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11400s Max Out With Margin Measurements

Question: If our surgeon removes a sebaceous cyst from the back that measures 2.5 x 1.75 x 0.5 cm, should we add up all the dimensions or should we just use the biggest dimension of 2.5? Is the answer the same if this were a tumor instead of a cyst?

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Move Provider Signature To The Top Of Your Documentation

Checklist Extra: The physician’s credentials have a role to play, too.

Your CPT® coding may be spick and span, but if you fail to fulfill your physician signature requirements, your claims could end up in hot waters because not following these rules can trigger audits and other compliance headaches. Getting your provider to sign your patient’s charts is a basic documentation prerequisite that calls for your relentless compliance.

Basic: The treating physician’s signature serves as a legible identifier for the provided/ordered services. Payers require that the signature must be present in the documentation that comes with your claim.

Check out the following Q&A and find out why stamped signatures just won’t do you any good.

Get to the Bottom line Of Handwritten vs. Electronic Signatures

Question 1: Some of our physicians use handwritten signatures on their charts and others prefer electronic signatures. Is either kind acceptable?

Answer 1: According to CMS,, “Medicare requires a legible identifier for services provided/ordered.” That “identifier” — or signature — can be electronic or handwritten, as long as the provider meets certain criteria. Legible first and last names, a legible first initial with last name, or even an illegible signature over a printed or typed name are acceptable. You’re also covered if the provider’s signature is illegible but is on a page with other information identifying the signer such as a typed name.

“Also be sure to include the provider’s credentials,” says Cindy Hinton, CPC, CCP, CHCC, founder of Advanced Coding Solutions in Franklin, Tenn. “The credentials themselves can be with the signature or they can be identified elsewhere on the note.”

Example: Pre-printed forms might include the physician’s name and credentials at the top, side, or…

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Avoid These 5 Major Modifier Errors to Keep Your Cash Flowing

Reporting modifier 78 for a staged procedure? Expect denials.

When it comes to appending CPT® modifiers to your codes, the rules can be daunting, and Medicare’s regulations only compound the confusion. But if you’re up to speed on these key modifier billing practices, you’ll be raking in deserved pay.

Check out the following five tips to ensure that you aren’t missing any opportunities.

1. Don’t Avoid Modifier 26.

If your physician provides an interpretation and report for an x-ray or other radiological service in the treatment of a patient, that’s not always just part of his E/M—in some cases, you can separately bill for the interpretation and report by appending modifier 26 (Professional component) to the CPT® code.

Typically, the technologist that performed the patient’s x-ray will bill the code — such as 71010 (Radiologic examination, chest; single view, frontal) — with modifier TC (Technical component) to indicate that he is billing for the equipment, room charge, film and radiologic technician, but not for the physician’s interpretation. If the physician who renders the interpretation is with a separate professional group and is not a hospital employee, you should report the service with modifier 26 to obtain his proper share of the reimbursement.

2. Know the Difference Between Modifiers 58 and 78.

Because both modifier 58 and 78 describe procedures performed during another surgery’s global period, it can be easy to confuse them. But differentiating between the two can mean the difference between collecting your due and filing endless appeals.

Key: You’ll report modifier 78 (Unplanned return to the operating room for a related procedure during the postoperative period) when conditions arising from the initial surgery (complications) rather than the patient’s condition…

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J0881 and J0885 Are Commonly Reported Codes — Master Their Uncommon Requirements

Modifiers and test results are among the ‘instant denial’ triggers for these codes.

Whether you search under medical oncology, hematology, or hematology/oncology, J0881 and J0885 rank first and third on the lists of the top 10 codes reported to the CMS database (2009). These J-codes for erythropoiesis stimulating agents (ESAs) carry a heavy load of very specific reporting requirements and volatile reimbursement rates. To be sure your claims for these frequently reported codes are as clean and accurate as possible, apply the tips below.

Learn more: These recently available top 10 rankings are listed in a file posted by Frank Cohen, MPA, principal and Senior Analyst for The Frank Cohen Group. Choose the link for “Top 10 procedure codes by frequency for all specialties” at

Warm Up With Code and ESA Definitions

The HCPCS codes in focus are as follows:

  • J0881, Injection, darbepoetin alfa, 1 mcg (non-ESRD use)
  • J0885, Injection, epoetin alfa (for non-ESRD use), 1000 units.

Code J0881 is appropriate to report the supply of Aranesp. Code J0885 applies instead to supply of Epogen or Procrit. Keep in mind that the J codes represent only the supply. You should report the ESA administration separately using 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for intramuscular (IM) administration, says Janae Ballard, CPC, CPC-H, CPMA, CEMC, PCS, FCS, coding manager for The Coding Source, based in Los Angeles.

Both codes indicate they are specific to “non-ESRD use.” ESRD is short for end stage renal disease. Consequently, these codes are appropriate when the injection is connected to oncologic use.

What ESAs do: ESAs stimulate bone marrow to produce more red blood cells, according to…

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394.x-398.x and 424.x: Clarify the Role of ‘Rheumatic’

Use this cheat sheet to aid your non-congenital valve disorder coding


Code Descriptor Role of ‘Rheumatic’




394.0 Mitral stenosis Use if specified as rheumatic or unspecified. If specified as non-rheumatic, use 424.0.
394.1 Rheumatic mitral insufficiency Specific to rheumatic cases. For others, use 424.0.
394.2 Mitral stenosis with insufficiency Use if specified as rheumatic or unspecified. If specified as non-rheumatic, use 424.0.
394.9 Other and unspecified mitral valve disease Use if specified as rheumatic or unspecified. If specified as non-rheumatic, use 424.0.
424.0 Mitral valve disorders Use if specified as non-rheumatic. Also use for mitral insufficiency of unspecified cause.
395.0 Rheumatic aortic stenosis Specific to rheumatic cases. For others, use 424.1.
395.1 Rheumatic aortic insufficiency Specific to rheumatic cases. For others, use 424.1.
395.2 Rheumatic aortic stenosis with insufficiency Specific to rheumatic cases. For others, use 424.1.
395.9 Other and unspecified rheumatic aortic diseases Specific to rheumatic cases. For others, use 424.1.
424.1 Aortic valve disorders Use if specified as non-rheumatic or unspecified. If specified as rheumatic, see 395.x.


396.0 Mitral valve

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4 Common Interventional PM Procedures You Can’t Afford To Miss

Get the lowdown on when to code separately for fluoroscopy.

If your physician performs interventional pain management (IPM) services, you’ll need to be up to speed on four top IPM procedures to make sure you’re earning full deserved reimbursement for your claims.

Difference: Pain management specialists are physicians who study pain and perform less invasive injections (soft tissue, peripheral nerve, and joint injections) and medication management to help relieve patients’ pain. One common pain management procedure is trigger point injection (20552, Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) or 20553, single or multiple trigger point[s], 3 or more muscle[s]). An interventional pain management specialist’s scope includes spinal diagnostic and therapeutic procedures and other invasive techniques like nerve stimulator or opioid pump insertion, says Scott Groudine, MD, an anesthesiologist in Albany, N.Y. When submitting claims, you’ll use specialty designation 72 for pain management or 09 for interventional pain management.

Learn the Most Common Injections

All injections are not created equal – and they’re not coded the same. Here’s your guide to four types of treatments that commonly fall under the IPM umbrella.

Facet injections: CPT® includes a range of codes describing the various sites and levels associated with paravertebral facet joint and facet joint nerve injections. You’ll find these in code family 64490-64495 (Injection(s), diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT]). If your physician uses ultrasound guidance during the injection procedure, turn to the Category III code section of CPT® instead. There you’ll find codes 0216T-0218T (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with ultrasound guidance). You’ll choose the appropriate code based on the anatomic injection site…

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ICD-10: I42.- Requires More Cardiomyopathy Details Than 425.4 Does

Tip: A diagnosis that falls under an ICD-9 ‘other’ code may have its own ICD-10 code.

Under ICD-9, when the manual doesn’t offer a code specific to your diagnosis, you usually choose one of the catch-all “other specified” codes available, such as 425.4 (Other primary cardiomyopathies). When you start applying ICD-10 codes in October 2013, you may find that your catch-all code has been divided into more specific options. Here’s how the ICD-10 counterparts for 425.4 will look.

ICD-9 coding rules: Cardiomyopathy literally means disease of the heart muscle and can refer to many types of heart disease. ICD-9 offers one code for “other” primary cardiomyopathies: 425.4. It’s appropriate for cardiomyopathy NOS, congestive, constrictive, familial, hypertrophic, idiopathic, nonobstructive, obstructive (but see 425.1 for hypertrophic obstructive), and restrictive. Code 425.4 is also appropriate for cardiovascular collagenosis.

ICD-10 changes: ICD-10 divides your options for “other” cardiomyopathy among three codes:

  • I42.2, Other hypertrophic cardiomyopathy
  • I42.5, Other restrictive cardiomyopathy
  • I42.8, Other cardiomyopathies.

Code I42.2 will be appropriate for other cardiomyopathy: hypertrophic, nonobstructive. Code I42.5 will be appropriate for other cardiomyopathy: restrictive, constrictive NOS. Code I42.8 is appropriate for any other cardiomyopathies not listed elsewhere, including newborn and obscure of Africa, as well as cardiovascular collagenosis.

Caution: Check the index and full I42.- range in the tabular list before choosing an “other” code. For example, several of the diagnoses that fall under 425.4 in ICD-9 do not fall under the “other” cardiomyopathy codes in ICD- 10. Specifically, obstructive cardiomyopathy is coded to I42.1 under ICD-10, congestive falls under I42.0, and familial and idiopathic fall under I42.9.

Remember: When ICD-10 goes into effect on Oct. 1, 2013, you should apply the code set and official guidelines in effect for the date of service reported. Learn more at and

Be ready…

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What Do DRG’s LOS Columns Mean?

Question: In the CMS DRG datasheet, what is the difference between the column titled “Geometric Mean LOS” and the one labeled “Arithmetic Mean LOS”?
Answer: The geometric mean length of stay or (GMLOS) is the national mean length of stay for ea…

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Choosing for Tympanostomy Anesthesia

Question: I’m looking for the anesthesia code for a tympanostomy of the left ear, performed on a 10-month-old child. What’s the correct choice?
Answer: The correct code is 00126 (Anesthesia for procedures on external, middle, and inner ear includin…

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Avoid EHR Penalties with These Proposed Additional Exemptions

Check whether your group might fall into one of four new categories.

The push toward e-prescribing is in full swing, with physicians possibly being subjected to a one percent payment hit on CMS claims in 2012 if you don’t successfully participate in e-prescribing this year (and larger hits in 2013 and 2014). If your physicians haven’t yet met e-prescribing criteria, take hope: CMS has proposed four additional ways that eligible professionals (EPs) can potentially avoid the adjustment in 2012.

The imminent penalty for physicians who don’t e-prescribe “has created quite a bit of concern about circumstances where doctors will potentially be penalized, not necessarily because of failure to electronically prescribe, but more so because of some complexities with regard to the measurement,” said Michael Rapp, MD, JD, director of the quality measurement and health assessment group at CMS, during a May 26 CMS Open Door Forum.

Previously, physicians could apply for a hardship exemption only if they could prove a lack of access to the internet in their area or limited access to pharmacies that accepted electronic prescribing. Under the new proposal, EPs would be eligible to request a hardship exemption that CMS would determine on a case-by-case basis if they meet one of the following additional four criteria, Rapp said.

1. Registering With Intent to Adopt EHR Technology
Practitioners who intend to start participating in the HER (Electronic Health Record) Incentive Program might still be getting their technology in place, so they may not have e-prescribed ten times within the first six months of 2011, as is required to avoid the penalty. The new proposal aims to offer those practices a potential exemption.

2. Prescribing Meds That Legally Cannot Be Electronically Transmitted
Many state, local, or…

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93224-93227 Take on Extra Jobs in 2011 to Make Up for Code Deletions


12, 24, and 48 hour services all have roles in this coding shake-up.

Cardiology codes are always changing, trying to keep pace with technology and current practice. For this reason, Holter monitor codes saw big changes this year. Here’s what you need to know.

Start With a Nutshell Holter Service Description

Dynamic electrocardiography (ECG), also called Holter monitoring, involves ECG recording, usually over 24 hours. The goal is to obtain and analyze a record of the patient’s ECG activity during a typical day. The medical record usually will include the reason for the test, copies of ECG strips showing abnormalities or symptomatic episodes, the patient’s diary of symptoms, statistics for abnormal episodes, the physician’s interpretation, and documentation of recording times.

Understand Your Newly Reduced Coding Options

In 2010, you chose among the following code ranges for these services:

  • 93224-93227, Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage, with visual superimposition scanning
  • 93230-93233, Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout
  • 93235-93237, Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous computerized monitoring and non-continuous recording, and real-time data analysis using a device capable of producing intermittent full-sized waveform tracings, possibly patient activated

In 2011, your coding options have changed. A new note under 93229 tells you “93230-93237 have been deleted. To report external electrocardiographic rhythm derived monitoring for up to 48 hours, see 93224-93227.” CPT® Changes 2011: An Insider’s View states that 93224-93227 have been revised to accommodate reporting the services described by 93230-93233 and 93235-93237.


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Answer 3 Questions Before You Code CTS Shots

Verify evidence of previous treatments for successful claims.

If you’re coding for a patient’s carpal tunnel syndrome (CTS) injection, double check for previous, less invasive CTS treatments before getting too far with your claim. If the physician administers an injection during the patient’s initial visit for CTS, you could be facing a denial. Some payers allow CTS injection therapy only when other treatments have failed. Check out these FAQs to make each CTS coding scenario a snap.

Should the Physician Try Other Treatments Before 20526?

Yes. The FP would likely try less invasive treatments before resorting to CTS injection (20526, Injection, therapeutic [e.g. local anesthetic, corticosteroid], carpal tunnel), confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. These treatments might include, but are not limited to:

  • splinting (or bracing)
  • medication (non-steroidal anti-inflammatory)
  • occupational therapy.

If the patient’s symptoms don’t improve after these attempts, the physician may then proceed with a corticosteroid injection of the carpal tunnel, Hammer says.

Caveat: Check with the payer if you are unsure of its “previous treatment” requirements. Even evidence of previous treatments might not be enough to convince some insurers, says Jacqui Jones, a physician office manager in Klamath Falls, Ore. “We have had a couple of contracted HMOs [health maintenance organizations] impose conservative nonsurgical treatment – even with previous treatment and positive nerve conduction velocities ordered by another physician,” says Jones.

What Diagnoses Support Carpal Tunnel?

Patients that become candidates for CTS injections may present initially with “complaints of progressively worse numbness and tingling (782.0, Disturbance of skin sensation) in their hand and wrist, particularly the thumb, index, and middle finger,” Hammer explains. As the CTS…

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Use -79 for Repeat Wart Freezing Within Global Period

Question: Eight days after an initial wart freezing, the patient returns, and the physician freezes another wart. Is the second procedure bundled into the first, or can we report it with a modifier?
Answer: You may be able to report the second occurren…

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Multiple X-Ray Charges OK for Different Purposes

Question: A new patient presented to the office because of an injured left ankle she hurt while doing yard work. The FP performed a detailed history and examination. He suspected a fracture and ordered a two-view ankle x-ray, which revealed a bimalleolar fracture. The physician provided local anesthesia and used closed treatment to manipulate the fracture. He then ordered a second two-view ankle x-ray to confirm proper alignment. Notes indicated moderate medical decision making. Can I code both ankle x-rays in this scenario?

Answer: Since the physician ordered separate x-rays for different purposes (identifying the fracture, then ensuring proper bone placement), you can code for both. On the claim, report the following:

  • 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history;, a detailed examination; and medical decision making of low complexity) for the evaluation and management service that diagnosed the fracture and led to the decision to treat it.
  • 27810 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli]; with manipulation) for the fracture care
  • 73600 (Radiologic examination, ankle; 2 views) x 2 for the x-rays (one before the surgery, and one to ensure proper bone placement postsurgery)
  • 824.4 (Fracture of ankle; bimalleolar, closed) appended to 99203, 27810, and 73600 to represent the patient’s ankle fracture
  • E016.X (Activities involving property and land maintenance, building and construction) appended to 99203, 27810, and 73600 to represent the cause of the patient’s ankle fracture. The nature of the “yard work” that the patient was doing will determine the appropriate last digit of this code.

Modifier alert: Be sure to check with your payer before filing…

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338.3 Example Boosts Your Non-Chemo Encounter Coding Savvy

Be sure your coding complies with ICD-9 official guidelines for pain management.

If you don’t know when to check ICD-9 official guidelines, you may have just a 50-50 chance of choosing the proper order for your diagnosis codes.

Case in point: Patients may present to the office for treatment related to pain caused by a neoplasm. In such cases, you will need to determine, which diagnosis codes to report, and you will need to decide what order to list the codes in on your claim. With that in mind, consider how you should code the scenario below.

Start by Examining the Neoplasm-Related Pain Case

Read the following scenario and determine proper ICD-9 coding based on the information given. You’ll find a helpful hint on which section of the official guidelines to review if you get stuck.

Scenario: The physician documents that a patient with lung cancer (middle lobe, primary malignant neoplasm) presented to the office for the purpose of pain management. The pain is documented as acute and caused by the neoplasm.

Hint: See section I.C.6.a.5 of the Official Guidelines for instructions on properly coding these sorts of encounters. The CDC posts ICD-9 guidelines online at:

Next, Determine Which Neoplasm and Pain Codes Apply

For this scenario, before you can decide what order to put the codes in, you will need to decide which codes to report.

Neoplasm: For a primary malignant neoplasm of the lung’s middle lobe, you should report 162.4 (Malignant neoplasm of middle lobe bronchus or lung), says Denae M. Merrill, CPC, HCC coding specialist in Michigan.

Pain: To choose the proper pain diagnosis code, you want to be sure you keep in mind that the neoplasm is the cause. The ICD-9 index entry for pain has several subentries to consider:

  • Cancer associated
  • Neoplasm

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Get to Know 3 E/M Myths That Could Affect Your Practice

Hint: Just because your doctor visits the ICU doesn’t mean he can report critical care.

Most medical practices report outpatient E/M codes (99201-99215) every day, but some Part B providers are still falling victim to several of the most common E/M myths. Button up your coding processes by dispelling these three commonly-held misunderstandings.


Myth 1: When reporting 99211 “incident to” a physician, you should bill it under the name of the physician on record for that patient.

Reality: When a service such as a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of the physician) is billed incident to the physician, make sure you file the claim under the supervising physician’s name. The OIG recently found that many practices are billing incident to services under a physician’s name who was not on the premises during the encounter. Often, practice management systems use the physician of record rather than the supervising physician when billing services. This arrangement makes allotting finances between physicians easier, but it causes incident to criteria to appear to be unmet. “Incident to” requires that the supervising physician is directly available, generally considered to be in or immediately adjacent to the office suite.


Myth 2: If a patient has symptoms of a particular illness, you can count that information toward both the history of present illness (HPI) and review of systems (ROS).

Reality: You can’t “double dip” and count the same information toward two separate elements.

Example: If the patient suffered a sprain or fracture, the doctor would typically address the musculoskeletal system during a ROS. Examples of a musculoskeletal ROS might include symptoms such as poor range of motion, joint pain, dislocation, or muscle stiffness, among others. These can be…

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