493.2x: Your Physician's Notes are Your Best Bet Here

You should have the right information ready prior to referring to your ICD-9 coding manual to save yourself from trouble.

It always helps to have the right documentation in place. When a patient comes to the pulmonologist with asthma or bronchitis, and symptoms of chronic obstructive pulmonary disease, your physician's notes may be your best choice.

You should have the right information ready prior to referring to your ICD-9 coding manual to save yourself from trouble. Ensure the documentation supports the physician's diagnosis. After this, be on the lookout for any associated acute conditions. When you face the situation, ask these three important questions that can help you breathe easily through your lung diagnosis coding.

Check whether the patient has status asthmaticus or acute exacerbation before using 493.20

If a pulmonologist diagnosed a patient with both asthma and chronic obstructive pulmonary disease, go to the v493.x section of ICD-9 and choose from the three options: 493.20, 493.21, and 493.22. For some payers, 493.20 is default code. It is always better to check with your pulmonologist first to see if the patient has status asthmaticus or acute exacerbation before settling with 493.20.

Note of caution: A diagnosis of 'status asthmaticus' is the most acute presentation and takes precedence over any type of COPD; as such you should primarily list the most acute diagnosis addressed if the physician documents both findings. On the claim, you should report 493.21, and not 493.22 (an acute exacerbation). If status asthmaticus is documented by the provider with any type of COPD or with acute bronchitis, the status asthmaticus should be sequenced first. It supersedes any type of COPD including that with acute exacerbation or acute bronchitis.

Don't report 466.0 for obstructive chronic bronchitis

When your pulmonologist documents chronic obstructive bronchitis with an episode of acute bronchitis, you should code 491.22. You should not report 466.0 (Acute bronchitis) for the obstructive chronic bronchitis since this code fails to capture the patient complexity of an acute-on-chronic illness, as in 491.22.

Get thorough documentation from your pulmonologist

If you are coding COPD, full details are very important. The documentation should include a listing of signs, symptoms, and conditions. A mere entry of “shortness of breath and cough" may not just be enough. Since cardiopulmonary diseases manifest themselves in this fashion, these symptoms can represent a progression of chronic illness or other acute issues, either related or not related to the patient's chronic disease. As such, clinical evaluation, based on a detailed history, is of prime importance. In order to determine a new illness or a progressing/exacerbating chronic illness, the physician may order blood studies, along with radiographical and physiological evaluations. Just listing COPD as the diagnosis does not reflect the patient's present status. Including the signs, symptoms, or the exacerbation will aid in justifying the medical necessity of the studies ordered. The payer will better understand that these aren't routine surveillance studies.

Don't Trip Up Your Foot and Ankle Claims

Be aware of some of the more common foot procedures your family physician might face if you want to get the rightful reimbursements for your foot and ankle claims.

You need to be aware of some of the more common foot procedures your family physician might face if you want to get the rightful reimbursements for your foot and ankle claims.

You should have sound basic knowledge

Sudden impact or simple wear-and-tear can cause toe, foot and ankle problems. As such you need to be aware of the differences between these diagnoses or you may miss a subtle difference and report the wrong code.

One thing to bear in mind is that you might require modifiers to help differentiate work on different areas of the feet or for that matter toes. These modifiers include LT and RT, TA-T9 and sometimes 59 depending on the service your physician provides. These modifiers become all the more important if the FP carries out the same procedure on more than one foot or toe.

Be aware of the difference between Bunions and Hallux Valgus

A bunion is an enlargement of bone or tissue around the metatarsophalangeal (MTP) joint of the great toe. It's often caused by patients wearing shoes that are too narrow around the toe box and can cause pain and deformity of the toes.

Remember: A common mistaken belief is that "hallux valgus" and "bunion" refer to the same thing. Even though CPT code lists bunion procedure codes like 28290 as "hallux valgus corrections," doctors who carry out these are not necessarily correcting a hallux valgus, according to ICD-9 terminology. If you look up 735.0, the definition reads, "Angled displacement of the great toe, causing it to ride over or under other toes."

As such, you should not report 735.0 unless the patient has an angular deformity of the great toe. As per this definition, a person could have a bunion but not necessarily a hallux valgus deformity; however experts say that the above definition is not actually followed. Hallux valgus is simply a valgus deformity of the distal great toe and does not have to overlap for a physician to call it hallux valgus.

If the patient's great toe is not overlapping or impinging upon the second toe, but he still has an obvious bunion, take a look at 727.1; this code specifically says 'bunion' and the ICD-9 definition is "enlarged first metatarsal head due to inflamed bursa; results in laterally displaced great toe."

For more on this particular topic and for other coding updates, sign up for a one-stop medical coding guide like http://www.supercoder.com/ and stay informed.

See Which Audit Process You Need to Follow for Your Practice

Remember that the same audit process and timeline will not work for every practice to identify the needs of your practice.

Internal audits are a way to ensure you're on track and nothing has gone wrong. See to it that your pediatric practice conducts regular internal audits if you don't want to lose money and overlook billing mistakes that could result in missed billing opportunities.

But before starting your audits, you should explain to everyone in your practice why you should go for an internal audit and how an internal audit will benefit your practice.

Internal audit charts: Internal chart audits make it possible to find and fix coding mistakes and self report rather than letting the payer find them. If your staff members are not willing to participate, let them know that the point of the audit is to improve coding down the line.

Types of internal audits:

Prospective audit: Your practice assesses new claims before you file them. Such an audit helps you identify and rectify problems prior to sending the claim, which could mean you will discover improper coding or charges that would have been missed otherwise. However, remember that this kind of chart audit can delay billing.

Retrospective audit: Your practice takes a look at paid claims. On the other hand, this type of audit do not delay billing but causes your office to be proactive in finding problems before you submit the claim.

But remember that the same audit process and timeline won't work for every practice to identify your practice's needs.

What should be done: Your practice must determine for itself what types of audits your staff can reasonably compete and what effects on claim submission timing and cash flow your practice can handle.

You should remember that an audit is much more than coding; it involves documentation, coding, billing and data input, denials management and office process following policies and procedures.

Orthopedic Coding: Additional Neurostimulator & Arthrodesis Codes

Your orthopedic practice will enjoy the additional neurostimulator and arthrodesis codes as far as the new and revised CPT codes for your orthopedic practice in 2011 is concerned.

This time your orthopedic practice will enjoy the additional neurostimulator and arthrodesis codes as far as the new and revised CPT codes for your orthopedic practice in 2011 is concerned. You'll be required to report arthrodesis procedures that include discectomy, osteophytectomy and spinal cord decompression with two just-in bundled codes: 22551, 22552.

Since 22552 is an add-on code, you would report it with 22551 to reflect any additional interspace the neurosurgeon treats below C2. Prior to this, bundled procedure would have been reported as 63075 for the discectomy, osteophytectomy and spinal cord/nerve decompression and 22554-51 for the arthrodesis. This is one of several code pairs which were used together more than 90 percent of the time, leading CMS to request a bundled code from CPT.

Now you'll be able to describe fully tibial and cranial neurostimulator services with four new codes: 64566, 64568, 64569 and 64570. And if your neurosurgeon carries out chemodenervation, you'll have a new code to code for work on the salivary glands: 64611.

This year don't let code descriptor changes trip you up when you turn to 20664 for halo application, as the revision this time does away with the phrase "requiring general anesthesia:" 20664 (Revised). Add-on allograft codes 20930 and 20931 received changes, which will be for 2011: 20930 (Revised) and 20931 (Revised).

The development of many bone graft extenders including demineralized bone matrix and bone morphogenic protein led to frequent questions regarding the appropriate coding for these materials. The revision of 20930 places these materials in the same category as other non-structural bone extenders that are not obtained directly from the patient being tended to." Closed vertebral facture code 22315 now deletes the phrase with or without anesthesia: 22315 (Revised) and code 22851.

More Documentation Requirements add to Physician Burden

More Documentation Requirements add to Physician Burden
Medical Coders need to look on Medical coding because more documentation is requirements add to physician burden.
Medical Coding, Code lookup

Home health agencies will have less control over new doctor-related payment condition. Agencies are hoping for some big changes to one troublesome provision in the 2011 proposed payment rule – the face-to-face doctor encounter requirement.


The mandate for the face-to-face encounter was in the Patient Protection and Affordable Care Act health care reform law enacted this year. However, the CMS version of the requirement is more stricter than the law calls for.


For instance: The proposed rule also requires that the encounter be for the primary reason home care services are required and that doctors furnish 'unprecedented' physician documentation about the encounter and why the patient meets homebound criteria.


According to industry experts, the proposed face-to-face encounter requirement is riddled with problems for home health agencies. To start with, agencies have very little influence over whether their patients make it to a physician for a visit.


It is absolutely not proper to place a requirement on home health providers for which they have no control whatsoever, as a consultant puts it. “How is the staff of the home health provider supposed to ensure that the patient goes to the physician and that the physician documents right in her office records?"


One can make appointments for patients; however we cannot ensure they keep them; that their transportation is unfailing, that they feel well enough to make the trip. In fact, there are many reasons that patients fail to see the doctor despite the best efforts of the home care staff to make it happen.


For more on this, sign up for a one-stop medical coding website http://www.supercoder.com/. Such a site comes with a code lookup tool that will help you in your coding.

Pathology/Lab | Stain Codes from Microbiology, Hematology and Surgical Pathology Earn Proper Payment

"Clinical labs and anatomic pathologists use special stains to aid in microscopic examination of tissues or cells, but they shouldnt necessarily report the same codes for the same stain. Coders must know which CPT code to use based not only on the type of stain but also on the stain substrate and the reason for the procedure. Many special stain processes are described by 85535-85536, 87205-87207 and 88312-88313. Without properly applying these codes, laboratories may sacrifice payment for legitimate staining services, says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, laboratory coding and compliance consultants in Longwood, Fla.

Codes 88312 -88313

Two special stain codes appear as add-on codes in the CPT surgical pathology section: 88312 (special stains [list separately in addition to code for surgical pathology examination]; group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each) and 88313 (... group II, all other [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, each). In their most straightforward application, these codes describe the special staining of any surgical pathology tissue specimen. For example, an acid fast stain carried out on a transbronchial lung biopsy for diagnosis of disease such as tuberculosis would be reported as 88312, in addition to the surgical pathology service (88305, level IV surgical pathology, gross and microscopic examination, lung, transbronchial biopsy). Similarly, a trichrome stain to evaluate fibrosis observed in a liver biopsy (88307) is reported as 88313.

Despite the fact that 88312 and 88313 are add-on codes in surgical pathology, they also describe special staining services for specimens other than surgical pathology tissues. For example, if a trichrome stain for ova and parasites is carried out on a direct smear from a stool sample, the service is reported as 88312. There is no code in the microbiology section for this stain, so the service must be reported with one of the special stain codes from surgical pathology, Dettwyler says. A directional note in the microbiology section of the CPT manual states, For complex special stains, see 88312, 88313.

Another point coders find confusing about the ova and parasites stain is the fact that a trichrome stain is reported with 88312, even though trichrome is listed as an example under 88313. But in the ova and parasites stain, the trichrome is used to identify microorganisms, and should therefore be listed as 88312 because its definition lists group I for microorganisms, Dettwyler says. The trichrome stain described by 88313 is a tissue dye technique used to highlight connective tissue, muscle, cytoplasm and nuclei, and is therefore considered a group II stain.

Although CPT directs the use of 88312 or 88313 for special stains on specimens other than tissue, some laboratories have reported denials from both Medicare and third-party payers. Sometimes the problem is that a clinical laboratory has certification for microbiology and parasitology, but not for anatomic pathology, Dettwyler says. Then when the lab reports codes from the surgical pathology section, such as 88312 or 88313, payment is denied. Labs can appeal the denials and ask the carrier to add these special stain codes to those allowed under the labs certification specialty.

Yet another use of 88313 for nonsurgical specimens is the reporting of iron stains for bone marrow aspiration requiring physician evaluation. Although there are separate codes for iron stains for blood and bone marrow smears (85535-85536), a note following these codes directs coders, For iron stains on bone marrow or other tissues with physician evaluation, use 88313. Further, CPT directs coders to special stain codes 88312 and 88313 in a note under the bone marrow aspiration codes (85095 and 85097).

For example, a pathologist may evaluate bone marrow aspiration smears, plus a cellblock made from the clot, and also interpret an iron stain for the diagnosis of iron-deficiency anemia (280). These services are reported as 85097 (bone marrow; smear interpretation only, with or without differential cell count), 88305 ( cell block, any source) and 88313x2 for the iron stain if it is carried out on both the aspirate and the cell block.

Codes 85535-85536

Hematology code 85535 (iron stain [RBC or bone marrow smears]) describes technologist appraisal of sideroblastic or reticuloendothelial bone marrow iron stores. Code 85536 (iron stain, peripheral blood) was added in CPT 2001 to report microscopic analysis by a medical technologist for abnormal iron accumulations in peripheral blood. Because the wording allows reporting a red-blood-cell iron stain with either code, 85536 should be used for peripheral blood smears, and 85535 reserved for RBCs other than peripheral blood.

For example, if a physician suspects sideroblastic anemia and requests an iron stain on peripheral blood, the stain is reported as 85536. The stain may be reported in addition to the pathologists evaluation of the smear (85060, blood smear, peripheral, interpretation by physician with written report).

CPT 2001 also added a note following 85536 directing coders to use 88313 for physician evaluation of iron stains on bone marrow or other tissues. For instance, a pathologist may evaluate a bone marrow biopsy (85102, bone marrow biopsy, needle or trocar) and decalcify the specimen (88311, decalcification procedure [list separately in addition to code for surgical pathology examination]) to permit an iron stain evaluation (88313) of the bone marrow.

Codes 87205-87210

The 87205-87210 family of codes reports special microbiology stains for direct smears from various sources. The stains are 87205 (smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types), 87206 ( fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types) and 87207 ( special stain for inclusion bodies or intracellular parasites [e.g., malaria, coccidia, microsporidia, cytomegalovirus, herpes viruses]). The stain substrate includes direct smears from sources such as blood, urine, stool, sputum, synovial fluid, cerebrospinal fluid (CSF) or vaginal smears.

Codes 87205 -87207 describe special stains used to indicate the presence of disease-causing organisms in direct smears, says Kathleen Ohrt, MT (ASCP), SM, microbiology technical specialist at Beebe Medical Center in Lewes, Del. These tests are often run concurrent with a culture. Although some of the same stains may be used to identify cultured organisms, the 87205 family of codes should not be used for cultures, Ohrt says. Stains and other tests to identify cultured organisms are included in the codes for presumptive and definitive identification, she says.

Some clinical examples illustrate how to use codes 87205-87210:

For a urine or vaginal smear evaluated for bacteria using a Giemsa stain, report 87205.

For a vaginal smear evaluated for Trichomonas or Monilia using a wet mount such as KOH or saline preps, report 87210 (wet mount for infectious agents [e.g., saline, India ink, KOH preps]).

For a Giemsa stain of a peripheral blood smear for suspected malaria, report 87207. Regardless of the fact that Giemsa stain is listed under 87205, in this case it is used as a special stain for the sporozoan malarial organism, Plasmodium, rather than a bacteria or fungi, and should be reported as 87207. Note that the peripheral blood is typically concentrated for this stain, which is separately reportable as 87015 (concentration [any type], for infectious agents).

Report an acid-fast bacilli (AFB) stain of a sputum smear with 87206. This may be an acid fast stain, or a fluorescent stain, Ohrt says. Typically, the sputum is also concentrated, which is reported separately according to CPT direction for thick smear preparation, use 87015.

For a synovial fluid smear, either a Gram stain for bacteria, or Giemsa or Wright stain for cells should be reported with 87205.

Gram staining of a direct CSF smear to indicate the presence of bacteria such as meningococci is reported as 87205. The CSF would typically be cultured at the same time, reportable as 87070 (culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive identification of isolates), Ohrt says.

Special staining of a direct smear from a herpetic vesicle for inclusion bodies, such as the Tzanck stain for herpes simplex virus, would be reported with 87207. Note that this is the only code from this family listed in the physician fee schedule with modifier -26 (professional component). If a pathologist provides a professional interpretation and report of a special stain for inclusion bodies or intracellular parasites, 87207-26 should be reported for the service, Dettwyler says.

Remember that not all microbiology staining of direct smears is reported with 87205-87210. A note associated with these codes in the CPT manual directs coders, For complex special stains, see 88312, 88313. Recall the earlier example of a stool smear trichrome stain for ova and parasites reported with 88312.

Because CPT directs coders to special stain services listed in divergent parts of the pathology and laboratory section, coders should be familiar with all of these codes."

Get Reimbursed for Nonelective Abortions

Technological advances enable physicians to detect pregnancy in its earliest stages but make coding for spontaneous or missed abortions more complicated. When a patient presents with no prior pregnancy diagnosis, tools such as ultrasound and beta subunit HCG (human chorionic gonadotropin, a pregnancy test that helps determine the stage of pregnancy) confirm pregnancy and enable physicians to determine how far it has progressed. When a patient presents with a pregnancy that has already terminated through nonelective abortion, coding for diagnosis and procedural care can be a challenge, especially for very early-term pregnancies. Often, women who did not seek medical attention for early diagnosis of pregnancy will not identify a delayed menstrual cycle as the loss of a pregnancy and will not be aware that conception occurred. If a pregnancy is diagnosed and terminates, either by spontaneous or induced means, the abortion codes should be used to report the related physician services.

Abortion Terminology


Familiarization with the common types of abortions is the first step to assigning the right ICD-9 and CPT codes.

Complete: The complete expulsion or extraction from its mother of a fetus or embryo; complete expulsion from the uterus of any other product of conception.

Elective: Without medical justification but done in a legal way.

Incomplete: Part of the products of conception have been passed but part (usually the placenta) remains in the uterus.

Induced: Expulsion of the fetus and products of conception brought on purposefully by drugs or mechanical means.

Inevitable: Characterized by rupture of the membranes in the presence of cervical dilation in a pre-viable pregnancy.

Missed: Death of the fetus in utero prior to 22 weeks, with retention of the products of conception.

Septic: An infectious abortion complicated by fever, endometriosis or parametritis.

Spontaneous: An abortion that has not been induced artificially. The term is usually limited to pregnancies of less than 22 weeks gestation.

Editors note: CPT codes for induced abortion (59840-59857) do not distinguish between elective (not medically necessary) or nonelective (medically necessary) abortions. ICD-9 codes 634.x-637.9 describe spontaneous (nonelective) (the fourth digit indicates the contributing complication), legally induced (elective), illegally induced (elective) and unspecified abortion (nonelective).

Spontaneous vs. Missed Abortion

Carla Bryan, CPC, practice manager at Womens Care, a two-physician, one-nurse midwife ob/gyn practice in Hartsville, S.C., says that when determining the right CPT code for a nonelective abortion, the first parameter is whether surgery was required to complete the process. If the patient presents with a spontaneous abortion that is complete (meaning there were no products of conception retained in the uterus), we treat the patient and code it as an evaluation and management (E/M) visit, with no other CPT code, since nothing else was done. Code 634.x (spontaneous abortion) is used for diagnosis. If Bryans physician must evacuate a dead fetus from the uterus through a dilation and curettage (D&C), 632 (missed abortion) is used for the diagnosis, and 59820 (treatment of missed abortion, completed surgically; first trimester) or 59821 (treatment of missed abortion, completed surgically; second trimester) is used for the D&C. By using the code for missed abortion, you indicate that there are retained products of conception that must be surgically removed. A spontaneous abortion code implies that there are no retained products in the uterus and, therefore, no procedural code, she says.

If Its Not Technically a Pregnancy

What procedural codes apply when the patient enters the exam room unaware that she is pregnant, and the diagnosis is something other than a missed abortion? One example is when a physician performs a D&C for a blighted ovum (631, other abnormal product of conception). The code for dilation and curettage, nonobstetrical (58120) doesnt appear to be the answer, but the correct code depends on when or if the blighted ovum and pregnancy were discovered.

The treatment for a blighted ovum, which is a fertilized egg that fails to develop a fetus within it, may be the same as a missed abortion, but only if a pregnancy has been confirmed. Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature and an independent coding educator, explains the distinctions. A blighted ovum may reabsorb before it is detected, or the patient may exhibit signs of miscarriage. The patient may come in with unexplained vaginal bleeding before she realizes that she may have been pregnant, and a pregnancy test comes back negative. If this is the case, Witt explains, and there is a negative pregnancy test, the proper code for the D&C is 58120 (dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) even if the pathology report indicates a blighted ovum after the fact.

On the other hand, if the patient has been diagnosed as pregnant either prior to or at the same visit, and then begins bleeding, the patient may spontaneously abort (E/M code only) or may require surgery to remove the contents. The blighted ovum may not show up until the pathological reports come back, but because there was a positive pregnancy test, 59812 is used to indicate treatment of incomplete abortion, any trimester, competed surgically.

Although unusual, a patient with a blighted ovum may complain of a missed period only. The physician is likely to order a pregnancy test and do an ultrasound. If the pregnancy test is positive, and the ultrasound reveals a blighted ovum (but no symptoms of abortion, i.e., discharge or vaginal bleeding), the physician will perform a D&C, and 59820 or 59821 would be used along with code 631.

With a blighted ovum, says Witt, you are not inducing abortion because there is no fetus; rather you may be helping along what nature has already started. She adds that, before tests revealed pregnancy at its earliest stages, physicians were more inclined to let nature takes its course and let the body either expel or reabsorb the blighted ovum. But D&Cs or other abortion methods are now employed much more frequently to treat incomplete abortions or induce abortions when a pregnancy is not viable.