How to Report New Code Category W44

One of the goals of medical coding is documenting encounter notes to the highest degree of specificity. ICD-10-CM had some existing codes for documenting foreign bodies entering through a natural…

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3 Coding Compliance Strategies to Improve Reimbursement, Quality

Medical coders are typically behind the scenes of patient care, analyzing records, selecting codes for billing, and managing patient data. But to Jannifer Owens, a revenue cycle expert with over…

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Bringing Coding Compliance into the Digital Age Prevents Denials

Hospitals have relied on a relatively manual process and retrospective audits for coding compliance, but new technology is streamlining the process, allowing providers to get ahead of denials. Healthcare technology…

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HPI Know-How Helps You Catch Level 4 and 5 E/M Opportunities

 

Beware of CPT® and Medicare differences when counting HPI elements.

Not accurately accounting for the history of presentillness (HPI) documented by your oncologist could result in missing appropriate opportunities to report level 4 or 5 E/M visits. Ensure you’re not missing higher paying possibilities by reviewing this guide to capturing HPI elements.

Brush Up on What Qualifies as an HPI Element

HPI is one of the three parts comprising an outpatient E/M history. It describes the patient’s present illness or problem, from the first sign/symptom to the current status, and typically drives a provider’s decisions about the physical examination and treatment. “The information gathered during the physical exam (PE) portion of a patient’s evaluation often only shows a very limited picture of the patient’s problem. However, speaking with a patient and gathering the history of the patient’s problem” can help fill out the picture, explains Amanda S. Stoltman, CCS-P, compliance coder at Urology Associates in Muncie, Ind.

 Start counting:

HPI also will often determine the level of service you’ll report. You’ll count the HPI elements to help you determine which level of service you can report. There are seven or eight HPI elements, depending on which source you are following. For Medicare, the eight elements are as follows: 

  • Location
  • Quality
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying factors
  • Associated signs and symptoms.

Medicare includes the above list in both the 1995 and 1997 E/M Documentation Guidelines, available at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.

In contrast: CPT® lists only seven HPI elements in the E/M Services Guidelines, with duration not making the list. Therefore, for Medicare and payers following its guidelines, you should consider duration and timing separately. With payers that follow AMA rules, however, be aware that they don’t consider duration and timing to be two separate elements. Rumor has it...

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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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Coding Retrobulbar Blocks? Three Questions Help You Decide How

Coding your anesthesia provider’s service is never cut and dried, especially with intricate procedures such as retrobulbar block placement. Answer these three questions regarding your anesthesiologist’s involvement in the case to know how to correctly code her services every time.

Does The Anesthesiologist Handle Everything?

Because administering anesthesia for retrobulbar blocks is riskier than other ocular injections, some surgeons (or facilities) prefer to have the anesthesia team handle everything. If your anesthesiologist is involved throughout the case, she administers the initial block and then administers monitored anesthesia care (MAC) during the case.

Code it: Your anesthesiologist places the block in preparation for the procedure, not as a separate pain management service. Therefore, you only code for the eye procedure instead of the procedure and block. Choose the appropriate code from 00140-00148 (Anesthesia for procedures on eye …). Depending on carrier requirements, append modifier QS (Monitored anesthesia care service) to indicate MAC, says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Expect your anesthesiologist to report discontinuous time in this scenario. She will place the block, leave the room while the block takes effect, and return in time for the procedure. Because she won’t be with the patient from start to finish, watch your time units. Calculate the time she spends placing the block and with the patient during the procedure for the total minutes.

Caution: Patients needing retrobulbar blocks often are scheduled back to back, which can make tracking your anesthesia provider’s time tricky. Be careful to ensure that case times don’t overlap when calculating the number of cases your anesthesiologist medically directs or supervises. Some practices decide to avoid potential compliance risks by not trying to capture the discontinuous time.

Does the Anesthesiologist Only Monitor?

Some facilities — and many...

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Auditors Review Your Notes Based on the Regs as of the Service Date

auditorIf you performed a consult in 2006, the auditor will use 2006 guidelines — not today’s rules.

Most Part B practices have grown accustomed to tucking consult regulations into the backs of their minds, since Medicare no longer pays for...

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How Do You Code Sigmoidoscopy with Anoscopy, Biopsy?

Question: Notes indicate that the gastroenterologist performs a rigid sigmoidoscopy; during the encounter, he also performs an anoscopy without anesthesia and three biopsies of the mucous membrane. How should I report this episode? Can I report the exam separately with 46600? Answer: You can report a single code for these three services. On the claim, report 45305 (Proctosigmodoscopy, rigid; with biopsy, single or [...] Related articles:

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