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.