Apply 722.8x Series for Failed Back Syndrome Diagnosis

Question: What diagnosis applies to "failed back syndrome"?

Michigan Subscriber

Answer: Check with the physician, but your best option is probably a code from 722.80-722.83 (Postlaminectomy syndrome), depending on the location. This descriptor doesn't specify failed back syndrome, but some carriers (such as Empire Medicare Services) include "failed back surgery syndrome" in the 722.8x series.


- You Be the Coder and Reader Questions were answered by Margaret Lamb, RHIT, CPC, anesthesia coder with Great Falls Clinic in Great Falls, Mont. 

Optimize Payment by Knowing When to Use Modifier -59 vs. -51

Modifier -59 (distinct procedural service) is often appended incorrectly or overlooked in favor of modifier -51 (multiple procedures). In the ob/gyn or any specialty setting, this can result in denied claims and lost revenue.

Modifier -59 essentially unbundles procedures. It is the coders and the physicians way of saying to the carrier, Yes, I know procedure B is normally bundled into procedure A, but take a look at this case, which justifies additional reimbursement for additional work done. If the physician can show through his or her operative notes that a distinct procedural service occurred, many commercial carriers will honor the modifier and pay for the additional procedure.

Dont Confuse -59 With Multiple Procedures

Modifier -59 is easily confused with -51. The difference is that -51 is used for procedures that are not normally bundled, but are stand-alone procedures. The -51 modifier simply acknowledges to the carrier that you performed multiple services on the same day and that you anticipate a reduction in fees (generally 50 percent on the second procedure, more on subsequent procedures). Use modifier -59 when you are trying to say that the additional procedure (which is normally an integral part of another procedure performed that day) was distinct and should be allowed to be billed and paid separately.

CPTs rules on modifiers clarify the distinction between the two. Modifier -59 is appended when the procedure identified by CPT as a separate procedure involves:

A different session or patient encounter;

A different procedure or surgery;

A different site or organ system;

A separate incision/excision;

A separate lesion; or

Treatment of a separate injury (or area of injury in extensive injuries).

Modifier -51 indicates multiple procedures that would not normally be bundled together anyway, and is used when:

Multiple medical procedures are performed at the same session by the same provider;

Multiple, related operative procedures are performed at the same session by the same provider;

Operative procedures are performed in combination at the same session, by the same provider, whether through the same or another incision or involving the same or different anatomy; or

A combination of medical and operative procedures is performed at the same session by the same provider.

An Ob/gyn Vignette Using -59

The following ob/gyn scenario, offered by Melanie Witt, RN, CPC, MA, an independent ob-gyn coding educator, illustrates the proper use of modifier -59.

781.99 Is Best Sensory Integration Disorder Choice

Question: What diagnosis should we submit for sensory integration disorder?

Nevada Subscriber

Answer: Sensory integration disorder is not a recognized diagnosis in ICD-9, so the most accurate choice is 781.99 (Other symptoms involving nervous and musculoskeletal systems).


Also known as sensory integration dysfunction, SID is a neurological disorder that results from the brain's inability to integrate certain information received from the body's five basic sensory systems. Physicians often detect SID in young children. Signs can include (but are not limited to) oversensitivity to touch, movement, sights, or sounds; a tendency to be easily distracted; an activity level that is unusually high or unusually low; difficulty in making transitions from one situation to another; and delays in speech, language, or motor skills or academic achievement.

Look to 726.4 for Intersection Syndrome

Question: Which diagnosis code should I use if the surgeon documents "intersection syndrome" of the wrist?

California Subscriber
 
Answer: Intersection syndrome is an overuse syndrome of the wrist, during which the patient
has pain at the intersection of the abductor pollicis longus and extensor pollicis brevis tendons. The American Society for Surgery of the Hand recommends that practices report 726.4 (Enthesopathy of wrist and carpus) when the physician documents intersection syndrome of the wrist.

Clarification: MRI and MR Arthrography of the Shoulder

Last months article, How to Code Arthrographies for Increased Pay Up, on page 62 was missing information intended to clarify the differences between the magnetic resonance imaging (MRI) and magnetic resonance (MR) arthrography of the shoulder, when each is used and how each should be coded.

The two procedures are similar and are used to determine conditions and diseases of the shoulder region, specifically for evaluation of the soft tissue (like ligaments, cartilage, tendons and muscles, rotator cuffs, and so forth). The biggest difference between the two is the contrast injection.

During an MRI with contrast, the medium is injected intravenously and images are taken to show the enhancement of the structures in the limb, explains Ellen Ratnofsky, RN, BSN, CS, of Healthcare Administrative Partners Inc., which provides medical billing and practice management services in seven states. MR arthrography of the shoulder, however, would include an intra-articular injection of contrast, usually gadolinium. In other words, the agent is delivered directly into the cavity of the joint. The injection often is aided by fluoroscopic guidance to ensure that the needle is positioned correctly. This is then followed by an MRI study.

A standard MRI with contrast typically is reported using CPT 73220 (magnetic resonance [e.g., proton] imaging, upper extremity, other than joint), Ratnofsky says. A diagnosis code that could be associated with an MRI of the shoulder is ICD-9 171.2 (malignant neoplasm of connective tissue of upper limb, including shoulder).

The MR arthrogram would be assigned codes 23350 (injection procedure for shoulder arthrography) for the shoulder injection , followed by the MRI code 73221 (magnetic resonance [e.g., proton] imaging, any joint of upper extremity). Fluoroscopic guidance, if used, would be coded 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]). It frequently is conducted to diagnose problems with the rotator cuff, i.e., 726.10-726.19 (rotator cuff syndrome of shoulder and allied disorders) and 840.4 (sprains and strains of shoulder and upper arm; rotator cuff [capsule]).

Ratnofsky adds a cautionary note to Radiology Practices using MR arthrography. In many areas it is considered investigational. Coders should check with local carriers at least once every year and ask that requirements and guidelines for these studies be provided in writing.

Although some practices may have radiologists conduct MR arthrography, others rely on the technologists to perform the injection. In addition, the concerns about radiation and adverse reactions to contrast agents with MRIs that were stated are not universally accepted.

Reader Question: Acoustic Neuroma

Question: Our radiologist performed a CT of the head without contrast. The diagnosis is suspected acoustic neuroma, which, to my understanding, is an acceptable code for this procedure. We thought we should code first for suspected condition (V71.8, observation and evaluation for suspected conditions not found; observation for other specified suspected conditions) and then for the acoustic neuroma (225.1, benign neoplasm of brain and other parts of nervous system; cranial nerves). How can I report this diagnosis?

Maggie Kissinger
Diversified Billing, Lafayette, Calif.

Answer: You should refrain from using a V-code as a primary diagnosis, if possible. Many insurers do not recognize V-codes, and some even consider them as routine and not payable. Instead, you should code the signs or symptoms the patient presents to the physician that prompted the physician to suspect acoustic neuroma. Many of the symptoms represent a covered diagnosis as well.

You also should refrain from coding the acoustic neuroma without being certain that the patient definitely has this condition. Insurers build a file based on the patients submitted diagnosis codes, so you dont want to document a condition that the patient does not have it will be recorded in his file permanently.

You Can Use Congenital Echo For Any Anomaly ...

even if of little clinical value
Do the results of a regular echocardiogram show a congenital anomaly? If so, use congenital codes. But if your cardiologist looks for a congenital anomaly and finds nothing, revert back to the normal echo codes.
How a Normal Echo Becomes a Congenital Echo
If your cardiologist does not know that a congenital anomaly exists until he performs the normal echocardiography, you can change your focus to congenital codes 93303, 93304, 93315-93317 as appropriate.

Keep in mind: This rule remains true even if your cardiologist finds a congenital abnormality with little or no clinical significance. You should still report the congenital echocardiography codes. 

Example 1: A cardiologist sets out to perform a normal echocardiogram to assess an 89-year-old patient's murmur (785.2, Undiagnosed heart murmur). The echocardiography reveals a tiny muscular VSD (745.4, Ventricular septal defect). Although the cardiologist deems the VSD clinically insignificant, you should still use the congenital echocardiography codes.

Example 2: A cardiologist performs an echo on a patient and discovers a patent foramen ovale (PFO) that does not warrant any treatment. In this case, you would still use the congenital echo codes (93303, 93304, 93315-93317). "Even though the PFO is likely to close, it's still a congenital heart defect and therefore a congenital echocardiogram exam," says Elizabeth Crawford, technical director of the echo lab, Children's Hospital, Boston.
No Evidence of Congenital Heart Disease, Then Normal Echo
When a patient undergoes an echocardiogram and the results do not point to congenital heart disease, you should not report the congenital echocardiography codes. You will not have justification. 

For example: If your cardiologist suspects congenital heart disease because a physician detected a heart murmur in a newborn baby or the patient's family history suggests that a congenital anomaly might be present, he might order a congenital echocardiogram. 

If the results do not reveal anything congenital, you must report the normal echo codes (93307, 93308, 93312-93314). 

"You have all the appropriate clinical indications for performing the echo. It's just that you didn't find anything that was a congenital condition," says Sheldrian LeFlore, CPC, senior consultant with Gates, Moore & Company in Atlanta.

"If we find nothing, we find nothing," Crawford says. "Even if the patient has a full exam but does not have anything congenital - like our heart transplant patients - they are not congenital exams; we know they don't have congenital heart disease." 

So you would report the normal echo codes (93307, 93308, 93312-93314).

Reader question: Tinnitus Coding

Question: The internist documented "ringing in head" for a new patient. What diagnosis code applies?


Oklahoma SubscriberAnswer: Submit the best-fitting choice from 388.3x (Tinnitus). The fifth-digit options describe unspecified, subjective (when only the patient hears the ringing sound), and objective tinnitus (when the physician and patient can both hear the ringing sound). Include an additional code for the external cause, if applicable, to identify the reason for the ear condition (such as E928.1, Exposure to noise, for long-term exposure to loud factory noise).Explanation: Although your internist documented ringing in the head rather than ringing in the ear, both perceptions apply to tinnitus. The ICD-9 notation with 388.3x states "Perception of sound in absence of external noise and may affect one or both ears and/or head."

What are HCPCS codes?

Coding professionals are also required to use HCPCS (Healthcare Common Procedure Coding System) Codes to describe any service that a medical practitioner may provide to a Medicare patient. These codes are constantly monitored by the Centers for Medicare and Medicaid Services (CMS).
The HCPCS is divided into two subsystems, known as level I and level II of the HCPCS.

Level I codes of the HCPCS are based on and are similar to the CPT® (Current Procedural Terminology) codes.  The coding system (consisting of 5-digit numeric codes) is developed and maintained by the American Medical Association (AMA).


Level II of the HCPCS is used to describe products, supplies, and services that are not included in the CPT® codes, such as ambulance services and medical equipment, prosthetics, and supplies especially when they are used outside the physician’s office. To report the services and supplies that are not covered by CPT® codes, coders can use level II HCPCS codes. Level II HCPCS codes are also known as alpha-numeric codes as they are made up of a single letter plus 4 numeric digits.

Level II codes do not generally define the costs that were incurred by a physician’s office and hence are dealt differently by Medicare or Medicaid.

The HCPCS Level II was developed and came into use in the 1980s. Later on, in 2003, the Secretary of Health and Human Services (HHS) assigned an authority under the Health Insurance Portability & Accountability Act of 1996 (HIPAA) legislation to CMS to maintain and distribute HCPCS Level II codes. This code set is revised quarterly on the basis of feedback from the general public, providers, healthcare products manufacturers, vendors, etc.


It is interesting to note that the CPT® codes may crosswalk to HCPCS codes, but there is no equivalent for HCPCS in the ICD (International Classification of Diseases) manual.

What are CPT® codes?

CPT® stands for Current Procedural Terminology, and they are five-digit numerals that describe the procedures or services that the physician (or other healthcare provider) provided to the patient. These may include office and hospital visits, surgeries, x-rays, lab tests and home health services.

Sometimes it takes more than one code to describe what the physician actually did for the patient, and other times it takes additional two digits (a modifier) appended to the CPT® code to describe the service.


CPT® codes have been around since Medicare was established and are updated every year by the AMA. The AMA adds new CPT® codes for medical services, procedures, diagnosis, equipment, etc. every year as new procedures develop and standards of medical care change. It is for this reason that it’s called Current Procedural Terminology. Some other codes are deleted as procedures become obsolete. It thus becomes extremely important for medical practices to get a new CPT® manual each year.

Why use CPT® codes                     
CPT® codes are used in the healthcare sector mainly to:

• identify symptoms that must be diagnosed and to inform other healthcare professionals about allergies
• report services performed by a physician or surgeon and to get reimbursed by the Medicare or other insurance payers
• plan for service requirement in underserved areas

Consultation Codes are Back: CPT® 2014 Introduces 4 New Consultation Codes

Interestingly, four new codes have been added that describe the work of two medical professionals who discuss a patient’s condition over phone or Internet.

A few years ago, Medicare and other carriers stopped recognizing consultation codes. But all that is about to change as CPT® 2014 has added four new consultation codes with effect from January 1, 2014.
So from the first day of the New Year, if two medical professionals discuss a patient’s condition via phone or internet, you’ll report the following codes:

• 99446 – Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
• 99447 – … 11-20 minutes of medical consultative discussion and review
• 99448 – … 21-30 minutes of medical consultative discussion and review
• 99449 – … 31 minutes or more of medical consultative discussion and review.

These codes are more likely to be used for complex or urgent cases where the situation makes it difficult for the consultation to provide a face-to-face service, reads CPT® 2014 guidelines. For example, the consultant may be located far away.
Questions related to time
Coders need to be alert to:

• Why these codes are broken into time
• How that time will be measured (reading, discussing, interpreting, further research, etc.).
• How will the time be documented
• Will it be documented

Tips you’d like to make note of:

• For consultations less than 5 minutes, avoid using these codes
• Major part of the service time reported (more than half) must be devoted to the medical consultative verbal/Internet discussion.
  • The consult includes review of related medical records, path/lab studies, imaging, medications, and similar date.
  • A single code covers all contact time and review time, so add together and calculate the total time spent when multiple calls/internet contacts are performed for a single consult.

The earlier you’re up to speed on the 2014 CPT^® changes, such as the above-mentioned new codes for inter-professional consultations, the more likely for you to see fewer payment delays for those services. An online tool like SuperCoder’s Fast Coder can help you get 2014 CPT^® code details instantly – including new, revised, and deleted codes. The easy-to-use tool will help you get:

• Essential instructions from CPT® coding guidelines
• Upcoming and historical Info for the CPT® code(s) and/or keyword(s) entered
• The Coding Institute’s written simple explanations containing CPT® codes or keywords searched
• All personal notes for the CPT® code entered and all personal notes containing the code(s) and/or keyword(s) entered.
• And much more.

Append 76 for Multiple Nebulizer Treatments

Question: A patient with acute asthma requires three same-visit nebulizer treatments to control his asthma. Should I bill 94640 and J7613 multiple times, one time, or one time with a modifier for each additional treatment?

Washington Subscriber
Answer: When a patient receives multiple aerosol treatments on the same date, you should use 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) for the first treatment.

Catch: Subsequent treatments will require modifier 76 (Repeat procedure by same physician), according to CPT.

Therefore, you would code the example of three nebulizer treatments as:
 
 94640 - first treatment
 
 94640-76 x 2 - two subsequent treatments.

For the inhalation solution, you should report three units of J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg). Because J7613 represents one "unit dose," you should report per nebulizer treatment or, in your case, J7613 x 3. If the internist meets the criteria for reporting an E/M code, you should report the appropriate-level E/M code (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient ...) as well.

If the physician performs and documents a significant, separate E/M from the treatment (94640), append the E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). 

Water Down These Hydration/Injection NCCI 12.0 Edits

Hint: Look to modifier 25, not 59, to bypass E/M and injection edits
When your ob-gyn provides hydration or injection services, you should count that as part of the surgical procedure. The National Correct Coding Initiative (NCCI) version 12.0 strikes at the following new hydration and injection codes:

- C8950 -- Intravenous infusion for therapy/diagnosis; up to 1 hour

- C8951 -- -each additional hour

- 90760 -- Intravenous infusion, hydration; initial, up to 1 hour

- +90761 -- -each additional hour, up to 8 hours (list separately in addition to code for primary procedure)

- 90772 -- Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

- 90774 -- ... intravenous push, single or initial substance/drug

- +90775 -- -each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure).

In a nutshell: These new hydration and injection codes have been added to all surgical procedures. That means you shouldn't report the hydration, IV push or diagnostic injection separately from the surgery -- unless your documentation meets the criteria for supporting the use of a modifier (such as 59, Distinct procedural service).

Red flag: -With the addition of the new and renumbered injection codes, coders need to be aware that all of the E/M service levels have been bundled into each of them (such as, 90760-90775),- Witt says. This means that if you did not use an -approved- modifier to bypass the edit and bill both, payers would reimburse only the injection code, not the E/M service.

Keep in mind: You can use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to bypass an NCCI edit anytime your ob-gyn performs a procedure as well as an E/M visit -- but this modifier goes only on the E/M code, Witt says. -This is why when NCCI bundled 99205 into 90772 and gave this edit a modifier indicator of 1, you can use modifier 25 on 99205 to bypass this edit.-

Medicare has indicated that although a physician may be able to make a case for billing the intramuscular injection code with a higher-level E/M service (it would have to be separate and significant from the injection), you should never bill both when the E/M level is only 99211. For this reason, the bundling indicator assigned to 99211 is -0.-

Here’s How to Report History of Chlamydia

What diagnosis code should I report for a history of Chlamydia?

You should report V13.29 (Personal history of other diseases; other genital system and obstetric disorders; other genital system and obstetric disorders) or V13.02 (Personal history, urinary [tract] infection), as Chlamydia can cause urinary tract infections. Be on the lookout: As neither of these codes is very informative, the ICD-9 staff will put this issue on the agenda for discussion at the next Coordination and Maintenance Committee meeting to perhaps develop a V code just for this. Keep watching The Ob-gyn Coding Alert  for the latest information. ICD-10: When ICD-9 becomes ICD-10 in 2013,you'll report Z87.49 (Personal history of other diseases of the genitourinary system) instead of V13.29 and Z87.41 (Personal history, urinary [tract] infection[s]) instead of V13.02.

Examine Ovary Along With Dermoid Cyst Removals

:What CPT code should I report for the removal of a dermoid cyst via a laparoscope?

You need to carefully read your ob-gyn's op and pathology report. You would report 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) if the ob-gyn removed no part of the ovary with the cyst. On the other hand, you would report 58661 (... with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]) if the ob-gyn removed part of the ovary along with the cyst.

58720: Make Use of Modifiers LT, RT

My ob-gyn performed an exploratory laparotomy, partial left salpingectomy, left oophorectomy, right ovarian cystectomy. I billed with 58720 and 58925-51, but the insurance company only paid for 58720. What did I do wrong?

You should have added modifier LT (Left side) to 58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral [separate procedure]) and modifier RT (Right side) to 58925 (Ovarian cystectomy, unilateral or bilateral). This lets the payer know your ob-gyn performed these procedures on two different sides.The Correct Coding Initiative (CCI) does not bundle these codes, but notice how 58720's descriptor does include "separate procedure." This might have caused payer problems.Also, you should have billed 58925 first, because it has higher relative value units (RVUs) than 58720.

Don't Lose Sleep Over Medicare's New 99211 Rule

Why you'll now get paid for both 90780 and an E/M

Although you can expect your reimbursement to increase now that Medicare will pay for 99211 in addition to drug administration codes (90780-90788), make sure you code with caution -- CMS still will not let you report the codes together.

In the 2004 Medicare Physician Fee Schedule, which took effect Jan. 1, CMS adds 0.17 relative value units (RVUs) to therapeutic infusion and injection codes 90780-90788. The RVU increase equals the RVUs for E/M code 99211 (Office or other outpatient visit for the E/M of an established patient ...). Therefore, Medicare considers 99211 included in the codes when you bill them on the same day.
Pick Up an Extra $21
Because infusion and injection codes (90780-90788) now include the same RVUs as 99211, you will get paid for an infusion or injection and E/M service every time you report 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) or 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular).

The bottom line: You'll now pick up the national average of $21 that 99211 pays when you submit codes 90780-90788.

Previously, most allergy practices didn't bill 99211 on the same day as 90780-90788 because Medicare considers the E/M service included in the procedures.

"I cannot think of a situation in which there would be a significantly separate service that would be provided by a nurse during the administration of an injection or infusion," says Bruce Rappoport, MD, CPC, who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.

Watch Out for Modifier -25
In the rare case that a practice bills for 90780-90788 in addition to a higher-level office visit (for example, 99212), coders should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, according to CMS transmittal 34, dated Dec. 24, 2003.

Red flag: Remember that you can bill only a physician's service, not the nurse's, with a 99212 or higher, says Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla. Also, Medicare would most likely pay only for the E/M code, not the infusion or injection code.

ICD-9 & CPT code for feeding difficulty

You should bill (99211-99215, Office or other outpatient visit for the E/M of an established patient, usually the presenting problem[s] are minimal;

Watch out: If your group had not previously treated the infant in any location, you would use the new patient office visit codes (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient …).

Link the office visit code to the infant’s problem(s). Some applicable ICD-9 codes you can report for the baby include:
-------------------------------------------------------------------------------------------------------------------
Pediatric Coding Corner: 4 Tips Ensure Success in Coding Feeding Problems for 2010
Use expanded 779.3x to describe newborn issues.
Brings an expanded 779.3x (Feeding problems in newborn).

• 779.31 (Feeding problems in newborn): Feeding problems can be broadly categorized as underfeeding and overfeeding. Underfeeding results from the infant’s failure to take sufficient amounts of milk. Oftentimes, family physicians spot this problem when there is a failure to gain weight appropriate for their age or when the mother notices that their infant suckles infrequently or for only short periods of time. Overfeeding results from supplemental foods and therefore is not a problem in the perinatal period.

• 779.32 (Bilious vomiting in newborn): Bilious vomiting is vomiting of gastric contents containing bile, often described as greenish vomitus.

• 779.33 (Other vomiting in newborn): Vomiting is the complete emptying of the stomach contents often occurring after feeding.

• 779.34 (Failure to thrive in newborn): This occurs when an infant’s physical growth as measured by his weight and height is significantly below the average for his age group.

Most of these conditions were previously lumped under 779.3. These changes make the coder’s job much easier. “The more specific the codes, the better for all,” says Gwenn S. O’Keeffe, MD, CEO and founder of

Incorporating these new codes into your practice will be a breeze with four easy tips:

1: Use 779.31, 779.34 for Follow-Up Visit Problems
Remember that follow-up visits after a hospital discharge are not necessarily well visits. After a newborn has been discharged from the hospital, “we always do a two- to three-day follow-up visit,” notes Charles Scott, MD, FAAP, a pediatrician at Medford Pediatric and Adolescent Medicine in New Jersey.

Family physicians make use of this visit to evaluate the presence of any problems a newborn may have, and commonly, this will include feeding problems. For example, during a visit, the mother relays to the FP that her infant seems to have difficulty latching onto her nipple. Code 779.31. Likely in this case, the FP will spot low birth weight gains. Therefore, also code 779.34.

2: Distinguish Between Regurgitation, Vomiting

Regurgitation means retuning small amounts of swallowed milk shortly after or while feeding. Compare this to vomiting, which is the complete emptying of stomach contents. Although regurgitation is a natural occurrence during the first months of life, it often makes new parents worry.
Example: During an office visit, a mother tells the FP that she is worried when she notices small amounts of milk coming from her infant’s mouth after feeding. There is no specific code for regurgitation in the ICD-9-CM.
In the ICD-9-CM 2009 index to diseases, the listing for “regurgitation” leads to the code for vomiting alone (787.03). Using the new 2010 codes, here are three possible scenarios:
1.If the FP documents the mother’s observation as newborn vomiting, consider coding it as 779.33 in 2010.
2.Use 779.31 if documentation indicates it’s a feeding problem.
3.If the FP otherwise considers it a normal part of being a newborn, then no code is necessary.
3: Reserve 799.34 for Newborn Period
ICD-9 codes 760-779 are for conditions which have their origins in the perinatal period only, which occurs before birth through the first 28 days after. Look to codes outside this section for similar conditions for older patients.
Example: An FP notes that a 1-month-old (30 days) infant has low weight gain. On evaluation, the FP finds the infant to be below the normal average weight for his age.
The FP diagnoses failure to thrive.
In this case, 783.41 would be the appropriate code. Code 779.34 is for newborns 28 days old or younger.
4: Code for the Specific Disease if Applicable
When the FP specifies obstruction as a diagnosis, there may be no need to use 779.32. Bilious vomiting is inherently a part of intestinal obstruction and is the hallmark sign of the presence of intestinal obstruction.
Example: Three days after delivery, a newborn had vomiting of greenish gastric secretions and was feeding poorly. The FP who evaluates her gives a diagnosis of intestinal obstruction. Code this as:
• 751.1 -- Atresia and stenosis of small intestine
• 779.31 -- feeding problems in newborn.

What CPT code would i use for an excisional biopsy of a duputyren band on the finger?

Watch your surgeon's documentation for clues regarding partial or complete treatment and the number of digits involved, and you'll be on your way to clean Dupuytren contracture release claims every time.

What happens: Dupuytren contracture release involves excising contracted fibrotic bands of the palmar fascia. Surgeons can either use a standard open incision with fasciectomy (known as the McCash technique) or percutaneous fasciotomy (known as the Luck technique). Here's how to break down these techniques into coding realities.

Fasciotomy Can be Open or Percutaneous
If the surgeon completes fasciotomy to treat Dupuytren's contracture (728.6, Contracture of palmar fascia), check the operative notes for whether he used an open or percutaneous approach. Then, choose between 26040 (Fasciotomy, palmar [e.g., Dupuytren's contracture]; percutaneous) or 26045 (... open, partial) and report the correct code for each finger the surgeon treats.

Extra codes: Your orthopedist can perform percutaneous or minimally invasive treatment of Dupuytren's contracture in an office setting, which means you'll need to report additional codes. Report 26040 for the procedure, along with the appropriate E/M choice. Because of the work involved, your most likely options are 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

The most common type of percutaneous treatment is needle aponeurotomy, or NA. The physician uses the tip of a hypodermic needle as a very small knife to divide the contracting cords of Dupuytren's disease.

Count Digits With Fasciectomy
Your surgeon might opt for fasciectomy to treat more extensive cases of Dupuytren's contracture. Base your codes on whether he completes a palm-only procedure or also accesses the digits:
26121 -- Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft)

26123 -- Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft).

When reporting 26123, append +26125 (... each additional digit [List separately in addition to code for primary procedure]) as needed. Code "26125 is an add-on code required to identify each additional digit," CPT directs you to report +26125 with 26123. Because 26121 applies to palm-only procedures, you don't need codes specifically for digits.

Tip: When coding these cases, you're looking at "otomy" versus "ectomy. "If coders will watch for the wording, they'll know which codes to use.

Use Office Visit Code for Bee Sting Counseling

The mother of a 10-year-old patient who is allergic to bee stings wants to consult with our allergist without the child present. No physician referred her. The consultation will last more than 45 minutes. Which CPT code should I use for the consultation?
Answer: You should report this service as an office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...), not a consultation (99241-99245, Office consultation for a new or established patient ...). To report 99241-99245, CPT requires another physician or other appropriate source, such as a school nurse or social worker, to request your allergist's opinion. And, the allergist must send a written report of her findings to the requesting party.

Although the scenario doesn't meet CPT's consultation criteria, you may report the visit based on time. When counseling accounts for more than 50 percent of a patient and/or family encounter, you should consider time the key factor in selecting the appropriate E/M service level.

In your example, the allergist spends 100 percent of the 45-minute visit counseling the mother about her concerns. Therefore, you should report 99215 (... physicians typically spend 40 minutes face-to-face with the patient and/or family) for an established patient.

How Can You Report Tube Removal?

Question: A physician in another city placed a laparoscopic jejunostomy tube one month ago. A second physician, locally, attempted to remove the feeding tube in his office, but it broke off. Our surgeon then attempted to remove the broken portion in the office, he but failed and had to schedule a trip to the operating room. My surgeon has suggested 43760 for this. Is this correct?

Florida Subscriber

Answer: Code 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance: APC 0121) describes removal and replacement of a gastrostomy tube, which has not occurred in this case. Rather, your surgeon only removed a portion of the feeding tube.

CPT does not contain a specific code to describe removal only of a feeding tube. Generally, the physician would include the tube removal in any E/M service he provides at the same time. In this case, however, you might argue that 43760 with modifier 52 (Reduced service) is appropriate.

Assuming that he removed the broken portion of the feeding tube endoscopically, your best bet in this case is more likely a code for foreign-body removal, such as 43215 (Esophagoscopy, rigid or flexible; with removal of foreign body: APC 0141).

43246 Includes Removal

How should we bill for an EGD with PEG removal?

The correct code for an esophagogastroduodenoscopy (EGD) with removal of a percutaneous endoscopic gastrostomy (PEG) tube is 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube).

The procedure you describe involves your surgeon replacing a feeding tube that runs through the patient's skin straight into the stomach. The removal of the old PEG tube is incidental to its replacement, so you only need the one code.

44238 Captures Lap Intestinal Hernia Repair

If the surgeon performs a laparoscopic release and repair of an incarcerated internal hernia of the small intestine, should I bill an unlisted code such as 49659?

You should use an unlisted code, but the better choice is 44238 (Unlisted laparoscopy procedure, intestine [except rectum]) instead of 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy).

That's because the lap hernia codes (49650- 49659) describe laparoscopic repair of hernias in the abdominal wall. The situation you describe involves an internal hernia in the small intestine, and CPT does not provide a specific code for that service.

Option:If your surgeon performed an open release and repair of an incarcerated internal hernia of the small intestine, you would still use a code that involved the "intestines." Your choice for an open procedure would be 44050 (Reduction of volvulus, intussusception, internal hernia, by laparotomy).

238.2: Code Original Excision Dx

If patient comes for the re-excision of a dysplastic nevus. Do I bill the re-excision using a benign or malignant ICD-9?

Follow this to do this properly.

Check pathology report from the original biopsy and make sure it states "dysplastic nevus." If biopsy showed a dysplastic lesion, then the diagnosis is benign, and you should report the diagnosis as 238.2 (Neoplasm of uncertain behavior of skin).

With that diagnosis, you should code the re-excision using a code from the series 11400-11446 (Excision, benign lesion ...) based on lesion's site and size.Important:

If you have a previous malignant lesion diagnosis and the surgeon performs a re-excision because there was a concern about clear margins from the first excision, use the original diagnosis code and the same family of lesion excision codes, even if the pathology subsequently comes back as benign.

Catch Up Your Outpatient Edits to CCI 18.0

Counting on version 17.3 will put you behind.
If you're used to ignoring new CCI edits for the Hospital Outpatient Prospective Payment Systems (OPPS) because the implementation date lags by a quarter -- don't count on it.

Here's why: CMS has announced that the outpatient code editor (OCE) version 18.0 will include the OCE version 17.3 and the new version 18.0, both of which will be implemented at the same time on Jan. 1.

That means you'll need to code according to CCI version 18.0 for inpatient and outpatient billing starting Jan. 1, or face denials.

Describe Abnormal Feces Fluidity With 787.91

A patient says she has had chronic bowel problems for the last 10 years, with diarrhea or loose stool for two to three days in a row, then constipation for another week. Diagnostic tests are being ordered. Because the diagnostic tests are only covered for certain conditions, what diagnosis should be listed? Since this has been her way of functioning for so long, it cannot be considered a change in bowel habits.

Colorado Subscriber Answer: Your ICD-9 report should include: 787.91 (Diarrhea), which describes the patient's abnormal frequency and fluidity of feces. This ICD-9 does not specify chronicity but best describes her symptoms with a code that should justify testing to rule out conditions which can cause similar bowel patterns and that can be treated.

Separate Documentation Keys Modifier 25 Coding

Having trouble with my modifier 25 coding, specifically with documentation to prove a separate E/M service. What documentation should look for to report modifier 25?

- When you are coding an encounter during which the physician provides an E/M service and performs another procedure, you should separate the documentation  and make sure there are two distinct processes. If you follow this documentation advice, your accuracy should improve on claims containing modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

When examining the E/M documentation, make sure you have the history, exam and medical decision-making in the patient's chart. Also, be sure you have documentation to show the E/M service's distinct nature. For the procedure note, make sure it includes notes and diagnosis codes that explain the reason for the procedure.

Diagnosis coding: For modifier 25 claims, you should include a diagnosis code (or codes) to represent accurately the reason for the E/M service and the procedure. Remember, the E/M and the procedure could end up with the same diagnosis code, but this is acceptable.

-The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date,- according to CPT. However, many payers have edits in place that will not allow payment for both services when you cite a single diagnosis, so be sure to report multiple diagnoses when appropriate.

Skin Graft Is More Than Suturing

 Question: The patient sliced the tip of his finger trying to catch a piece of falling metal. Examination revealed a 1.0-cm square avulsion injury to the radial aspect of the index finger down to subcutaneous tissue. There was no bone involvement or exposure, and no nail involvement. The patient wanted the skin replaced as a graft.

The surgeon performed digital block and additional preparation, then sutured the patient's own skin, from the finger, back in place.

The surgeon wants to code this as a full-thickness free graft, while I think this is wound repair. Who's right?

Michigan Subscriber
Answer: From the information you provide, you are correct to want to report wound repair -- probably complex repair, such as 13131 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm) -- for this procedure.

A free skin graft (for example, 15240, Full-thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 20 sq cm or less) includes both suturing the donor skin to the graft location and direct closure of the donor site. In this case, there is no -donor site.- The surgeon is merely re-attaching skin by suture to the area from which it was lost.

CPT instructions preceding the graft codes expressly state, -These codes are not intended to be reported for simple graft application alone or application stabilized with dressings -- Further, CPT also specifies that complex repair -includes the repair of wounds requiring more than layered closure,- including -retention sutures.-
 

Simplify Your Place-of-Service Coding With This List

Fingertip guide to your most common POS eliminates confusion
Choosing the correct place-of-service (POS) code for your claims is essential to avoiding denials and even investigation for fraud. Keep on your auditor's good side by choosing your code based on these descriptions, straight from CMS:

11 (Office) -- Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis and treatment of illness or injury on an ambulatory basis. Fair market value for the office must be paid for this office to qualify for an office and POS 11.
 21 (Inpatient hospital) -- A facility, other than psychiatric, that primarily provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
 22 (Outpatient hospital) -- A portion of a hospital that provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

23 (Emergency room -- hospital) -- A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

 31 (Skilled nursing facility) -- A facility that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing or rehabilitative services but does not provide the level of  care or treatment available in a hospital.
 32 (Nursing facility) -- A facility that primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.
 33 (Custodial care facility) -- A facility that provides room, board and other personal assistance services, generally on a long-term basis, and does not include a medical component.

ICD-9 Lesion Coding: Why Patience Pays

The info you need is in the pathology report, not necessarily encounter notes
When assigning a diagnosis for lesion removal, remember that you should wait and rely on the pathology report to choose the correct ICD-9, rather than refer to the surgeon's own note.

Consider this example of why this is important:

The procedure: Your surgeon documents, -I removed one approximately 9-mm lesion from the patient's wrist using surgical curettage. Lesion had a red outer crust and an irregular border, but it looked dissimilar from the patient's actinic keratosis spots on her face, so I am uncertain of the lesion's status. Sent lesion to the lab, and will await results.-

What not to do: In this case, based on the documentation, you might be tempted to assign a diagnosis of 238.2 (Neoplasm of uncertain behavior of other and unspecified sites and tissues; skin) to this claim. But this is a mistake.

Here's why: -You can report 238.2 only if the pathologist who examines the sample states that the lesion exhibits uncertain behavior, not when the physician thinks it might be,- says Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC, medical coding instructor for Orion Medical Services in Eugene, Ore. -It has to come from the histopathology. So unless the physician is looking at it under the microscope, that code has to be assigned from the pathologist.-

In fact, according to ICD-9, -uncertain behavior- means something totally different from what people think, Felthauser says.
Example: -Sometimes a physician will review a patient's lesion that is growing in size, or changing color or irritating a patient, and from looking at the lesion it is -uncertain- to the physician whether this lesion is benign or malignant, so he elects to remove it and send it to pathology for review,- Felthauser says. -But if the lesion has not yet been histologically assessed, you should not report 238.2.-

If you code this report, you should either wait for the pathology report to determine the correct ICD-9 code, report a diagnosis code based on the symptoms, or select an -unspecified- code such as 239.2 (Neoplasms of unspecified nature; bone, soft tissue, and skin).

Tip: -If the lesion was irritated, bleeding or had other such features, make sure you have that information documented as well because most carriers do not cover -cosmetic- removals of benign skin neoplasms,- Felthauser says. -So you need to make sure there is documentation as to why he chose to remove it, and remember to code for those services.-

CPT for ultrasound biopsy of the axillary tail lymph node with biopsy clip placement?

If the radiologist performs a breast biopsy with clip placement, don’t forget to report +19295 (Image-guided placement, metallic localization clip, percutaneous, during breast biopsy).

Tip: If the radiologist performs the breast biopsy using stereotactic guidance, payers include a follow-up mammogram in the guidance codes. So if the radiologist performs a follow-up mammogram to confirm clip placement, you should not report the mammo-gram separately.

When your radiologist performs a stereotactic breast biopsy, you first need to determine which biopsy code to report. You’ll have to decide between 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance) and 19103 (… percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance) based on the documentation your radiologist provides.

How to choose: "The difference between 19102 and 19103 is that 19102 is only the needle core biopsy using imaging," explains Karen Caputo, CCS-P, certified coder for the University of Toledo Physicians in Ohio. You’ll see the radiologist use a different device (also with imaging) for 19103.

19102: You’ll use 19102 when your physician documents that he simply inserts the device and then pulls out a core of tissue, says Laura Singleton, billing specialist at the Center for Surgery & Breast Health in Joliet, Ill. Keep in mind that your physician may make several "passes" in order to ensure that he has obtained a sufficient sample for pathology, Singleton adds.

Key: For both 19102 and 19103, report one unit per lesion -- not per sample -- unless your payer tells you otherwise in writing.

19103: Code 19103, like 19102, reflects a percutaneous procedure, but for 19103 the physician uses a "more sophisticated device that has suction or a rotating action to obtain the sample," Singleton explains.

For example, the radiologist may use a Mammotome device, which vacuums, cuts, and removes tissue samples.

"Generally 19103 is the code to use for stereotactic biopsies because of the automated vacuum assisted or rotating device that is used

Not ePrescribing? Request Exemption From ePrescribing From CMS by Jan. 31

If you do not have an electronic prescribing (ePrescribing or eScribing) system yet in place, you better get a move on it fast. And if you have not filed for a Medicare ePrescribing hardship exemption, you should do it latest by January 31 or else be prepared to face the 1.5 percent payment penalty in 2013.
The physicians who missed the original June 30 deadline have one more chance to request exemption as the Centers for Medicare & Medicaid Services (CMS) has now reopened the Communications Support Web page at https://www.qualitynet.org/portal/server.pt/community/communications_support_system/234.
Note: Physicians who have made 25 claims using the e-prescribing code G8553 in 2012 will be eligible for avoiding payment adjustments for 2013. Also as a general rule of eligibility, you should remember that if you can’t write a prescription, you are not qualified to do ePrescribing.
Check Out the Hardship Exemptions
The physicians will be subject to the payment adjustment unless they start e-prescribing or meet any of the following exclusion criteria:

• The EP is not a physician (or MD, DO, podiatrist), nurse practitioner or a physician assistant.
• Your practice has Part B claims less than 10 percent of MPFS allowed charges for encounter codes mentioned in the eRx denominator for service dates between Jan.1, 2012 to June 30, 2012 (for 2013 payment adjustment) and Jan.1, 2013 to June 30, 2013 (for 2014 payment adjustments)
• Your practice doesn’t have 100 cases with eRx encounter codes for service dates between Jan.1, 2012 to June 30, 2012 (for 2013 payment adjustment) and Jan.1, 2013 to June 30, 2013 (for 2014 payment adjustments)
• Your practitioner doesn’t hold prescribing privileges and reports G8644 (Eligible professional does not have prescribing privileges) on a Part B claim between Jan.1, 2012 to June 30, 2012 (for 2013 payment adjustment) and Jan.1, 2013 to June 30, 2013 (for 2014 payment adjustments)
• Your practice is established in a rural area that has limited Internet access.  Report G8642 (The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848[a][5][a] of the social security act) at least once.
• There are not enough pharmacies in the area here your practice is based that can do ePrescribing. Report G8643 (The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption for the application of the payment adjustment under section 1848[a][5][a] of the social security act) at least once.
• Your practice is unable to e-prescribe due to local, state or federal laws
• Your practice has less than 100 prescriptions in six months corresponding to the reporting period

Sequestration Budget: Brace Yourself for 2% Cuts Starting April 1

The sequestration budget cuts are here. And health care plans and drug plans will be reduced by 2% starting April 1.

March 1 has come and gone, but with no life-saving action from Congress to avoid $85 billion in federal spending cuts known as the sequester.

The 2% Medicare cut will affect physicians, hospitals, health care providers, health plans, and prescription drug plans, but will have no direct effect on Medicare beneficiaries. "Our lawmakers have failed to act, and Medicare patients and physicians will now feel real pain in the form of new cuts that come at an already difficult time for the nation's economy," AMA President Jeremy A. Lazarus, MD, said in a statement issued on March 1.

Although the 2% cut may not seem large if compared to the reductions in other federal agencies, physicians say it will still have a huge impact. “The across-the-board cut will hit physicians particularly hard because of the fundamentally flawed Medicare physician payment system. Since 2001 Medicare payments for physician services have only increased by four percent, while the cost of caring for patients has gone up by more than 20 percent. A two percent cut widens the already enormous gap between what Medicare pays and the actual cost of caring for seniors,” said Dr. Lazarus.

The present cuts could make it difficult for patients to get care, Lazarus said. “Physicians continue to face drastic cuts from the SGR, and an additional two percent cut coming from sequestration further threatens access to care for patients and prevents needed improvements in Medicare.”

"It’s a very difficult time to plan your practice and plan hiring new employees because you don’t understand what you’re going to be getting paid and what you can afford," said Dr. David L. Bronson, president of the American College of Physicians.

Other Medicare cuts

Federal law already triggers Medicare cuts every year to keep the program financially sound. As most practices would be aware, Congress has stepped in a number of times to eliminate those cuts. Congress voted earlier this year to eliminate a 27 per cent Medicare payment cut that was supposed to kick in for 2012. Even without the 27 per cent reduction, total Medicare reimbursements for many practices in 2013 have fallen at least 2 to 3 per cent from last year based on changes in the 2013 relative value units (RVUs).

CMS to Delay Setting Criteria for Stage 3 Meaningful Use

The Centers for Medicare & Medicaid Services (CMS) recently announced that it will delay setting the criteria and rules on stage 3 meaningful use of electronic health records until 2014.

At the HIMSS 2013 conference held earlier in March 2013 in New Orleans, Marilyn Tavenner, Acting CMS Administrator, announced that the rulemaking process for Stage 3 won't take place in 2013 as was the plan earlier. The agency would instead wait and measure the success of the existing stages and review any problems. The agency would also review the feedback received from healthcare professionals and physicians.

Tavenner said that CMS plans to use this delay to concentrate on accomplishing increased interoperability across EHR systems and enhancing the exchange of health information.

This has been proposed by the AMA (American Medical Association) and organized medicine. They suggested that the CMS should first review how stage 1 and stage 2 are rolling out before setting the rules and criteria for stage 3, which is supposed to be implemented in the year 2016.

AMA has expressed its appreciation over the CMS’ decision, and says that it had submitted formal comments on Stage 3 earlier in 2013, recommending that CMS should review the earlier stages of the meaningful use program and resolve any present problems before setting down new rules for the next stage.

"[I]t is a serious mistake to keep adding stages and requirements to the meaningful use program without evaluating Stage 1 of the program," AMA CEO and Executive Vice President James L. Madara, MD, wrote in the letter. "[A]n evaluation should occur between each stage of the meaningful use program and prior to finalizing the requirements for the next stage.

"It makes no sense to add stages and requirements to a program when even savvy EHR users and specialists are having difficulty meeting the Stage 1 measures."
Background:
The three stages of meaningful use program that had been decided are:

Stage 1: This stage started in the year 2011 and is the beginning point for all providers. “Meaningful use” includes transferring data to EHRs and being able to share info.
Stage 2: The rules for this stage have already been decided and it shall be implemented in the year 2014. “Meaningful use” will include standards such as allowing the patients to gain access to their health information and also allowing exchange of electronic health information between healthcare providers.
Stage 3: This stage is expected to be implemented in 2016. “Meaningful use” will comprise of showing that the quality of healthcare has been improved.

Fiscal 2014 Budget Offers Sequester and SGR Repeal

If the recent physician cuts have been giving you sleepless nights, there’s a ray of hope. Rather than facing more cuts, physicians will now be on the receiving end of some federal largesse.

On April 9, 2013, President Barack Obama released a budget proposal for fiscal 2014. The proposed budget assumes the repeal of Medicare's sustainable growth rate (SGR) formula and the 26.5% physician pay cut that it would trigger.

Sen. Patty Murray, chair of the Senate budget committee, presented his budget proposal, which factors in the $1.8 trillion cost of maintaining Medicare rates at their present level over a course of 10 years.

This budget also withdraws sequestration — the automatic, across-the-board cuts — that includes a 2% cuts in Medicare reimbursement for physicians. These cuts were scheduled for April 1 this year (Read our last month’s news story “Sequestration Budget: Brace yourself for 2% Cuts Starting April 1” on codinginstitute.com). The proposed budget gives out nearly $1 trillion to replace the sequester cuts.

The budget also offers a deficit-neutral reserve fund that will replace the SGR with a new payment plan. Under this plan, physician pay rates would be frozen at their present level.

AMA President Jeremy A. Lazarus, MD, said in a statement, "We are pleased that President Obama's 2014 budget recognizes the need to eliminate the broken Medicare physician payment formula known as the SGR and move toward new ways of delivering and paying for care that reward quality and reduce costs. The president's proposals align with many of the principles developed by the AMA and 110 other physician organizations on transitioning Medicare to include an array of accountable payment models." You can go to http://www.ama-assn.org/ama/pub/news/news/2013-04-10-statement-on-presidents-budget.page to read the statement given by Dr. Lazarus in its entirety.

Although Medicare spending would come down substantially, the cuts would also come at a cost — and will have maximum effect on hospitals, drug companies, nursing homes, and wealthy seniors, who would ultimately end up paying considerably higher premiums. The budget would reduce the deficit by raising an additional $580 billion in revenue over a period of 10 years; especially by closing tax loopholes and making some tax-code changes for the wealthy class.
"While eliminating the SGR would be a step forward, the budget takes a step backward by aiming to achieve more savings through the Medicare Independent Payment Advisory Board (IPAB), which would set another arbitrary spending target and rely solely on payment cuts to reach it," Dr. Lazarus further said in his statement. "The AMA strongly supports bipartisan proposals to eliminate this panel."

The plan offered by Senate is also similar to the president's plan, and it offers to reduce the deficit by $1.85 trillion over a period of 10 years with a combination of increasing revenue and reducing spending.

Bill EKG during any surgery or inparticular open heart surgery and post surgery (during recovery)?

EKG is usually done in continuous manner during a heart surgery, and therefore it's considered an integral part of the main surgery and so would not be paid separately. Physicians need to monitor patient's heart's electrophysiologic behavior throughout the procedure.

Electrocardiograms are considered incidental to a stress test, a cardiac test which
includes an ECG as part of the test, and as part of initial hospital care. A 3 lead ECG is considered
incidental to a 12 lead ECG. Separate reimbursement is not provided for ECGs which are considered incidental.
An ECG is considered mutually exclusive to provider services for cardiac rehabilitation (93797). Separate
reimbursement is not provided for ECGs which are considered mutually exclusive.

To bill ECG/EKG (93000-93010 / 93040-93042), the specific request for the procedure should come from the doctor. Check the CPT guidelines before code 93000:

"Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated. There must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report. It is not appropriate to use these codes for reviewing the telemetry monitor strips taken from a monitoring system. The need for an electrocardiogram or rhythm strip should be supported by documentation in the patient medical record."

Also, EKG machine/electrodes come under "routine supplies" when done in a hospital. Routine supplies are items used during the normal course of treatment, which are directly related to and/or integral to the performance of separately payable therapy, treatments, procedures, or services. These supplies are customarily used during the course of treatment and are normally found in the floor stock, which are generally
used by all patients in that specific area/or location. Reusable supplies and equipment may also be considered routine.

Routine supplies should not be separately billed to a patient or a payor. When charging for routine supplies, hospitals have an option to include the charge in the charge of procedure/service, the accommodation charge, the operating room charge, or the E&M visit, or capture it on the hospital Cost Report.

The CCI bundling policy shows that CABG code (33510) bundles EKG code 93000 with a modifier indicator 1, suggesting you cannot bill EKG separately.

Difference from coding a "93015 and 93325 or a 93351?

report 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report), 93350 (Echocardiography, transthoracic, real-time with image documentation [2D], with or without M-mode recording, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report), and add-on codes +93320 (Doppler echocardiography ...) and +93325 (Doppler echocardiography color flow velocity mapping ...) if the documentation supports that the physician performed these procedures. See the CPT statement in parentheses under the description of 93350: "The appropriate stress testing code from the 93015-93018 series should be reported in addition to 93350 to capture the exercise stress portion of the study."

Code 93350 describes stress echocardiography only and does not include the cardiovascular stress portion of the procedure. Consequently, you need to report 93015 to cover services for the cardiovascular stress component.

When a single physician performs a stress echo and a complete cardiovascular stress test, report 93351 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision).

Professional component only: If your cardiologist provides only the professional component of the stress test and stress echo (such as in a facility), CPT® guidelines instruct you to append modifier 26 (Professional component) to 93351.

This language brings the CPT® approach more in line with Medicare policy, which states that "93351 (26) is payable when performed by a physician in a facility setting" (www.cms.gov/MLNMattersArticles/downloads/MM6617.pdf).

Limited elements: In some cases, the cardiologist may perform a stress echo without performing all of the stress test's professional services. In those situations, CPT® indicates you should report:

93350 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report) AND
Code(s) for the stress test element provided (choose from 93016-93018, Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress ...).
The Medicare Physician Fee Schedule lists both professional and technical services for 93350, so remember to append modifier 26 to 93350 when you're reporting professional services only.

Bill 99231 and another physician bill 99239 on the same day

Several physicians might be managing the care of a patient, and all might try to bill for the discharge -- but only the attending physician should bill for the discharge, CMS indicates.

The Medicare Claims Processing Manual notes, "Only the attending physician of record reports the discharge day management service. Physicians or qualified nonphysician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT® code range 99231- 99233) for a final visit."

The doctor cannot report an inpatient service unless a face-toface encounter occurs on that day. If the physician does not see the patient on the day of discharge, or any other day during the hospitalization, he may not report any E/M service. You should, however, report face-to-face services based on when the direct contact (face-to-face service) occurs. Here's how:

1. If the physician sees the patient the day prior to discharge, the physician can report the appropriate subsequent hospital care code (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...).

2. If the physician sees the patient on the day of discharge, he may choose the most appropriate code that represents the amount of floor/unit time the physician spends with the patient and other activities directed toward the discharge. For discharge services of 30 minutes or less, use 99238 (Hospital discharge day management; 30 minutes or less). Report discharge services taking more than 30 minutes as 99239 (... more than 30 minutes). The time spent with the patient and floor time must be documented in the chart along with what was done during that time. Keep in mind that if these services are performed during the postoperative global period of a procedure performed by the same provider, these would not be separately reportable.

Proper way to bill '64493' '64494' '64495' to Medicare

You may override the related edits with a modifier when the fluoroscopic guidance is unrelated to the lumbar or sacral injection codes in your question.

The Correct Coding Initiative (CCI) edits bundle 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid]) into the following codes:

64483, Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
64493, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level.

The edits make sense because both 64483 and 64493 include fluoroscopic guidance in their descriptors. Additionally, parenthetical notes with the codes in CPT® state that fluoroscopic guidance and localization are inclusive components of 64479-64484 and 64490-64495, and the codes in question fall in these ranges.

The CCI edits have a modifier indicator of 1, which means you may use a modifier to override the edits under appropriate circumstances. For instance, an appropriate circumstance could involve the bundled service being performed at a separate session during a distinct procedure. CMS offers more information on overriding edits in the “Modifier 59 Article” available in the Downloads section at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.

The fluoroscopic guidance code is not reportable with the injection codes, which bundle the image guidance when fluoroscopy or CT imaging is used. The 2012 changes in CPT® bundle imaging guidance in 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed), whereas 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) and 64494 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; second level [List separately in addition to code for primary procedure]) already included fluoroscopy.

You shouldn't bill separately for 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid]) when reporting these injection codes.

Vaccine CPT updates 2013 by AMA

The American Medical Association has been releasing and updating CPT codes since 2006, and recently the CPT updates 2013 codes for vaccines has been published.
Some of the codes that have been accepted and will be included in the 2013 codes are:

• Code 90653
• Code 90739
• Code 90672

The codes that are accepted to be included in the 2014 codebook are:

• Code 90685
• Code 90686
• Code  90687
• Code 90688

There are codes with the description “trivalent”, meaning “conferring immunity to three different pathogenic strains or species”:

• Code 90655
• Code 90656
• Code 90657
• Code 90658
• Code 90660

The newsletter of CPT® Assistant is published every month. Apart from the Coding Consultation section, it also contains detailed articles, commentaries, updates, and other timely facts to help keep your claims system running smoothly.
One can also look-up for reference articles online with Supercoder’s Code Connect, an online tool that has all the AMA’s CPT® Assistant denial busting — and accuracy boosting — reference articles. Easily refer to thousands of archived articles from the AMA to improve your accuracy and overturn denials.
Some unique features of Supercoder’s Code Connect featuring CPT Assistant are:

• CPT® Assistant 2012 & 1990-2011 Archives help to save time and increase efficiency.
• Every month receive the scoop on hot topics featured in the just released issue of CPT® Assistant.
• Get a better understanding of codes to file cleaner claims.

With Supercoder’s Code Connect featuring CPT® Assistant, one only needs to enter a CPT® code and instantly connect with all of the CPT® Assistant articles that the AMA has published on the code since 1990.
Supercoder’s Code Connect featuring CPT® Assistant, helps you get the updated and official guidance from the AMA to verify if you are coding correctly and let your practice become compliant and profitable.

Avoid These Common Coding Mistakes To Get The Reimbursement You Deserve

We all want to do a perfect job, report accurate claims, and get the complete reimbursement for the services that are performed in our services. And denial, of course, is something that we would never want to see. But if you have been receiving denials on your Part B codes lately, there could be a number of reasons. One important thing that could be doing wrong is inaccurately linking the diagnoses listed on the encounter form with the procedure codes. The codes you use to report the services your physician rendered decide the payment your practice will get, and sometimes you could be over- or under-coding, thus inviting denials or, in worst cases, audit attacks.
Have a look at these top five sources of claims denials that you should avoid:

1. Inaccurate reporting of diagnosis codes
Coders often incorrectly link ICD-9 codes with corresponding medical procedures. Several coders have complained of rejections when they report the CPT® code 15823.
Medicare will often reject this service as cosmetic surgery unless you tie it to an appropriate diagnosis code that proves medical necessity, such as 374.30 (Ptosis of eyelid, unspecified) and 374.34 (Blepharochalasis).

2. Improper reporting of bilateral services
Errors related to unilateral versus bilateral can also cause problems in processing your claims. Reporting the procedure code 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report) is especially problematic.

3. Misuse of alpha modifier
Coders are found to often misuse–or not use–the eye modifiers (-LT, Left side; and -RT, Right side). But these modifiers can be the key to making sure that you get the reimbursement you deserve, especially when your physician performs similar procedures on both the eyes of the patient.
If, during the postoperative period for cataract surgery on a patient’s left eye, the physician notices that the right eye also has a cataract, and so he provides the service for the other eye. In this case you would report the code 66830 for the first eye. You should report the surgery for the other eye (right) using one of the eye modifiers.

 4. Overlooking Eyelid-Modifier Opportunities
Occasionally, the eyelid modifiers (-E1–-E4) are preferable to the eye modifiers -RT and -LT. Consider for example, your ophthalmologist performs 67904 (Repair of blepharoptosis; [tarso] levator resection or advancement, external approach) on the patient’s both upper eye lids. When the procedure is performed bilaterally, you should use the codes 67904–50 for Medicare. In this case, you should not use the eye modifiers or the eyelid modifiers.

5. Using Outdated Manuals
Use of an old, obsolete, or deleted procedure or diagnosis codes is a very common error. Practices are often found to be submitting codes that have been removed from the CPT® manual or they use some specific codes in error, particularly the age-specific codes.
Keep these common errors in mind to prevent them from happening the next time, and to ensure that you submit slick claims.

You Be the Coder: Coding Inpatient E/M

Question: When the ED physician is called to the floor to evaluate an inpatient and the visit does not qualify for critical care, what evaluation and management (E/M) code would be correct to use for the encounter?

Michigan Subscriber

Answer: There are three general groups of E/M codes the ED physician can use depending upon the service provided beyond the critical care codes.

1. If the ED physician was formally asked by the patients attending physician to assess the patient for a particular reason and that request was recorded in the patients chart either by the attending physician or by a nurse who recorded the order, then this could be considered a consultation and billed using consultation codes 99251-99255.

2. If no formal request was made and recorded in the chart, then the ED physician must use the subsequent inpatient visit codes 99231-99233. This is probably the most common situation.

3. If a procedure is performed, such as CPR, the appropriate service code would be used. Depending upon the circumstance, an E/M code could be used in addition to a procedure code, but the documentation must be complete to support the visit code in addition to the procedure code.

In all of these instances, the ED coder should take care to record the appropriate place of service (21, inpatient hospital) on the HCFA-1500, rather than the place of service for the ED (23, emergency room, hospital).

HCFA Delays Launch of APC/OPPS to August 1

The Health Care Financing Administration (HCFA) has moved back the start date of the new Outpatient Prospective Payment System (OPPS) until Aug. 1, 2000. Unfortunately, even an extra months delay will not help the medical industry if coders do not now gain knowledge on the Ambulatory Payment Classification rules.

HCFA published the official rules in the Federal Register on April 17, but the register can be hard to navigate.

ED outpatient coders and clinicians, who will be directly affected by the new rules, should visit HCFAs Web site at http://www.hcfa.gov/regs/hopps/default.htm to find a much simpler presentation of the new APC regulations. There is a chart that will help direct coders to the section of rules that apply to their specialty.

If you have questions about any of the data HCFA provides on their Web page, send them to outpatientPPS@hcfa.gov. Use of this e-mail address is limited to specific questions regarding the new payment system data outlined on the Web site.

As always, ED Coding Alert welcomes your feedback and aims to address your issues in upcoming publications. E-mail us your questions at questions@medville.com.

Understanding the Terminology: Open vs. Closed Fracture

Some coders confuse the indication of an open or closed fracture to mean that the treatment of that injury was open or closed, when, in fact, these terms mean two different things.

An open fracture is one where the skin overlying the fracture has been violated through the subcutaneous tissue, explains John Stimler, DO, FACEP, a practicing emergency physician in Jacksonville, FL, and a past president of the Florida chapter of the American College of Emergency Physicians. Often, this is because one end of a fractured bone has punctured the skin. However, a laceration or puncture wound over the fracture would also constitute an open fracture, he adds.

A closed fracture is one in which the skin overlying the broken bone is not violated through the subcutaneous tissue.

A superficial contusion or abrasion that is not into the subcutaneous area would be considered a closed fracture, Stimler notes. Open treatment of a fracture indicates that the physician had to surgically open the skin and go in to repair the injury, says Kenneth DeHart, MD, FACEP, president of Care First Health Specialists, an emergency physician group in Myrtle Beach, SC, and chairman of the American College of Emergency Physicians advisory committee on coding and nomenclature.

A good example would be a bone that is fractured in several places, he explains. The physician would have to make an incision and go in and set each of the pieces. Injuries that are this complicated are almost always managed by a consulting physician and not by the ED doctor, notes DeHart.

To be clear, it is possible to have open treatment of a closed injury, though you almost never have closed treatment of an open fracture.

Because of the high risk of infection, open fractures are rarely repaired in the ED. In most cases, the ED physician would stabilize the patient and he or she would be sent to the operating room to have the injury repaired by a specialist, who would assume treatment for the patient and use the orthopedic codes. (See article, Use Orthopedic Codes Plus Modifier -54 to Get Paid for ED Fracture Care, page 3, ECA December 1998 issue.)

Codes indicating open treatment and manipulation are rarely used for the ED physicians service, notes DeHart.

Generally, ED physicians dont manipulate unless there is acute neurovascular compromise, DeHart notes. You may have a closed fracture with a one-degree bend to it, and the physician would put it in traction before putting on a castthat would be manipulation.

Four Quick Documentation Strategies to Satisfy E/M Guidelines

Despite the confusion over the implementation of the 1997 Evaluation and Management (E/M) Guidelines, EDs must still adhere to either the 1995 or 1997 version. The 1995 guidelines are considered most beneficial to emergency medicine. Here are some key tips to ensure ED physicians are providing the right documentation to justify the appropriate level of service.

Remind ED physicians to document vital signs, orders, ED course, critical care time in dictations. (Coders dont always get the nurses notes.) For templated records, review for consistency and accuracy in how templates are used. Routinely communicate problems to physicians until resolved. Provide copies of records that indicate inconsistency between stated problems or RN/MD notes.

Encourage physicians to discontinue use of term non-contributory, when documenting the history. Recommend, reviewed and negative. Ask them to indicate whether nurses notes have been reviewed, and include references to pertinent information.

Remind the MDs to always record their review of system(s) identified in the history of present illness, plus other related systems. Remind them also that they must have a review of systems for all E/M levels but the lowest (99281).

If patient information is unobtainable or unreliable, the physician must record the reason for this in order to satisfy stated requirements.

G0105, 45378: Use This Coding Combination For Your High-Risk Patients

Irrespective of findings, stick to V10.05 to define condition.

Correctly reporting colorectal cancer screenings on patients at high risk for the disease can depend on fine points like allocating the right V code. Read this expert medical coding article and know what ICD-9 codes apply in this scenario.

Examine the following given scenario and the medical coding advice that follows to ace these claims -- and recover your deserved reimbursement for these services:

Scenario: A patient has a personal history of colon cancer, went through treatment for colon cancer six years before, however she is presently facing no symptoms. Her 2006 colonoscopy came out clear, as well as her recent one carried out about a month ago. You billed 45378 for the procedure, and then you selected V10.05, from the ICD-9 codes, for the diagnosis. Though, the patient called complaining you should've billed the procedure as routine as her last two colonoscopies were clean. How would you resolve this?

Choose G0105 Or 45378, But Get The History Diagnosis Right

In case you're billing Medicare, you smust report the procedure as a high risk screening with code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). Then, from ICD-9 codes, report V code V10.05 (Personal history of malignant neoplasm of large intestine) as the primary diagnosis.

Code V10.05 fits the bill for primary diagnosis as the patient presents to the office for a screening exam and not precisely for follow-up assessment of the cancer. In case the encounter's purpose is for cancer surveillance and follow-up at an interval close by the surgical treatment, you could, as an alternative, code V67.09 (Follow-up examination following other surgery) as your primary diagnosis. Though, keep in mind that this ICD-9 code is seldom used.

On the contrary, certain commercial carriers would need the code 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) with modifier 33 (Preventive services) appended to signify that the service was preventive, and the V code V10.05 as diagnosis.

Don't forget: From ICD-9 codes, you must list V10.05 as your primary diagnosis for both circumstances (Medicare and commercial payers), irrespective of the fact that the results were clear or not. Use this ICD-9 code if all treatment focused toward the cancer is complete and there are no symptoms of current disease . Don't make the error of reporting a cancer code (153.3, Malignant neoplasm of sigmoid colon) or the family history code (V16.0, Family history of malignant neoplasm of gastrointestinal tract).

Draw On Diplomacy To Confer With Patients

Complaints like this from patients on a screening colonoscopy are common in the gastroenterology practice. The best guidance is to talk it out with your patient, and make clear how their cancer history influences the medical coding.