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Reporting modifier 78 for a staged procedure? Expect denials.
When it comes to appending CPT® modifiers to your codes, the rules can be daunting, and Medicare’s regulations only compound the confusion. But if you’re up to speed on these key modifier billing practices, you’ll be raking in deserved pay.
Check out the following five tips to ensure that you aren’t missing any opportunities.
1. Don’t Avoid Modifier 26.
If your physician provides an interpretation and report for an x-ray or other radiological service in the treatment of a patient, that’s not always just part of his E/M—in some cases, you can separately bill for the interpretation and report by appending modifier 26 (Professional component) to the CPT® code.
Typically, the technologist that performed the patient’s x-ray will bill the code — such as 71010 (Radiologic examination, chest; single view, frontal) — with modifier TC (Technical component) to indicate that he is billing for the equipment, room charge, film and radiologic technician, but not for the physician’s interpretation. If the physician who renders the interpretation is with a separate professional group and is not a hospital employee, you should report the service with modifier 26 to obtain his proper share of the reimbursement.
2. Know the Difference Between Modifiers 58 and 78.
Because both modifier 58 and 78 describe procedures performed during another surgery’s global period, it can be easy to confuse them. But differentiating between the two can mean the difference between collecting your due and filing endless appeals.
Key: You’ll report modifier 78 (Unplanned return to the operating room for a related procedure during the postoperative period) when conditions arising from the initial surgery (complications) rather than the patient’s condition...
Keep your CCI edits in mind for PFT bundles.
When a patient presents with common respiratory conditions, your pulmonologist should perform an extensive history and examination, and may order several diagnostic tests before he can settle with a definite diagnosis to report in the claim. Along with the primary diagnosis (if achieved), you should report the patient’s signs and symptoms or else risk an audit.
Consider this scenario: The pulmonologist sees a patient for fever, shortness of breath, chest pain, weight loss, and fatigue. After undergoing a detailed history and examination, the patient becomes suspect for hypersensitivity pneumonitis, otherwise known as extrinsic allergic alveolitis (495.x). The physician orders a diagnostic bronchoscopy with fluoroscopic guidance, as well as a spirometry to verify the patient’s condition. To justify each service performed by the same provider or group, you might be accumulating payer inquiries or denials. This 2-step technique should carry you through potentially puzzling spirometry-E/M coding situations.
1. Don’t Leave Out Signs and Symptoms On Your Claim
First on your to-do list is to report the patient’s signs and symptoms. In this case, you would code 780.6 (Fever and other physiologic disturbances of temperature regulation), 786.05 (Shortness of breath), 786.50 (Unspecified chest pain), 783.21 (Loss of weight), and 780.79 (Other malaise and fatigue). Because these signs and symptoms resemble other respiratory problems, the physician performs a level four E/M and orders some diagnostic tests. Report the procedures with: 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) for the bronchoscopy with fluoroscopic guidance. Your physician is likely to perform this on a separate date. 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the pulmonary function test (PFT); and 99214 (Office...
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...
Boost your bottom line by reporting new annual wellness visits correctly. If you want your annual visit claims to be picture perfect in 2011, then follow these five tips to avoid future denials and keep your physician’s claim on the fast track to success.
Background: The Affordable Care Act (ACA) extended preventive coverage to more than 88 million patients covered by health insurance, and Medicare has codified that benefit in the form of an annual wellness visit. Medicare valued the new annual wellness codes based on a level 4, problem-oriented new and established E/M service.
The two new codes are:
G0438 — Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit
G0439 — Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit.
Tip 1: Apply G0438 to Second Year of Coverage
Be wary of applying these codes to new Medicare patients coming in to your physician’s practice in 2011. The reason is that Medicare will only reimburse the initial visit (G0438) during the second year the patient is eligible for Medicare Part B. In other words, during the first year of the patient’s coverage, Medicare will only cover the Initial Preventive Physical Exam (IPPE), also known as the Welcome to Medicare exam.
Tip 2: CMS Limits G0438 to One Physician
If your FP sees the patient for the initial visit (G0438) and the patient sees a different physician for the next annual wellness visit, that second physician will only receive reimbursement for the subsequent visit (G0439), despite having never seen the patient before.
Here’s why: CMS has indicated that when a patient returns to the same or new physician in a third year, they might only pay for the subsequent visit, says Melanie Witt, RN, COBGC, MA, an...
Correct Coding Initiative version 17.1 brings 11,831 new edit pairs, effective April 1 for physicians. That’s the word from a March 17 announcement by Frank Cohen, principal and senior analyst for the Frank Cohen Group. Here’s a look at the major pointers you need to keep in mind to comply with the new cardiology-related edits, including cardiac catheterization, radiological supervision and interpretation, cardiac rehabilitation, and more.
1. Prevent Denials by Remembering 93454-93461 Are Diagnostic
New edits will prevent you from reporting heart catheter/angiography codes 93454- 93461 (column 2) with the following cardiovascular therapeutic services and procedures (column 1):
The 929xx codes in column 1 describe coronary therapies. The 934xx codes in column 2 are diagnostic procedures. You should never use the 934xx diagnostic codes in column 2 to report catheter placement and coronary angiography performed as an integral part of the therapeutic column 1 services.
Opportunity: The edits have a modifier indicator of 1, so you may override them with an appropriate modifier when the procedures are distinct. If you report both codes in the edit pair and don’t append a modifier to the column 2 code, Medicare (and payers applying Medicare rules) will reimburse you for only the column 1 code.
The AMA, via CPT Assistant (April 2005), indicates that you may report a true diagnostic catheterization in addition to the therapeutic procedures described by 92980 and 92982: “These two distinct procedures (diagnostic catheterization and therapeutic procedures), therefore, should...
Facing denials on your tibial/peroneal codes? No worries, help is at hand.
The new tibial/peroneal service codes are below. Note that all of the codes include angioplasty in the same vessel when that service is performed.
The first four codes apply to the initial tibial or peroneal vessel treated in a single leg:
The final four codes are add-on codes that you use to report services on each additional ipsilateral (same side) vessel treated in the tibial/peroneal territory:
The general rule for the revascularization codes is that you should report the one code that represents the most intensive service performed in a single...
If you mistake modifiers 52 and 53 as one or the other because they’re both used for incomplete procedures, you’ll end up losing your reimbursement. Remember these two have extremely distinctive functions.
Consider a situation when the gastroenterologist performs an esophagogastroduodenoscopy (EGD) to examine the lining of the esophagus, stomach, and upper duodenum of a patient as part of a GERD evaluation.
Suppose that while inserting the endoscope, the patient registers unstable vital signs. The gastroenterologist, then, decides it is not in the patient’s best interest to continue the procedure. You would report this on your claim using:
Other situations that would call for a discontinued procedure include respiratory distress (786.09), hypoxia (799.02), irregular heart rhythm (427.9), and others usually related to the sedation medications.
Modifier 53 Defined: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances, or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.
In addition, you shouldn’t disregard the importance of submitting documentation that shows:
Taking on the same scenario, the gastroenterologist begins the diagnostic EGD but stopped without examining the entire upper gastrointestinal tract because she encounters an obstructing lesion in the middle of the stomach. In this case, you should attach modifier 52 to the CPT, says Margaret Lamb, RHIT, CPC, of Great Falls Clinic...