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Primary vs. Secondary Diagnosis

Question: Many of our ophthalmology patients claim general reasons for their visit, such as “I can’t see well,” or “My vision is foggy.” We code these visits with 368.8 as the primary diagnosis because this is the primary reason for the visit. Any other problems or underlying causes of the blurry vision we report as secondary diagnoses. Is 368.8 the most appropriate code to use in these situations, and should we list it first?

Answer: You should only report 368.8 (Other specified visual disturbances) as a primary diagnosis code when the ophthalmologist doesn’t find a more definitive diagnosis during the course of the visit.

Carriers often consider a visit for blurred vision the same thing as a routine exam and Medicare will not pay for this service.

Primary vs. secondary: Whenever possible, you should list a more definitive diagnosis as primary and then the patient’s complaint of blurred vision as secondary. For example, if the ophthalmologist discovers that a cataract is causing the patient’s blurry vision, you would first list 366.12 (Incipient cataract) and then 368.8. You should always strive to report the most descriptive and accurate ICD-9 codes possible. If a patient claims her only reason for the visit is a routine exam, experts recommend that the ophthalmologist ask her a series of detailed questions to uncover any other complaints she may have but doesn’t think of right away. In obtaining a comprehensive history when a patient denies any blurriness of vision, the ophthalmologist should also ask, “Do your eyes chronically itch, burn, or water?” This may lead you to report dry eye syndrome (375.15, Tear film insufficiency, unspecified) or allergic conjunctivitis (372.14, Other chronic allergic conjunctivitis).

Do this: Rather than ask if a patient’s vision is blurry, ask if there is…

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Assistant Surgeon Coding: Which Modifier To Use?

Question: Our surgeon assisted another surgeon from a different practice on a laparoscopic partial colon resection for a patient with Crohn’s disease. The other surgeon scrubbed out, and our surgeon proceeded to ligate an internal hemorrhoid. How can…

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Incomplete Colonoscopy: Modifier 52 or 53?

Question: I’m receiving contradictory guidance on which modifier to use when a gastroenterologist does an incomplete colonoscopy. Should I use modifier 52 or 53?
Answer: CPT 2011 ends the days of arguing over whether to use modifier 52 or 53 for …

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Is 99211 + 95115 OK?

Question: If a nurse has to check vitals to make sure an allergy injection is the correct quantity or if she has to educate the patient about the administration or side effects of the injections, we’ve been billing 99211 with 95115 or 95117. There is…

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No Correct Coding Initiative Bundle? Find Modifier Details in MPFS.

Question: Sometimes I cannot find my two-code pair in the CCI edits. How do I know which code would be considered a column 1 code and which would be considered a column 2 code, so that I could put my modifier on the correct code?

Answer: If the codes are not listed, the codes are not bundled per the Correct Coding Initiative (CCI). You would not need a CCI modifier, such as 25 (Significant, separately identifiable evaluation and management service by the same physician on  the same day of the procedure or other service), 57 (Decision for surgery), or 59 (Distinct procedural service), to override the edit when appropriate.

A private payer could have a black box edit. You would need to check with a rep for a recommendation.

Watch out: Just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. While you won’t need a CCI modifier to override the edit, you might need apayment modifier.

You can find Medicare’s other allowed modifiers for any given CPT code in the Medicare Physician Fee Schedule (MPFS). Columns Y-AC indicate if modifier 51 (Multiple procedure), 50 (Bilateral procedure), etc. apply.

To determine which code receives modifier 51, you need to know the code’s relative value units, which are also listed in the MPFS. Private payers may not adjust claim items in descending order as Medicare’s Outpatient Code Editor software does. If you append modifier 51 to a higher valued item, the private payer may apply the adjustment based on your coding, costing you payment. You should instead list the items in descending relative value order from highest to lowest. Append modifier 51 to the lower priced procedure as necessary. The insurer will then apply the typical 50 percent,…

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What Items Does 86580 Include?

Question: I would like to know the correct codes for billing a PPD test provided in the office. Should I use 86580 with V74.1 and what should I bill for the PPD administration?
Answer: You are using the correct diagnosis code: V74.1 (Special screening …

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Does Modifier GY on 92015 Equal Payment?

Question: A doctor recently told me that appending modifier GY to the refraction code would guarantee payment by a secondary insurer when Medicare denies it. Is this true?
Answer: Modifier GY (Item or service statutorily excluded or does not meet the …

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Comply With Medicare Signature Rules or Risk Payments

Question: One of our physicians likes to sign everything with just his initials, or sometimes an illegible scrawl. Do we need some type of documentation to support what an auditor might not be able to read?
Answer: Yes, you would be wise to keep a sign…

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Is 44145 the CPT code for Lap-to-Open Colectomy?

Question: What codes would you use for lower anterior resection with anal anastomosis and divered ileostomy with mobilization of splenic flexure, which was converted to an open procedure?
Answer: You’ll report the open procedure codes for this case. …

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A4556 Urodynamics Supply Advice Needs to Be in Writing

 Question: We have always reported A4556 for the electrodes our urologist uses during urodynamics procedures. This year, however, DMERC has refused reimbursement, stating we should instead be using code A4595 or A4557. Those two “replacement” code…

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93270 Requires Minimum Transmission

CPT Assistant offers ECG recording checklist.
Question: May we report 93270 even when the only transmission was the test transmission?
Answer: You should be able to report 93270 (Wearable patient activated electrocardiographic rhythm derived event reco…

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Cyst Expression: I&D or Excision?

Question: Documentation reads, “The cyst was excised after performing a central incision directly on the cyst. All the material was expressed, then cyst capsule was removed completely and excised completely. Packing was performed.” Should I code the procedure as an I&D or an excision?

Answer: You should look at the pathology report and any further excision description to reach the correct code set. “Excision is defined as full thickness [through the dermis] removal of a lesion …,” according to CPT’s Excision-Benign Lesions guidelines. The documentation you provided does not indicate what tissue levels the excision involved. A cyst can be epidermal or sebaceous (706.2). A lesion that is removed from the epidermis (top skin layer) does not meet CPT’s excision definition.

The sebaceous gland extends through the dermis. Excision that deep would qualify for an excision code. An excision code (such as 11400, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) requires further documentation detailing the lesion’s morphology, size (including margins), and anatomical location. Without this information, the I&D code (10060, Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) may be more appropriate. The physician made a cut to drain the cyst and then drained (expressed) all the material. The cyst capsule removal is part of the treatment of the I&D to prevent the blockage from reoccurring.

Take more coding challenges with Family Practice Coding Alert. Written by Jen Godreau, BA, CPC, CPEDC, content director of, Family Practice Coding Alert, Volume 12, Number 6.

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Medicare Repeat Pap Smears: Find Out If 99000 Is OK

Hint: Abnormal versus insufficient cells mean different diagnosis codes.

When a patient returns to your office for a repeat Pap smear, you’ve got to weigh your options of E/M and specimen handling codes, as well as diagnosis codes. Take this challenge to see how you fare and prevent payment from slipping through your fingers.

Question 1: When a patient comes in for a second Pap smear, what CPT code(s) should you apply and why?
Question 2: Will you receive reimbursement for handling the repeat Pap smear? Why or why not?

Question 3: If the patient comes back in for a Pap smear due to abnormal results, what ICD-9 code(s) should you use and why?

Question 4: If the patient has a repeat Pap because the lab did not have enough cells in the specimen to interpret the results, what ICD-9 code(s) should you use and why?

Answer 1: Here’s What CPT Codes
When the patient comes in for a second Pap smear, submit the appropriate E/M office visit code (99211-99215). You will probably be able to report 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) for this visit becausethe patient likely will come in only for the Pap smear and CPT does not include a specific code for taking the Pap. Code 99212 carries 1.08 relative value units (RVUs), unadjusted for geography. That translates to about $31 for this visit (using the new conversion factor of 28.3868).
Answer 2: Handling the Specimen Depends on Payer

Some private payers will reimburse for handling the repeat Pap smear specimen (99000, Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory). But Medicare carriers consider the collection and handling part of a problem E/M…

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Protect Incident To Pay

Incident-to services are on auditors radar. To prevent paybacks, you’ve got to know when to use incident to – and capture full pay, and when to bill services directly – and lose the standard 15%. Test your incident to savvy with this question:

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RFA: 64622, 64623 Vs. 64640

With multiple ways to denervate the sensory nerve/nerve branches, pain management coders may argue about which 64xxx code is right. You’ve got to dig into the chart note to identify the method used. See if you’re up to the challenge with this Supercoder Forum Insight.

Question: A provider is doing RFA’s of the left L4, L5, S1, S2, S3 and SA. He is billing 64622 x 1 and 64623 x 4. The other pain provider states this is incorrect and that he should be billing 64640 for S1, S2, S3 and SA. Which coding is correct?

Answer: This is a complex coding issue because there are several different methods to denervate the sensory nerve/nerve branches that provide innervations from the SI joint. Because of this, the coding will depend somewhat on the method used.

However, I can say that reporting 64622 and 64623 x 4 is incorrect. The “paravertebral facet joint nerves” that provide innervations to the facet joints in the cervical, thoracic, and lumbar regions are the medial branches off the dorsal ramus. In the sacrum, there are indeed medial branches, but – as their name indicates – the path for these nerve branches is to the midline to provide innervations to the multifidus muscles and not laterally to the SI joint. So, following the published CPT Instructions for Use of the CPT Codebook – “Do not select a CPT code that merely approximates the service provided”, even though they are similar, procedures performed on the lateral branches of the sacral nerves should not be reported as paravertebral facet joint nerve procedures (i.e., paravertebral facet joint injections or destructions).

A few of the more common techniques are:

  • Separate destruction of each nerve/nerve branch. According to CPT Assistant (Dec. 2009), you would code 64622 for the L5

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Medical Coders: Accepting a PFFS Plan is Your Choice

auditorHere are the pros and cons to help guide your decision.

Question: Our practice is considering accepting patients with PFFS plans. We’re heard that some patients are starting to have them, but we’re not sure whether we’re going to accept them or not. Are PFFS plans beneficial for us?

Answer: PFFS are Private Fee-for-Service plans, which are non-network plans. These plans let members receive care from any doctor or hospital that accepts the plan’s payment terms and conditions.

If your practice decides to accept these terms, you would become a “deemed” provider. Plan members can receive covered services from any deemed provider in the U.S. However, member patients must confirm that the provider is deemed every time a service is provided.

PFFS plans are different from Medicare Advantage plans because they do not require a doctor or hospital to contract with a health plan to provide services. This means that doctors or hospitals that do not agree to the PFFS plans’ terms and conditions may choose not to provide health care services to a plan member, except in emergencies.

Coming soon: Starting in 2011, PFFS plans will have to measure and report on their providers’ quality of care. But the catch is that they’ll also have to form provider networks with contracts.

In counties where there are two or more non-PFFS plans, PFFS plans will no longer be able to simply “deem” providers into the plan without a contract. Under current law, PFFS plans don’t have to prove they can meet access standards if they allow any willing qualified Medicare provider to participate, and they pay as traditional Medicare would pay.

One argument is that the network requirement would provide better access to care because there would be contracts between the providers of services and the plan. On the…

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