will find multiple services covered by the just-in code 49418. Medicare assigned this code a 0-day global period, meaning Medicare does not bundle visits on subsequent days into the procedure payment.
Tread carefully: Medicare's national fee schedule () prices for 49418 vary considerably based on whether you are reporting a facility service ($234.78) or non-facility service ($1,519.08). This is a difference of more than $1,200; therefore you should make it a point to watch your place of service code.
Rectify the codes listed in 49419's line note
On the whole, changes demonstrate the 'coding lag' that occurs in keeping up with advances in new surgical procedures. As a matter of fact, the addition of 49418 is part of a larger reworking of tunneled intraperitoneal (IP) catheter codes to bring them in sequence with present practice. To begin with, CPT revises 49419:
Defined as a 'complete' procedure, you will find multiple services covered by the just-in code 49418. Medicare assigned this code a 0-day global period, meaning Medicare does not bundle visits on subsequent days into the procedure payment.
Tread carefully: Medicare's national fee schedule () prices for 49418 vary considerably based on whether you are reporting a facility service ($234.78) or non-facility service ($1,519.08). This is a difference of more than $1,200; therefore you should make it a point to watch your place of service code.
Rectify the codes listed in 49419's line note
On the whole, changes demonstrate the 'coding lag' that occurs in keeping up with advances in new surgical procedures. As a matter of fact, the addition of 49418 is part of a larger reworking of tunneled intraperitoneal (IP) catheter codes to bring them in sequence with present practice. To begin with, CPT revises 49419:
Last year: 49419-- Insertion of intraperitoneal cannula or catheter, with subcutaneous reservoir, permanent (that is., totally implantable)
This year: 49419 -- Insertion of tunneled intraperitoneal catheter, with subcutaneous port (that is totally implantable).
Why: By referencing subcutaneous port, the code language reflects the present technology. What's more, CPT removed the term "cannula" since physicians normally carry out these procedures using a catheter only.
According to AMA's published errata, you will need to rectify the CPT manual note following 49419. The note should read as here: (changes underlined): "49420 has been deleted." In order to report open placement of a tunneled peritoneal catheter for dialysis, code 49421. Whereas to report open or percutaneous peritoneal drainage or lavage, see 49020, 49021, 49040, 49041, 49080, 49081, as proper. To report percutaneous insertion of a tunneled peritoneal catheter minus subcutaneous port, go for 49418.
Among other code changes, focus on 49422
Other changes pertaining to IP catheter coding include the following:
According to the Symposium presentation, these changes are part of an endeavor to 'clean up' codes that overlapped and caused confusion. For instance, the terms temporary and permanent (used last year) caused confusion over whether they referred to placement or to device itself. What's more, CPT 2011 added the term 'tunneled' to acknowledge the subcutaneous channel in which the doctor places the catheter.
Deletion: See to it that you catch CPT 2011 deleted 49420. The additions and revisions of other, more specific codes made 49420 obsolete.
Instruction: You should not miss the note with 49422. This code is only for removal of a tunneled catheter. If the doctor removes a non-tunneled IP catheter, CPT guides you to report the proper E/M code.
Why: By referencing subcutaneous port, the code language reflects the present technology. What's more, CPT removed the term "cannula" since physicians normally carry out these procedures using a catheter only.
According to AMA's published errata, you will need to rectify the CPT manual note following 49419. The note should read as here: (changes underlined): "49420 has been deleted." In order to report open placement of a tunneled peritoneal catheter for dialysis, code 49421. Whereas to report open or percutaneous peritoneal drainage or lavage, see 49020, 49021, 49040, 49041, 49080, 49081, as proper. To report percutaneous insertion of a tunneled peritoneal catheter minus subcutaneous port, go for 49418.
Among other code changes, focus on 49422
Other changes pertaining to IP catheter coding include the following:
According to the Symposium presentation, these changes are part of an endeavor to 'clean up' codes that overlapped and caused confusion. For instance, the terms temporary and permanent (used last year) caused confusion over whether they referred to placement or to device itself. What's more, CPT 2011 added the term 'tunneled' to acknowledge the subcutaneous channel in which the doctor places the catheter.
Deletion: See to it that you catch CPT 2011 deleted 49420. The additions and revisions of other, more specific codes made 49420 obsolete.
Instruction: You should not miss the note with 49422. This code is only for removal of a tunneled catheter. If the doctor removes a non-tunneled IP catheter, CPT guides you to report the proper E/M code.
Tuesday, March 22, 2011
One Medicare Contractor Says Yes To RNS and LPNS
According to CMS staffers, MACs can figure out whether they will allow licensed practical nurses (LPNs) and registered nurses (RNs) to carry out annual wellness visits (AWVs) and collect from Medicare for those services. That is the word from a February 22 CMS Open Door Forum where practices called in with several questions impacting Part B providers.
One person called into the forum to enquire about a Q&A posted on the Web site of WPS Medicare, a Part B payer in four states, which asks whether an RN or LPN can perform “the entire annual wellness visit (AWV, G0438-G0439)." WPS responds on the website, “Yes, an RN or LPN can perform the visit; they need to be under the direct supervision of a doctor and the state license needs to allow for them to do all the components of the service. The caller enquired whether this is a general CMS policy or if it's applicable to WPS Medicare.
Remember, the LPN is not billing, reminding the caller that the visit would be billed under the physician's NPI as 'incident to'. However the caller still considered it 'odd' that an LPN could carry out an AWV since it is similar to an E/M service.
It is a different sort of service; there is not really any clinical judgment involved. It is a service which includes a sort of administrative steps; verifying that people have some preventive services done and things like that; and as such it's intended to be a collaborative service.
Remember that CMS doesn't have a national policy allowing LPNs and RNs to carry out AWVs; however representatives from the agency confirmed that it is within the rights of the individual MACs to make this determination.
Payment adjustments will soon be on the way
If you are looking for more money from your Medicare payer based on adjustments in the Affordable Care Act, CMS has a piece of advice for you – sit tight. The money that your MAC owes you is in process and contractors are working hard to get those adjustments out to you.
The agency erroneously processes 'hundreds of millions of claims' affected by the Affordable Care Act, and plans to reprocess those claims within the next two weeks; however the complete situation could take many months to resolve. It won't be something where everybody's claims will all of a sudden on one day start to be reprocessed. We have been working closely with our Medicare claims administration contractors to ensure all of these claims get reprocessed in an organized and deliberate manner so that we are not impending or jeopardizing new claims that come into the program.
Key: Don't resubmit your claims in an attempt to reprocess them at the accurate levels. If you resubmit claims, there is a very high possibility that those claims will be denied as duplicate claims. Allow the systems to do their work; it may not be as quickly as you would want; however let me assure you that we're trying our best so we can automatically reprocess as quickly as possible.
To add to it, do not submit a 'reopening' to your MAC regarding your claims as that could slow down your claim processing infinitely.
All claims cannot be reprocessed: Under some circumstances, your MAC won't reprocess the claim automatically. If the charge submitted on a claim is below the new rate, those affected providers will have to contact their Medicare contractor to ask for an adjustment. If your submitted charge is at or above the new rate, and I am primarily focused on physician claims paid under the Medicare Physician Fee Schedule…then those claims can easily be reprocessed, not a problem," said CMS's Stewart Streimer.
Your MAC won't send you a payment for every claim that it reprocesses. As an alternative, the MAC will aggregate your claims and will attach the remittance to your next payment.
For More Information :-
One person called into the forum to enquire about a Q&A posted on the Web site of WPS Medicare, a Part B payer in four states, which asks whether an RN or LPN can perform “the entire annual wellness visit (AWV, G0438-G0439)." WPS responds on the website, “Yes, an RN or LPN can perform the visit; they need to be under the direct supervision of a doctor and the state license needs to allow for them to do all the components of the service. The caller enquired whether this is a general CMS policy or if it's applicable to WPS Medicare.
Remember, the LPN is not billing, reminding the caller that the visit would be billed under the physician's NPI as 'incident to'. However the caller still considered it 'odd' that an LPN could carry out an AWV since it is similar to an E/M service.
It is a different sort of service; there is not really any clinical judgment involved. It is a service which includes a sort of administrative steps; verifying that people have some preventive services done and things like that; and as such it's intended to be a collaborative service.
Remember that CMS doesn't have a national policy allowing LPNs and RNs to carry out AWVs; however representatives from the agency confirmed that it is within the rights of the individual MACs to make this determination.
Payment adjustments will soon be on the way
If you are looking for more money from your Medicare payer based on adjustments in the Affordable Care Act, CMS has a piece of advice for you – sit tight. The money that your MAC owes you is in process and contractors are working hard to get those adjustments out to you.
The agency erroneously processes 'hundreds of millions of claims' affected by the Affordable Care Act, and plans to reprocess those claims within the next two weeks; however the complete situation could take many months to resolve. It won't be something where everybody's claims will all of a sudden on one day start to be reprocessed. We have been working closely with our Medicare claims administration contractors to ensure all of these claims get reprocessed in an organized and deliberate manner so that we are not impending or jeopardizing new claims that come into the program.
Key: Don't resubmit your claims in an attempt to reprocess them at the accurate levels. If you resubmit claims, there is a very high possibility that those claims will be denied as duplicate claims. Allow the systems to do their work; it may not be as quickly as you would want; however let me assure you that we're trying our best so we can automatically reprocess as quickly as possible.
To add to it, do not submit a 'reopening' to your MAC regarding your claims as that could slow down your claim processing infinitely.
All claims cannot be reprocessed: Under some circumstances, your MAC won't reprocess the claim automatically. If the charge submitted on a claim is below the new rate, those affected providers will have to contact their Medicare contractor to ask for an adjustment. If your submitted charge is at or above the new rate, and I am primarily focused on physician claims paid under the Medicare Physician Fee Schedule…then those claims can easily be reprocessed, not a problem," said CMS's Stewart Streimer.
Your MAC won't send you a payment for every claim that it reprocesses. As an alternative, the MAC will aggregate your claims and will attach the remittance to your next payment.
For More Information :-
Easy Guidelines - Profit $16 from 94664
One thing you should remember while reporting for inhaler demo/ evaluation is the type of service the provider is using; however do not stop with just that. When coding for inhaler services, documentation requirements and qualifying modifiers are just as important.
When you are confused why some payers would deny reimbursement for some inhaler claims, here are some ideas that could guide you to a better understanding of how inhaler service codes work out.
Your ticket to diskus demo pay: 94664
If the nurse or medical assistant taught someone to use an Advair Diskus (Advair Diskus is an “aerosol generator) -- or any other diskus, you should code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).
Bundle dose in teaching session
The patient may administer medication dose during the teaching session. Both services (treatment + teaching) are bundled into one CPT: 94640; as such you should not report them separately.
Here's why: The administration was carried out as part of the demonstration/evaluation.
Separate education? End it with modifier 59
During an outpatient visit, an asthmatic patient is wheezing and having breathing problems; this requires one or more bronchodilator treatments for intervention: 493.01; 493.02; 493.21, or 493.22. Prior to the visit, the patient did not use his MDI device, nebulizer and the like properly; therefore after the treatment, he was given an education about the use of these devices.
Report it: First, report 94640 (adding modifier 76, Repeat procedure or service by same physician, to separate line items of 94640 for multiple treatments) apart from the proper E/M code minus a modifier, unless the payer needs modifier 25 with the E/M. Then code 94664 with modifier 59 (Distinct procedural service), as the patient required additional instruction for his daily maintenance medication.
This is dissimilar from the medication provided for immediate intervention – 94640.
To put it briefly: If the patient required separate education after receiving an inhalation treatment on the same day, you'd bill both services (treatment plus education) adding modifier 59 to 94664.
Logic: The CCI places a level one edit on 94640 as well as 94664. Therefore, Medicare and payers that follow CCI edits may need modifier 59 on the component code (94664) to indicate that the teaching is a distinct procedure service from the inhalation treatment. It's important that the teaching was not part of the treatment for the patient, which would be one parallel encounter – teaching while treating.
Easy $16 with the aid of medical necessity support
If payers wouldn't pay your 94664 claim, you would need to support it with documentation indicating medical necessity to reimburse about $16 national rate (0.47 RVUs multiplied by 2011 conversion factor of 33.9764). For example, in the plan of treatment portion of the written record you might need to state that the patient needs a teaching session on the use of his MDI, diskus, nebulizer, and the like. What's more, do not forget to note why the session is required.
Source URL :-
When you are confused why some payers would deny reimbursement for some inhaler claims, here are some ideas that could guide you to a better understanding of how inhaler service codes work out.
Your ticket to diskus demo pay: 94664
If the nurse or medical assistant taught someone to use an Advair Diskus (Advair Diskus is an “aerosol generator) -- or any other diskus, you should code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).
Bundle dose in teaching session
The patient may administer medication dose during the teaching session. Both services (treatment + teaching) are bundled into one CPT: 94640; as such you should not report them separately.
Here's why: The administration was carried out as part of the demonstration/evaluation.
Separate education? End it with modifier 59
During an outpatient visit, an asthmatic patient is wheezing and having breathing problems; this requires one or more bronchodilator treatments for intervention: 493.01; 493.02; 493.21, or 493.22. Prior to the visit, the patient did not use his MDI device, nebulizer and the like properly; therefore after the treatment, he was given an education about the use of these devices.
Report it: First, report 94640 (adding modifier 76, Repeat procedure or service by same physician, to separate line items of 94640 for multiple treatments) apart from the proper E/M code minus a modifier, unless the payer needs modifier 25 with the E/M. Then code 94664 with modifier 59 (Distinct procedural service), as the patient required additional instruction for his daily maintenance medication.
This is dissimilar from the medication provided for immediate intervention – 94640.
To put it briefly: If the patient required separate education after receiving an inhalation treatment on the same day, you'd bill both services (treatment plus education) adding modifier 59 to 94664.
Logic: The CCI places a level one edit on 94640 as well as 94664. Therefore, Medicare and payers that follow CCI edits may need modifier 59 on the component code (94664) to indicate that the teaching is a distinct procedure service from the inhalation treatment. It's important that the teaching was not part of the treatment for the patient, which would be one parallel encounter – teaching while treating.
Easy $16 with the aid of medical necessity support
If payers wouldn't pay your 94664 claim, you would need to support it with documentation indicating medical necessity to reimburse about $16 national rate (0.47 RVUs multiplied by 2011 conversion factor of 33.9764). For example, in the plan of treatment portion of the written record you might need to state that the patient needs a teaching session on the use of his MDI, diskus, nebulizer, and the like. What's more, do not forget to note why the session is required.
Source URL :-
Monday, March 21, 2011
Watchfulness is the Key to Proper Reimbursements
The CMS has identified a claims processing issue that impacts rural health clinics (RHCs) submitting claims for preventive health care services on or post January 1, 2011. Watchfulness will help you assure rightful reimbursement if your practice is an RHC.
PPACA of 2010 waive the coinsurance and deductible for the initial preventive physical examination (IPPE), the Annual Wellness Visit (AWV), and other Medicare-covered preventive services recommended by the US Preventive Services Task Force (USPSTF) with a grade of "A" or "B," starting from January 1 this year. But then Medicare contractors will not implement the systems changes required to process claims correctly for these RHC services until April 4 this year.
Since additional revenue lines are not separately payable, contractors have been taught to move the associated charges to the non-covered field and to override reason code 31577 more than one unit is reported with revenue code 052X. This will allow claims to continue processing and not holdup payments.
Providers who submit claims between January 1 and April 3, 2011 should not resubmit affected claims. You do not need to resubmit since the contractors will mass adjust the claims in any case. Resubmission would be unnecessary work on the part of RHC.
Process: To make certain the charges are shown as covered, contractors will mass adjust the affected claims within 30 days post the claims processing instructions in Transmittal 2122, Change Request (CR) 7208, are implemented April 4, 2011. Detailed HCPCS Level II coding is called for; but then to ensure that coinsurance and deductibles are not applied to these preventive services when submitted by RHCs on a 71X type of claim with DOS on or post January 1 this year.
When the doctor provides one or more preventive service that meets the specified criteria as part of an RHC visit, charges for these services must be subtracted from the total charge for purposes of calculating beneficiary copayments and deductibles. For instance, if the total charge for the visit is $150, of which $50 is for a qualified preventive service, the beneficiary copayment and deductible is based on $100 of the entire charge. If no other rural health clinics service takes place along with the preventive service, no copayment or deductible applies.
PPACA of 2010 waive the coinsurance and deductible for the initial preventive physical examination (IPPE), the Annual Wellness Visit (AWV), and other Medicare-covered preventive services recommended by the US Preventive Services Task Force (USPSTF) with a grade of "A" or "B," starting from January 1 this year. But then Medicare contractors will not implement the systems changes required to process claims correctly for these RHC services until April 4 this year.
Since additional revenue lines are not separately payable, contractors have been taught to move the associated charges to the non-covered field and to override reason code 31577 more than one unit is reported with revenue code 052X. This will allow claims to continue processing and not holdup payments.
Providers who submit claims between January 1 and April 3, 2011 should not resubmit affected claims. You do not need to resubmit since the contractors will mass adjust the claims in any case. Resubmission would be unnecessary work on the part of RHC.
Process: To make certain the charges are shown as covered, contractors will mass adjust the affected claims within 30 days post the claims processing instructions in Transmittal 2122, Change Request (CR) 7208, are implemented April 4, 2011. Detailed HCPCS Level II coding is called for; but then to ensure that coinsurance and deductibles are not applied to these preventive services when submitted by RHCs on a 71X type of claim with DOS on or post January 1 this year.
When the doctor provides one or more preventive service that meets the specified criteria as part of an RHC visit, charges for these services must be subtracted from the total charge for purposes of calculating beneficiary copayments and deductibles. For instance, if the total charge for the visit is $150, of which $50 is for a qualified preventive service, the beneficiary copayment and deductible is based on $100 of the entire charge. If no other rural health clinics service takes place along with the preventive service, no copayment or deductible applies.
Multiple reporting is dictated by payer guidelines
While billing for multilevel radiofrequency, we code 64622 for the first level and +64623 for each additional level up to a total of four. Our payers reject the fourth level as a duplicate, even if a modifier has been appended. How should we distinguish between the third and fourth levels so that they both will be reimbursed?
For the first level, you are right in reporting 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) and for additional levels, +64623 (…lumbar or sacral, each additional level [List separately in addition to code for primary procedure]).
Choice: You might need to include an additional note stating 'three additional levels' next to +64623. Now if all the levels were on the same side, you could also bill the add-on codes as a single line item and three in the 'units of service' field, 24G of the 1500 form(). For instance, code 64622-RT (Right side) on line one of your claim and +64623 x3 RT on line two. For fluoroscopic guidance include any codes such as 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, subarachnoid, or sacroiliac joint], inclusive of neurolytic agent destruction).
Some payers will not pay for multiple units while others have certain ways to submit the claim. Still others limit the number of levels the doctor can ablate during a single session. An electronic system might not permit you to bill more than one modifier, meaning that you should submit a paper claim. Due to these types of variances, check your local guidelines to figure out the best way to submit the claim.
For the first level, you are right in reporting 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) and for additional levels, +64623 (…lumbar or sacral, each additional level [List separately in addition to code for primary procedure]).
Choice: You might need to include an additional note stating 'three additional levels' next to +64623. Now if all the levels were on the same side, you could also bill the add-on codes as a single line item and three in the 'units of service' field, 24G of the 1500 form(). For instance, code 64622-RT (Right side) on line one of your claim and +64623 x3 RT on line two. For fluoroscopic guidance include any codes such as 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, subarachnoid, or sacroiliac joint], inclusive of neurolytic agent destruction).
Some payers will not pay for multiple units while others have certain ways to submit the claim. Still others limit the number of levels the doctor can ablate during a single session. An electronic system might not permit you to bill more than one modifier, meaning that you should submit a paper claim. Due to these types of variances, check your local guidelines to figure out the best way to submit the claim.
Thursday, March 17, 2011
You Should Know When You Can Use Modifier 62
Remember that all CPT code is not eligible for reimbursement with a co-surgeon. Find out when you can use modifier 62 (Two surgeons) by looking to column AB in the Excel version of the 2011 Fee Schedule database, available for download at www.cms.gov/PhysicianFeeSched.
For modifier 62 claims, most payers shell out an additional fee (normally 125 percent of the ‘usual' fee for the procedure, divided equally between the two surgeons). Stay away from reimbursement problems by checking these claims cautiously.
A "2" in column AB next to the code you are investigating means that Medicare will pay for a co-surgeon for that procedure and that you do not require to submit documentation with the claim, so long as each surgeon is of a different specialty.
A "1" in column AB indicates that Medicare may pay for a co-surgeon; however you must submit documentation to explain the medical necessity for a co-surgeon. In comparison, a "0" means that Medicare will never pay two surgeons for the service whereas a "9" means that the concept of co-surgery doesn't apply for that particular code (and as such you should never apply modifier 62).
For instance: Medicare takes most wound repairs to be comparatively simple procedures and as such not eligible for payment with a co-surgeon. For example, the database assigns a "0" to column AB for codes 12001-12006, which means that you cannot be reimbursed with a co-surgeon with these procedures.
However for more extensive repairs such as those described by 12007, CMS assigns a "1" to column AB, meaning that Medicare may pay for a co-surgeon if documentation clearly explains why this is required.
To claim co-surgeons, each surgeon must carry out a distinct portion of a single CPT procedure and each surgeon must dictate and submit his own operative report for his portion of the surgery.
Source URL :- http://www.supercoder.com/coding-newsletters/my-gastroenterology-coding-alert/reader-question-make-the-most-of-modifier-62-article
For modifier 62 claims, most payers shell out an additional fee (normally 125 percent of the ‘usual' fee for the procedure, divided equally between the two surgeons). Stay away from reimbursement problems by checking these claims cautiously.
A "2" in column AB next to the code you are investigating means that Medicare will pay for a co-surgeon for that procedure and that you do not require to submit documentation with the claim, so long as each surgeon is of a different specialty.
A "1" in column AB indicates that Medicare may pay for a co-surgeon; however you must submit documentation to explain the medical necessity for a co-surgeon. In comparison, a "0" means that Medicare will never pay two surgeons for the service whereas a "9" means that the concept of co-surgery doesn't apply for that particular code (and as such you should never apply modifier 62).
For instance: Medicare takes most wound repairs to be comparatively simple procedures and as such not eligible for payment with a co-surgeon. For example, the database assigns a "0" to column AB for codes 12001-12006, which means that you cannot be reimbursed with a co-surgeon with these procedures.
However for more extensive repairs such as those described by 12007, CMS assigns a "1" to column AB, meaning that Medicare may pay for a co-surgeon if documentation clearly explains why this is required.
To claim co-surgeons, each surgeon must carry out a distinct portion of a single CPT procedure and each surgeon must dictate and submit his own operative report for his portion of the surgery.
Source URL :- http://www.supercoder.com/coding-newsletters/my-gastroenterology-coding-alert/reader-question-make-the-most-of-modifier-62-article
Mild Coding: Turning to 63030, 63047 Could Trip You Up
Properly reporting minimally invasive lumbar decompression (MILD) procedures with open and endoscopic techniques just got a bit easier. Follow this scenario and coding advice when your neurosurgeon performs a MILD.
Scenario: Through a small incision and using fluoroscopic guidance, the surgeon performs an epidurogram to identify the specific lumbar stenosis location, followed by a small laminotomy and decompressive resection of the ligamentum flavum to treat the patient's central canal spinal stenosis. As a result, should you go for 63030 or 63047 for this procedure?
The answer is no. You would report these services with 'unlisted spine code, or 22899 or 64999, unlisted procedure, nervous system, according to CPT Assistant. The rationale is that the MILD procedure involves a fluoroscopic, needle-based procedure without direct visualization of critical neural structures. MILD procedure devices "aren't intended for disc procedures" but should be used for "tissue resection at the perilaminar space inside the interlaminar space, and at the ventral aspect of the lamina. These devices aren't intended for use near the lateral neutral elements and remain dorsal to the dura using image guidance and anatomical landmarks, states the CPT Assistant.
As such, you wouldn't use code 63030, (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-aided approaches; 1 interspace, lumbar), "as the MILD procedure is a needle-based approach and isn't intended for removal of disc material versus an open surgical or open with endoscopic-assisted approach (code 63030)," CPT Assistant says.
You'd report 63030 "only when an open surgical technique is used and the intrinsic vital components of this code are carried out; namely, a resection of the vertebral component, spinous processes, and lamina, which must cover a discectomy, for decompression of the nerve root(s), as well as any laminotomy or laminectomy foraminotomy along with partial facetectomy, as required for decompression of the nerves or needed as part of the surgical approach.
Further, CPT Assistant explains that you would not use 63047 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [example, spinal or lateral recess stenosis]), single vertebral segment: lumbar) when your surgeon carries out a MILD procedure as code 63047 is only reported if anopen surgical technique is used when the intrinsic components of this code's key elements are carried out, namely a resection of the vertebral component, spinous processes which includes a laminotomy, laminectomy or hemilaminectomy (unilateral or bilateral) lamina, along with foraminotomy with partial facetectomy."
Also considered part of 63047 services are repairs of small dural "lacerations or leaks, and harvesting and placement of soft tissue graft, muscle, or fat when got from within the primary surgical incision" and wouldn't be reported separately.
Scenario: Through a small incision and using fluoroscopic guidance, the surgeon performs an epidurogram to identify the specific lumbar stenosis location, followed by a small laminotomy and decompressive resection of the ligamentum flavum to treat the patient's central canal spinal stenosis. As a result, should you go for 63030 or 63047 for this procedure?
The answer is no. You would report these services with 'unlisted spine code, or 22899 or 64999, unlisted procedure, nervous system, according to CPT Assistant. The rationale is that the MILD procedure involves a fluoroscopic, needle-based procedure without direct visualization of critical neural structures. MILD procedure devices "aren't intended for disc procedures" but should be used for "tissue resection at the perilaminar space inside the interlaminar space, and at the ventral aspect of the lamina. These devices aren't intended for use near the lateral neutral elements and remain dorsal to the dura using image guidance and anatomical landmarks, states the CPT Assistant.
As such, you wouldn't use code 63030, (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-aided approaches; 1 interspace, lumbar), "as the MILD procedure is a needle-based approach and isn't intended for removal of disc material versus an open surgical or open with endoscopic-assisted approach (code 63030)," CPT Assistant says.
You'd report 63030 "only when an open surgical technique is used and the intrinsic vital components of this code are carried out; namely, a resection of the vertebral component, spinous processes, and lamina, which must cover a discectomy, for decompression of the nerve root(s), as well as any laminotomy or laminectomy foraminotomy along with partial facetectomy, as required for decompression of the nerves or needed as part of the surgical approach.
Further, CPT Assistant explains that you would not use 63047 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [example, spinal or lateral recess stenosis]), single vertebral segment: lumbar) when your surgeon carries out a MILD procedure as code 63047 is only reported if anopen surgical technique is used when the intrinsic components of this code's key elements are carried out, namely a resection of the vertebral component, spinous processes which includes a laminotomy, laminectomy or hemilaminectomy (unilateral or bilateral) lamina, along with foraminotomy with partial facetectomy."
Also considered part of 63047 services are repairs of small dural "lacerations or leaks, and harvesting and placement of soft tissue graft, muscle, or fat when got from within the primary surgical incision" and wouldn't be reported separately.
Tuesday, March 15, 2011
Coding and Compliance Pitfalls: Stay Away From These Deadly Myths
Here are some common myths in the medical industry that you and your staff need to stay clear from.
Myth one: You need to bill the same amount to everyone
The fact is, you cannot bill your Medicare patients more than you do all your other patients. If your practice maintains various fee schedules (Source "http://www.supercoder.com/coding-tools/fee-schedules"), the government payers should be the lowest-priced among the group.
But then as long as you're following a contract or have consistent non-discriminatory billing policies in writing, billing may differ within your practice. But then, practically speaking, you should keep your billing policies consistent to stay away from accusations or discrimination.
Myth two: You have to send three bills before you write something off
Well, you have to make a reasonable attempt at gathering the co-pay, deductible, and when applicable, the balance of the bill; however that does not necessarily mean sending three bills.
Waiving deductibles and copayments regularly can violate several federal laws and regulations, including the Federal False Claims Act, anti-kickback statutes, and compliance guidelines for individual and small group physician practices. In the Federal False Claims Act, the OIG identifies three criteria that can end up in a violation: The waivers are routine, the waiver is given without regard to the individual's financial hardship, and the provider fails to pass on to the payer its proportional share of the discount.
Be careful: OIG regulations are not your only concern as far as collecting copays is concerned. Take a look at your payer contracts as well. Many contracts require that copays are collected during the time of service. A provider can lose participating status if they fail to toe the guidelines.
One reason you may be able to write off a patient's copay, deductible or balance is if the patient meets the criteria of financial hardship. In order for your practice to accept financial hardship as terms for a debt-off, the patient needs to be able to prove he's unable to pay. In case you cannot establish financial hardship, CMS requires that you make a reasonable endeavor to collect money from a patient. This might comprise sending three bills, followed by two phone calls, and a final notice. That cycle is at your practice's discretion. If you cannot collect it ultimately, be sure to document your efforts.
Myth three: You can bill only a single diagnosis code per claim
Well, you should bill as many diagnosis codes as you need to establish medical necessity for the services you are billing. Some payers' computer systems used to be able to read only one diagnosis code per line. However, now you should always be able to report all relevant diagnoses for each visit, and link the proper diagnoses to each service on each line.
This will become important when ICD-10 codes go into effect in 2013 at which point diagnosis coding will expand considerably.
Myth Four: E/M codes are assigned only by the level of medical decision-making (MDM).
Medical decision-making (MDM) is only one of three important components, depending on the category of the code. However you should always think about the nature of the patient's presenting problem when figuring out which code is most accurate.
Myth Five: If you are a Medicaid provider, you have to accept all Medicaid patients partly state-funded and state-designed, it's hard to give a general rule. Many states will allow some flexibility allowing you to limit new admits to your patient mix.
Some states may allow you to limit the number of Medicaid patients that you see. Most Medicaids recognize that you can go broke minus the ability to keep a viable patient mix.
Check with your state: If you are not clear regarding whether your state allows limitation of Medicaid patients, get in touch with your state's Department of Health and Human Services rather than contacting your payer.
Myth six: Medicare HMOs have to toe the same rules as Medicare
Medicare HMOs have a set of guidelines that they must follow; what's more, they've to cover everything Medicare would cover. However, they can also opt to cover other things, and they can require referrals, authorizations, and other things that Medicare would not need.
Myth seven: Secondary insurance always pays what Medicare does not
Well, secondary insurance is more likely to pick up what Medicare does not pay. However, secondary insurance does not have to pay for everything that Medicare does not. Oftentimes, secondary payers will only pay up to a certain amount and if Medicare has already shelled out that amount, they will not pay any more. Supplemental insurance will only pay Medicare's copays and deductibles, not everything else Medicare does not reimburse.
The fact is, you cannot bill your Medicare patients more than you do all your other patients. If your practice maintains various fee schedules (Source "http://www.supercoder.com/coding-tools/fee-schedules"), the government payers should be the lowest-priced among the group.
But then as long as you're following a contract or have consistent non-discriminatory billing policies in writing, billing may differ within your practice. But then, practically speaking, you should keep your billing policies consistent to stay away from accusations or discrimination.
Myth two: You have to send three bills before you write something off
Well, you have to make a reasonable attempt at gathering the co-pay, deductible, and when applicable, the balance of the bill; however that does not necessarily mean sending three bills.
Waiving deductibles and copayments regularly can violate several federal laws and regulations, including the Federal False Claims Act, anti-kickback statutes, and compliance guidelines for individual and small group physician practices. In the Federal False Claims Act, the OIG identifies three criteria that can end up in a violation: The waivers are routine, the waiver is given without regard to the individual's financial hardship, and the provider fails to pass on to the payer its proportional share of the discount.
Be careful: OIG regulations are not your only concern as far as collecting copays is concerned. Take a look at your payer contracts as well. Many contracts require that copays are collected during the time of service. A provider can lose participating status if they fail to toe the guidelines.
One reason you may be able to write off a patient's copay, deductible or balance is if the patient meets the criteria of financial hardship. In order for your practice to accept financial hardship as terms for a debt-off, the patient needs to be able to prove he's unable to pay. In case you cannot establish financial hardship, CMS requires that you make a reasonable endeavor to collect money from a patient. This might comprise sending three bills, followed by two phone calls, and a final notice. That cycle is at your practice's discretion. If you cannot collect it ultimately, be sure to document your efforts.
Myth three: You can bill only a single diagnosis code per claim
Well, you should bill as many diagnosis codes as you need to establish medical necessity for the services you are billing. Some payers' computer systems used to be able to read only one diagnosis code per line. However, now you should always be able to report all relevant diagnoses for each visit, and link the proper diagnoses to each service on each line.
This will become important when ICD-10 codes go into effect in 2013 at which point diagnosis coding will expand considerably.
Myth Four: E/M codes are assigned only by the level of medical decision-making (MDM).
Medical decision-making (MDM) is only one of three important components, depending on the category of the code. However you should always think about the nature of the patient's presenting problem when figuring out which code is most accurate.
Myth Five: If you are a Medicaid provider, you have to accept all Medicaid patients partly state-funded and state-designed, it's hard to give a general rule. Many states will allow some flexibility allowing you to limit new admits to your patient mix.
Some states may allow you to limit the number of Medicaid patients that you see. Most Medicaids recognize that you can go broke minus the ability to keep a viable patient mix.
Check with your state: If you are not clear regarding whether your state allows limitation of Medicaid patients, get in touch with your state's Department of Health and Human Services rather than contacting your payer.
Myth six: Medicare HMOs have to toe the same rules as Medicare
Medicare HMOs have a set of guidelines that they must follow; what's more, they've to cover everything Medicare would cover. However, they can also opt to cover other things, and they can require referrals, authorizations, and other things that Medicare would not need.
Myth seven: Secondary insurance always pays what Medicare does not
Well, secondary insurance is more likely to pick up what Medicare does not pay. However, secondary insurance does not have to pay for everything that Medicare does not. Oftentimes, secondary payers will only pay up to a certain amount and if Medicare has already shelled out that amount, they will not pay any more. Supplemental insurance will only pay Medicare's copays and deductibles, not everything else Medicare does not reimburse.
Now Modifier GZ Denials Will Arrive Faster
Many a time, when Medicare payers process denials in a speedy manner, it's bad news for your practice. However, when you are using modifier GZ, you are already anticipating a denial. CMS has made that happen faster with a new regulation indicating that all claims with modifier GZ added will be denied immediately.
Why to use GZ: It happens to even the best-run medical practices – the doctor has just carried out a non-covered service and there is no ABN on file.
If you should have had a patient sign an ABN but failed to do so, you should add modifier GZ (Item or service expected to be denied as not reasonable and necessary) to the CPT code describing the non-covered service the doctor provided. The advantage to reporting modifier GZ is to avoid the potential for fraud and abuse charges – by adding this modifier, you are telling Medicare that you know you carried out a non-covered service and you know they are not going to pay for it.
What the just-in rule means: Previously, your modifier GZ claims were potentially subject to complex medical reviews, which can slow claims and create logjams in your billing processes. But then the agency's new policy will ensure that these claims will be denied right away.
In writing: Effective for dates of service on and after July 1 this year, contractors shall automatically deny claim line(s) items submitted with a GZ modifier. Your explanation of benefits will list the denial codes CO and 50 (these services are non-covered services as this is not deemed a ‘medical necessity' by the payer.)
Plan beforehand: Do not allow yourself to resort to modifier GZ. You should have a policy in place to collect ABNs when necessary. For more on this and to read Transmittal 2148, visit a medical coding guide like http://supercoder.com/.
If you should have had a patient sign an ABN but failed to do so, you should add modifier GZ (Item or service expected to be denied as not reasonable and necessary) to the CPT code describing the non-covered service the doctor provided. The advantage to reporting modifier GZ is to avoid the potential for fraud and abuse charges – by adding this modifier, you are telling Medicare that you know you carried out a non-covered service and you know they are not going to pay for it.
What the just-in rule means: Previously, your modifier GZ claims were potentially subject to complex medical reviews, which can slow claims and create logjams in your billing processes. But then the agency's new policy will ensure that these claims will be denied right away.
In writing: Effective for dates of service on and after July 1 this year, contractors shall automatically deny claim line(s) items submitted with a GZ modifier. Your explanation of benefits will list the denial codes CO and 50 (these services are non-covered services as this is not deemed a ‘medical necessity' by the payer.)
Plan beforehand: Do not allow yourself to resort to modifier GZ. You should have a policy in place to collect ABNs when necessary. For more on this and to read Transmittal 2148, visit a medical coding guide like http://supercoder.com/.
Coordinate With Surgeon to Get Your Rightful Reimbursement
When more than one doctor is involved in a patient's cataract care, ensure that diagnosis and procedure codes match up because if they don't, you will get a denial. Here are two pointers to get paid on time for cataract co-management.
Match codes in order to avoid denials
The first reason for cataract co-management denials is the OD reporting a different diagnosis code than the ophthalmologist. If the code doesn't match up, one of those doctors is going to be denied, experts warn.
Here's what you can do: Stay away from across-the-board use of 366.10 (Senile cataract, unspecified) and retrieve the exact diagnosis code from the ophthalmologist prior to sending out a claim.
For instance: If the ophthalmologist uses 366.13 (Anterior subcapsular polar senile cataract), the optometrist should also code 366.13.
Do not miss: The same applies to matching the surgical CPT code you both are reporting. While 66984 applies to the majority of cataract patients, once in a while, the procedure will be difficult and the surgeon will code 66982.
Good tidings: As 66982 has a higher relative value than 66984, the postoperative care will also reimburse the OD at a higher level.
Make it a point to append modifier 55 to either 66984 or 66982 to correctly represent the post-op services you have provided.
Good idea: Insert a note on the claim form explaining that any documentation required is available upon request. May practices have successfully used this technique to stay away from denials.
The first reason for cataract co-management denials is the OD reporting a different diagnosis code than the ophthalmologist. If the code doesn't match up, one of those doctors is going to be denied, experts warn.
Here's what you can do: Stay away from across-the-board use of 366.10 (Senile cataract, unspecified) and retrieve the exact diagnosis code from the ophthalmologist prior to sending out a claim.
For instance: If the ophthalmologist uses 366.13 (Anterior subcapsular polar senile cataract), the optometrist should also code 366.13.
Do not miss: The same applies to matching the surgical CPT code you both are reporting. While 66984 applies to the majority of cataract patients, once in a while, the procedure will be difficult and the surgeon will code 66982.
Good tidings: As 66982 has a higher relative value than 66984, the postoperative care will also reimburse the OD at a higher level.
Make it a point to append modifier 55 to either 66984 or 66982 to correctly represent the post-op services you have provided.
Good idea: Insert a note on the claim form explaining that any documentation required is available upon request. May practices have successfully used this technique to stay away from denials.
Gather accurate fees with surgeon's input
Yet another common co-management billing mistake is overlooking changes in the surgeon's fee structure. It is vital to stay in the loop when the ophthalmologist increases her fees so you can earn the total 20 percent of the Medicare allowable to which you're entitled for postoperative care.
But then: That would only apply if the surgeon was charging less than the Medicare allowable, which is unlikely.
Remember: Many a time, the surgeon will provide initial postoperative care prior to transferring the patient to the OD. In this situation, it is important to coordinate on the number of days each doctor is providing care and enter those numbers on separate claim forms.
Watch out: Does the surgeon keep each patient the same number of days prior to referring back to you? That may command attention from insurers. If the surgeon always sends the patient back to you after the one-week visit, payers may suspect that you have a deal with the surgeon.
Find your share: To find out the split, first calculate 20 percent of the overall charge for the service. After this, divide that total by 90, which is the cataract postoperative global period. This provides you the per-day value of the postoperative management service. In the units field, write in the number of days of service your OD provides, which, multiplied by the per-day rate, will yield your total charge for the service.
Tip: The OD can assume care on the day after the patient is last seen by the surgeon.
Call the surgeon after you see the patient to figure out if she's filing for postoperative care and, if so, how many days she'll report so that you can bill for the balance. This is also good time to remind that office to include modifier 54 on its claim form, or else you run the risk of the payer denying your co-management claim.
Give this a try: If the surgeon is not already using a postoperative form that covers all the bases, offer to help design one. A good form could show the surgery date, which eye the surgeon treated (if not both), the surgeon's postoperative care dates, and the number of days that represents. What's more, the form could point to the date and the OD assumed care, the initial refraction, and the resultant acuities. E-mail or fax this completed form back to the surgeon to share the record of the patient's continuing care.
Yet another common co-management billing mistake is overlooking changes in the surgeon's fee structure. It is vital to stay in the loop when the ophthalmologist increases her fees so you can earn the total 20 percent of the Medicare allowable to which you're entitled for postoperative care.
But then: That would only apply if the surgeon was charging less than the Medicare allowable, which is unlikely.
Remember: Many a time, the surgeon will provide initial postoperative care prior to transferring the patient to the OD. In this situation, it is important to coordinate on the number of days each doctor is providing care and enter those numbers on separate claim forms.
Watch out: Does the surgeon keep each patient the same number of days prior to referring back to you? That may command attention from insurers. If the surgeon always sends the patient back to you after the one-week visit, payers may suspect that you have a deal with the surgeon.
Find your share: To find out the split, first calculate 20 percent of the overall charge for the service. After this, divide that total by 90, which is the cataract postoperative global period. This provides you the per-day value of the postoperative management service. In the units field, write in the number of days of service your OD provides, which, multiplied by the per-day rate, will yield your total charge for the service.
Tip: The OD can assume care on the day after the patient is last seen by the surgeon.
Call the surgeon after you see the patient to figure out if she's filing for postoperative care and, if so, how many days she'll report so that you can bill for the balance. This is also good time to remind that office to include modifier 54 on its claim form, or else you run the risk of the payer denying your co-management claim.
Give this a try: If the surgeon is not already using a postoperative form that covers all the bases, offer to help design one. A good form could show the surgery date, which eye the surgeon treated (if not both), the surgeon's postoperative care dates, and the number of days that represents. What's more, the form could point to the date and the OD assumed care, the initial refraction, and the resultant acuities. E-mail or fax this completed form back to the surgeon to share the record of the patient's continuing care.
Eye Infection, Strep Diagnoses Post ICD-10
When ICD-10 goes into effect, you will have to gear up for changes across the board as far as diagnosis coding is concerned. Many a time, you will have more choices that may need changing the way you document services and a coder reports it. Take a look at the following examples of how ICD-10 will alter your coding choices after October 1, 2013.
Get on top of upcoming eye infection coding changes
Conjunctivitis is an eye infection that can affect patients of all ages. And most likely your practice is familiar with the signs and symptoms of this condition. However, like all other conditions, conjunctivitis will come under new codes after ICD-10 goes into effect.
Presently, there are several coding options for conjunctivitis, depending on the type of condition that the doctor treats. Under ICD-10, you will not only have to denote the specific type of conjunctivitis by using the most proper diagnosis code, but you'll also have to point out which eye was affected.
Documentation: Already, your doctors should be including the affected eye in their documentation. As a coder, all you need to do to capture this already present information is to format your superbill to capture the additional anatomical information.
Medical coder tips: On your superbill, after ‘conjunctivitis, list the available choices to prompt the doctor to enter this information. A condensed system could include:
Conjunctivitis is an eye infection that can affect patients of all ages. And most likely your practice is familiar with the signs and symptoms of this condition. However, like all other conditions, conjunctivitis will come under new codes after ICD-10 goes into effect.
Presently, there are several coding options for conjunctivitis, depending on the type of condition that the doctor treats. Under ICD-10, you will not only have to denote the specific type of conjunctivitis by using the most proper diagnosis code, but you'll also have to point out which eye was affected.
Documentation: Already, your doctors should be including the affected eye in their documentation. As a coder, all you need to do to capture this already present information is to format your superbill to capture the additional anatomical information.
Medical coder tips: On your superbill, after ‘conjunctivitis, list the available choices to prompt the doctor to enter this information. A condensed system could include:
H10.3x, Unspecified acute conjunctivitis (x=0 for unspecified eye, 1 for right eye, 2 for left eye, and 3 for bilateral)
H10.40x (x=1 for right eye, 2 for left eye, 3 for bilateral, and 9 for unspecified eye)
Key: Remember that the "x" digits in the H10.3x and H10.40x examples above do not translate exactly from one conjunctivitis condition to the other. For H10.3x, a "0" for the final digit refers to an unspecified eye, whereas for H10.40x, a "9" for the final digit refers to an unspecified eye. As such, physician training will be imperative for this condition, and the coder should screen all conjunctivitis diagnoses right away post ICD-10 implementation prior to sending out claims to the insurer.
Strep throat coding changes should be minimal
Probably, primary care practices see patients with symptoms of strep throat every day, and this common illness is marked by pain and redness in the throat, potential fever, and sometimes flushed cheeks (scarlet fever).
While using the ICD-9-CM code set, you use 034.0 (Streptococcal sore throat) if the patient suffers from streptococcal sore throat. The ICD-9 manual also points you to this code if the patient suffers from streptococcal tonsillitis.
ICD-10 changes: With effect from October 1, 2013, you will not have a simple catch-all code for streptococcal throat infections. In its place, ICD-10 codes (Source "http://www.supercoder.com/icd-10/")will differentiate between the following two types of conditions:
Key: Remember that the "x" digits in the H10.3x and H10.40x examples above do not translate exactly from one conjunctivitis condition to the other. For H10.3x, a "0" for the final digit refers to an unspecified eye, whereas for H10.40x, a "9" for the final digit refers to an unspecified eye. As such, physician training will be imperative for this condition, and the coder should screen all conjunctivitis diagnoses right away post ICD-10 implementation prior to sending out claims to the insurer.
Strep throat coding changes should be minimal
Probably, primary care practices see patients with symptoms of strep throat every day, and this common illness is marked by pain and redness in the throat, potential fever, and sometimes flushed cheeks (scarlet fever).
While using the ICD-9-CM code set, you use 034.0 (Streptococcal sore throat) if the patient suffers from streptococcal sore throat. The ICD-9 manual also points you to this code if the patient suffers from streptococcal tonsillitis.
ICD-10 changes: With effect from October 1, 2013, you will not have a simple catch-all code for streptococcal throat infections. In its place, ICD-10 codes (Source "http://www.supercoder.com/icd-10/")will differentiate between the following two types of conditions:
J02.0 (Streptococcal pharyngitis)
J03.00 (Acute streptococcal tonsillitis, unspecified)
J03.01 (Acute recurrent streptococcal tonsillitis)
Documentation: You shouldn't report the strep] throat diagnosis code unless your practice gets confirmation from a lab test (either rapid strep or throat culture) indicating that the patient tested positive for a streptococcal throat infection. If you do not have a positive lab test confirming strep throat, you should just report the diagnosis codes for the symptoms (sore throat, fever, scarlet fever, etc.)
As such, your documentation must include a copy of the laboratory report confirming that the patient had strep throat prior to selecting your diagnosis code.
Key: Your doctor will require to clearly note which type of throat condition the patient has. Contrary to previous years, when one code covered both streptococcal pharyngitis and streptococcal tonsillitis, that will not be the case post ICD-10. As such, it'll be important for your documentation to include a notation of whether the patient's streptococcal infection affected the pharynx or the tonsils.
What's more, if the patient suffers from streptococcal tonsillitis, you'll have to further delineate whether he's experiencing an acute or recurrent condition. If you use J03.01 (recurrent), your documentation will have to confirm that the patient has suffered from the condition in the past.
Medical coder tips: See to it that you print both new strep throat codes on your superbills before ICD-10 goes into effect. You should also let your practitioners know that they'll need to differentiate between streptococcal pharyngitis versus streptococcal tonsillitis.
Documentation: You shouldn't report the strep] throat diagnosis code unless your practice gets confirmation from a lab test (either rapid strep or throat culture) indicating that the patient tested positive for a streptococcal throat infection. If you do not have a positive lab test confirming strep throat, you should just report the diagnosis codes for the symptoms (sore throat, fever, scarlet fever, etc.)
As such, your documentation must include a copy of the laboratory report confirming that the patient had strep throat prior to selecting your diagnosis code.
Key: Your doctor will require to clearly note which type of throat condition the patient has. Contrary to previous years, when one code covered both streptococcal pharyngitis and streptococcal tonsillitis, that will not be the case post ICD-10. As such, it'll be important for your documentation to include a notation of whether the patient's streptococcal infection affected the pharynx or the tonsils.
What's more, if the patient suffers from streptococcal tonsillitis, you'll have to further delineate whether he's experiencing an acute or recurrent condition. If you use J03.01 (recurrent), your documentation will have to confirm that the patient has suffered from the condition in the past.
Medical coder tips: See to it that you print both new strep throat codes on your superbills before ICD-10 goes into effect. You should also let your practitioners know that they'll need to differentiate between streptococcal pharyngitis versus streptococcal tonsillitis.
Hold vaccine claims or submit them now?
You should contact the provider relations department directly if your insurer has not said a peep about whether it'll accept the new vaccine administration codes 90460-90461.
If you want to find out which payers are reimbursing for vaccines, get in touch with all of the payers with whom you're contracted and enquire them for specific advice on the just-in codes. What's more, it is recommended that offices only send a few claims to see how they are processing before they send hundreds and find out that they're all denying.
Blue Cross and Blue Shield of Georgia has the just-in codes loaded into its systems for all claims with dates of service on or after January 1 this year. However the insurer had initially asked practices not to submit claims until February 3. If you had billed the just-in codes before February 3, the system would have denied the second or third unit of 90460 or 90461 as a duplicate and you would have had to call the claims department and have the claim reprocessed for correct payment.
The claims systems for Aetna, Guardian, Taylor Benefit Systems, Humana, and Coventry Health Care are all ready to accept the vaccine claims for all DOS effective January 1, 2011.
The United Health Care website indicates that practices should not use the just-in codes until April 1; however a UHC rep said that this information was posted to the Website mistakenly. According to the UHC website, you will have to rebill all of those claims with the just-in administration fees and write ‘corrected claim' at the top of your claim form.
Source URL :- http://www.supercoder.com/coding-newsletters/my-pediatric-coding-alert/practice-perspective-get-to-know-whether-to-hold-vaccine-claims-or-submit-them-now-article
The United Health Care website indicates that practices should not use the just-in codes until April 1; however a UHC rep said that this information was posted to the Website mistakenly. According to the UHC website, you will have to rebill all of those claims with the just-in administration fees and write ‘corrected claim' at the top of your claim form.
Source URL :- http://www.supercoder.com/coding-newsletters/my-pediatric-coding-alert/practice-perspective-get-to-know-whether-to-hold-vaccine-claims-or-submit-them-now-article
Successful Internal Audits are Certainly Doable
What does proper scheduling and scrutinizing documentation have to do with your achievement?
Self audit's a process. Prior to jumping in and taking on the job, you need to gear yourself and your staff for it. As you most likely know, government payers are not the only insurers who carry out audits. Private insurance companies too audit practices; therefore you should see to it that your gastroenterology office will be left hassle-free should an auditor pay a visit.
Sense of purpose: If your gastroenterology practice does not conduct regular internal audits, you are probably losing money and overlooking billing mistakes that could end up in missed billing opportunities and wrong coding. Figure out areas where your practice's inefficiencies may be delaying payment or allowing for missed charges, while also evaluating your compliance with payer regulation and coding guidelines by learning how, when, and why to carry out internal audits.
Demythologize some important elements of self audit that are embedded within the following fabrications.
Myth one: Internal audits
Internal audits are a way to ensure you're on track and nothing has gone awry; as such you need to let every member of your practice including physicians and non-physician practitioners – know why you are doing an internal audit. Owing to the stigma that the word ‘audit' brings to most people, you'd most likely have to figure out whether they are helping to bring in the right amount of money and cutting out denials.
Everyone in your practice should understand that there is light at the end of the tunnel: Internal audits can bring about opportunities for education, opportunities for the development of better forms, and opportunities to tune up the practice. What's more, internal chart audits make it possible to find and correct coding errors and self report, rather than letting the payer find them.
Reality: Internal audits are the main thing that'll protect providers. Auditing is a method of determining which providers need education related to documentation and proper code selection.
As a matter of fact, a large percentage of the audit focuses on the doctor's documentation, and not how the coders and their managers are carrying out their tasks.
If staff members are apprehensive of losing their jobs, they're misinformed. Doctors are happy to improve documentation as it keeps them from a government audit by not raising flags, and it often brings in more money.
Myth two: All audits have the same approach
As a matter of fact, there are two types of internal chart audits your practice needs to look at prior to determining which work best in your office.
Sense of purpose: If your gastroenterology practice does not conduct regular internal audits, you are probably losing money and overlooking billing mistakes that could end up in missed billing opportunities and wrong coding. Figure out areas where your practice's inefficiencies may be delaying payment or allowing for missed charges, while also evaluating your compliance with payer regulation and coding guidelines by learning how, when, and why to carry out internal audits.
Demythologize some important elements of self audit that are embedded within the following fabrications.
Myth one: Internal audits
Internal audits are a way to ensure you're on track and nothing has gone awry; as such you need to let every member of your practice including physicians and non-physician practitioners – know why you are doing an internal audit. Owing to the stigma that the word ‘audit' brings to most people, you'd most likely have to figure out whether they are helping to bring in the right amount of money and cutting out denials.
Everyone in your practice should understand that there is light at the end of the tunnel: Internal audits can bring about opportunities for education, opportunities for the development of better forms, and opportunities to tune up the practice. What's more, internal chart audits make it possible to find and correct coding errors and self report, rather than letting the payer find them.
Reality: Internal audits are the main thing that'll protect providers. Auditing is a method of determining which providers need education related to documentation and proper code selection.
As a matter of fact, a large percentage of the audit focuses on the doctor's documentation, and not how the coders and their managers are carrying out their tasks.
If staff members are apprehensive of losing their jobs, they're misinformed. Doctors are happy to improve documentation as it keeps them from a government audit by not raising flags, and it often brings in more money.
Myth two: All audits have the same approach
As a matter of fact, there are two types of internal chart audits your practice needs to look at prior to determining which work best in your office.
Prospective audit -- Your practice examines new claims prior to filing them.
Retrospective audit -- Your practice examines paid claims.
A prospective audit helps you identify and rectify problems prior to sending the claim, which could mean you will discover improper coding or charges that would otherwise have been missed. However, remember that this type of chart audit can potentially delay billing.
Choice: Retrospective chart audits don't delay billing, however causes your office to be reactive by refilling claims rather than proactive in finding problems prior to submitting the claim.
Your practice must figure out itself what types of audits your staff can practically complete and what effects on claims submission timing and cash flow the practice can handle. When reviewing charts, most auditing specialists recommend that you review 10 to 15 records per physician during your audit – you should examine the documentation and figure out which ICD-9 and CPT codes you think apply to the chart, then check which codes were in reality assigned to the services.
Myth three: End and start audits whenever you like
Schedule gives life to the whole internal audit process; minus this, all your efforts might go to waste. Depending on the size and type of your practice, you should decide how often your practice carries out an internal audit. Think about the amount of resources the practice can devote to the audit when conducting day-to-day office business.
Pointer: Bear in mind that the more often you can audit, the cleaner your claims will continue. At a minimum, you should carry out an internal audit at least two times a year. After you have prepared your staff for the auditing process and determined when you will carry out an audit, you will need to define and focus on the audit.
First enquire what do we want to accomplish and then focus on these points:
A prospective audit helps you identify and rectify problems prior to sending the claim, which could mean you will discover improper coding or charges that would otherwise have been missed. However, remember that this type of chart audit can potentially delay billing.
Choice: Retrospective chart audits don't delay billing, however causes your office to be reactive by refilling claims rather than proactive in finding problems prior to submitting the claim.
Your practice must figure out itself what types of audits your staff can practically complete and what effects on claims submission timing and cash flow the practice can handle. When reviewing charts, most auditing specialists recommend that you review 10 to 15 records per physician during your audit – you should examine the documentation and figure out which ICD-9 and CPT codes you think apply to the chart, then check which codes were in reality assigned to the services.
Myth three: End and start audits whenever you like
Schedule gives life to the whole internal audit process; minus this, all your efforts might go to waste. Depending on the size and type of your practice, you should decide how often your practice carries out an internal audit. Think about the amount of resources the practice can devote to the audit when conducting day-to-day office business.
Pointer: Bear in mind that the more often you can audit, the cleaner your claims will continue. At a minimum, you should carry out an internal audit at least two times a year. After you have prepared your staff for the auditing process and determined when you will carry out an audit, you will need to define and focus on the audit.
First enquire what do we want to accomplish and then focus on these points:
Figure out the audit's scope. Which providers, services, date range and payers will it address?
Figure out how to choose charts. Will you fix this process for each provider or will you randomize the chart selection? Pull charts and organize supporting documentation, say for instance a printout of physician notes, account billing history, CMS 1500(http://www.supercoder.com/scrubber/cms1500/) forms and explanations of benefits.
Thursday, March 10, 2011
Tips to Help You Get Closer to ICD-10 Compliance
As is likely, when ICD-9 becomes ICD-10, there will not always be a simple crosswalk relationship between old and new codes. Sometimes you will have more options that may need changing the way you document services and a coder reports it. Here are some examples of how ICD-10 will alter your coding options from October 1, 2013.
Rejoice sinusitis codes' one-to-one relationship for ICD-10
At present: When your doctor treats a patient for sinusitis, you should use the proper sinusitis code for sinus membrane lining inflammation. For acute sinusitis, report 461.x. For chronic sinusitis, frequent or persistent infections lasting more than three months – use 473.x.
For both acute and chronic conditions, you will select the fourth digit code based on where the sinusitis occurs. For example, for ethmoidal chronic sinusitis, you should use 473.2, Chronic sinusitis; ethmoidal. Your otolaryngologist will most probably prescribe a decongestant, pain reliever or antibiotics to treat sinusitis.
Good tidings: These sinusitis choices have a one-to-one match with soon-to-come ICD-10 codes. For acute sinusitis diagnoses, you will look at the J01.-0 codes. For example, 461.0 (Acute maxillary sinusitis) translates to J01.00 (Acute maxillary sinusitis, unspecified). Remember how the definitions are generally identical. Just as in ICD-9, the fourth digit changes to specify location.
For chronic sinusitis diagnoses, you will have to take a look at J32.- codes. For example, in the mentioned instance, 473.2 maps direction to J32.2 (Chronic ethmoidal sinusitis). What's more, this is a direct one-to-one ratio with identical definitions. Just like ICD-9, the fourth digit changes to specify location.
Physician documentation: Presently, the doctor should pinpoint the location of the sinusitis. This will not change in year 2013.
Tips: You will scrap the 461.x and 473.x options and turn to J01.-0 and J32.- in your ICD-10 manual. Apart from the change in code number and the addition of a letter, you should treat these claims the same as before.Osteoarthritis will need heightened documentation in 2013
Imagine your diagnoses osteoarthrosis (715.xx-716. xx) in a new patient. These codes specify location, primary or secondary.
ICD-10 difference: After October 1, 2013, you should look to:
M15 (Polyosteoarthritis)
M16 (Osteoarthritis of hip)
M17 (Osteoarthritis of knee)
M18 (Osteoarthritis of first carpometacarpal joint)
M19 (Other and unspecified osteoarthritis).
These codes are broken down into location, primary and secondary such as your ICD-9 codes; however they also sometimes specify unilateral, bilateral and post-traumatic indications:
Physician documentation: In order to submit the most detailed diagnosis, the doctor will need to maintain osteoarthrosis documentation; however expand it to unilateral, bilateral, and/or post-traumatic specification. Some important terms are '"osteoarthritis," "arthritis," "arthrosis," "DJD," "arthropathy," "post traumatic arthritis," and "traumatic arthritis."
Tips: Note how codes M19.01--M19.93 entail unspecified locations. ICD-10 no longer group unspecified locations together with the specific locations for each type. You'll find them at the end of the code grouping (M19.90--"M19.93) for each specific type, however in an unspecified location.
What's more, traumatic osteoarthritis is now more properly indexed and described as post-traumatic osteoarthritis, the true condition. Source URL :- http://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/icd-10-3-tips-will-get-you-closer-to-icd-10-compliance-article
At present: When your doctor treats a patient for sinusitis, you should use the proper sinusitis code for sinus membrane lining inflammation. For acute sinusitis, report 461.x. For chronic sinusitis, frequent or persistent infections lasting more than three months – use 473.x.
For both acute and chronic conditions, you will select the fourth digit code based on where the sinusitis occurs. For example, for ethmoidal chronic sinusitis, you should use 473.2, Chronic sinusitis; ethmoidal. Your otolaryngologist will most probably prescribe a decongestant, pain reliever or antibiotics to treat sinusitis.
Good tidings: These sinusitis choices have a one-to-one match with soon-to-come ICD-10 codes. For acute sinusitis diagnoses, you will look at the J01.-0 codes. For example, 461.0 (Acute maxillary sinusitis) translates to J01.00 (Acute maxillary sinusitis, unspecified). Remember how the definitions are generally identical. Just as in ICD-9, the fourth digit changes to specify location.
For chronic sinusitis diagnoses, you will have to take a look at J32.- codes. For example, in the mentioned instance, 473.2 maps direction to J32.2 (Chronic ethmoidal sinusitis). What's more, this is a direct one-to-one ratio with identical definitions. Just like ICD-9, the fourth digit changes to specify location.
Physician documentation: Presently, the doctor should pinpoint the location of the sinusitis. This will not change in year 2013.
Tips: You will scrap the 461.x and 473.x options and turn to J01.-0 and J32.- in your ICD-10 manual. Apart from the change in code number and the addition of a letter, you should treat these claims the same as before.
Imagine your diagnoses osteoarthrosis (715.xx-716. xx) in a new patient. These codes specify location, primary or secondary.
ICD-10 difference: After October 1, 2013, you should look to:
These codes are broken down into location, primary and secondary such as your ICD-9 codes; however they also sometimes specify unilateral, bilateral and post-traumatic indications:
Physician documentation: In order to submit the most detailed diagnosis, the doctor will need to maintain osteoarthrosis documentation; however expand it to unilateral, bilateral, and/or post-traumatic specification. Some important terms are '"osteoarthritis," "arthritis," "arthrosis," "DJD," "arthropathy," "post traumatic arthritis," and "traumatic arthritis."
Tips: Note how codes M19.01--M19.93 entail unspecified locations. ICD-10 no longer group unspecified locations together with the specific locations for each type. You'll find them at the end of the code grouping (M19.90--"M19.93) for each specific type, however in an unspecified location.
What's more, traumatic osteoarthritis is now more properly indexed and described as post-traumatic osteoarthritis, the true condition. Source URL :- http://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/icd-10-3-tips-will-get-you-closer-to-icd-10-compliance-article
Focus On Drug Dependence versus Abuse to Assign Diagnosis
ICD-9 does not provide a specific code for a urine drug test. The same is the case with ICD-10 too. The proper diagnosis code for billing a lab drug test depends on the signs, symptoms, patient condition, or other reason for the test, say for instance screening.
Example: The physician orders a drug screen for a patient diagnosed with Cannabis dependence who uses the drug intermittently. Code the ordering diagnosis as 304.32 (Cannabis dependence, episodic use) with ICD-9.
Cross walking from ICD-9 to ICD-10: Even though ICD-10 provides more detail than ICD-9, leading to more code choices for ICD-10, the opposite is correct in this instance. The subsequent three ICD-9 codes crosswalk to a single ICD-10 code (F12.20, Cannabis dependence, uncomplicated):
304.30 -- Cannabis dependence, unspecified use
304.31 -- Cannabis dependence, continuous use
Example: The physician orders a drug screen for a patient diagnosed with Cannabis dependence who uses the drug intermittently. Code the ordering diagnosis as 304.32 (Cannabis dependence, episodic use) with ICD-9.
Cross walking from ICD-9 to ICD-10: Even though ICD-10 provides more detail than ICD-9, leading to more code choices for ICD-10, the opposite is correct in this instance. The subsequent three ICD-9 codes crosswalk to a single ICD-10 code (F12.20, Cannabis dependence, uncomplicated):
304.32 -- Cannabis dependence, episodic use.
Report different codes for abuse or use
Both ICD-9 as well as ICD-10 differentiates between drug dependence versus drug abuse. For example, 304.3x identifies Cannabis dependence while 305.2x (Non-dependent Cannabis abuse) identifies Cannabis abuse.
Likewise, ICD-10 provides F12.20 for Cannabis dependence, and F12.10 (Cannabis abuse, uncomplicated) for Cannabis abuse.
Article Source :- http://www.supercoder.com/coding-newsletters/my-icd-10-coding-alert/reader-question-focus-on-drug-dependence-vs-abuse-to-assign-diagnosis-108833-article
What's more, ICD-10 provides separate codes for drug use when the doctor does not specify whether the use constitutes dependence or abuse. For example, you would code Cannabis use as F12.90 (Cannabis use, unspecified, uncomplicated).
Report different codes for abuse or use
Both ICD-9 as well as ICD-10 differentiates between drug dependence versus drug abuse. For example, 304.3x identifies Cannabis dependence while 305.2x (Non-dependent Cannabis abuse) identifies Cannabis abuse.
Likewise, ICD-10 provides F12.20 for Cannabis dependence, and F12.10 (Cannabis abuse, uncomplicated) for Cannabis abuse.
Article Source :- http://www.supercoder.com/coding-newsletters/my-icd-10-coding-alert/reader-question-focus-on-drug-dependence-vs-abuse-to-assign-diagnosis-108833-article
What's more, ICD-10 provides separate codes for drug use when the doctor does not specify whether the use constitutes dependence or abuse. For example, you would code Cannabis use as F12.90 (Cannabis use, unspecified, uncomplicated).
Tuesday, March 8, 2011
CPT 2011: Femoral/Popliteal Coding Options
This time CPT 2011 adds new codes for lower extremity endovascular revascularization covering angioplasty, atherectomy, and stenting.
Here we'll take a look at the femoral/popliteal codes 37224-37227.
Master the single code approach for fem/pop coding
Remember that all of the codes include angioplasty in the same vessel when that service is carried out:
Angioplasty: 37224 -- Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal angioplasty
Atherectomy (and angioplasty): 37225 -- … with atherectomy, covers angioplasty within the same vessel, when carried out
Stent (& angioplasty): 37226 -- … with transluminal stent placement(s), covers angioplasty within the same vessel, when carried out
Stent & atherectomy (and angioplasty): 37227 -- … with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when carried out.
Note: Usually, the rule for 37224-37227 is that you should report the one code that represents the most intensive service carried out in a single lower extremity vessel.
Example: When the radiologist carries out a stent placement, atherectomy, and angioplasty in the left popliteal vessel, you should report 37227 only. That code includes stent placement, atherectomy, and angioplasty. In this scenario, you shouldn't report 37224 (angioplasty), 37225 (atherectomy), or 37226 (stent placement) separately or in addition to 37227.
Take a look at the change from component coding
According to CPT guidelines, in addition to the intervention carried out, the codes include:
Accessing the vessel
Selectively catheterizing the vessel
Crossing the lesion
Radiological supervision and interpretation for the intervention carried out
Any embolic protection used
Closure of arteriotomy (incision in the artery)
Here we'll take a look at the femoral/popliteal codes 37224-37227.
Master the single code approach for fem/pop coding
Remember that all of the codes include angioplasty in the same vessel when that service is carried out:
Note: Usually, the rule for 37224-37227 is that you should report the one code that represents the most intensive service carried out in a single lower extremity vessel.
Example: When the radiologist carries out a stent placement, atherectomy, and angioplasty in the left popliteal vessel, you should report 37227 only. That code includes stent placement, atherectomy, and angioplasty. In this scenario, you shouldn't report 37224 (angioplasty), 37225 (atherectomy), or 37226 (stent placement) separately or in addition to 37227.
Take a look at the change from component coding
According to CPT guidelines, in addition to the intervention carried out, the codes include:
Imaging carried out to document the intervention was completed.
To avoid denials, apply this territory rule
The just-in codes 37220-+37235 apply to different territories. Every territory has its own specific set of guidelines. Codes 37224-37227 come under the femoral/popliteal vascular territory.
Important rule: According to CPT, the entire femoral/popliteal territory in 1 lower extremity is considered a single vessel for CPT reporting.
Source URL :- http://www.supercoder.com/coding-newsletters/my-radiology-coding-alert/cpt-2011-37224-37227-revolutionize-your-femoralpopliteal-coding-options-article
Consequently, you should report a single code even if the radiologist carried out various interventions for various lesions in the popliteal artery and in the common, deep, and superficial femoral arteries in the same leg at the same session.
In situations such as these, you should use the code for the most complex service.
To avoid denials, apply this territory rule
The just-in codes 37220-+37235 apply to different territories. Every territory has its own specific set of guidelines. Codes 37224-37227 come under the femoral/popliteal vascular territory.
Important rule: According to CPT, the entire femoral/popliteal territory in 1 lower extremity is considered a single vessel for CPT reporting.
Source URL :- http://www.supercoder.com/coding-newsletters/my-radiology-coding-alert/cpt-2011-37224-37227-revolutionize-your-femoralpopliteal-coding-options-article
Consequently, you should report a single code even if the radiologist carried out various interventions for various lesions in the popliteal artery and in the common, deep, and superficial femoral arteries in the same leg at the same session.
In situations such as these, you should use the code for the most complex service.
Prepare for ICD-10 Codes Effect
Each year, there are millions of people suffering from kidney ailments. As those numbers are on the rise, the diagnosis code for this code will still rank among your commonly used codes when ICD-10 becomes effective in 2013.
Good tidings: You will almost find a one-to-one code correspondence between ICD-9 2011 and ICD-10 2011for "calculus of kidney and ureter" codes.
The key difference is that ICD-10 offers a code (N20.2) that is proper when the patient has calculi of both the kidney and the ureter. Under ICD-9, you would report the same diagnosis using two codes (592.0 and 592.1).
Instructional news: The 'includes' notes for these codes are almost identical for ICD-9 and ICD-10. Take special care in reviewing the 'excludes' notes, though, as ICD-10 has two different types of excludes notes that have two different meanings.
According to ICD-9 guidelines, an 'excludes' note shows terms that you should code elsewhere. The guidelines state that the term excludes means 'do not code here'. For instance, an ICD-9 excludes note guides you to assign 275.49 for nephrocalcinosis rather than using a code in the 592 range (Calculus of kidney and ureter).
In comparison, ICD-10 has both "Excludes1" and "Excludes2" notes. As per ICD-10 guidelines, Excludes 1 means 'NOT CODED HERE.' As a matter of fact, you should never report the excluded code at the same time as the code above the Excludes 1 note. Excludes 1 means the 'two conditions cannot take place together'.
Instead, an Excludes2 note tells you that the excluded term should be reported using another code. However if the patient has both conditions you may report both codes. In other words, when an Excludes2 note appears under a code it's acceptable to use both the code as well as the excluded code together.
An instance of Excludes1: ICD-10 lists an Excludes1 note directly under N20 (Calculus of kidney and ureter). This means the note applies to the entire N20 range. The excluded terms are "nephrocalcinosis" (E83.5-, Disorders of calcium metabolism) and "that with hydronephrosis" (N13.2, Hydronephrosis with renal and ureteral calculous obstruction).
As these terms are listed as an Excludes1 note, you should never report N20 - with N13.2 or the code for nephrocalcinosis (E83.5).
Excludes2example: Code N21.0 (Calculus in bladder) has an Excludes2 note for staghorn calculus indicating you should report N20.0 in place of N21.0 for that diagnosis. However because this is an Excludes2 note, if the documentation shows both "staghorncalculus" (N20.0) and "calculus in bladder" (N21.0), you may use the codes for each on the same claim.
Remember: When ICD-10 goes into effect, you should apply the codes and official guidelines in effect at that time. Learn more at a one-stop medical coding guide like Supercoder.
Good tidings: You will almost find a one-to-one code correspondence between ICD-9 2011 and ICD-10 2011for "calculus of kidney and ureter" codes.
The key difference is that ICD-10 offers a code (N20.2) that is proper when the patient has calculi of both the kidney and the ureter. Under ICD-9, you would report the same diagnosis using two codes (592.0 and 592.1).
Instructional news: The 'includes' notes for these codes are almost identical for ICD-9 and ICD-10. Take special care in reviewing the 'excludes' notes, though, as ICD-10 has two different types of excludes notes that have two different meanings.
According to ICD-9 guidelines, an 'excludes' note shows terms that you should code elsewhere. The guidelines state that the term excludes means 'do not code here'. For instance, an ICD-9 excludes note guides you to assign 275.49 for nephrocalcinosis rather than using a code in the 592 range (Calculus of kidney and ureter).
In comparison, ICD-10 has both "Excludes1" and "Excludes2" notes. As per ICD-10 guidelines, Excludes 1 means 'NOT CODED HERE.' As a matter of fact, you should never report the excluded code at the same time as the code above the Excludes 1 note. Excludes 1 means the 'two conditions cannot take place together'.
Instead, an Excludes2 note tells you that the excluded term should be reported using another code. However if the patient has both conditions you may report both codes. In other words, when an Excludes2 note appears under a code it's acceptable to use both the code as well as the excluded code together.
An instance of Excludes1: ICD-10 lists an Excludes1 note directly under N20 (Calculus of kidney and ureter). This means the note applies to the entire N20 range. The excluded terms are "nephrocalcinosis" (E83.5-, Disorders of calcium metabolism) and "that with hydronephrosis" (N13.2, Hydronephrosis with renal and ureteral calculous obstruction).
As these terms are listed as an Excludes1 note, you should never report N20 - with N13.2 or the code for nephrocalcinosis (E83.5).
Excludes2example: Code N21.0 (Calculus in bladder) has an Excludes2 note for staghorn calculus indicating you should report N20.0 in place of N21.0 for that diagnosis. However because this is an Excludes2 note, if the documentation shows both "staghorncalculus" (N20.0) and "calculus in bladder" (N21.0), you may use the codes for each on the same claim.
Remember: When ICD-10 goes into effect, you should apply the codes and official guidelines in effect at that time. Learn more at a one-stop medical coding guide like Supercoder.
Monday, March 7, 2011
Cpt 2011: IP Catheter Code Changes
For intraperitoneal (IP) catheter coding, confusing terms such as 'temporary' and 'permanent' are a thing of the past. Here's how CPT 2011 freshened up your options:
New code 49418 begins the IP catheter code changes
Defined as a 'complete' procedure, you will find multiple services covered by new code 49418 (Insertion of tunneled intraperitoneal catheter [example dialysis, intraperitoneal chemotherapy instillation, management of ascites], complete procedure, including imaging guidance, catheter placement, contrast injection when carried out, and radiological supervision and interpretation, percutaneous).
Medicare assigned this just-in code a 0-day global period, which means Medicare does not bundle visits on subsequent days into the procedure payment.
Progress carefully: Medicare's national fee schedule prices for 49418 differ significantly based on whether you're reporting a facility service ($234.78) or non-facility service ($1,519.08). That is a difference of more than $1,200; as such be sure to watch your place of service code.
Rectify the codes listed in 49419's line note
Overall, changes show the 'coding lag' that occurs in keeping up with advances in new surgical procedures. In fact, the addition of 49418 is part of a larger reworking of tunneled intraperitoneal (IP) catheter codes to bring them in line with present practice. To begin with, CPT revises 49419:
2010: 49419
2011: 49419
Here's why: By referencing subcutaneous port, the code language reflects present technology.
What's more, CPT removed the term 'cannula' as doctors commonly carry out these procedures using a catheter only.
According to AMA's published errata: You will require correcting the CPT manual note following 49419. The note should read as follows: 49420 has made an exit. To report open placement of a tunneled peritoneal catheter for dialysis, report 49421. To report open or percutaneous peritoneal drainage or lavage, take a look at 49020, 49021, 49040, 49041, 49080, 49081 as proper. To report percutaneous insertion of a tunneled peritoneal catheter without subcutaneous port, go for 49418.
Among other code changes, focus on 49422 note
Other changes related to IP catheter coding include the following:
According to the symposium, these changes are part of an attempt to 'clean up' codes that overlapped and caused confusion. For instance, the terms temporary and permanent (used last year), caused confusion over whether they referred to placement or to the device itself. That apart, CPT 2011 added the term 'tunneled' to acknowledge the subcutaneous channel in which the physician places the catheter.
Exit: See to it that you catch that this year's CPT deleted 49420. The revisions and additions of other, more specific codes made 49420 obsolete.
Vital instruction: Do not miss the note with 49422. This code is for removal of a tunneled catheter only. If the physician removes a non-tunneled IP catheter, CPT guides you to use the proper E/M code.
Source URL :- http://www.supercoder.com/coding-newsletters/my-radiology-coding-alert/cpt-2011-49418-49422-changes-bring-ip-catheter-coding-up-to-date-article
New code 49418 begins the IP catheter code changes
Defined as a 'complete' procedure, you will find multiple services covered by new code 49418 (Insertion of tunneled intraperitoneal catheter [example dialysis, intraperitoneal chemotherapy instillation, management of ascites], complete procedure, including imaging guidance, catheter placement, contrast injection when carried out, and radiological supervision and interpretation, percutaneous).
Medicare assigned this just-in code a 0-day global period, which means Medicare does not bundle visits on subsequent days into the procedure payment.
Progress carefully: Medicare's national fee schedule prices for 49418 differ significantly based on whether you're reporting a facility service ($234.78) or non-facility service ($1,519.08). That is a difference of more than $1,200; as such be sure to watch your place of service code.
Rectify the codes listed in 49419's line note
Overall, changes show the 'coding lag' that occurs in keeping up with advances in new surgical procedures. In fact, the addition of 49418 is part of a larger reworking of tunneled intraperitoneal (IP) catheter codes to bring them in line with present practice. To begin with, CPT revises 49419:
2010: 49419
2011: 49419
Here's why: By referencing subcutaneous port, the code language reflects present technology.
What's more, CPT removed the term 'cannula' as doctors commonly carry out these procedures using a catheter only.
According to AMA's published errata: You will require correcting the CPT manual note following 49419. The note should read as follows: 49420 has made an exit. To report open placement of a tunneled peritoneal catheter for dialysis, report 49421. To report open or percutaneous peritoneal drainage or lavage, take a look at 49020, 49021, 49040, 49041, 49080, 49081 as proper. To report percutaneous insertion of a tunneled peritoneal catheter without subcutaneous port, go for 49418.
Among other code changes, focus on 49422 note
Other changes related to IP catheter coding include the following:
According to the symposium, these changes are part of an attempt to 'clean up' codes that overlapped and caused confusion. For instance, the terms temporary and permanent (used last year), caused confusion over whether they referred to placement or to the device itself. That apart, CPT 2011 added the term 'tunneled' to acknowledge the subcutaneous channel in which the physician places the catheter.
Exit: See to it that you catch that this year's CPT deleted 49420. The revisions and additions of other, more specific codes made 49420 obsolete.
Vital instruction: Do not miss the note with 49422. This code is for removal of a tunneled catheter only. If the physician removes a non-tunneled IP catheter, CPT guides you to use the proper E/M code.
Source URL :- http://www.supercoder.com/coding-newsletters/my-radiology-coding-alert/cpt-2011-49418-49422-changes-bring-ip-catheter-coding-up-to-date-article
Obama Budget to Delay Medicare Cuts for Two More Years
Last December, Part B practices heaved a sigh of relief when Congress froze Medicare payments at 2010 levels throughout 2011. And because of that vote, you have not had to deal with the potentially devastating 25 percent cuts that you would have faced on January 1 this year.
However the cuts are still poised to take effect next year. Until and unless of course Obama's new budget proposal clears administrative barriers.
On February 14 this year, the White House Office Management and Budget made its new budget proposal public. Accordingly, this would delay Medicare cuts for a couple of years more, through December 31, 2013. The pay cuts would still kick in as of 2014; however physician advocacy groups hope that a lasting solution to the Medicare payment issues (http://supercoder.com/)will be established by then.
According to a statement from Office of Management and Budget director Jack Lew, "In December, there was a bipartisan agreement to pay for a one-year extension of the so called 'doc fix,' which was not needed by budget rules; however was the right thing to do." "Building on that, our budget identifies $62 bn of specific health savings to pay for the coming two years of this fix, establishing a clear pattern that, consistent with our budget, this needs to be paid in the times to come.
Aside from this, Obama's budget proposal also includes $250 M in grants to states to reform the way medical liability disputes are resolved. The Department of Justice would award the grants with the Department of Health and Human Services.
However the cuts are still poised to take effect next year. Until and unless of course Obama's new budget proposal clears administrative barriers.
On February 14 this year, the White House Office Management and Budget made its new budget proposal public. Accordingly, this would delay Medicare cuts for a couple of years more, through December 31, 2013. The pay cuts would still kick in as of 2014; however physician advocacy groups hope that a lasting solution to the Medicare payment issues (http://supercoder.com/)will be established by then.
According to a statement from Office of Management and Budget director Jack Lew, "In December, there was a bipartisan agreement to pay for a one-year extension of the so called 'doc fix,' which was not needed by budget rules; however was the right thing to do." "Building on that, our budget identifies $62 bn of specific health savings to pay for the coming two years of this fix, establishing a clear pattern that, consistent with our budget, this needs to be paid in the times to come.
Aside from this, Obama's budget proposal also includes $250 M in grants to states to reform the way medical liability disputes are resolved. The Department of Justice would award the grants with the Department of Health and Human Services.
Wednesday, March 2, 2011
You Cannot Separately Bill For Starting the IV
Recently, our surgeon carried out an emergency room consult and administered intravenous sedation to perform an incision and drainage of a perirectal abscess. So if I charge for the consult and the procedure, can I code for the IV sedation also?
Well you can only report an intravenous (IV) sedation in addition to an E/M and procedure under certain circumstances. Only a conscious sedation is reportable separately and even that is only in some instances.
If your surgeon carried out conscious sedation, you may be able to bill that with the right documentation and depending on exactly which I&D code you are using. Remember that any code that has the ‘target' symbol in CPT codes(http://www.supercoder.com/cpt-codes/) includes conscious sedation, which means that you cannot bill the service separately.
If the IV sedation you talked about was conscious sedation for allowable procedure such as 45005 (Incision and drainage of submucosal abscess, rectum), you'll require to document who was monitoring the patient during the case (name and credentials like John Doe, RN). You will also need to document what drug was used and how much as well as the patient's vitals prior to, during, and after the sedation. If you do not have the documentation, you cannot bill for the conscious sedation.
If you cannot bill conscious sedation, you are unlucky for the IV. Beginning an IV is a facility service in the ED; as such you cannot separately bill for starting the IV.
If your surgeon carried out conscious sedation, you may be able to bill that with the right documentation and depending on exactly which I&D code you are using. Remember that any code that has the ‘target' symbol in CPT codes(http://www.supercoder.com/cpt-codes/) includes conscious sedation, which means that you cannot bill the service separately.
If the IV sedation you talked about was conscious sedation for allowable procedure such as 45005 (Incision and drainage of submucosal abscess, rectum), you'll require to document who was monitoring the patient during the case (name and credentials like John Doe, RN). You will also need to document what drug was used and how much as well as the patient's vitals prior to, during, and after the sedation. If you do not have the documentation, you cannot bill for the conscious sedation.
If you cannot bill conscious sedation, you are unlucky for the IV. Beginning an IV is a facility service in the ED; as such you cannot separately bill for starting the IV.
New Insurance Calls for New Verification
A patient has received new coverage but hasn't received an insurance identification card as yet. How should you file a claim on a patient who has new coverage?
Preferably, when patients call to make appointments you should have someone in your office corroborate their insurance coverage and eligibility, more so if you know the patient is going to have new insurance.
The start of the year is the time when benefits verification tends to be most useful. While verification is good practice all year long, January is the time when you will see more insurance charges – including payer, benefit, and deductible/copay changes than at any other time during the year as most employers hold open enrollment in December.
Finding out about insurance changes before the appointment gives you time to check if you're a participating provider with the payer and verify coverage. If the patient does not have an identification number with her new insurance company, ask for the name of the insurer and the policy number from the patient or from the patient's employer. After this, call the insurer and verify the coverage and the date of eligibility, and get the proper information to identify the patient on your claim.
Article Source :- http://www.supercoder.com/coding-newsletters/my-optometry-coding-alert/reader-questions-new-year-new-insurance-new-verification-104790-article
Note of caution: The date of eligibility is an important question to ask the payer as many employees do not make health insurance coverage immediately available to new workers. A patient with a new job and new insurance may be in your office for a visit; however his insurance is not effective for two months.
Option: Even though verifying coverage beforehand is the way to go, many practices have patients corroborate their insurance coverage and note any changes when they check in for their appointments. If you are not able to verify the insurance coverage, or you find the patient's not eligible for coverage on the day of the visit, inform the patient of the problem and ask if he wants to reschedule the appointment (unless it is an emergency visit). Or else, explain to the patient that the visit and services may not be covered, and that he must pay the bill himself. Have the patient sign a waiver stating that the services rendered that day may not be covered by the new insurance, and that he's responsible financially. You should keep the signed waiver in the patient record.
The start of the year is the time when benefits verification tends to be most useful. While verification is good practice all year long, January is the time when you will see more insurance charges – including payer, benefit, and deductible/copay changes than at any other time during the year as most employers hold open enrollment in December.
Finding out about insurance changes before the appointment gives you time to check if you're a participating provider with the payer and verify coverage. If the patient does not have an identification number with her new insurance company, ask for the name of the insurer and the policy number from the patient or from the patient's employer. After this, call the insurer and verify the coverage and the date of eligibility, and get the proper information to identify the patient on your claim.
Article Source :- http://www.supercoder.com/coding-newsletters/my-optometry-coding-alert/reader-questions-new-year-new-insurance-new-verification-104790-article
Note of caution: The date of eligibility is an important question to ask the payer as many employees do not make health insurance coverage immediately available to new workers. A patient with a new job and new insurance may be in your office for a visit; however his insurance is not effective for two months.
Option: Even though verifying coverage beforehand is the way to go, many practices have patients corroborate their insurance coverage and note any changes when they check in for their appointments. If you are not able to verify the insurance coverage, or you find the patient's not eligible for coverage on the day of the visit, inform the patient of the problem and ask if he wants to reschedule the appointment (unless it is an emergency visit). Or else, explain to the patient that the visit and services may not be covered, and that he must pay the bill himself. Have the patient sign a waiver stating that the services rendered that day may not be covered by the new insurance, and that he's responsible financially. You should keep the signed waiver in the patient record.
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