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.

New Codes for Peritoneal Cavity Chemo and Interstitial Device Placement

If your oncology practice provides chemotherapy into the peritoneal cavity using an indwelling port or catheter, your task will get a lot easier with effect from January 1 next year.

Here's why?

The American Medical Association (AMA) has announced the CPT 2011 codes, and they include a code specific to that service: 96446 (Chemotherapy administration into the peritoneal cavity through indwelling port or catheter).

You will also have new codes describing placement of interstitial devices for radiation therapy guidance, such as the following:

+49327 -- Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (for instance, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if carried out, single or multiple (List separately in addition to code for primary procedure)

+49412 -- Placement of interstitial device(s) for radiation therapy guidance (for instance fiducial markers, dosimeter), open, intra-abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if carried out, single or multiple (List separately in addition to code for primary procedure)

57156 -- Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy.

Evaluation /Management (E/M) service: Subsequent day observation care will also get new codes (99224-99226), reportable per day. Pay special attention to these codes as they will change the way you code an observation stay longer than forty eight hours.

Source Code:- www.supercoder.com/coding-newsletters/my-oncology-hematology-coding-alert/cpt-2011-update-expect-new-codes-for-peritoneal-cavity-chemo-and-interstitial-device-placement-article

Coding Life Becomes Easier With This Denial Busting Tool

Is the CPT-ICD 9 code linkage pushing you towards denials? Well, ICD Cross-Ref tool lets you know whether you are safe.

To get this Cross-Ref tool and stay away from denials, sign up for Supercoder as the site has come up with this denial busting tool with effect from November 2. This CrossRef allows a coder to look up a surgical CPT procedure code and see which diagnosis codes Medicare and private payers allow.

So the next time you need to take a look at the ICD-9-CM codes that Medicare and private payers accept for a given surgical procedure rightaway, all you need to do is become an Advantage Plus member of the site and look under 'Tools' section. When you do so, you can have access to surgical (series 10000-60000) CPT procedure code to ICD-9-CM CrossRef under Tools.

What's more, come December 1 and you will get common diagnoses associated with radiology (70000 series), pathology (80000 series) and medicine (90000 series) codes.

Not just this, there are more reasons now to become members of Supercoder as it puts more spot on coding with Lay Terms for every CPT code (http://www.supercoder.com/cpt-codes) for major specialties. And to add to it all, SuperCoder Codesets & Tools and Advantage members should look for this feature in addition to visually helpful anatomical illustrations under Code Details.

What's more, onboard Supercoder, you can even have access to ICD-9-CM codes 2011 as well as the CCI Tool, CCI Alert feature, Fee Schedule and lots more!

So get onboard Supercoder today and stay away from denials!

FAQ to Boost Your Pain Management ICD-9 Coding

FAQ to boost your pain management ICD-9 coding

If you do not know how many diagnosis codes you can report, you could find yourself assigning the wrong code. Here's a question followed by the answer that'll help you get quick tips to help your pain management ICD-9 coding:

How many diagnosis codes are 'too many'?

Question: Our pain management specialist treated a patient with diabetes, however he was actually seeing the patient to treat a complication of the diabetic polyneuropathy. During his evaluation, the doctor also noted that the patient has shoulder joint inflammation. Should we use the neuropathy complication only or several ICD-9 codes to represent various conditions of the patient?

Answer: Normally, the primary diagnosis code that you list on your claim should represent the main reason for the encounter, or the condition with the highest risk of morbidity/mortality that the physician tends to during the visit. However, when you deal with a condition like diabetes, the situation changes.

Section 1.A.6 of the ICD-9-CM official

Guidelines for coding and reporting certain conditions have both an underlying etiology and multiple body system manifestations owing to the underlying etiology. For conditions such as this, the ICD-9-CM(http://www.supercoder.com/icd9-codes/) has a coding convention that requires that the underlying condition be sequenced first after the manifestation.

If a patient has more than one manifestation of diabetes, more than one code from category 250 may be used with as many manifestation codes as are needed to describe the patient's diabetic condition fully.

As such, you should first use 250.6x (Diabetes with neurological manifestations). Remember to add a fifth digit to reflect the patient's type of diabetes and status of control. Your secondary code should represent the specific pain manifestation being treated. In this case, you should report 357.2 (Polyneuropathy in diabetes) as the secondary diagnosis. As because your pain practitioner documented joint inflammation, you should also report the right code describing that condition (716.91, Arthropathy, unspecified; shoulder region).

Why so many codes: Even though many payers will link only the first, main diagnosis code that you list to support the provided service's medical necessity, reporting all the diagnoses that follow the HIPAA-mandated guidelines is compliant coding. As of July 2007, Medicare must accept up to eight diagnoses for each electronic claim reported. The additional diagnoses might indicate more complex presenting problems and can provide the help you might need for a higher-level E/M service.

Review Billed Service Levels with These Tips

You cannot get inside your ENT's head to know whether his MDM requires the E/M service code that he reported – however Medicare auditors are training eyes on this area while examining E/M claims, so you need to stay alert.

Auditors are not scrutinizing the exam or history as much as they weigh toward medical decision-making. However you can be your otolaryngologist's front line of defense and ensure his notes withstand scrutiny if you follow these tips:

Tip 1: Take this strategy's help to identify a mismatch

When your staff gets together for an education meet next time, remind your ENTs that medical necessity should be the overarching factor they use to choose the E/M service level. Just because a physician does a comprehensive history and examination does not mean he should report 99215. Medical necessity should drive the components that he carries out. This is of particular importance with the implementation of EHR systems, which automatically code encounters without regard to medical necessity. It's very easy to document high levels of history and exams, particularly for established patients, which'll result in level four services when the medical necessity may dictate only level two or three services.

You can help ensure your doctors are choosing the proper codes by occasionally pulling a sample of their charts. Take a look at the patient's chief complaint and the encounter's outcome or its final diagnosis. If the main ICD-9 code doesn't support a billed upper level of service, you should really read the chart notes.

Tip 2: Look for potential MBM-boosting factors

However, complimenting factors could make 99214 and 461.x a match. The patient may have comorbidities or other chronic conditions. And medications that the patient is already taking or or adverse reactions the patient had to previous medications could up the level of MDM. Comorbidities, frequency of episodes of sinusitis, the plan of care, and the like may complicate the medical decision making also.

To add to it, evaluation of symptoms possibly related to sinusitis like fatigue, headache, fever and cough can boost the MDM. When you work up a sinusitis, if a patient has these other symptoms also, then you ensure he does not have any problems that could be more serious.

Source URL :-  http://www.supercoder.com/coding-newsletters/my-otolaryngology-coding-alert/em-services-5-tips-help-you-review-billed-service-levels-article

Tip 3: Uncover extra complexity in these places

Medication can lead to a higher-level MDM another way. Take a look at the tests and medications the otolaryngologist ordered for clues to the extra complexity the doctor may not be explaining. Here are a couple of tips to make identifying increased complexity easier:

See the history of present illness and review of systems to determine what the ENT is trying to rule out.

Encourage your ENTs to state what diagnoses they hope to rule out or confirm.

Be wary: Do not put such ‘rule out' diagnoses on your claims. Doing so would not be right coding.

Tip 4: Give due credit for clear management options

Intimate your doctors that they should indicate clearly when they are taking an immediate step that they do not believe will solve the patient's problem. For instance, they may try antibiotics before a more aggressive treatment, however that the patient may need a more aggressive approach can boost the level of MDM. Documenting the extra step shows that the physician considered more management options (one element of MDM).

Tip 5: Look at patient's complexity

Sometimes a low level of MDM can support a 99214. You cannot just look at the MDM; you also have to look at the complexity of the patient.

Make Perfect your ICD-9 Coding Skills

OB-Gyn - ensure you have coded high-risk or complicated obstetrical care correctly - and that means perfecting your ICD-9 coding skills.

You can get increased payments when your ob-gyn provides additional visits outside of the normal global ob package; however you'll have to ensure you have coded high-risk or complicated obstetrical care correctly – and that means perfecting your ICD-9 coding (http://www.supercoder.com/icd9-codes/) skills.

Be firm on perfect ICD-9s

To demonstrate the reason for the additional service, you have to link the ICD-9 code on the CMS-1500 claim form (boxes 21 and 24E) to an E/M code. You can add this to the claim that includes the global service or you can submit it as an additional claim.

Here's an example: A 33-year-old patient, gravida 3, para 2 (both normal spontaneous vaginal delivery [NSVD] full term), is tended to 19 times due to developing pre-eclampsia. Post delivery, you review the case and find that the patient required six additional visits (beyond the usual 13) for this care. The documentation for three of these visits supports reporting 99212 while three of the visits have more extensive documentation that supports reporting 99213.

To add to it, post delivery, the patient experiences prolonged pain and irritation owing to a hemorrhoid. The ob-gyn tends to her for a thrombosed hemorrhoid, which he incises in the office two weeks post-delivery. In the end, the ob-gyn rechecks the patient at her six weeks postpartum visit.

Break it down: When coding for this patient, remember the claim form must note both the CPT codes describing the additional services as well as the diagnoses that depict why the patient required the additional services.

Heads up: Observe the fifth digits of these ICD-9-codes. The digit ‘3' that takes place in most of these codes has become a ‘4' in the last ICD-9 code to indicate a postpartum condition rather than an antepartum one. In other words, the patient has been discharged from the hospital after giving birth. Using ‘3' indicates she did not deliver during the hospital stay.

To add to it, after delivery, the patient experiences prolonged pain and irritation owing to a hemorrhoid. The ob-gyn sees her for a thrombosed hemorrhoid, which he incises in the office two weeks post delivery. In the end, the ob-gyn rechecks the patient at her six weeks postpartum visit.