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10120 or Beyond: Site, Depth, Complexity Drive Códe Choice

Follow 3 pointers to snag maximum pay.

From just under the skin to deep within the bowels, your general surgeon might perform a foreign body removal (FBR) that calls on a wide range of coding know-how. Zero in on the right codè every time by implementing these four principles:

1. Use 10120-10121 for Any Site Under Skin

If your surgeon makes an opening to remove any foreign body, such as a glass shard or a metal filing, but doesn’t indicate an anatomic site or depth in the op report, you’ll probably choose 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). You can’t choose a more specific codè if the surgical report doesn’t provide any more documentation.

Caveat: Because the codè requires incision, look for a sharp object when considering 10120. If the documentation doesn’t include this detail, use an E/M service codè (such as 99201-99215, Office or Other Outpatient Services) instead of the skin FBR codè.

Look for complications: If the surgeon uses the term “simple” in the op note or fails to note any extenuating circumstances, you’re good to go with 10120. But the surgeon might perform a complicated FBR, meaning that the foreign body was harder than usual to remove. In these situations, the note should indicate, for example, extended exploration around the wound site, presence of a complicating infection, or sometimes the need to use visualization and localization techniques, such as x-ray. In those cases, you should choose 10121 (… complicated) for a subcutaneous FBR with no mention of anatomic site.

2. Search Musculoskeletal Codè for Specific Site

CPT® contains higher-paying FBR codè s than 10120-10121, but the surgeon needs to document the following two details before you can use the codès:

Location: You’ll find myriad FBR codès scattered throughout CPT®’s “Musculoskeletal System” section (20000-29999),…

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Adjust Your Codès Easily When Diágnosis Changes During A Patient’s Hospital Stay

Educate your physicián to keep you in the loop on patients’ development.

Just because a patient enters the hospital with one diágnosis doesn’t mean she’ll have that diágnosis for her entire stay. And if you bill for your physicián’s hospital visits with an out-of-date diágnosis, you could lose money or face fraud charges.

The problem: Diagnoses can change in the hospital due to various reasons, including the following, among others: The physicián may narrow down the patient’s problem. For example, a patient may be admitted with chest páin, and the doctor may rule out myocardial infarction and decide the problem is actually gastrointestinal in nature.

The patient may develop other problems. The patient may be admitted for dehydration problems but may start having chest páins.  The patient may experience complications that lead their original complaint to worsen significantly.  You can’t wait for the hospital to send you medical rècords and hope to bill in a timely fashion. You could be waiting six weeks after the patient gets out of the hospital for any rècords. So it’s up to your physicián to let you know if a patient’s diágnosis has changed.

Do this: Educate your physiciáns, and let them know that just because the patient has been admitted with a particular diágnosis doesn’t mean they should bill for that diágnosis for each visit.  To help your physicián track his hospital visits, you might consider giving each physicián a simple form to rècord these evaluations. The physicián could put a sticker with the patient’s hospital identifier on the form and then write the date of each visit, the level of service and the diágnosis.  Each sheet will have roóm for 10 or 12 patient visits.

Diágnosis Tracking Is In the Cards

Another approach is to give your doctor a…

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Overcome 3 Myths and Claim Reimbursement Opportunities using Modifier 22

Don’t fall for these common body habitus, time, and fee traps.

If you overuse Modifièr 22 (Increased procedural services), you may face increased scrutiny from your payers or even the Office of Inspector General (OIG). But if you avoid the modifièr entirely, you’re likely missing out on reimbursement your cardiologist deserves.

How it works: When a procedure requires significant additional time or effort that falls outside the normal effort of services described by a particular CPT® codè — and no other CPT® codè better describes the work involved in the procedure — you should look to modifièr 22. Modifièr 22 represents those extenuating circumstances that do not merit the use of an additional or alternative CPT® codè but do land outside the norm and may support added reimbursement for a given procedure.  Take a look at these three myths — and the realities — to ensure you don’t fall victim to these modifièr 22 trouble spots.

Myth 1: Morbid Obesity Means Automatic 22

Sometimes, an interventional cardiologist may need to spend more time than usual positioning a morbidly obese patient for a procedure and accèssing the vessels involved in that procedure. In that case, it may be appropriate to append modifièr 22 to the relevant surgical codè. However, it’s not appropriate to assume that just because the patient is morbidly obese you can always append modifièr 22.  “Modifièr 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, Manager of Compliance education for the University of Washington Physiciáns Compliance Program in Seattle.

“Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifièr 22 should not be appended,” warns Maggie Mac, CPC,

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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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Specialists’ Non-Physicián Practitioners Can Collect Primary Care Incentive Bonuses

Question: Our cardiology practice employs a non-physicián practitioner (NPP) who performs a lot of E/M services for our patients, and that NPP received a bonus payment as part of the Primary Care Incentive Payment Program, which surprised us. We wan…

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Follow 3 Tips to Improve Your A/R Process and Boost Your Collections

Avoid the ‘code it, bill it, and forget it’ mentality — don’t be afraid to follow up on your claims.

The economic downturn coupled with looming healthcare changes means that your practice — and all others — are under more pressure than ever to collect every penny you deserve.  You can refine your accounts receivable (A/R) process quickly and easily to bring in the money without a lot of extra effort.

A/R defined: “Accounts receivable (A/R) is the money that is owed to the practice,” explains Elin Baklid-Kunz, MBA, CPC, CCS, a director of physician services in Daytona, Fla., during The Coding Institute’s audioconference “Top A/R Tactics: Fight Back Against Lower Payments and Increased Government Scrutiny.”

Follow these three best practices to set your practice on an improved A/R track and avoid thousands in lost reimbursement.

1. Monitor Each Claim You Send Out

The first step in perfecting your A/R process is to make sure someone in your practice is paying attention to what happens to every claim you submit. Ask questions such as: “did the insurance company even receive the claim?” and “Did the patient pay her copay portion of the bill?”  “There are companies out there I call ‘code it, bill it, and forget it companies,’” says coding, billing, and practice management consultant Steven M. Verno, CMBS, CMSCS, CEMCS, CPM-MCS, in The Coding Institute’s audio conference “Reveal and Recover Hidden Money You Didn’t Know You Missed.”

“They code the claim, they bill the claim, and then they forget about it. They leave it out there and don’t do anything to bring the money in. They don’t follow up on the claim.”  Following up on your submitted claims early in the game can save you time. First ensure that once your practice submits a claim that it is…

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Put Your ePrescribing Knowhow Into Meaningful Use

Get your system moving before June 30th or you’ll pay the price.

If you do not have an electronic prescribing (ePrescribing or eScribing) system yet in place, or have not integrated one into your electronic medical record (EMR) system, you better get a move on it. You only have until June 30, 2011 to submit at least ten claims to Medicare demonstrating that you are a successful eScriber for 2011. Otherwise, you are at risk of not only losing the bonus in 2011 but according to the rulemaking for 2011, also facing penalties assessed, reducing your Medicare fee schedule by 1 percent in 2012.

With limited time, it is smart to consider a stand-alone internet based system which you can implement relatively easy. You could get this system up and running right away, at a low cost, with simplified a implementation timeline and without depending on your electronic health record (EHR) selection and implementation which is both much more extensive, costly and more complicated to implement.

If you’re still asking, “Can our practice afford not to adopt ePrescribing?” Then, the answer is NO. Today you need to start doing something.

Background: eScribing is part of Centers for Medicare and Medicaid Services’ (CMS) incentive program called the Physician Quality Reporting System (PQRS). PQRS offers incentives to practices that meet CMS-set goals for the implementation and practice of electronic prescription on a regular basis. The system was designed with “a carrot and a stick”. While we have been enjoying the “carrot” for the past few years, the “stick is on the cusp of being implemented as of June 30th per the 2011 Rulemaking. CMS will pay you when you implement eScribing in 2011 (a 1 percent bonus), it will penalize you when you don’t put it into practice, a 1percent penalty…

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Remember Diagnosis to Support 62311 Post-Op

Question:
Our state’s Medicaid carrier denies our claims when we submit 62311 with modifier 59 for postoperative pain management. They say the 62311 is bundled with the anesthesia procedure code. How should we handle this?  -Ohio Subscriber
Answer:

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Coding 96372 With 90471

Question:
During an office visit, our nurse administered a B12 injection and a flu shot to an established patient. Can we code for both injections in addition to the office visit? (Illinois Subscriber)

Answer:
The answer depends on the circumstances. …

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New Year, New Insurance = New Verification

Question:

How should I file a claim on a patient who has new coverage but has not received an insurance identification card yet? (South Carolina Subscriber)


Answer:

Ideally, when patients call to make appointments, you should have someone in your office confirm their insurance coverage and eligibility, especially if you know the patient is going to have new insurance.  Now is the time of year when benefits verification tends to be most useful. While verification is good practice all year long, January is the time when you’ll see more insurance changes – including payer, benefit, and deductible/copay changes – than at any other time during the year because most employers hold open enrollment in December.

Finding out about insurance changes before the appointment gives you time to check if you are a participating provider with the payer and verify coverage. If the patient doesn’t yet have an identification number with her new insurance company, ask for the name of the insurer and the policy number from the patient, or from the patient’s employer. Then, call the insurer and verify the coverage and the date of eligibility, and get the appropriate information to identify the patient on your claim.

Warning: The date of eligibility is an important question to ask the payer because many employers don’t make health insurance coverage immediately available to new workers. A patient with a new job and new insurance coverage may be in your office for a visit today, but his insurance isn’t effective for two months.

Alternative: Although verifying coverage in advance is preferable, many practices have patients confirm their insurance coverage and note any changes when they check in for their appointments. If you are unable to verify the insurance coverage, or you find that the patient is not eligible for coverage on…

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Does One-Hour E/M Warrant Add-on Prolonged Service Code?

Question:
Our physician provided a one hour E/M service, most of which was spent on counseling, so we reported 99215 and one unit of +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient c…

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5 Tips Lead You to G0438, G0439 Coding Success

Boost your bottom line by reporting new annual wellness visits correctly.  If you want your annual visit claims to be picture perfect in 2011, then follow these five tips to avoid future denials and keep your physician’s claim on the fast track to success.

Background: The Affordable Care Act (ACA) extended preventive coverage to more than 88 million patients covered by health insurance, and Medicare has codified that benefit in the form of an annual wellness visit. Medicare valued the new annual wellness codes based on a level 4, problem-oriented new and established E/M service.

The two new codes are:

G0438 — Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit

G0439 — Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit.

Tip 1: Apply G0438 to Second Year of Coverage

Be wary of applying these codes to new Medicare patients coming in to your physician’s practice in 2011.  The reason is that Medicare will only reimburse the initial visit (G0438) during the second year the patient is eligible for Medicare Part B. In other words, during the first year of the patient’s coverage, Medicare will only cover the Initial Preventive Physical Exam (IPPE), also known as the Welcome to Medicare exam.

Tip 2: CMS Limits G0438 to One Physician

If your FP sees the patient for the initial visit (G0438) and the patient sees a different physician for the next annual wellness visit, that second physician will only receive reimbursement for the subsequent visit (G0439), despite having never seen the patient before.

Here’s why: CMS has indicated that when a patient returns to the same or new physician in a third year, they might only pay for the subsequent visit, says Melanie Witt, RN, COBGC, MA, an…

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Simplify Your Endometrial Cancer Claims In Just Three Steps

If your ob-gyn converts a laparoscopic to an open procedure, your coding for endometrial cancer surgeries can drastically transform. Follow these three steps to ward against denials.

Review This Op Note

Preoperative diagnosis: Adenocarcinoma of the endometrium.

Postoperative diagnosis: Same as above, but greater than 50 percent myometrial invasion, pathology pending.

Operation performed: Laparoscopic assisted transvaginal hysterectomy (LAVH) with bilateral salpingo-oophorectomy, laparotomy with pelvic and periaortic node dissection, partial omentectomy, pelvic washings.

Procedure: Exam of the pelvic organs revealed an 8-week-size uterus. The right and left ovaries appear to be within normal limits. The ob-gyn found no evidence of excrescences or signs of metastatic disease in the lower pelvis along the bowel or serosa, nor did he discover evidence of metastatic disease in the upper abdomen, liver and dome of the diaphragm. He then performed a dissection.

He removed the uterus vaginally with the assistance of the laparoscope, and the pathologist was present to open the organ and render an opinion.

The pathologist saw an enlarged, fungating, relatively superficial lesion of the endometrium. Up in the patient’s right fundal area, however, the pathologist saw an invasion of the myometrium at least two-thirds of the way through. Given this finding, the ob-gyn decided to perform an open pelvic node dissection. He removed the laparoscope and made a new incision to enter the peritoneum.

He obtained pelvic washings from the right cul-de-sac and pelvic area. He then performed a partial omentectomy with the aid of multiple Kelly clamps.

The ob-gyn did a pelvic node dissection, first on the right side identifying the ureter evenly. He carried down the dissection to include the internal and external iliac lymph nodes. He performed the same procedure on the left side. The dissection took place below the bifurcation of the aorta….

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Revision of a Tricuspid Valve – Why is it necessary?

The tricuspid valve is the atrioventricular valve in the right hand section of the human heart, which regulates the flow of blood from the right atrium (top chamber) to the right ventricle (the bottom chamber).

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