Provider News

Part B Payment: Expect Claims To Be Released Today

MACs won’t process June claims until today, in hopes that Congress will act.

The Senate’s delays could mean serious payment crunches for your practice.

Last month, the freeze that has been keeping the Medicare conversion factor at 2009 levels expired, meaning that Part B practices were due to face a 21-percent cut effective for dates of service June 1 and thereafter. Because Congress had not yet intervened to stop those cuts, CMS initially instructed MACs to hold claims for the first 10 business days of June while lawmakers could deliberate whether to eliminate the looming cuts.

When the Senate reconvened on June 7, many analysts expected its members to vote on H.R. 4213, “The American Jobs and Closing Tax Loopholes Act of 2010,” which was expected to increase your payments through the end of this year, according to the text listed on the House Ways and Means Committee Web site. However, the bill has not passed, leading CMS to extend the MACs’ claims hold through June 17.

According to a June 14 CMS notification, the agency directed its contractors “to continue holding June 1 and later claims through Thursday, June 17, lifting the hold on Friday, June 18.”

CMS acknowledged in its June 14 notification that the lengthened claims hold period “may present cash flow problems for some Medicare providers. However, we expect that the delay, if any, beyond the normal processing period will be only a few days.”

The impact of the 17-day claims hold will vary, depending on the practice and how many Medicare patients it sees, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Those practices with large Medicare populations could face a cash flow crisis, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I,...

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June 18, 2010
Provider News

Diagnosis Coding: Here’s How To Decode Your Physician’s Notes

If the doctor does not circle a diagnosis, it may be up to you to find one.

Don’t let an incomplete superbill damage your chances of submitting an accurate claim. If the doctor in your office fails to indicate the ICD-9 code for the condition that he treated, you should read through his documentation to find which diagnoses you should report.

Open the Notes When You Have to — and Even When You Don’t

Suppose your physician hands you a superbill with the procedures circled and the diagnosis left blank.

You could ask the physician which diagnosis to report, or you could examine the documentation yourself. If your office has a policy that includes “coding by abstraction” by certified/qualified coders, then submitting charges based on what is supported (documented) in the note is appropriate, says Barbara J. Cobuzzi, MBA, CPC, CPCH,CPC-P, CENTC, CHCC, with CRN Healthcare Solutions in Tinton Falls, N.J. The physician should be signing off on these charges as part of your internal policy.

Some practices choose to review the documentation and compare it against any diagnoses recorded on the superbill, even when they aren’t required to. This ensures that the documentation matches the code selection every time.

When in Doubt, Confirm With the Physician

If you are new at coding diagnoses from the physician’s notes, you should doublecheck your code selections with the practitioners before submitting your claims.

“Until a coder feels comfortable with the ICD-9 books and the codes used more often in their office, it’s a good idea to run the choices by a clinician,” says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with the Physician Services Division of UPMC in Pittsburgh. “You never want to give a patient a disease or symptom they don’t have  ” or one more...

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June 16, 2010
Provider News

Emergency Coders: Check for Critical Care & You Could Gain $50

If patient’s critical care and visit satisfies time regs, 99291 is the better bet.

When scouring the notes for evidence of an emergency department caveat scenario, coders can easily forget to ask themselves one simple question: Can I report a critical care code for this scenario?

The answer’s yes more often than you might think, says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La.

“Many patients who qualify for the caveat may also be candidates for critical care. If the condition is severe enough that the patient’s ability to provide this information is impaired, then the condition may be critical,” she explains.

Critical Care Omits Specific History Component

Considering critical care and the caveat simultaneously can make your head spin, as the ED caveat does not even apply to 99291 (Critical care, evaluation and management of the critical ill or critically injured patient; first 30-74 minutes) or +99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

Why? “There are not the same bullet-counting requirements for documentation of history, physical examination, or MDM [medical decision making] for critical care,” explains Edelberg. The descriptors for critical care concern only E/M of the critically ill or injured patient.

So when your physician invokes the emergency department caveat for a patient, check to see if the patient was critically ill or injured; if she was, and the physician documents at least 30 minutes of critical care, consider 99291.

Payout: The only level of service you can invoke the emergency department caveat on is 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a...

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June 13, 2010
Provider News

Radiology Coding: Watch for 4 Key ICD-9 Additions

From head to toe, the new diagnosis codes hold something for everyone.

Whether your patients present with cardiologic, orthopedic, or gynecologic complaints, the next round of ICD-9 codes could hold important changes for you. Here’s the rundown on the new codes most relevant to radiologists — including a new option for retained magnetic metal fragments.

Remember: ICD-9 2011 will go into effect Oct. 1, 2010. The official version will be released in the fall, so the codes below are not yet final.

1. Look Forward to More Specific Ectasia Codes

The proposed changes to ICD-9 2011 add four codes specific to aortic ectasia. These codes are among the most significant changes for radiology coders because you may see that term in your radiologist’s findings, says Helen L. Avery, CPC, CHC, CPC-I, manager of revenue cycle services for Los Angeles-based Sinaiko Healthcare Consulting Inc. “Ectasia” means dilation or enlargement, and aortic ectasia typically refers to enlargement that is milder than an aneurysm. But ICD-9 2010 does not distinguish ectasia from aneurysm, indexing aortic ectasia to 441.9 (Aortic aneurysm of unspecified site without mention of rupture) and 441.5 (Aortic aneurysm of unspecified site, ruptured).

The proposed 2011 codes are specific to aortic ectasia and differ based on anatomic site:

  • 447.70 — Aortic ectasia, unspecified site
  • 447.71 — Thoracic aortic ectasia
  • 447.72 — Abdominal aortic ectasia
  • 447.73 — Thoracoabdominal aortic ectasia.

2. Watch for ‘Claudication’ in Stenosis Report

Another one of the important changes is the proposed addition of 724.03 (Spinal stenosis, lumbar region, with neurogenic claudication), says Avery. The code refers to lumbar spinal stenosis, which is a narrowing of the spinal canal, according to the Sept. 16-17, 2009, ICD-9-CM Coordination and Maintenance Committee meeting proposal (available here). Neurogenic claudication “is a commonly used term for a...

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June 10, 2010
Provider News

Lawsuit Pushes Red Flags Rule Back — Again

Amidst an AMA lawsuit, the FTC appears to take a wait-and-see approach.

After a year’s worth of extensions of the Red Flags Rule, medical practices were ready to buckle down and ensure that their plans were in place, because the rule was set to take effect on June 1.

However, just days shy of that deadline, the Federal Trade Commission (FTC) announced that it would be delaying enforcement until Dec. 31, 2010, “at the request of several Members of Congress,” according to a May 28 FTC news release.

Under the Red Flags Rule, “certain businesses and organizations — including many doctor’s offices, hospitals, and other health care providers — are required to spot and heed the red flags that often can be the telltale signs of identity theft,” according to an article on the Federal Trade Commission’s Web site.

To comply with the Red Flags Rule, covered entities are expected to create a written red flags program to prevent and detect potential identity theft cases.

According to the FTC, the rule applies to businesses that qualify as creditors or financial institutions, and the FTC’s broad definition indicates that it applies to many medical practices. “Health care providers are creditors if they bill consumers after their services are completed,” the FTC Web site says. “Health care providers that accept insurance are considered creditors if the consumer ultimately is responsible for the medical fees.”

However, simply “accepting credit cards as a form of payment does not make you a creditor under the rule.”

Congress requested the delay in part to “pass legislation that will resolve any questions as to which entities are covered by the Rule,” the FTC press release indicated. “Congress needs to fix the unintended consequences of the legislation establishing the Red Flags Rule — and to...

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June 7, 2010
Provider News

Medicare: 21% Cut Continues to Loom, With May 31 Deadline Nearing

CMS instructs MACs to hold claims for ten business days while Congress mulls bill.

Impending cuts to your Medicare pay have been a familiar story this year, but hopefully you won’t face a 21-percent payment drop while you’re trying to enjoy your summer.

Last month, Congress voted to extend freezing the conversion factor at 2009 levels so Part B practices wouldn’t have to face a 21 percent cut to the conversion factor, which was supposed to go into effect on April 1. Once the president signed the extension into law, it meant that practices didn’t have to worry about the Medicare cuts until June 1, in hopes that the government would find a more permanent solution to the pay cut crisis before the conversion factor freeze expires on May 31.

New Bill Could Put Off Cuts

The House Ways and Means Committee published the text of H.R. 4213, “The American Jobs and Closing Tax Loopholes Act of 2010,” on its website on May 20. The bill would increase your payments through the end of this year, according to the text listed on the Committee’s Web site, which states, “In lieu of the update to the single conversion factor … that would otherwise apply for 2010 for the period beginning on June 1, 2010, and ending on December 31, 2010, the update to the single conversion factor shall be 1.3 percent.” The bill also includes provisions that would ensure that additional cuts don’t take place through 2013.

The American College of Physicians posted support for the bill on its website, but the AMA expressed disappointment. “An intervention to delay a looming Medicare physician payment cut will provide temporary stability for seniors and their physicians, but the AMA is deeply disappointed that Congress will once again fail to permanently correct the...

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June 3, 2010
Cardiology / CMS / MAC / Provider News

MACs Differ on Response to CMS’s Cardiology Payment Adjustments

Don’t look for a raise just yet, in most cases.

CMS may talk, but MACs don’t always listen — at least not quickly.

As we told you in last week’s Insider, CMS recently corrected several “technical errors” published in the 2010 Fee Schedule, and thanks to these corrections, Medicare will increase payment for several cardiology-related testing codes, including codes 75571-75574 (Heart CT) and 78451-78454 (Heart muscle SPECT imaging).

Although many practices are eager to see the payment boosts in their next Medicare payments, that may be an overly ambitious goal at this point.

“I inquired with a few MAC carriers such as Trailblazer, Noridian, and Palmetto, and was told different things by different Medicare payers,” says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CCC, CEMS, CMS, CEO of Terry Fletcher Consulting Inc.

“One did not even know there was a change,” she says. “Next, Noridian said that they will be making the adjustments when they get the directive from CMS. And Palmetto said they would need the provider to contact them and then batch retroactive to January the myocardial perfusion imaging claims and send a letter to request the increase,” she says.

Bottom line: Until CMS provides a clear answer to the MACs regarding when they must implement the changes, you may not see your pay increases, but keep an eye on your carrier’s Web site for information on when it intends to reprocess claims using the new rates.

@ Part B Insider. Editor: Torrey Kim, CPC

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May 27, 2010
CCI / Medicare / NCCI / Provider News

2 Reasons to Think Twice Before Reporting 78070 With 78803

Sometimes CCI compliance requires looking beyond the edit pairs.

Correct Coding Initiative (CCI) edits don’t bundle SPECT (78803) and planar (78070) parathyroid imaging codes, but coding experts often tell you not to code the two together for SPECT and planar parathyroid imaging on the same date.

Add some method to this madness by looking at the information offered by two coding resources, the Society of Nuclear Medicine (SNM) and the NCCI Policy Manual for Medicare Services (CCI Manual).

1. SNM Singles Out 78803

SNM’s online Practice Management Coding Corner features a Q&A that recommends reporting 78070 (Parathyroid imaging) for planar imaging alone, but 78803 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; tomographic) for parathyroid SPECT imaging with or without planar, says Jackie Miller, RHIA, CCS-P, CPC, vice president of product development for Coding Metrix Inc. in Powder Springs, Ga.

Support: “Choose the single code that describes the protocol and procedure performed,” states the Q&A, located at http://interactive.snm.org/index.cfm?PageID=2442&RPID=1995. SNM “would NOT recommend coding both CPT codes,” the article notes.

2. CCI Makes the Case for SPECT Code

Although there is notyou won’t find any a specific edit bundling 78070 and 78803, CCI does address the SPECT/planar issue in the CCI Manual, says Miller.

CCI Manual, Chapter 9, Section E.2, explains that you may not report a SPECT study and planar study of the same limited area because “Single photon emission computed tomography (SPECT) studies represent an enhanced methodology over standard planar nuclear imaging. When a limited anatomic area is studied, there is no additional information procured by obtaining both planar and SPECT studies.”

Bonus tip: The manual indicates you may report both planar and SPECT codes only when the size of the scanned area makes both sets necessary, such as with whole body bone scans with...

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May 25, 2010
Medicare / Oig / Provider News

Cost of Freezing Conversion Factor is Over $6 Billion — Just for 2010

Plus: The OIG recovered over $1.5 billion in fiscal year 2009, and is on the lookout to collect more.

With less than two weeks to go before Medicare payments once again threaten to decrease by 21 percent, a new report sheds light on the financial outcome of Congressional actions.

Although the 2010 Physician Fee Schedule originally included a conversion factor that would have been 21 percent lower than the 2009 level, practices haven’t felt that cut yet this year,because legislators have voted several times to freeze payments, which now use the conversion factor of $36.0791. That freeze will expire on May 31, after which your Medicare payments will drop considerably unless Congress steps in once more.

However, one government entity’s calculations show that the freeze is costly. According to a May 7 Congressional Budget Office report, freezing payments at the current levels for the rest of 2010 would cost the government… … $6.5 billion. The AMA has turned up the heat on Congress to replace the current payment method, releasing a print ad aimed at Congress to demonstrate that “more delays of permanent reform now increase the cost for taxpayers,” and that the association “calls on Congress to fix the flawed Medicare physician payment formula now.”

Congress has not yet introduced a bill to extend the payment freeze past May 31. Keep an eye on the Insider for more information as this story develops.

To read the Congressional Budget Office’s calculation sheet,visit www.cbo.gov/budget/factsheets/2010b/SGR-menu.pdf.

@ Part B Insider. Editor: Torrey Kim, CPC

Sign up for the upcoming on-demand Webinar, 5 Steps to Optimize Your Office’s Coding & Billing Practices, or order the CD/transcripts.

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May 24, 2010
CCI / modifier 59 / Provider News

Make Sure You’re Applying Massive Prostate Biopsy, Urethral Dilation Bundlings

Modifier 59 sometimes will rescue your reimbursement.

Just when you’re finally getting a handle on all the 2010 coding changes, here comes round two of the Correct Coding Initiative (CCI) edits. Version 16.1, which took effect April 1, will tie your hands when coding many common urology procedures, including prostate biopsies and urethral dilations.

Heads up: CCI 16.1 includes 2,054 new active pairs and 1,947 modifier changes, says Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions Inc. in Clearwater, Fla.

“For urology, there will be 78 edit pair additions and two edit pair deletions,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.To ensure you get paid appropriately for your urologist’s services this quarter, here’s the rundown of the most important changes.

Say Goodbye to Biopsy with Several Prostate Procedures

You can no longer report prostate biopsy codes 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) or 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance) with 52630 (Transurethral resection; residual or re-growth of obstructive prostate tissue including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]). Your payer will reimburse you for 52630 but deny the biopsy codes, and you cannot use a modifier to separate these new edits.

“I have a major issue with the bundling of 55700 and 52630,” laments Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. Kater says her urologists perform a good number of prostate biopsies transrectally and 55700 is what she uses because the descriptor says “any approach.” When you are performing two separate procedures utilizing two different approaches, how can they be bundled?”

Silver lining: CCI also bundles...

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May 20, 2010
CCI / NCCI / Provider News

Avoid Denials With This Lowdown on Newborn CCI Bundles

These edits took effect April 1, so start observing them yesterday.

The latest version of the Correct Coding Initiative (CCI) has an edit that family practice coders should note – especially if the practice treats newborn patients.

Get to know the new CCI 16.1 edit and get ready to observe it with this expert breakdown. Check Column 1 on These Hospital E/Ms According to CCI 16.1, these codes are in column 1 of the mutually exclusive edits:

  • 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …)
  • 99232 (… an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity …)
  • 99233 (… a detailed interval history; a detailed examination; medical decision making of high complexity …).

Column 2 of these edits includes these codes:

  • 99460 (Initial hospital or birthing center care, per day,for evaluation and management of normal newborn infant)
  • 99461 (Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center)
  • 99462 (Subsequent hospital care, per day. for evaluation and management of normal newborn).

Translation: An FP may not report both normal newborn care and subsequent hospital care for a newborn on the same date of service. If the FP performs normal newborn services (99460-99462) on the same date that the newborn later becomes ill and receives subsequent hospital care (99231-99233), you should only report a code from the 99231-99233 code set, explains Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

The...

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May 20, 2010
Provider News

CMS Changes Conversion Factor Yet Again

Plus: Look for an increase in your DEXA scan reimbursement.

The bad news: Your carrier won’t be paying your claims using the conversion factor of $36.0846 anymore.

The good news: CMS is only changing the conversion factor by less than a penny, making it $36.0791, according to CMS Transmittal 700, issued on May 10. MACs will use this 2010 conversion factor to calculate your payments, but keep in mind that after May 31, you’re still due to face a 21 percent pay cut unless Congress intervenes. Keep an eye on the Insider for more information on whether Congress steps in...

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May 16, 2010
Audit / Provider News

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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May 12, 2010
Provider News

AAPC National Conference Location Changed to Jacksonville, FL

Get the latest from the National AAPC CEO and President, Reed Pew.

To all registered AAPC conference participants:

We have chosen Jacksonville, Florida to relocate our conference due to the extent of the flooding in Nashville, TN. It will be...

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May 6, 2010