Molecular Pathology: 83890-83914: Keep On Piling in 2012

Notice payer guidance for novel MoPath codes -- some might surprise you.

With Medicare payment for 101 CPT codes 2012 meant for molecular pathology codes (81200-81048) hanging in the wind, does that mean you mustn't use the codes? That depends.

One thing is clear – a lot of payers will continue accepting the molecular diagnostics "stacking codes" (83890-83914,Molecular diagnostics …) this year. Despite AMA instruction to use the stacking codes merely for services not defined by new Tier 1 or Tier 2 codes, CMS's failure to price the new CPT codes 2012 keeps 83890-83914 in the spotlight.

CMS to Labs: Usage of Both Code Families

You're used to billing molecular diagnostics with stacking CPT codes 83890-83914, and that doesn't change in 2012 for most payers.

Use novel codes, too: Medicare desires that, besides the stacking codes, labs furthermore list the novel single CPT code that would be eventually used for payment purposes in case the CPT codes 2012 were active. CMS also demands that your Medicare claims reveal a charge for the new CPT code, although the Medicare acceptable for the new molecular pathology procedure CPT codes 2012 is $0.00.

Here's why: The Physician Fee Schedule lists molecular pathology CPT codes 81200-81408 with procedure status indicator "B" (Bundled Code Payments for covered services are always bundled into payment for other services not specified…).

However these services would traditionally be allocated a procedure status indicator of "I" (Not Valid for Medicare purposes Medicare uses another code for the reporting of, and the payment for these services), assigning these particular CPT codes a procedure status of B will permit CMS to collect claims information significant to assessing eventual pricing of these novel molecular pathology CPT codes 2012.

Opportunity: Even though Medicare doesn't need labs to list novel molecular pathology CPT codes 2012, doing so gives you an opportunity to provide pricing information that could impact the subsequent payment for these services.

Do this: You can make available pricing input meant for molecular pathology tests that your lab carries out by implementing the following listed steps and safeguards:

• Have the Medicare transmittal along with your compliance documents.
• Report the applicable 81200-81408 CPT code and price it as per the amount you believe signifies its fair market value, identifying that the amount may be different than the sum of the prices you've given to the stacking CPT codes.
• For the reason that CMS doesn't offer a modifier or any other mechanism to specify that the molecular pathology CPT code (from the range 81200-81408) on your claim is non-payable, you must observe all such claims to confirm that your Medicare contractor rejects the charge submitted with the novel CPT code 2012.

Botox Reimbursement for Achalasia and Anal Conditions Is Gaining Wider Recognition

Plus, know what is the botox protocol that Bluecross/Blue Shield follows

Reimbursement for the usage of Botulinum toxin type A, usually called Botox, to treat achalasia (530.0) is becoming more usual with Medicare carriers. A lot of carriers are also covering Botox injections meant for the treatment of anal fissures and anal spasms. Medical Coding differences among carriers for these three diagnoses continue to challenge gastroenterologists. Similarly, caution in billing for the drug is essential to avoid common mistakes that could result in lost reimbursement.

Botox Suitable Only After Others Fail

In nearly all cases, Botox injections for achalasia are the treatment of last resort. Reimbursement for Botox treatment naturally needs the gastroenterologist to present documentation that more conventional therapies have now been tried or that these therapies are certainly a risk to the patient. Common conventional therapies involve splitting the esophageal muscles, a surgical procedure named myotomy, along with balloon dilation, which carries the risk of complications for instance internal bleeding or esophageal perforation.

In a patient with achalasia, the sphincter at the lower end of the esophagus fails to appropriately relax and the esophagus distends over time. In advanced cases, the usual passage of food from the esophagus into the stomach becomes more and more difficult and the patient has trouble swallowing. Botox injections reduce the lower esophageal sphincter letting food to work its way through the digestive system.

Selective Coverage for Further Botox Therapies

Gastroenterologists also use Botox therapy for anal fissures (565.0) and anal spasms (564.6). Medicare coverage and reimbursement for these diagnoses is spotty, but seems to be increasing. AdministarFederal is one carrier in Indiana and Kentucky that includes the usage of Botox for anal fissures. CPT code 64640 (destruction by neurolytic agent; other peripheral nerve or branch) is required. New Jersey includes Botox injections for anal fissures and anal spasms. Both of these CPT codes are covered diagnoses while reporting 64640.

Though, CPT medical coding for these diagnoses differs, making it significant for gastroenterologists to know their own state's LMRP. For instance, Pennsylvania covers Botox therapy for anal spasm as well as anal fissure, however endorses the use of CPT code 20999 (unlisted procedure, musculoskeletal system, general) along with a description of the procedure performed. Tennessee also covers these two diagnoses but needs 90799. Virginia has delivered a draft LMRP for Botox that involves coverage for achalasia as well as anal fissure, however the draft does not include definite coding guidelines.

In ordee to inject Botox for anal fissures, a flexible sigmoidoscopy, colonoscopy or proctosigmoidoscopy is vital. The gastroenterologist must use the suitable base CPT code for the procedure (i.e., 45330 [sigmoidoscopy, flexible; diagnostic], 45378 [colonoscopy, flexible, proximal to splenic flexure; diagnostic] or 45300 [proctosigmoidoscopy, rigid; diagnostic]) and 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for administering the Botox.

Commercial carriers appear to be more accepting of Botox therapies meant for the diagnoses of anal fissure as well as anal spasm. For instance, Aetna's Botox policy bulletin specifies that the payer covers its usage for treating anal spasm and anal fissure. Blue Cross/Blue Shield of Tennessee as well as Blue Shield of California also cover Botox therapy meant for chronic anal fissure.

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99211 Coding Quiz: Can You Identify Which of These Quick-Visit Services Qualify for 99211?

Hint: You can't automatically tack 99211 on to every service just because the nurse was present.

Most practices agree that 99211 is a ubiquitous code, reported nearly every day for visits ranging from blood pressure checks to medication updates. But the so-called "nurse visit" code may not always be appropriate. Many MACs are scrutinizing these claims and targeting them as "areas of concern," as WPS Medicare did this past April. Check out these common clinical scenarios and determine whether 99211 is appropriate for the circumstances.

Know Whether 99211 Applies to X-Rays

Question 1: A patient comes to see the physician for a leg problem. The staff performs x-rays and then the patient waits in the exam room for the doctor, but gets a call and has to leave before she actually sees the physician. Does 99211 apply to this visit?

Answer 1: "What is unanswered is was the x-ray ordered by the doctor?" asks Ruby Woodward, BSN, ACS-OR, coding and research specialist at Twin Cities Orthopedics in St. Louis Park, Minn. "If the physician ordered and read it, bill the x-ray unmodified. If the physician did not order the x-ray, then nothing can be billed."

In short, Woodward says, you cannot report 99211 unless an actual evaluation and management service was provided.

Will 99211 Cover Vaccines?

Question 2: A patient presents for vaccines only. The nurse administers two vaccines and the patient leaves. Should you report 99211 with the vaccine administration codes?

Answer 2: Not as a rule, no. If the nurse simply administers a vaccine and the patient leaves, the nurse most likely has not met the criteria for billing 99211. If, however, the nurse spends a lot of time counseling the patient or the patient has other diagnoses that the nurse goes over, then 99211 might be appropriate.

In some cases, depending on the CCI edits for the specific vaccine codes you're using, you may need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99211.

In black and white: "Services billed to Medicare under CPT code 99211 must be reasonable and necessary for the diagnosis and treatment of an illness or injury," says a policy on 99211 written by Part B MAC WPS Medicare.

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Reimbursement Roundup: Modifier PT Helps Your Practice Capture Screening-Turned-Diagnostic Colonoscopy Pay

New modifier became effective Jan. 1 -- here's how you'll report it.

The question of how to code a screening colonoscopy that becomes diagnostic during the course of the procedure -- and whether the patient's deductible applies -- has long puzzled some practices, but a new Medicare modifier solves that problem. Learn how modifier PT (CRC screening test converted to diagnostic test or other procedure) can solve your colonoscopy reimbursement woes.

Get to Know Modifier PT Basics

Effective Jan. 1, Medicare carriers accept new modifier PT to explain when your physician starts a screening colonoscopy that then becomes a diagnostic procedure.

"This tells the MAC contractor that the service started as a screening procedure (e.g. G0105 [Colorectal cancer screening; colonoscopy on individual at high risk], G0121 [Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk]) but an abnormality was found and the procedure became diagnostic or therapeutic," says Joel V. Brill, MD, AGAF, CHCQM, American Gastroenterological Association, AMA/Specialty Society Relative Value Update Committee (RUC) Advisory Committee Member.

Source URL :- http://www.supercoder.com/coding-newsletters/my-practice-management-alert/reimbursement-roundup-modifier-pt-helps-your-practice-capture-screening-turned-diagnostic-colonoscopy-pay-article

When appended to your procedure code, "the modifier will indicate to Medicare to waive the deductible for a diagnostic procedure," says Christine Ross, CPC, with Digestive Healthcare Center in Hillsborough, N.J.

Why the change? Practices needed a way to tell MACs that their procedures started out as screening services but changed to diagnostic but didn't want patients subjected to deductibles for these services. "The Affordable Care Act waives the Part B deductible for colorectal cancer screening tests that become diagnostic," CMS noted in MLN Matters article MM7012, which announced the new modifier PT (www.cms.gov/MLNMattersArticles/downloads/MM7012.pdf).

Avoid Reporting G Code With Modifier PT

Once the physician indicates that the screening procedure has turned diagnostic, you'll bill only the diagnostic colonoscopy code, and not the screening code (G0104-G0106, G0120-G0121). Not only is this correct coding, but it's also the only way you can use modifier PT.

The MLN Matters article notes that modifier PT should only be appended to a CPT code in the surgical range of 10000 to 69999. Therefore, you should not append modifier PT to a G code, says Brill, who represents the American Gastroenterological Association on the CPT Editorial Panel.

Medical Office Billing and Collections Alert

Reimbursement Roundup: Modifier PT Helps Your Practice Capture Screening-Turned-Diagnostic Colonoscopy Pay

New modifier became effective Jan. 1 -- here's how you'll report it.

The question of how to code a screening colonoscopy that becomes diagnostic during the course of the procedure -- and whether the patient's deductible applies -- has long puzzled some practices, but a new Medicare modifier solves that problem. Learn how modifier PT (CRC screening test converted to diagnostic test or other procedure) can solve your colonoscopy reimbursement woes.

Get to Know Modifier PT Basics

Effective Jan. 1, Medicare carriers accept new modifier PT to explain when your physician starts a screening colonoscopy that then becomes a diagnostic procedure.

"This tells the MAC contractor that the service started as a screening procedure (e.g. G0105 [Colorectal cancer screening; colonoscopy on individual at high risk], G0121 [Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk]) but an abnormality was found and the procedure became diagnostic or therapeutic," says Joel V. Brill, MD, AGAF, CHCQM, American Gastroenterological Association, AMA/Specialty Society Relative Value Update Committee (RUC) Advisory Committee Member.

When appended to your procedure code, "the modifier will indicate to Medicare to waive the deductible for a diagnostic procedure," says Christine Ross, CPC, with Digestive Healthcare Center in Hillsborough, N.J.

Why the change? Practices needed a way to tell MACs that their procedures started out as screening services but changed to diagnostic but didn't want patients subjected to deductibles for these services. "The Affordable Care Act waives the Part B deductible for colorectal cancer screening tests that become diagnostic," CMS noted in MLN Matters article MM7012, which announced the new modifier PT (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7012.pdf).

Avoid Reporting G Code With Modifier PT

Once the physician indicates that the screening procedure has turned diagnostic, you'll bill only the diagnostic colonoscopy code, and not the screening code (G0104-G0106, G0120-G0121). Not only is this correct coding, but it's also the only way you can use modifier PT.

The MLN Matters article notes that modifier PT should only be appended to a CPT code in the surgical range of 10000 to 69999. Therefore, you should not append modifier PT to a G code, says Brill, who represents the American Gastroenterological Association on the CPT Editorial Panel.

Coding Corner: Overcome Modifier 22 Mishaps With 3 Mythbusters

Making assumptions about automatically applying 22 will land you in OIG hot water.

If you overuse modifier 22 (Increased procedural services) you'll wind up facing scrutiny -- or worse -- from your payers or even the Office of Inspector General (OIG). But if you avoid the modifier entirely, you're likely missing out on reimbursement your physician deserves.

How it works: When a procedure requires significant additional time or effort that falls outside the range of services described by a particular CPT code -- and no other CPT code better describes the work involved in the procedure" you should look to modifier 22. Modifier 22 represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code but instead raise the reimbursement for a given procedure.

Take a look at these three myths -- and the realities -- to ensure you don't fall victim to the modifier 22 catch-22.

Myth #1: Morbid Obesity Means Automatic 22

While morbid obesity is sometimes an appropriate reason to use modifier 22, it's not appropriate to assume that just because the patient is morbidly obese you can append modifier 22.

"Modifier 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

"Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifier 22 should not be appended," warns Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, director of best practices -- network operations at Mount Sinai Hospital in New York City.

There are some scenarios where you usually be considering whether modifier 22 is appropriate -- such as reoperations, unusual body habitus (obesity, unusually thin, tall, short, etc.), altered anatomy (congenital or due to trauma or previous surgery), and very extensive injury or disease -- but do not automatically append modifier 22 without the documentation to back it up. You'll only be able to append modifier 22 when a procedure requires substantially greater additional time or effort because of the patient's obesity.

Check the notes: To support appending the modifier, your physician should document how the patient's obesity increased the complexity of that particular case. CPT specifically recommends that surgeons document the reason for the additional effort, such as "increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required."

Article source :- http://www.supercoder.com/coding-newsletters/my-practice-management-alert/coding-corner-overcome-modifier-22-mishaps-with-3-mythbusters-article

Tips for Spot-On Well-Woman Coding

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

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

Break out services for Medicare

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

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

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

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

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

Stay away from high-risk coding

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

Secondly, you should rely on CPT codes for private insurers

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

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

Don't Fall a Victim to Modifier 22 Catch-22

Remember that details or the lack of it on physician's notes can make or mar your claim.

If you overuse modifier 22 (Increased procedural services) you could face increased scrutiny from your payers or even the OIG. However if you stay away from the modifier completely or use minimally, you are likely missing out on payments your otolaryngologist deserves. What's more, if and when the modifier 22 is used, it's the documentation that'll hold the pillars that support the case for additional payment.

How it functions: When a procedure calls for significant additional time or effort that falls outside the normal range of services described by a particular CPT code and no other CPT code better describes the work involved in the procedure, you should turn to modifier 22. This modifier represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code however instead when used will raise the payment for a given procedure.

Take a look at this case and see to it that you don't fall victim to the modifier 22 catch-22.

Here's a scenario: A morbidly obese patient with abnormally small tonsils and a small mouth requires the otolaryngologist to reposition the tongue blade from one area to the next in order to see the tonsils in their totality.

For morbid obesity do not tag automatic 22

In the provided situation, it is proper to add modifier 22 to 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]). But then it is not proper to assume that just because the patient is morbidly obese you can always append modifier 22.

This modifier is about extra procedural work and even though morbid obesity might lead to extra work, it is not enough in itself. Unless time is significant or the intensity of the procedure is increased owing to the obesity, then modifier 22 shouldn't be added.

Do not tag automatic 22 for morbid obesity

In this situation, it's proper to add modifier 22 to 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]). However, it's not appropriate to assume that just because the patient is morbidly obese you can always append modifier 22.

Modifier 22 is about extra procedural work and even though morbid obesity might lead to more work, it's not enough in itself. Unless time is significant or the intensity of the procedure is increased owing to the obesity, then modifier 22 shouldn't be added.

Take a look at the notes: In order to support adding the modifier, your otolaryngologist should document how the patient's obesity increased the complexity of that particular case. CPT specifically recommends that physicians document the reason for the added effort such as increased intensity, time, technical difficulty of procedure, increased risk, severity of patient's condition, physical and mental effort needed.

Even though you can (in theory) add modifier 22 based only on the description of the work in the body of the note, practically, it's not possible to get the payments if you do not quantify the extra effort.

Remember: Indicate the patient's BMI in the documentation and on the claim to support your modifier 22 use as well when you're basing the modifier use on obesity. Report the proper code from the 278.0x (Overweight and obesity) range and the matching V code (V85.0-V85.54, BMI).

Criteria for Observation Codes' Use for Physician Services

Don't use discharge code 99217 in all observation situations

Oftentimes deciding on what observation code to use can be a challenge more particularly since you have to look into two sets of this type. One set (99234-99236) pertains to the care provided on a single calendar date whereas another set concerns care that spans two calendar dates (99218-99220).

Figure out the criteria for observation codes' use for doctor services by debunking these three errors.

Fallacy 1: Observation services aid extended inpatient care

First and foremost, you'd want to ensure that the service carried out by your gastroenterology qualifies as an observation. The doctor should choose for observation to prevent a lengthy inpatient admission. For example, an observation status is proper when:

The encounter certainly lacks diagnostic, where a more precise diagnosis could decide admission or discharge.

The patient's condition requires extensive therapy in order to possibly be abated.

For instance: The gastroenterology tends to a patient at the hospital who experiences abdominal pain and nausea with vomiting. The doctor admits the patient to observation status to run tests and make sure the patient does not need inpatient care for gastric issues.

Fallacy 2: Documentation just another paperwork

The doctor's notes on the encounter would tell you how many calendar days the observation service lasted.

Take into consideration this scenario: For example, the gastroenterologist admits the patient to observation at 9 p.m. on Wednesday. The doctor orders blood tests to check the patient's enzyme levels and performs a hydrogen breath test to check for any traces of bacterial overgrowth. The results of both tests turn out to be normal. The doctor keeps the patient overnight for monitoring; her notes indicate a level two observation.

Report it: You'd report the Wednesday services with 99219. To add to it, one more important component of coding multi-calendar date observation codes is reporting 99217 on the date of discharge service. Link 789.00 and 787.01 to both CPTs to describe the patient's symptoms.

Go for 99218-99220 for all the care rendered by the admitting physician on the date the patient was admitted to observation.

For the documentation requirements, the CMS Claims Processing (Source "http://www.supercoder.com/scrubber/cms1500/") Manual indicates that a doctor can bill the initial observation care codes, provided he finishes a medical observation record for the patient. This record should contain dated and timed admitting orders of the doctor, and mirror the care the patient gets while in observation, nursing notes, and progress notes made by the physician while the patient was in observation status.

This record should be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.

Fallacy 3: Same-day observation codes require a discharge code

What happens when your gastroenterologist admits a patient to observation status and discharges him on the same calendar date? Then you would go for 99234-99236. In this situation, you would not have to code the 99217 discharge code. CPT allows the use of 99217 “if the discharge is on other than the initial date of ‘observation status'," as specified on the code's descriptor.

Same-day observation services 99234-99236 involve documenting the time of the visit in hours (with a minimum of eight hours documented on the same calendar date, also referred to as the 8-hour rule).

Four Phases to Help you Begin Your ICD-10 Preparations Right Way

Start your initial plan of conversion straight away so you can project your practice's timeline.

Medical practices that have got an early start to ICD-10 transition say that it's not an easy task as far as the process's vast nature is concerned. So if your practice has been putting off its preparations, it is time to get onboard the ICD-10 train.

Procrastinators should be careful: ICD-10 will go into effect on October 1, 2013, and CMS will not provide you a grace period post that date. To put it in other words, you will be better placed of you have your ICD-10 systems ready prior to that date so that your claims continue to flow smoothly. Experts warn that if you're not ready, your claims may not flow at all.

Key: The transition will have no effect on CPT code or HCPCS code use. Both of these coding systems will remain to be used as they are now.

4 phases help you begin preparing right away

At a medical practice, every month is a busy month. But then it's very important that you make time for your ICD-10 preparation sooner rather than later. An important takeaway message from today's session is the totally critical importance of not delaying in getting this implementation process started.

You should institute a well-planned implementation process to be ready in year 2013 rather than hastily scrambling your ICD-10(http://www.supercoder.com/icd-10/icd-10-bridge) program together at the last minute.

Here's how you should do it: break your ICD-10 implementation planning program into four phases. Here're the goals for each phase with suggested timelines:

Phase 1: Implementation plan development and impact assessment, suggested to span from the first quarter of year 2009 through the second quarter of this year

Phase 2: Implementation preparation, suggested to take place between the first quarter of this year and the second quarter of 2013

Phase 3: "Go live" preparation, should potentially take place between the 1st and 2nd quarters of 2013

Phase 4: Post-implementation follow-up, suggested to occur between the fourth quarter of 2013 and fourth quarter of 2014.

Normally, your phase one work should be approaching completion or at least be well on its way. For those of you who may not have gotten started yet or who have hardly gotten started, I urge you to move forward with this as soon as possible.

Reason: You will not be able to schedule phases through four until phase one is done, and you need to be able to calculate the resources you will require for those subsequent phases. Till you know the scope of the effect of ICD-10 in your organization, you do not know how much time and resources will be required to finish the preparation activities; as such you do not want to wait too long prior to making that assessment.

You Should Know When You Can Use Modifier 62

Remember that all CPT code is not eligible for reimbursement with a co-surgeon. Find out when you can use modifier 62 (Two surgeons) by looking to column AB in the Excel version of the 2011 Fee Schedule database, available for download at www.cms.gov/PhysicianFeeSched.

For modifier 62 claims, most payers shell out an additional fee (normally 125 percent of the ‘usual' fee for the procedure, divided equally between the two surgeons). Stay away from reimbursement problems by checking these claims cautiously.

A "2" in column AB next to the code you are investigating means that Medicare will pay for a co-surgeon for that procedure and that you do not require to submit documentation with the claim, so long as each surgeon is of a different specialty.

A "1" in column AB indicates that Medicare may pay for a co-surgeon; however you must submit documentation to explain the medical necessity for a co-surgeon. In comparison, a "0" means that Medicare will never pay two surgeons for the service whereas a "9" means that the concept of co-surgery doesn't apply for that particular code (and as such you should never apply modifier 62).

For instance: Medicare takes most wound repairs to be comparatively simple procedures and as such not eligible for payment with a co-surgeon. For example, the database assigns a "0" to column AB for codes 12001-12006, which means that you cannot be reimbursed with a co-surgeon with these procedures.

However for more extensive repairs such as those described by 12007, CMS assigns a "1" to column AB, meaning that Medicare may pay for a co-surgeon if documentation clearly explains why this is required.

To claim co-surgeons, each surgeon must carry out a distinct portion of a single CPT procedure and each surgeon must dictate and submit his own operative report for his portion of the surgery.

Source URL :- http://www.supercoder.com/coding-newsletters/my-gastroenterology-coding-alert/reader-question-make-the-most-of-modifier-62-article

Now Modifier GZ Denials Will Arrive Faster

Many a time, when Medicare payers process denials in a speedy manner, it's bad news for your practice. However, when you are using modifier GZ, you are already anticipating a denial. CMS has made that happen faster with a new regulation indicating that all claims with modifier GZ added will be denied immediately.

Why to use GZ: It happens to even the best-run medical practices – the doctor has just carried out a non-covered service and there is no ABN on file.

If you should have had a patient sign an ABN but failed to do so, you should add modifier GZ (Item or service expected to be denied as not reasonable and necessary) to the CPT code describing the non-covered service the doctor provided. The advantage to reporting modifier GZ is to avoid the potential for fraud and abuse charges – by adding this modifier, you are telling Medicare that you know you carried out a non-covered service and you know they are not going to pay for it.

What the just-in rule means: Previously, your modifier GZ claims were potentially subject to complex medical reviews, which can slow claims and create logjams in your billing processes. But then the agency's new policy will ensure that these claims will be denied right away.

In writing: Effective for dates of service on and after July 1 this year, contractors shall automatically deny claim line(s) items submitted with a GZ modifier. Your explanation of benefits will list the denial codes CO and 50 (these services are non-covered services as this is not deemed a ‘medical necessity' by the payer.)

Plan beforehand: Do not allow yourself to resort to modifier GZ. You should have a policy in place to collect ABNs when necessary. For more on this and to read Transmittal 2148, visit a medical coding guide like http://supercoder.com/.

Coordinate With Surgeon to Get Your Rightful Reimbursement

When more than one doctor is involved in a patient's cataract care, ensure that diagnosis and procedure codes match up because if they don't, you will get a denial. Here are two pointers to get paid on time for cataract co-management.

Match codes in order to avoid denials

The first reason for cataract co-management denials is the OD reporting a different diagnosis code than the ophthalmologist. If the code doesn't match up, one of those doctors is going to be denied, experts warn.

Here's what you can do: Stay away from across-the-board use of 366.10 (Senile cataract, unspecified) and retrieve the exact diagnosis code from the ophthalmologist prior to sending out a claim.

For instance: If the ophthalmologist uses 366.13 (Anterior subcapsular polar senile cataract), the optometrist should also code 366.13.

Do not miss: The same applies to matching the surgical CPT code you both are reporting. While 66984 applies to the majority of cataract patients, once in a while, the procedure will be difficult and the surgeon will code 66982.

Good tidings: As 66982 has a higher relative value than 66984, the postoperative care will also reimburse the OD at a higher level.

Make it a point to append modifier 55 to either 66984 or 66982 to correctly represent the post-op services you have provided.

Good idea: Insert a note on the claim form explaining that any documentation required is available upon request. May practices have successfully used this technique to stay away from denials.

Gather accurate fees with surgeon's input

Yet another common co-management billing mistake is overlooking changes in the surgeon's fee structure. It is vital to stay in the loop when the ophthalmologist increases her fees so you can earn the total 20 percent of the Medicare allowable to which you're entitled for postoperative care.

But then: That would only apply if the surgeon was charging less than the Medicare allowable, which is unlikely.

Remember: Many a time, the surgeon will provide initial postoperative care prior to transferring the patient to the OD. In this situation, it is important to coordinate on the number of days each doctor is providing care and enter those numbers on separate claim forms.

Watch out: Does the surgeon keep each patient the same number of days prior to referring back to you? That may command attention from insurers. If the surgeon always sends the patient back to you after the one-week visit, payers may suspect that you have a deal with the surgeon.

Find your share: To find out the split, first calculate 20 percent of the overall charge for the service. After this, divide that total by 90, which is the cataract postoperative global period. This provides you the per-day value of the postoperative management service. In the units field, write in the number of days of service your OD provides, which, multiplied by the per-day rate, will yield your total charge for the service.

Tip: The OD can assume care on the day after the patient is last seen by the surgeon.

Call the surgeon after you see the patient to figure out if she's filing for postoperative care and, if so, how many days she'll report so that you can bill for the balance. This is also good time to remind that office to include modifier 54 on its claim form, or else you run the risk of the payer denying your co-management claim.

Give this a try: If the surgeon is not already using a postoperative form that covers all the bases, offer to help design one. A good form could show the surgery date, which eye the surgeon treated (if not both), the surgeon's postoperative care dates, and the number of days that represents. What's more, the form could point to the date and the OD assumed care, the initial refraction, and the resultant acuities. E-mail or fax this completed form back to the surgeon to share the record of the patient's continuing care.

Use 45990 for Rectal Exam with Anesthesia

In a particular case, the surgeon used a bivalve, suctioned the old blood from where a hemorrhoid had necrosed and fallen off; however the large vessel underneath was continuing to bleed (all done under anesthesia). After this he sutured the bleeding site. If you fail to find a proper CPT code for this, what should you do in this situation?

Well, the procedure described above is a rectal exam under anesthesia (45990, Anorectal exam, surgical, requiring anesthesia [general, spinal, or epidural], diagnostic). According to CCI edits, you shouldn’t report 45990 in conjunction with 45300-45327 (Proctosigmoidoscopy), 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 57410 (Pelvic examination under anesthesia), and 99170 (Anogenital examination with colposcopic magnification in childhood for suspected trauma).

Physician responsibility: Anorerctal exam is primarily done by placing the patient in left lateral decubitus position. This exam is chiefly done to study anal fissures, anal fistula, anal mass and hemorrhoids. The patient is provided general, spinal or epidural anesthesia and the physician carries out a diagnostic digital rectal exam by inserting a lubricated gloved index finger after relaxation of anal sphincter mainly to examine the perineal area. An ansoscope is inserted into the rectum to visualize the anal canal and distal rectum. Soon after removing the anoscope, a rigid proctosigmoidoscope is inserted to the anus to visualize sigmoid colon and rectal lumen.

Source URL :- http://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/reader-questions-consider-45990-for-rectal-exam-with-anesthesia-article

Know the Difference between Aerosol & Gaseous Ventilation

Not sure about the difference between aerosol and gaseous ventilation? Well, read on and find out the key differences between the two. Both aerosol (78586, 78587) as well as gaseous (78591, 78593, 78594) studies are part of the ventilation code series.

The ICD-9 code depends ( source "http://www.supercoder.com/icd9-codes/")  on whether or not the internist identified a cause.

Aerosol tests include the patient inhaling nebulized (reduced to a fine spray) aerosol agents with radioactive particles. The vital term to look for indicating aerosol is DTPA, the radioactive aerosol the provider has the patient inhale. Often times you would encounter other terms such as Technetium DTPA, particulate, and mist.

Physician's note for gaseous ventilation studies normally refer to the gas used, typically Xenon gas (such as Xenon-133 or Xe 133). One more possibility is Krypton gas (Krypton-81 or Kr 81), even though you may not see this much in practice.

CPT code further differentiates gaseous ventilation studies by whether the patient takes only a single breath or for that matter she does rebreathing and washout without plain oxygen. Rebreathing is inhalation of the gas exhaled earlier. 'Rebreathing' is inhalation of the gas exhaled previously. 'Washout' is the elimination of the radioisotope from the lungs. The xenon gas exams usually consist of three phases:

1. A single breath – the patient takes a single deep inhalation

2. Rebreathing – the patient takes normal breaths while rebreathing a mix of oxygen and xenon

3. Washout -- the patient breathes room air while exhaling the xenon, clearing the lungs of the radioactive gas.

For Modifier Details, Explore CCI, Fee Schedule

Scenario: In your day to day coding, you may sometimes get denials that appear to be related to bundling issues; however you may not find the two-day code pair in the CCI edits. How can you find out which is the column 2 code so that you can put the modifier on the correct code?

If you cannot find the codes listed in the Correct Coding Initiative (CCI) edit tables, then they are not bundled under that system. See to it that you check both the mutually exclusive and non-mutually exclusive edit tables.

If your code pair is not bundled under correct coding initiative, then you would not need a CCI modifier such as 25 (Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service), 57 (Decision for surgery), or 59 (Distinct procedural service), to override the edit pair.

You need to tread carefully: Just because a code does not have a bundle in correct coding initiative does not mean a modifier is out of the picture. While you will not need a CCI modifier to override the edit, you might need a payment modifier.

You can get Medicare's other allowed modifiers for any given CPT code in the Medicare Physician Fee Schedule (MPFS)(http://www.supercoder.com/coding-tools/fee-schedules). Columns Y-AC indicate if a modifier such as 50 (Bilateral procedure), and the like, applies. For more on this, sign up for a medical coding guide like Supercoder, which comes with a fee schedule tool to help you in your coding job.

Modifier 62: Ease Your Multi-Provider Coding Confusion

When you come face-to-face with multi-provider situation, the last thing you would want is to mess up your coding by assigning the wrong modifier(s). As such, you really need to know how to assign the proper modifiers.

Here's a scenario: A 70-year-old female patient who presents with COPD and coronary artery disease, status post myocardial infarction (CAD s/p MI) has a 28 mm of inner diameter thoracic aortic aneurysm. Imaging studies indicate the aneurysm to be descending. The cardiologist teams up with a thoracic surgeon and decides to perform an open operative repair with graft replacement of the diseased segment.

The key in a multi-provider scenario is to treat each physician's work as a separate activity. But then, deciding when to report a case as co-surgery, assistant surgery -- or something else -- has more to it than meets the eye. Here are some expert advice:

Modifier 62, 81, 82

In this situation, a modifier is at hand; but then, more importantly you should be able to tell what role each modifier plays so that your procedure codes blend well together. Take a look at these common modifiers used in multi-provider situations:

Modifier 62 (Two surgeons). Use this modifier to each surgeon's procedure when the physicians perform distinct, separate portions of the same procedure. Also called co-surgery, modifier 62 applies when the skill of two surgeons (normally of different skills) is called for in the management of a special surgical procedure.

Opt between modifier 80 (Assistant surgeon), modifier 81 (minimum assistant surgeon), and modifier 82 (Assistant surgeon [when qualified resident surgeon not available]) when one surgeon aids the other with multiple portions of the case rather than completing his work independently. What to look for? Ensure your physician indicates in his documentation that he is working with an assistant surgeon, what the assistant surgeon did, and why he or she was used during the case.

When you report a nonphysician practitioner's (NPP's) involvement to Medicare, attach modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery).

But remember that not all payers recognize modifier AS. You should verify the proper way to report the NPP's service before completing your claim.

Stay away from the modifier 51 trap

When you are coding for multiple procedures during the same operative session, it is easy to fall into the lure of using modifier 51 (Multiple procedures). However you could end up in the gutters if you are not careful enough.

Here's why: Modifier 51 tells you that a surgeon was present carrying out multiple procedures. If a surgeon is not present physically for multiple procedures in a surgical case, it is not proper to indicate that he was busy using modifier 51.

Two surgeons require two echo claims

In the given scenario, both surgeons should bill 33880. (Then, you'd use 441.2 (Thoracic aneurysm without mention of rupture) with 33880 to describe the condition. Finally, you should use modifier 62 to 33880 to show that two surgeons performed the repair.

Catch: You do not use modifier 62 if the physicians are not reporting the same CPT code(source"http://www.supercoder.com/cpt-codes"). If each doctor can represent his work with a separate CPT code, leave out modifier 62. Ensure both surgeons send a claim with the same code and modifier declared or you would end up throwing away about $4,000 in reimbursements (56.62 RVUs multiplied by 2011 conversion factor of 33.9764; $1,923.74 for each surgeon).

CCI Edits - Codes You Shouldn't Pair

Sometimes you might not be able to find your two-code pair in the CCI edits. How would you know which code would be considered as column 1 code and which would be considered as column 2 code in order to put your modifier on the proper code?

If the codes are not listed, the codes are not bundled under the CCI (Correct Coding Initiative ) edit pairs. For that reason, most likely you would need a CCI modifier such as 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), 57 (Decision for surgery), or 59 (Distinct procedural service), to override the edit when required.

A private payer could have a black box edit, though. You need to check with a rep for a recommendation. To add to it, the CCI manual and CPT guidelines may offer broad instructions on types of services that normally should not be reported together. You should also be sure you check both non-mutually exclusive and mutually exclusive CCI edits.

But remember that just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. Even if you do not need a CCI modifier to override an edit, you might need a payment modifier for a code.

You can get Medicare's other allowed modifiers for any CPT code that is in the Medicare Physician Fee Schedule (MPFS). Columns Y-AC point to whether certain modifiers such as modifier 50 apply.

Article source :-  http://www.supercoder.com/coding-newsletters/my-cardiology-coding-alert/reader-questions-look-beyond-cci-for-codes-you-shouldnt-pair-article

CPT 2011 Provides Revised Debridement Code Guidelines Latest CPT comes to your rescue with revised debridement code guidelines that explain how to cho

Latest CPT comes to your rescue with revised debridement code guidelines that explain how to choose between the two code groups.

Not sure when to go for a debridement code and an active wound code? Well, the latest CPT comes to your rescue with revised debridement code guidelines that explain how to choose between the two code groups.

According to Chad Rubin, MD, FACS, American College of Surgeons AMA Specialty Society Relative Value Scale Update Committee (RUC) Alternate Member with Albert E. Bothe, Jr. MD, FACS, American College of Surgeons, AMA CPT Editorial Panel Member, ""Depth is the only documentation item you need to determine the proper code."

Active wound care (which has a 0 day global period) is for active wound care of the skin, dermis, or epidermis. For deeper wound care, go for debridement codes in the proper location.

For instance: Codes 11040 and 11041 have been shown the door this time. The parenthetical note under the codes' deletion reads, "For debridement of skin, i.e., epidermis and/or dermis only, see 97597, 97598."

The codes are then revised to mirror the change. For example, 11042 removes "Skin, and" and adds after subcutaneous tissue "includes epidermis and dermis, if performed."

Code 97597's revision involves "mainly rewording to make clear how active wound care is separate from integumentary wound care."

The latest CPT code set includes guidelines that indicate two requirements for active wound care management. These guidelines focus on:

Intent: "Active wound care procedures are performed to remove devitalized and/or necrotic tissue and promote healing."

For further information on when to choose a debridement code and an active wound code as well as on the latest CPT changes (http://www.supercoder.com/cpt-codes), sign up for a medical coding guide like Supercoder!

Supercoder give you ways to boost your Hemoccult Test Coding.

If you want to keep the money coming for in-office examination of fecal occult blood test (FOBT), you should train eyes on the difference between three hemoccult codes and their purpose.

Here's a scenario:

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

Assign the right code for each type of collection

Since the year 2007, CPT has assigned two codes that you can use for post digital rectal exam (DREs) and consecutive specimen collection:

82270

82272

Update: With effect from January 1, 2007, CPT has terminated HCPCS code G0107 and replaced by 82270 even for routine Medicare screening FOBT.

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

Do not forget: There are interval limitations for screenings established by Medicare and most commercial carriers.

On the other hand, if a patient presents to the office with symptoms, the gastroenterologist would carry out a diagnostic FOBT, and you should bill it with 82272. One can bill CPT 82272 if 1 to 3 specimens are obtained. The diagnosis code for the test would be related to the patient's presenting symptoms.

Count number of tests

If you are still not sure whether you have got the right code by differentiating screening from diagnostic, you can look further into the test's details. Identify how many tests the gastroenterologist or lab performs. For a three-specimen collection, you would go for 82270. Use a single-specimen collection with 82272.

Red flag: Even though 82270 involves analysis of three specimens, you should always assign 82270 with a “1" in the units field. Some coders incorrectly interpret 82270's descriptor of “one to three simultaneous determinations" to mean they should bill “each of the three determinations with one unit of CPT 82270 (82270 x 3)." The revised description more clearly reminds providers that the code identifies as many as three consecutive determinations.

What if: The patient fails to collect all three samples. You may still bill 82270. If this happens, the laboratory should carry out analysis of the one or two collected specimen, report the results accordingly and record one unit of 82270.

Determine who obtains the sample

Where the sample is collected and who performs it can also include you in to the right FOBT code. CPT Code 82270 will always be billed as a separate service when the developer has been placed on the cards after the three completed cards (or one completed triple card) have been returned to the office. In a nutshell, the doctor should not collect the specimen in the office.

Instead you should use 82272 when the doctor carries out a digital rectal exam in the office and obtains a sample at that time.