Difference between "Diagnostic" and "Therapeutic" Injections

Are you aware of the difference between 'diagnostic' and 'therapeutic' injections or nerve blocks? And how does the provider decide which to do?

Physicians use diagnostic nerve blocks to figure out the sources of the patient's pain. These blocks normally contain an anesthetic with a known duration of relief. Therapeutic nerve blocks cover local anesthetic to control acute pain, once the doctor corroborates the source and cause of discomfort. Most CPT section headings for injection or nerve block codes mention 'diagnostic or therapeutic'. Often the codes cover for both situations, meaning you could most likely report the same code for both diagnostic and therapeutic injections, based on the type of block and administration site.

Source URL :- http://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/reader-questions-distinguish-diagnostic-from-therapeutic-nerve-block-103751-article

Here's an example:

A provider might inject an anesthetic and a steroid into a facet joint or a peripheral nerve to figure out whether that's the source of the patient's pain. A nerve block might be both diagnostic and therapeutic in that situation. However payers may want to know whether the block is diagnostic or therapeutic. Specifying such can be a criterion of coverage. Teach your physicians on the importance of documenting whether the patient gets a diagnostic or therapeutic block.

Bear in mind: Take a look at whether you may report radiological guidance separately or whether it is included. For instance, you shouldn't report imaging guidance with a code like 64490. According to the code definition, "with image guidance" and CPT guidelines before the code tell you that fluoroscopy and CPT guidance as well as contrast injections are included in 64490.

Standby: Take a Look at Documentation of 4 Areas before Submitting Claims

As we know, CPT's evaluation & management section includes only one code for standby time; however limited choices do not guarantee payment. Take a look at these four areas to see you get your well-deserved payments.

You should code based on availability and not care. Your first step in gearing up to submit a claim for standby service is to understand what you are reporting and what you are not. Code 99360 does not represent patient care, rather, it represents availability.

You need to document three important factors. Even though CPT includes a standby code, may payers don't reimburse for the service. Thorough documentation of your provider's service is paramount as you might be faced with an appeal. While coding 99360 for standby care, here are some key tips to keep in mind.

1. Yet another doctor must request that your anesthesiologist make himself available for standby time. You require this request in writing along with justification for why the other physician requests anesthesia standby.

2. The chart should cover a note by the anesthesiologist documenting that his service might be required.

3. Information about the anesthesiologist's involvement in the case.

You should also double check times and locations

Being able to report standby service hinges on a couple of important factors, which are time and location. You anesthesiologist must be in attendance for standby for at least 30 minutes and he must document that time. CPT indicates that if the time's less than 30 minutes, you do not report it separately. However, it is always a good idea to document patient care irrespective of whether it is billable or not.

Remember: Coding for standby time means your anesthesiologist doesn't have face to face contact with the patient. You should report his total time of availability, if it's 30 minutes or more. If your anesthesiologist is on standby for less than 30 minutes, document his availability, however do not charge for the time.

For more on this and for other anesthesia CPT codes, sign up for a one-stop medical coding guide like Supercoder. When you get onboard this, you'll have access to SuperCoder's Anesthesia Coder's PowerPack that comes with just the tools you need to code faster, ensure accuracy and stop denials. Some of the tools that'll help you stay away from denials are Anesthesia Analyst, Anesthesia Coding Alert, CPT Assistant, Stedman's Medical Dictionary, and lots more.

Depth and Location Key to Ulcer Reporting

Your dermatologist carries out a decubitus ulcer excision or debridement; here you will have to choose from about 25 possible codes. You will have an easier time selecting the right code if you are aware about the following:

Find out whether the wound closed. If so, by what method?

In some instances, the dermatologist may debride the ulcer and allow the wound to stay open to heal. On the other hand, the dermatologist may excise the ulcer, clear all infection, and close the wound. You need distinguish debridement from excision by what the documentation specifies, and not by the ulcer's removal.

Find out where the ulcer was.


There are nine ICD-9 codes for decubitus ulcers (707.00-707.09); with these options around, you now have many codes to choose from, specific to the ulcer's location on the body.
Find out how deep was the debridement.

You can report debridement (11040-11044) based on three different skin levels - partial thickness, full thickness, or subcutaneous -- or as deep as muscle or even bone. Say for instance, 11044 describes a debridement that involves chipping off pieces of diseased bone to get rid of the wound of infection.

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

Find out whether anything else was excised besides ulcer.

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

In yet another instance, if the dermatologist carries out an ostectomy during the excision of an ischial pressure ulcer, you should code 15941 if the wound was then closed with primary suture (15940) or with skin flap closure (15944).

Like always, your ability to answer these questions depends largely on the quality and specificity of documentation in the operative report.

For More Info :- http://www.supercoder.com/coding-newsletters/my-dermatology-coding-alert/4-questions-guide-your-ulcer-reporting-article

CPT 2011 Codes Help Solve Your 'Middle Day' Code Dilemma

While reporting the middle day observations, this year you have new options to choose from. If you want to find out how CPT additions will have a say on your orthopedist's observation care services, read on and find out:

New codes bring clarity with them. Before the start of this year, coding for the 'middle days' of an observation service was a pain in the neck. Even though, it's not the norm, there are situation where a patient is admitted to observation and remains in that status for three or more days. The E/M section of CPT 2011 addresses these middle days with new codes. The three codes that parallel the hospital subsequent care series in terms of component requirements and time frames are 99224, 99225 and 99226.

There has been some confusion on ways to report the middle day for those cases when an observation period transcends three calendar days. The new CPT codes

99224-99226 stamp out insurer variances. There has been some uncertainty about how to report the middle day for those cases when an observation period transcends three calendar days. The new codes however solve the problem.

Prior guidance for these 'extended' observation and middle day observation stays created some confusion and led to different policies such as the Spring 1993 edition of CPT Assistant, which instructed coders to “use the unlisted evaluation and management service code to report these services."

However, when setting policy on 'middle day' observation coding, payers often took their own path. They would often call for 99499; but then some carriers preferred 99231-99233 or 99211-99215. Technically speaking, observation codes are outpatient codes.

But be ready for disappointing reimbursement. Physicians and coders who were excited about the new subsequent care observation codes will not be too happy when they hear the accepted payments for these codes. The Relative Value Update Committee had compared this year's codes 99224-99226 for subsequent observation care to subsequent hospital care and had requested the same work value. However, the Center for Medicare disagreed with the proposal.

You should focus this time clarification in your CPT 2011 manual. All that fine green print on time in your evaluation & management CPT 2011 manual comes down to one thing: you can round to the closest time code. However that advice from CPT is quite opposed to Medicare's threshold time guideline. This year's CPT tells you that you can use the code closest to the documented time. This advice is nothing new. In choosing time, the doctor must have spent a time closest to the chosen code, according to CPT Assistant, Aug 2004.

For further CPT details and for other information relating to CPT Assistant, sign up for a one-stop medical coding guide like Supercoder. This site comes with a CPT Assistant Code Connect for just $199.95 to help your understanding. In fact, the site offers 20 years of CPT Assistant articles and reader questions linked to every applicable CPT code.  Source URL :- http://www.supercoder.com/coding-newsletters/my-orthopedic-coding-alert/cpt-2011-99224-99225-99226-solve-middle-day-code-dilemma-103938-article

Strategies for Reporting E/M Services & Minor Surgical Procedures Using TP RULES

Want to ensure your ob-gyn gets paid for E/M services and minor surgical procedures performed in a teaching setting? Well you can ensure it so long as you know the requirements for Medicare's teaching physician rules.

Here are some sure-fire strategies for reporting E/M services and minor surgical procedures using the teaching physician rules.

a) You should report outpatient services based on 'key portions'. Think that the TP provides an E/M service such as an office visit (99201-99215) without the resident present. The TP may be able to use some of the resident's work under TP guideline.

Here's how: If the resident also carried out the E/M service the TP carried out, your ob-gyn would have to duplicate the 'critical and key portions' of the resident's services to bill under this guideline. The TP should define and be able to defend those critical and key portions.

b) You should ensure resident's presence for evaluations

If the resident didn't attend the TP's patient evaluation and also did not carry out a complete evaluation and management service, the TP must bill and document the office visit as he would in a nonteaching setting. To put it in other words, to support a 99202 claim, the ob-gyn would have to document an expanded problem-focused history, an expanded problem-focused exam, and straightforward medical decision-making.

c) Thirdly, you should document ob-gyn presence for critical care. Documentation requirements for the claims are high however an ob-gyn can also code when he and the resident perform critical care jointly.

d) You should also let supervision guide surgical claims. When you report minor surgeries and endoscopic procedures, you should ensure the ob-gyn documents that he directly supervised the entire procedure. That means the physician must be present in the room. For instance, he cannot view the session through a monitor in another room.

e) You should keep the primary-care exception in mind. If your ob-gyn is also treating a primary-care clinic patient, you might be able to use the primary-care exception rule.

To put it in a nutshell, Medicare allows a TP to get paid when a resident provides an E/M service without the TP's direct supervision. These cases must fall under the MCM's primary-care exception, which refers to E/M new patient codes 99201-99203 and established patient codes 99211-99213.

For further details on which modifier to use for primary care exception and for other ob-gyn coding updates, sign up for a one-stop medical coding guide like Supercoder.com "http://www.supercoder.com"

When to Use 'Uncertain Behavior Diagnosis Code'?

You may be in for a great loss if you always use diagnosis code 238.2 while reporting 11100 for a biopsy procedure your surgeon performs. The best way to know when to use the 'uncertain behavior' diagnosis code is understanding what that code descriptor really means.

Here are some expert tips to ensure you are zeroing on the correct diagnosis code for all your 11100 claims:

a) If your general surgeon carries out a biopsy, make it a point to wait until the pathology report comes back to select the proper diagnosis and procedure codes to report – even though this will not always affect the CPT code you'll wind up choosing.

Here's why: The biopsy specimen's pathology will have a say on the ICD-9 code you report. However, most CPT procedure codes are not based on the specimen results. There are certain CPT codes which are linked to some specific diagnoses; however in totality CPT is about what you did; while ICD-9 is about the outcome or the reason for it.

You should know the Meaning Behind 'Uncertain' Codes when you code 238.2 as the diagnosis for a biopsy procedure, you're conveying to the payer what the pathologist said in his path report that he was uncertain as to the morphology of the lesion. Uncertain behavior does not mean that the coder is uncertain or that the doctor thinks the lesion looks suspicious but it might be benign. By Uncertain behavior we mean to say that a specimen has been examined by a pathologist and that the cells are of mixed types.

How it functions: Uncertain behavior diagnoses are proper for specimens identified as hyperplastic (hyperplasia) or precancerous. If you submit a claim with 238.2 as a diagnosis before you have the pathology report back, you may have in actuality told the insurer that the patient has a disease process that he doesn't actually have or may have however has not yet been corroborated. If you aren't sure as to what a lesion is, you use unspecified, not uncertain. Uncertain is reserved for a pathologist only diagnosis.

b) Secondly, you should never code just to ensure you will be paid for a procedure. In an instance of a biopsy, waiting to code until you have the pathology report shouldn't have a say on your reimbursement amount anyway. You may have to wait for some more time to see the reimbursement if you need to hold a claim while you wait for the pathology report; however your coding will be much more spot on.

If you biopsy a lesion and the results come back as precancerous this is exactly the diagnosis you'd use so it's a perfectly payable diagnosis. On the contrary, insurers are looking for more and more reasons to deny payment. If you had carried a biopsy and indicated that the patient has hyperplasia and then the doctor found out that the biopsy indicated melanoma and the patient returned to have excision of the melanoma and the insurer ever compared the documentation there could be trouble.

For more on this and other information relating to ICD-9 codes, sign up for a one-stop medical coding guide like Supercoder.
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Use 69610-RT for More Complex Procedure

In a particular situation, my physician evaluated the patient's right ear and cleared the canal of all cerumen. The tympanic membrane was visualized and had retained a tube. The physician removed a tube in the anterior superior aspect of the eardrum with a Rosen needle. He removed an epithelial callus around the tube site with a Rosen needle. Also Ciprodex was applied. After this, a paper patch was then placed in an overlay technique and positioned using the operative microscope. Post this the physician went to the left ear and removed some dry debris. He removed an extruded tube and there was no perforation in situ. He debrided the canal and applied Ciprodex. So how do you code for this situation?

Well, first you should code the more complex procedure with 69610-RT (Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch; Right side).

Stay away from these options: you can't code for the binocular microscope (92504) as it's a separate procedure and inclusive with any other ear procedure carried out. Likewise, the removal of impacted cerumen (69610) is also a separate procedure, and insurers consider it inclusive with any other ear procedure. What's more, if the carried out this service in the operating room, you can't report 69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) as even though the physician used the operating microscope, coding 69990 requires the use of microsurgical technique. These procedures do not have any evidence of microsurgery.

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

Typically, if an otologic procedure needs a transcanal or endaural approach with incision of the tympanic membrane and access through the middle ear and tympanic membrane procedures, you shouldn't report it separately. But then your physician carried out these services on two ears and should be paid for them as separate procedures.

Here's what your claim should look like: 69610-RT, 69424-59-LT or 92504-59-LT depending on the type of anesthesia the physician used.

For further details on ways to tackle this scenario and for other medical coding updates, sign up for a one-stop medical coding guide like Supercoder. Onboard such a site, you will also get a Physician Coding Bundle that comes packed with the most powerful physician coding tools to give you everything you need to fight denials under one roof.

Gear Up Your Ambulatory Surgical Center for ICD-10

Deferring your ambulatory surgical center ICD-10 learning for a later date? Well, CMS thinks it's high time you took your preparation seriously. The ICD-10 implementation does not mean you just need to get yourself a new coding manual; it includes changes that should be started as soon as possible.

There's no denying that a lot of practices have tucked ICD-10 preparedness into the back of their minds, CMS wants to keep it on the forefront of yours. Keeping this in mind, the agency has come up with a free service that allows you to get an email notification whenever the information on its ICD-10 page gets updated. So the next time the agency announces an ICD-10 webinar, transcript, article or tip sheet, you will get instant notification via email.

The site had some time back posted an executive summary of its ICD-10 vendor conference where vendors told the agency that they have implemented plans in place for both Version 5010 and ICD-10 and are quite sure that they can meet the implementation guidelines. However vendors did show their concern that there is no testing period for ICD-10 prior to October 1, 2013 deadline.

In this direction, vendors were keen on listening to what the payers are doing to get ready for ICD-10 as any mistake on the part of the MAC could slow payments to practices.

In addition, vendors noted that medical providers, more particularly those in small to mid-sized practices – are not training eyes on ICD-10 as yet; but then the vendors think that providers should get ready for the transition because if you don't comply, you'll not get your rightful reimbursements.

Remember: While training your ambulatory surgical center staff working with diagnosis coding in any form, consider the following:

Key players – be it physicians, business office support-coders, billers, collections/denials)

Extent of training

Method of training

Continuing education

For more ways to keep your ambulatory surgical center up to date with ICD-10 and for other ASC coding updates, sign up for a one-stop medical coding guide like Supercoder. Such a site comes with a tool - ASC Authority – to help you keep your ambulatory surgical center compliant and capturing all allowed procedures.

ASC authority features more than 20 details of HCPCS codes, Ambulatory Payment Classification codes, and Fee Schedule facts all in one page. To top it all, the ICD-10 Bridge will help your ambulatory surgical center make the right transition from ICD-9 to ICD-10.

Tips To Get Proper Payments for Your Hemoccult Test Coding

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

Well, you should assign two codes that you can use for post digital rectal exam (DREs) and consecutive specimen collection: Since 2007, CPT has assigned two codes that you can use for post digital rectal exam (DREs) and consecutive specimen collection: 82270 and 82272.

From January 1, 2007, CPT has terminated HCPCS code G0107 and replaced by 82270 even for routine Medicare screening FOBT.

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

You should ask the reason for the test. 'Why' is the keyword that can lead you to the proper CPT for FOBT; therefore do not hesitate to find out why your gastroenterologist has ordered it. If the test is for screening purposes, then you should report 82270. The ICD-9 code for screening hemoccults should be V76.51.

Do not forget: There are interval limitations for screening established by Medicare and most commercial carriers. On the contrary, if a patient presents to the office with symptoms, the gastroenterologist would carry out a diagnostic FOBT, and you should bill it with 82272. CPT 82272 can be billed if 1 to 3 specimens are obtained. The diagnosis code for the test would be related to the patient's presenting symptoms.

If you want to keep the money flowing for in-office examination of fecal occult blood test (FOBT), sign up for a one-stop medical coding guide like Supercoder.

Colon Motility & Manometric Studies: You've Got New CPT Codes

As a gastroenterology coder, there are a lot of changes you need to sort through this year.

This year, CPT put an end to your search for a code on colon motility by coming up with a new code for manometric study in addition to two revised codes for esophageal pH monitoring.

The new manometric study codes are 91117 and 91013. Code 91117 is just for the study itself, not for the same session with catheter placement. The radiologist may place the catheter in a procedure before and the gastroenterologist may come in and out to supervise the testing and any provocations that are carried out. Therefore, you should include the provocations in the study and report 97117 only once no matter how many times the testing is done.

You can go for 91013 in cases like assessment of the effect on the measured esophageal motility when the patient's esophagus is exposed to different stimulant liquids. This code is also applicable when intravenous medications are administered to try to produce symptoms. CPT 91010 is included in 91013 and wouldn't be billed separately.

Change the way you use 91034, 91035: Apart from 91117 and 91013, this year CPT revised esophageal pH monitoring codes to describe the site of attachment:

91034 -- Esophagus, gastroesophageal reflux test, with nasal catheter pH electrode[s] placement, recording, analysis and interpretation

91035 -- with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation

As per the revisions, 91034 is for the nasal approach where the catheter goes through the nose and down the patient's neck to the monitor. The patient walks around for 24 hours wearing the device and recording her symptoms of belching, pain, and the like. The device manufacturers figured a way to directly attach the device into the nose without having to have a catheter through the nose.

Apart from these, there are other revisions pertaining to your gastroenterology coding. For more on these and for other updates relating to your gastroenterology coding, sign up for a one-stop medical coding guide like Supercoder.

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Use Medicine Series Vaccine Administration with Counseling Codes On Older Patients

By now, we all are aware that CMS has created HCPCS codes (Q2035, Q2036, Q2037, Q2038, and Q2039) and payment allowances to replace 90658. Apart from this, you will be able to use medicine series vaccine administration with counseling codes on older patients and when a nurse provides the counseling, thanks to CPT 2011. Since counseling for adolescents can involve as much time as counseling on vaccines for younger children, the American Academy of Pediatrics suggested that the age limitation on the vaccine administration with counseling codes be raised. Just-in codes extend vaccine administration with counseling to patients through 18 years of age.

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

The just-in administration with counseling code extend the counseling opportunity to any "qualified health care professional" practicing within his/her state described scope of practice. An RP, LPN or medical technician could provide the counseling and the practice could still use the vaccine administration along with counseling code.

On a concluding note, you should remember the just-in administration codes - 90460 and 90461 are per vaccine/toxoid component. This means that if your doctor provides counseling and administration for a combination vaccine such as MMR, you will report 90460 for the first component and 90461 for each additional component. In the MMR example, you'd code 90460 once and 90461 twice. You'd report only a single vaccine administration code for a combination vaccine irrespective of the number of components prior to this year.

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


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CPT 2011 Brings Two New Codes for Diabetic Foot Ulcer Treatment

CPT Codes 76881

This year, CPT comes with two new codes to report diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity - G0440-G0441. You will have to use temporary G codes when reporting diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity for a Medicare beneficiary in 2011.

CPT introduced G0440 and G0441 to put an end to the confusion providers put forth the different global periods for two tissue cultured skin substitute codes.

This year, for your ultrasound coding, you can bid 76880 good bye as CPT 2011 deletes this code. In its place, you can use two new CPT 76881 and 76882. A complete procedure (76881) includes real time scans of a specific joint that covers examination of the muscles, tendons, joint, other soft-tissue structures, and any identifiable aberration. A limited study (76882) involves examining the extremity where a specific anatomic structure such as a tendon or muscle is evaluated. You'd also report 76882 to assess a soft-tissue mass that may be present in an extremity where knowledge of its cystic or solid characteristics is called for.

Bear in mind: When the podiatrist carries out spectral and color Doppler evaluation of the extremities, you should use the proper code (93925-93926, 93930-93931, 93970 or 93971) in association with 76881 or 76882. In the meantime, CPT 2011 revises and revalues codes for non-invasive physiologic studies of the upper or lower extremity arteries: 93922, 93923, and 93924.

This year you'll find 93922-93924's code descriptors clearly differentiating between a limited study and a complete bilateral study, with additional instructions on how to report these codes properly.

Now you will never have to worry about choosing between a debridement code and an active wound code. This year's CPT revises debridement code guidelines to clarify the confusion. Depth is the only documentation item you require to figure out the correct code. Active wound care, which has a 0 day global period, refers to active wound care of the skin, dermis, or epidermis. For deeper wound care, you should go for debridement codes in the appropriate location.

Say for instance codes 11040 and 11041 have been axed. The parenthetical note under the codes' deletion says, for debridement of skin, that is, epidermis and/or dermis only, go for 97597 and 97598."

For further details on this and for other CPT 2011 coding guidelines, sign up for a one-stop medical coding guide like Supercoder.

CPT Changes Pediatric Critical Transport Code Bundles This Year

This year CPT brought a whole new crop of bundles with pediatric critical care and transport services. As a matter of fact, CPT went retro with pediatric critical care transport codes 99466-99467, reverting the bundles back to the 2007 rules.

CPT 2011 has changed which services are bundled into critical care codes 99291-99292 based on whether a facility or professional reports the services. In addition, CPT has returned the list of services bundled into 99466-99467 to the bundles that were in effect as of 2007.

This year, the following services are included when carried out during the pediatric patient transport by the physician providing critical care and may not be reported separately: Routine monitoring evaluations, interpretation of cardiac output measurements (93562), Chest x-rays (71010-71020), Pulse oximetry (94760-94762), Blood gases and information data stored in computers (for instance, ECGs, blood pressures, hematologic data - 99090), Gastric intubation (43752-43753), Temporary transcutaneous pacing (92953), Ventilatory management (94002-94003, 94660-94662), Vascular access procedures (36000, 36400-36406, 36415, 36591, and 3660

Critical care: In the present year, pediatricians from your practice will still face the following services as being bundled into critical care: interpretations of cardiac output measurements, chest xrays, pulse oximetry, blood gases, information data stored in computers, gastric intubation, temporary transcutaneous pacing, vent management, and vascular access. But then, facilities will be able to report these services separately from critical care and will not face the bundles.

Bear in mind: This means that you can report the critical care code ( Source "http://www.supercoder.com")only, even if the facility is reporting the critical care codes in addition to the separate x-rays, intubation, and other services separately.

You should not report new observation care codes with other E/M service. CPT 2011 adds 99224-99226 as far as coding subsequent observation care is concerned. Even though confusion surrounded these codes when CPT first debuted, recently some rules have come to light on how you can report them.

When to bill: Subsequent observation care starts after the initial observation care DOS.

In addition, you should not report subsequent observation care on the same date as initial observation care codes (99218-99220), nor can you report observation services on the same date as office or emergency department services. What's more, you cannot report the new subsequent observation codes on the same date as observation care discharge (99217).

Twin delivery claims: Submit picture perfect claims

If you thought you can report a twin caesarean delivery with the help of 59510 with modifier 22 attached, think again as this may not be the case always. You will need to adjust your twin delivery reporting as per the insurance company's preference.

Here are four tricky twin delivery situations to help you in your coding:

When it comes to patients having twins, most ob-gyns first attempt a vaginal delivery as long as the physician has not identified any complications.

In this instance, you should report 59400 for the first baby and 59409-51 for the second.

Remember: Both CPT and the American Congress of Obstetricians and Gynecologists (ACOG) recommend you use modifier 51 for the second delivery. But you may encounter some payers who want to see modifier 59 instead. Other coders report adding modifier 22 to the global delivery (59400) if the patient had more than the average of 13 visits and to account for the second delivery in cases where the payer does not permit separate billing for the additional delivery. When this instruction is in writing, you should follow it.

Best bet: Send a letter of explanation with the claim to avoid immediate denial by the claim processor. A simple form letter explaining the high-risk nature of multiple-gestation pregnancies will routinely go straight to medical review and save the trouble of denial resubmissions or lost reimbursement through write-offs.

First delivery is vaginal, second is Cesarean. If the doctor delivers the first baby vaginally however the second through Cesarean, assuming he provided global care, go for 59510 for the second baby and 59409-51 for the first. You should report 651.01 with V27.2 as diagnoses.

For the second twin born by cesarean, go for more ICD-9 codes to explain why the ob-gyn had to carry out the cesarean.

All cesarean deliveries. When the doctor delivers all of the babies, whether twins, triplets, and the like by cesarean, you should submit 59510 with modifier 22 added. Since the ob-gyn made only one incision, he carried out only one cesarean, however the modifier shows that the doctor carried out a significantly more difficult delivery due to the presence of multiple babies. This can depend on the carrier too. Also ensure that you include a letter with the claim that outlines the additional work that the ob-gyn carried out to give the carrier a true picture of why you are asking for additional reimbursement.

Babies coming on different days. Once in a while, multiple-gestation babies will be born on different days. For instance a patient is at 38 weeks gestation and carrying twins in two sacs. While one membrane ruptures, the ob-gyn delivers the baby vaginally. After two days, the second ruptures, and the second baby delivers vaginally as well. In this instance, you should report the first baby as a delivery only (59409) on the DOS. You shouldn't bill the global first because you are still offering prenatal care due to the retained twin. You'll have to attach a letter explaining the situation to the insurance company.

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

Unlisted Procedure Coding: Boost Your Chances Of Payment

You shouldn't choose a CPT code that merely approximates the service provided. This rule is important for compliant coding, however it leaves you with the tough job of submitting a claim without a procedure-specific code. Boost your chances of getting the payments by heeding these advice: You should suggest a proper fee for the service
 
Since unlisted procedure codes don't appear in the Medicare Physician Fee Schedule, they don't have assigned fees or global periods. Your payers will normally determine payment for unlisted procedure claims based on the documentation you provide.
 
You can suggest a fee by making a comparison of the unlisted procedure to a similar, listed procedure with an established reimbursement value. Experts say it helps put your service in perspective with something reviewers are familiar with. 

But the best choice would be: Rather than leave it up to the insurer to figure out which code is the nearest to what your physician carried out, you should explicitly make reference to the nearest equivalent listed procedure. In any case, the treating physician is well-equipped to make this determination. 

Inform the carrier how the procedure you are coding for compares to and differs from the assigned procedure code.  

You should answer these questions: 

a) Was the unlisted procedure more or less difficult than the comparison procedure?
b) Did it take more time to complete; and if it did by how much?
c) Was there a greater risk of complication?
d) Will the patient need a longer recovery and more postoperative attention?
e) Did it call for special training skill or equipment?

You should not let denials go without appeal 
 
This is a known fact that even the best documentation will not always get the payment your radiologist deserves for an unlisted procedure. If the payment isn't proper, you may need to appeal. Make an effort to find out where your unlisted claim is going. See to it that you get the name and department so that you can follow up on your request. 


What you should do: When your radiologist over and over again performs the same type of unlisted procedure, prepare an information file so you do not have to reinvent the wheel every time you submit a claim. Each time you are denied a similar claim, you'll already have an appeals packet ready to send the payer to defend your claim.

Tactics to Stay Away From Irrational Denials

Your steps in fighting for your claim could make or mar your practice's chance for a fair reimbursement.

Sometimes you may be in a situation where you wanted to contest a denial by an insurance company based on irrational payer guidelines. There's no doubt that it may seem like trying to break down a stone wall, however you are not helpless to change the situation to your favor.

As such what can you do here? Your steps in fighting for your claim could make or mar your practice's chance for a fair reimbursement. But then the insurance company can set any rules it wants and you are forced to play by them when your doctors sign the contracts. Nevertheless, you can still walk past the barriers by following these tactics.

The first and foremost thing you need to do is to get a copy of your contract and see what degree of latitude your payer can take relative to AMA and CMS coding rules. If the insurer is violating what's set forth in the contract, use the contract in your appeal to fight this arbitrary policy and get it overturned.

If the contract is silent on this or allows such arbitrary use of rules in favor of the payer, you should gear up to drop the payer as one of your participating payers. Do not get jittery – be all set to drop them in this stage.

Third, conduct a meeting between your physicians and the medical director. Enquire the medical director to justify this policy in clinical terms as to why the insurer doesn't reimburse a physician for the diagnostic colonoscopy and the removal of polyps when you apply modifier 59 (Distinct procedural service) to indicate different sites. Enlighten on the fact that breaking the colonoscopy and the biopsy into multiple sessions will make the payer incur multiple facility fees, multiple anesthesia sessions as well as the physician professional fees.

Annual Visit Codes: Physicians Should Document Certain Elements

medical coding reource, radiology coding

You shouldn't choose a CPT code that merely approximates the service provided. This rule is important for compliant coding, however it leaves you with the tough job of submitting a claim without a procedure-specific code. Boost your chances of getting the payments by heeding these advice:

You should suggest a proper fee for the service

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

You can suggest a fee by making a comparison of the unlisted procedure to a similar, listed procedure with an established reimbursement value. Experts say it helps put your service in perspective with something reviewers are familiar with.

But the best choice would be: Rather than leave it up to the insurer to figure out which code is the nearest to what your physician carried out, you should explicitly make reference to the nearest equivalent listed procedure. In any case, the treating physician is well-equipped to make this determination.

Inform the carrier how the procedure you are coding for compares to and differs from the assigned procedure code.

You should answer these questions:

a) Was the unlisted procedure more or less difficult than the comparison procedure?

b) Did it take more time to complete; and if it did by how much?

c) Was there a greater risk of complication?

d) Will the patient need a longer recovery and more postoperative attention?

e) Did it call for special training skill or equipment?

You should not let denials go without appeal

This is a known fact that even the best documentation will not always get the payment your radiologist deserves for an unlisted procedure. If the payment isn't proper, you may need to appeal. Make an effort to find out where your unlisted claim is going. See to it that you get the name and department so that you can follow up on your request.

What you should do: When your radiologist over and over again performs the same type of unlisted procedure, prepare an information file so you do not have to reinvent the wheel every time you submit a claim. Each time you are denied a similar claim, you'll already have an appeals packet ready to send the payer to defend your claim.

For more tips to boost your chances of getting paid and for other specialty-specific articles to assist your radiology coding, sign up for a good medical coding resource like Supercoder.com

Tips for Spot-On Well-Woman Coding

In order to report a well-woman exam correctly, you need to be aware of two important concepts: How Medicare and private payers' guidelines differ, and when you should code breast/pelvic exams and Pap smears separately.

Want to know more about well-woman coding? Take a look at these quick tips:

Break out services for Medicare

First, if the ob-gyn provides a complete well-woman exam for a Medicare patient, you should use G0101 for the breast and pelvic exams, and bill the patient for the non-covered part of the exam using 99387 or 99397.

When the doctor also gets hold of a Pap smear, use Q0091. Bear in mind that you can also report a new or established patient evaluation & management code (99201-99215) apart from G0101 and Q0091 if the doctor addresses significant problems at the time of the well-woman visit.

However the doctor must have documented a separate and distinct evaluation & management service and you must add modifier 25 to the evaluation & management code. For instance the doctor carries out the well-woman exam but also evaluates and manages the patient's ongoing dysfunctional uterine bleeding.

Remember that for Medicare patients at normal risk, you can report a Pap smear once every two years. The diagnoses your doctor will use in these instances include V72.31, V76.2, V76.47 or V76.49.

And when your coding system changes in year 2013, you will report the following equivalents: V72.31 = ZØ1.411, V76.2 = Z12.4, V76.47 = Z12.72 and V76.49 = Z12.89.

Stay away from high-risk coding

You can bill the Pap smears annually if the patient is high-risk. In order to classify a patient has high-risk, you will have to report V15.89 for medical justification of a screening Pap smear.

Secondly, you should rely on CPT codes for private insurers

Even though most commercial payers follow Medicare's lead when setting coding policies, many accept neither G0101 nor Q0091 for well-woman visits. This is owing to the fact that Medicare codes only include a physical examination however don't cover history or counseling. In those instances, you may use one of CPT's preventive-medicine codes (99381- 99397), as per your payer's policies.

Tip: The right preventive-medicine code depends on whether the patient is new or established, and the patient's age.