General / Hot Coding Topics

3 Steps to Keep Discontinued Procedure Claims Moving

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...

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June 8, 2011
Hot Coding Topics

Diagnosis Coding: G Codes Are Your Key To Coding Correct High Risk Colonoscopy

Get your hemorrhoid report right and stress-free in a snap. We’ll tell you the difference between internal and external hemorrhoids, but you can learn more from this sample physician’s report:

PREPROCEDURE DIAGNOSIS: History of colon polyps and partial colon resection, right colon.

POSTPROCEDURE DIAGNOSES:

  1. Normal operative site.
  2. Mild diverticulosis of the sigmoid colon.
  3. Internal hemorrhoids.

PROCEDURE: Total colonoscopy.

PROCEDURE IN DETAIL: The 60-year-old patient presents to the office to be evaluated for the preprocedure diagnosis. The patient also apparently had an x-ray done at the hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed. She was prepped the night before and on the morning of the test with oral Fleet’s, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push. Digital rectal exam was done, unremarkable. At that point, the Pentax video colonoscope was inserted. The rectal vault appeared normal. The sigmoid showed diverticula throughout, mild to moderate in nature. The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized. The scope was passed a short distance up the ileum, which appeared normal. The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area. The scope was then retroflexed, and anal verge visualized showed some internal hemorrhoids.

RECOMMENDATIONS: Repeat colonoscopy in three years.

Let Location Guide You

You can easily identify external hemorrhoids (455.3-455.5) because of its place of appearance. This type of hemorrhoid has a fleshy growth and occurs around the anus — specifically, outside the anal verge which is at the distal end of the anal canal. On the other hand, internal hemorrhoids (455.0-455.2) occur inside the...

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March 7, 2011
Anesthesiologist / Coding Challenge

Anesthesia Coding: Find the Missing EGD Reimbursement Link

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

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

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

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

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

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

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

Also note the...

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June 7, 2010
Hot Coding Topics / Medicare

Examine These FAQ to Sort Your Medicare Cancer Screen Codes

Remember frequency rules differ for average, high risk.

Getting Medicare to pony up for colorectal cancer screenings is not difficult provided you follow its frequency guidelines and eligibility requirements to the letter. A coding slip up on one of these items will knock you out of the saddle, and Medicare won’t accept the claim at all.

Rope in all the coding info you’ll need via this Medicare colorectal cancer screening FAQ.

Who’s Eligible for Average-Risk Test?

If the Medicare patient is 50-plus years old, he is eligible for a covered Medicare screening, confirms Dena Rumisek, CPC, biller at Michigan’s Grand River Gastroenterology PC.

However: These patients are considered average risk, and can have a colorectal cancer screening only once every 10 years, says Cheryl Ray, CCS, CPMA, of Atlantic Gastroenterology in Greenville, N.C. Ignore Medicare’s frequency guidelines at your peril, experts warn.

“Medicare is very stringent on the date … it has to be 10 years or longer — it can’t be 9 years and 360 days,” between covered screening colonoscopies, assures Rumisek.

Example: A 68-year-old established Medicare patient reports for a screening colonoscopy on Dec. 5, 2009. The patient’s records indicate that he last had a covered screening on Sept. 15, 1998. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

What ICD-9 Codes Are In Play for G0121?

Just one, provided there is no need for any therapeutic intervention during the colonoscopy. Medicare requires V76.51 (Special screening for malignant neoplasms; colon) on all G0121 claims. You might list other identified conditions secondarily, including diverticulosis (562.10) or hemorrhoids (455.0).

Always list the V code first for an average-risk screening, however.

What if the Patient Had a Recent Flexible Sig?

The frequency rules differ depending on whether other related...

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May 25, 2010
Anesthesia / Hot Coding Topics / ICD-9 / MAC

Unlock Pay With Anesthesia V Code Advice

Don’t be caught asleep: Patient history is one element of proper Dx coding.

Many coders hesitate to report V codes, or simply use them incorrectly, but sometimes this section of ICD-9 most accurately describes the reason for the patient’s condition....

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May 6, 2010
Hot Coding Topics / Medicare / Oig / RAC

Gastro Coders: Be Aware of Medicare Screening Reqs Or Risk Payment Denial

Following 10-year-rule eliminates G0121 rejection.

If you slip up on screening colonoscopy claims’ frequency guidelines and eligibility requirements, Medicare will pay you zilch.

Use this guidance to capture every screening dollar your gastroenterologist deserves.

Home in on Eligibility Requirements for...

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April 12, 2010
Coding Challenge / E/M

Is E/M Possible Pre-Colonoscopy?

Question: A local family physician refers a patient to our gastroenterologist for a diagnostic colonoscopy. The patient reports to the practice and meets the gastroenterologist for the first time. After answering some patient questions during a brief introduction, the gastroenterologist performs a diagnostic colonoscopy with brushing. The patient had never met the gastroenterologist before. Is the time he spent with the patient [...] Related articles:

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February 3, 2010
CPT 2010 / Hot Coding Topics / radiology

Celebrate CT Colonography’s 2010 Move to Category I

But don’t assume the new codes will yield improved fees. Virtual colonoscopy coverage may be a mixed bag, but the AMA showed some confidence in the service by moving its codes from temporary Category III status to full-fledged Category I in 2010. The switch from Category III to Category I does offer some hope of better reimbursement [...] Related articles:

  1. New CPT Codes for Cardiac CT, Imaging Appear for 2010Plus: Say goodbye to two perfusion codes. If you’ve ever...
  2. Virtual Colonoscopy Reimbursement: Still ‘Virtual’ For Now Many cancer clinicians are all for virtual colonoscopy because...
  3. Don’t Wait for CPT: Maximize Virtual Colonoscopy Payment Now Learn whether to file an ABN with 0066T, 0067T....

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November 30, 2009