Coding Challenge

Medical Coding: Ease Counseling Codes Acceptance With Distinct Dxs

Study frequency guidelines before you bill for counseling services.

Question: A 60-year-old established Medicare patient with a confirmed diagnosis of vanishing lung (emphysema) reports to the family physician (FP) for a medication check and blood work; the patient is a moderate smoker. During the medication check and blood work, which took about 5 minutes, the patient tells the practice’s non-physician practitioner (NPP) “I think I’m ready to quit smoking; can you help?” The NPP spends the next 7 minutes providing smoking cessation counseling for the patient. Can I report a cessation code and an E/M?

Answer: Provided the patient meets Medicare’s requirements for cessation counseling, you can report the following:

  • 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 or less are spent performing or supervising these services.) for the E/M
  • 492.0 (Emphysema; emphysematous bleb) appended to
  • 99211 to represent the patient’s emphysema
  • 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) for the smoking cessation counseling
  • 305.1 (Tobacco use disorder) appended to 99406 to represent the patient’s tobacco dependency.

Know the rules: According to Medicare, its patients are entitled to smoking and tobacco use cessation counseling provided the patient is either:

  • a tobacco user who has an illness caused or complicated by tobacco use or
  • taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on Food and Drug Administration-approved information.

Additionally, note these two frequency guidelines for spot-on 99406 and 99407 (… intensive, greater than 10 minutes) claims:

  • Medicare will

...

Comments Off on Medical Coding: Ease Counseling Codes Acceptance With Distinct Dxs
June 13, 2010
Coding Challenge

Ophthalmology Coders: Does Old BB-Gun Injury Have Bearing on Coding?

The reason your patient is visiting is key. Question: We have a patient who came in for a routine eye exam, but reported retinal damage from a BB-gun incident six years ago. What would be the best way to code this? This is a new patient, and I do not h...

Comments Off on Ophthalmology Coders: Does Old BB-Gun Injury Have Bearing on Coding?
June 13, 2010
Anesthesiologist / Coding Challenge

Anesthesia Coding: Find the Missing EGD Reimbursement Link

Warning: Just including EGD diagnosis with your claim doesn’t guarantee reimbursement — here’s help.

Question: Our anesthesiologist provided anesthesia during an esophagogastroduodenoscopy (EGD) procedure, at the request of the attending physician. We coded the anesthesia portion with 00810. A note in the documentation mentions the request was due to the patient’s symptoms, but no other details were provided. The claim we submitted was denied, but we followed all of the other guidelines provided by the payer, including proof that the anesthesiologist administered Propofol. What did we do wrong?

Answer: One key to the denial might be found in the lack of coding for the patient’s condition. Your diagnosis code should indicate the co-existing medical condition that justifies your anesthesiologist’s involvement in the case, not the gastrointestinal condition leading to the endoscopy.

You may want to consult with your anesthesiologist to verify that the patient had a condition such as:

  • Parkinson’s disease (332.0)
  • Heart conditions (such as 410.xx, Acute myocardial infarction or 427.41, Ventricular fibrillation)
  • Mental retardation (318.x)
  • Seizure disorders (such as 780.39, Other convulsions)
  • Anxiety (such as 300.0x, Anxiety states)
  • Pregnancy
  • History of drug or alcohol abuse.

These are just some of the conditions that payers may require to justify the presence of an anesthesiologist at a colonoscopy. ICD-9 2010 also has two codes to describe failed sedation attempts: 995.24 (Failed moderate sedation during procedure) and V15.80 (Personal history of failed moderate sedation).

If your anesthesiologist’s documentation confirms one of these conditions, 995.24 or V15.80 would also justify an anesthesiologist’s involvement to most payers. The conditions listed above constitute the medical necessity of anesthesia with the procedure. If you used a screening diagnosis or treatment of commonly found conditions instead of the clinical condition requiring anesthesia, payers will not pay you for these services.

Also note the...

Comments Off on Anesthesia Coding: Find the Missing EGD Reimbursement Link
June 7, 2010
Coding Challenge / modifier 53

Oncology Coding: Determine the Proper Adverse Reaction Code

Remember to describe all the circumstances surrounding a push to get full reimbursement.

Question: If a non-Hodgkin’s lymphoma patient has an adverse reaction to Rituximab less than 15 minutes into the ordered hour-long infusion, should I report a push?

Answer: Experts suggest the most appropriate way to report a discontinued infusion is to append modifier 53 (Discontinued procedure) to the appropriate chemotherapy infusion code, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

You should use modifier 53 when a physician stops a procedure “due to extenuating circumstances or those that threaten the well-being of the patient,” according to CPT.

Modifier 53 describes an unexpected problem, beyond the physician’s or patient’s control, that necessitates ending the procedure. The physician doesn’t elect to discontinue the procedure as much as he is forced to do so because of the circumstances.

Push: CPT guidelines include “an infusion of 15 minutes or less” as one definition of a push, but 96413-53 describes the ordered and provided service more accurately than a push code (such as 96409, Chemotherapy administration; intravenous, push technique, single or initial substance/drug).

HCPCS: Your documentation should describe the circumstances, the administration start and stop times, and the amount of drug delivered and discarded. If you’re coding for the drug (J9310, Injection, rituximab, 100 mg), you should be able to report the entire amount, assuming you discarded the amount not administered.

ICD-9: Remember also to report the appropriate ICD- 9 codes, such as V58.12 (Encounter for antineoplastic immunotherapy) and 202.8x (Other lymphomas), and a code to indicate why the procedure stopped, such as V64.1 (Surgical or other procedure not carried out because of contraindication) or E933.1 (Drugs, medicinal, and biological substances causing adverse effects in therapeutic use; antineoplastic and immunosuppressive drugs).

Also watch for...

Comments Off on Oncology Coding: Determine the Proper Adverse Reaction Code
June 3, 2010
Coding Challenge

Medical Records: 5 Reasons Your EMR Transition Will Pay Off

The hard work and hassle of ditching paper documentation is not in vain.

Question: Our office is weighing the pros and cons of transitioning to electronic medical records (EMRs). We know the process is a huge undertaking that often results in even lower productivity and more confusion. So, is making the change really worth it?

Answer: If you haven’t witnessed or lead a conversion from paper records to an electronic medical record (EMR) system, it’s easy to get overwhelmed by the potential downsides. But experts agree that yes, going electronic is worth it. Here are a few reasons why:

1. You Open More Cash Inlets. Many research studies pull their data via electronic records. So, if you can’t tune in to participate, opportunities for cash perks will fly by. “Grant money and incentive programs are available, for example, and they want data in the electronic form,” points out Francine Wheelock, PT, MPA, manager of clinical systems for MaineGeneral Health.

Just look at nationwide push for value-based purchasing and outcome data, and expect to go electronic if you want to be in the loop.

Stay alert: Last year, the federal government launched the Health Information Technology for Economic and Clinical Health (HITECH) Act, which plans to pay eligible healthcare professionals incentives for the “meaningful use” of certain EMRs.

“SLPs, OTs and PTs are not eligible for the incentive payment,” confirms Kate Romanow, director of health care regulatory advocacy for the American Speech-Language Hearing Association. But they may be eligible in the future, so therapists “may want to consider implementing EHRs now,” she says.

Plus, you can enhance coordination of care with healthcare providers who are eligible for HITECH incentives and are adopting EHRs, points out Sarah Nicholls, assistant director for payment policy and advocacy for the American Physical Therapy Association....

Comments Off on Medical Records: 5 Reasons Your EMR Transition Will Pay Off
June 1, 2010
Coding Challenge / pathology

Medical Coders: Focus on Fibroid Diagnosis

Find out why you should code the pathology exam of uterus with leiomyomas as 88307.

Question: When our pathologist diagnoses uterine fibroid tumors, what ICD-9 code should we use?

Pennsylvania Subscriber

Answer: You should choose the diagnosis based on the fibroid’s location:

  • Submucous fibroids (218.0, Submucous leiomyoma of uterus) grow from the uterine wall toward the uterine cavity. They are also called intracavitary fibroids.
  • Intramural fibroids (218.1, Intramural leiomyoma of uterus) grow within the uterine wall (myometrium). They are also called interstitial fibroids.
  • Subserous fibroids (218.2, Subserous leiomyoma of uterus) grow outward from the uterine wall toward the abdominal cavity. They are also called subperitoneal fibroids.
  • If the physician does not specify the uterine fibroid’s location, assign 218.9 (Leiomyoma of uterus, unspecified) as the diagnosis.

CPT alert: You should code the pathology exam of uterus with leiomyomas as 88307 (Level V — Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, other than neoplastic/prolapse).

Although ICD9 classifies leiomyoma as a benign neoplasm, a coding convention supported by the American Medical Association and the College of American Pathologists dictates that you code this condition as 88307, not 88309 (Level VI — Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic).

For myomectomy specimens — fibroid tumors that the surgeon removes while leaving the uterus intact — bill the pathology exam as 88305 (Level IV — Surgical pathology, gross and microscopic examination, leiomyoma[s], uterine myomectomy — without uterus).

@ Pathology/Lab Coding Alert. Editor: Ellen Garver, CPC

Sign up for the upcoming live audio conference, Optimize Your Fibroid Coding and Billing: The Bottom-Line Basics for the Best Reimbursement, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Comments Off on Medical Coders: Focus on Fibroid Diagnosis
May 27, 2010
Coding Challenge

Cardio Coders: Discover Disconnect Date’s Proper Place

Tip: You need to know the hook-up date and disconnect day.

Question: Which date(s) of service should I report for 30-day cardiac event monitoring?

Washington Subscriber

Answer: For Noridian Medicare, your Part B administrator for Washington, you’ll need to know both (1) the date the staff hooked up the patient and (2) the day they disconnected the patient. But knowing which dates to report is only half the battle — you also need to know where to report them.

When you’re reporting 30-day cardiac event monitoring, Noridian requires providers to report the hook-up date as the “from” date and the disconnect date as the “through” date in Item 19 of the CMS-1500 (or its electronic equivalent).

Watch out: You should report only the “from” date (that is, the hook-up date) in Item 24A (or its electronic equivalent), Noridian instructs. You should not report the “through” (disconnect) date in 24A because if you have dates spanning two months and only a single unit, “the system inappropriately suspends the claim and asks the provider for clarification,” Noridian states.

The codes for 30-day monitoring include 93268-93272 (Wearable patient activated electrocardiographic rhythm derived event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time …) and 93012-93014 (Telephonic transmission of post-symptom electrocardiogram rhythm strip[s], 24-hour attended monitoring, per 30 day period of time).

Or if the “monitoring service meets the definition of the new 30-day cardiovascular telemetry service,” look to 93228-93229 (Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage [retrievable with query] with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days …), Noridian states.

Learn more: You can read more from...

Comments Off on Cardio Coders: Discover Disconnect Date’s Proper Place
May 25, 2010
Coding Challenge / E/M / modifier 25 / modifier 26 / radiology

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:...

Comments Off on Use 3 CPT, Modifier, and ICD-9 Code Pairs to Ace This X-Ray Claim
May 24, 2010
Coding Challenge / modifier 26

Hip Injection With Fluoro — Is Coding Both Allowed?

You have two options depending on how the physician performed the procedure.

Question: Our orthopedist administered a hip injection under fluoroscopy. Can I report both codes?

Wyoming Subscriber

Answer: You can code both the injection and fluoroscopy, but the correct choices depend on how your physician completed the procedure.

Option 1: If your orthopedist injected radiopaque dye and performed the arthrography concurrently, code the procedure with 27093 (Injection procedure for hip arthrography; without anesthesia).

Option 2: If he completed the guidance and injection as separate procedures, submit 20610 (Arthrocentesis, aspiration, and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) for the injection. Include 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) for the fluoroscopic guidance.

Remember to append modifier 26 (Professional component) to 77002 because your physician performed the service but doesn’t own the fluoroscopy equipment.

SI change: If the physician injects the sacroiliac joint instead of the hip joint, choose either 20610 (Arthrocentesis, aspiration, and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) or 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid).

@ Orthopedic Coding Alert. Editor: Leigh DeLozier, CPC

Sign up for the upcoming live audio conference, Coding Tips for Hip Procedures, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Comments Off on Hip Injection With Fluoro — Is Coding Both Allowed?
May 20, 2010
Coding Challenge / CPT / surgery

Surgical Coders: Don’t Overstate Debridement

Tip: This encounter involves topical applications and patient care instruction in addition to removing devitalized tissue.

Question: When the surgeon performs a wound VAC or cleans a wound by scraping with a sharp curette (not excising tissue), is it appropriate to use a debridement code or should we report an active wound care management code from the range 97597-97606?

Ohio Subscriber

Answer: Physicians typically use the debridement codes (11000-11001, Debridement of extensive eczematous or infected skin; … or 11004-11005, Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; …) for debridement by any method.

Without...

Comments Off on Surgical Coders: Don’t Overstate Debridement
May 20, 2010
Coding Challenge

Medical Coders: Don’t Let Shorthand Block You From Correct Code

If you have a question, be sure to ask your physician.

Question: A patient reports to the ER at 8 a.m. on a Sunday morning. He reports a horrible toothache that started on Friday; he says he planned to “tough it out” over the weekend and see his dentist Monday, but the pain was too severe; he reports 10 on a 10-point pain scale. The ER physician performs an “inf. Aveo block,” according to the notes. What condition do the notes reflect, and how should I code this scenario?

Massachusetts Subscriber

Answer: You should double-check with the physician before filing...

Comments Off on Medical Coders: Don’t Let Shorthand Block You From Correct Code
May 18, 2010
Coding Challenge

Pay Attention to Button TURP Technique

Be careful — the similarity to a laser procedure may deceive you.

Question: My urologist is performing a new procedure called a “button TURP.” I thought 52601 or 53852 might be correct, but now I’m thinking an unlisted procedure code may be more appropriate. What code should I use for this procedure?

California Subscriber

Answer: You should report 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) for the button transurethral resection of the prostate (TURP) procedure.
Why: The button TURP is a bipolar...

Comments Off on Pay Attention to Button TURP Technique
May 13, 2010
Coding Challenge / E/M / modifier 25

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,...

Comments Off on Ensure Counseling Claims With Pointed Questions
May 9, 2010
Coding Challenge / E/M / modifier 90

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?...

Comments Off on Medical Coders: Use 36415 for Lab Draws
May 5, 2010
Coding Challenge / Medicare / modifier

Append Modifier Q6 for Fill-In Physician

Before using modifier Q6 for a non-Medicare patient, check with the commercial payer — here’s why.

Question: We hired a locum tenens for two weeks. Do we code the same for the replacement physician as for a full-time...

Comments Off on Append Modifier Q6 for Fill-In Physician
May 2, 2010