Question: I have a path report that says “PIN III.” My problem is that the report also says “carcinoma was not identified,” so I’m confused about what to report. Which ICD-9 code is best? Answer: With a diagnosis of PIN III, you should repo...
Many new codes abound in final update to proposed ICD-9-CM code set.
If you’ve felt that your skin cancer diagnoses could use a bit more specificity, ICD-9 will deliver this October if the proposed list of new, deleted, and revised diagnosis codes becomes final. The list of ICD-9 changes was recently posted to the CMS Website, and includes the final full set of changes that the agency will make to ICD-9 codes. After the new codes take effect on Oct. 1, CMS will only add new ICD- 9 codes on an emergency basis as it prepares to switch over the diagnosis coding system to ICD-10.
Seek Out Skin Cancer Changes
You’ll find a significant expansion to the 173.x (Other malignant neoplasm of skin) categories, including changes to 173.0x (…Skin of lip), 173.1x (Eyelid, including canthus), 173.2x (Skin of ear and external auditory canal), 173.3x (Skin of other and unspecified parts of face), 173.4x (Scalp and skin of neck), 173.5x (Skin of trunk, except scrotum), 173.6x (Skin of upper limb, including shoulder), 173.7x (Skin of lower limb, including hip), 173.8x (Other specified sites of skin), and 173.9x (Skin, site unspecified).
Among these changes, for example, you’ll find the following new codes to delineate various types of skin cancers:
The changes in the other skin cancer categories referenced above follow this pattern, with the fifth digit of “0” referring to an unspecified malignant neoplasm, “1” denoting a basal cell cancer, “2” referring to a squamous cell carcinoma,” and “9” describing another...
Tactics help you recoup deserved pay for 24357-24359.
Tennis elbow claims faults can wreak havoc on your reimbursement for these services. But you can clean up your method if you can spot in the note how the surgeon reached the elbow tendon and whether the tendon was released or repaired. By doing so, you stand to gain your full earned pay for codes 24357, 24358, and 24359, which is $437.27, $514.74, and $647.59, respectively.
Review Structures Treated
When you are confident in your elbow anatomy knowledge, you’ll have a better chance of understanding where the operative note is directing you. The codes are simple and can easily be applied if you are reading correctly. “Coding these procedures became much easier when CPT condensed the codes from the previous five down to the current three,” confirms Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA. The bones, –humerus above and the radius and ulna below– articulate in a manner to allow 180 degrees of movement that helps you use the upper limb for various functions.
The numerous muscles that originate and insert around the joint allow movement; particularly important is the bundle of extensors including the muscle extensor carpi radialis brevis (ECRB) that originates at the lateral epicondyle which is the lateral prominence of the humerus at the elbow joint. Repeated back movements of the wrist joint, as seen when playing tennis, can cause small micro tears in the tendon of origin and result in inflammation known as lateral epicondylitis or ‘tennis elbow.’ The term is highly deceptive, though; the condition affects non-athletes as well, and is not solely confined to tennis players. As the pathology progresses, the damaged tendon(s) may rupture and...
Question:
We have a patient who had a severe crush injury of the left hand which led to a comminuted fracture of the left 3rd and 5th metacarpals with an intra-articular fracture of the proximal phalanx of the left index finger. The physician’s documentation indicates the following:
Would I report 11043 and 97605 with ICD-9 682.4 and 681.00?
-North Carolina Subscriber
Answer:
The correct codes in this situation would be 11010 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and
subcutaneous tissues), 11011 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle), or 11012 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and...
When two surgeons work together to perform one procedure, each physician’s individual documentation requirements can get jumbled up. Make sure your physician isn’t passing the documentation buck and that he or she knows to follow these four tips when you submit claims with modifier 62.
Tip 1: Each physician should identify the other as a co-surgeon. Also make sure that the other physician is billing with modifier 62. A lot of confusion can arise when physicians from different practices are reporting the same procedure.
You may find yourself in a situation where one physician may report the other physician’s work as that of an assistant surgeon, in which case the claims would not correspond. This means a denial will hit your desk. One surgeon cannot simply indicate the other as the co-surgeon. Both physicians must submit claims for the same procedure, both with modifier 62. To accomplish this all you only need to call with a simple courtesy to the other physician’s billing or coding department.
Tip 2: Each physician should document her own operative notes. When surgeons are acting as “co-surgeons,” it is implied that they are each performing a distinct part of the procedure, which means they can’t “share” the same documentation. Each physician should provide a note detailing what portion of the procedure he or she performed, how much work was involved, and how long the procedure took. Including a brief explanation of the need for co-surgeons will help to avoid denials and reimbursement delays.
Tip 3: Each physician must link the same diagnosis code to the common procedure code. Though this requirement may seem obvious, if two physicians serve as co-surgeons to perform one procedure, the diagnosis code(s) they link to the CPT® code should be the same. Before submitting a claim with modifier 62, someone...
If you’re just plodding though nerve surgery claims, you could be stepping over a great deal of well-earned reimbursement. Coding and billing peripheral nerve surgeries for conditions such as tarsal tunnel and diabetic neuropathy can involve a frazzling number of codes. Podiatry coders often struggle to navigate the various coding guidelines that payers use for these procedures. Use these five tips to maximize payment for your podiatrist’s hard work on nerve surgeries:
Tip 1: Check CCI edits and your local Medicare guidelines
If you’re billing codes that the Correct Coding Initiative bundles together — and your documentation and diagnosis codes can’t justify breaking the bundle — you’re not going to see one extra cent for that bundled procedure code.
Example: A California Medicare patient injures his foot when he falls off a ladder and requires peripheral nerve surgery to correct the damage the injury caused. The podiatrist performs the following:
28035 — Release, tarsal tunnel (posterior tibial nerve decompression)
64712 — Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve
64704 — Neuroplasty; nerve of hand or foot
+64727 — Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)
64708 — Neuroplasty, major peripheral nerve, arm or leg, open; other than specified.
If you report all these codes, you’re bound to get a denial on 64704 — this is one of the codes the Correct Coding Initiative (CCI) bundles into 28035. Unless you can justify billing 64704 separately (and if that’s the case, append modifier 59, Distinct procedural service, to the code), you shouldn’t list it all.
Unbundling is not automatic: Be aware that you can’t automatically override a CCI edit with modifier 59 just because documentation supports a separate site,...
When two surgeons work together to perform one procedure, each physician’s individual documentation requirements can get jumbled up. Make sure your physician isn’t passing the documentation buck and that he or she knows to follow these four tips when you submit claims with modifier 62.
Tip 1: Each physician should identify the other as a co-surgeon. Also make sure that the other physician is billing with modifier 62. A lot of confusion can arise when physicians from different practices are reporting the same procedure.
You may find yourself in a situation where one physician may report the other physician’s work as that of an assistant surgeon, in which case the claims would not correspond. This means a denial will hit your desk. One surgeon cannot simply indicate the other as the co-surgeon. Both physicians must submit claims for the same procedure, both with modifier 62. To accomplish this all you only need to call with a simple courtesy to the other physician’s billing or coding department.
Tip 2: Each physician should document her own operative notes. When surgeons are acting as “co-surgeons,” it is implied that they are each performing a distinct part of the procedure, which means they can’t “share” the same documentation. Each physician should provide a note detailing what portion of the procedure he or she performed, how much work was involved, and how long the procedure took. Including a brief explanation of the need for co-surgeons will help to avoid denials and reimbursement delays.
Tip 3: Each physician must link the same diagnosis code to the common procedure code. Though this requirement may seem obvious, if two physicians serve as co-surgeons to perform one procedure, the diagnosis code(s) they link to the CPT® code should be the same. Before submitting a claim with modifier 62, someone...
Do you ever meet with parents before their baby is even born? In these cases, you might be hesitant to charge for the visits because the patient isn’t present yet—but can you collect anything for the physician’s time? Check out the following 4 options, along with our expert advice before billing to insurance.
1. Consider an Office Visit
Some practices think of meet-and-greets, in which they tell the parents about the way they run their practice, more as an office visit, such as 99201. However, this would need to be billed based on time to the mother’s insurance company and would likely be questioned by the insurance company. For practices that do charge for these services, there’s a diagnosis code you can use: V65.11. ICD-9 guidelines allow you to list the code as a first or additional diagnosis.
2. Ensure You Meet Criteria Before Using 99401-99404
As an alternative to use a problem-oriented office visit code, the American Academy of Pediatrics (AAP) suggests the pediatrician may deem an appropriate counseling or risk factor reduction code. You may report these codes for prenatal counseling “if a family comes to the pediatrician/neonatologist either self-referred or sent by another provider to discuss a risk-reduction intervention (i.e., seeking advice to avoid a future problem or complication),” according to the AAP’s Coding for Pediatrics 2009.
You would report the service under the mother’s insurance, according to the AAP. Make sure you don’t use 99401-99404 if the mother or her fetus has any existing symptoms, an identified problem, or a specific illness. As per CPT®’s Counseling Risk Factor Reduction and Behavior Change Intervention guidelines, “these codes are used to report services for the purpose of promoting health and preventing illness or injury.”
Codes 99401-99404 aren’t necessarily shoo-ins for typical meet and greets. The AAP gives...
Find out what colporrhaphy code you’ll use for an injury repair.
If you’re stuck trying to figure out what code to use for a vaginal cuff repair, you should ask yourself one main question: Why did the ob-gyn need to perform the repair? The answer is the best way to decide what code (and possibly modifiers) to choose. Follow these three expert steps, and you’ll find the solution to one of the most frequently asked questions in an ob-gyn office: “Which CPT® code should I use for repair of vaginal cuff?”
Q1: How Do I Decide What Repair Code to Use?
The first thing you should do when the ob-gyn performs a vaginal cuff repair is examine the operative report to determine why the patient required the repair, says Cindy Foley, Billing Manager for three separate gynecology practices in Syracuse, N.Y.
Q2: If Repair Dealt With Loose Sutures, What Should I Do?
You read your op notes and discovered the vaginal cuff repair dealt with loose sutures. Suppose the patient, who underwent a total abdominal hysterectomy (58150, Total abdominal hysterectomy corpus and cervix], with or without removal of tube[s],with or without removal of ovary[s]), needs to return to the operating room for a vaginal cuff repair because the original sutures became loose and a simple re-closure is documented. In this case, you should report 58999 (Unlisted procedure, female genital system [nonobstetrical]). You would also need to submit your op report along with a cover letter that explains in simple, straightforward language exactly what your ob-gyn did, says Melanie Witt, RN, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.
Remember to explicitly reference the nearest equivalent listed procedure in your explanatory note. For example, you might consider comparing the work to 12020 (Treatment of superficial wound dehiscence; simple closure), which...
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...
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: http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
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:
...
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...
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...
Question: 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 Answer: Yes. In this situation, ...
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...
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...