Make Your CPT® Code Look-Up Easy And Tension Free With CPT® Assistant

Coding would have so much easier if only there were not so many code revisions, additions, and deletions happening every year, and so many CCI edits to keep a track of. If medical terms were easy and you didn't have to sit with a dictionary, if comprehending the physician documentation wouldn't leave you scratching your head and pouring over manuals for a simple CPT® codes lookup, coding would be fun too. Right?

Wrong! Even with all these challenges slowing you down, coding can be fun and simple too. Yes, you can now report accurate, clean, and error-free claims and get minimum number of denials.

So what are the resources you need for accurate and denial-free claims?

You must have access to a medical dictionary, such as Stedman's, and have access to CPT® manual, HCPCS codes, ICD-9 and ICD-10 codes in your medical tools basket. Either an online access or printed copies will do, but make sure that you have the most updated manuals. In addition, you should also have access to CPT® Assistant.

What is CPT® Assistant?

Published by the American Medical Association (AMA), CPT® Assistant is an essential denial-busting and accuracy-boosting tool. It allows you to quickly lookup a CPT® code . Here you can find all the articles that have been published by the AMA on that particular code since 1990. Not only will you be able to understand the rationale behind the code, you will also get answers to your day-to-day burning coding questions.

Why should you have an access to CPT® Assistant

AMA's CPT® Assistant is an effective tool that can help you report accurate claims and also learn the reason why a particular code be used. You get timely articles and practical coding advice every day of the month sitting at the comfort of your desk.

You can get your subscription to the coding assistant from the AMA at an incredibly affordable price. Have a look at the features of the CPT® Assistant:

• Boosts accuracy: With the CPT® Assistant you can now understand the rationale behind each code and get the latest, up-to-date information on every code that you need for your specialty.

• Saves time: You can read the articles that have been published by the AMA on a particular CPT code in the last two decades and that too in just a few seconds.

• Provides the latest coding info: You can learn about the latest coding trends and developments with the new articles. You can also learn about the coding changes that will go into effect and have already come into use.

• Reduces Accounts Receivable (A/R): Overturning denials would not be such a tough deal when you will have accurate coding knowledge and definitive guidance at hand from the AMA.

Write Effective CPT Modifier 22 Summary Letters to Avert Appeals With These 4 Tips

Do you avoid using modifier 22 because you might face increased scrutiny or may be even denial? However, avoiding the modifier altogether can get you to lose the reimbursement that your cardiologist rightfully deserves.

How modifier 22 works: When a procedure requires extra time or effort that falls outside the range of services that a particular CPT® code describes—and no other CPT® code better describes the procedure —you should append modifier 22.

Documenting the need for modifier 22

Modifier 22 is about extra procedural work and you must ensure that time or the intensity of the procedure significantly increased when your physician performed the procedure on the patient. For this, your physician should document how and why the patient's condition increased the difficulty of that particular case. Your physician should note the need for the additional effort in his documentation.

You can effectively demonstrate a procedure's increased nature by comparing it to the actual time, effort, or circumstances to the typical time and effort taken for performing that particular procedure.

Putting your case forward

In cases when you do need to append modifier -22, you also will need to convince Medicare that the procedure warrants extra payment. Consider writing a brief procedure summary and explain in it why the procedure was different or unusual. You can write this summary in a cover letter and attach it to your claim form and your physician's operative notes. If you don't do this, you might find it tough to appeal denials, should you face one.

Refer to the following list of 4 pointers when composing effective summaries:

1. Do not over-explain. Try explaining why the part of the surgical procedure is "unusual" in two or three short, simple statements. You can explain the patient scenario in the cover letter and direct your payers to the attached detailed report.

2. Use key terms and phrases in the summary. Try writing phrases such as "new technology," "extra time and effort," "the procedure was difficult because it involved factors such as…" in your cover letter. All these factors made the total procedure continue for XX minutes rather than the usual XY minutes it takes.

3. Refer to the description offered by your CPT® codes for cardiology. Explain the CPT® codes for typical procedure, that your cardiologist used, in your summary and explain how the scenario you are describing is atypical or unusual.

4. Stress on the fact that you are expecting a certain increase in your reimbursement. Remember to emphasize the fact that the extra effort for the procedure deserves additional reimbursement over the allowable percentage. In other words, you must explain that the procedure that your cardiologist performed is worth the extra you're asking for.

5. Name your price. Simply identifying the increased effort in your documentation and on the claim will not automatically get you increased payment. If you do not increase your fee, you will get the same payment result as if the modifier was not appended.

How CPT Terminology Can Ensure Accurate Coding And Increased Reimbursement

We as coders know all too well the importance of appropriate documentation for fair and appropriate payment for the services that are performed by the physicians. It is just as important, however, to use correct CPT® terminology when listing those procedures at the top of an operative report.

This can be difficult, however, since the words used to describe procedures and conditions in CPT® and ICD-9 can differ from the clinical terminology that physicians use to dictate the procedure. Although coders must always read the complete operative report, and especially focus on the procedure notes, many coders ignore to do so. This can cause them to report the procedure inaccurately and get denials or low reimbursements.

As a result, the words and descriptions that the physician uses in his notes assume much more importance. However in cases when the physician doesn't dictate in a language similar to the one used in CPT® or ICD-9 manuals, many coders can find themselves lost in the complicated — and at times, incomprehensible — report. This can cause you an incorrect CPT® codes look up, a lower — or higher —reimbursement, audits and even OIG attacks, delays in getting the bills out, and denials by carriers; and internally it can also make it difficult and more expensive to provide training to the staff.

Correct Terminology Can Reduce Denials

Insist that your physicians use CPT® and ICD-9 language. As stated above this will help your practice reduce revenue loss (or inappropriate gain) and speed the billing process. In addition, this can also decrease denials and protect your practice during subsequent audits.

Know The Terminology Yourself

Whether or not you have undertaken any formal training in coding, you must know your medical terminology to stay in the loop. If you can't understand what your physician is talking about or mentions in his notes, you're not doing the best you can at your coding office.

You can try learning medical terminology on your own or take an educational course to actually simplify your life in office. If you don't know the medical terms, you can have a difficult time understanding the physician as well as the patients' needs.

You must also consider that terms and medical CPT® codes are intentionally precise in their description of a diagnosis, procedure, or even the examination findings. With a proper knowledge of terminology, you can understand the physician's notes accurately.

You can visit these Web sites to beef up your medical terminology:

• To test your knowledge of the medical words and take some quick quizzes, visit the University of Minnesota's Web site
• You can buy a copy of the "Quick and Easy Medical Terminology" by Peggy Leonard at your local bookstore.

• To know how to pronounce the medical terms, try the Merriam-Webster dictionary to know the meaning as well as hear the pronunciation. Simply type in the medical term, and your computer will speak to you with the correct pronunciation.

Ease Your Coding Woes With CPT® Assistant

If there were not so many coding updates every year, a little less number of revisions, less additions, and less deletions happening every year, coding would have been easier. If medical terms were not so difficult and you didn't always need to have a medical dictionary on your side, coding could have been fun too.

But coding can still be easy and fun, provided that you have the right tools assisting you. There are numerous challenges and issues on your every coding day to slow you down, but don't lose heart just yet. You can report clean, accurate, and error-free claims each time and get minimum number of denials, and, most importantly, the reimbursement you truly deserve.
Here's what you need to do to report accurate and denial-free claims:

Like it or not, it is very important that you have a personal copy of a good medical dictionary. Besides you must also have access to the latest CPT® manual, HCPCS codes, ICD-9 manual and ICD-10 codes in your medical tools kit. You can either an online access or printed copies of these. Plus, very importantly, you should also have access to AMA's CPT® Assistant.

Know what is CPT® Assistant
CPT® Assistant is published by the American Medical Association (AMA), the source of CPT codes. This is an essential denial-busting and accuracy-boosting tool that allows you to quickly find details on a particular CPT® code. In it you can find all the articles that have been published by the AMA on the CPT code since 1990. The articles will not only help you understand the rationale behind your specific CPT code, but will also help you get answers to your day-to-day coding questions.

Why must you get an access to CPT® Assistant
AMA's CPT® Assistant is an effective denial-busting tool that can help you code accurate claims. You can get articles and practical coding advice every day of the month while being at the comfort of your office desk or even home.

You can get your subscription to the coding assistant at an incredibly affordable price. Here's a quick look at the highlights of the CPT® Assistant:

• Accuracy booster: With the CPT® Assistant on your side, you can learn the reason why a particular code is appropriate in a specific case. In addition, you also get the latest, up-to-date information on the codes that you need to use for your specialty.
• Time saver: How many times you have wished that you could get out of the office faster. You can now turn your desire into reality. Quickly read the articles that have been published by the AMA on a particular CPT code in the last two decades and find the codes most appropriate for your case.
• Gives the latest coding info: Learn about the 2013 coding changes and updates with the new articles.
• Reduces Accounts Receivable (A/R): Overturning denials won't be such difficult when you will have accurate coding know-how and definitive guidance from the AMA.

Boost Your Cardioversion and Defibrilltation Coding

Identifying services from the clinical chart is problematic even for emergency coding veterans. The problem gets accentuated when it comes to cardioversions and defibrillations as these emergency codes get used interchangeably along with added complication of identifying "chemical" or "electrical" cardioversions. Any slips in identifying the right procedure results in wrong emergency coding and hence leading to claim denials.

The problem lies in distinguishing each procedure, before assigning emergency code for them. After discerning the proper procedure, emergency code can be recorded and that will help in securing the deserved payments. For identifying the procedure and emergency code, it is important to examine the documentation carefully to look for clues about the procedure.

Step 1 Identifying in between cardioversion and defibrillation

In order to identify defribillation, one must understand the procedure, what it entails and the tell tale signs. One must begin by recognizing defibrillation which is an electric shock given to patient to normalize heart rhythm and it is an emergency procedure. According to Michael A. Granovsky (MD, FACEP, CPC), President of LoxigHealth, some more indicators for defibrillations in the documentation are (1) delivering electrical shock at any point in the cardiac cycle (2) unconscious patient (3) pulse less cardiac rythms. A very simple method to identify defibrillation is to check whether CPR was ongoing immediately before the shocks were delivered.

There are a few distinct clues in order to identify cardioversion. The objective of cardioversion is to convert one cardiac rhythm to another or electrical rhythm i.e. to convert from abnormal rhythm to normal rhythm.

You can then allocate the right emergency code as per the identification made.

Step 2 Identify in between Chemical or Electrical Cardioversion

In cardioversion, physician can either perform chemical or electrical. A chemical cardioversion is given to patients who are not considered unstable i.e. they are not hemodynamically unstable. For responding to symptoms like shortness of breath, or low blood pressure, chemical cardioversion procedure is used. But if these symptoms become severe or progressing, electrical cardioversion procedure is used by the physician. Emergency department patients who are unresponsive to drugs being used in chemical cardioversion may be given electrical cardioversion. Typically, electrical cardioversion is among the urgent procedures.

Elective electrical cardioversion means that patients consent is taken in the ED before the procedure is initiated. The procedure is for patients who are stable but their condition is expected to deteriorate quickly. n order to identify whether the procedure was elective electrical cardioversion, one must sift through the complete documentation as there will be substantial proof of ER Physician taking consent from the patient for performing the procedure as well as communicating to patient the benefits as well as complication which may result from the due procedure. There is divided opinion among experts as some experts believe elective cardioversion to be a scheduled procedure while others believe that it does not necessarily be a scheduled procedure. Since there is no clear cut resolution, it is better to ask the physician to make specific documentation describing the procedure as elective or not.

Documentation is integral to make the right choice of emergency code. There are also consistent coding changes which pose further challenges. One can also refer to AMA CPT Assistant which helps you keep track of all coding changes. CPT Assistant also answers many difficult questions, provides references and much more.

CPT Billing Stay Clear Of These Top 5 Chargemaster Pitfalls

Charge description master can be a difficult and complicated process, but by knowing the most common CDM difficulties — and knowing how to deal with them you can ensure a smoother process, better compliance, and more reimbursement.

1. Right Code, Wrong Place
We have all been through this. There are a handful of frustrating codes that we always mix up. However, when you factor the charge description master (CDM) into the mix, a few incorrect codes can quickly add up to big money — and possibly major compliance errors and resultant audit attacks.

Another common problem is incorrectly billing for outpatient services that your facility's physicians provides in multiple locations. In case your hospital provides services for the same patient in several different parts of the facility, you must make a note of where each service was performed and attach it to the appropriate CPT® billing code for that particular department.

2. Linking The CPT® and HCPCS Codes Incorrectly
While you always stay alert to the links between incorrect (or medically unnecessary) diagnoses and procedures, but keep in mind that some situations actually call for you to link some HCPCS codes with the CPT® codes.

3. Mysterious Mistakes in Services or Supplies
Always let the charge description master (CDM) coordinator know as soon as possible about the change in the cost of services and supplies. Sometimes the coordinator doesn't find out the change for a long time, and may only discover the change during a revenue code edit.
To have an up-to-date chargemaster, it is extremely important that you keep the communication lines open and keep learning about the new procedures and code changes. The key here is to implement the new codes as soon as they are released, and get them into the CDM.

4. Not Documenting Medical Necessity
This is another common yet a much problematic error. This can be especially a difficulty when the physician orders some specific tests. In such cases, the costs can be high and the medical-necessity requirements can be very specific.
Observation is yet another place where a number of practices lose a lot of revenue because of incomplete or incorrect medical-necessity documentation.

5. Not Cleaning Regularly
You should give your chargemaster a major update at least once every year. You should also update the chargemaster every three months to keep current with the CPT® code changes and National Correct Coding Initiative (NCCI) edits. In addition, you should examine closely the new CMS regulations to see what you need to change or update. This may include new services, supplies, and physician's fee schedule revisions. Also perform a detailed annual review of the services performed in each department regularly.

However, when "cleaning out" the unused CPT® codes, you should not delete them completely. You should instead make them inactive as you may need them in future to provide long-term financial information.

Get Prepared For A New ICD-10 Code Set Started oct 2014

You would probably have been hearing about the implementation of ICD-10 for quite some time now, but till date medical offices continue to use the ICD-9 codes to describe diagnoses. But this is only until 1 October, 2014, when, after a number of hurdles and delays, ICD-10 will finally go into effect.
Need for the change
A number of ICD-9 codes have become outdated and their descriptors are also now obsolete. To keep current with the latest medical technology, procedures, and terminology, this 30-year old manual will now be replaced forever.
What do I use now?
You will continue to use ICD-9 manual until October 2014. This code set comprises:

• Volume 1: This is a numeric list that classifies diseases by their cause (etiology) and their analysis (anatomy).
• Volume 2: This numeric list alphabetic index helps find codes in Volume 1.
• Volume 3: Used only by hospitals, this procedural classification has a tabular section and an index.

What is the difference between ICD-10 and ICD-9
Let's have a look at why the replacement is necessary and what changes you need to keep in mind before you start preparing yourself for the transition.

• The former will have two systems:
  • ICD-10-CM, which is the diagnostic coding system for all healthcare applications. It will replace ICD-9-CM volume 1 (the numeric list that classifies diseases by their cause (etiology) and their analysis (anatomy) and volume 2 (thenumeric list alphabetic index that coders use to find codes in Volume 1).
  • ICD-10-PCS, a procedural coding system that is for use only on in-patients. It will replace ICD-9-CM volume 3 (the procedural classification that has a tabular section and an index. This is generally used only by the hospitals.)
• ICD-9 has mostly numeric, 3 to 5 digits codes; however, the new code set has alphanumeric codes and contains 3 to 7 characters, with the first character alphabetical. For example, if you need to lookup ICD-10 code for "hypertensive heart disease", your ICD-10 codes look up will show you these options:
  • I11—Hypertensive heart disease
  • I110—Hypertensive heart disease with heart failure
  • I119—Hypertensive heart disease without heart failure

Remember that you will have to use these along with your CPT® cardiology codes, or else your claim form would be incomplete and you will have to see a denial.

• ICD-10 also has laterality unlike ICD-9 code set. The characters in the former will identify when the treatment was performed on right or left side, whether it was an initial encounter or a subsequent encounter, and will also provide other clinical information. In the latter, you need additional documentation to prove these facts.

• Another big difference between the two is that there are only 13,000 codes in the current system, with no space to make any more additions, but the new system will have more than 68,000 codes. It has also been designed in such a manner that it is flexible for addition of new codes.

Your Key to Unlocking Biofeedback Reimbursement

Biofeedback may help patients relax, but it often stresses out coders trying to make sure their physicians get reimbursed properly. Take control of your biofeedback reimbursement by following these steps to correct coding.

The key to reimbursement for biofeedback treatment is the work you must do beforehand, because Medicare and commercial payers want to make sure the patient is a good candidate for biofeedback.

Once you prove that the patient is a good candidate, most carriers will reimburse for biofeedback as an alternative to surgery, says Jean Acevedo, LHRM, CPC, president of Acevedo Consulting Inc. in Florida. "In some states, the Medicare carrier looks at biofeedback training as being covered under Medicare as reasonable and necessary for re-education of certain muscle groups, treatment of muscle abnormalities, and incapacitating muscle spasm or weakness," Acevedo says.

"And when it comes to the bladder, at least in Florida, they combine for the treatment of stress urge or persistent post-prostatectomy urinary incontinence," Acevedo adds.

Use CPT 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) when the urologist treats urinary incontinence with biofeedback. Some coders use 90901 (Biofeedback training by any modality) to treat urinary incontinence. Do not add 51784 (Electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique) because 90911 includes electromyography (EMG) and/or manometry.
Make Medical Necessity a Must
You must show medical necessity for biofeedback training on a patient-by-patient basis. CMS gives carriers discretion to determine if biofeedback should be paid as an initial treatment modality.

"The key for the physician," Acevedo says, "is that clearly their documentation for the encounter leading up to the biofeedback therapy must document that more 'conventional' treatments have not been successful."

Have the physician in your office submit detailed notes outlining the medical necessity. For example, diagnosis codes such as 625.6 (Stress incontinence, female) or 788.35 (Post-void dribbling) clearly warrant biofeedback treatment. Double-check your carriers' coverage policies to confirm that the condition could call for biofeedback treatment.

For example, Cigna Medicare's biofeedback local medical review policy for Tennessee stipulates that only the following ICD-9 codes constitute medical necessity and will be reimbursed for biofeedback:

• 599.82 - Intrinsic (urethral) sphincter deficiency [ISD]
• 625.6 - Stress incontinence, female
• 728.2 - Muscular wasting and disuse atrophy ...
• 787.6 - Incontinence of feces
• 788.30 - Urinary incontinence, unspecified
• 788.32 - Stress incontinence, male
• 788.33 - Mixed incontinence, (male) (female)
• V48.3 - Mechanical and motor problems with neck and trunk
• V49.2 - Motor problems with limbs.
  
  Medicare is more conservative in its reimbursement than most private carriers, so pay attention to the specific diagnosis code used. Even Medicare's

Improve Your Angio Skills With This Carotid Scenario

Knowing right from left can get you a $105 reward.

How do you handle a medical billing and coding case with a common carotid placement through both common and internal carotid imaging?

Have a look at the following scenario: By means of femoral access and common carotid placement, the physician images the right common carotid as well as right internal carotid. The physician documents normal anatomy and maintains that there are no abnormalities in the common carotid, however she finds stenosis in the internal carotid.

Determine your answer, and then see if your solution to this medical billing and coding scenario is similar to the experts'.

Image 2 Vessels From Same Placement?

The scenario specifies catheter placement terminated in the common carotid, however the cardiologist imaged both the common and internal carotid arteries. Supposing your documentation supports it, you will be able to report imaging for both the common as well as internal carotid arteries.

This imaging of both vessels is possible as the contrast flows upward. Consequently, physicians can inject contrast at the common carotid artery and render the interpretation of not only the common carotid bifurcation, specifying what is seen ([for example,] the common carotid bifurcation was clean and free of disease), however also intracranial segments of the internal carotid artery.

The codes: For the unilateral common (cervical) carotid artery angiography, you must report CPT code 75676 (Angiography, carotid, cervical, unilateral, radiological supervision and interpretation). You should apply 75665 (Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation) for unilateral intracranial (cerebral) carotid artery angiography.

Keep in mind to verify that the physician's documentation for the scenario stated above supports reporting the cerebral code (based on what she performed and the recorded findings) along with the cervical code to attain medical billing and coding accuracy.

Rake in Rightful Correct Carotid Fee

Along with imaging, you need to select the proper catheter placement code. One significant factor is whether the cardiologist worked in the left or right carotid arteries. In the scenario mentioned above, the cardiologist placed the catheter in the patient's right common carotid.

Impact: The right common carotid originates from the innominate artery which branches from the aorta. Consequently, from a femoral approach, the innominate is the first-order catheterization, and the right common carotid is a second-order catheterization. Then again, the patient's left common carotid originates from the aorta in a typical patient and is consequently a first-order catheterization.

Medical Billing and Coding Tip: Due to these anatomical differences, the proper code for a right common carotid cath placement, as described in the above scenario, is second order CPT 36216 (Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family).

Alternatively, for a left common carotid cath placement, you would report first-order code 36215 (…each first order thoracic or brachiocephalic branch, within a vascular family) for a patient who has a normal anatomy.

CPT 2010 brings about many urodynamics coding changes

We can heave a sigh of relief because when we compare the coding changes in 2010 with that of recent years, it’s a record low. But notwithstanding this, urogynecology coding is not spared the CPT onslaught; CPT 2010 brings with it a lot of changes for urodynamics coding.

So it’s better that you get a grip on these new CPT codes for 2010, if you want your urodynamics practice to get its well-deserved reimbursements.

As a result of the CPT changes, you will now have three new urodynamics codes: • 51727, • 51728, • 51729. And these codes have been added at the expense of 51772 and 51795, which AMA decided to show the door. Several of the urodynamics codes have been combined into new sets of code to reduce costs and payments. This means that your doctors cannot bill for each individual urodynamic procedure.

When your ob-gyn performs a complex cystometrogram and a urethral pressure profile (UPP), you’ll use the new combination code 51727. The new code 51728 is the new combination code for the CMG with a voiding pressure study, but the big change is the new code 51729 as most obgyns perform a complex urodynamics workup which includes all three. This code includes the complex cystometrogram, the bladder voiding pressure, the UPP, and the Valsalva leak point pressure study if performed additionally.

To get the proper reimbursements for your practice, you need to keep pace with the many urodynamics changes that CPT has brought with it this year. And doing so is not such a big ask if you sign up for a one-stop coding website. When you go for one, you will chance upon all the urodynamics coding updates at one place. So get going!

CPT 2010: Gather Molecular studies preparation pay

When your pathologist carries out sterile macroscopic dissection to prep tissue for molecular diagnostics tests, you did not have a way to capture the service prior to this. Take advantage of this new payment opportunity by learning when you can and cannot use the 2010 codes, how to document the service and what you need to know for correct billing.

Tip 1: Know the ‘Macro' service

CPT 2010 introduces two new codes to describe surgical pathology tissue prep for some ancillary tests. These codes describe macroscopic examination and processing of the target tissue like a sentimental lymph node for non-microscopic molecular analysis.

The processing covers work like dissecting an appropriate portion of the tissue away from the main specimen and cutting and labeling thin sections under sterile conditions.

Tip 2: Apply codes to pre-analytic work

You shouldn't report 88387 or +88388 when the pathologist retrospectively chooses tissue block for molecular analysis based on the initial slide review.

You have to think ‘pre-analytic and ‘macroscopic' when deciding whether to use one of these codes. Early indications are that some labs are using them incorrectly if you are selecting tumor cells from paraffin embedded material or cutting sections from a block for send-out, that's not covered by 88387 or +88388.

Tip 3: Ban 88387-88388 for microbiology or flow cytometry prep

According to CPT 2010, you shouldn't go for 88387-88388 for tissue preparation for microbiologic cultures or flow cytometric studies.

That rules out reporting 88387 or +88388 as prep for any microbiology codes or 88182-88189.

Tip 4: Avoid 88387-88388 for Microscopy Prep

As the code descriptors specifically reference no-microscopic analytic studies, you shouldn't report 88387 or +88388 for tissue prep for special stains or immunohistochemistry-based tumor morphometry analysis.

Tip 5: Go for codes with ancillary molecular diagnostics

According to the code definition, you should go for 88387 or +88388 for special tissue prep for "nucleic-acid based molecular studies".

CPT 2010: New Options for HLA Testing

You have been stuck with 86805-86822 for human leukocyte antigen (HLA) testing; now we have some new options for human leukocyte antigen (HLA) testing.

For more on the new options and how you should report HLA typing and cross match for transplant patients, read on:

Know HLA typing – The old fashioned serology way

CPT has chosen four new codes for HLA typing using serologic methods, which labs have used for years.

Recognize ‘class' terminology: The lab report might state that the test was for HLA class I antigens. To choose the proper code, you will need to know how the class terminology aligns with the code definitions. While Class I refers to A, B and C, Class II refers to certain DQ and DR antigens.

For Molecular Diagnostics, update your HLA typing codes

Many labs now carry out HLA typing using molecular diagnostics methods instead of serologic testing. How will you report these tests?

Problem: Till last year, AMA direction published in CPT Assistant indicated that you should continue to report 86812-86817, even if the lab carried out HLA typing by molecular diagnostics techniques like high resolution polymerase chain reaction (PCR).

Solution: CPT 2009 had added the following instruction following code 86822. For HLA typing by molecular pathology techniques, see 83890-83914 with the right genetic testing modifiers 4A-4G. This instruction frees your lab to gather proper pay by choosing the molecular diagnostics codes that describe each step of a specific HLA typing test.

CPT 2011 Asks for CMS re-Examination of Time as Averages or Thresholds

All that fine green print on time in your E/M CPT 2011 manual comes down to one thing: you can round to the closest time code. However, that advice from CPT contradicts Medicare's threshold time guideline.

CPT treats times as averages

CPT 2011 indicates that you can use the code closest to the documented time. That piece of advice is nothing new. In choosing time, the doctor must have spent a time closest to the chosen code, according to CPT Assistant, Aug. 2004.

Your documented time must be equal to or cross the average time given to bill that level. For a 35-minutes spent on a medically necessary counseling-dominated visit is a 99214, according to CPT you could report 99215.

Medicare has considered times thresholds

Medicare has always considered the times indicated in CPT's code descriptors to represent minimums. The doctor would choose the lower code (for example 99214… physicians typically spend 25 minutes face-to-face with the patient and/or family …) unless the time was greater or equal to the higher-level code's required time (such as 40 minutes for 99215).

Will Medicare alter its position?

When questioned on whether Medicare would change the allotments from thresholds to averages at the CPT® and RBRVS 2011 Annual Symposium, medical directors were hesitant to give a definitive answer. "I do not want to say one way either 'yes' or 'no' at this juncture," said E/M expert Deborah Patterson, MD, clinical medical director for Trailblazer Health Enterprises, LLC in Dallas.

Prepare yourself for New ICD-10 Code set started October 2014

You would probably have been hearing about the implementation of ICD-10 for quite some time now, but till date medical offices continue to use the ICD-9 codes to describe diagnoses. But this is only until 1 October, 2014, when, after a number of hurdles and delays, ICD-10 will finally go into effect.


Need for the change
A number of ICD-9 codes have become outdated and their descriptors are also now obsolete. To keep current with the latest medical technology, procedures, and terminology, this 30-year old manual will now be replaced forever.
What do I use now?
You will continue to use ICD-9 manual until October 2014. This code set comprises:

• Volume 1: This is a numeric list that classifies diseases by their cause (etiology) and their analysis (anatomy).
• Volume 2: This numeric list alphabetic index helps find codes in Volume 1.
• Volume 3: Used only by hospitals, this procedural classification has a tabular section and an index.

What is the difference between ICD-10 and ICD-9
Let's have a look at why the replacement is necessary and what changes you need to keep in mind before you start preparing yourself for the transition.

• The former will have two systems:
  • ICD-10-CM, which is the diagnostic coding system for all healthcare applications. It will replace ICD-9-CM volume 1 (the numeric list that classifies diseases by their cause (etiology) and their analysis (anatomy) and volume 2 (thenumeric list alphabetic index that coders use to find codes in Volume 1).
  • ICD-10-PCS, a procedural coding system that is for use only on in-patients. It will replace ICD-9-CM volume 3 (the procedural classification that has a tabular section and an index. This is generally used only by the hospitals.)
• ICD-9 has mostly numeric, 3 to 5 digits codes; however, the new code set has alphanumeric codes and contains 3 to 7 characters, with the first character alphabetical. For example, if you need to lookup ICD-10 code for "hypertensive heart disease", your ICD-10 codes look up will show you these options:
  • I11—Hypertensive heart disease
  • I110—Hypertensive heart disease with heart failure
  • I119—Hypertensive heart disease without heart failure

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Remember that you will have to use these along with your CPT® cardiology codes, or else your claim form would be incomplete and you will have to see a denial.

• ICD-10 also has laterality unlike ICD-9 code set. The characters in the former will identify when the treatment was performed on right or left side, whether it was an initial encounter or a subsequent encounter, and will also provide other clinical information. In the latter, you need additional documentation to prove these facts.

• Another big difference between the two is that there are only 13,000 codes in the current system, with no space to make any more additions, but the new system will have more than 68,000 codes. It has also been designed in such a manner that it is flexible for addition of new codes.

Ace Your CPT Medical Coding With These Resources

Coding is certainly not an easy job, and there are numerous challenges in your way to accurate claims and full reimbursement. There are so many code revisions, additions, and deletions happening every year that it becomes extremely difficult to keep a track of them. 

Top these up with the complex medical jargon that you don’t understand, and you have the perfect recipe for failure. Right? Wrong. Even with all these problems slowing you down, coding can still be fun and simple. With the right coding resources in your basket, you can become a pro in no time, and report accurate, clean, and error-free claims. 

 Let’s have a look at the resources that can make your life easier and your claims cleaner:

•  Medical dictionary: You must have access to a medical dictionary, such as Stedman’s. This will help you understand the medical terms and procedures and find correct codes for it.
•   Latest copies of CPT® manual, HCPCS codes, ICD-9. Update your copies at least once every year.  New and revised CPT® codes go into effect January 1 of each year, and HCPCS codes are updated every quarter. Before you do a HCPCS code lookup, make sure that you have the most current info. ICD-9 is going to be changed to ICD-10 codes in October 2014. Most of the information is easily available online, so you can also start preparing for your transition. You can get an online access or the printed copies, full material or a specific portion that you need for your practice. But whatever you do, just make sure to have the most updated manuals.
• CPT® Assistant. CPT® Assistant is published by the American Medical Association (AMA), and it is an essential denial-busting and accuracy-boosting tool. It will help you quickly lookup a CPT® code, and also all the articles that have been published by the AMA on that particular code since 1990. You can understand the rationale behind a code and also get answers to your day-to-day burning coding questions.

You can get your subscription to the coding assistant from the AMA at an affordable price. Take a look at the beneficial features of the CPT® Assistant: 

•      Accuracy boosting: You can learn the rationale behind a code and get the latest, up-to-date information on every code that you need for your practice.

•      Time saver: In just a few clicks, you can read all the articles that have been published by the AMA on a specific CPT® code in the last two decades.

•      Get the most updated coding info: stay on top of the coding trends and developments with the new articles that are published every month. Also learn about the code changes that are supposed to go into effect and have already come into use.

•      Reduce your Accounts Receivable (A/R): Even the thought of overturning denials would sound impossible to most. But with the accurate coding knowledge and definitive guidance at hand from the AMA, it would be no more difficult.

•      Lessens appeals work: You can easily argue your case and appeal denials by cutting 'n' pasting or presenting the PDF® CPT® medical coding articles to insurance payers.

Report 94799 for MIP and MEP Tests

Question: Recently, Medicare denied my claim for 94799, which I used when my allergist performed maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) tests. Which code(s) should I use?

Minnesota Subscriber

Answer: CPT offers no codes that describe maximum inspiratory pressure and maximum expiratory pressure. Some allergists simply do not charge for these services, although others attempt payment with 94799 (Unlisted pulmonary service or procedure). But insurers often deny this code because unlisted-procedure codes carry no descriptions, fees or work values.

Before reporting 94799, you should know that both Medicare and private carriers will deny the claim pending review of your physician's documentation that supports the provided service. And insurers require that you send the physician's documentation and his or her charge for the service with the claim. You may also help your chances if you supply the carrier with a rationale for the chosen fee, which should be comparable to a procedure with the same amount of work and effort.

For example, you may compare MIP with spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). Include a cover letter with the claim that references the other procedures and highlights the similarities.
 In some cases, insurers may not pay for 94799 even if you support the code with proper documentation. For instance, if your allergist performs an experimental procedure, you can almost guarantee that the payer will deny your claim.
 - Information for Reader Questions and You Be the Coder provided by a number of coding experts, including Teresa Thompson, CPC, CCC, a nationally recognized coding, compliance and reimbursement speaker and president of TM Consulting in Carlsburg, Wash.; and Richard H. Tuck, MD, FAAP, medical director of Quality Care Partners in Zanesville, Ohio.

Can i Bill 52330 with 50590?

Proper modifier use is key to surviving these kidney stone scenarios

ESWL is ESWL is ESWL right? Wrong. Multiple stones in each kidney fragmented stones and stent placements are just a few of the things that can complicate coding for extracorporeal shockwave lithotripsy (ESWL).

ESWL represented by 50590 (Lithotripsy extracorporeal shock wave) is one of the most frequently performed procedures in urology practices as well as a popular and effective treatment for renal calculus (kidney stones). Our experts give you the facts for seven tricky ESWL coding scenarios.

Scenario 1: Multiple Stones in 1 Kidney

Problem: The urologist performs ESWL to break up multiple stones in the same kidney. Can you bill CPT Codes CPT 50590 for each stone the urologist fragments?
Solution: Sorry - if there are several stones in one kidney you cannot charge 50590 more than once for that session says Carolyn Zell CPC billing manager for the Urology Team in Austin Texas.

Scenario 2: Stones in Right Kidney and Right Ureter

Problem: The urologist finds stones in both the right kidney and the right ureter. Can you bill for ESWL performed on both sites?

Solution: Whether the stones are in the renal pelvis the calyx the ureteropelvic junction the ureter or all four locations use 50590 only once per kidney for each session. The code is valued to cover those occasions when multiple stones are treated as well.

Scenario 3: Stones in Both Kidneys
Problem: Most urologists would treat bilateral stones with ESWL at different times one within the global period of the first. How can they get reimbursed for both procedures?

Solution: Usually when faced with bilateral kidney stones urologists will indicate in the preoperative note that the ESWL will be staged with one kidney initially and another several weeks later. This prospective planning for a staged procedure must be clearly documented in the preoperative note the patient's chart or the operative note of the first procedure.

Append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the second 50590 if done at a different time says Lisa Center CPC quality review coordinator for the Freeman Health Center in Joplin Kan.

Note: When a patient has stones in both kidneys some urologists may treat both with ESWL at the same time although this is ""rare "" Center says. Report 50590 with modifier -50 (Bilateral procedure) in this case.

Remember: Use -LT (Left) and -RT (Right) modifiers to indicate which kidney the ESWL targeted Center says. If the left kidney stone is treated first use 50590-LT; for the second ESWL use 50590-RT-58.

Scenario 4: ESWL Followed by Stent Placement

Problem: Three days after an ESWL a patient returns for a stone obstructing the ureter. In the operating room the urologist places a stent. Code 50590 has a 90-day global period so the postoperative stent placement would normally be included in the fee for 50590. Can you code for the stent placement?

Solution: Medicare views the need for a stent such as a stone obstructing the ureter as a complication so you should append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to 52332 (Cystourethroscopy with insertion of indwelling ureteral stent [e.g. Gibbons or double-J type]) says Karen Delebreau coding specialist with Urological Surgeons in Green Bay Wis.

For commercial and private carriers bill the treatment of this scenario exactly the same appending modifier -78 to the second procedure code. However some private payers might view this as a new problem and therefore require you to append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to 52332.
Remember: Medicare will not pay for any postsurgical complications treated out of the operating room in locations such as your office the emergency department at the bedside or in a treatment room in the hospital.

Scenario 5: Recurring Stones Post-ESWL
Problem: A patient with another stone presents within the global postoperative period of a previous ESWL. Since it's a new stone the urologist did not write in the preoperative note for the first ESWL that a second ESWL would be staged. How should you report this procedure?

Solution: If the second ESWL is for a different stone in the same kidney and done within the postoperative period of the first ESWL Center advises using modifier -79 (Unrelated procedure) to indicate an unrelated procedure. ""It's unrelated to the first surgery "" Center says. ""Even though it's the same procedure it's a different stone.""
Kidney stones do tend to recur most often within months or years after an ESWL treatment. If a urologist performs another ESWL on a patient after the global period for the previous one has expired report code 50590 without modifiers Center says.

Scenario 6: ESWL Followed by More Extensive Procedure
Problem: The urologist performs an ESWL for a renal pelvic stone. After one month the physician realizes the stone was incompletely fragmented by the ESWL and decides to perform 50081 (Percutaneous nephrostolithotomy or pyelostolithotomy with or without dilation endoscopy lithotripsy stenting or basket extraction; over 2 cm). The diagnosis for both procedures is 592.0 (Calculus of kidney).

Solution: When a procedure is performed in a global period for the same diagnosis as was linked to the initial procedure - and the second procedure was not planned or staged at the time of the initial procedure - the second procedure must be more extensive than the original procedure to be separately billable. The coder should bill 50081 with modifier -58 appended. This will bring full payment for 50081 but a new 90-day global period would begin.
In this particular clinical scenario modifier -58 is used on a more invasive second procedure during the 90-day global period of the first unsuccessful surgery. This procedure was not prospectively planned or staged and documentation of this fact is not necessary as was needed in Scenario # 3 above.

However: This is a good scenario to bounce off your carriers Delebreau says. ""If it's group insurance and it's the same stone I usually don't hesitate to use a -58 because it's related "" she says. She had heard different advice about Medicare though so she investigated.
""I checked with some representatives and I explained situations like this where they're going back to re-treat the same stone "" she says ""and I've been told that I could still use the -58 as long as it's the same stone.""

Scenario 7: Stone Moved Back Into Kidney Before ESWL
Problem: Using cystourethroscopy and a ureteral catheter a urologist displaces a stone out of the ureter and back into the kidney with plans to perform ESWL on the stone later. How should you code both procedures?

Solution: For the first procedure in which the stone is moved into the kidney use 52330 (Cystourethroscopy [including ureteral catheterization]; with manipulation without removal of ureteral calculus) Center says. ""After the cysto and stone manipulation into the renal pelvis using the ureteral catheter the doctor would take the patient over to the ESWL machine "" she says.
Since 52330 is bundled into code 50590 bill 50590 for the ESWL and 52330 for the stone manipulation with modifier -59 (Distinct procedural service). Modifier -59 indicates that the stone manipulation was performed earlier in the day at a previous separate encounter.

Include age criteria to old parameters for correct polysomnography reportin

When a pulmonologist presents a (PSG), checking patient age in addition to look for parameters recorded and the hours spent recording and monitoring the patient will govern your code choice for reporting the procedure.

 Lookout for Number of Parameters Recorded

One thing that helps you differentiate a polysomnography from a sleep study when your pulmonologist performs it is that in a polysomnography your pulmonologist will be staging the sleep study by recording, monitoring and interpreting various parameters.

The parameters that your pulmonologist will record and monitor will include frontal, central and occipital lead electroencephalogram (EEG), left and right electrooculogram (EOG), and submental electromyogram (EMG), with four or more additional parameters: ECG, airflow (nasal and/or oral), respiratory effort, oxyhemoglobin saturation (SpO2), extremity muscle activity (bilateral anterior tibialis EMG), and body positions.

3 key parameters: One source for confusion when reporting a polysomnography will be in the counting of the number of parameters recorded as the descriptors to polysomnography codes mention the word “additional.” Remember that the EEG, EOG, and submental EMG are the three required parameters recorded. You’ll count any other parameter(s) that your pulmonologist includes beyond these three as “additional” and that number will guide your CPT® code selection. .

Check Age of the Patient

Two new codes for 2013 require you to know the patient’s age if your pulmonologist records four or more additional parameters. Based on the age and the use of CPAP or bi-level ventilation, you have four code choices to report a polysomnography that your pulmonologist performs:

    95782 (Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
    95783 (…younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist)
    95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)
    95811 (…age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist)

Choose Single CPT® Code For Less Than Three Parameters Recorded

When your pulmonologist performs a polysomnography and only records up to three parameters in addition to the standard three parameters of EEG, EOG, and EMG, you will not have to look for the age of the patient to arrive at the right code choice to report this study. When your pulmonologist records only one to three additional parameters, you have only one CPT® code choice to report the study regardless of the patient’s age.

If your pulmonologist only records one to three additional parameters, you will have to report the study with 95808 (Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist).

Example: Your pulmonologist assesses a 5-year-old patient for obstructive sleep apnea. His mother complains that the child often snores during sleep, and sometimes gasps for breath during sleep. She also complains that the child has his mouth open and is usually breathing through his mouth during sleep. Lately, she has observed that the child has problems with concentration in his studies at school that is affecting his performance. Since your pulmonologist wants to assess the child for OSA, he orders an EEG, submental EMG, Electrooculogram (EOG), respiratory effort, end tidal PCO2, and SPO2.

What to report: Since your pulmonologist records only three additional parameters above the standard parameters (EEG, EOG and submental EMG) you can report the PSG with 95807 even though the age of the patient is below six.

Suppose in the same example, your pulmonologist also records other parameters such as ECG, nasal pressure and body positions. In that case, you’ll have to report the PSG with 95782 as your pulmonologist recorded more than 4 additional parameters and the age of the patient is below six.

Count Hours to See You Need a Modifier

When your pulmonologist performs a polysomnography on a patient, one of the guidelines that needs to be followed is that a minimum number of hours of continuous and simultaneous monitoring and recording of the various physiological and pathophysiological parameters of sleep are performed to make the study complete.“95808-95811 require a minimum of 6 recorded hours.  95782-95783 require a minimum of 7 recorded hours,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia.

If, for any reason, your pulmonologist is not able to maintain this monitoring and recording of the parameters for the stipulated hours corresponding to the service, you will still be able to report the appropriate PSG CPT® code, but you will need to append the modifier 52 (Reduced services). This will enable the payer to know that the PSG was performed but the time stipulated by the guidelines was not met.“Documentation indicating the reason for the reduced or shortened hours is advisable to demonstrate that the study is still reasonable and necessary,” adds Pohlig.

If the reduced service was due to patient not be able to tolerate the study and your pulmonologist had to abort the procedure in the very beginning, you might consider reporting the procedure with the appropriate CPT® code and appending the modifier 53 (Discontinued procedure) to it.

Correct ICD-9 Codes for Follow-up and 368.10 Joins Palmetto LCD ICD-9 Choices

Read two scenarios n see what ICD-9 codes apply.

410.31 or 410.32 applies to Follow-Up?

Question: The patient is in the hospital for a 410.31, and after that is discharged. The patient is arranged to be seen in the office again for a follow-up visit. Concerning this follow-up visit, which is certainly less than 8 weeks from the myocardial infarction, is it suitable to use the fifth digit of "2" on the MI (410.32), or would you still use ICD-9 code 410.31?

Answer: You must use 410.32 (Acute myocardial infarction of inferoposterior wall; subsequent episode of care) for this particular follow-up visit. ICD-9 notes with the 410.xx fifth digit selections state that you must use fifth-digit 2 to specify an episode of care succeeding the initial episode when the patient is admitted for additional observation, evaluation or for treating a myocardial infarction that has been offered initial treatment, but is still less than 8 weeks old."

You must report 410.31 (Acute myocardial infarction of inferoposterior wall; initial episode of care) only in the initial episode of care. The fifth digit "1" is applicable until the patient is discharged, irrespective of where the cardiologist offers the care. Notes in the ICD-9 manual explain that you use "1" for the initial episode of care, irrespective of the number of times a patient may be transferred in the initial episode of care."

In case documentation doesn't mention the episode of care (initial or subsequent), you must use fifth digit "0" (Episode of care unspecified).

In case the patient returns more than eight weeks post infarction, you must use 414.8 (Other specified forms of chronic ischemic heart disease). Notes with this code agree it is suitable for any condition classifiable to 410 defined as chronic, or presenting with symptoms post 8 weeks from date of infarction."

368.10 Joins Palmetto LCD ICD-9 Options

Question: You see a notice that your LCD for Noninvasive Vascular Testing (L31712) was reviewed. How has it changed?

Answer: The Palmetto GBA local coverage determination (LCD) you talk about has had two revisions since September. Both add ICD-9 codes backing up coverage for a variety of services.

For example: The revision adds ICD-9 codes 454.8 (Varicose veins of lower extremities with other complications) and 586 (Renal failure unspecified) to the list of ICD9 codes supporting these particular procedure codes:

•     93965 (Noninvasive physiologic studies of extremity veins, complete bilateral study (e.g., Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography)
•     93970 (Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study
•     93971 (Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study)

Compliance Tips: Optometrists,Now You Can Break The HIPAA Training Ice

Let's face it - a company memo requiring attendance at a HIPAAtraining seminar is not the same thing as two tickets to see Pearl Jam or Jerry Seinfeld.

While it seems difficult to get your optometry practice animated or concerned over protected health information, here's a quick and clever introduction used by Steve Paul, IS manager for the Seattle-based Children's Home Society of Washington, to help warm the crowd:

At the beginning of the training session, Paul asks all of the attendees to introduce themselves to the person seated next to them by sharing such basic information as their name and their department. The introductions continue as Paul asks his audience to share their age and their weight - followed then by their drug addictions and their history of sexually transmitted diseases!

"Some of the younger employees have no problem sharing age and weight, but by the time I get to the STDs, they look at me like I'm crazy," he says. According to Paul, the exercise allows him to broach the importance of HIPAAtraining by giving his attendees "the sense of why information regarding our residents should be kept private." When the training is done, he happily informs the audience that they've been officially "HIPAA-tized."

"I have found [this introduction] successful at every level I've used it, including private conversations and groups," Paul says. "The feedback I've received is that it personalizes the issues and makes the purpose of the training come to life."

Otolaryngology Answer Five Crucial Questions for Tympanic Repair To Determine Code Selection

Several factors make the selection of a tympanic repair code difficult. Probably the most important is that there are many tympanic repair procedures, from the relatively simple paper patch"" repair to radical tympanoplasty and mastoidectomy with ossicular chain reconstruction.

Tympanic perforations can be caused by trauma" middle-ear infection cholesteatoma or other disease. Fifteen codes in the "Repair" subsection of the 69000 series (auditory section) of the CPT manual may be used to report this continuum of tympanic repair procedures and selecting the correct code can be overwhelming.

The coder may lack the knowledge of medical and CPT terminology required to understand how the codes differ from each other. The otolaryngologist may be unaware that the codes do not correspond with the tympanoplasty categories (type I through type V) that he or she is familiar with. For example mastoidectomy a major factor in tympanoplasty coding figures very little in determining the clinical type of tympanoplasty performed.

The difficulties with the codes may be further exacerbated because some of the descriptors do not necessarily match what the otolaryngologist performs.

"This is a classic example of the importance of using CPT rather than clinical terminology at the top of the operative report" says Randa Blackwell coding and reimbursement specialist with the department of otolaryngology at the University of Maryland in Baltimore. She says new inexperienced coders are unlikely to know the clinical difference between mastoidectomy and mastoidotomy as well as the clinical subtleties that differentiate radical from modified radical or a tympanoplasty with mastoidectomy from a tympanoplasty/mastoidectomy with reconstructed wall.

However if the otolaryngologist's documentation provides clear answers to the following questions it may be possible to zero in quickly on the correct code.

No. 1: Was the Surgery Performed in the Office or the OR?

The simplest tympanic repair is often referred to as a paper patch and is reported with 69610 (tympanic membrane repair with or without site preparation or perforation for closure with or without patch). This procedure involves patching a small puncture of the eardrum with a cigarette-type paper and is typically performed in the otolaryngologist's office. Three or four applications of a patch may be needed before the perforation closes completely.

The paper-patch technique sometimes fails and even if the patch is placed correctly it does not always provide prompt or adequate closure of the tympanic membrane perforation. In such cases the otolaryngologist may need to perform myringoplasty which involves using a fat or soft-tissue graft (usually temporalis fascia) to repair the perforation. Unlike the paper patch myringoplasty is typically performed in the operating room (OR) and is coded 69620 (myringoplasty [surgery confined to drumhead and donor area]).

Note: For a discussion on billing tympanic repair grafts see sidebar on page 76.

No. 2: Was Surgery Confined to the Drumhead?

Myringoplasty is often confused with tympanoplasty which is also performed in the OR. However in CPT terms myringoplasty (69620) is a relatively straightforward procedure (8.06 transitioned RVUs and a 10-day global period) but tympanoplasties are more complex procedures (all the tympanoplasty codes have 90-day global periods and describe procedures that require anesthesia and are performed in the OR).

"The key to distinguishing between myringoplasty and tympanoplasty is knowing if the surgery was confined to the drumhead and the donor site for the graft to repair the perforation " says Lee Eisenberg MD an otolaryngologist in private practice in Englewood N.J. and a member of CPT's editorial panel and executive committee. "If the surgery was confined to the drumhead it's a myringoplasty. This means the otolaryngologist enlarged the perforation freshening the edges and then placed a small piece of fat or fascia (harvested at the donor area see code descriptor) into or under the perforation. If however the otolaryngologist elevates the canal wall skin to repair the perforated eardrum or look at the ossicular chain inside the middle ear the procedure is likely best described by a tympanoplasty code."

Myringoplasty is performed via the ear canal but tympanoplasty a more complex procedure often uses a postauricular incision Eisenberg says.

Because there are a dozen tympanoplasty codes simply noting that a tympanoplasty was performed does not provide enough information to select the correct code for the procedure. To do so you must ask further questions:

No. 3: Was the Mastoid Affected? How Extensively?

The tympanoplasty codes in the CPT manual do not parallel the clinical classification system used by many physicians by which tympanoplasties are placed in one of five "types " none of which include mastoidectomy. As a result many otolaryngologists and their coders try to match for example a type I tympanostomy with a myringoplasty or a type V tympanostomy with a more complicated tympanostomy code when no connection or similarity exists.

"The tympanoplasty-by-type terminology is not useful for coders " Blackwell says. "Although a type I tympanoplasty may sometimes conform to a 69620 myringoplasty many procedures categorized by any of the five types may also be categorized as a basic tympanoplasty or one of its variants." Eisenberg recommends that otolaryngologists limit the use of clinical terminology to the procedure notes and use CPT terminology whenever possible at the top of the operative report.

To understand how CPT organizes the tympanoplasty codes think of the codes as being arranged in four groups:

1. Without mastoidectomy

2. With mastoidectomy (or mastoidotomy)

3. With mastoidectomy and reconstruction of the canal wall

4. With modified radical or radical mastoidectomy.

Tympanoplasty may be performed with or without mastoidectomy (excision of the mastoid a group of air cells in the bone behind the pinna). In either case the tympanoplasty may include canalplasty (enlarging the ear canal) atticotomy (when the surgeon drills on the posterior bony canal wall to look into the attic) and/or middle-ear surgery such as removing cholesteatomas or granulation tissue or just looking at the ossicles.

If the condition that resulted in the perforated tympanic membrane is limited to the ear the otolaryngologist performs a tympanoplasty without mastoidectomy (69631 tympanoplasty without mastoidectomy [including canalplasty atticotomy and/or middle ear surgery] initial or revision; without ossicular chain reconstruction]). The patient is anesthetized and the middle ear is entered through either the ear canal or postauricular incision then a piece of temporalis fascia is placed beneath the perforation.

In many cases the otolaryngologist suspects that the mastoid is affected (due to cholesteatoma or a chronic draining ear for example) or that a mastoidectomy is needed because of a previously failed tympanoplasty. Like the ethmoid sinuses behind the nose the mastoid in its normal state resembles a honeycomb composed of many bony partitions or air cells.

When a More Extensive Procedure Is Required

If the otolaryngologist decides to enter the mastoid he or she may perform an antrotomy or mastoidotomy to view the mastoid antrum and then evaluate the need for more extensive surgery. This procedure is reported with 69635 (tympanoplasty with antrotomy or mastoidotomy [including canalplasty atticotomy middle ear surgery and/or tympanic membrane repair]; without ossicular chain reconstruction).

If the otolaryngologist decides to do a more complete procedure a mastoidectomy is performed in conjunction with the tympanoplasty. This procedure coded as 69641 (tympanoplasty with mastoidectomy [including canalplasty middle ear surgery tympanic membrane repair]; without ossicular chain reconstruction) involves drilling out all or most of the cells in the mastoid.

If the canal wall is taken down to remove completely all the mastoid contents and is reconstructed use 69643 ( with intact or reconstructed wall without ossicular chain reconstruction).

If the patient's condition is particularly severe a modified radical or radical mastoidectomy may be needed. Either procedure is coded 69645 ( radical or complete without ossicular chain reconstruction). In the radical technique the otolaryngologist removes most of the mastoid canal wall and middle-ear bones. The modified radical mastoidectomy meanwhile aims to maintain an aerated middle ear.

Note: CPT also includes a series of codes (69501-69511) to report mastoid surgery performed without tympanoplasty.

According to Eisenberg 69645 is confusing because it identifies and describes only a radical mastoidectomy. There is no code for tympanoplasty with modified radical mastoidectomy even though this procedure is preferable and may be performed more often than the true radical mastoidectomy (neither procedure is frequently performed).

Eisenberg maintains that the way the codes are written implies that 69645 and its derivative 69646 should be used for radical and modified radical mastoidectomies.

No. 4: Was Ossicular Chain Reconstruction Done?

If during the course of any of the tympanoplasties described above a defect in the bones is discovered in the bones of the middle ear (ossicles) or if an eroded bone had to be removed during surgery the otolaryngologist may repair the defect by replacing the bone(s) a service referred to as ossicular chain reconstruction. Any middle- ear repairs during tympanoplasty are more likely to be attempted if the ear is dry and not infected.

Sometimes the need for such repairs can be determined prior to surgery. Often however it becomes clear to the otolaryngologist only when the ear is opened completely and examined under the operating microscope. The most common bone erosion occurs at the tip of the incus (anvil) which is connected by a piece of bone only 1.5 mm thick to the stapes (stirrup bone). If the patient had prior infections the circulation to the bone may be obstructed and infection can wear away the connection.

To repair the defect there are several options. A piece of tragal cartilage (the cartilage in front of the ear canal) may be placed or more commonly the patient's incus or one from a donor is reshaped to replace the missing ossicle.

In some cases a prosthesis made of synthetic material is used instead of bone. For example the physician may insert a strut made from artificial bone. This is porous and allows blood vessels to grow resulting in the complete assimilation of the artificial bone.

Each group of tympanoplasty codes described earlier 69631 69635 (mastoidotomy) 69641 69643 and 69645 includes a secondary code that includes ossicular reconstruction. Two of the categories tympanoplasty without mastoidectomy and tympanoplasty with mastoidotomy also include a tertiary code if a prosthesis is used to aid the reconstruction. The codes are listed as follows:

• 69632 tympanoplasty without mastoidectomy ... initial or revision; with ssicular chain reconstruction (e.g. postfenestration)
  
  
• 69633 with ossicular chain reconstruction and synthetic prosthesis (e.g. partial ossicular replacement prosthesis [PORP] total ossicular replacement prosthesis [TORP])
  
  
• 69636 tympanoplasty with antrotomy or mastoid-otomy ...; with ossicular chain reconstruction
  
  
• 69637 with ossicular chain reconstruction and synthetic prosthesis (e.g. partial ossicular replacement prosthesis [PORP] total ossicular replacement prosthesis [TORP])
  
  
• 69642 tympanoplasty with mastoidectomy ...; with ossicular chain reconstruction
  
  
• 69644 with intact or reconstructed canal wall with ossicular chain reconstruction
  
  
• 69646 radical or complete with ossicular chain reconstruction.
  

If ossicular chain reconstruction is performed with either bone or a synthetic prosthesis these codes should be used in place of the primary codes they follow.

No. 5: Was a Revision Performed?

Sometimes a tympanoplasty with mastoidectomy is performed but the patient continues to manifest symptoms such as cholesteatoma. Or the patient may have had acute mastoiditis that required mastoidectomy and now requires a revision mastoidectomy but also has a middle-ear disease that necessitates tympanoplasty. In such cases the otolaryngologist may decide to perform a revision mastoidectomy which is a much different procedure from a mastoidectomy performed on a patient with no history of previous mastoid intervention.

CPT includes one code (69604 revision mastoidectomy; resulting in tympanoplasty) for revision mastoidectomies performed with tympanoplasty. There is however no specific code for tympanoplasty revisions Blackwell notes. If the otolaryngologist performs a revision tympanoplasty the correct tympanoplasty code should be chosen from those listed earlier based on what
was performed.

If the revision makes the tympanoplasty more difficult modifier -22 (unusual procedural services) may be used as long as there is appropriate supporting documentation.

As with all documentation the dictation that supports the request for additional fees to compensate for the extra effort required to perform the procedure should use terminology that is CPT-compatible Blackwell says."