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)

Billing Corner: Combat Primary vs. Secondary Payer Challenges

Medical Billing

Once a patient is covered by two insurance companies, for instance patients whose employer as well as spouse's employer both offer health benefits, claims processing can be puzzling. Add in different payer claims processes and patients who might not offer you all the information you require, and primary plus secondary payer cases can result in reimbursement loss -- not to mention medical billing headaches.

You can get the most out of your practice's reimbursement and diminish the costs involved in administering claims for patients covered by more than one payer in case you comprehend coordination of benefits (COB) and how both insurers are supposed to pay.

In this article, you'll learn the basics about billing two payers.

Take a look at these first three questions -- with answers from the medical billing experts -- to get the scoop on what you are required to do to make certain you're on the right track with multiple payer medical billing situations.

1. What Does Coordination of Benefits Even Mean?

COB is usually a common clause in a lot of health insurance policies. It identifies how the insurer will reimburse for services once more than one insurance plan is applied to a claim.

Coordination of benefits occurs when there are two policies in place (i.e., one is the husband's employer policy and the other is the wife's employer policy). The primary policy pays, and then the secondary coverage will evaluate the claim paying any difference between what the primary insurance has paid and what the secondary coverage permits.

2. How Does State Law Factor Into COB Rules?

COB rules can follow state law definition as well as state law requirements.

But even though COB rules can be governed by state law, and maximum insurers have COB rules in their contracts, a lot of payers follow model rules established by the National Association of Insurance Commissioners (NAIC).

Medical Billing Update: In case the health benefits are not under state law jurisdiction, as well-defined by the Employee Retirement Income Security Act (ERISA), specifically 29 USC 18, 1144(a), then COB might fall under Federal Regulation jurisdiction as defined in 29 CFR 2560-503-1.

3. How Do I Know Which Is the Primary Payer?

As per the NAIC rules, the plan that pays first is recognized as the primary plan; on the other hand, the plan that pays second is identified as the secondary plan. The primary plan should pay benefits as if the secondary insurer did not exist. The secondary plan can simply just consider what another plan paid when it is secondary to that plan in order to ensure accurate medical billing.

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