Code-Specific Primer to Work for Your Claims

Getting on top of the new codes and pages of new guidelines this year's CPT introduced for cardiology is no easy task. Therefore to make it easy for you, here's a code-by-code as well as a briefing on when you shouldn't assign these codes on your claim.

Begin here: The codes in spotlight are:

93451 - Right heart catheterization (RHC) including measurement(s) of oxygen saturation and cardiac output, when carried out

93452
93453

Tip: Right Heart Catheterization: 93451 applies to a narrow group

Code 93451 approximately replaces 2010 code 93501 (RHC). However, prior to choosing new code 93451, you need to be sure you understand when it applies and the many cases when another code would be more apt.

RHC defined: As per CPT guidelines, RHC includes cath placement in the right-sided cardiac chambers or structures. This includes the right atrium (RA), right ventricle (RV), pulmonary artery (PA), and wedge locations.

According to CPT 2011 guidelines , RHC also includes taking blood samples to measure blood gases and measuring cardiac output if the doctor performs them. This may include oxygen saturations, wedge pressures, and thermodilution studies.

Coding tip: Medical coders who had pre-2011 RHC, reviewed note that auditors wanted to see all right heart chambers and structures documented to support the RHC code. This means that if the doctor cannot enter one of the structures or chambers, he should explain briefly why to make the documentation complete.

Beyond 93451: CPT includes an instruction under 93451 telling you not to report the code with 93453 (combined RHC and LHC) or with 93456, 93457, 93460, or 93461 (which all include RHC apart from other services). One more time you should stay away from reporting 93451 is if the RHC is for a congenital case. After this you should report 93530 (RHC, for congenital cardiac anomalies) in place of 93451.

Bonus tips: According to CPT guidelines, you shouldn't report 93503 with 93451 or any other diagnostic cardiac cath codes. What's more, you should not append modifier 51 (multiple procedures) to 93451. And if you code manually, take extra care not to swap your digits.

Left Heart Catheterization: 93452 Covers ventriculography, too

If the cardiologist catheterizes only left heart structures, you will need to find out whether your 93452 is proper for your LHC case. Code 93452 roughly covers the same services you would have coded last year using 93510 and 93555.

LHC defined: The main indicator for LHC is that the doctor crossed the aortic valve. According to CPT guidelines, LHC involves catheter placement in a left-sided (systemic) cardiac chamber(s) (left ventricle or left atrium) and includes left ventricular injection(s) when carried out." Also it includes taking left ventricular pressures.

This means left ventriculography injection, supervision, interpretation and report are all included when performed. Consequently, you should not report +93565 in addition to 93452.

Report separately: Even though CPT includes multiple services in 93452, there are some services you may report separately. In some instances, the cardiologist may carry out LHC using a transapical puncture of the left ventricle or a transseptal puncture when the septum is intact. CPT guidelines instruct that in that case, apart from the appropriate LHC code, such as 93452, you should report +93462.

More comprehensive options: Be sure to watch for cases where a code that is more comprehensive than 93452 is proper. Particularly, CPT instructs you not to report 93452 with 93453 (RHC and LHC) or 93458-93461 which specify that they include LHC along with coronary angiography and other services.

93453 brings 93451 and 93452 together

The services 93453 describe would in effect have been covered by 93526, 93543 and 93555 (imaging S&I) last year. Since the procedure involves LHC, remember that the key identifier for that procedure is that the physician crossed the aortic valve.

Code 93453 involves both RHC and LHC as such once you understand when 93451 is proper for an RHC service and 93452 is proper for an LHC service, you are well on your way to mastering when to report 93453. Many of the same rules apply, as do many of the same restrictions.

CCI 17.1: Get on Top of These Three Key Highlights for Cardiology This Quarter

Take a look at these major pointers to comply with the just-in cardiology-related edits, including cardiac catheterization, radiological supervision and interpretation, cardiac rehabilitation, and more.

Avoid denials by remembering 93454-93461 are diagnostic

Just-in edits will prevent you from reporting heart catheter/angiography codes 93454- 93461 (column 2) with the following cardiovascular therapeutic services and procedures (column 1):

92975, 92980, 92982, 92995

Take away: In column 1, the 929xx codes describe coronary therapies. You shouldn't use the 934xx diagnostic codes in column 2 to report catheter placement and coronary angiography performed as an integral part of the therapeutic column 1 services.

Opportunity: The edits have a modifier indicator of 1; as such you may override them with a proper modifier when the procedures are distinct. If you report both codes in the edit pair and do not add a modifier to the column 2 code, Medicare will reimburse you for only the column 1 code.

The AMA, via CPT Assistant (April 2005), indicates that you may report a true diagnostic catheterization apart from the therapeutic procedures described by 92980 and 92982:These two distinct procedures, therefore, should be reported separately when carried out at the same session or on the same day at a different session."

When the cardiologist does carry out a distinct 93454-93461 diagnostic service on the same date as a cardiovascular therapeutic service, you should append modifier 59 (Distinct procedural service) to the diagnostic code. You may also require to add modifier 51 (Multiple procedures).

Modifier 59 identifies the procedure as being a distinct procedural service while modifier 51 identifies multiple procedures were performed during the same session. Even though CPT identifies many codes as modifier 51 exempt, 93454-93461 are not currently exempt. But then, Medicare and other payers may tell you not to use modifier 51 since they'll apply the multiple procedure rule themselves.

Hints: You should also add modifier 26 (Professional component) to 93454-93461 when you need to indicate you're reporting only the professional component of the service. The Medicare physician fee schedule shows different PC and TC for these codes.

Follow S&I instructions to stay compliant

Like many other existing edits, a large number of the just-in cardiology-related edits help keep your coding in line with CPT guidelines for using radiology codes with procedure codes.

Example 1: Code 0236T includes radiological supervision and interpretation (S&I) in its definition. As such, you should not be surprised to know that the latest CCI bundles radiology codes 75600-75630 (Aortography … radiological supervision and interpretation) into 0236T.

Example 2: Now CCI bundles 75600-75774 and 75810-75891 into 37205. But then this should not restrict your coding since a CPT instruction with 37205 tells you that the proper code for S&I related to 37205 is 75960.

Good move: To stay away from denials, check code definitions, CPT guidelines, and CCI edits prior to reporting an S&I code with a procedure code – both to ensure you report the proper S&I code for the procedure and to be sure you comply with CCI edits.

Watch for blood draw, pulmonary services, EEG and others

In the latest CCI, it bundles many of the same column 2 codes into the following column 1 codes:

93660, 93724, 93797-93798

While the column two codes in the edits are not entirely identical for each of the column 1 codes above, there is a definite pattern. Here's a sampling of the column 2 codes:

364xx, 366xx, 37202, 43752, 94xxx, 958xx, 95955

Bottom line: Before you report a tilt table exam, an antitachycardia-pacemaker analysis, or outpatient cardiac rehab code, take a look at the CCI edits to verify that you haven't included one of the many bundled codes on your claim.

For Repeat Procedure, Turn to Modifiers 76 Or 77

Point to remember: When the physician carries out exactly the same procedure a couple of times, modifier 59 won't be applicable.

Here's a question: Is modifier 76 or 59 proper when the radiologist reviews two studies on the same date of service (DOS), but the scans don't merit the same codes?

Answer: Well, unless your payer tells you in a different way, go for modifiers 76 (Repeat procedure or service by same doctor or other qualified health care professional) and 77 (Repeat procedure or service by another doctor or other qualified health care professional) only when the provider(s) carry out the exact same exam twice.

First example: If a patient in the intensive care unit (ICU) has two single-view chest X-rays (71010, Radiologic examination, chest; single view, frontal) on the same day, use the second exam with modifier 76 or 77 (depending on whether both exams involved the same doctor).

Second example: If a patient has a complete ankle exam (73610, Radiologic examination, ankle; complete, minimum of three views) followed later in the day by a limited exam (73600, … two views) go for modifier 59 (Distinct procedural service) in order to tell the payer the provider carried out the exams in separate encounters.

Source URL :- http://www.supercoder.com/code-lookup/modifiers/

Catch this:

2011 CPT code changes the descriptors for modifiers 76 and 77 to clarify that the modifiers do not apply only to physician services. Other qualified health care professionals are now clearly included, as well. CPT made the same revision to modifier 78 (Unplanned return to the operating/ procedure room by the same doctor or other qualified health care professional following initial procedure for a related procedure during the postoperative period).

Which CPT And HCPCS Codes for MOPP?

While coding for your oncology practice, you may sometimes question – which CPT and HCPCS codes are appropriate for MOPP? Answer: Well, the MOPP (also called MVPP) combination chemotherapy regimen includes:

M: Mechlorethamine (Mustargen)
O: Vincristine (Oncovin or Vincasar)
P: Procarbazine (Matulane)
P: Prednisone.

You should code mechlorathemine using J9230 (Injection, mechlorethamine hydrochloride,
[nitrogen mustard], 10 mg). Since it's an antineoplastic, you should report administration using the appropriate chemotherapy administration code(s) (96401-96549).

You should report vincristine using J9370 (Vincristine sulfate, 1 mg). Bear in mind that HCPCS 2011 deleted J9375 (Vincristine sulfate, 2 mg) and J9380 (Vincristine sulfate, 5 mg). Since vincristine also happens to be a chemotherapy drug, you should again use the proper chemotherapy administration code(s) (96401-96549). Do not report these drugs: As part of the MOPP regimen, Procarbazine and prednisone are given orally. HCPCS offers S0182 (Procarbazine hydrochloride, oral, 50 mg) and J7506 (Prednisone, oral, per 5mg), however you shouldn't report supply (HCPCS) or administration (CPT) codes for these drugs on your Part B claims. CMS doesn't cover ‘self-administered' drugs under Part B. (Take a look at Medicare Benefit Policy Manual, chapter 15, section 50.5, www.cms.gov/Manuals/IOM/list.asp.) Exception: The provider may consider it necessary to administer the injectable form of prednisone, such as J1030 (Injection, methylprednisolone acetate, 40 mg). In that rare instance, you may be able to code the drug and administration.

Medicare benefit Policy Manual, chapter 15, section 50.4.3, explains that Medicare does not cover a medication's injectable form if the oral route is standard and medically proper. However the manual indicates there could be an exception if special medical circumstances justify an injection rather than the oral form. If the injectable form is utilized, the provider should briefly document the reason why to help support your code choice.

Note of caution: See to it that you code based on the detailed documentation rather than from a protocol's abbreviation. For instance, the oncologist may change the order based on white blood and platelet counts. For more on this and for other medical coding updates pertaining to CPT and HCPCS codes, sign up for a one-stop medical coding guide like Supercoder.com

How Lyme disease, ear pain diagnosis will change in 2013

Suggestion: Your diagnosis coding will depend on which ear was affected once ICD-10 hits. Since CMS has reiterated that it'll not push back the deadlines for the conversion to ICD-10, you will need to have your ICD-10 coding skills ready by October 1, 2013. Here are some examples of how ICD-10 will change your coding choices for two common conditions. Lyme disease Dx will need thorough documentation of attributable conditions

Right now, if a patient is confirmed to have Lyme disease, you report code 088.81 (Lyme disease). ICD-10 changes: With effect from October 1, 2013, you will find that the Lyme disease diagnosis codes have been expanded to include symptoms due to confirmed cases of Lyme disease, as below:

A69.20 (Lyme disease, unspecified)

A69.21 (Meningitis due to Lyme disease)

A69.22 (Other neurologic disorders in Lyme disease)

A69.23 (Arthritis due to Lyme disease)

A69.29 (Other conditions associated with Lyme disease) Documentation: Your doctor will need to clearly note whether the patient has Lyme disease alone (A69.20) or Lyme disease with other contributing factors (A69.21- A69.22). For example, you cannot use A69.21 unless the documentation includes confirmation that the patient ails from meningitis as well as Lyme disease, and that the two conditions are related. You shouldn't report the Lyme disease diagnosis code unless your practice gets confirmation from a lab test indicating that the patient tested positive for a Lyme disease. If you do not have a positive lab test confirming strep throat, you should simply use the diagnosis codes for the symptoms. As such, your documentation must include a copy of the laboratory report confirming that the patient had Lyme disease before you select your diagnosis code. ICD-10 coding tips: teach your practitioners about the just-in ICD-10 codes and let them know that documentation must indicate which specific Lyme disease diagnosis the patient has. Otalgia will need identification of affected ear To put it simply, otalgia refers to an ear ache. Part B practices often report otalgia diagnoses when patients complain of ear pain however no more definitive diagnosis is found. Presently, the ICD-9 manual offers just one code for unspecified otalgia: 388.70 (Otalgia, unspecified). ICD-10 coding changes: From October 1, 2013, you will be dealing with a series of four codes that describe otalgia, organized according to the location of the diagnosis, as here: Documentation: Doctors should already include the affected ear in their documentation. All you require to do as a coder to capture this already present information is to format your superbill to see to it that physicians document the additional anatomical information. Tips: You can arrange your superbill in a way that ensures that the physician documents all information applicable for you to submit the most proper code. For example, you can print it like this: H92.0x (x=1 for right ear, x=2 for left ear, x=3 for bilateral, and x=9 for unspecified ear) Or you can simply list "H92.0x" and have the doctor circle "left ear," "right ear," or "bilateral" on the form.

Article  Source  :- http://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/icd-10-preparation-get-to-know-how-lyme-disease-ear-pain-diagnoses-will-change-in-2013-article

Strategies to Ease Your Spinal Osteotomies

When your orthopedic surgeon carries out spinal osteotomies, you have a much better chance of achieving full reimbursements if the procedure note clearly defines the surgeon's intent and approach. Particularly, you should look cautiously for whether the doctor carried out decompression beyond the osteotomy and scrutinize the operative note for indications that a discectomy has been carried out.

Spinal osteotomy is carried out when fusion alone wouldn't make proper a spinal deformity like a change in anterior or lateral curvature of the spine. Osteotomies are indicated only when a corrective fusion isn't enough. If the degree of deformity is serious, only then is an osteotomy indicated.

When the operating surgeon removes a portion of the vertebral segment(s) using codes in the 22206 to 22226 range, go for spinal osteotomy.

Important: Spot on selection depends on three factors: a) the approach, b) the anatomical location of the procedure in the spine, and c) the number of vertebral segments operated upon. Remember that location refers to the area of the spine which is being worked on - which can be cervical (C1-C7), thoracic (T1-T12), lumbar (L1-L5) or sacral (S1-S4).

Find out the approach

Go through the notes to identify the patient's position (supine or prone) to get started. When doctors add information about the approach to the operative report, ‘this helps the coder to choose the proper code to be billed.

Report code 22206, 22207 or 22208 when the neurosurgeon uses a posterior or posterolateral approach for pedicle subtraction osteotomy (PSO), three column closing wedge posterior osteotomy, and vertebral column resection (VCR).

These codes are to be used for osteotomies that remove a V-shaped wedge from the vertebral body, at least two-thirds, along with all of the posterior elements - pedicles, articulating facets, lamina and spinous process.

Depending upon location, you'd use code 22210, 22212 or 22214 for posterior approach in the cervical, thoracic, and lumbar regions, respectively for Ponte osteotomy, posterior closing wedge osteotomy (with or without opening of the anterior column), Smith-Peterson osteotomy, and polysegmental osteotomy. These codes describe osteotomies that remove part or all of the posterior elements but do not remove the vertebral body.

Likewise, if the approach is an anterior one for osteotomy and discectomy and the procedure involves a single vertebral segment, you'd report codes 22220 for the cervical region, 22222 for the thoracic region and 22224 for the lumbar region.

Built in add-ons for multiple levels

For every additional vertebral segment in the posterior or posterolateral approach after the first segment operated upon, report 22216 apart from the primary procedure code.

The CPT book lists the add-on code under each primary approach code for each additional vertebral segment that would need to be billed. For instance, for primary code 22210 for cervical osteotomy of spine posterior approach, 1 vertebral segment, the add-on code for additional vertebral segment would be 22216. Osteotomy procedures are reported as per vertebral level. If the posterior elements were removed from T10, T11 and T12 as in the Ponte or Smith-Peterson osteotomies, you'd report 22212 for T10, 22216 x2 for T11 and T12.

Do not report decompression separately

Decompression of the spinal cord, cauda equina, and/or single or multiple nerve roots is meant in osteotomies and the codes for osteotomies are inclusive of these. Decompression is basically inherent to an osteotomy. These Osteotomy procedures involve removing a piece of the vertebrae to rectify spinal alignment; these codes replace laminectomy, laminotomy, and discectomy procedures and should not be reported at the same levels.

The levels of decompression need to be stated clearly in all operative notes. Minus this documentation, you'd not be able to bill for the decompression separately from the osteotomy. In order to report the right number for every root being decompressed, you should be on the lookout for details for every level to avoid any overlap or to miss reporting a procedure.

Select codes 63047 and 63048 for decompressions that are separate and distinct in anatomical locations from the osteotomy.

+33225: Find out Which Primary Code this Case Study Supports

Here's a real-life case study to see if you can pinpoint the codes this documentation does – and does not – back up.

Start by analyzing the report excerpt

An incision was made along the left deltopectoral groove, and an ICD pocket was dissected out, was prepared with extensive dissection.

Three different guidewires were advanced into the left subclavian vein utilizing the Seldinger technique across the open pocket. Then the middle of these wires was used to further a coronary sinus sheath for placement of the left ventricular lead. With some difficulty, we're able to further the coronary sinus sheath in the mid coronary sinus and an angiogram was got. After this a left ventricular lead was then advanced in the lateral cardiac vein and the tip was advanced to the near LV apex. Electrical testing was carried out at three difficult locations and the rest of these noted a lead impedance of 840 ohms and an R wave value of 17.1 mV.

After this, the bipolar right ventricular defibrillator active fixation lead was advanced to the right ventricle, various areas were checked and the lead was finally fixated along the RV.

Hereafter the bipolar right ventricular defibrillator active fixation lead was advanced to the right atrium. Various areas checked and the lead was finally fixated along the RV septum and tested.

Then a bipolar screw in type right atrial lead was advanced to the right atrium while the lead was fixated to the right atrial wall. After this the coronary sinus sheath was removed with the cutting device maintaining a good lead position of the LV lead.

After this, all the three leads were then sutured to the pectoral fascia over the Silastic sleeves. The ICD pocket was irrigated. Soon the leads were then attached to the ICD/BiV device. Post this, the ICD was placed in the pacer pocket after a standard dose of thrombin material in the pocket. The ICD pocket was sutured closed.

The patient was provided propofol and the following establishment of sufficient general anesthesia. Ventricular fibrillation was encouraged. The advice analyzed and delivered three separate DC countershocks, at last at 36V and the patient converted back to normal sinus rhythm. Patient was made to wake up from sedation without obvious side effects.

Add-On Code

The case study appears to be a new implant of a Biventricular Defibrillator with follow-up testing at implant. While going through the first two paragraphs, you should focus on the terms describing placement of the left ventricular lead via the coronary sinus. The right code for this portion is +33225.

Tips for documentation: You may see this lead referred to as either a left ventricular (LV) lead or coronary sinus lead.

For that add-on code, add the primary code

The next few paragraphs of the documentation describe lead fixation for the RV and RA. What's more, the cardiologist attaches the leads to the device, places the device in the pacer pocket, and sutures the pocket closed. One code 33249 covers all of this.

Add-on note: CPT lists 33249 as a proper primary code for add-on code +33225.

Defib Testing gets you the final code

The last paragraph of the case study excerpt describes 93641. As far as defib testing is concerned, you want to see impedance in the documentation.

Term tip: The defibrillation threshold is the minimum energy amount required during ventricular arrhythmia to defibrillate the heart dependably. Being aware of the patient's DFT helps the cardiologist confirm that the cardioverter-defibrillator (ICD) programming will provide enough of a shock to defibrillate the patient's heart.

Add modifiers to at least one code

Code 93641 requires modifier 26 (PC) to indicate you are claiming only the physician work (and practice expense and malpractice expense) for this service. For this code, the Medicare Fee Schedule (Physician) lists a PC/TC indicator of "1". This means you may use modifier 26 with the code.

You may require a modifier on 33225 because it is an add-on code for 33249. However you may need a 59 modifier on the 93641, depending on the carrier. You should not need one, however you never know with carrier's software.

Source URL : - http://www.supercoder.com/coding-newsletters/my-cardiology-coding-alert/electrophysiology-33225-decide-which-primary-code-this-case-study-supports-article

Your practice should hit these points

In a case such as this, the doctor would normally use fluoroscopy, too; but again it is not documented in this case.

No documentation of fluoroscopy means you shouldn't bill fluoroscopy. When fluoroscopy is documented, you should report 71090-26.

ICD-9: The case-study excerpt also does not mention indications for you to choose ICD-9 diagnosis codes.

What's more, check your local requirements for diagnosis codes that support medical necessity for 33225.