CO2 Dermabrasion and Multiple Allergens

ICD9 Codes

Question: How would you code for CO2 laser dermabrasion for treating a basal cell carcinoma?

Answer: You should report 15780 (Dermabrasion; total face [e.g., for acne scarring, fine wrinkling, rhytids, general keratosis]), 15781 (... segmental, face), 15782 (... regional, other than face), or 15783 (... superficial, any site [e.g., tattoo removal]) for a dermabrasion procedure.

For showing that the procedure is medically necessary, you must link the CPT code to an ICD-9 codes from the 173.0-173.9 (Other malignant neoplasm of skin) series. You should select the code from that series that signifies the site of the carcinoma.

Warning: Most carriers think of dermabrasion procedures to be cosmetic and will reimburse you for them simply under definite medical circumstances. For instance, Aetna considers dermabrasion -- whether by dermaplaning or CO2 laser -- medically essential for elimination of superficial basal cell carcinomas as well as pre-cancerous actinic keratosis only when you meet two criteria:

• conventional ways of removal for instance cryotherapy, curettage, and excision are impractical owing to the number and distribution of the lesions, and
• the member has failed a trial of 5-fluorouracil (5-FU) (Efudex), lest contraindicated.

Testing Multiple Allergens
Question: Your dermatologist scratch- tested a patient, who has problems of skin rashes, for reactions to dogs, cats, ragweed, oak, maple, penicillin, dust mites, as well as bees. What codes must you report?

Answer: You must report 95004 (Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction…) x 4 units for the ragweed, oak, maple, as well as dust mites, and CPT code 95010 (Percutaneous tests [scratch, puncture, prick] sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, including test interpretation and report by a physician, specify number of tests) x 4 units for the dog, cat, penicillin, and bee stings.

A dermatologist has numerous ways of determining the source of a patient's skin rashes. Furthermore, they generally want to test several substances all at once. Keep in mind that every substance counts as a distinct test. Make certain to code for every single allergen administered by putting the number in the "units" field of your claim form.

Quick fact: The percutaneous test is also termed as scratch test, prick test or puncture test. Here, the dermatologist applies test solutions of probable allergens to scratches or shallow punctures on a patient's skin.

The kind of solutions your dermatologist applies will decide the code you report: CPT code 95004 for allergenic extracts and CPT codes 95010 for antibiotics, biologicals, stinging insects, and local anesthetic agents.

Follow-Up: Discover Billing Problems in Your Audit? Here's How to Solve Them

Medical Billing

If your physician is trapped in a coding rut, give him the tools to get on track.

Do you have one physician on staff who reports level- four E/M codes for every visit? In case you thought your practice was safe to this type of mistake, your self-audit might expose medical billing problems you didn't know you had.

In case you code the charts of numerous physicians at the similar practice, it may be tough to notice trends in the physician's coding habits.

For example, one physician might code each visit as a 99214 (Office or other outpatient visit for the evaluation and management of an established patient …), however as her charts are mixed in with other physicians' in the practice, you don't notice the pattern as you never code a heap of her charts at the similar time. Besides, as a lot of practices now have their own urologists do their own indiviudal E/M coding, you may have never studied an E/M chart to check on its accuracy.

Medical Billing Tip: Remind Your Physicians How to Select a Level

In case you discover E/M coding difficulties in your chart review, you must remind your physicians how to choose the accurate level. First, highlight to the physicians that the nature of the presenting problem will set the primary level of care that is necessary.

Prior to taking the patient's history of existing illness, earlier medical history, social history, family history, as well as review of systems, the physician must have a pretty good idea what level of service he'll be carrying out based on the presenting illness or injury. Then, the physician must do the exam as well as medical decision-making that meet the level that's necessary for that illness severity, based on the patient's history.

Complexity, MDM is different With Each Patient

In case you find that one of your physicians miscodes his E/M visits, tell him again that even if he constantly sees the same diagnoses (which is unlikely), the complication of the visit and the medical decision-making will differ from one patient to the next.

Medical Billing Example: A 25-year-old female going through an ear infection and no other medical problems might qualify simply as a level-two office visit (99212) as the physician only carried out a problem-focused history and exam, and straightforward medical decision-making.

Though, assume the physician sees a 22-year-old patient with an ear infection, and the patient has hearing loss and balance issues owing to a head injury. The patient has already been on three rounds of antibiotics and it is not improving.

Although this patient also has an ear infection, the coding changes from our previous example above. This patient may be eligible for a level-four or maybe even a level-five visit, depending on the number of treatment options, the tests ordered, the medications ordered, etc.

Remember: In case you carry out medical billing for a surgeon or specialist, the fact that the physician is a specialist does not decide the level of complexity.

Pacing Systems: +33225 Confusion? Here is the Solution

CPT 33206

Mark this LV-lead modification in your manual.

Some biventricular upgrade cases have been frustrating for medical coders, but there's good news.

Looking for the accurate code combination is much easier now that the AMA has published an official rectification to the main CPT codes you might report with +33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator [including upgrade to dual chamber system and pocket revision] [List separately in addition to code for primary procedure]).

Add Gen Change Codes to Primary Options

The corrections document for AMA's CPT® 2012 manual reviews the parenthetical instruction following +33225. The revision adds four CPT codes to the list of possible primary codes for +33225:

• 33228 (Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system
• 33229 (multiple lead system)
• 33263 (Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; dual lead system)
• 33264 (multiple lead system)

Keep in mind that because +33225 is an add-on code, you should report it in addition to a primary code. You may never report +33225 without an accurate primary code.

Review These Upgrade Cases for Denials

The addition of CPT codes 33228, 33229, 33262, and 33264 to the list of primary codes resolves an issue many coders have faced as the codes became effective in January.

Affected cases are upgrades from a single- or dual-lead pacemaker or implantable cardioverter-defibrillator system to a biventricular (BiV) system. Specifically, the cases involve the physician placing the left ventricle lead (+33225), altering the pulse generator, and connecting earlier placed lead(s) to the new battery.

For instance, assume the physician does away with an existing single pacer generator, inserts a BiV pacer generator, connects the present right ventricle (RV) lead, and implants and connects a new left ventricle (LV) lead. The 2012 coding guidelines originally published didn't propose clear guidance on how to code this scenario.

The problem: The logical assumption is that you must report +33225 with the applicable generator change code when a case includes LV lead placement (+33225) and generator change (such as 33228, 33229, 33263, or 33264). However, CPT® did not list the novel generator change codes as acceptable primary codes for +33225.

Result: When practices attempted to report the generator change CPT codes along with +33225, they received denials.

Practices were left trying to find a different coding option. Some coders wondered if at all they could code the LV lead placement (+33225), a new system insertion (such as 33206-33208, Insertion of new or replacement of permanent pacemaker with transvenous electrode[s] …), and possibly battery removal (such as 33233, Removal of permanent pacemaker pulse generator only). This is technically inappropriate from a coding perspective as there was an LV lead added, however no RA or RV lead changed. The new system codes need lead insertion or replacement, so CPT 33206 -33208 would not be appropriate here.

Documentation: 4 Important Items You Don't Want to Miss In the Anesthesia Record

Medical Billing and Coding

Extra units for reimbursement might be lurking in places other than the charge ticket.

Anesthesia coders have an edge over co-workers in other specialties: you have more resources when it's time to comb through charts for all the info you need. Use that access to the anesthesia record, charge ticket, and surgical report to find every detail that might help you in achieving medical billing and coding accuracy.

Unique challenge: A lot of practices use a charge ticket along with the anesthesia record. Many times, inconsistencies occur when information is transferred from the anesthesia record to the charge ticket. It's vital to compare the charge ticket to the anesthesia record, to ensure all key components are accounted for.

Read on for important medical billing and coding information you must focus on in your provider's anesthesia record.

1. Line Placements

Line placement is one service you can code together with the anesthesia service, so don't miss that chance.

Watch for notes concerning Swan-Ganz catheters (93503, Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes), arterial lines, CPT codes 36620-36625 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; …), or central venous catheter placement, CPT codes 36555-36571. Your provider must also evidently document the line's purpose, like additional monitoring or for use in postoperative pain management prior to the procedure.

2. Diagnosis and Procedure

You should know the procedure being carried out in order to select the accurate anesthesia code. General information concerning the patient's diagnosis and any past or present health conditions that can affect the procedure might change your coding.

Here's why: Conditions like hypertension, past coronary or pulmonary problems, or chronic diseases can escalate the anesthesiologist's risk or help explain the need for anesthesia. For instance, the anesthesiologist might need to take extra precautions during surgery on an obese patient with hypertension. A diagnosis of claustrophobia or Parkinson's can support medical necessity for anesthesia during "standard" procedures like an MRI.

3. Type of Anesthesia

Did the physician or CRNA offer general anesthesia, a regional, or observed anesthesia care (MAC)? The answer to this medical billing and coding question can definitely affect your coding, for instance when you need to append modifier G8 (Monitored anesthesia care [MAC] for deep complex, complicated, or markedly invasive surgical procedure) or G9 (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition) to the claim.

4. TEE, Fluoro, BIS Monitoring

You can sometimes distinctly report other services the anesthesiologist delivers during the procedure. Watch for documentation of these, including:

• Transesophageal echocardiography (TEE) probe placement (93313, Echocardiography, transesophageal, real-time with image documentation [2D] [with or without M-mode recording]; placement of transesophageal probe only). Ask your providers to specify "monitoring" or "diagnostic" when they use TEE so you can code appropriately.
• Fluoroscopic guidance for blocks or catheters used to provide postoperative pain management or placement of a central venous or Swan-Ganz catheter. These services are signified by CPT codes like 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) and +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting [List separately in addition to code for primary procedure]).

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Coding Guidelines: Tips Establish How You Must Report Late Effects (Sequela)

ICD9 Codes 

Here's the code you must sequence first.

You might be aware of what late effects are in ICD-9, but how do you deal with them in ICD-10-CM? In fact, sequela is the new term in ICD-10 and by the sequela extension of "S" substitutes the late effects categories in ICD-9-CM. Read this article to know how your ICD-9 codes will change when ICD-10 implementation hits.

Example: Current late effect ICD-9 codes 905.1 (Late effect of fracture of spine and trunk without mention of spinal cord lesion) will become M48.43xS (Fatigue fracture of vertebra, cervicothoracic region, sequela of fracture).

Follow these coding tips before you report a late effect code, so that your practice is never "late" collecting ethical reimbursement.

Medical Coding and Billing Tip 1: Review the Definition

"Sequela" is the new term used for late effects. Keep in mind that a late effect is the residual effect that takes place after the acute period of an illness or injury has terminated. For example, you'll report a sequela ICD-10 codes for the scar formation after a burn.

Medical Coding and Billing Tip 2: Time for Sequela Varies

You won't find any time limit stating when you can start using a late effect code. Why not? For the reason that late effects vary. The residual effect may be obvious early, like in the case of a cerebral infarction, or it may take place months or years later, like an effect due to a previous injury.

Medical Coding and Billing Tip 3: Generally, You Need 2 Codes -- In This Order

When you code late effects, you'll normally need two codes. You must sequence the condition or nature of the late effect first. You would code the late effect code second.


For instance, you might report M81.8 (Other osteoporosis without current pathological fracture) followed by E64.8 (Sequelae of other nutritional deficiencies [calcium deficiency]). The condition is osteoporosis, and the late effect is the calcium deficiency.

Exceptions: You may come across instances when you will report the late effect followed by a manifestation code.

A different situation is when the late effect has been expanded (at the fourth, fifth, or sixth character) to reflect the manifestation. For example instance, check out I69.191 (Dysphagia following nontraumatic intracerebral hemorrhage). The "following" means the definition includes the late effect.

You must never report the code for the acute phase of an illness or injury, even though that is what led to the late effect. Also, evade the activity codes Y93.- or External Cause Status codes Y99.- with sequela(e) codes.

Medical Coding and Billing Tip 4: Here's How to Use Extension "S"

In case you're looking at injury sequela(e) from ICD-10-CM's Chapter 19, you'll find most of the codes have a 7th character, which involves the code extension of "S." While using extension "S," you are required using both the injury code that precipitated the sequela and the code for the sequela itself. Bottom line: You'll add the "S" only to the injury code, not the sequela code.

Refresh Your E-Prescribing Knowledge With This Advice

Medical Billing and Coding

Explore these incentives for adopting eRx.

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

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

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

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

Medical Billing and Coding Tip: Note These Enrollment Guidelines

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

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

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

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

Diabetes Management: Follow These Simple Steps to Ace Diabetes Coding

ICD9 Codes

Tip: Concentrate on diabetic complications related to existing episode of care.

Selecting the accurate diabetes diagnosis can seem quite complex, thanks to factors like your family physician seeing patients with more complicated cases than in the past and their treating diabetic manifestations. Use these expert medical billing and coding steps for perfect diabetes diagnosis coding to make certain that your ICD-9 codes validate the services you bill.

1. Select the Fourth Digit First

You'll start code selection with diagnosis family 250.xx (Diabetes mellitus). Decide the fourth digit in line with the type of diabetic complication the patient has, if any.

Example: A patient comes with diabetic hypoglycemia. You must report 250.8 (Diabetes with other specified manifestations) as your first four digits. In case, on the other hand, the patient presents with diabetes devoid of any complications, your first four digits will essentially be ICD-9 code 250.0 (Diabetes mellitus without mention of complication).

Medical Billing and Coding Tip: Diabetes patients might have more than one complication. If this is the case, you must code only the complication most applicable to services the physician renders that day.

2. Ascertain the Type for Fifth Digit

The fifth digit of the diagnosis ICD-9 codes OF Supercoder.com delivers the final two pieces of information on the patient's diabetic situation: the diabetes type (I or II) and whether or not it is controlled.

To choose the proper fifth digit, you should first know what the following listed ICD-9 descriptor terms mean:

• Type I – (The patient's pancreatic beta cells no longer produce insulin. People with type I diabetes must take insulin. ICD-9 descriptors also refer to type I as "juvenile type" diabetes)
• Type II (The patient's beta cells do not produce sufficient insulin, or the beta cells have developed insulin resistance. People with type II may not have to take insulin)
• Not stated as uncontrolled (The patient's diabetes is managed sufficiently by diet and/or insulin)
• Uncontrolled (A patient can have uncontrolled diabetes when the physician documents that blood sugar levels are not acceptably stable under the current treatment regimen, when the patient is not in compliance with his diabetes management plan, or if the patient is taking medications for another illness that interfere with diabetes management)

Medical Billing and Coding Tip: First, you must check the physician's documentation to see what sort of diabetes the patient has and whether the condition is controlled. Then select one of the following fifth digits:

• 0 (Type II or unspecified type, not stated as uncontrolled)
• 1 (Type I (juvenile type), not stated as uncontrolled)
• 2 (Type II or unspecified type, uncontrolled)
• 3 (Type I (juvenile type), uncontrolled)

CCI 18.0: Bring up to date Your Multi-layer Compression, Foreign Body Removal Coding With These Edits

CCI Edits

In case your practice offers neurostimulion services, you must note these changes.

CCI edits 18.0, effective Jan.1, brings significant changes that could influence your coding for some particular orthopedic services. Our experts advise you on what's critical in the latest round.

Look for Neurostimultors and Epiphyseal Bar Excision Adjustments

As per lestest CCI edits, you can no report neurostimulator electrode array placement, pulse generator implantation, as well as revision or removal of these together with epiphyseal bar excision code 20150 (Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incision).

Pediatric orthopedicians may have the occasional chance of using these codes. Removal of an epiphyseal bar is carried out for growth disturbances in long bones owing to premature fusion of a portion of the growth plate. This can take place because of trauma or infection that leads to the fusion of the epiphysis to the metaphysis. In the rare circumstance that the neurostimulator electrodes and generator are applied for postoperative pain control, NCCI guidelines would probably bundle the procedure. Were the electrodes implanted for an unrelated diagnosis, for instance chronic low back pain, the 59 modifier would be applicable.

Keep in mind that 20150 is the column 1 code in this edit. The following codes are the column 2 codes according to CCI Edits 18.0:

• 0282T – (Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial. Including removal at the conclusion of trial period)
• 0283T – (Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; permanent, with implantation of a pulse generator)
• 0284T – (Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed)

Once you have a patient with multiple comorbidities being treated for an epiphyseal bar, you can ahead and report multi-layer compression with modifier 59 (Distinct procedural service).

Adjust Multi-layer Compression Coding

As per the latest CCI edits , you report the application of multi-layer compression with 20150. Here yet again, 20150 is a column 1 code. You report the following column 2 codes, with apt modifier, if these are carried out in the same session and in case suitable documentation supports the same.

• 29582 – (Application of multi-layer compression system; thigh and leg, including ankle and foot, when performed)
• 29583 – (Application of multi-layer compression system; upper arm and forearm)
• 29584 – (Application of multi-layer compression system; upper arm, forearm, hand, and fingers)

ICD-10 Update: You'll Be Required to Be More Precise with Muscle and Connective Tissue Disorders When ICD-10 Hits

ICD9 Codes

Pay attention to the site of involvement.

While you're coding for ligament disorders, palmar fascia contracture, foreign body granulomas, and muscle spasm, your ICD-10 code choices will increase substantially. Read on for advice on how to best describe these and other common connective tissue conditions.

Get Clinical Staff Used to Even More Specifics

To prepare doctors for this level of detail, you must start training now. Before the ICD-10 implementation date, coders will require educating their physicians on the need for a much higher degree of specificity in their diagnostic statements.

Identify Discrete Codes for Paraplegia, Fibromatoses

The ICD-9 codes for definite muscle disorders like 728.3 (Other specific muscle disorders) which includes disorders like athrogryposis and immobility syndrome (paraplegic) translate to two different ICD-10 codes. The ICD-10 code for immobility syndrome is M62.3 (Immobility syndrome [paraplegic]) and that for other specific disorders is M62.89 (Other specified disorders of muscle). "Immobility syndrome has been awarded a specific code for ICD-10, while ‘other specified disorders of the muscle' has been left undefined to capture the remainder of the unspecified muscle disorders.

The ICD-9 code used for fibrosis in muscle ligaments, 728.79 (Other fibromatoses of muscle ligament and fascia), extends to a couple of ICD-10 codes as below:

• M72.1 (Knuckle pads)
• M72.4 (Pseudosarcomatous fibromatosis)

Narrow Down To a Common Code for Ligament Disorders

The ligament disorder code in ICD-10 is more generalized for including a broader array of ligament disorders. While the ICD-9 code 728.4 (Laxity of ligament) was exclusively descriptive of ligament laxity, the ICD-10 code M24.20 (Disorder of ligament, unspecified site) defines ‘disorder of ligament'. This means that disorders other than a lax ligament can be reported with this code.

There is a wider scope for the ICD-10 codes M62.89 (Other specified disorders of muscle). The disorder can be in muscle tendons, fascia, ligament, or aponeurosis. The ICD-9 code 728.89 (Other disorders of muscle ligament and fascia), on the other hand, is more specific for ligament and fascia.

As far as the unspecified disorders of the connective tissues are concerned, you have ICD9 codes 728.9 (Unspecified disorder of muscle ligament and fascia). In ICD-10, you will go for code M62.9 (Disorder of muscle, unspecified). ICD-10 has listed a code definite to the muscle alone. There is also a definite code for disorder of ligament for ICD-10. The ligamentous disorder code is broken down by location, RT vs LT, with unspecified code for each body area when RT and LT are not listed. Coders can now be more definite as the actual tissue affected.

Grab Extra $368 in Ethical Reimbursement to Your Cyst Excision Claims

CPT Codes

Mixing up branchial and preauricular cysts can put you in the wrong CPT section.

Unless you comprehend neck and ear anatomy, you could lose precious dollars for your otolaryngology practice. In case your ENT carries out a facial tissue transfer (14040) and you report branchial cleft cyst excision (42810) as an alternative, you'll lose 10.82 relative value units -- which is $368 of lost revenue. Know if your vocab is up to par by examining the following operative report and also know what CPT codes apply.

Code This Excision

Procedure: Excision of left preauricular first branchial cleft sinus tract in a earlier operated field.

Pre-/postoperative diagnosis(es): Intermittent left preauricular first branchial cleft sinus tract.

Note: This procedure qualifies for modifier 22 as it is a revision surgery in a previously operated field.

Specimens sent to lab: Overlying skin as well as the deep sinus tract.

Indications for surgery: Intermittent left preauricular sinus tract.

Findings in surgery: Scarred preauricular areas from previous excision with no cutaneous fistula and no distinct sinus tract.

Procedure: An incision was made with the #11 scalpel blade everywhere in the area that the parents had specified most recently drained. This area was above the tragal cartilage region. A portion of the tragal cartilage was transected as the deep plane of the excision. Then, dissection was performed inferiorly and superiorly besides anteriorly to eliminate this portion of the pretragal scar and deep tissue. The depth of the dissection was the parotid gland. It was obvious that there was a huge amount of scar tissue at the anterior excision site, and this was felt to also comprise branchial cleft sinus tissue. Consequently, additional excision of the scar was carried out with the #11 and #15 scalpels, and a huge portion of tissue removed down to and comprising a portion of the superficial aspect of the parotid gland....

Next to the removal of the specimen, a noteworthy defect was present in the preauricular region. The closure of this area needed undermining the facial skin inferior to the oracle and after that anteriorly about one-third to 40 percent of the way to the corner of the mouth and lateral canthus of the eye. After that the tissue advanced and portion of the tissue rotated to allow a closure in a parotidectomy or fascial fashion in the preauricular area with a T-segment going anteriorly at the level of the tragus. Plicating 3-0 chromic sutures were used to reduce the space made vacant by excision of the deep tissue. This closure of the deep space was made potential by advancing the adipose tissue posteriorly and superiorly. Yet again, this tissue was held in place with 3-0 chromic suture.

Check Cleft Type

Recognizing whether the cyst excision was in the neck or ear region evades using a CPT codes from an incorrect CPT anatomy section.

Make ceratin that you don't lump branchial and preauricular cysts. Each is from a different embryological source.

Link Branchial to Neck's 42810-42815

For branchial cysts, you'll be in the neck section. Brachial cleft cysts are congenital cysts that arise in the lateral aspect of the neck when the second branchial cleft fails to close during embryonic development. At about the fourth week of embryonic life, four branchial (or pharyngeal) clefts develop between five ridges termed as the branchial (or pharyngeal) arches. These arches and clefts contribute to the development of various structures of the head and neck.

You must use CPT code 42810 (Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues) once the branchial cyst is superficial. In case the provider dissects all the way to the tongue base or tonsillar pillars, you must report CPT 42815 (Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx).

Think Ear for Preauricular Cyst

Preauricular cysts come from the six hillocks that form the external ear.

Result: You can't use CPT code 42810 or 42815 for the above operative report. This is a preauricular sinus track, and you should use 42815 when the cyst is in the neck around the tonsil area.

Resolve Your ICD-9 Coding For These Gastroenterology Scenarios

ICD9 Codes

Read the following gastroenterology scenarios and know what ICD-9 codes apply.

Liver Metastasis

Question: A patient comes for chemotherapy for treating a secondary liver neoplasm which metastasized from the primary colon neoplasm. How should you report your ICD-9 codes?

Answer: You must describe your diagnoses by reporting the following listed ICD-9 codes in this order:

• V58.11 (Encounter for antineoplastic chemotherapy) as primary diagnosis in case the main focus of the encounter is for chemotherapy;
• 197.7 (Secondary malignant neoplasm of respiratory and digestive systems; liver, specified as secondary) for the site being treated (liver metastasis);
• the accurate 153.x-154.x code to describe your primary cancer irrespective of it being treated or not.

Gastric Inlet Patch Claim

Question: What diagnosis code you must select for gastric inlet patch?

Answer: In case you are referring to an esophageal inlet patch, this condition is taken in account as a congenital anomaly -- a remnant of gastric mucosa which is essentially left behind during the descent of the stomach in embryologic development. Esophageal inlet patch can be spotted in about 4.5 percent of infants and up to 12 percent of children. Its presence is expected to be around 1 to 10 percent in adults. As it is of no clinical significance, patients are not required to experience any treatments or regular follow-ups. You might use ICD-9 code 750.4 (Other specified anomalies of esophagus) to report the diagnosis.

Ultrasound Abnormal Findings

Question: What ICD9 codes must you bill after physician orders a patient for an ultrasound and he writes down "1.9cm hypoechoic focus in liver"?
Answer: You must go with 793.6 (Nonspecific [abnormal] findings on radiological and other examination of abdominal area, including retroperitoneum). At times, gastroenterologists would review radiographic studies or additional studies which, even though abnormal, are not diagnostic and do necessitate further studies. 793.6 helps clarify medical necessity for review of similar tests or for the performance of further diagnostic studies (793.5, Nonspecific [abnormal findings] on radiological and other examination of genitourinary organs).

You can go ahead and use 793.6 on your claim once the physician ends up ordering multiple studies on a patient to come up with a conclusive diagnosis. A lot of insurance companies would like to see you use this code for tracking utilization of high cost radiological studies.

Infectious Pouchitis

Question: Notes point toward pouchitis. How should you report this? Should you consider another code in case the pouchitis is infectious?

Answer:ICD-9 code 569.71 (Pouchitis) covers usual cases of pouchitis. However, you should report 569.71 and 997.4 (Digestive system complications not elsewhere classified) in case the pouchitis is infectious. Pouchitis, which is categorized by inflammation of the mucosa of the small intestine, can take plae after ileostomy or ileo-anal anastomosis procedures.

Assess Your Billing Procedures With Internal Audits, Before an External Auditor Does

Medical Billing and Coding

Beginning with a baseline audit will bring success to your practice.

Would you pass an audit in case a payer auditor showed up at your practice door? You must be using internal chart reviews to assess your practice's compliance and medical billing processes -- before someone else does.

Gain from Internal Review

Carrying out internal audits can help you safeguard medical billing and coding compliance and might also help you get money you've been leaving on the table. Finding problems early helps ease risk.

Audits will also expose discrepancies in documentation and coding so you can focus your staff education. For instance, maybe something conveyed was misunderstood, or confusing, and that will come out in the audit.

Medical Billing Tip: Refer to these internal audits as "reviews" to make certain that employees don't hear the word "audit" and panic. Few people equate an "audit" with finding mistakes; however "reviews" are taken as check-ups of your coding practices.

Begin With a Baseline Evaluation

You must begin your audit efforts by carrying out a baseline audit -- the first comprehensive audit your practice undergoes. Then you can choose how often you will carry out internal audits each year.

Why? With the information garnered from a baseline audit, you'll be able to ease future auditing efforts and concentrate on the most significant areas to your insurers. Your goal is to get every provider and biller as nearly 100 percent compliance and accuracy as possible.

Follow a Checklist

Your first step in the auditing procedure is to slim down the parameters of your audit. You must answer the following questions before you get started to ensure accurate medical billing:

• What is the focus of the audit? You are required to know exactly what you want to achieve.
• What will be the audit's scope? Reflect on which providers, services, date ranges, and payers your audit will address. Look at areas for instance incident-to billing, modifier use, as well as code edit unbundling.
• How will you choose charts? Will you define this process for each provider, or will you randomize the chart selection? You must select a minimum of 20 charts per provider for your review. That chart selection must include a range of types of services, involving E/M services, consultations, hospital services, and surgical procedures.
• What documentation will you evaluate? Pull charts and organize supporting documentation, for instance a printout of physician notes, account billing history, CMS-1500 forms, and clarifications of benefits (EOBs) to assess during your audit. In case your practice is doing everything as per what the payers need, the next step is to define whether you have supporting documentation.
• Why am I finding denials? All through an audit, or even in a separate billing review, you must be reviewing denials. In case your review shows that your medical billing practices are perfect but claims are still being denied, you need to examine.

CCI 18.0: Know The Meaning Behind These New Pelvic Repair, Paracentesis Edits

You learned how to use the novel codes; now you have to apply these bundles.

Take a moment to learn how CCI edits affects your Implanon, paracentesis, EMG, pelvic exent, and colpopexy services. Here's the good news: Even though you'll see a diverse array of allowed modifier use, most of these edits reflect either CPT guidelines or common sense.

1. Pelvic Repair Edits Make Sense Because of 15777's Intent

New add-on code 15777 (Implantation of biologic implant) gets the CCI 18.0 treatment, in that CPT codes 45560, 57240-57265, and 57285 all bundle 15777.

This makes sense when you take in account the intent of this code. CPT instructions inform you not to use this code in place of 57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach [List separately in addition to code for primary procedure]). To sum up, you can and must use 57267 with CPT codes 45560, 57240-57265, and 57285 when suitable. The same is not true for 15777.

The modifier indicator is a "1," which implies that you can separate this bundle with a modifier (such as, 59, Distinct procedural service).

2. Pick Apart These New Paracentesis Codes' Edits

Keep in mind that the new parancentesis CPT codes 49082 (Abdominal paracentesis [diagnostic or therapeutic]; without imaging guidance), 49083 (... with imaging guidance), and 49084 (Peritoneal lavage, including imaging guidiance, when performed)? Though only a gyn-oncologist will possibly have a need to report these codes, you must be aware of the bundles that affect them.

The entire abdominal hysterectomy codes (58150-58210), the pelvic exent procedure code (58240), and cancer codes 58950-58958 now bundle the novel codes 49082-49084.

Some CCI edits have a modifier indicator of "1," implying that you can separate them with a modifier, and others with a "0," implying you cannot.

3. Think Again Before Reporting 95938 With EMGs

Electromyography studies (EMG) did not emit CCI 18.0's notice.

As per CCI edits, codes 51784 (Electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique) along with 51785 (Needle electromyography studies [EMG] of anal or urethral sphincter, any technique) now bundle novel code 95938 (Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs).

You can separate these services with a modifier (such as, 59), as these edits have a modifier indicator of "1".

4. Don't Slip These Pelvic Exent and Colpopexy Edits

As per CCI edits, you have two more edits that could influence your ob-gyn practice, however be cautious: one edit has a modifier indicator of "1" and the other a modifier indicator of "0."

The pelvic exent CPT 58240 (Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube[s], with or without removal of ovary[s], with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof) at the present bundles 0288T (Anoscopy, with delivery of thermal energy to the muscle of the anal canal [e.g., for fecal incontinence]).

ICD-10: PSA Screenings and Ureteral Stone Diagnoses

When ICD-9 to ICD-10 transition takes place in 2013, you will not always have an easy one-to-one relationship between old codes and the new codes. See how your ICD-9 codes will change in the following instances when the ICD-10 transition finally takes place.

V Code for Z Code on PSA Screenings

You'll discover a one-to-one relationship for both screening as well as diagnostic PSA diagnoses.

While your urologist carries out a prostate specific antigen (PSA) test, you'll report either screening PSA using diagnosis code V76.44 (Special screening for malignant neoplasms; prostate) or diagnostic PSA code, (Elevated prostate specific antigen [PSA]). When ICD-9 codes change to ICD-10 codes, you'll still have one screening diagnosis code and one eminent PSA diagnosis code.

ICD-10 difference: Once your urologist orders a screening PSA test to be carried out for a patient with no signs or symptoms of disease, you must use diagnosis code V76.44 as the reason for the test under ICD-9. With ICD-10, you'll report Z12.5 (Special screening for malignant neoplasms; prostate).

After your urologist orders a diagnostic PSA test and the documentation requires that the test result demonstrates an elevated PSA, you must report 790.93 as the ICD-9 diagnosis. Once ICD-10 comes around, you'll use R97.2 (Elevated prostate specific antigen [PSA]).

Physician documentation: Presently, the physician must identify whether the PSA test is a screening or diagnostic test. This won't change in 2013.

Coder tips: You'll scrap the V76.44 and 790.93 options and turn to Z12.5 and R97.2 as ICD-10 codes options in your ICD-10 manual.

ICD-10: 591: Increase Your Hydronephrosis Coding in 2013

Check the urologist's documentation for mention of infection for coding accuracy

Once your urologist documents that a patient is going through hydronephrosis, you report 591 (Hydronephrosis) -- which may involve any or all of the following mentioned clinical scenarios: early hydronephrosis, hydronephrosis along with an atrophic kidney, a functionless along with infected kidney, recurrent hydronephrosis, or a primary or secondary type of hydronephrosis.

When ICD-9 changes to ICD-10 in 2013, you'll still have single diagnosis code for atrophic, early, functionless, intermittent, primary, and secondary not somewhere else classified (NEC) hydronephrosis: N13.30 (Unspecified hydronephrosis). For additional specified kinds of hydronephrosis NEC, you'll use N13.39 (Other hydronephrosis).

ICD-10 difference: Once your urologist confirms the patient has hydronephrosis along with an infection, an obstruction, or a ureteral stricture you'll need to learn new ICD-10 codes. With ICD-10, you'll report one of the following:

• Including infection (including obstruction or stricture with infection) -- N13.6, (Pyonephrosis)
• Including obstruction by renal or ureteral calculus -- N13.2, (Hydronephrosis with renal and ureteral calculous obstruction)
• Including ureteral obstruction or stricture NEC -- N13.1, (Hydronephrosis with ureteral stricture, not elsewhere classified)

Once your urologist documents that a patient has congenital hydronephrosis, you have a one-to-one ICD-9 to ICD-10 code interchange. The ICD9 codes you use is 753.29 (Obstructive defects of renal pelvis and ureter, other) and the  ICD-10 code of Supercoder you'll use is Q62.0 (Congenital hydronephrosis).

Use These Latest Instrumentation Updates For Spine Surgery

Plus, know that you should not report fluoroscopy with facet injections

As per CPT® 2012, you will see a variation in the guidelines for instrumentation for spinal procedures. Below is a quick refresher on the novel instrumentation revisions.

What is new in 2012? The review for CPT® 2012 in spinal instrumentation states that you will simply use the insertion code when your surgeon carries out a removal with variation of instrumentation in overlapping spinal levels. You apply this even though your surgeon performs the insertion at new levels when an overlap exists with the previously instrumented segments.

2 key changes: While you are reporting spinal instrumentation in 2012, ensure you apply the following revisions:

1. You must not report CPT®code 22849 (Reinsertion of spinal fixation device) for reinsertion of instrumentation and codes 22850 (Removal of posterior nonsegmental instrumentation [e.g., Harrington rod]) -22855 (Removal of anterior instrumentation) meant for removal of instrumentation along with the insertion codes +22840 (Posterior non-segmental instrumentation [e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation] [List separately in addition to code for primary procedure]) as well as +22848 (Pelvic fixation [attachment of caudal end of instrumentation to pelvic bony structures] other than sacrum [List separately in addition to code for primary procedure]).

2. Once your surgeon inserts new instrumentation at levels beside previously instrumented segments and also gets rid of or revises the earlier placed instrumentation in the same session for instance there is an overlap between the originally placed instrumentation and the recently placed instrumentation, you only report the correct insertion code (+22840-+22848). You will not report the reinsertion (22849) or removal (22850, 22852 [Removal of posterior segmental instrumentation], and 22855) procedures besides the insertion of the new instrumentation (+22840-+22848).

Avoid Reporting Fluoroscopy Along with Facet Injections

Question: Your provider bills the following:

• 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) -50 (Bilateral procedure)
• 64494 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; second level [List separately in addition to code for primary procedure]) -50 (Bilateral procedure)
• 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed) -59 (Distinct procedural service) RT and 27096 -59 LT
• 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid])
• J1030 (Injection, methylprednisolone acetate, 40 mg)

Payers are negating 64493 as being redundant to 77003. How can you get 64493 paid while billing 77003? Can you add a modifier to 77003?

Answer: The fluoroscopic guidance code is not reportable along with the injection codes, which bundle the image guidance once fluoroscopy or CT imaging is used. The CPT 2012 changes bundle imaging guidance in 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed), whereas 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) and 64494 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; second level [List separately in addition to code for primary procedure]) already included fluoroscopy.

You must not bill separately for 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid]) when reporting these injection CPT codes. Moreover, you should not append -59 (Distinct procedural services)

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