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The Unethical Practice of Medical Up-Coding

No one enjoys opening medical bills — or paying them, for that matter. Best Medical Coding Course!

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Urinary Incontinence Evaluation and Management

The evaluation of UI has as its goal confirmation of the diagnosis, identification of any reversible causes, and identification of factors that require further diagnostic or therapeutic interventions

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CPT 2011 Begs CMS Reexamination of Time as Averages or Thresholds

All that fine green print on time in your E/M CPT 2011 manual boils down to one thing: you can round to the closest time code.
But that advice from CPT contradicts Medicare’s threshold time guideline.
CPT Treats Times as Averages
 CPT 2011 indicates…

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E/M Coding Makes OIG 2011 Work Plan

Make sure your postop office visit documentation measures up.

The OIG has once again set its sights on several new targets to go with the upcoming new year, and this time the feds will be double- and triple-checking your E/M documentation.

On Oct. 1, the OIG published its 2011 Work Plan, which outlines the areas that the Office of Audit Services, Office of Evaluations and Inspections, Office of Investigations, Office of Counsel to the Inspector General, Office of Management  and Policy, and Immediate Office of the Inspector General will address during the 2011 fiscal year. When the OIG targets an issue in its Work Plan, you can expect the agency to carefully review and audit sample claims of those services.

The Work Plan “describes the specific audits and evaluations that we have underway or plan to initiate in the year ahead considering our discretionary and statutorily mandated resources,” the document indicates.

On the agenda for next year, the OIG has indicated that its investigators will “review the extent of potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations.” The OIG also plans to hone in on whether payments for E/M services performed during the global periods of other procedures were appropriate.

In addition, the OIG will scrutinize Medicare payments for Part B imaging services, outpatient physical therapy services, sleep testing, diagnostic tests, and claims with modifier GY on them (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, it is not a contract benefit).

The OIG also intends to “review Medicare payments for observation services provided during outpatient visits in hospitals” to assess whether hospitals’ use of observation services affects Medicare beneficiaries’ care.

Keep your compliance plan up to date with tips from Part B Insider,

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History of Present Illness Must Be Taken by MD, NPP

Don’t let nurses do the doctor’s work, or risk downcoded E/Ms upon audit.

The only parts of the E/M visit that an RN can document independently are the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs, according to a June 4, 2010 Frequently Asked Questions (FAQ) answer from Palmetto GBA, Part B carrier for Ohio. The physician or mid-level provider must review those three areas and write a statement that the documentation is correct or add to it.

Only the physician or non-physician practitioner who conducts the E/M service can perform the History of Present Illness (HPI),  Palmetto says.

Exception: In some cases, an office or Emergency Department triage nurse can document “pertinent information” regarding the Chief Complaint or HPI, Palmetto says. But you should treat those notes as “preliminary information.” The doctor providing the E/M service must “document that he or she explored the HPI in more detail,” Palmetto explains.

Other payers have expanded on Palmetto’s announcement, letting physicians know that they cannot simply initial the nurse’s documentation. For example, Noridian Medicare publishes a policy that states, “Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be ‘I have reviewed the HPI and agree with above.’”

Good news: Thanks to this clarification, your doctor won’t have to repeat the triage nurse’s work. Right now, if the nurse writes “knee pain x 4 days,” at the top of the note, some auditors might insist that your doctor needs to write “knee pain x 4 days” in his/her own handwriting underneath. But that requirement is a thing of the past if your carrier echoes Palmetto’s requirement.

Bad news: Now this carrier has made it…

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Use 3 CPT, Modifier, and ICD-9 Code Pairs to Ace This X-Ray Claim

Decipher why you should include a seconding diagnosis.

Question: A 38-year-old patient presents to the emergency room with complaints of wheezing, coughing, and trouble catching her breath. After the nonphysician practitioner (NPP) performs a problem-focused history, the physician performs a detailed history and exam and discovers focal ronchi. The physician orders a two-view chest x-ray to check for upper respiratory infection (URI) The chest x-ray results reveal acute URI, and the ronchi clears up upon reevaluation. The patient is treated with antibiotics. How should I code this scenario?

Answer:You’ll submit two of each for this claim: CPT codes, modifiers,and ICD-9 codes. On the claim, report the following:

  • 71020 (Radiologic examination, chest, 2 views, frontal and lateral) for the x-ray
  • Modifier 26 (Professional component) appended 71020 to show that you are coding for the physician’s services only
  • 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination;and Medical decision making of moderate complexity….) for the E/M
  • Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 show that the E/M and the x-rays were separate services
  • 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site) appended to 71020 and 99284 to represent the patient’s URI
  • 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) appended to 71020 and 99284 to represent the patient’s focal ronchi.

Secondary Dx decoded: Even though the focal ronchi cleared up on reexamination, you should still include 786.7 on the claim. It will help paint a more lucid portrait of the patient’s condition, and can only strengthen your medical necessity case for the chest-x-ray.

Part B Insider. Editor:…

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Ensure Counseling Claims With Pointed Questions

This modifier is key to E&M and counseling codes cohabiting on your claim.

Question: Can I report alcohol cessation counseling codes along with E/M codes, or do I have to choose one or the other?

Idaho Subscriber

Answer: You can,…

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Check 33208 Global to Prevent E&M Snafu

When an EM service occurs during a postop global period for reasons unrelated to the original procedure, use this modifier.

Question: If the cardiologist performs a pacemaker insertion in the hospital and later visits the patient in observation, should I

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Medical Coders: Use 36415 for Lab Draws

You have two options depending on the next step.

Question: Our vascular office performs blooddraws and analysis for a local hospital. Can we bill for a lab draw in an office setting, and if so, what codes should we use?

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Emergency Department Specific Exception Allows You to Sidestep Some HPI Rules

Use these FAQs to achieve level 5.

A patient reports to the emergency department in such severe respiratory distress that she cannot communicate during the history of present illness (HPI) portion of the E/M service. The patient also presents to…

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Stay Alert: Modifier 57 Isn’t for Consults Only

Even though Medicare no longer accepts consult codes, you can still apply modifier 57.

Question: In our ob-gyn office, we used to apply modifier 57 to inpatient consult codes. Now that Medicare doesn’t accept consult codes, how should we use

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EM CODING: Don’t Bill High-Level E&M Codes Until You Read This

Sicker patients may not always mean higher MDM.

If your physician bills a lot of high-level office visits, he may be at risk of an audit — which may not be cause for concern — if his documentation justifies his…

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Radiology Medical Coders – Tighten Up Your LAP-BAND Coding

If your radiologist performs adjustments during the bariatric surgery’s global period, do this.

Question: Our radiologists perform percutaneous LAP-BAND adjustments. We report S2083 for the service and 77002 for the fluoroscopy. Is this the correct fluoroscopy code?

Connecticut Subscriber

Answer:

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CMS Clarifies Split/Shared Visit Rule Now That Consults Are No Longer Payable

Plus: CMS reps cite current Medicare law and advise that practices should report just one inpatient care code per patient, per day.

Although CMS has eliminated payment for consult codes, it will continue to honor split/shared visits — as long…

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Follow 3 Steps on the Path to Paid Cerumen Removal

Medicare won’t pay 69210 alone, so here’s how to unlock payment.

Impacted cerumen removal is a fairly straightforward procedure, but billing for the procedure is not always so simple.

The problem: Most payers, including Medicare,consider 69210 (Removal impacted cerumen [separate

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Quick Quiz: Think You Understand the New Consult Rules? Find Out Fast

Test your 2010 consultation coding understanding with these questions and answers.

Consultation coding has every practice on edge this year. Ensure that you’ve got a handle on this complicated coding and billing situation by taking this three-question quiz and then…

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