Extenuating Circumstances – MedicalCodingNews.Org

10120 or Beyond: Site, Depth, Complexity Drive Códe Choice

Follow 3 pointers to snag maximum pay.

From just under the skin to deep within the bowels, your general surgeon might perform a foreign body removal (FBR) that calls on a wide range of coding know-how. Zero in on the right codè every time by implementing these four principles:

1. Use 10120-10121 for Any Site Under Skin

If your surgeon makes an opening to remove any foreign body, such as a glass shard or a metal filing, but doesn’t indicate an anatomic site or depth in the op report, you’ll probably choose 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). You can’t choose a more specific codè if the surgical report doesn’t provide any more documentation.

Caveat: Because the codè requires incision, look for a sharp object when considering 10120. If the documentation doesn’t include this detail, use an E/M service codè (such as 99201-99215, Office or Other Outpatient Services) instead of the skin FBR codè.

Look for complications: If the surgeon uses the term “simple” in the op note or fails to note any extenuating circumstances, you’re good to go with 10120. But the surgeon might perform a complicated FBR, meaning that the foreign body was harder than usual to remove. In these situations, the note should indicate, for example, extended exploration around the wound site, presence of a complicating infection, or sometimes the need to use visualization and localization techniques, such as x-ray. In those cases, you should choose 10121 (… complicated) for a subcutaneous FBR with no mention of anatomic site.

2. Search Musculoskeletal Codè for Specific Site

CPT® contains higher-paying FBR codè s than 10120-10121, but the surgeon needs to document the following two details before you can use the codès:

Location: You’ll find myriad FBR codès scattered throughout CPT®’s “Musculoskeletal System” section (20000-29999),...

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May 20, 2011

Coder's Cranium / General / Hot Coding Topics / Provider News

Overcome 3 Myths and Claim Reimbursement Opportunities using Modifier 22

Don’t fall for these common body habitus, time, and fee traps.

If you overuse Modifièr 22 (Increased procedural services), you may face increased scrutiny from your payers or even the Office of Inspector General (OIG). But if you avoid the modifièr entirely, you’re likely missing out on reimbursement your cardiologist deserves.

How it works: When a procedure requires significant additional time or effort that falls outside the normal effort of services described by a particular CPT® codè — and no other CPT® codè better describes the work involved in the procedure — you should look to modifièr 22. Modifièr 22 represents those extenuating circumstances that do not merit the use of an additional or alternative CPT® codè but do land outside the norm and may support added reimbursement for a given procedure. Take a look at these three myths — and the realities — to ensure you don’t fall victim to these modifièr 22 trouble spots.

Myth 1: Morbid Obesity Means Automatic 22

Sometimes, an interventional cardiologist may need to spend more time than usual positioning a morbidly obese patient for a procedure and accèssing the vessels involved in that procedure. In that case, it may be appropriate to append modifièr 22 to the relevant surgical codè. However, it’s not appropriate to assume that just because the patient is morbidly obese you can always append modifièr 22. “Modifièr 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, Manager of Compliance education for the University of Washington Physiciáns Compliance Program in Seattle.

“Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifièr 22 should not be appended,” warns Maggie Mac, CPC,...

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May 20, 2011

Coder's Cranium / modifier 52 / modifier 53

Modifiers 52 or 53? Prevent Denials By Making The Correct Choice

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:

43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the EDG
Modifier 53 (Discontinued procedure) to show that the GI discontinued the EGD.

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:

that the physician began the procedure;
why the procedure was discontinued;
the percentage of the procedure performed.

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...

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February 17, 2011

Coding Challenge / modifier 53

Oncology Coding: Determine the Proper Adverse Reaction Code

Remember to describe all the circumstances surrounding a push to get full reimbursement.

Question: If a non-Hodgkin’s lymphoma patient has an adverse reaction to Rituximab less than 15 minutes into the ordered hour-long infusion, should I report a push?

Answer: Experts suggest the most appropriate way to report a discontinued infusion is to append modifier 53 (Discontinued procedure) to the appropriate chemotherapy infusion code, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

You should use modifier 53 when a physician stops a procedure “due to extenuating circumstances or those that threaten the well-being of the patient,” according to CPT.

Modifier 53 describes an unexpected problem, beyond the physician’s or patient’s control, that necessitates ending the procedure. The physician doesn’t elect to discontinue the procedure as much as he is forced to do so because of the circumstances.

Push: CPT guidelines include “an infusion of 15 minutes or less” as one definition of a push, but 96413-53 describes the ordered and provided service more accurately than a push code (such as 96409, Chemotherapy administration; intravenous, push technique, single or initial substance/drug).

HCPCS: Your documentation should describe the circumstances, the administration start and stop times, and the amount of drug delivered and discarded. If you’re coding for the drug (J9310, Injection, rituximab, 100 mg), you should be able to report the entire amount, assuming you discarded the amount not administered.

ICD-9: Remember also to report the appropriate ICD- 9 codes, such as V58.12 (Encounter for antineoplastic immunotherapy) and 202.8x (Other lymphomas), and a code to indicate why the procedure stopped, such as V64.1 (Surgical or other procedure not carried out because of contraindication) or E933.1 (Drugs, medicinal, and biological substances causing adverse effects in therapeutic use; antineoplastic and immunosuppressive drugs).

Also watch for...

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June 3, 2010

Anesthesiologist / Hot Coding Topics / modifier 52 / modifier 53 / modifier 73 / modifier 74 / Pain Management

Employ Modifier 53 For Discontinued Anesthesia Services

Pain management specialties might make use of modifier 52 as well.

The situation is bound to happen: A patient undergoing surgery has complications, and your anesthesiologist must stop his services. Are you prepared to recognize a situation that calls for...

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May 9, 2010