CMS / Provider News

CMS: Prove Your Exemption From the E-Prescribing Penalty With New G Codes

Even if you don’t have prescribing privileges, you can rest assured now as CMS will not cut your pay as a penalty for failing to comply with the new e-prescribing incentive program.

As you are probably aware, starting in 2012, you may be subject to a one percent payment adjustment on your Part B pay if you don’t successfully participate in e-prescribing this year. In 2013, that payment adjustment will go up to 1.5 percent, and in 2014 it will rise to two percent, CMS’s Daniel Green, MD noted on a Feb. 15 CMS-sponsored call.

“To earn an incentive in 2011, an eligible professional must e-prescribe 25 times during the year, ten of which must be in the first six months,” Green said. “If they are a successful e-prescriber during the calendar year, they not only would avoid the 2012 payment adjustment, they would get a one percent 2011 payment incentive, and they would be exempt from the 2013 payment adjustment,” he explained.

“Earning an incentive in 2011 does not necessarily exempt the eligible professional or group practice from a payment adjustment in 2012,” Green explained.

How to Avoid the Adjustment

CMS reps said that they’ve been flooded with calls about the 2012 payment adjustment, and described ways that you can avoid the adjustment if you qualify.

Not eligible to prescribe: If you are not a physician, nurse practitioner, or physician assistant between Jan. 1 and June 30, 2011, you can avoid the e-prescribing penalty. In addition, if you don’t have prescribing privileges at least once on a claim between Jan. 1 and June 30, 2011, you should append G8644 (Eligible professional does not have prescribing privileges) at least once before June 30 to ensure that your MAC knows you are not subject to the penalty, said CMS’s Michelle...

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March 27, 2011
Hot Coding Topics / ICD-10 / Provider News

ICD-10: Prep Yourself for New Hyperlipidemia Codes

When ICD-10 goes into effect in 2013, high cholesterol will still be a challenge for your patients. Here’s a look at how coding for this, and similar diagnoses, compares between ICD-9 and ICD-10.

ICD-9-CM Codes:

  • 272.0, Pure hypercholesterolemia
  • 272.1, Pure hyperglyceridemia
  • 272.2, Mixed hyperlipidemia
  • 272.4, Other and unspecified hyperlipidemia

ICD-10 Codes:

  • E78.0, Pure hypercholesterolemia
  • E78.1, Pure hyperglyceridemia
  • E78.2, Mixed hyperlipidemia
  • E78.4, Other hyperlipidemia
  • E78.5, Hyperlipidemia, unspecified

Change: ICD-10 offers a one-to-one code match with ICD-9 for pure hypercholesterolemia (272.0, E78.0), pure hyperglyceridemia (272.1, E78.1), and mixed hyperlipidemia (272.2, E78.2). But where ICD-9 offers one code for “other and unspecified hyperlipidemia” (272.4), ICD-10 offers one code for “other” (E78.4) and a different code for “unspecified” (E78.5).

Documentation: Your clinicians’ documentation shouldn’t need to change from its current form. All you need to do as a coder to capture this already present information is to format your superbill to capture the difference between “other” and “unspecified” hyperlipidemia. “Other” means the physician documented the type, but ICD-10 doesn’t offer a code specific to the documented type. “Unspecified” means the physician did not document the type of hyperlipidemia.

Bonus tip: The notes with the ICD-9 and ICD-10 codes for lipid metabolism disorders are very similar, but there are a few differences. For example, while 272.1 includes “hypertriglyceridemia, essential,” E78.1 includes “elevated fasting triglycerides.”

Under E78.2, ICD-10 adds “combined hyperlipidemia NOS,” “elevated cholesterol with elevated triglycerides NEC,” and “Hyperlipidemia, group C.” Code E78.2 also has an Excludes1 note, telling you instead to code E78.4 for “familial combined hyperlipidemia” and E78.5 for “cerebrotendinous cholesterosis [van Bogaert-Scherer- Epstein] (E75.5).”

Remember: When ICD-10 goes into effect on Oct. 1, 2013, you should apply the code set and official guidelines in effect for the date of service reported. Learn more at www.cms.gov/ICD10/ and...

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March 25, 2011
Hot Coding Topics

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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March 24, 2011
Hot Coding Topics / modifier 25

AK Removals: Earn $120 by Following 17000-17111 with 99201

Stick to these 3 tips for your E/M and lesion removal procedures.

You can report both the E/M and lesion removal if the E/M service was a significant and separately identifiable service for an E/M service with actinic keratoses (AK) removal procedure.

Always verify with your carrier before appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

You can only consider reporting modifier 25 when coding an E/M service, says Janet Palazzo, CPC, coder for a practice in Cherry Hill, N.J. If the procedures you are reporting don’t fall under E/M services, it is possible the encounter qualifies for another modifier instead.

Have a look at the following three tips to help you report these services accurately so your practice won’t miss out on about $41 for 99201 and $80 for 17000 or more, according to national averages indicated in Medicare’s 2011 Physician Fee Schedule.

1. Know When You Should Charge an E/M

Each insurer has its own guidelines for office visits (99201- 99215, Office or other outpatient visit …) and lesion removals (17000-17111, Destruction, Benign or Premalignant Lesions). So, knowing whether to appeal an E/M denial is difficult unless you know that the service deserves payment.

You should report the office visit (99201-99215) in addition to the procedure when the dermatologist performs a significant, separately identifiable E/M service from the AK removal, especially if the patient is new to your practice.

Along with the appropriate E/M code, report any diagnoses that come with that examination, which may include more than just the AK.

For example, if a patient comes in for an initial AK visit, you should charge an E/M service, since the physician has to examine the area and discuss...

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March 21, 2011
Hot Coding Topics

Inhaler Education Claims: 4 Quick Guidelines to Help You Report Correct Claims

When reporting inhaler service, you should remember the type of device the provider is using, but shouldn’t stop with just that. Documentation requirements and qualifying modifiers are just as important when coding for inhaler services.

When you’re confused why some payers would deny reimbursement for certain inhaler claims, the following ideas could guide you to a better understanding of how inhaler service codes work out.

94664 Is Your Ticket to Diskus Demo Pay

The Advair Diskus is an “aerosol generator.” If the nurse/medical assistant taught someone to use an Advair Diskus — or any other diskus — you should report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

For example, a pulmonologist starts a patient with asthma (493.00, Extrinsic asthma; unspecified or 493.20, Chronic obstructive asthma; unspecified) on Advair. A nurse then teaches the patient how to use the Diskus. As per CPT guidelines, you should report 99201-99215 for the office visit and 94664 without a modifier, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

In addition, CMS transmittal R954CP also indicates that modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) applies only to E/M services performed with procedures that carry a global fee, which 94664 does not have.

Nonetheless, many payers will only pay for the service if you append modifier 25 to the visit code. It’s always best to check with your major insurers’ policy first.

Bundle Dose in Teaching Session

The patient may administer medication dose during the teaching session. Both services (treatment + teaching) are bundled into one CPT: 94640 (Pressurized or nonpressurized inhalation treatment for acute...

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March 16, 2011
Hot Coding Topics / ICD-10 / Provider News

ICD-10: A J Code To Replace 471.0 In 2013

Nasal cavity polyp also goes by the term “choanal” and “nasopharyngeal.” If the otolaryngologist performed a removal of a middle turbinate endoscopically, you would report it with CPT 31240 — subsequently linking this procedure to a diagnosis...

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March 16, 2011
Hot Coding Topics

Stop Letting Complex Dermatitis Tests Rob You Of Your Deserved Pay

Keeping track of all the different potential allergens that may be causing a patient’s skin rash is challenging enough. But when you add the complexity of different kinds of dermatitis tests that a dermatologist can perform, it’s enough to cause a coder to break out in a rash herself. The variety and complexity of allergy tests can certainly lead to coding mishaps — but understanding the codes and having clear documentation can help clear things up.

The tests that dermatologists commonly perform to learn the source of a patient’s allergic dermatitis include scratch tests and patch tests. Knowing what code to use means understanding what each test does, and how.

Count Each Allergen in Scratch Tests

Procedure: Percutaneous tests

AKA: Scratch tests, prick tests, puncture tests, Multi-Test

Codes: 95004 (Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests) and 95010 (Percutaneous tests [scratch, puncture, prick] sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, including test interpretation and report by a physician, specify number of tests).

In these tests, the dermatologist applies test solutions of possible allergens to scratches or shallow punctures of the skin. The code you report will depend on the type of solutions applied — allergenic extracts, such as dust, cat dander, and molds (95004), or antibiotics, biologicals, stinging insects, and local anesthetic agents (95010).

Dermatologists usually want to test several substances at once (often in blocks of eight), and each substance counts as a separate test, notes Pamela Biffle, CPC, CPC-P, CPC-I, CCSP, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas. Be sure to code for each allergen administered by putting the number in the “units” field of your claim form.

Hidden trap: Code...

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March 14, 2011
Coding Challenge

How Should You Report Cannulation of Colovesical Fistula?

Question: I’m unsure how to code for cannulation of colovesical fistula. The doctor also did a cystoscopy with bilateral retrogrades and bladder biopsies. How should I report this procedure? Answer: There is no specific CPT code for cannulation of th...

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March 13, 2011
Provider News

93224-93226: Snag Extra Cash With These Tips

The catch is you have to make the request for your rightful dollars.

Here’s a piece of good news for you. As per the Medicare’s April update, three Holter monitor codes will get a slight boost in pay.

The change has an implementation date of April 4, 2011, and an effective date of Jan. 1, 2011. That means contractors have to be ready to comply with the change by April 4, but the change in practice expense relative value units (PE RVUs) is retroactive to Jan. 1 dates of service.

Medicare isn’t requiring contractors to search their files to adjust claims they have already paid (which is good news for any physician who reports a code seeing a fee decrease). But contractors do have to adjust claims if you bring them to their attention. Take a look at how many 93224-93227 services you provided from January to March to see if making the claim for the small increase in RVUs is worth your time.

93224: The PE RVUs for 93224 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation) will change from 2.30 to 2.53. That’s a difference of .23 RVUs. Multiply that by the 2011 conversion factor (33.9764), and you can expect roughly an additional $7.81 for this code. (Remember that geographic region will affect your fee, as well).

93225: For 93225 (…recording [includes connection, recording, and disconnection]), the PE RVUs only increase by .09, changing from 0.82 to 0.91. So the additional reimbursement should be roughly $3.06.

93226: You may see an additional $4.76 for 93226 (… scanning analysis with report). Its PE RVUs change from 1.21 to 1.35.

Swan-Ganz: If you ever report 93503 (Insertion and placement of flow directed catheter [e.g.,...

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March 13, 2011
Hot Coding Topics / Provider News

Be In The Know With Chemodenervation and Botulinum Toxin Changes

Effective April 1, your practice’s bottom line is going to be hit, especially if your provider uses chemodenervation to treat patients. Reason: Medicare Physician Fee Schedule is all set to introduce a bunch of changes. So here’s the big news.

Bilateral Indicator Shifts to ‘2’

Neurologists and pain management specialists sometimes use chemodenervation to help relieve symptoms of spasmodic torticollis (333.83), cerebral palsy (such as 343.x), or other conditions. The codes you rely on for these procedures include:

  • 64613 — Chemodenervation of muscle(s); neck muscle(s) (e.g., for spasmodic torticollis, spasmodic dysphonia)
  • 64614 — … extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis).

Previous versions of the physician fee schedule listed a bilateral status indicator of “1” for 64613 and 64614. That meant you could append modifier 50 (Bilateral procedure) and receive additional payment if your provider injected botulinum toxin into bilateral anatomic sites, such as the right and left upper extremities.

Medicare is changing the bilateral status indicator for 64613 and 64614 to “2,” effective April 1, 2011. You’ll no longer be able to report the service bilaterally, even if your provider chooses that treatment option.

“Medicare now considers that the RVUs (relative value units) are already based on the procedure being performed as a bilateral procedure,” explains Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co.

Pay cut: Submitting a claim with modifier 50 means the payer will reimburse at 100 percent for the first procedure and at 50 percent for the second contralateral procedure. Based on the national conversion factor of $33.9764, Medicare pays $145.42 for code 64613 in a facility setting and $164.11 in a non-facility setting. Medicare pays $151.87 for code 64614 in a facility setting and $174.98 in a nonfacility setting. Once the...

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March 12, 2011
Hot Coding Topics

A-Scans: Report Denial Proof 76511 Claim With Accurate Bilateral, Modifier Reporting

One of the most common procedures in ophthalmology is A-scan ultrasound biometry, which is associated with some of the most uncommon coding problems.

According to CPT, A-scans — 76511, 76516, and 76519 — are the shortened names for amplitude modulation scans, “one-dimensional ultrasonic measurement procedures,” notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director, Best Practices-Network Operations at Mount Sinai Hospital in New York City.

Ophthalmologists use 76511 (Ophthalmic ultrasound, diagnostic; quantitative A-scan only) to diagnose eye-related complications such as eye tumors, hemorrhages, retinal detachment, etc.

Physicians use 76516 (Ophthalmic biometry by ultrasound echography, A-scan) to measure the axial length of the eye in preparation for cataract surgery.

And 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) allows ophthalmologists to determine the intraocular lens calculation prior to cataract surgery only.

Typically, most A-scans are performed bilaterally. However, circumstances may only require the physician to perform a unilateral scan.

Each A-scan code has separate requirements when billed bilaterally. For example, payers consider 76511 unilateral, requiring the use of modifiers LT/RT/50 (Left side/Right side/Bilateral procedure) or the units value of “2.”

But 76516 is inherently bilateral, so you shouldn’t append modifier 50 to it.

For CPT Code 76519, some payers (including Medicare) consider only the technical component bilateral whereas the professional component is unilateral.

Some non-Medicare payers, on the other hand, want you to bill globally and don’t typically divide the professional and technical components, so you must determine which insurance company you are coding for and what its policy is for billing A-scans.

Medicare carriers for Part B services have published articles specifying their preference to report a bilateral service with a single line item with modifier 50 and one unit of service, whereas [some] non-Medicare payers prefer reporting bilateral services with two line items...

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March 12, 2011
Hot Coding Topics

Choose The Most Appropriate Code with an Optometrist Expert Help

Even small ophthalmology practices are likely to have a Humphrey visual field analyzer, yet many ophthalmologists don’t know the secrets for securing adequate reimbursement for these services — and they even go so far as to put themselves at risk for costly audits due to lack of documentation.

CPT lists three different visual field examinations — and the higher the code, the higher the reimbursement.:

  • 92081 — Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (e.g., tangent screen, Autoplot, arc perimeter or single stimulus level automated test, such as Octopus 3 or 7 equivalent)
  • 92082 — … intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33)
  • 92083 — … extended examination (e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2 or 30/60-2).

A common mistake ophthalmologists make is billing 92082 when they could legitimately bill 92083.

The key to choosing the correct VF code is in the code descriptors themselves. For example, if the ophthalmologist plots only two isopters on the Goldmann perimeter, CPT would call that “intermediate,” based on its description of 92082. If you plotted three isopters, however, that would be an “extended” examination that would qualify for 92083.

Rule of thumb: An intermediate test is one of the screening tests that you would use if you suspect neurological damage. But ophthalmologists use the threshold exam (92083) when they suspect something that causes a slow, progressive dimming of peripheral vision, like glaucoma. Glaucoma causes a loss of vision like a light bulb slowly becoming...

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March 8, 2011
Coder's Cranium / modifier 50

Know When to Append Modifier 50 on Bilateral CTS Shots

Your orthopedist injects both of a patient’s wrists to treat carpal tunnel syndrome. Should you just file 20526 with modifier 50 appended and forget about it? Not so fast: If the physician injects both the patient’s wrists to treat CTS, you will ty...

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March 8, 2011
Hot Coding Topics

Emergency Reporting: Know When To Use +99140 With These Tips

Reporting any qualifying circumstances (QC) codes for anesthesia can be tricky, but knowing when to classify a situation as a true emergency can be a real challenge unless you’re well-versed in the emergency conditions guidelines. Check coding definitions and your provider’s documentation to know whether you can legitimately add two extra units for +99140 (Anesthesia complicated by emergency conditions [specify] [List separately in addition to code for primary anesthesia procedure]) to your claim.

CPT includes a note with +99140 stating that “an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body parts.” Your key to knowing a case meets emergency conditions lies in your anesthesiologist’s notes.

“Quite a number of cases come in where the anesthesiologist marks ‘emergency’ but many times the ‘emergency’ isn’t all that clear,” says Leslie Johnson, CCS-P, CPC, director of coding and education for Medi-Corp., Inc., of New Jersey. Documentation supporting an emergency will depend on each case, so read the chart thoroughly when your provider indicates an emergency.

Solution: Talk with your anesthesia providers to clarify what constitutes an emergency and when you can include +99140. If there’s a real reason to report an emergency (such as a ruptured appendix, 540.0), your physician should clearly document the reason. Another diagnosis code to indicate a problem (such as unstable angina, 411.1) could help show the payer you’re reporting an unusual situation. The second diagnosis can also help in an appeal if a payer that ordinarily recognizes +99140 denies the claim.

“An OB patient who comes in for a cesarean section isn’t automatically an emergency,” explains Scott Groudine, M.D., professor of anesthesiology at Albany Medical Center in New York. “However, a diagnosis of fetal distress and prolapsed cord virtually always...

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March 8, 2011