CPT Coding for Sphenopalatine Artery Ligation

Endoscopic transnasal approach for ligation of the sphenopalatine artery may be the surgical technique of choice for control of a severe epistaxis when traditional treatment has met with failure. But the fact is there's no CPT code for this operative procedure.

Let us say a patient with coagulopathy has epistaxis which hasn't been controlled with nasal packing. The bleeding takes form from the posterior nasal cavity of the posterior ethmoid artery or a branch of the sphenopalatine artery. In order to put a check on the nose bleed, the otolaryngologist decides to carry out an endoscopic transnasal sphenopalatine artery ligation.

When you are left with a definitive CPT code to describe the procedure, you should look at other similar CPT codes, and try to work around it.

31238: You should upgrade Endoscopic Control of Nasal Hemorrhage with Modifier 22. You can report 31238 for endoscopic transnasal sphenopalatine artery ligation appended by modifier 22.

But even though 31238-22 is a practical and accurate coding choice, payer reimbursement may be lower than what surgeons feel is constant with the associated physician work: about $200.46.

31299: You may also choose to go for unlisted procedure code 31299. Some coders would actually recommend this option; however you should be careful of the mistakes. They need appeal with documentation explaining what was done.

Documentation requirements may prove to be difficult. Practices aren't sure about what charge to attach to the unlisted code. While declaring a charge benchmark, you should choose a reasonably close existing code and give justification for its use.

Some experts are of the opinion that an unlisted code when carrying out a procedure that has a CPT code for an open approach however doesn't have a CPT code for an endoscopic approach. Why? Because there's no way for the RUC to account for the relative units associated with this endoscopic approach when and if a new CPT is created for the endoscopic approach.

Tip: While submitting an unlisted code, make it a point to ask your physicians to include information at the top of the operative note explaining the procedure and listing a comparable procedure and code for setting payment.

Also, make a habit of attaching a detailed operative note to your claim since it'll be subjected to a strict medical review. What's more, a cover letter explaining in lay language what services were carried out and the justification for the charge submitted could help you escape potential denial or audit.

863XX & 873XX are two new CPT Codes For linical Lab Test

As we get ready to enter the final quarter of this year, the talk that's taking center stage now is the CPT 2012 code changes.

Two new 2012 CPT codes made its debut at the annual CMS laboratory public meeting for pricing new test codes for payment on the clinical laboratory fee schedule (CLFS). One of them is if your lab runs a single-result test for HIV-1 antigens and HIV-1/HIV-2 antibodies, you'll have a new code to use in the coming year.

More on the horizon? Not really. This year there were five codes on the agency's 'reconsideration request' list. Even though this year's meeting featured much discussion about drug test coding there were no new codes on the horizon.

In the coming year, you can expect these two just-in clinical lab test codes (although numbering is yet to be determined). These codes will provide more specific reporting for newer tests you may have added to your menu.

863XX -- Nuclear Matrix Protein 22 (NMP22), qualitative

873XX -- HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result

Drug Testing
Apart from pricing recommendations for the just-in codes, the agency heard public comments for reconsideration requests for these CPT codes 2011: G0434, G0435, 86481

Drug screen: Many commentators suggested altering G0434 to include only CLIA waived tests while coming up with a new CPT code for moderate complexity tests priced at four times G0434. The present grouping under G0434 fines clinical labs that carry out these tests using instrumented moderate complexity systems. This instrument provides clinical advantages like higher specificity that commentators said shouldn't be disheartened by coding and reimbursement.

Pricing proposal

The agency received industry input during the July 18, 2011 public meeting for the new codes. You can get CMS's proposed payments at www.cms.gov/ClinicalLabFeeSched/ and you can make comments on the recommended pricing. The agency will post final payment determinations on the same website in October this year.

Almost everyone at the public meeting expressed their willingness for crosswalks for the new CPT codes.

The AMA proposed 101 new CPT 2012 codes for molecular assays in cancer, genetics and histocompatibility all right, however CMS will not consider setting prices for those codes on the CLFS in 2012 since they were not under consideration at the public meeting.

67840 or 11440 - Which is the Right CPT CODE for Lesion Removals?

In a particular situation, your ophthalmologist takes off lesions from a patient's eyelids. While doing so, you may find yourself embroiled in a dilemma that you can solve only by assessing the physician's notes. You need to figure out whether the procedure is an integumentary procedure or an eyelid surgery procedure.

The answer determines whether you should turn over to codes 11440-11446 in your CPT manual or whether you should instead look at 67840. Your code selection depends on the number, location, type and size of the lesions. Take a look at these expert tips so that you make the right choice every time:

First step: You need to dig into your ophthalmologist's procedure documentation to figure out which code set you should go for. As a simple rule, you should go for 11440-11446 if the excision involves mainly skin.

To report 67840, see to it that the surgery involves more than the eyelid's skin. Say for instance, the procedure might involve lid margin, tarsus and/or palpebral conjunctiva.

Here's a CPT coding tip: Choose the proper lesion excision size code based on the report of the ophthalmologist. If the doctor does not measure the lesion before he cuts it out, he is bringing down the reimbursement in half.

Remember: Choosing the most appropriate CPT codes to describe the physician's work is the motivating factor behind your code assignment determination. As such, you should never base your code selection on reimbursement value.

Malignant in comparison to benign matters too

Step two: When your ophthalmology carries out an eyelid lesion excision that involves the eyelid mainly, you know you should go for the integumentary lesion excision codes.

The next question is which code in this section you should go for.

Well, for benign lesions, you should go for 11440-11446 while for malignant lesions you should turn to 11640-11646. Since a lesion's nature can be very deceptive based on the visual examination, you should always wait for the pathology report prior to billing the excision. Then choose your code based on the pathologic findings and the lesion size.

Bear in mind: You shouldn't use lesion excision and/or repair codes for skin tags. There are different codes for skin tag removal.

Multiple-lesion pitfalls to watch out for

Ophthalmologists will not always excise just one lesion at one go. As such you will face one more coding challenge when your physician does away with multiple lesions. Since 67840 is an excision code, which means you report it by the lid you can't report it with units – quite unlike the integumentary codes.

CPT Codes 2011: A Lowdown on Femoral Popliteal Service Codes

2011 has lots of changes as far as CPT codes and guidelines for your cardiology services are concerned. Here's a lowdown on this year's CPT codes that'll stand your cardiology coding in good stead.

Among the key changes, CPT 2011 has added new codes for lower extremity endovascular revascularization which includes angioplasty, atherectomy and stenting. This year's femoral/popliteal service codes include 37224 for angioplasty, 37225 for atherectomy (and angioplasty), 37226 for stent (and angioplasty) and 37227 for stent and atherectomy (and angioplasty).

Generally, for 37224-37227, you should go for one code that represents the most intensive service carried out in a single lower extremity vessel. Say for instance when the cardiologist carries out a stent placement, atherectomy, and angioplasty in the left popliteal vessel, you should use only 37227. This code includes stent placement, atherectomy, and angioplasty. In this situation, you shouldn't use the three codes 37224, 37225, or for that matter 37226 separately or in addition to 37227.

Territory rule:

This year's CPT codes - 37220-+37235- apply to different 'territories' and each territory has its own specific set of guidelines. The codes - 37224-37227 - fall under the femoral/popliteal vascular territory.

Important rule: According to CPT, the whole femoral/popliteal territory in 1 lower extremity is taken as a single vessel for CPT coding.

As such, you should go for a single code even if the cardiologist carried out various interventions for several lesions in the political artery and in the common, deep, and superficial femoral arteries in the same leg during the same session.

In situations like this, you should use the code for the most complex service. Say for instance if the cardiologist carries out angioplasty in the left popliteal artery and atherectomy in the left common femoral, you should go for atherectomy code 37225 only.

Remember: The codes are unilateral, which means they apply to a service on a single side of the body. According to CPT, if the physician treats the identical territory in both legs at the same session, you should go for modifier 59 (Distinct procedural service) to indicate both legs are involved.

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Five Strategies to Ease Your Sports Exam Coding

Getting calls all year-round from parents requesting sports physicals for their children might be a common feature for your pediatric practice. Even though the physical may be fairly simple to carry out, it is not always straightforward to code.

If you are clueless about how to code a sports exam, think about these choices that will put your CPT coding on the right track while dodging non-payment issues.

Perform less and code office visit

When a pediatrician provides a true sports exam, CPT offers no direct match. Pediatricians may provide a shortened well-care visit, in which they assess the risks, perform an exam, and order vaccine and labs.

Encourage full well check

In order to avoid V70.3 non-coverage issues, try to schedule patients for preventive medicine services rather than for sports physicals. Sometimes parents misinterpret the sports physical as the child or adolescent's complete annual physical examination. Having the patient come in for the annual ensures she gets the full service.

Consider forms policy

For patients who have received a recent preventive medicine service, think about using that information to complete a sports form. Few pediatric practices have a set fee the patient pays for this service such as a $20 forms fee.

Some practices will include completion of forms at the time of an E/M visit; however charge if the forms are brought in at another time. There's additional office overhead involved if the chart must be pulled and reviewed, the form completed, mailed, or faxed, and the chart refiled.

Drawback: For liability reasons, your physician may not want to issue a form without checking the patient to see if his status has changed.

Charge parent

When a parent insists or the school calls for an abbreviated exam on a patient who has not had a well check in the previous half of the year, you might want to put into practice a financial plan. Physicals required for sports are normally the patient's responsibility. Insurers normally do not cover the service.

Best practice: If you expect the insurer will not cover the sports physical, have the parent sign an advance beneficiary notice (ABN). Ensure the parent understands she will have to pay if the insurer does not cover the sports exam, and notify her of the price.

Tool: You can use a private payer version of Medicare's form to educate the parent and ensure she is aware of her choices and responsibilities.

Check state scope of practice laws

Once you decide on the best strategy for your practice, confirm that your state allows you to use that technique. For instance, certain states publish guidelines indicating that a physical done within the last 12 months is enough and the patient does not require an updated form, whereas other states need children to bring in new forms for each individual sport they intend to play.

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Increase your Coding Options for Patients Refusing Dilation

A patient shows up for an exam, however he won’t let the ophthalmologist dilate his pupils that day. Whatever the reason – time, the drive home, etc, you are stuck trying to find the best way to report a dilation at a separate visit.
Most Medicare carriers assume that a dilated fundus exam will be part of any comprehensive eye exam you carry out and bill with 92004 or 92014.

Without dilation, you cannot carry out the fundus exam and without the fundus exam, you don’t have a comprehensive service.

Count two visits as one service

According to CPT, a comprehensive ophthalmological service “often includes" examination with dilation, therefore dilation is not necessarily required to bill 92004 or 92014. But some payers and state specific guidelines may have their own dilation requirements. For instance, according to Trailblazer, the 92004/92014 exams should be done under dilation unless “medically contraindicated. Check with your carrier if you get a denial you think is unfounded.

Do not submit bill until second appointment

The real challenge comes into play when you are expecting the patient to come back for the dilated exam and he never shows up. This’s a difficult situation as you do not want to bill for services not rendered, nor do you want to undercode a visit.

If you bill the insurance company for the initial visit before the time of the second visit, and the patient does not show up, document carefully that the patient refused dilation on the first visit, scheduled a return visit and then refused to keep the appointment. But then it is not recommended to bill for services that have not been rendered or refused by patients under any circumstances.

Better idea: Do not file the claim until the second appointment. You could downcode to a 92002/92012 (intermediate service) if the patient failed to show up and you wouldn’t have to pursue the patient to return. You couldn’t bill the comprehensive codes in this case as the first visit didn’t include a dilated fundus examination.

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