Everything your Ob-Gyn Practice Needs to Know about PQRS and eRx

If your Ob-Gyn practice is not taking part in both the PQRS and eRx programs, you could be facing penalties and missing out on hard-earned money. 

And even if you’re participating, you need to be well-versed with the latest updates. You can avoid the adjustments and take advantage of the incentives the CMS provides for e-Prescribing if you have sound understanding of eRx Incentive Program, hardship exemptions and payment adjustment exclusions, how to submit a hardship exemption request, and other aspects of e-prescribing!

At present, only about one in five health care professionals who can participate in the PQRS do so. Even though participation in both the programs is non-compulsory, providers who are able to take part in these programs but opt not to, will receive payment reductions from Medicare in the coming years.

To ensure your payments don’t get slashed, you can tune in to a FREE webinar on The Ins and Outs of Physician Quality Reporting and E-Prescribing for Ob-Gyn by coding expert, Melanie Witt, RN, CPC, COBGC, MA.

This 60-minute webinar will help you clear all your E-prescribing doubts. In the webinar, you’ll

·         Find out where you can get the latest updates and information on the programs to ensure successful participation.

·         Figure out which reporting period and data submission method is best for your practice as CMS offers more than one method 

·         The claim examples in the webinar will make everything easier for you

·         Learn which quality measures you can quickly adopt for easy reporting every time

·         Learn why getting into the habit of reporting quality measures now may enhance your practice’s value to commercial payers as they are eyeing the agency’s progress with PQRS and E-Rx programs

All this and a thousand other e-prescribing tips for no cost at all. Visit this link to register for this FREE webinar. http://www.supercoder.com/exclusives/webinars

Learn How to Code Nitroglycerin Injections and Brace Rx Management Documentation

Use 37202 for Nitroglycerin Injections

Question: Can you charge for nitroglycerin injections x 2 when carrying out a right posterior tibial angioplasty as well as right peroneal angioplasty? If so, which codes do you use for the full service?

Answer: You are not supposed to separately code nitroglycerin injections in catheter services for accurate CPT coding. The injections are a normal part of the procedure and must not be reported with their own codes.

Caution: Some coders wish to report 37202 (Transcatheter therapy, infusion other than for thrombolysis, any type [e.g., spasmolytic, vasoconstrictive]) for these nitroglycerin bolus injections. However, you must reserve 37202 for "prolonged infusions into peripheral arteries," as per CPT® Assistant (April 1998).

For the right posterior tibial and right peroneal angioplasty CPT coding, you should report 37228 (Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty) for one vessel and +37232 (Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty [List separately in addition to code for primary procedure]) for the second vessel.

For CPT coding purposes, CPT® counts the posterior tibial as well as the peroneal as separate vessels in the same vascular territory. So you may report every single intervention in this case separately.

Strengthen Rx Management Documentation

Question: Is there a specific code for writing a prescription?

Answer: As per CPT coding , writing prescriptions are a part of an E/M service. This is just part of the cost of seeing patients, much similar to office supplies. There is no particular code that payers will reimburse for writing a prescription.

Note: In case you review the Table of Risk in the 1995 or year 1997 E/M Documentation Guidelines, you'll see "Prescription drug management" designated as "Moderate" level of risk under "Management Options Selected." This is how prescription drug management can affect your E/M level.

Best possible practice is for the provider to document prescription's actual management. For instance, in case the cardiologist renews a cholesterol-related prescription, the plan of care may maintain that the patient has been bearing the present dosage well and it is keeping her numbers where they are required to be, therefore the physician is now renewing the prescription. As another instance, the physician may state that she's selecting a specific cardiovascular drug as it is safer in combination with the patient's diabetes medication.

Medical Coding and Billing Tip: ICD-9 includes V68.1 (Issue of repeat prescriptions), however you shouldn't report V68.1 with an E/M code in case the only cause the patient comes in is to pick up a prescription. Without face-to-face time and an actual evaluation and management service, you must not bill an E/M code.

Carefully Read Your Botox Treatment Report

HCPCS Code J0585

Don't oversee 5 documentation essentials -- including sites and number of units.

While a dermatologist treats blepharospasm (the uncontrollable contracting of eyelid muscles) with Botox, grab one of those J codes and combine it with a chemodenervation procedure. As long as you get the coding process going smoothly -- which means submitting the right documentation and reporting the right combination of codes -- you'll avoiding your medical coding and billing challenges easily.

For such a distinct application of ophthalmic reconstructive surgery, you must use 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) along with J0585 (Injection, onabotulinumtoxinA, 1 unit). Bill J0585 per total units used, not per eye.

Reporting HCPCS code J0585 or J0587 (Injection, rimabotulinumtoxinB, 100 units) has not been a reimbursement hassle, as long as you bill them properly with the drug being paid. More to the point, a lot of practices around the country have used them successfully without any trouble.

Draw the line: Append modifier JW (Drug amount discarded/not administered to any patient) to HCPCS Code J0585 to specify wasted Botox supply. Though, do not use it for claims billing while the drug code description already includes the amount administered and the amount wasted.

Learn Guidelines to Your Advantage

You must peruse your physician's chart note, which must involve:

• a diagnosis that essentially supports medical necessity, and
• a notation that the patient has been unresponsive to conventional techniques (such as medication and physical therapy) of controlling and/or treating spastic circumstances.

Good idea: In addition, physician must not miss some vital details in the documentation, particularly:

• Number of injections: Keep in mind that every injection site for spasms may need multiple units of botulinum.
• Injection sites and units injected at each site: The payer will reimburse for simply one injection code per site irrespective of the number of needle passes made into the site (being defined as a single contiguous body part -- for instance, the eyelid or elbow -- excluding when the procedure is bilateral). Correct documentation of multiple or complex injections can support and warrant additional reimbursement.
• Amount of medication wastage; and
• Results/response to the injections.

Your dermatologist's documentation is important, even at the E/M visit level. As far as the visit goes, you can make up a form, questionnaire-type flow sheet. It hinges on the cosmetic procedure as to what sorts of questions you wish to ask. We have dissimilar medical coding and billing questions for Botox versus laser versus surgery procedures. Always keep in mind your ABN in case reporting cosmetic procedures on Medicare patients.

These references must guide your practice to a accurate accounting of what takes place in the procedure, and consequently help you with medical coding and billing the procedure.

Watch Your Number of Treatments

Treatments may be continued lest any two consecutive treatments with the correct or maximum dose failed to produce a satisfactory clinical response. It is usually not considered medically necessary to give botulinum toxin type A injections for spastic or excess muscular contraction conditions more regularly than every 90 days.

Know What Modifiers You Must Select In This Turb-Post-Op OV Scenario

Question: A patient who is coming back for follow-up after unilateral endoscopic maxillary antrostomy with tissue removal and turbinectomy complains of a cough and fever. The otolaryngologist assesses and manages the problem and also carries out endoscopic sinus debridement on the patient. What modifiers do you need to report the encounter?

Answer: As the unrelated office visit as well as a staged debridement (planned staging for the endoscopic maxillary antrostomy) took place during the turbinectomy's 90-day global period, you will be required to use modifiers 24 (Unrelated evaluation and management service by the same physician during a postoperative period) with the EM service and modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) with the debridement. To show the E/M is a important and separate service from the debridement, you will also use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Generally, you would not charge an E/M service that takes place within an active postoperative period. But as the otolaryngologist carries out the E/M service for a problem that is unrelated to the turbinectomy you must bill the office visit appended with modifier 24 for accurate medical coding and billing.

You must also use modifier 58 with the debridement code (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). Modifier 58 specifies that the otolaryngologist carries out a procedure -- debridement -- that is a planned staged procedure related to the therapy and healing to attain the desired results from the maxillary antrostomy.

The scenario's same-day service and procedure necessitate modifier 25 as 31237 is a minor procedure, which has a built in mini EM service. You would usually include a minor related E/M service with the debridement. But as the otolaryngologist in your example carries out an important and separate service from the debridement, you must also report the office visit (9921X, Office or other outpatient visit for the evaluation and management of an established patient …) appended with modifier 25.

Medical Coding and Billing Tip: Although the patient requires debridement because of sinus surgery, the antrostomy does not make global surgery modifiers necessary. Functional endoscopic sinus surgery (FESS) codes involving 31267 contain zero global days. Once a non zero global day surgery (such as 90 days) is carried out with the zero global day FESS surgery, that entire surgical encounter gets the longer global attached to it for the total time the longer global exists (such as the full 90 days).

Your ICD-9 coding must demonstrate the office visit's separate nature from the debridement as well as the turbinectomy. Different diagnoses will tell the insurer that the otolaryngologist assessed and managed a significant and separate problem from the day's procedure (31237) and that the problem is not related to the active postoperative period created by the turbinectomy. The debridement also must only have the maxillary sinusitis (473.0) associated with it, as it is staged to the 31267 and not linked to the the turbinectomy.

Here's how: You must link the definitive acute diagnosis, for instance upper respiratory infection (465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site), to the E/M code. For the debridement, use the suitable sinus surgery diagnoses, for instance chronic maxillary sinusitis (473.0).

The claim could read:
CPT codes ICD-9 codes
9921X-24-25 465.9
31237-58 473.0


ICD-10: When your diagnosis coding system changes in 2013, you will use J32.0 (Chronic maxillary sinusitis) instead of 473.0. Instead of ICD-9 coding option 465.9, you'll report J06.9 (Acute upper respiratory infection, unspecified).

CPT 17110: Destruction of Molluscum Contagiosum or Plantar Warts and Plasma Ablation

CPT 17110

Code for Destruction of Molluscum Contagiosum or Plantar Warts

Question: What code is used to bill for destruction of molluscum contagiosum or plantar warts?

You can use CPT codes 17110 and 17111 for destruction of common or plantar warts. The codes 17110 and 17111 have been revised to co destruction of benign lesions other than skin tags or cutaneous vascular lesions. Coders are no longer supposed to use CPT codes 17000 and 17003 for destruction of warts or molluscum contagiosum, as these codes now do not include destruction of benign lesions.

In case the physician destroys one to fourteen warts (or molluscum), then you code CPT 17110. Keep in mind that you should only code 17100 once, even if the physician has destroyed fourteen lesions.

In case the physician destroys fifteen or more warts (or molluscum), then you should code17111. Even in case the physician destroys thirty-five warts, it is suitable to only use the code 17111 a single time.

Formal definitions of the codes are as follows:

• CPT 17110 – (Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions)
• CPT 17111 – (15 or more lesions)

CPT 17110 Definition Includes Plasma Ablation, Too

Question: Your gastroenterologist treats a patient who has a gastrostomy tube. The op note specifies that the patient has "some issues with granulation tissue at the stomal site that gets irritated and bleeds." The physician carried out"argon plasma photoablation of granulation tissue at stomal site." Can you use CPT 17110 even though its descriptor says nothing about plasma ablation?

Answer: Certainly. You should use 17110 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) for the procedure. Link that to a diagnosis of 701.5 (Other abnormal granulation tissue).

Even though CPT 17110 doesn't specifically mention plasma ablation, the wording doesn't discard it completely, either. Gastroenterologists generally use argon plasma coagulation -- jet of ionized gas -- to treat bleeding inside the body.

The following otolaryngology medical coding and billing case samples help you in getting cleaner claims.

Use HCPCS Code for Cerumen Removal Prior to Test

Question: You've lost an appeal on CPT 69210 being billed on the same day as 92567. You're told "the rationale for upholding the denial is: CPT code 69210 is incidental to CPT code 92567 and this code is not separately reimbursed per the ERM, CMS and Encoder Pro. In addition, modifiers are not allowed."

Answer: There's a distinct HCPCS code just for this situation. When your physician does away with impacted earwax so your audiologist can carry out diagnostics, you report G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing).

That's assuming that your physician is getting rid of the earwax separate from the audiologist testing. Medicare will not pay for an audiologist to remove ear wax; CPT 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) is a surgical code. Medicare's policy maintains that audiologists may only carry out diagnostic procedures, such as 92567 (Tympanometry [impedance testing]), never therapeutic (let alone surgical) procedures.

The Correct Coding Initiative bundles CPT 69210 to many audiological test codes (92552, 92553, 92555, 92556, 92567, 92568, and 92586, for example). Though, G0268 is not bundled with audiology services.

Take care: Code 69210 does not define "simple" impaction for instance one that might be addressed through irrigation. In case your physician or a medical assistant can flush the ear out to lessen the patient's symptoms, an impaction really never existed. In case the earwax is effortlessly removed, even with instruments, the procedure does not qualify for 69210. You must link 380.4 (Impacted cerumen) to 69210 to support medical necessity.

To qualify for CPT 69210 , the procedure must necessitate "substantial physician effort and require instrumentation" to eliminate the impacted cerumen, according to Medicare.

Ensure Pathologist Renders 'Uncertain' Dx

Question: What is the dissimilarity between coding a neoplasm of unspecified morphology and one of uncertain behavior?

Answer: Only a pathologist can render a diagnosis of uncertain behavior, for example 238.0 (Neoplasm of uncertain behavior of other and unspecified sites and tissues; bone and articular cartilage). "Uncertain behavior" means the pathologist cannot fully decide the morphology of the cancer. In a physician practice, in case you are uncertain as to what a lesion is as you're waiting for lab results, use an "unspecified" medical coding and billing diagnosis, for instance 239.2 (Neoplasm of unspecified nature; bone, soft tissue, and skin).

Accurately Report Pouchoscopy and Overcome Keofeed Reporting Confusion

Know How to Appropriately Report Pouchoscopy With Additional Procedures

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

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

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

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

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

Address the Keofeed Reporting Confusion

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

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

E/M on Time and EpiPen® Kit Pay

Base E/M on Time for Counseling/Coordination Only

Question: In case the physician documents: "Time spent in the evaluation of the patient with mostly medical decision making time (two thirds) is 75 min" can you choose the E/M code based on time alone?

Answer: No, you cannot code based on time with just the documentation mentioned above.

Here's why: You must only code for an E/M service based on time alone if no less than 50 percent of the visit was spent on counseling or coordination of care.

How it works: According to CPT manual, you can use the code closest to the documented time. If you are coding by time, choose the closest typical time.

Your documented time must be equal to or goes beyond the average time given to bill that level. For a 35 minute visit spent on a medically necessary counseling-dominated visit, according to CPT you could report medical billing code 99215 (Office or other outpatient visit for the evaluation and management of an established patient … Physicians typically spend 40 minutes face-to-face with the patient and/or family).

Tip: CPT maintains that "this includes time spent with parties who have assumed responsibility for the care of the patient or decision-making, whether or not they are family members (for example, foster parents, person acting in loco parentis, legal guardian."

Keep in mind that although the AMA, via CPT Assistant, directs you to code based on the "closest" time, maximum Medicare payers have always considered the times specified in CPT's code descriptors to represent minimums. Under those regulations, the physician would choose the lower medical billing code (for instance 99214, … physician typically spends 25 minutes face-to-face with the patient and/or family …) except the time was greater than or equal to the higher-level code's needed time (such as 40 minutes for 99215).

Seize EpiPen® Kit Pay With J0171

Question: You used the EpiPen® kit in the office for a patient who went through an allergic reaction to contrast dye. How do you bill for using this kit?

Answer: Use of an EpiPen® denotes an injection of epinephrine. As such, it would be suitable to code its administration using medical coding and billing codes 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) and HCPCS codes J0171 (Injection, adrenalin, epinephrine, 0.1 mg).

No History and RVU Order

Don't Assume Comprehensive Level If There is No History

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

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

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

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

Base Your Billing Order on RVU Order

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

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

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

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

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

Learn J3301 Billing and Know if Ability to Bill the Patient Expire

J3301

Generic vs. Brand Name Won't Alter Your J3301 Billing

Question: Your doctor is using Kenalog 40 (NDC 0003029328) from Bristol Meyers Squibb. He says HCPCS code J3301 is not the accurate code to bill as that is a generic code. Is there a different code to distinguish generics from non-generic when billing?

Answer: For Kenalog injections, you must use J3300 (Injection, triamcinolone acetonide, preservative free, 1 mg) or J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) for the Kenalog itself.

Pointer: Be wary of the code descriptors while reporting units. For HCPCS code J3300, you must report 1 unit per 1 mg. On the other hand, you must report 1 unit per 10 mg for J3301.

These are the codes you should use, irrespective of the company you get the Kenalog from. Kenalog is actually the brand name whereas the generic drug name is triamcinolone acetonide. The HCPCS tabular listing is decided by generic drug name. If you look up triamcinolone acetonide you'll see it lists HCPCs code J3300 and J3301 as the proper codes. The HCPCS drug table listing comprises brand name as well. When you search Kenalog it eventually refers you to triamcinolone acetonide.

Does Ability to Bill the Patient Expire?

Question: Is there a time limit on when you can bill a patient for their balance due after the insurance company processes the claim? For instance, in case the patient still owes a balance (according to insurance's allowed charges) after two or three years, are you able to still bill the patient?

Answer: There is no national regulation that restricts when you can bill a patient. You must check your state's laws, nevertheless, to make certain there is nothing specific to your area that places a time limit on when you can bill a patient. You should also check your payer contracts to be guarantee there is no requirement you have agreed to by signing as a participating provider.

Medical Coding and Billing Tip: Just for the reason that there is no time limit, that doesn't mean it is the best thing to bill a patient for the first time three years after she had a procedure or service. In case you upset a patient by billing her for the first time a long time after the service -- which possibly meant she believed she didn't owe anything for the reason that you had not sent a billing statement -- you may lose a patient and will probably have difficulty collecting the fee.

As per medical coding and billing experts, an unhappy ex-patient is right to tell anyone who will listen that your practice is bad news. She may even go ahead and complain to the state medical board and get you investigated for your business practices. You must consider the public relations effect of billing three years after a service.




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Diagnosis Coding for Post-LASIK Cataracts

Plus, learn that you should also give credit for time spent with patient

Dx for Post-LASIK Cataracts

Question: A patient who went through LASIK surgery now has cataracts. One of our ophthalmologists carried out topography for calculating the IOL power. The cataract diagnosis (366.16) is not listed as a covered code for that particular diagnostic service. Which ICD-9 coding option should you use for the topography?

Answer: Some payers accept V45.69 (Other states following surgery of eye and adnexa), specifying previous LASIK surgery, as a covered diagnosis for corneal topography. Though, some payers, for instance Cigna, require that V45.69 must be accompanied by ICD-9 coding option 367.22 (Irregular astigmatism). You must check with your payer to see in case it has such limitations.

Corneal topography is an alternate method for deciding IOL power in cases in which earlier LASIK surgery makes it problematic to use an A-scan or IOL Master. Report 92025 (Computerized corneal topography, unilateral or bilateral, with interpretation and report) for the test.

99214: Give Credit for Time Spent With Patient

Question: Your ophthalmologist spends a lot of time talking about treatment possibilities, imaging results, as well as other issues with patients. How is she ought to document this to support coding E/M based on time?

Answer: While counseling and/or coordination of care take up more than 50 percent of the encounter, and you select to code based on time, CPT®'s E/M ophthalmology coding guidelines tell you "the extent of counseling and/or coordination of care must be documented in the medical record." Medicare's 1995 and 1997 E/M documentation guidelines further add that the physician must document the total length of the encounter, how much of the total time was spent in counseling plus "describe the counseling and/or activities to coordinate care."

Remember: In the office or outpatient setting, you must count only face-to-face time that the physician actually spends with the patient. In the hospital or in a nursing facility, you may count floor/unit time, as per both ophthalmology coding CPT® guidelines and Medicare's documentation guidelines. CPT® guidelines define the encounter as a "physician/patient and/or family encounter."

Example: The physician may document spending 20 minutes of a 25-minute encounter with an established patient talking about test results (she should be specific when documenting the test results) and going over the likely outcome of a procedure. The physician then fills in the remaining details of the visit, as suitable. In this situation, based on the 25-minute session (total time), you should report ophthalmology coding CPT code 99214, which CPT® specifies as usually lasting 25 minutes:

• Office or other outpatient visit for the evaluation and management of an established patient, which needs at least 2 of these 3 key components (A detailed history; A detailed examination; Medical decision making of moderate complexity)
• Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient's and/or family's requirements. Generally, the presenting problem(s) are of moderate to high severity. Physicians normally spend 25 minutes face-to-face with the patient and/or family.

Fluoroscopy and RF Lesioning Code

Date of Service Guides Approval of 27096 with Fluoro

Question: Some of your payers deny 77003 when you bill it with SI joint injections in the same session. You realize the fluoroscopy is not any more payable with facet joint injections, however shouldn't you get paid for the SI joint injection?

Answer: Your first step in deciding whether you can bill the fluoroscopy and sacroiliac (SI) joint injection separately is certainly to check the date of service.

Effective Jan. 1, 2012, fluoroscopy is included with the SI joint injection, thus you can't bill for both procedures in the same patient encounter. Instead, you'll only bill medical billing code 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed). As the descriptor now states "with image guidance," you must not also report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid]). CPT® comprises the parenthetical note "Do not report 77003 in conjunction with medical billing code 27096…" specifying that fluoroscopic guidance used in performance of a SI joint injection is not separately billable. Furthermore, it would not be compliant coding to append modifier 59 (Distinct procedural service) to 77003 to evade the NCCI edits, in case the fluoroscopy was only used with the SI joint injection.

Choosing the Accurate RF Lesioning Code

Question: How do you code radiofrequency lesioning of the greater occipital nerve?

Answer: Review your physician's procedure documentation, as the accurate choice hinges on the mode of radiofrequency (RF) used to create the nerve lesion(s).

While she uses continuous RF to do away with the greater occipital nerve, report 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). In case she uses pulsed RF, though, CPT® directs you to medical billing code 64999 (Unlisted procedure, nervous system).

Explanation: Continuous (a.k.a. standard or thermal) RF therapy uses continuous radio wave energy to heat up nerve tissue to a point that it creates a destruction of the target nerve. This neurolytic lesioning reduces the patient's pain by interrupting the sensory nerve pathways.

On the other hand, pulsed RF therapy uses shorter continuous bursts of radio wave energy at much lower temperatures. Pulsed RF is not considered to be destructive; the technique "stuns" the target nerve tissue to stop it from transmitting pain signals rather than directly damaging the target nerve tissue.

Heads up: Certain payers now look at the provider's documentation for the temperature related to the RF. For instance, United Healthcare's coverage policy for Ablative Treatment for Spinal pain contains the requirements of "temperature 60 degrees Celsius or more and duration of ablation 40-90 seconds." Providers who cover this type of information in their documentation make correct medical coding and billing easier.

Initial NF Visit Billing and G8644

Keep Initial NF Visit Billing for the Physician

Question: You are receiving denial C0-170 (Payment is denied when preformed/billed by this type of provider) from Medicare when I bill for an initial nursing facility visit our physician assistant (PA) did. I am using place of service code 31 (Skilled Nursing Facility) as well as provider type 38 (Physician assistant). Why are you getting this denial?

Answer: You are not supposed to bill an initial visit in a skilled nursing facility (SNF) or nursing facility (NF) using 99304-99306 (Initial nursing facility care, per day, for the evaluation and management of a patient …) under a physician assistant (PA), according to Medicare medical coding and billing rules. Medicare says that a physician must carry out this type of service, per 42 Code of Federal Regulations (42 C.F.R. 483.40 [c] [4]).

As per CMS, the Social Security Act mentions in Section 1819(b)(6)(A) that "the medical care of every resident must be provided under the supervision of a physician." This implies that non-physician practitioners, including Pas, cannot carry out the initial comprehensive visit in SNFs.

Remember: CMS defines the initial visit as "the initial comprehensive assessment visit during which a physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident."

Furthermore, according to the Long Term Care regulations (42 CFR 483.40 [c][4] and [e][2]), the physician may not give away a task that the physician must personally carry out. Consequently, the physician may not delegate the initial visit in a SNF to your PA.

Medical Coding and Billing Tip: This rule is also applicable to the NF (POS 32) with one exception: A qualified NPP, who is not employed by the facility, may carry out initial visit in the NF setting when the state law allows.

G8644 Applies For ‘No License' Exceptions

Question: Is HCPCS code G8644 used when a provider doesn't have authority as per federal law to write a prescription? Or does it point out that the eligible provider didn't have e-prescribing technology to submit an e-rx?

Answer: You must use G8644 (Eligible provider does not have prescribing privileges) for a physician or non-physician provider who would otherwise be needed to participate in the ePrescribe program however the provider does not have prescribing privileges (such as no license to prescribe). The one-time reporting of code HCPCS code G8644 was needed in 2011 for the provider to be granted an exception.

As per CMS's 2011 Electronic Prescribing (eRx) Incentive Program Update CMS has this to say about HCPCS code G8633: "there will be a G8644 code which can be used by eligible professionals to show that they do not have prescribing privileges.

What V Code Applies for Negative Urinalysis on Day 2

Question: A private pay patient visited for a well check. The internist then ordered a urinalysis, which came back abnormal. The patient came back in the next day to take the test again, which came back normal. For the second test's diagnosis, should you use V67.59 (Following other treatment; other) or V72.6 (Laboratory examination)?

Answer: Essentially, you are ought to use neither V67.59 nor V72.6 as your ICD-9 coding options. As an alternative, report day 1's abnormality -- for example, hematuria (599.7x) or proteinuria (791.0) -- together with V67.9 (Unspecified follow-up examination).

The abnormality-V67.9 combo specifies that this finding was found that prompted a recheck, in which the condition was no longer present. Some experts recommend using the V code alone as your ICD-9 coding option, which even though optimal coding, does not meet insurers' requirements for reporting the original problem.

ICD-9 specifies that you can use V67.9 as either a primary or secondary code. Payers generally prefer that you first list the primary diagnosis -- for example, hematuria (382.9) -- and secondarily list the recheck (V67.9).

For accurate ICD-9 coding , you would use V67.9, rather than V67.59, as the patient did not receive any treatment for the abnormality.

In case the internist had prescribed antibiotic treatment, you would as an alternative use V67.59. Prior antibiotic treatment counts as "other" in ICD-9's V67.59 descriptor. Since a reason was present for the recheck, V72.6 is not suitable.

"V72.6 is not to be used if any sign or symptoms, or reason for a test is documented," as per ICD-9-CM Official Guidelines Section I.C.18.d.15.

Medical Coding and Billing Tip: As far as CPT codes are concerned, you must report the dipstick or specimen handling. In case staff carried out the dipstick in your office or shared lab, you must assign 81000 (Urinalysis, by dip stick or tablet reagent … non-automated, with microscopy) or 81002 (… non-automated, without microscopy). As an alternative, report 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory) if an outside lab carried out the urinalysis. Code 99000 is also aimed to reflect the work involved in the preparation of a specimen before sending it to the [outside] laboratory.

Except the nurse did important evaluation and/or counseling, do not report 99211 (Office or other outpatient visit … Typically, 5 minutes are spent performing or supervising these services). A urine recheck alone does not frequently support charging a medically necessary face-to- face encounter.

Ace the ABCs of ABVD With These HCPCS and CPT Essentials

Make this J9040 mistake and you'll end up reporting 15 times more units than you should.

The ABVD regimen for the treatment of Hodgkin's disease may have been around since the 1970s, however the way you report the service to insurance companies has definitely seen some changes over the years. Get the proper CPT and HCPCS coding choices down pat with the help of tips and tactics below.

Capture Drug Dollars With These HCPCS Codes

"ABVD" refers to the first letters of the drugs which are used in the regimen, which consist of Adriamycin, bleomycin, vinblastine, and dacarbazine.

Adriamycin: Coded using HCPCS code J9000 (Injection, doxorubicin hydrochloride, 10 mg), Adriamycin is a brand name for generic chemotherapy drug doxorubicin whose specialties consist of hematology and oncology. You also may find doxorubicin sold under the brand name Rubex.

Bleomycin: One more chemotherapy drug, bleomycin is marketed under the brand name Blenoxane and is coded using J9040 (Injection, bleomycin sulfate, 15 units).

Vinblastine: Sold under names like Velban and Alkaban-AQ, vinblastine is also a chemotherapy drug. Report it using code J9360 (Injection, vinblastine sulfate, 1 mg).

Dacarbazine: You may see this chemotherapy drug sold under the name DTIC-Dome. Your code selection will depend on the amount of drug used: HCPCS code J9130 (Dacarbazine, 100 mg) or J9140 (Dacarbazine, 200 mg).

Make Things Easier by Following an ABVD Example

For ABVD, the patient usually gets pushes of bleomycin, doxorubicin, and vinblastine. The patient also gets an intravenous infusion of dacarbazine. The oncologist will order the dosage based on the patient's body mass.

Example: A nurse administers the following to a patient who is suffering from Hodgkin's disease (201.x, Hodgkin's disease):

18.9 units bleomycin, IV push, 9 minutes

47.25 mg doxorubicin, IV push, 5 minutes

11.34 mg vinblastine, IV push, 2 minutes

708.75 mg dacarbazine, IV infusion, 1 hour.

CPT solution: Supposing the one-hour dacarbazine infusion is your initial service, you must assign initial infusion code 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for that particular service.

For each of the three chemotherapy IV pushes in the above example, you must report +96411 (Chemotherapy administration; intravenous, push technique, each additional substance/drug [List separately in addition tocode for primary procedure]). For maximum payers, you must report +96411 with a quantity of 3, however verify the accurate medical coding and billing reporting structure for your local commercial payers.

Watch for: The nurse also may administer an antiemetic with this regimen, so you must be wary of further reportable drugs and administration services.

Know How to Report Discharge Services

Question: A patient gets admitted to the hospital but then his condition warrants transfer to another facility, and then he is discharged on the same day. How is the physician ought to report his services?

Answer: You must not report 99238-99239 when the patient is admitted and discharged on the same date of calendar. When this takes place, the physician picks from CPT 99221-CPT 99223(initial inpatient care) or 99234-99236(admission and discharge on the same day). Choose 99234-99238 when the patient stay is less than 8 hours on the same calendar day and the insurer agrees with these codes. Documentation should mirror two components of service: the corresponding elements of both the admission as well as the discharge, and the period of time the patient spent in the hospital. Interchangeably, in case the patient stay is less than 8 hours, or the insurer does not recognize 99234-99236(admission and discharge on the same day), report only initial inpatient care CPT 99221- CPT 99223 as appropriate.

Key Elements

Study the basic billing principles of discharge services: what, who, and when.

Hospital discharge day management codes are essentially used to report the physician's total extent of time spent preparing the patient for discharge. These codes involve, as appropriate:

• Final examination of the patient;
• Discussion of the hospital stay, even though the time spent by the physician on that date is not continuous;
• Guidelines for continuing care to all pertinent caregivers; and
• Preparation of discharge records, prescriptions, as well as referral forms.

Hospitalists must report one discharge code per hospitalization, however only when the service takes place after the admission's initial date: 99238, hospital discharge day management, 30 minutes or less; or 99239, hospital discharge day management, more than 30 minutes. Choose one of the two medical coding and billing codes, hinging on the cumulative discharge service time given on the patient's hospital unit/floor during a single calendar day. You must not count time for services carried out outside of the patient's unit or floor (i.e., calls to the receiving physician/facility made from the physician's private office) or services carried out after the patient physically leaves the hospital.

Transfers of Care

The admitting physician or group is accountable for carrying out discharge services unless a formal transfer of care takes place, for instance the patient's transfer from the ICU to the standard medical floor as the patient's condition becomes better. Without this transfer of care, co-managing physicians must simply report subsequent hospital-care codes , CPT 99231- CPT 99233, for the final patient encounter. A sample of this is surgical co-management: In case a surgeon is acknowledged as the attending of record, they are in charge for postoperative management of the patient, including discharge services.

Providers in a dissimilar group or specialty report CPT 99231- CPT 99233 for their medically necessary care.

ICD-9: V72.83 and V10.05

V72.83 Frequently Won't Stand Alone

Question: Your surgeon carries out a pre-bypass surgery EGD and records acute esophagitis. What ICD-9 coding options should we list for the claim?

Answer: Since you must always report the most specific diagnosis, you must list the code for the esophagogastroduodenoscopy (EGD) findings: 530.12 (Acute esophagitis).

However you should also list ICD-9 coding options to demonstrate the reason for the EGD as a pre-op procedure for gastric bypass surgery. Submit the following listed codes to document the reason for the test:

• 278.01 -- Morbid obesity
• V85.xx -- Body mass index …
• V72.83 -- Other specified preoperative examination.

FYI: A lot of payers won't accept ICD-9 coding option V72.83 as primary diagnosis, thus reporting findings from the EGD is vital. In case no symptoms appear, listing obesity and BMI that demonstrate medical necessity for the bypass surgery serve to demonstrate medical necessity for the service.

153.3 Vs. V10.05 -- Get the History Right

Question: You have a patient who had a colon resection for cancer over six months ago. Two months after the surgery, he had a Mediport inserted for chemotherapy. The patient has accomplished the course of treatment and comes to your surgeon's office to talk over when to schedule the Medi-port removal as he is in remission. Your surgeon also examines the incisions from the initial resection as well as the Medi-port insertion. The surgeon then dictates the diagnosis for the service as "colon cancer" although he's scheduling the Medi-port removal as the colon cancer treatment is complete. Shouldn't the diagnosis be "history of colon cancer"?

Answer: You are right that in case all treatment directed toward the cancer is complete and there are no signs of current disease, you must use a history of cancer code in place of a cancer code.

Do this: Report the reason for the encounter as V10.05 (Personal history of malignant neoplasm of large intestine). You must not use the family history code (V16.0, Family history of malignant neoplasm of gastrointestinal tract).

You must not report the cancer diagnosis with the ICD9 coding option 153.3 (Malignant neoplasm of sigmoid colon) for this patient encounter.

Answer 3 Questions to Enhance Your Nurse Code Reporting

Be on the safe side by following 99211's coding requirements.

If used correctly, 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician), otherwise known as the "nurse code," can certainly be a revenue boosting tool. Nurse your billing woes by answering these three medical billing and coding questions.

Question 1: Was the Provider of the Service On Site?

This refers to the "incident to" clause as defined by Medicare, which says: "Even though the 99211 code does not need the presence of the physician in the patient's room or a face-to-face encounter with the physician, the service would be done by face-to-face encounter with the physician's staff and ‘incident to' (meaning the physician must be in the office suite and immediately available) a physician's service."

In brief and for accurate medical billing and coding, your practice must document a face-to-face assessment by a dermatologist's staff and the rendering of a medical service that has an impact on the patient's care. The "incident to" clause stems from Medicare's prerequisite which states that the physician should at least be in the office when the service is delivered.

Why: Medicare considers these services to be an integral even though "incidental" part of the physician's professional service. However, for medical billing and coding accuracy, you can bill 99211 as "incident to" other health professionals like physician assistants or nurses.

Question 2: Was an E/M Service Provided?

It's necessary for you to meet 99211's criteria. In general, the provider should review the patient's history, carry out a limited assessment, or do some kind of decision making. A change in the medical regimen is not an AMA CPT prerequisite to bill 99211. Though, this may be needed by various payers and as such included in their coverage policies/provider education materials.

With any physician services, the E/M services reported by 99211 should always be medically necessary, and the ancillary staff must sufficiently document these services. Something which is as simple as a blood-pressure check with a review of meds can be billed with a 99211 (CPT states ‘presenting problem[s] is minimal'). In case there is a change in plan of care, then the MD should be involved, thus raising the E/M level.

Question 3: Was Service Rendered Face-to-Face?

Red flag: Phone calls with patients are not appropriate with the CPT codes 99211 face-to-face necessities. The dermatologist or his staff must talk to the patient in person. One of the chief purposes of 99211 is to offer a mechanism to report services rendered by other individuals in the practice (e.g., a nurse or other clinical staff member).

The staff member may consult with the dermatologist, however direct involvement of the dermatologist is not essential.

Medical Billing and Coding Update: Medicare has it a different way. Though the physician's presence is not needed at every single 99211 service involving a Medicare patient, the physician should have started the service as part of an on-going plan of care in which he or she will be an on-going participant.

4 Clues Ease Your Milia Treatments Coding

AS far as benign lesions are concerned, numbers matters instead of size.

Having a tough time reporting milia treatments? Part of the challenge is discriminating between acne surgery codes and destruction codes. These four medical billing and coding clues help you evade big headaches on possible denials.

Clue 1: Explore Destruction vs. Removal

The major difference between 10040 (Acne surgery -- e.g., marsupialization, opening or removal of multiple milia, comedones, cysts and pustules) and 17110 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) is that the CPT code 17110 is a destruction code while the 10040 code is a removal code.

"Code choices must be fairly simple by definition alone. The code 10040 signifies that an incision is made into the cyst or milia for removal and code 17110 is for destruction.

Hint: In CPT, any code with a prefix of "17" is a destruction code. As mentioned in 17110's description, the most common forms of destruction include the application of liquid nitrogen or other chemical agent (a.k.a. cryosurgery), curettage, electrodessication, or the use of a laser.

Keep in mind that your dermatologist generally removes a milia by using a comedone extractor, which is a tool of the size of tweezers.

Clue 2: Choose Destruction Series Based on Diagnosis

The CPT code series 17110-17111 states the destruction of benign lesions that is medically necessary. In case you'd use a destruction code for reporting milia treatment, you must keep in mind that 17110 is for up to 14 lesions while 17111 (…15 or more lesions) is for 15 or more lesions treated at one time. Therefore, you will never code CPT codes 17110 and 17111 together on any patient or at any given time.

Red flag: While assigning codes for benign or premalignant lesions, the number of lesions definitely matters. Moreover, a proper ICD-9 code must come with reporting 17110-17111. Some of the most common include ICD- 9 code 702.11 (Inflamed seborrheic keratosis) 078.10 (Viral warts, unspecified), 706.2 (Sebaceous cyst), and 078.19 (Other specified viral warts [e.g., common wart, flat wart, verruca plantaris]), to which group milia belongs.

Clue 3: Understand I&D of Foreign Body

I&D means "incision and drainage" and frequently applies to to the removal of a foreign body in the skin as well as subcutaneous tissue (including nails). It is actually a common treatment for an abscess in which a scalpel or needle is inserted into the skin covering the pus and the pus is drained. While treating milia this way, 10040 is applicable. Whereas most insurance carriers may deny a claim for 10040, submitted with a diagnosis of simple acne, they will generally pay for a diagnosis of symptomatic milia for removal (706.2, Sebaceous cyst). The reason is that they consider ICD-9 code 706.2 as medically necessary. A decent example of symptomatic milia would be aninflamed milia on the nasal bridge irritated by eyeglasses.

Clue 4: See Symptomatic in the Big Picture

Milias are actually tiny white bumps of keratin in the glands of the skin. They are very common in newborns' faces -- commonly on the tip of the nose or chin -- however are also found in adults. Medicare and maximum carriers have a benign lesion destruction/removal policy that you should meet in order to bill milia treatment. Look out for the appropriate symptoms that must be indicated in your dermatologist's pathology report, for example:

• inflammation
• bleeding
• clinical suspicion for malignancy
• pain
• irritation (various carriers differ on policies for this symptom).

Improve Your Angio Skills With This Carotid Scenario

Knowing right from left can get you a $105 reward.

How do you handle a medical billing and coding case with a common carotid placement through both common and internal carotid imaging?

Have a look at the following scenario: By means of femoral access and common carotid placement, the physician images the right common carotid as well as right internal carotid. The physician documents normal anatomy and maintains that there are no abnormalities in the common carotid, however she finds stenosis in the internal carotid.

Determine your answer, and then see if your solution to this medical billing and coding scenario is similar to the experts'.

Image 2 Vessels From Same Placement?

The scenario specifies catheter placement terminated in the common carotid, however the cardiologist imaged both the common and internal carotid arteries. Supposing your documentation supports it, you will be able to report imaging for both the common as well as internal carotid arteries.

This imaging of both vessels is possible as the contrast flows upward. Consequently, physicians can inject contrast at the common carotid artery and render the interpretation of not only the common carotid bifurcation, specifying what is seen ([for example,] the common carotid bifurcation was clean and free of disease), however also intracranial segments of the internal carotid artery.

The codes: For the unilateral common (cervical) carotid artery angiography, you must report CPT code 75676 (Angiography, carotid, cervical, unilateral, radiological supervision and interpretation). You should apply 75665 (Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation) for unilateral intracranial (cerebral) carotid artery angiography.

Keep in mind to verify that the physician's documentation for the scenario stated above supports reporting the cerebral code (based on what she performed and the recorded findings) along with the cervical code to attain medical billing and coding accuracy.

Rake in Rightful Correct Carotid Fee

Along with imaging, you need to select the proper catheter placement code. One significant factor is whether the cardiologist worked in the left or right carotid arteries. In the scenario mentioned above, the cardiologist placed the catheter in the patient's right common carotid.

Impact: The right common carotid originates from the innominate artery which branches from the aorta. Consequently, from a femoral approach, the innominate is the first-order catheterization, and the right common carotid is a second-order catheterization. Then again, the patient's left common carotid originates from the aorta in a typical patient and is consequently a first-order catheterization.

Medical Billing and Coding Tip: Due to these anatomical differences, the proper code for a right common carotid cath placement, as described in the above scenario, is second order CPT 36216 (Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family).

Alternatively, for a left common carotid cath placement, you would report first-order code 36215 (…each first order thoracic or brachiocephalic branch, within a vascular family) for a patient who has a normal anatomy.

Case Study Challenge: Check Your CC Knowledge by Studying These Detailed Scenarios

You want clinical critical care examples? You got them here.

The details of critical care coding are difficult to determine without some concrete examples to illustrate 99291 scenarios. So what does a really detailed clinical scenario for critical care look like?

Here are the two medical billing and coding scenarios to throw more light.

The challenge: Look at these case studies and see in case you can get all the codes -- diagnosis (ICD-9) and procedure/service (CPT) -- right:

Scenario 1: Physician Treats CHF

A patient comes to the ED with deteriorating shortness of breath (SOB); the physician observes the patient and discovers high blood pressure and tachycardia. The physician orders a Cardizem drip to control the patient's heart rate; she after that orders labs, a chest x-ray, and an electrocardiogram (EKG).

The physician carries out multiple re-evaluations, interprets both the x-ray and EKG, and diagnoses congestive heart failure as well as atrial fibrillation. Total encounter time is 50 minutes; the EKG interpretation takes the physician four minutes.

Answer: On the claim, you must report the following:

• CPT code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the 46 minutes of critical care;
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99291 to display that the critical care and EKG were distinct services, in case your payer requires it;
• CPT code 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the EKG;
• ICD-9 code 428.0 (Congestive heart failure, unspecified) appended to 99291 and 93010 to signify the patient's heart failure;
• ICD-9 code 427.31 (Atrial fibrillation) appended to 99291 and 93010 to signify the patient's atrial fibrillation; and
• ICD-9 code 786.05 (Shortness of breath) appended to 99291 and 93010 to signify the patient's symptoms.

Scenario 2: Physician Treats Respiratory Failure

A patient comes to the ED with dyspnea and wheezing; the history portion of the exam discloses the patient has asthma. The physician finds the patient in respiratory distress with retractions as well as accessory muscle use. He then orders labs, a chest x-ray, an EKG, and an ABG (arterial blood gas).

The patient gets three rounds of Albuterol and Atrovent Nebs, and steroids by mouth. The physician carries out multiple re-evaluations, interprets the x-rays, EKG, and ABG. The patient starts having evidently increased difficulty breathing in one of the re-evals, and the physician places the patient on BiPAP (bilevel positive airway pressure). In spite of the BiPAP, the patient's rapid deterioration stays.

The ED physician intubates the patient and then admits him to the intensive care unit (ICU). Final diagnosis is asthma and also acute respiratory failure. The physician documents 110 minutes of encounter time with the patient; the physician spent five minutes on intubation and five minutes interpreting the EKG.

Answer: On this claim, you must report the following ICD-9 codes and CPT codes :

• 99291 (for the first 74 minutes of critical care);
• +99292 (… each additional 30 minutes [List separately in addition to code for primary procedure]) for the remaining 26 minutes of critical care;
• modifier 25 (appended to 99291 and +99292 to show that the critical care and the other procedures were separate services, if the payer requires it);
• 31500 (Intubation, endotrachael, emergency procedure) for the intubation;
• 93010 for the EKG interpretation;
• 518.81 (Acute respiratory failure; appended to 99291, +99292, 31500, and 93010 to represent the patient's respiratory failure)
• 493.90 (Asthma, unspecified; appended to 99291, +99292, 31500, and 93010 to represent the patient's asthma diagnosis)

What is Medical Billing and Coding

What is Medical Billing and Coding

ICD-9/ICD-10 Update: Know Your Regions to Choose Best Radiculopathy Diagnosis

Plus: Get ready now for expanded diagnosis choices under ICD-10.

Your physician's notes document "radiculopathy," however that doesn't send you to a definite diagnosis code. Dig deeper for the reason of the patient's problem and the affected region to make the best ICD-9 code choice.

Identify the Signs and Causes

Radiculopathy takes place when one or more spinal nerve roots become inflamed, compressed, or go through a compromised blood supply. The nerve root problem can result in pain, weakness, or numbness in the region(s) affected by the individual spinal nerve(s).

ICD-9 includes two main code choices for radiculopathy diagnoses: ICD-9 code 723.4 (Brachial neuritis or radiculitis NOS) or 724.4 (Thoracic or lumbosacral neuritis or radiculitis, unspecified).

Caution: Diagnosis ICD-9 code 724.2 (Lumbago) refers to lumbago or low back pain. Radiculopathy in the lumbosacral region of the spine can present as low back pain, so it's important to determine whether the patient has low back pain or radiculopathy.

Common reasons of low back pain involve disc degeneration, spondylosis, sprain, muscle trigger point, fibromyalgia, compression fracture, or injury.. These specific causes are different from those for radiculopathy, which is why knowing the original circumstances can help your physician diagnose -- and you select the ICD9 codes -- correctly.

Watch for the Affected Region

While reporting radiculopathy, you must concentrate and focus on the spinal region involved. The anatomical location of the patient's symptoms (cervical, thoracic, lumbar, sacral, or coccygeal) is certainly your best guide.

Reminder: The affected regions may overlap, however the nerve roots are discrete. Your physician might document nerve roots that cross from one anatomic region to another, for instance L5-S1. You'll report the lumbosacral regional involvement.

Prepare for More Detailed Choices With ICD-10

Once ICD-10 goes into effect, you'll have eight possible code choices for radiculopathy. Each incldes a specific spinal region:

• M54.11 – (Radiculopathy, occipital-atlanto-axial region)
• M54.12 -- (Radiculopathy, cervical region)
• M54.13 -- (Radiculopathy, cervicothoracic region)
• M54.14 -- (Radiculopathy, thoracic region)
• M54.15 -- (Radiculopathy, thoracolumbar region)
• M54.16 -- (Radiculopathy, lumbar region)
• M54.17 -- (Radiculopathy, lumbosacral region)
• M54.18 -- (Radiculopathy, sacral and sacrococcygeal region)

Medical Billing and Coding Tip: Having more precise diagnosis choices under ICD-10 means providers will require to be more detailed in their documentation so you can code more precisely. Even though ICD-10 won't be implemented until October 2014, now is the perfect time to start helping your providers get ready for how their documentation will change.

ICD-10: 2-Code Pressure Ulcer Reduces to Just 1 for ICD-10

ICD9 Codes

You won't require an additional code for 'stage.'While you report a pressure (decubitus) ulcer diagnosis in ICD-9, you have to use two ICD-9 codes -- one for reporting the location, and one for reporting the stage. All that modifies once ICD-10 goes into effect. Even though the number of ICD-9 codes substantially increase from 14 under ICD-9 to over 150 in ICD-10, you'll just require one code for reporting the pressure ulcer location and stage when you start reporting using the new diagnosis code set. Ascertain Pressure Ulcer Site With ICD-9, you have nine "location" ICD9 codes to choose from, as follows:

• 707.00 – (Pressure ulcer; unspecified site)
• 707.01 – (… elbow)
• 707.02 – (… upper back)
• 707.03 – (… lower back)
• 707.04 – (… hip)
• 707.05 – (… buttock)
• 707.06 – (… ankle)
• 707.07 – (… heel)
• 707.09 – (… other site)

ICD-10 provides much better site specificity, creating many more code options, as follows:

• L89.9_ -- (Pressure ulcer of unspecified site)
• L89.00_ -- (Pressure ulcer of unspecified elbow)
• L89.01_ -- (Pressure ulcer of right elbow)
• L89.02_ -- (Pressure ulcer of left elbow)
• L89.10_ -- (Pressure ulcer of unspecified part of back)
• L89.11_ -- (Pressure ulcer of right upper back)
• L89.12_ -- (Pressure ulcer of left upper back)
• L89.13_ -- (Pressure ulcer of right lower back)
• L89.14_ -- (Pressure ulcer of left lower back)
• L89.15_ -- (Pressure ulcer of sacral region)
• L89.20_ -- (Pressure ulcer of unspecified hip)
• L89.21_ -- (Pressure ulcer of right hip)
• L89.22_ -- (Pressure ulcer of left hip)
• L89.30_ -- (Pressure ulcer of unspecified buttock)
• L89.31_ -- (Pressure ulcer of right buttock)
• L89.32_ -- (Pressure ulcer of left buttock)
• L89.4_ -- (Pressure ulcer of contiguous site of back, buttock and hip)
• L89.50_ -- (Pressure ulcer of unspecified ankle)
• L89.51_ -- (Pressure ulcer of right ankle)
• L89.52_ -- (Pressure ulcer of left ankle)
• L89.60_ -- (Pressure ulcer of unspecified heel)
• L89.61_ -- (Pressure ulcer of right heel)
• L89.62_ -- (Pressure ulcer of left heel)
• L89.81_ -- (Pressure ulcer of head)
• L89.89_ -- (Pressure ulcer of other site) Report Pressure Ulcer StageFollowing pressure-ulcer site ICD-9 codes 707.0x, ICD-9 asks coders to see additional code to identify pressure ulcer stage (707.20-707.25)." The "stage" codes provide the following listed diagnostic information:
• 707.21 – (Pressure ulcer, stage I. This stage involves intact skin with redness of a localized area, usually over a bony prominence)
• 707.22 – (Pressure ulcer, stage II. Stage II ulcers may have intact or ruptured serum-filled blisters and a partial-thickness loss of dermis.)
• 707.23 – (Pressure ulcer, stage III. Full-thickness tissue loss is characteristic of this stage, possibly with subcutaneous fat visible.)
• 707.24 – (Pressure ulcer, stage IV. Exposed bone, tendon or muscle from full-thickness tissue loss defines this stage.)

ICD-10 identifies the same four stages – and also "unstageable" or "unspecified stage" pressure ulcers. But in place of using an additional code to capture the stage information, each one of the site codes includes a final digit to account for these six "stage" choices.

For instance: L89.11_ expands to the following listed six codes:

• L89.110 – (Pressure ulcer of right upper back, unstageable)
• L89.111 -- (… stage 1)
• L89.112 -- (… stage 2)
• L89.113 -- (… stage 3)
• L89.114 -- (… stage 4)
• L89.119 -- (… unspecified stage)