Apply 722.8x Series for Failed Back Syndrome Diagnosis

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

Michigan Subscriber

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


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

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

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

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

Dont Confuse -59 With Multiple Procedures

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

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

A different session or patient encounter;

A different procedure or surgery;

A different site or organ system;

A separate incision/excision;

A separate lesion; or

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

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

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

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

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

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

An Ob/gyn Vignette Using -59

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

781.99 Is Best Sensory Integration Disorder Choice

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

Nevada Subscriber

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


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

Look to 726.4 for Intersection Syndrome

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

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

Clarification: MRI and MR Arthrography of the Shoulder

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

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

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

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

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

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

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

Reader Question: Acoustic Neuroma

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

Maggie Kissinger
Diversified Billing, Lafayette, Calif.

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

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

You Can Use Congenital Echo For Any Anomaly ...

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

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

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

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

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

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

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

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

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

Reader question: Tinnitus Coding

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


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

What are HCPCS codes?

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

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


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

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

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


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

What are CPT® codes?

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

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


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

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

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

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

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

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

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

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

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

Tips you’d like to make note of:

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

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

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

Append 76 for Multiple Nebulizer Treatments

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

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

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

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

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

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