CCI Edits 16.3: Include Wound Repair In Free-Flap Grafts or Risk Denials

The latest CCI edits 16.3 that went into effect on October 1 this year creates a coding bundle naming simple wound repair codes 12001-12007 and 12041-12047 as intrinsic components of 15756, 15757, 15758.

What does this mean? In the above pairings, CCI lists the wound repair codes as column 2 codes, which means they are considered components of the comprehensive codes (15756-15758) under Column 1.

Do not miss: These bundles have a modifier indicator of one; as such you may use a modifier like 59 to override the edit if the clinical circumstances merit separate reimbursement like a separate encounter on the same date, a separate anatomical site or a separate indication.

Catch this debridement/site prep bundle

The latest CCI edits (Source "http://www.supercoder.com/coding-tools/cci-edits-checker/") addresses another aspect of your skin graft coding with a new edit bundling 11040 as a component of 15002. This edit indicates that Medicare considers debridement to be an essential component of site prep procedures. But CCI has also marked these bundles with modifier indicator 1 so you may report 11040 along with 15002 or 15004 under appropriate clinical circumstances with an appropriate modifier.

New edits target hematoma, nail repair

From October 1, CPT code 11740 includes 11730. As with other CCI edits, these bundles are marked with modifier indicator '1', allowing separate reporting if clinically necessary, with the right modifier appended to the component (column 2) code.

These would not be used together on the same site. They would have to be carried out on different nails.

Differentiate Wound Repair versus Tissue Transfer to Achieve Proper Coding

When your surgeon carries out a wound repair closure, you could be miscoding if you turn to 12001-13160 automatically. You need to dig deep into the surgeon's documentation to see if the tissue transfer code is more apt. However knowing the difference between wound repairs and tissue transfers is only the start. See to it that your surgeon gets the reimbursement he deserves:

Know the difference between transfers and repairs
For wound closure procedures, you will first need to decide between wound repair codes 12001-13160 and adjacent tissue transfer codes 14000-14300.

Determine overall area and location
According to CPT instructions, once you determine that your surgeon carried out a tissue transfer, you will need to narrow down your code selection by determining the total area of the primary and secondary defects.

After adding up the affected area, look at the repair's anatomical location to narrow your choices further.

Skip separate lesion removal coding

You shouldn't separately report any lesion removals your surgeon carries out during a tissue transfer procedure. The excision of the benigh lesion or of the malignant lesion is not separately reported with the tissue codes. This guidance is reinforced by both CPT and CMS/CCI guidelines.

Exception: If your surgeon carries out an excision on a separate day from the tissue transfer, you may go on to report the procedures separately. You might stand witness to this scenario if your surgeon is waiting for the pathology report to be sure the lesion margins are clear prior to closing the operative wound. If the tissue transfer takes place during the excision's 10-day global period, go for modifier 58 to the tissue transfer code.    Source URL :- http://www.supercoder.com/coding-newsletters/my-general-surgery-coding-alert/wound-repair-differentiate-wound-repair-vs-tissue-transfer-to-achieve-proper-coding-in-just-3-steps-article

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).

Five Common Pitfalls you Should be Arare of While Using PQRS

Whether you are new to CMS's Physician Quality Reporting System program or you have been gathering bonuses from it for a while, you can use some tips on ways to stay away from common PQRS mistakes. CMS representatives throw light on these issues and shared the following information about the five most common PQRS pitfalls.

Missing your suitable population. When you are opting for measures to report, you should carefully review all ICD-9-CM diagnoses and CPT service codes that'll qualify claims for inclusion in physician quality reporting measurement calculations.

Remember that some measures have specified patient demographics that must be met prior to reporting them such as age or gender parameters.

For those measures that need you to capture specific clinical values for coding, see to it that the people in your practice who code your claims have access to them or else they won't know the claims are eligible for PQRS.

Reporting wrong information. This means that you have used wrong specifications, quality data codes or individual NPI numbers.

See to it that you use correct measure specifications for the current year and reporting method. For measures that need more than one QDC (quality data code, which refers to a CPT or G code), make sure that you have reported all of the codes on the claim, and that any applicable modifiers are applied.

Make sure you include the individual rendering NPI number(s) on the claim. quality data codes should be submitted on the line item of the claim as a zero charge. If your billing software doesn't allow a zero charge line item, you can enter one cent as your charge as you can't leave the submitted charge field blank.

Missing the reporting frequency. Each and every PQRS measure has its own reporting frequency or time frame requirement for each eligible patient seen during the reporting period per eligible professional (NPI). Some measures need you to report once per patient, per NPI, each reporting period whereas others may need to be reported once per procedure carried out, once per acute episode or once per visit.

You can find the reporting frequency in the instructions section of each measure specification – however even if you know the frequency requirements, you won't be able to find them if the practitioner's documentation is not thorough. See to it that all members of the team understand and capture this information in the clinical record to facilitate reporting.

Confusing PQRS with other CMS programs. PQRS is different from the EHR program, however because the programs have similar requirements, many professionals become confused. The programs have different materials and requirements and you will need to call a separate help desk for assistance on them.

Knowing who to call for help. If you have questions about PQRS, do not just abandon the program. In its place, get in touch with the QualityNet Help Desk at 866-288-8912 or send an email to qnetsupport@sdps.org.

Remember: Various reporting errors can be avoided. Therefore report carefully since all diagnoses listed on the CMS-1500 (http://www.supercoder.com/scrubber/cms1500/) or electronic equivalent at an encounter during the reporting period will be counted in analysis.

Hone Your Colonic Polyp Vocabulary with these two Tips

Find out how a pathology report can save your claim.

Remember that not all patients who present to the office with colon polyps will be diagnosed with colon cancer. This is the second-leading cause of cancer-related deaths in the United States and normally starts as small, benign adenomatous lump, and becomes cancerous overtime.

Colon cancer (colorectal cancer as it is regularly called) is a cancer which starts in the large bowel portion of the gastrointestinal (GI) system. Since it comes in many forms and symptoms, coding the definitive diagnosis might be risky. Safeguard your practice's deserved dollars with these three tips:

1. Do not go looking for 'benign', 'malignant'

Irrespective of whether or not you are dealing with a full-blown colorectal cancer, you should be looking at the different terms used to describe benign or malignant colonic polyps. Some of these cover:

Adenomas including tubular adenomas and tubulovillous adenomas

Hyperplastic polyps

Inflammatory polyps

Familial adenomatous polyposis, a rare hereditary disorder that causes hundreds of polyps in the lining of the colon starting in the teenage years. If this is not treated, the patient becomes high risk to develop colon cancer.

Hereditary nonpolyposis colorectal cancer, a hereditary disorder that leads to an increased risk of developing colon cancer.

However first, you have to achieve the task of determining, without a doubt if a polyp is benign or malignant. If you think you'd find the clues in the pathology report (PR), think again. Normally, the PR will not use the term 'benign" or 'malignant'. But then it'll use a description that points to the usual behavior of the polyp. It is up to you to interpret those descriptions into benign or malignant.

Key: Experts tell you that you always wait for the pathology report to come back before deciding on a particular ICD-9. Even the gastroenterologists, themselves normally defer to the pathology report prior to making a recommendation.

2. Check with ICD-9 Neoplasm table

The ICD-9 codes Alphabetic Index to Diseases (Volume 2) features a neoplasm table where you can choose a definitive diagnosis code for a polyp. All diagnosis codes for neoplastic polyps -- and some non-neoplastic polyps -- will come from this table. Consider three things when choosing the right polyp code:

a) Body part. For malignant primary neoplastic polyps in the colon, you should look for the specific site of the colon which the doctor should mention in the procedure report.(I'e., traverse, sigmoid, ascending and descending).

For all other behaviors, the code descriptions make a general reference to the colon, large intestine or for that matter digestive system.

b) Behavior. In particular, behavior refers to the polyp's capacity to spread. If the polyp happens to be benign, it's noncancerous; of it is malignant, it's cancerous. A polyp can also be defined as 'uncertain' (235.2, Neoplasm of uncertain behavior of stomach, intestines and rectum) if its behavior is unpredictable and requires further investigation. On the contrary, an unspecified polyp (239.0, Neoplasm of unspecified nature of digestive system) needs to be determined further by lab tests.

c) Malignant polyp's nature. Further, you'd classify a malignant polyp into primary, secondary or in situ. A primary malignant colonic polyp (153.0-154.0) is one where the colon is the original site of the cancer. Secondary (197.5, Secondary malignant neoplasm of large intestine and rectum) means the cancer has metastasized from another site to the colon. An in situ malignant colonic polyp (230.3-230.4) is one where the cancer is remains confined to the colon.   Source URL  :- http://www.supercoder.com/coding-newsletters/my-gastroenterology-coding-alert/diagnosis-coding-2-tips-to-hone-your-colonic-polyp-vocabulary-106130-article

Modifier 51 or 59? Choose Carefully

The physician controlled a patient's hemorrhage (30901) and removed a benign lesion from patient's temple (17110) during the same encounter. How should you go about this situation – report modifier 51 or 59?

As per coding rules, you should append modifier 51 (Multiple procedures) only when the doctor completes multiple procedures during the same encounter, and to add modifier 59 (Distinct procedural service) only when the two procedures you want to submit are not usually submitted together but are proper under the circumstances. Often modifier 59 is used to code pairs that have an active bundling edit through the correct coding initiative (CCI). Present CCI edits don't bundle codes 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) and 17110 (Destruction [example laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions).

You will most likely find different opinions on whether to add modifier 51 or 59. Some medical coders go for modifier 51 since most payers will process the encounter as a multiple surgical reduction irrespective of whether you include the modifier or not. Other medical coders recommend modifier 59 since reporting 51 could set you up for one of three undesirable (or at least aggravating outcomes); the payer does not bring down the payment correctly; the payer denies the entire claim; or the payer requests additional documentation prior to considering payment. Of the two modifiers, most probably modifier 51 is most appropriate in this example.

Source URL :- http://www.supercoder.com/coding-newsletters/my-family-practice-coding-alert/reader-questions-choose-carefully-between-modifiers-51-and-59-article

Tip you can follow: Whichever modifier you choose, add it to the lowest relative value units – (RVUs) -- in this instance, code 30901 with 2.82 relative value units.

What's more, double-check the code you are submitting for the lesion removal. As noted, the code you indicated (17110) is for destruction of a lesion by one of various methods. If the doctor removed the lesion through excision, you'll need to use a code from the series of codes for excision of benign skin lesions, 11400-11446.

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.