Medical Billing: PMFSH Tips to help you Stay Away From Denials

If you're not billing higher level evaluation & management services because your physician glosses over a patient's PMFSH, you could be missing out on your reimbursements.

Here are some medical billing tips to ensure your physician is capturing and you are recognizing every history component the patient points out:

First, find out the PMFSH level – none, pertinent and complete

For medical coding and billing ( Source "http://www.supercoder.com") purposes, the history part of an evaluation & management service needs these three elements – history of present illness (HPI), review of systems (ROS), and past medical, family and social history (PMFSH). As such, the PMFSH helps determine patient history level, which has a huge impact on the evaluation & management level you report. Not knowing the PMFSH level will mean you'll not be able to decide which level of evaluation & management code you should report on the claim.

Second, zoom in on a code based on the PMFSH Element Requirement

After you determine the level of PMFSH contained in your physician's documentation, you can see which codes that history element supports.

Note of caution: If your physician doesn't document any PMFSH elements, you can only reach an extended problem-focused level of history; this means the highest codes you will be able to report are a level-two new patient code or a three-level established patient code. In order to get a level-four and level five new patient visits and level-five established patient visits, it's essential to have an all-encompassing level of history.

Third, do not neglect these areas

As per evaluation & management guidelines, if a patient's past medical, family and social history has not changed since a prior visit, your physician need not document the information once more. However, it's important that he documents that he reviewed the prior information in order to ensure it's up to date and also note in the present encounter's documentation on the date and place of the initial prior acquisition of the PMFSH. In fact if you neglect any of these criteria, some payers will give no PMFSH credit.

Joining an ACO Will Benefit Practices: CMS Outlines How

Going by the "shared savings program, accountable care organization (ACO) participants will collect a part of the amount the agency saves.

You have probably heard about Medicare's proposed 'shared savings program,' which will utilize ACOs to boost patient outcomes and bring down costs. However, that changed this week as the agency announced that it wrote a proposed rule for the program outlining what it'll cover.

What are ACOs?

ACOs aim to use coordinated care between health care providers to put the 'beneficiary and family at the center of care'. ACOs include several healthcare professionals who work together, including physicians, hospitals, and other members of the patient's care team. This 'case management' approach is meant to offer patient-centric care, thus resulting in better outcomes and lower costs.

As per the proposed rule, that appeared in the April 7 Federal Register, health care providers who participate in ACOs will be rewarded since Medicare will link payment rewards to patient outcomes. For example, the proposed rule notes that providers should be accountable for the cost of care, and be paid for reducing unnecessary expenditures and be responsible for excess expenditures.

Healthcare providers won't be required to join ACOs, however those who join will share the funds that CMS saves by using the system. Physicians will gather their portion of the shared savings as bonuses under the system. The ACOs are eligible to share in savings up to 52.5 percent under the one-sided model; however up to 65 percent under the two-sided model.

The one-sided model refers to a standard shared savings kind of plan in which ACOs wouldn't be responsible for any portion of the losses above the expenditure target. The agency recommends this model for "ACOs not immediately ready to accept risk, say for instance, physician-driven organizations and smaller ACOs, the proposed rule points to.

While the two-sided model explains a shared savings/losses plan, in which the ACO would share in savings and risk liability for any losses. All one-sided ACOs will mechanically become two-sided ACOs by the third year of the program.

ACOs would gather their bonuses based on how they meet 65 quality performance standard measures separated into the following five categories:

Patient/caregiver experience

Care coordination

Patient safety

Preventive health

At risk population/frail elderly health

You can submit comments on the ACO program through early June through email to www.regulations.gov or through the mail.

37228-+37235: Four Steps to get TP trunk Services Pay

With a new section for endovascular revascularization in this year's CPT, you'll need to ensure your practice is up to date while billing for tibial/peroneal revascularization services.

Remember initial/additional designation

CPT 2011 divides the just-in codes by initial or additional vessel -- each including angioplasty in the same vessel, when the surgeon performs it -- as here:

Initial vessel: The first four codes apply to the initial tibial or peroneal vessel treated in a single leg:

Angioplasty: 37228

Atherectomy (and angioplasty): 37229

Stent (and angioplasty): 37230

Stent and atherectomy (and angioplasty): 37231

Additional vessel: Report the remaining four add-on codes to report services on each additional ipsilateral (same side) vessel treated in the tibial/peroneal territory:

Angioplasty: +37232

Atherectomy (and angioplasty): +37233

Stent (and angioplasty): +37234

Stent and atherectomy (and angioplasty): +37235
Revascularization general rule: You should report the one code that represents the most intensive service performed in a single lower extremity vessel. All lesser services in that vessel are included in that one code.

Count vessels carefully – more so for TP Trunk

The just-in revascularization codes (37220-+37235) apply to different "territories." Each territory has its own specific set of guidelines. Codes 37228-+37235 come under the tibial/peroneal vascular territory.

The tibial/peroneal arteries include anterior tibial (AT), posterior tibial (PT) and peroneal. This means the just-in codes relate to three vessels in each leg for the tibial/peroneal territory. Since you may report one code per vessel, you may use one initial code and up to two add-on codes per leg (for a total of three vessels). The three-vessel approach is somewhat similar to the iliac territory; however differs from the femoral/popliteal territory, which counts as a single vessel for coding.

Master coding for two legs or two territories

The just-in revascularization codes are unilateral, which means they apply to a service on a single side of the body. CPT indicates that if the doctor treats the identical territory in both legs at the same session, you should add modifier 59 (Distinct procedural service) to show both legs are involved.

However, watch out for payers' modifier preferences. Some may prefer you to use modifier 50, modifiers RT and LT or some combination of modifiers for procedures on both legs.

On the contrary, If the surgeon treats more than one territory in the same leg, you should report multiple codes, says CPT.

Consider included services

According to CPT guidelines, the endovascular revascularization codes include these services: accessing and catheterizing the vessel, crossing the lesion, any radiological supervision or embolic protection, arteriotomy closure, and imaging of the completed intervention.

Extras: If the doctor caries out mechanical thrombectomy (such as 37184-+37185, primary, or +37186, secondary), thrombolysis (such as 37201, 75896), or both to restore blood flow to the occluded area, according to CPT, you may report those services separately.

Article Source :- http://www.supercoder.com/coding-newsletters/my-general-surgery-coding-alert/cpt-2011-37228-37235-4-steps-garner-tp-trunk-services-pay-article

CPT Provides you An Assist on Multi-arthroscopy Encounters

In a particular situation, my orthopedist carried out a medial and lateral meniscectomy on a patient, and also performed a synovectomy in the patellofemoral compartment. Because the arthroscopic procedures were carried out in separate knee compartments, is it possible to code for their procedures or do I have to select one? Well, you should be able to report both procedures. You should report the following on the claim:

29880 (Arthroscopy, knee, surgical; with meniscectomy [medial AND lateral, including any meniscal shaving])

29875 (… synovectomy, limited [example, plica or shelf resection [separate procedure]]) for the synovectomy

modifier 59 (Distinct procedural service) added to 29875 to show that the synovectomy and meniscectomy were different services. Explanation: In case the payer challenges the appropriateness of this coding, note this guidance from the August 2001 CPT Assistant: Arthroscopic synovectomy is reported using 29875 and 29876. Limited synovectomy (29875) involves resection of the synovium and may cover partial resection of the plica of one knee compartment… 29875 is designated as a "separate procedure". Normally, codes with the 'separate procedure' designation would not be additionally reported when the procedure or service is carried out as an integral component of another procedure or service. But then when a procedure or service designated as a separate procedure is carried out independently or is thought of as unrelated or distinct from the other procedure(s) or service(s) provided at the time, then it would be proper to report the code in combination with the other procedure(s) or service(s). Modifier -59, Distinct Procedural Service should be added to the separate procedure code to indicate that the procedure was distinct from the overall procedure. For instance, if the knee arthroscopy with limited synovectomy were carried out in a different knee compartment than another knee procedure, modifier 59 would be added to code 29875 to show that a different compartment was involved. For more on this and for other medical coding updates regarding orthopedic coding, sign up for a one-stop medical coding guide like Supercoder.

Article Source :- http://www.supercoder.com/coding-newsletters/my-orthopedic-coding-alert/you-be-the-coder-cpt-gives-you-an-assist-on-multi-arthroscopy-encounters-article

Hold vaccine claims or submit them now?

You should contact the provider relations department directly if your insurer has not said a peep about whether it'll accept the new vaccine administration codes 90460-90461.

If you want to find out which payers are reimbursing for vaccines, get in touch with all of the payers with whom you're contracted and enquire them for specific advice on the just-in codes. What's more, it is recommended that offices only send a few claims to see how they are processing before they send hundreds and find out that they're all denying.

Blue Cross and Blue Shield of Georgia has the just-in codes loaded into its systems for all claims with dates of service on or after January 1 this year. However the insurer had initially asked practices not to submit claims until February 3. If you had billed the just-in codes before February 3, the system would have denied the second or third unit of 90460 or 90461 as a duplicate and you would have had to call the claims department and have the claim reprocessed for correct payment.

The claims systems for Aetna, Guardian, Taylor Benefit Systems, Humana, and Coventry Health Care are all ready to accept the vaccine claims for all DOS effective January 1, 2011.

The United Health Care website indicates that practices should not use the just-in codes until April 1; however a UHC rep said that this information was posted to the Website mistakenly. According to the UHC website, you will have to rebill all of those claims with the just-in administration fees and write ‘corrected claim' at the top of your claim form.

Source URL :- http://www.supercoder.com/coding-newsletters/my-pediatric-coding-alert/practice-perspective-get-to-know-whether-to-hold-vaccine-claims-or-submit-them-now-article

Know the Pneumonia Diagnosis Difference

Do you know the difference between 'lobar pneumonia' and 'lobular pneumonia'? When there's no further clarification from the physician, is code 481 (Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]), which includes lobar pneumonia, organism unspecified, the right code assignment for both "lobar pneumonia" and "multilobar pneumonia?" When should you report 481 versus 485?

A patient with lobar pneumonia has pneumonia that impacts a large and continuous area of the lobe of a lung. A patient who's diagnosed with lobular pneumonia, or bronchopneumonia, has an acute inflammation of the walls of his bronchioles, affecting many small areas of his lung tissue rather than the large area affected by lobar pneumonia.

One more distinction between 481 and 485 is the cause. Code 481 is for pneumonia in which the causative agent happens to be pneumococci. Compared to this, code 485, "Bronchopneumonia, organism unspecified" is an unspecified code used in situations where the causative agent isn't mentioned.

Multilobar pneumonia impacts more than one lobe of your patient's lungs and is a more serious illness than lobar pneumonia. Absent any additional details about your patient's pneumonia, you'd list 481 for either lobar or multilobar pneumonia. But then the most spot on code for pneumonia of any type should be determined by the physician, in part based on the casual organism.

You will list 485 (Bronchopneumonia, organism unspecified) when your patient has lobular pneumonia, however you're unable to figure out the causative organism.

Know More about Modifier KK on Your Pet Oncological Claims

You bill the global service for NaF-18 PET scans for bone mets. Are you supposed to add modifier KX to these claims for Medicare?

Well, the answer is no. Since you are reporting the global service, Medicare does not require you to append modifier KX (Requirements specified in the medical policy have been met).

In transmittal 2096, CR 7125, CMS published the guidelines on coding these services (including a helpful chart showing which tracer codes pair with which PET codes).

TC/global: When you report a global or technical only claim with A9580 (Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries) and an NaF PET service to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis, the transmittal instructs carriers to process claims that cover all of the following (apart from A9580).

One of these modifiers:

PI (Positron emission tomography [PET] or PET/ computed tomography [CT] to tell about the initial treatment strategy of tumors ) or

PS (Positron emission tomography [PET] or PET/ computed tomography [CT] to tell about the subsequent treatment strategy of cancerous tumors )

modifier Q0 (Investigational clinical service provided in a clinical research study).

Professional component (PC): When you use modifier 26 (professional component) and modifier KX on your PET oncologic claim to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis, the transmittal instructs carriers to process claims that include all of the same items in the bullet list mentioned.

The difference: Code A9580 belongs only on global and technical claims. Carriers will reject professional claims for A9580 as the assumption is that the facility (the entity providing the technical part of the service) bears the cost of the A9580 agent and should be paid for it.

The presence of modifier KX on the professional claim shows contractors they should process the service as PET NaF-18 rather than PET with FDG.