Ph + Impedance Testing: The CCI Edits Can Ease Things for You

Time is a crucial element while selecting between 91037 and 91038.

When your physician's note proposes impedance and pH tests being carried out together, you would turn to the 9103x series of your medical CPT manual. Easy? Not exactly. Take the following scenario in point.

Scenario: The motility specialist carries out impedance + pH test for over an hour. The patient, who complains of recurrent as well as painful heartburn, leaves the office with the catheter in position till the next day.

Dilemma: Can you bill 91038 by itself, or do you require to add 91034 at all?

The key is to recognize what each code involves, but you should not just base your choice on the obvious. You must give weight to Correct Coding Initiative (CCI) edits, too. These guidelines should keep you on the right track.

1. Look for 91037-91038 for Impedance Catheter

While reporting esophageal function (impedance) tests, you would define it using two medical CPT codes:

91037 –- i.e. Esophageal function test, gastroesophageal reflux test including nasal catheter intraluminal impedance electrode(s) placement, recording, analysis as well as interpretation

91038 -- i.e. ...prolonged (greater than 1 hour, up to 24 hours)

Keep in mind the descriptors for 91037 and 91038 represent a time measurement, which implies that you must apply 91037 for testing that goes up to one hour. In case the monitoring goes for more than one hour, bill 91038 as a substitute. You should not bill both codes for the same test. You should apply only a single code to report the session.

What happens: In an impedance test, the catheter goes in the patient's body transnasally. This particular test measures bolus transit dynamics along with either pH measurement or esophageal muscular function in the assessment of symptoms involving chest pain, swallowing trouble, or chronic heartburn which is unresponsive to medication. At times, physicians would carry out these tests in conjunction with manometry or pH testing.

Together motility study (manometry) as well as esophageal function testing uses a nasal catheter. Though, the impedance probe is multi-purpose and measures more much more than the motility test (91010, Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report; 2-dimensional data) or the gastroesophageal reflux test (91034, Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation).

2. Single Code Defines Cather-Based pH Test

When a gastroenterologist carries out an esophageal acid reflux test using either a disposable or a reusable nasal catheter, you would then reportmedical CPT 91034.

Pointer: Medical CPT 91034 should be your go-to code irrespective of how long the nasal catheter remains in place. Generally, though, the physician will leave the catheter in place for about a day. Earlier, you had to differentiate between standard and "extended" pH monitoring. Currently, only single code (91034) defines a catheter-based pH service.

How to Code Cosmetic Ptosis Repair

Having issue how to code Cosmetic Ptosis repair. For more on this and all 2011 CPT updates visit a medical coding guide like Supercoder.

There is this Medicare patient of ours who'll be having a leva to resection on his right eye for ptosis. The ophthalmologist wants to do this as a bilateral procedure; however the patient's left eye is a non-seeing eye. As the operation on the right side may be medically necessary, but the left side would likely be considered cosmetic, how should I go about coding this surgery?

Well, you should report each side of the bilateral procedure on a separate line, appending modifiers LT (left side) and RT (Right side), linking each side to the appropriate diagnosis code explaining the necessity for the surgery.

In this situation, one side will be medically necessary, while the other will be cosmetic – the procedure will not benefit the vision on the non-seeing eye.

Here's what you need to do: Before the surgery, have the patient sign an advance beneficiary notice of non-coverage (ABN) prior to surgery, stating that he's aware that Medicare will not cover the procedure carried out on the left eye. Ensure your ABN is in layman's terms and specifies the specific reasons for non-coverage. (you shouldn't use CPT Code, ICD 9 codes on the ABN form).

You must also specify the estimated cost of the service on the ABN. The original signed ABN indicating the patients decision ( be sure the patient has chosen one of the options) to accept financial responsibility, is maintained by the practice and a fully executed copy must be provided to the patient. Append modifier (Waiver of liability statement on file) to the procedure done on the non-seeing eye to indicate that the patient was informed before and has selected the option to be responsible for the non-covered service and unpaid amount.

For instance: The patient has congenital ptosis (743.61), and his left eye is non-seeing. The ophthalmologist carries out levator resection (67904, Repair of blepharoptosis; [tarso] levator resection or advancement, external approach) bilaterally. Code as follows:

Line 1: 67904-RT linked to 743.61

Line 2: 67904-LT-GA linked to V50.1 (Elective surgery for purposes other than remedying health states; other plastic surgery for unacceptable cosmetic appearance).

If your documentation shows that the procedure was medically necessary on the right side, Medicare will reimburse the full amount for 67904-RT. The cosmetic diagnosis linked to 67904-LT-GA will prompt the carrier to deny the specific service due to the diagnosis and non-coverage of cosmetic services, and the explanation of benefits (EOB) received by the patient will confirm that the patient is responsible for payment.

Don’t assume ICD-10 diagnosis codes -- 424.1 will split under the new cardiology codes next year

 The coming year there will be major code changes when ICD-10 comes into effect. Like any other practice there will be major changes for cardiology codes. For instance, there will be new code set divides for diagnosis code 424.1 under ICD 9-CM that is used to report aortic valve disorders, and you need to ensure that you are updated with all the code changes to keep your practice compliant and profitable. A disorder of the aortic valve refers to a problem with the valve between the aorta and the left ventricle.

When ICD-10 becomes effective then there will be a range of codes specifying 424.1 that will be from 135.0 – 135.9. There will be a range of codes to choose from for multiple aortic valve disorder codes in the I35. - range under ICD-10. ICD-10 will have separate codes for stenosis, insufficiency, stenosis with insufficiency, other, and unspecified.

To ensure correct coding you need to ensure that you document correctly if the aortic valve disease is rheumatic or not. You also need to ensure that you have adequate knowledge regarding whether the condition is congenital because it will affect the choice of codes that will be used. Since there will be multiple code options for aortic valve disorders under ICD-10, documentation needs to be specific about the type of disorder to identify the most specific code.

There are some tips that can be followed to code correctly. If the documentation shows stenosis and insufficiency then only the code 135.2 should be used instead of I35.0 and I35.1 together. Insufficiency can also be documented by using incompetence or regurgitation. When 135.8 is used the term “other” specifies that the physician documented the type, but ICD-10 will not have any code that will specify the documented type. The "unspecified" in I35.9 would mean that the physician did not document the type.

Document Now to Save Yourself Trouble Later on

If Medicare carries out an audit and figures out that your documentation is not in proper order, you could find yourself having to repay them for all the claims they find problems with.

Medicare only sees the front portion of the form when you send in a CMS-1500 form. What Medicare fails to see is what is on the other side of that form, which is your documentation. They presuppose that your document is right until they carry out an audit.

If Medicare carries out an audit and figures out that your documentation is not in proper order, you could find yourself having to repay them for all the claims they find problems with. That is the reason why it is vital to cautiously document the medical necessity of the visual field exam in the patient's medical record.

According to experts, one of the weak areas of optometrists is the "interpretation and report" portion of several codes. For instance code 92083 provides one example. As per your record of a visual field, "Informed patient test for OD showed small area we need to watch; have return in three months." In a postpayment audit, Medicare will not accept this billing. Here's why? Interpretation and report" needs assessment of both eyes.

Bear in mind: All three visual field codes have a TC and PC. When you bill 92083, you are telling Medicare you performed both the TC and the PC. It is better to have a form just for visual fields, apart from your regular notes.

This may sound excess, but remember that in case of an audit, such a form could save you money.

For further details on this and for other medical coding updates, sign up for a one-stop medical coding guide like http://www.supercoder.com/.

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.