Hot Coding Topics

ICD-9 2011 Diagnosis Coding: New Ectasia Codes Come Oct. 1

Check out V13.65 for corrected congenital heart malformations.

Each October you’re faced with new ICD-9 codes to add to your diagnosis arsenal. 2011 is no exception, with new ectasia, congenital malformation, and body mass index (BMI) codes you’ll need to learn. Take a look at the proposed changes that will affect your cardiology practice, so that you’re ready when fall rolls around.

End Your Ectasia Hunt at 447.7x

The proposed changes to ICD-9 2011 add four codes specific to aortic ectasia, which could be among the most significant changes for cardiology coders.

“Ectasia” means dilation or enlargement, and aortic ectasia often refers to an enlargement that is milder than an aneurysm. But ICD-9 2010 does not distinguish ectasia from aneurysm, linking 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 are 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.

New Corrected Congenital Malformations Code

A number of new codes deal with congenital malformations of the heart and circulatory system. Code V13.65 (Personal history of [corrected] congenital malformations of heart and circulatory system) will be “very useful to our practice,” says Janel C. Peterson, CPC, with Alegent Health Clinic Heart and Vascular Specialists in Omaha, Neb.

Add BMI V Codes to Your E/M Arsenal

The ICD-9 proposal has “expanded the body mass index (BMI) codes to demonstrate higher BMIs with five new codes,” notes Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, with CRN Healthcare Solutions in Tinton Falls, N.J.

You’ll need to stop using V85.4 (Body Mass Index 40 and over, adult) on Oct. 1 and start...

Comments Off on ICD-9 2011 Diagnosis Coding: New Ectasia Codes Come Oct. 1
August 12, 2010
Coding Challenge

Medicare Repeat Pap Smears: Find Out If 99000 Is OK

Hint: Abnormal versus insufficient cells mean different diagnosis codes.

When a patient returns to your office for a repeat Pap smear, you’ve got to weigh your options of E/M and specimen handling codes, as well as diagnosis codes. Take this challenge to see how you fare and prevent payment from slipping through your fingers.

Question 1: When a patient comes in for a second Pap smear, what CPT code(s) should you apply and why?
 
Question 2: Will you receive reimbursement for handling the repeat Pap smear? Why or why not?

Question 3: If the patient comes back in for a Pap smear due to abnormal results, what ICD-9 code(s) should you use and why?

Question 4: If the patient has a repeat Pap because the lab did not have enough cells in the specimen to interpret the results, what ICD-9 code(s) should you use and why?

Answer 1: Here’s What CPT Codes
 
When the patient comes in for a second Pap smear, submit the appropriate E/M office visit code (99211-99215). You will probably be able to report 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) for this visit becausethe patient likely will come in only for the Pap smear and CPT does not include a specific code for taking the Pap. Code 99212 carries 1.08 relative value units (RVUs), unadjusted for geography. That translates to about $31 for this visit (using the new conversion factor of 28.3868).
Answer 2: Handling the Specimen Depends on Payer


Some private payers will reimburse for handling the repeat Pap smear specimen (99000, Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory). But Medicare carriers consider the collection and handling part of a problem E/M...

Comments Off on Medicare Repeat Pap Smears: Find Out If 99000 Is OK
August 12, 2010
Provider News

CCI 16.2 Bundles Paravertebral Facets With Anesthesia Procedures

Don’t assume separate coding for J0670, anymore.

The latest Correct Coding Initiative (CCI) edits contain plenty of anesthesia and pain management pairs you should check — and straight away. They went into effect July 1. CCI 16.2 encompasses 16,843 new edit pairs, according to analyst Frank Cohen, MPA, of MIT Solutions, Inc., in Clearwater, Fla. With 11 percent of all active edits affecting anesthesia procedures, you can’t afford to miss any of the changes.

Other Work Includes Paravertebral Facet Injection

Although the current CPT book doesn’t include them, you could begin using several new codes for paravertebral facet joint injections in January 2010. Now CCI edits bundle two of the new codes with every anesthesia code (00100-01999) and many nerve destruction procedures. The paravertebral injection codes affected are:

  • 0213T — Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level
  • 0216T — Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level.

Procedures paired with 0213T and 0216T range from 64600 (Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch) and 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) to 64650 (Chemodenervation of eccrine glands; both axillae). Most of the edit pairs carry a “0” modifier indicator, but CCI lists a few with modifier indicator “1.” Check the full CCI file to verify whether you can use a modifier to break specific edits.

ME Edits Also Hit 0213T-0218T

Paravertebral facet joint injection codes 0213T-0218T come into play as part of mutually exclusive (ME) edits, as well.

CCI 16.2 pairs each choice with corresponding codes involving fluoroscopy or CT guidance: 64490-64492 (Injection[s], diagnostic or...

Comments Off on CCI 16.2 Bundles Paravertebral Facets With Anesthesia Procedures
August 12, 2010
CMS / Hot Coding Topics / ICD-10

Watch for Denials If You Take Shortcuts on Form 5010

Say goodbye to form 4010A1 for ICD codes as well, starting in 2012.

Dig into your claim forms now to ensure that the beneficiary’s information is accurate to the letter, or you’ll face scores of denied claims on the new HIPAA 5010 forms.

Why it matters: CMS will deny claims on which the beneficiary’s name doesn’t perfectly match how it’s listed on his Medicare I.D. card when you begin using HIPAA 5010 form — the new Medicare universal claim form starting in 2012.

Include Jr. or Sr. Suffixes

“Whenever there is a name suffix, such as ‘Jr.’ or ‘Sr.’ abbreviations, etc., it must be included with the last name,” said Veronica Harshman of CMS’s Division of Medicare Billing Procedures during an April 28 Open Door Forum regarding the eligibility component of the HIPAA 5010 form.

You can include the suffix either with the patient’s last name or in the suffix field, specified CMS’s Chris Stahlecker during the call.

“The date of birth must also match exactly to what the Social Security Administration has on file,” Harshman said. CMS will use several new error codes on claims once the 5010 form goes into effect. “If you communicate with CMS through a third-party vendor (clearinghouse), it is strongly recommended that you discuss with them how these errors will be communicated to you and how these changes will impact you and your business,” Harshman advised.

Look for Production Systems Next Year

According to the HIPAA 5010 Final Rule, CMS will have a production 5010 system available as of Jan. 1, 2011, Harshman said.

The last day CMS will accept a 4010A1 form will be Dec. 31, 2011. As of Jan. 1, 2012, if you aren’t using the 5010 form, you’ll “lose the ability to receive eligibility data from Medicare,” Harshman said. In...

Comments Off on Watch for Denials If You Take Shortcuts on Form 5010
August 12, 2010
Coding Challenge

Protect Incident To Pay

Incident-to services are on auditors radar. To prevent paybacks, you’ve got to know when to use incident to – and capture full pay, and when to bill services directly – and lose the standard 15%. Test your incident to savvy with this question: Qu...

Comments Off on Protect Incident To Pay
August 12, 2010
Coding Challenge

RFA: 64622, 64623 Vs. 64640

With multiple ways to denervate the sensory nerve/nerve branches, pain management coders may argue about which 64xxx code is right. You’ve got to dig into the chart note to identify the method used. See if you’re up to the challenge with this Supercoder Forum Insight.

Question: A provider is doing RFA’s of the left L4, L5, S1, S2, S3 and SA. He is billing 64622 x 1 and 64623 x 4. The other pain provider states this is incorrect and that he should be billing 64640 for S1, S2, S3 and SA. Which coding is correct?

Answer: This is a complex coding issue because there are several different methods to denervate the sensory nerve/nerve branches that provide innervations from the SI joint. Because of this, the coding will depend somewhat on the method used.

However, I can say that reporting 64622 and 64623 x 4 is incorrect. The “paravertebral facet joint nerves” that provide innervations to the facet joints in the cervical, thoracic, and lumbar regions are the medial branches off the dorsal ramus. In the sacrum, there are indeed medial branches, but – as their name indicates – the path for these nerve branches is to the midline to provide innervations to the multifidus muscles and not laterally to the SI joint. So, following the published CPT Instructions for Use of the CPT Codebook – “Do not select a CPT code that merely approximates the service provided”, even though they are similar, procedures performed on the lateral branches of the sacral nerves should not be reported as paravertebral facet joint nerve procedures (i.e., paravertebral facet joint injections or destructions).

A few of the more common techniques are:

  • Separate destruction of each nerve/nerve branch. According to CPT Assistant (Dec. 2009), you would code 64622 for the L5

...

Comments Off on RFA: 64622, 64623 Vs. 64640
August 12, 2010
Provider News

CMS Clarifies How to Report Audiology Services

Look for a physician order for diagnostic audiology tests. If you thought CMS’s May transmittal on coding for audiology services was the last word on the subject, think again. On July 23, the agency rescinded the May directive and issued new guidance...

Comments Off on CMS Clarifies How to Report Audiology Services
August 12, 2010
CMS / Provider News

Proposed 2011 Fee Schedule Offers Vast Benefits for Primary Care Practices

CMS adds Obama recs into next year’s fee schedule.

The President signed the Patient Protection and Affordable Care Act (PPACA) into law on March 23, but many practices haven’t yet noticed significant impacts from the legislation. In 2011, however, you could see huge boosts from it, because CMS has proposed incorporating many of the law’s features into next year’s Physician Fee Schedule.

On June 25, CMS released its proposed Physician Fee Schedule for 2011. The 1,250-page document, which will be published in the July 13 Federal Register, offers several advantages to medical practices, including bonuses for primary care physicians. “Improving access to preventive services and primary care is a top priority for HHS,” said HHS Secretary Kathleen Sebelius in a June 25 statement. “The proposed rule is just one part of a broader effort we are making to improve the health status of Medicare beneficiaries.”

According to the proposal, primary care practitioners will benefit from a 10 percent bonus starting on January 1, as prescribed in the PPACA.

Practitioners who qualify will be doctors, nurse practitioners, clinical nurse specialists, or physician assistants with the primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatrics.

To qualify for the 10 percent bonus, the law stipulates that the primary care practitioners will have to bill at least 60 percent of their allowed charges as ‘primary care services,’ which are defined by E/M codes 99201-99215, nursing facility or rest home care codes 99304-99340, or home services codes 99341-99350.

“The rule we are proposing today is just one part of the Administration’s efforts to improve the health status of Medicare beneficiaries by expanding access to preventive services, and promoting early detection and prompt treatment of medical conditions,” said Jonathan Blum, deputy administrator and director of CMS’s Center for Medicare, in a...

Comments Off on Proposed 2011 Fee Schedule Offers Vast Benefits for Primary Care Practices
August 10, 2010
Coding Challenge

Medical Coders: Accepting a PFFS Plan is Your Choice

auditorHere are the pros and cons to help guide your decision.

Question: Our practice is considering accepting patients with PFFS plans. We’re heard that some patients are starting to have them, but we’re not sure whether we’re going to accept them or not. Are PFFS plans beneficial for us?

Answer: PFFS are Private Fee-for-Service plans, which are non-network plans. These plans let members receive care from any doctor or hospital that accepts the plan’s payment terms and conditions.

If your practice decides to accept these terms, you would become a “deemed” provider. Plan members can receive covered services from any deemed provider in the U.S. However, member patients must confirm that the provider is deemed every time a service is provided.

PFFS plans are different from Medicare Advantage plans because they do not require a doctor or hospital to contract with a health plan to provide services. This means that doctors or hospitals that do not agree to the PFFS plans’ terms and conditions may choose not to provide health care services to a plan member, except in emergencies.

Coming soon: Starting in 2011, PFFS plans will have to measure and report on their providers’ quality of care. But the catch is that they’ll also have to form provider networks with contracts.

In counties where there are two or more non-PFFS plans, PFFS plans will no longer be able to simply “deem” providers into the plan without a contract. Under current law, PFFS plans don’t have to prove they can meet access standards if they allow any willing qualified Medicare provider to participate, and they pay as traditional Medicare would pay.

One argument is that the network requirement would provide better access to care because there would be contracts between the providers of services and the plan. On the...

Comments Off on Medical Coders: Accepting a PFFS Plan is Your Choice
June 18, 2010
CMS / Hot Coding Topics / ICD-10

Heads Up Coders: 2013 ICD-10 Implementation Date Is Firm

Plus: CMS has proposed freezing the ICD-9 codeset after next year.

If you were hoping that the Oct. 1, 2013 ICD-10 implementation date wasn’t set in stone, you are out of luck. That’s the word from CMS during a June 15 CMS Open Door Forum entitled “ICD-10 Implementation in a 5010 Environment.”

“There will be no delays on this implementation period, and no grace period,” said Pat Brooks, RHIA, with CMS’s Hospital and Ambulatory Policy Group, during the call. “A number of you have contacted us about rumors you’ve heard about postponement of that date or changes to that date, but I can assure you that that is a firm implementation date,” she stressed.

Brooks indicated that the rumor about a potential delay in the implementation date continues to persist throughout the physician community, and recommended that practice managers alert their physicians to the fact that that the rumor is untrue.

The Oct. 1, 2013 date will be in effect for both inpatient and outpatient services. Keep in mind that the ICD-10 implementation will have no impact on CPT and HCPCS coding, Brooks said. You will still continue to bill your CPT and HCPCS procedure codes as before.

You’ll Find Nearly 55,000 Additional Codes

Currently, CMS publishes about 14,000 ICD-9 codes, but there are over 69,000 ICD-10 codes. The additional codes will allow you to provide greater detail in describing diagnoses and procedures, Brooks said.

If you’re wondering which specific codes ICD-10 includes for your specialty, you can check out the entire 2010 ICD-10 codeset, which CMS has posted on its Web site. “Later this year, we’ll be posting the 2011 update,” Brooks said during the call.

@ For more details on CMS’ upcoming plans, subscribe to Part B Insider (Editor: Torrey Kim, CPC).

Sign...

Comments Off on Heads Up Coders: 2013 ICD-10 Implementation Date Is Firm
June 18, 2010
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,...

Comments Off on Part B Payment: Expect Claims To Be Released Today
June 18, 2010
Hot Coding Topics

Radiology Coding: Bone Scan Rate Benefitting From Healthcare Reform

Don’t let 2006 DXA code references lead you to use wrong codes. Which codes should you use to reap the benefit of CMS’s new calculations for bone scan payment? During an April 13 CMS Open Door Forum, that’s what one caller wanted to know. Good ne...

Comments Off on Radiology Coding: Bone Scan Rate Benefitting From Healthcare Reform
June 16, 2010
Coder's Cranium

Billing How-To: Should A Provider Change Tax IDs?

Despite disadvantages, a new tax ID is a must when physicians leave your group.

Question: One of our optometrists wants to stop billing under the group’s tax ID and start billing under his own tax ID. I’m concerned that doing so will confuse the insurance companies and slow down his income, even though he has personally called some to notify them of the change and the effective date. Some payers are now asking for new W9 forms. Is there an easy way to do it?

Answer: Your optometrist can change his tax ID at any time, but you must submit a new W9 to your payers, in addition to a letter explaining that he will no longer be practicing under the group’s tax ID.

Downside: Yes, the optometrist’s income will be slowed. You also run the risk that the payer’s enrollment department does not handle the paperwork properly. Other billers have reported instances of the income being paid to the old tax ID or not being paid at all. Claims can also be lost even though the correct paperwork has been submitted multiple times.

If your optometrist is currently part of a group, and he is leaving the group, he needs his own tax ID. Many legal issues will arise from this. For example, if he is staying in the same office suite, he will have to pay market rent for the offices and staff that he is using. When patients move between the old practice and his new practice, questions will arise about which patients are considered new and which are considered established patients.

Much of this will have to be determined by the legal structure that is set up as he leaves the group. This can be a much more complex change than it appears on the...

Comments Off on Billing How-To: Should A Provider Change Tax IDs?
June 16, 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...

Comments Off on Diagnosis Coding: Here’s How To Decode Your Physician’s Notes
June 16, 2010
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
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...

Comments Off on Emergency Coders: Check for Critical Care & You Could Gain $50
June 13, 2010