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3 Steps to Keep Discontinued Procedure Claims Moving

You often turn to modifier 53 (discontinued procedure) when your anesthesiologist or the surgeon sees some risk that could threaten the patient’s health if the procedure continues.   However, Payers do recoil when it comes to reimbursing these claims.  Here are three easy steps by the experts to help you to get on the right track for reimbursement.

1) Conquer Electronic Filing Challenges

Gone are the days when you were told to submit paper claims reporting modifier 53 so you can append a written explanation with the claim.  With HIPAA and electronic standards, you can do the billing electronically.  Once you have billed electronically with modifier 53, the payer might request more information.  Thus the note should contain all the information the carrier needs.  For failed procedure, the record should state the reasons for the failure.  If your physician discontinued the procedure due to the patient’s condition, the record should detail what factors prevented the procedure from going forward.

2) Verify the Timing of Cancellation

Knowing exactly when the case was canceled in terms of the physician’s work will help guide your code choices.  If the physician cancels the procedure after induction, the case technically became a surgical procedure.  Determine the correct surgical code, such as 45380 for a colonoscopy with biopsy.  Then cross to the correct anesthesia code, such as 00810.  If the cancelled procedure took place in an outpatient hospital or ambulatory surgical center, some payers require modifier 73 or modifier 74.  In those situations, append modifier 73 or 74 to the anesthesia code instead of modifier 53 as modifiers 73 and 74 are specifically for outpatient hospital use.

3) Include the Correct Diagnosis

Indicate the reason for cancellation by reporting the appropriate diagnosis code or codes.   For a patient who experiences syncope while still in the…

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Are you sure that 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.  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) was 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 related (acute) (chronic)
  • Tumor associated.

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Ensure Your Physician’s Signatures Pass Muster By Answering 2 Key Questions

EMR signature pitfalls could be a daily challenge with which you often deal. Check your answers against our experts’ advice to verify your group’s signature compliance.

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 documents, Medicare requires a legible identifier for services provided or ordered.  The 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 (letterhead, addressograph, etc.).  Also be sure to include the provider’s credentials.  The credentials themselves can be with the signature or they can be identified elsewhere on the note.

Pre-printed forms might include the physician’s name and credentials at the top, side, or end.  All qualify as acceptable documentation as long as the coder or auditor can identify the provider’s credentials.  You can also use a signature log to back up your physician’s documentation.  The log should contain each provider’s printed or typed name and credentials, along with their signatures and initials. You can reference the signature log in order to verify a note that contains an otherwise unidentifiable signature.  This is an important resource when providers are signing notes that do not include their typed or pre-printed name.

Make sure that you update signature logs at least once a year.  Create separate logs by provider (physicians, CRNAs, AAs, residents, etc.) to help simplify tracking.  Stamped signatures don’t meet the CMS requirements.  Because a signature stamp can be used…

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Stop Forfeiting Level Four and Five E/Ms With 3 PFSH Tips

Make your physician’s job easier by letting the patient or nurse document the history.

If your physician glosses over a patient’s past, family, and social history (PFSH), you may be missing out on up to $69 per E/M.  Accurately counting the number of PFSH items could result in more money for an encounter, because the top-level E/M codes require PFSH elements in addition to an extended history of present illness, and more than 1 system reviewed. Learn these three quick tips to ensure your physician is capturing, and you’re recognizing, every history component the patient mentions.

1. Determine the Level of PFSH

For coding purposes, the history portion of an E/M service requires all three elements — history of present illness (HPI), review of systems (ROS), and a past, family and social history (PFSH).  Therefore, the PFSH helps determine patient history level, which has a great effect on the E/M level you can report.  If you do not know the PFSH level, you may have to select a lower level of E/M service than might otherwise be warranted.  There are three levels of PFSH: none, pertinent, and complete, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn.

Pertinent: To reach a detailed level of history for the encounter (in addition to an extended HPI and the review of 2-9 systems), you need a pertinent PFSH.  According to Medicare’s Documentation Guidelines for E/M Services, you need at least one specific item from any of the three PFSH areas to achieve the pertinent level.  When the physician asks only about one history area related to the main problem, this is a pertinent PFSH.

Complete: To reach a comprehensive level of history for the encounter (in addition to an extended HPI and the…

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Know the Ropes for Problem Discovered During Well-Visit

We have a Medicaid patient that came in for a ten year-old physical and was found to be sick, so we would like to append modifier 25 to report the well turned-sick visit. Is that accurate?- Virginia Subscriber
Yes. In this situation, …

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Considering Gilenya Administration? Answers to Top 3 FAQs are Here.

Staying with basic 99211 might be safest option.

If you’re shaky on how to report Gilenya (fingolimod) as a first-line treatment for relapsing forms of multiple sclerosis (MS, ICD-9 code 340), you’re not alone. Gilenya questions have circulated ever since the FDA approved the drug in September 2010. Check our answers to three of the most common questions coders have so you’ll be ready when your neurologist offers the initial treatment dose to patients.

1. What’s the Best HCPCS Code?

“Gilenya is newly approved by the FDA, so there’s no HCPCS code for the drug,”says Catherine Nolin, CPC, a specialty based coder with Central Main Medical Center in Lewiston.

Result: Your only HCPCS choice currently is J3490 (Unclassified drugs), but verify details before submitting the code. Physicians sometimes write a prescription so patients can obtain and purchase the medication from a local or specialty pharmacy before coming to the office for administration. In those situations, your office should not submit any J code for drug reimbursement.

2. How Should We Code for Monitoring?

When beginning treatment with Gilenya, the FDA recommends observing the patient for a period of six hours. After taking the initial dose of the oral medication, the patient is monitored for signs and symptoms of bradycardia. Your neurologist needs to be available in the office to manage any post-dose arrhythmia-related side effects.

Dilemma: Physicians don’t normally track the patient’s status following the administration – a nurse does. The only CPT E/M code allowed for nurse care is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services). The code only encompasses five minutes…

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Learn the Keys to Properly Coding MACE, Mitrofanoff, and More

You’ll be able to report anastomosis with some procedures and not others.

If your urologist sees pediatric patients you may occasionally run across some procedures that you’re not used to coding.  When your urologist performs a Malone antegrade colonic enema (MACE), a Mitrofanoff procedure, or a Monti procedure, you might be left scratching your head over the proper code choice.  Follow this expert guidance to ensure you’re reporting the proper codes for every pediatric surgery your urologist performs.

Differentiate MACE and Mitrofanoff Before Coding

The MACE and Mitrofanoff procedures are similar, as both are used mainly in pediatric patients and involve similar anatomy, which makes coding for them a challenge.

MACE: For the MACE procedure, the physician uses the appendix or other small section of bowel to create an opening attached to the skin (a cutaneous stoma) to be used to irrigate antegrade with a catheter fecal matter from the colon.  “The MACE is generally a pediatric procedure used on children, but could also be used on adults, with chronic constipation or fecal incontinence.  Usually these diagnoses are found in children who are born with spina bifida or other neurological abnormalities,” explains Janell Glascock, CCS, CPMA, certified coding specialist for the Indiana University Health Physicians, Urology Department in Indianapolis.

For the MACE procedure you will first report 50845 (Cutaneous appendico-vesicostomy), says Christy Shanley, CPC, billing manager for the University of California, Irvine Department of Urology. Append modifier 52 (Reduced services) because the urologist is doing part of an appendicovesicostomy (isolating the appendix but doesn’t remove it from the large bowel).  Then, report 44680-51 (Intestinal plication [separate procedure]; multiple procedures) for the plication of the bowel, Shanley says.

Mitrofanoff: “The Mitrofanoff [procedure] can also use the appendix, or other small bowel if the appendix is not available, and attaches…

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$56 Question—Are You Downcóding Your E/M Visits?

You’re not only losing revenue—you’re also coding improperly.

CMS data from previous years shows that medical practices undercodè E/M claims to the tune of over $1 billion annually—that’s money that physiciáns could have collected based on their documentation, but forfeited because they reported a lower-level codè than they should have. But remember that your responsibility as someone who submits claims to Medicarè is to codè based on the documentation—anything else is incorrect coding.

If you’re one of the practices that’s downcoding claims, take note of the following reasons that you should codè based on your documentation rather than undercoding.

Could You Be Triggering an Audit?

The number one reason that many practices undercodè is because they don’t want to “trigger an audit.” However, coding all low-level E/M codès is sure to get a payer’s attention, because the claims reviewers will be wondering why you never offer high-level evaluations to your patients.

When claims reviewers review “bell curves” to determine whether a practice is coding outside the norm, they aren’t just looking for upcoding—they are looking at trends across the board. This means that a practice with all 99212s and 99213s will be vulnerable, because nearly every practice sees more complex patients requiring high-level E/Ms at least once in a while. If an auditor reviews your rècords and determines that you’re deliberately downcoding claims, they’ll conclude that you’ve been coding improperly.

Consider Compliance Implications

If you’re deliberately undercoding your claims to stay under the radar, you’re technically violating the False Claims Act because you are knowingly submitting a false claim. “It’s a violation just as much as deliberate upcoding is a violation, but the government most likely isn’t going to pursue it because ultimately it savès the Medicarè program money,” says John B. Reiss, PhD, JD, a health care attorney…

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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

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

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

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