Hold Vaccine Claims or Submit Them Now? Get a Better Perspective

If your insurer has not said a peep about whether it'll accept the new vaccine administration codes 90460-90461; you should contact the provider relations department directly. That is how Bonnie Palmer with Lawrenceville Pediatrics in Georgia determined which claims she should submit now, and which she should hold onto.

Her local insurers provided her the following advice on submitting claims. If you like to follow her lead and determine which payers are reimbursing for vaccines, get in touch with all of the payers with whom you are contracted and ask them for specific advice on the new codes. That apart, she adds, “I'd recommend that offices only send a few claims to see how they are processing before they send hundreds and find out what they're all denying.

Article Source :- 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

Blue Cross and Blue Shield of Georgia has the new codes loaded into its systems for all claims with dates of service (DOS) on or after January 1 this year – but then the insurer initially asked practices not to submit these claims until February 3 this year. If you billed the just-in codes prior to February 3, the system denied the second or third unit of 90460 or 90461 as a duplicate and you'll have to call the claims department and have the claim reprocessed for proper payment.

The claims systems for Aetna, Humana, Guardian, Taylor Benefit Systems, and Coventry Health Care are all geared to accept the vaccine claims for all DOS on or after January 1, 2011.

The United Health Care Web site indicates that practices shouldn't use the just-in codes until April 1; however Palmer was told by a UHC rep that this information wasn't posted to the website the correct way. The UHC rep advised her that the insurer's system is actually capable of handling the new codes now for all DOS on or after January 1 this year. If you did bill your vaccine services with the old codes based on the wrong information on the UHC website, you will have to rebill all of those claims with the new administration fees and write 'corrected claim' at the top of your claim form.

The New Z Diagnosis Codes Will Replace Routine Health Check Codes

Take a look at these key factors in your physician's documentation.

It's a known fact that when ICD-9 becomes ICD-10 in 2013, you'll not always have a simple crosswalk relationship between old codes and the new ones. Many a time, you will have more choices that may need tweaking the way you document services and a coder reports it.

Here's a common routine child health check vision scenario that will help you discover what you will report post October 1, 2013.

Present way: When a patient comes in for a scheduled preventive wellness exam, you should attach V20.2 (Routine infant or child health check) to an annual visit code (99381-99385 for new patients, or 99391-99395 for established patients).

ICD-10 difference: This year, you will go for Z00.129 (Encounter for routine child health examination without abnormal findings) to reflect the physician's visit. If the physician did face abnormal findings during the visit, you would instead use Z00.121 (Encounter for routine child health examination with abnormal findings).

Physician documentation: The main difference between Z00.129 and Z00.121 is whether the visit showed an abnormal finding during the examination of the patient. The pediatrician must document this. For example, the physician might examine the patient and note, “patient appears severely speech delayed, which leads to the decision to carry our further testing".

Remember: 'Abnormal findings' does not refer to a blood test, biopsy, or a test that went to pathology. Oftentimes, these key abnormal findings would support a separate E/M visit billed with a modifier 25 (Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) during the time of a preventive medicine visit.

Tips for coders: Instead of relying on V20.2 as your catch-all annual visit diagnosis, you will need to examine your physician's documentation. To put it in other words, you will be looking at the examination part of the visit and what the pediatrician notes as his findings.

Article Source :-  http://www.supercoder.com/coding-newsletters/my-pediatric-coding-alert/icd-10-new-z-diagnosis-codes-will-replace-routine-health-check-codes-in-2013-article

ICD-10 Will Bring One-To-One Equivalents

As we get ready to embrace ICD-10 Codes, many of you might be dreading the transition. But rest assured. Many a time you'll find simple one-to-one relationships between old and new codes. That is the case for hyperplasia; but even then you need to stay alert. You'll still need to carry over the same coding conventions.

For example, think that your ob-gyn suspects hyperplasia. She detects and documents 'endometrial thickening' during an ultrasound examination. What diagnosis should you use here?

Just because your ob-gyn documents endometrial thickening doesn't mean the patient has endometrial hyperplasia (621.30, Endometrial hyperplasia, unspecified; or 621.31, Simple endometrial hyperplasia without atypia). Many coders commit this mistake.

Remember this pitfall: If you encounter the same scenario in 2013, you shouldn't necessarily report the straight forward hyperplasia equivalents N8500 (Endometrial hyperplasia, unspecified) and N8501 (Simple endometrial hyperplasia without atypia). Take note how these definitions are exactly the same.

Coding tips: Do not be swayed by 'endometrial thickening'. You shouldn't code this as hyperplasia as physicians do not always consider the thickening of the uterus "abnormal;" as a matter of fact, it is just a monthly 'ramp up' for all women. Don't report hyperplasia until the ob-gyn has carried out a biopsy, and you have a pathology report that confirms this condition.

Solution: As you have no code to describe the patient's condition, you should report 793.5 (Nonspecific abnormal findings by ultrasound of genitourinary organs). Endometrial thickening is a finding and not a diagnosis. As such, you should locate the diagnosis code in the signs and symptoms section of ICD-9. If you take a look under 'thickened endometrium', this'll lead you to 793.5.

In the ICD-10 alphabetic index, you will not see 'thickened endometrium' referenced at all so you would usually rely on the choices given by one of the equivalent tables that have been produced (such as the ICD-10 bridge found at a coding resource like Supercoder/) based on the ICD-9 code 793.5.

Word of caution: If you look up 793.5's ICD-10 equivalent, you will find that the National Center for Health Statistics still lists R93.4 (Abnormal findings on diagnostic imaging of urinary organs), which is incorrect because the uterus is not a urinary organ.

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.

Know More about Modifier KK on Your Pet Oncological Claims

You bill the global service for NaF-18 PET scans for bone mets. Are you supposed to add modifier KX to these claims for Medicare?

Well, the answer is no. Since you are reporting the global service, Medicare does not require you to append modifier KX (Requirements specified in the medical policy have been met).

In transmittal 2096, CR 7125, CMS published the guidelines on coding these services (including a helpful chart showing which tracer codes pair with which PET codes).

TC/global: When you report a global or technical only claim with A9580 (Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries) and an NaF PET service to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis, the transmittal instructs carriers to process claims that cover all of the following (apart from A9580).

One of these modifiers:

PI (Positron emission tomography [PET] or PET/ computed tomography [CT] to tell about the initial treatment strategy of tumors ) or

PS (Positron emission tomography [PET] or PET/ computed tomography [CT] to tell about the subsequent treatment strategy of cancerous tumors )

modifier Q0 (Investigational clinical service provided in a clinical research study).

Professional component (PC): When you use modifier 26 (professional component) and modifier KX on your PET oncologic claim to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis, the transmittal instructs carriers to process claims that include all of the same items in the bullet list mentioned.

The difference: Code A9580 belongs only on global and technical claims. Carriers will reject professional claims for A9580 as the assumption is that the facility (the entity providing the technical part of the service) bears the cost of the A9580 agent and should be paid for it.

The presence of modifier KX on the professional claim shows contractors they should process the service as PET NaF-18 rather than PET with FDG.

Use 45990 for Rectal Exam with Anesthesia

In a particular case, the surgeon used a bivalve, suctioned the old blood from where a hemorrhoid had necrosed and fallen off; however the large vessel underneath was continuing to bleed (all done under anesthesia). After this he sutured the bleeding site. If you fail to find a proper CPT code for this, what should you do in this situation?

Well, the procedure described above is a rectal exam under anesthesia (45990, Anorectal exam, surgical, requiring anesthesia [general, spinal, or epidural], diagnostic). According to CCI edits, you shouldn’t report 45990 in conjunction with 45300-45327 (Proctosigmoidoscopy), 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 57410 (Pelvic examination under anesthesia), and 99170 (Anogenital examination with colposcopic magnification in childhood for suspected trauma).

Physician responsibility: Anorerctal exam is primarily done by placing the patient in left lateral decubitus position. This exam is chiefly done to study anal fissures, anal fistula, anal mass and hemorrhoids. The patient is provided general, spinal or epidural anesthesia and the physician carries out a diagnostic digital rectal exam by inserting a lubricated gloved index finger after relaxation of anal sphincter mainly to examine the perineal area. An ansoscope is inserted into the rectum to visualize the anal canal and distal rectum. Soon after removing the anoscope, a rigid proctosigmoidoscope is inserted to the anus to visualize sigmoid colon and rectal lumen.

Source URL :- http://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/reader-questions-consider-45990-for-rectal-exam-with-anesthesia-article

Know the Difference between Aerosol & Gaseous Ventilation

Not sure about the difference between aerosol and gaseous ventilation? Well, read on and find out the key differences between the two. Both aerosol (78586, 78587) as well as gaseous (78591, 78593, 78594) studies are part of the ventilation code series.

The ICD-9 code depends ( source "http://www.supercoder.com/icd9-codes/")  on whether or not the internist identified a cause.

Aerosol tests include the patient inhaling nebulized (reduced to a fine spray) aerosol agents with radioactive particles. The vital term to look for indicating aerosol is DTPA, the radioactive aerosol the provider has the patient inhale. Often times you would encounter other terms such as Technetium DTPA, particulate, and mist.

Physician's note for gaseous ventilation studies normally refer to the gas used, typically Xenon gas (such as Xenon-133 or Xe 133). One more possibility is Krypton gas (Krypton-81 or Kr 81), even though you may not see this much in practice.

CPT code further differentiates gaseous ventilation studies by whether the patient takes only a single breath or for that matter she does rebreathing and washout without plain oxygen. Rebreathing is inhalation of the gas exhaled earlier. 'Rebreathing' is inhalation of the gas exhaled previously. 'Washout' is the elimination of the radioisotope from the lungs. The xenon gas exams usually consist of three phases:

1. A single breath – the patient takes a single deep inhalation

2. Rebreathing – the patient takes normal breaths while rebreathing a mix of oxygen and xenon

3. Washout -- the patient breathes room air while exhaling the xenon, clearing the lungs of the radioactive gas.