Tactics to Stay Away From Irrational Denials

Your steps in fighting for your claim could make or mar your practice's chance for a fair reimbursement.

Sometimes you may be in a situation where you wanted to contest a denial by an insurance company based on irrational payer guidelines. There's no doubt that it may seem like trying to break down a stone wall, however you are not helpless to change the situation to your favor.

As such what can you do here? Your steps in fighting for your claim could make or mar your practice's chance for a fair reimbursement. But then the insurance company can set any rules it wants and you are forced to play by them when your doctors sign the contracts. Nevertheless, you can still walk past the barriers by following these tactics.

The first and foremost thing you need to do is to get a copy of your contract and see what degree of latitude your payer can take relative to AMA and CMS coding rules. If the insurer is violating what's set forth in the contract, use the contract in your appeal to fight this arbitrary policy and get it overturned.

If the contract is silent on this or allows such arbitrary use of rules in favor of the payer, you should gear up to drop the payer as one of your participating payers. Do not get jittery – be all set to drop them in this stage.

Third, conduct a meeting between your physicians and the medical director. Enquire the medical director to justify this policy in clinical terms as to why the insurer doesn't reimburse a physician for the diagnostic colonoscopy and the removal of polyps when you apply modifier 59 (Distinct procedural service) to indicate different sites. Enlighten on the fact that breaking the colonoscopy and the biopsy into multiple sessions will make the payer incur multiple facility fees, multiple anesthesia sessions as well as the physician professional fees.

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.

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

Obama Budget to Delay Medicare Cuts for Two More Years

Last December, Part B practices heaved a sigh of relief when Congress froze Medicare payments at 2010 levels throughout 2011. And because of that vote, you have not had to deal with the potentially devastating 25 percent cuts that you would have faced on January 1 this year.

However the cuts are still poised to take effect next year. Until and unless of course Obama's new budget proposal clears administrative barriers.

On February 14 this year, the White House Office Management and Budget made its new budget proposal public. Accordingly, this would delay Medicare cuts for a couple of years more, through December 31, 2013. The pay cuts would still kick in as of 2014; however physician advocacy groups hope that a lasting solution to the Medicare payment issues (http://supercoder.com/)will be established by then.

According to a statement from Office of Management and Budget director Jack Lew, "In December, there was a bipartisan agreement to pay for a one-year extension of the so called 'doc fix,' which was not needed by budget rules; however was the right thing to do." "Building on that, our budget identifies $62 bn of specific health savings to pay for the coming two years of this fix, establishing a clear pattern that, consistent with our budget, this needs to be paid in the times to come.

Aside from this, Obama's budget proposal also includes $250 M in grants to states to reform the way medical liability disputes are resolved. The Department of Justice would award the grants with the Department of Health and Human Services.

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.

Stay Away From a 'Finders Keepers' Overpayment Mentality

Scenario: We found out that a patient overpaid us on her co-pay. We gathered $50, which was the last co-pay we had on record. It turns out that the patient's plan changed but is still under the same payer. However, her co-pay is now only $25 for an office visit. In this case, can we just credit her account or do we need to issue a refund?

Answer: You do need to issue a refund to the patient; however how you do that is up to the patient. As soon as you find out that a patient has overpaid you, your practice should notify the patient.

You cannot hold onto the money for an indefinite period of time.

You can credit the patient's account, however only if the patient agrees to that. If the patient will be returning your office you can suggest that you apply the overpayment as a credit toward the patient's co-payment for the next visit. But again if the patient does not want to apply it toward a future visit, you must return the overpayment.

You should offer two options:

A credit on the patient's account that you'll apply to future services

A refund of the overpayment

You may find it easier to just send the overpayment amount back to the patient with a letter explaining the situation, rather than notifying the patient and discussing options. Go for whichever process works best for your practice.

Bottomline: You cannot and shouldn't keep an overpayment – from a patient or a payer. That practice may land your provider into big trouble. The pact to return any overpayments is fundamental to a provider's eligibility to participate in the Medicare program. Section 1866(a)(1)(C) of the Social Security Act (42 U.S.C. § 1395cc) calls for participating providers to furnish information about payments made to them and to refund any payments paid incorrectly. The 2010 Patient Protection and Affordable Care Act creates new obligations under the False Claims Act (FCA) whereby a Medicare provider who fails to report timely amd refund an overpayment may be subject to substantial damamges and penalties.

Article Source :- http://www.supercoder.com/coding-newsletters/my-optometry-coding-alert/reader-questions-avoid-a-finders-keepers-overpayment-mentality-103512-article

CMS Announcements and Pecos Edits

According to CMS, it may not deny Provider Enrollment, Chain and Ownership System (PECOS) claims starting this month. But then there are two contradictiory statements doing the rounds. Find out which one to believe.

You may or may not meet claim denials this month owing to PECOs edits, depending on which CMS announcement you read.

Background: Presently, if you submit claims for services or items ordered/referred and the ordering or referring physician's information is not in the MAC's claims system or in PECOS, your practice will get an informational message letting you know that the practitioner's information is not there in the system. Earlier, it was believed that CMS would start denying these claims on January 3: however now that's up in the air.

Last November, CMS distributed an email that the agency referred to as an 'Important Update on PECOS and Ordering/Referring', in which CMS noted, "While there are some rumors that the edits will be turned on this month, we want to emphasize that the agency has not announced any date as to when ordering /referring edits will be turned on.

In writing: Even though the agency now clearly denies ever announcing that claim rejections would begin on January 3, MLN Matters article MM6417, which CMS distributed on Feb. 26, 2010, stated "Effective January 3, 2011, if the ordering/ referring provider is not in PECOS, the carrier or Part B MAC will search its claims system for the ordering/referring provider. If the ordering/referring provider is not in PECOS and is not in the claims system, the claim will be rejected."

So which CMS statement to believe? At this juncture, the agency seems to be indicating that you may not face ordering/referring denials this month, despite the earlier MLN Matters article to the contrary. Your best choice is to ensure that you and your ordering/referring providers are in PECOS as soon as possible, just in case the MAC edits become a reality.

For more on this and for other coding updates, sign up for a medical coding guide like Supercoder.com

Two New Codes for Diabetic Food Ulcer Treatment

CPT will come up new codes in 2011. The new codes are G0440 and G0441

As we go into the new year, the talk that's doing the rounds most among the coding community is the Cpt Code changes. CPT will come up with over 200 new codes with the purpose of helping you code more accurately. These changes will have an affect on several categories, and podiatry is no exception.

For podiatry, there are two new codes to report diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity.

The new codes are G0440 (Application of tissue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; first 25 sq cm or less) and G0441 (…each additional 25 sq cm) that'll put an end to the confusion providers put forth the different global periods for two tissue cultured skin substitute codes.

To cite an instance, a patient presents to the office with a history of diabetes and neuropathy. For the past six weeks, he has been treated for an ulcer with minimal results from standard conservative care. An exam shows an ulcer under the fifth metatarsal head. The ulcer measures one cm in diameter and shows necrotic tissue at the base. The podiatrist carried out a debridement, sharply removing it with scalpel and picking up at the skin margins and necrotic tissue. There's no exposure of the muscle or bone. If the podiatrist prepared for an application of Dermagraft or Appligraft, placing the substance in sterile normal fashion and then bandaging in standard fashion, you would use G0440.

For further details on this and to get all updates on how the CPT code changes (http://www.supercoder.com/cpt-codes) are affecting your specialty, sign up for a medical coding guide like Supercoder!

Congress Goes Ahead With One-Year Medicare Pay Fix

President Obama passed a bill that will freeze medical pay at present levels for another 12 months.

The new legislation helps you avoid the scheduled 25 percent drop in Medicare pay for the new year.

The up and down ride of conversion factor changes for 2011 has come to a conclusion thanks to a Senate Finance Committee bill that'll freeze Medicare pay at present levels for another 12 months.

The House of Representatives passed the Medicare and Medicaid Extenders Act of 2010 on December 9 and the Senate voted on it the day before. The bill will do away with the 25 percent cut that medical practices were going to face from January 1. President Obama made it official on December 15, 2010 when he signed the year-long delay into law.

Doctors cheered the news that they will not have to wait for the new Congress and Senate members to take their seats prior to finding out whether a payment fix would take place.

The bill passed as a bipartisan effort, and the Senate Finance Committee noted that it'll cost $14.9 billion over 10 years to implement the physician pay fix. It'll be funded by making minor adjustments to the Affordable Care Act, the health care legislation that President Obama signed into law last March.

Last-minute fix is a welcome sight, however not forever

The US Senate passed a quick, 1-month extension of the present SGR formula on November 18 in a first step to avoid the 23 percent payment cut physicians were facing on December 1. The House of Representatives had already recessed for Thanksgiving at that point and took up the one month fix when they returned on November 29.

While many are pleased that the Senate has acted swiftly on the pending payment cut, one remains sceptical about another round of short term fixes. One hopes that the ultimate result of this Congressional session will be a fix of atleast one year. This extended period must then be followed by a strong bipartisan commitment from Congress to work with the physician community to lastly replace the badly flawed SGR formula with a new update mechanism that works. The frequent disruptions and delayed payments caused by the present formula and Congress' inability to fix it except for short periods are simply not fair to our members who have payrolls and other practice management expenses.

Check whether ACF applies

Some pain management coders also code for anesthesia procedures, which means you have a second CF to consider: the anesthesia conversion factor, or ACF.

The 2011 national ACF will remain at $21.5696. Check your specific area; but then as anesthesia reimbursement changes from state to state and even within regions of the same state.

For more on the latest Medicare updates, sign up for a medical coding guide like Supercoder.com

HCPCS 2011 Brings new Options for Lymph Cancer Drugs

HCPCS 2011: C codes are appropriate only for Hospital Outpatient Prospective Payment System claims.

When all other treatments have failed, take a look at these drugs

You'll have three new J codes for leukemia and lymphoma treatments available for use in January, 2011.

J9302 answers call for Arzerra Code

If you provide Arzerra injections, you should take note of new code J9302 (Injection, ofatumumab, 10 mg). Oncologists normally use the medication to treat chronic lymphocytic leukemia in adults who haven't responded well to fludarabine or alemtuzumab.

As the suffix -mab in ofatumumab points to, this medication is a monoclonal antibody.

Remember: Earlier, hospitals had a C code available for this agent, C9260 (Injection, ofatumumab, 10 mg). However this code makes an exit in the latest HCPCS code sets. (Note that C codes are appropriate only for Hospital Outpatient Prospective Payment System claims.)

Train eyes on J9307 for Folotyn

One more new J code for 2011 is J9307 (Injection, pralatrexate, 1 mg), which is just right for Folotyn.

Oncologists normally use this folate analogue metabolic inhibitor to kill cancer cells in patients with peripher al T-cell lymphoma that hasn't responded to other medications or has returned.

HCPCS 2011 also axes the C code available to hospitals for this drug, C9259 (Injection, pralatrexate, 1 mg).

Flip to J9315 for Romidepsin

If your documentation shows your practice supplied Istodax, you have J9315 (Injection, romidepsin, 1 mg) at your service in the new year. The drug is a histone deacetylase inhibitor that slows the growth of cancer cells. It is intended for use in patients with cutaneous T-cell lymphoma who have been treated earlier with another drug.

In 2010, hospitals use C9265 (Injection, romidepsin, 1 mg) for this drug, however HCPCS 2011 deletes this code.

CPT 2011 Asks for CMS re-Examination of Time as Averages or Thresholds

CPT 2011: The doctor must have spent a time closest to the chosen code, according to CPT Assistant

All that fine green print on time in your E/M CPT 2011 manual comes down to one thing: you can round to the closest time code. However, that advice from CPT contradicts Medicare's threshold time guideline.

CPT treats times as averages

CPT 2011 indicates that you can use the code closest to the documented time. That piece of advice is nothing new. In choosing time, the doctor must have spent a time closest to the chosen code, according to CPT Assistant, Aug. 2004.

Your documented time must be equal to or cross the average time given to bill that level. For a 35-minutes spent on a medically necessary counseling-dominated visit is a 99214, according to CPT you could report 99215.

Medicare has considered times thresholds

Medicare has always considered the times indicated in CPT's code descriptors to represent minimums. The doctor would choose the lower code (for example 99214… physicians typically spend 25 minutes face-to-face with the patient and/or family …) unless the time was greater or equal to the higher-level code's required time (such as 40 minutes for 99215).

Will Medicare alter its position?

When questioned on whether Medicare would change the allotments from thresholds to averages at the CPT® and RBRVS 2011 Annual Symposium, medical directors were hesitant to give a definitive answer. "I do not want to say one way either 'yes' or 'no' at this juncture," said E/M expert Deborah Patterson, MD, clinical medical director for Trailblazer Health Enterprises, LLC in Dallas.

For more on CPT 2011 , sign up for a medical coding guide like Supercoder!

Maneuver the Medicare Opt-Out Process in Three Easy Steps

Medicare: You can find samples of the form online at specialty association Websites and even some Medicare carrier Websites.

If you've decided that 2011 is the year your practice's going to scrap Medicare, follow this plan to see to it that you do not miss any important components when you are boosting your no-Medicare plan.

Notify Medicare that you are opting out

First, file an affidavit with your Medicare contractors informing them that your physician is opting out. If you're already a participating provider, states CMS, “To opt out of Medicare, a participating doctor must first terminate his or her Medicare Part B participation pact."

Tool: You can find samples of the form online at specialty association Websites and even some Medicare carrier Websites. For example, you can get National Government Service's form at www.ngsmedicare.com/pdf/medicareoptoutaffidavit.pdf.

Create a patient contract

If your practice decided to opt out of Medicare, however your providers plan to see Medicare patients, you will need solid patient contracts. “The provider has to have a written ‘private contract' with each Medicare beneficiary to whom the provider provides any service, except in a life-threatening emergency.

This contract, among other things, inform your patients that you're no longer part of Medicare and therefore, neither they nor the provider will get any reimbursement from Medicare. You'll be able to treat patients with Medicare coverage just like before, however you won't bill Medicare for the services. In its place, you'll bill any secondary or supplementary insurance the patient may have, or bill the patient directly. For instance, Medigap insurance will not pay you money if you're opted out since Medigap pays only secondary to Medicare payment.

Point to remember: Medicare has various requirements for what it considers an acceptable private contract. Be wary that the contracts have to be made available to CMS upon request, even long after the two-year opt-out period expires.

Set up internal processes to avoid claim errors

Finally, implement procedures within your office to ensure that:

You never file a Medicare claim

You don't provide the info to your patient to file a Medicare claim

Rule breaker: Two exceptions to this are emergency or urgent care, and providing covered services that Medicare would consider unnecessary.

Do not miss: Set up reminder notices either electronically or on a paper calendar so that you know when the two-year optout period expires. If you decide to opt out again, you will need to fill out another affidavit.

For more on this, and for more medical coding updates, sign up for a medical coding guide like Supercoder!

Family Physicians likely to See Some Gains

Family Physicians: Congress voted to not only stave off a 21 percent cut to your Medicare pay, but to increase the conversion factor by 2.2 percent.

As everyone knows, the Congress voted to not only stave off a 21 percent cut to your Medicare pay, but to increase the conversion factor by 2.2 percent. However that vote only kept the cuts at bay through November 30.

With effect from December 1, your Medicare pay is likely to come down by over 23 percent, unless Congress intervenes to reverse the cuts. To add to it all, the 2011 payments are due to drop even further with effect from January 1, and medical practices are facing a perfect storm of payment nightmares.

Some practices will bear the brunt and face additional cuts. Affected groups include radiology, urology, oncology/hematology, pathology, and emergency medicine. But family physicians have better news to face thanks to the government seeking to give primary care practices boosts in the coming year.

Family medicine practices expect a two percent gain in Medicare allowed charges next year based on an ongoing transition in Medicare's practice expense RVUs, according to one impact table in the final rule. Internists and pediatricians should anticipate a one percent boost in their Medicare allowed charges, as per the same table.

Other practices that'll see their pay go up will be hand surgeons, who will watch their Medicare allowed charges increase on average by four percent. The following specialists will also see gains in the coming year: neurologists (2 percent), otolaryngologists (3 percent), dermatologists (4 percent), plastic surgeons (3percent), and colorectal surgeons (3 percent).

For more on the Fee Schedule, sign up for a medical coding guide like Supercoder!

Wrong Answer Could Weigh Heavily on your Medical Coding Practice

In Medical Coding a mistake can also impact on your practice’s reimbursements.

Your ophthalmologist provides a new patient with a standard office-visit E/M. You use an established patient E/M to report the encounter. And if you thought it’s no big deal, you are wrong.

Not only is the coding wrong, this mistake will also have an impact on your practice’s reimbursements. To add to it, Medicare’s non-payment of consultation codes means that medical coders will have to answer the new versus established question more often than before.

For Medicare and payers that follow their lead, medical coders will now have to choose the correct code, new or established, to bill for what used to be consults and didn’t have a new versus established component concept.

Here’s an expert advice on new and established patients.

If you ignore new patient E/Ms, you could be losing your deserved money

For physician practices, the difference between new and established patient codes is the payment rate. Think about this comparison of average national payouts for new and established level-two E/m codes respectively:

99202 pays about $68 per encounter (1.86 transitioned nonfacility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.8729)

99212 pays about $40 per encounter (1.08 transitioned nonfacility RVUs multiplied by the temporary 2010 Medicare conversion rate of 36.8729).

That is almost $30 lost if you report 99212 instead of 99202 mistakenly. The main difference between a new and established patient visit, service-wise, can be minimal: Often it includes simple tasks like setting up a new chart and quizzing the patient a little closer to get familiar with him.
First ask 3-year question

If your patient has had a face-to-face service with the ophthalmologist within the last three years, then the patient is considered established. So let us say a patient reports to your ophthalmologist and gets a level-three E/M service on April 20, 2010. The patient’s record points to the fact that she received a previous face-to-face E/M service from another ophthalmologist within the group on Dec. 14, 2008. Since this is an established patient, you should report 99213.

For established patients, Face Time is a must

As a coder, what would you do when the patient has received treatment from your ophthalmologist within the last three years, however the doctor didn’t actually lay eyes on the patient? This is a different coding situation; here’s what you need to do: ‘Interpret the phrase ‘new patient’ to mean a patient who hasn’t received any personal services – to put it separately, an E/M service or other face-to-face service from the physician or physician group practice within the last three years.

This means that you might be able to report a patient as new if your ophthalmologist provided services for the patient less than three years ago, provided it wasn’t a face-to-face service.

Check specialty when deciding status

Coders who work in multispecialty practices will have to pay attention to one more new/established patient status rule.

For more on this, and other evaluation & management coding guidelines, stay tuned to a medical coding guide like Supercoder

New Choice to Boost your Diagnosis Coding

ICD-9 Codes 2011 going to effect in October, and here new ‘attention deficit’ to boost your Diagnosis Coding

The 2011 ICD-9 codes going into effect on October 1 have a few welcome additions for younger patients. Here are some examples of new diagnoses you could find yourself reporting on a regular basis.

Attention deficit options provide a better starting point ICD-9 2011 adds the 799.5x family to the ‘I’ll defined and unknown causes of morbidity and mortality’ section. The just-arrived codes include:

799.51 -- Attention or concentration deficit

799.52 -- Cognitive communication deficit

799.53 -- Visuospatial deficit

799.54 -- Psychomotor deficit

799.55 -- Frontal lobe and executive function deficit

799.59 -- Other signs and symptoms involving cognition.

This new series will be useful for symptoms and signs as a diagnosis before the doctor establishes a definitive diagnosis. Physicians treat children with concerns regarding attention or activity. You do not have sufficinet information after the first visit for an official diagnosis; but then you still need something to report.

V codes address retained fragments

ICD-9 2011 also comes up with a series of specific V codes for diferent types of retained fragments. The series (V90.01- V90.9) address objects ranging from metal, plastic or wood to animal quills or spines, glass, teeth, and other specified foreign bodies, including radioactive fragments.

Remember that you won’t report a code for foreign body removal in conjunction with V90.x. These foreign bodies are retained. You will deal with it in terms of the patient’s history and physical, however not an actual procedure to remove the object.

Want to know more about these attention deficit choices and other 2011 ICD-9 code(http://www.supercoder.com/icd9-codes/) changes? Just stay tuned to a medical coding guide like Supercoder.

Three ways to add an Additional $293 in Minor Procedure Pay

You could be missing out on opportunities to capture higher-paying procedure codes if you are overlooking reporting these splinting and foreign body removal codes.

Procedure 1: Gather $38 for sport injury splinting

Pee-wee football has started up and with it the chance you will see an increased number of patients with jammed fingers. For a non-angulated finger, the pediatrician might fix the sprain, splint the finger and send the patient home.

For the finger splint application, you could report 29130, which contains 1.02 RVUs, using the Resource Based Relative Value Scale. Even though global fracture care codes include the initial cast or application, you may use the casting and splinting codes in addition to an appropriate E/M code with modifier 25 when you don't report a fracture treatment code.

Do not miss: For the history, exam, and medical decision making that led to the decision to splint the finger, you'd report a significant separate E/M service appended with modifier 25. As you are not reporting a global fracture care code, you may also code the x-ray.

Procedure 2: Use tapping procedure code to add on $38

If a toe is broken, the pediatrician might buddy tape it to the adjacent toe and refer the patient to an orthopedist. For the buddy tapping, you could code 29550 (Strapping toes). The Medicare Physician Fee Schedule, which many payers adopt, assigns the code 1.04 RVUs. Report the history, examination and medical decision making preceding the decision to buddy tape the toe with 99201-99215 appended with modifier 25.

For the x-ray, go for 73600.

Procedure 3: Capture $227 on splinter removal

Removing a splinter from a patient's foot can net you around $227. For example, a pediatrician removes a 3 mm wooden splinter from a child's foot. Rather than including the work in an E/M code, you can use 28190, which has 6.15 RVUs.

Tip: Prior to using 28190, check that the documentation includes two details. The code need excising or opening to remove the foreign body. You have to say how and what you removed. Proper documentation could read: “1 mm incision made with X, removed splinter. This entry meets 28190's requirements of incision and removal.

Source URL :- http://www.supercoder.com/coding-newsletters/my-pediatric-coding-alert/revenue-boosting-procedures-29130-29550-28190-3-ways-you-can-add-an-additional-293-in-minor-procedure-pay-article

CPT 2011 Bids Goodbye to 90465-90474, Welcomes Hello Vaccine

For combination vaccines that may involve counseling on as many as five different diseases, getting paid as though you counseled on one never seemed right, however CPT 2011 lets you capture that extra counseling work.

Multiple component vaccines (Pentacel, Kinrix, MMRV) have had an economic disincentive related to the loss of immunization administration codes with these vaccines.

As the present CPT vaccine administration codes (90465-90467) are coded per vaccine, the codes capture payment for only one counseling administration code.

CPT 2011 will delete 90465-90468. The 90471-90474 (Immunization administration ...) codes will remain.

Good news: In the coming year, you will report the immunization administration with counseling codes per component. Here's how:

Step 1: Report 90460 as vaccine adminstration W/ counseling base code

You shouldn't look at administration route when selecting which immunization adminstration with counseling code. For vaccine administration except for H1N1, you'll assign one code for each vaccine's initial component: 90460.

Step 2: Use second vaccine component with +90461

Pediatric coders can heave a sigh of relief as the complexities over deciding which 90465-90468 code to use as the base code will soon end. The CPT codes 2011 for the coming year give you only one vaccine administration with counseling base code (90460). You will report the same add on code for each additional vaccine component: +90461.

If the physician, nonphysician practitioner (NP), physician assistant (PA), or other healthcare qualified professional provides vaccine counseling to a patient less than 19 years old for a second disease/component, you will assign +90461 for the second vaccine component. You will always report +90461 in addition to 90460.

Step 3: Use units to report 3+ Administrations

You will keep using the same add-on code, +90461, for each additional vaccine component. Bill the add-on code, in addition to the number of units that represents the number of components.

For more information on CPT 2011 and the entire CPT code list, sign up for a medical coding guide like Supercoder.com

Do Not Miss Out On Ancillary Procedures with Kyphoplasty, Vertebroplasty

Report radiologic supervision and interpretation, however leave out bone biopsies.

When your orthopedist carries out a vertebroplasty or kyphoplasty procedure, you will need to decide if there are additional services you could be coding and reporting. Get the low down on what you can and cannot report separately.

Modifier 26 brings you radiology pay

You can report the operating surgeon's imaging for needle positioning and injection assessment during a kyphoplasty or vertebroplasty procedure. You will use either 72291 or 72292 in addition to fluoroscopic guidance.

CPT revised these codes for 2006 to use with either vertebroplasty or kyphoplasty. You should be sure to append modifier 26 (PC) to the appropriate radiology service code to show that the surgeon provided only the physician component of the service and didn't supply the equipment, etc.

Caution: If your surgeon doesn't personally carry out the guidance, you can't bill for it. Rather, the healthcare professional who provides the service (often the facility radiologist) will bill for it.

Include bone biopsy with main procedure

When you are reporting 22520-+22522 or 22523-+22525, you won't code separately for a bone biopsy. You shouldn't report 20225 if the biopsy occurs at any of the same spinal levels as the primary procedure.

Here is the reason: The CPT code descriptors stimulate this limitation as do many payer local coverage determinations (LCDs). To add to it, CCI edits(http://www.supercoder.com/coding-tools/cci-edits-checker/) bundle bone biopsy to vertebroplasty and kyphoplasty codes. As there's boney tissue removed during the process anyway, it wouldn't be right to charge for taking some specifically for a biopsy.

Alternative: If your surgeon carries out bone biopsy at a level not addressed by the vertebroplasty or kyphoplasty, but you may report the biopsy separated with modifier 59 (distinct procedural service) to indicate the unrelated nature and separate locations of the two procedures.

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.

For more on this and other CPT coding updates, sign up for a medical coding guide like Supercoder!

Do and Don't of Unlisted Procedure Coding

Keep this CPT instruction in mind: "Don't choose a CPT code that merely approximates the service provided." This rule is key for compliant coding, however it leaves you with tough job of submitting a claim without a procedure-specific code. Here are some do's and don'ts to increase your chances of getting the payment your practice earned.

Explain the procedure in Layman's Terms

If CPT does not offer a code specific to the service provided, then you should report the appropriate unlisted-procedure code like 37799 (Unlisted procedure, vascular surgery) for vascular sclerotherapy.

When you file a claim using an unlisted procedure code you should include a cover letter stating why you are using the unlisted code. This separate report should explain in simple straightforward language exactly what the physician did.

According to CPT Assistant (http://www.supercoder.com/coding-references/code-connect)(April 2001), you need to submit reporting documentation identifying the specifics of the procedure such as the procedure report when you file the claim. The supplemental documentation should define the service (nature, extent, need) and the time, effort and equipment required. According to CPT Assistant, you may also include the following factors:

Whether the doctor required help to carry out the service

Whether the procedure was independent of other services

Whether the doctor carried out additional procedures at the same site

Number of times the doctor carried out the service at the encounter

Extenuating circumstances that complicated the service.

You may even want to include diagrams or photographs to facilitate the person reviewing your claim better understand the procedure.

Do not try to use modifiers or multiple units

You shouldn't append modifiers to unlisted-procedure codes or try to report them more than once per encounter.

Suggest an appropriate fee for the service

Unlisted procedure codes don't appear in the Medicare Physician fee Schedule, so they don't have assigned fees or global periods. Your payers will generally determine payment for unlisted procedure claims based on the documentation you provide.

You can suggest a fee by comparing the unlisted procedure to a similar listed procedure with an established reimbursement value.