It’s every physician’s worst nightmare: Receive payment for services rendered, but then a payer identifies an aberrant pattern in claims data, audits the records, decides it has overpaid the practice,…
There are nine different Multiple Procedure indicators on the Medicare Physician Fee Schedule (MPFS), meaning there are a lot of payment adjustment possibilities you need to know. Here’s each indicator,…
Take a hint from a CPT®’s global period when choosing between modifiers 25 or 57
Contrary to popular thinking, modifier 57 does not apply exclusively for consultation codes only. Medicare may have stopped paying for consult codes, but this doesn’t mean you have to stop using modifier 57. Here are two tips on how you can use this modifier to suit your practice’s needs.
Background: Starting January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) eliminated consult codes from the Medicare fee schedule.
Non-Consult Inpatient Codes Keep Modifier 57 Alive
With CMS eliminated consult codes (99241-99245, 99251- 99255) for Medicare patients, you might have wondered if modifier 57 (Decision for surgery) would remain useful. The answer? You can still use this modifier for a non-consult inpatient E/M code, so long as your documentation supports it. This is because any major procedure includes E/M services the day before and the day of the procedure in the global period, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “The only way you can be paid properly for an E/M performed the day before the major surgery or the day of the surgery is to indicate that it was a decision for surgery (modifier 57), which also indicates to the payer that the major procedure was not a pre-scheduled service,” she explains.
Past: Say the pulmonologist carries out a level four inpatient consult in which she figures out the patient requires thoracoscopy with pleurodesis for his recurring, persistent pleural effusion (511.9). The physician decides to perform thoracoscopy with pleurodesis the day after the consult. In this case, appending modifier 57 to the E/M code (99254, Inpatient consultation for a new or established patient, which requires these 3...
Find out what colporrhaphy code you’ll use for an injury repair.
If you’re stuck trying to figure out what code to use for a vaginal cuff repair, you should ask yourself one main question: Why did the ob-gyn need to perform the repair? The answer is the best way to decide what code (and possibly modifiers) to choose. Follow these three expert steps, and you’ll find the solution to one of the most frequently asked questions in an ob-gyn office: “Which CPT® code should I use for repair of vaginal cuff?”
Q1: How Do I Decide What Repair Code to Use?
The first thing you should do when the ob-gyn performs a vaginal cuff repair is examine the operative report to determine why the patient required the repair, says Cindy Foley, Billing Manager for three separate gynecology practices in Syracuse, N.Y.
Q2: If Repair Dealt With Loose Sutures, What Should I Do?
You read your op notes and discovered the vaginal cuff repair dealt with loose sutures. Suppose the patient, who underwent a total abdominal hysterectomy (58150, Total abdominal hysterectomy corpus and cervix], with or without removal of tube[s],with or without removal of ovary[s]), needs to return to the operating room for a vaginal cuff repair because the original sutures became loose and a simple re-closure is documented. In this case, you should report 58999 (Unlisted procedure, female genital system [nonobstetrical]). You would also need to submit your op report along with a cover letter that explains in simple, straightforward language exactly what your ob-gyn did, says Melanie Witt, RN, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.
Remember to explicitly reference the nearest equivalent listed procedure in your explanatory note. For example, you might consider comparing the work to 12020 (Treatment of superficial wound dehiscence; simple closure), which...
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...
The new fifth-digit diagnosis codes for body mass index (BMI) can help you better document a patient’s condition, especially when the patient’s BMI might contribute to more complex risk factors for the anesthesiologist to handle. Having documentation of a high BMI doesn’t automatically lead to more pay, however. Watch two areas before assuming you can automatically append modifier 22 (Increased procedural services) because of BMI and potentially score a 20-30 percent higher pay for the procedure.
Not All Morbid Obesity Means Modifier 22
A patient is considered to be morbidly obese when his or her BMI is 40 or more. New BMI codes for 2011 include:
While morbid obesity can be an appropriate reason to report modifier 22, don’t assume you should always append the modifier just because the patient is morbidly obese.
Example 1: During surgical procedures that are performed because of morbid obesity (such as bariatric surgery), the patient must meet the morbidly obese criteria too support medical necessity for the procedure. In those type instances, simply having a patient who is morbidly obese doesn’t support using modifier 22. Remember, if you report a physical status modifier for a patient who is morbidly obese, it is not appropriate to also include modifier 22. Keep in mind that Medicare does not pay for physical status, qualifying circumstances, or extra work modifiers.
The anesthesia provider’s documentation should direct you to the correct BMI code as well as support when you can append modifier 22.
Example 2: The patient’s obesity might contribute to breathing problems that lead to lower oxygen and...
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...
This chart breaks down who is responsible for the charges: Modifier Did the patient sign the ABN? What does using this modifier mean? GA Yes The service is covered by Medicare only under certain circumstances. When you use this modifier, the pat...
Often a nurse or medical assistant helps a patient with an inhaler demo or evaluation, but whenever coding it, you must keep these three areas in mind: the type of device used, documentation requirements, and qualifying modifiers. Follow these four tips from our experts to understand why some payers might deny payment for the service — and what you can do to win deserved dollars.
1. Categorize the Diskus Correctly
Many physician offices use the Advair Diskus for their patients, which is an aerosol generator. “An aerosol generator is a device that produces airborne suspensions of small particles for inhalation therapy,” explains Peter Koukounas, owner of Hippocratic Solutions medical billing service in Fairfield, N.J. If the nurse or 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).
The physician 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. According to CPT guidelines, you should report 99201-99215 for the office visit (depending on whether you’re treating a new or established patient). Then report 94664, but don’t append 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.
CMS transmittal R954CP 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 have a global fee period. Code 94664 does not have a global fee period, which is why you don’t automatically include modifier 25.
Despite what CMS guidelines might...
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...
Question: Our physician x-rayed a patient’s symptomatic knee and ordered an x-ray of the other knee for comparative purposes. How should we report the comparison x-ray? Answer: Report the appropriate radiology code on two separate lines of your claim...
While you know for sure that you can report 91110 and 91111 for capsule study, but knowing just that is not enough to prevent your claims from being denied. We’ll tell you just when it is appropriate to report them and which modifiers to append.
Reporting a Repeat Procedure with 91110
Sometimes, your gastroenterologist would use a capsule study to image the intraluminal esophagus all the way through the ileum and reaching the colon. In this case, you should report 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report).
Let’s take an example. Patient comes in for a capsule endoscopy, but the capsule gets stuck in foodon hour five and visuals cannot be seen past the stomach. The gastroenterologist ends up repeating the procedure to see if she can see the small and large intestine.
First, you would code 91110 and then attach modifier 53 (Discontinued procedure) to indicate that the physician repeated the procedure. If the physician decides not to repeat the procedure, you should append modifier 52 (Reduced services) to reflect that the capsule imaged the patient’s anatomy until it became lodged in the food.
If you plan on repeating a capsule study due to technical problems, it is a good idea to pre-authorize payment for the second study with the carrier. You may need to provide records of the incomplete study.
CPT 91110’s descriptor clearly states the evaluation is from the esophagus to the ileum. The only time this won’t be true is when the gastroenterologist places the pill cam endoscopically for the study, says Joel V. Brill, MD, AGAF, chief medical officer at Predictive Health LLC in Phoenix. Again in this case, you should attach modifier 52 to 91110.
Know What ‘SB’ and ‘ESO’ Mean on PillCam...
When you come face-to-face with multi-provider situation, the last thing you would want is to mess up your coding by assigning the wrong modifier(s).
Imagine a 70-year-old female patient presenting with COPD and coronary artery disease, status post myocardial infarction (CAD s/p MI) having a 28 mm of inner diameter thoracic aortic aneurysm. Imaging studies indicate the aneurysm to be descending. The cardiologist, together with a thoracic surgeon, decides to perform an open operative repair with graft replacement of the diseased segment.
The main key in a multi-provider scenario is to treat each physician’s work as a separate activity. However, deciding when to report a case as co-surgery, assistant surgery — or something else — has more to it than meets the eye. Find out what with this expert’s advice.
You know that a modifier is at hand in this case, but more importantly you should be able to tell what role each modifier plays in order for your procedure codes to blend well together. Here are the most common modifiers used in multi-provider situations:
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2011 adds a new modifier to your coding arsenal and updates the descriptors for several others you might often use. Get ready for modifier GU (Waiver of liability statement issued as required by payer policy, routine notice). You might have times when ...
Make the transition to new iliac revascularization codes a little simpler by using this chart. Be sure to read “37220 to +37223 Revamp Your Iliac Intervention Coding Options” on the cover to get more information on these new codes. Use the appropri...
Question: Sometimes I cannot find my two-code pair in the CCI edits. How do I know which code would be considered a column 1 code and which would be considered a column 2 code, so that I could put my modifier on the correct code?
Answer: If the codes are not listed, the codes are not bundled per the Correct Coding Initiative (CCI). You would not need a CCI modifier, such as 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), 57 (Decision for surgery), or 59 (Distinct procedural service), to override the edit when appropriate.
A private payer could have a black box edit. You would need to check with a rep for a recommendation.
Watch out: Just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. While you won’t need a CCI modifier to override the edit, you might need apayment modifier.
You can find Medicare’s other allowed modifiers for any given CPT code in the Medicare Physician Fee Schedule (MPFS). Columns Y-AC indicate if modifier 51 (Multiple procedure), 50 (Bilateral procedure), etc. apply.
To determine which code receives modifier 51, you need to know the code’s relative value units, which are also listed in the MPFS. Private payers may not adjust claim items in descending order as Medicare’s Outpatient Code Editor software does. If you append modifier 51 to a higher valued item, the private payer may apply the adjustment based on your coding, costing you payment. You should instead list the items in descending relative value order from highest to lowest. Append modifier 51 to the lower priced procedure as necessary. The insurer will then apply the typical 50 percent,...