How bill a cerclge removal without anesthesia

Question: How do I bill for a cerclage removal performed in the office with a local anesthetic? I see 59871 in CPT, but that represents a removal under anesthesia other than local. Should I code 59899 for an unlisted procedure, or is there something better?

Missouri Subscriber

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.



Answer: If the same physician removing the cerclage suture also performed the cerclage, he or she cannot charge for the removal. The removal is included in the insertion. If the physician removing the cerclage did not perform the procedure, you can only code this service as an E/M service. You would not report 59899 (unlisted procedure, maternity care and delivery) because you are not performing a surgical procedure when you remove sutures. You can also bill for the local anesthetic if a block was used 64430 for a pudendal block or 64435 for a paracervical block.

Correct Coding Scenarios Using 94640, 94664, 94665

Example #1: A 13-year-old boy comes into the office for an unscheduled visit after soccer practice. He is coughing, wheezing and having difficulty breathing. After conducting a pulmonary function test and measuring the boys oxygen saturation, the physician provides nebulizer therapy. After 30 minutes, the patients symptoms have been only partially relieved and the treatment is repeated. The second inhalation alleviated the patients distress and, after observation, a metered-dose inhaler is prescribed. The nurse explains how the inhaler works and conducts a demonstration.

Coding:

Office visit E/M code (e.g., 99213, office or other outpatient visit, established patient) to reflect the level of service documented; with modifier -25 (significant and separately identifiable service)

Pulmonary function test 94010, spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation.

Oximetry 94760, noninvasive ear or pulse oximetry for oxygen saturation; single determination (note: Medicare and some payers may bundle oximetry with E/M code).

Nebulizer treatment 94640, nonpressurized inhalation treatment for acute airway obstruction.

Repeat treatment 94640-76, repeat procedure by same physician.

Demonstration 94664-59, aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation,-distinct procedural service.

Medication J7618 x 3 (two treatments, one demonstration), albuterol, all formulations including separated isomers, inhalation solution administered through DME, concentrated form, per 1 mg.

Example #2: A 75-year-old woman schedules an appointment because of tightness in her chest, accompanied by fever, difficulty catching her breath and cough. Symptoms have lasted four days and have worsened during that time. Suspecting pneumonia, the family physician uses nebulizer therapy to assist the patient in producing sputum for a sputum culture. The patient also indicates that the inhaler has eased her breathing. The physician prescribes antibiotics and an inhaler to relieve symptoms. Two days later, the patient calls the office saying the inhaler has not been working properly. An appointment is scheduled, and the nurse reviews use of the inhaler with the patient.

Coding:

First date of service E/M code (e.g., CPT 99214 , office or other outpatient visit, established patient) to reflect the level of service documented, with modifier -25 (significant and separately identifiable service).
Nebulizer therapy, first date 94664, aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation.
Demonstration, second date 94665, subsequent.

FAQs on the codes with answers provided by CMS

The following are FAQs on the codes with answers provided by CMS.

Q: What date of service should be used on the claim?
A: The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The reported date of service should be the 30th day.
Q: What place of service should be used on the claim?
A: The place of service reported on the claim should correspond to the place of service of the required face-to-face visit.
Q: If the codes became effective on Jan. 1 and, in general, cannot be billed until 29 days past discharge, will claims submitted before January 29th with the TCM codes be denied?
A: Because the TCM codes describe 30 days of services and because the TCM codes are new codes beginning on January 1, 2013, only 30-day periods beginning on or after January 1, 2013 are payable. Thus, the first payable date of service for TCM services is January 30, 2013.
Q: The CPT book describes services by the physician’s staff as “and/or licensed clinical staff under his or her direction.” Does this mean only RNs and LPNs, or may medical assistants also provide some parts of the TCM services?
A: Medicare encourages practitioners to follow CPT guidance in reporting TCM services. Medicare requires that when a practitioner bills Medicare for services and supplies commonly furnished in physician offices, the practitioner must meet the “incident to” requirements described in Chapter 15 Section 60 of the Benefit Policy Manual 100-02.
Q: Can the services be provided in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC)?
A: While FQHCs and RHCs are not paid separately by Medicare under the Physician Fee Schedule (PFS), the face-to-face visit component of TCM services could qualify as a billable visit in an FQHC or RHC. Additionally, physicians or other qualified providers who have a separate fee-for-service practice when not working at the RHC or FQHC may bill the CPT TCM codes, subject to the other existing requirements for billing under the MPFS.
Q: If the patient is readmitted in the 30-day period, can TCM still be reported?
A: Yes, TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge. CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.
Q: Can TCM services be reported if the beneficiary dies prior the 30th day following discharge?
A: Because the TCM codes describe 30 days of care, in cases when the beneficiary dies prior to the 30th day, practitioners should not report TCM services but may report any face-to-face visits that occurred under the appropriate evaluation and management code.
Q: Medicare will only pay one physician or qualified practitioner for TCM services per beneficiary per 30 day period following a discharge. If more than one practitioner reports TCM services for a beneficiary, how will Medicare determine which practitioner to pay?
A: Medicare will only pay the first eligible claim submitted during the 30 day period that commences with the day of discharge. Other practitioners may continue to report other reasonable and necessary services, including other E/M services, to beneficiaries during those 30 days.

Open Door Forum Call Including TCM Code Information

CMS is holding a Open Door Forum on Tuesday, March 12, 2013, at 2:00 p.m. Eastern (ET) which will include some information about TCM codes, and an opportunity for listeners to ask individual questions of the presenters.

CALL AGENDA: (subject to change)

I. Opening Remarks

• Chair – Stewart Streimer (CM)

• Co-Chair – Dr. William Rogers (OPE)

• Moderator – Barbara Cebuhar (in lieu of Matthew Brown, OPE)

II. Announcements & Updates

• Physician Compare Website Redesign
• DMEPOS Competitive Bidding
• Ordering & Referring
• Transitional Care Management:
• Health Insurance Marketplace

III. Open Q&A
Open Door Participation Instructions:
To participate by phone:
Dial: 1-800-837-1935 & Reference Conference ID: 78871126. Call in 15 minutes before the start of the call.

Persons participating by phone do not need to RSVP
TTY Communications Relay Services are available for the Hearing Impaired.  For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.
Encore: 1-855-859-2056; Conference ID: 78871126.
Encore is an audio recording of this call that can be accessed by dialing 1-855-859-2056 and entering the Conference ID. This recording will be accessible beginning 2 hours after the ODF and expires after 3 business days.

99495 – 99496 Management Of Transitional Care Services

These codes include:

• Moderate to high complexity medical decision making needs during care transition
• First interaction (can be face-to-face, by telephone, or electronic) with patient or his/her caregiver and must be done within 2 working days of discharge. If two separate attempts are made in a timely manner, but are unsuccessful and other TCM criteria are met, the service may be reported. Medicare, however, expects attempts to communicate to continue until they are successful.
• Initial face-to-face interaction within described time frame (99495 = 14 days and 99496 = 7 days) and include medication management
• All services  from the discharge day up to 29 days post-discharge

Examples of non face-to-face services provided by physicians and non-physician providers included in TCM codes are:

• Arrangement of follow-up and referrals with community resources and providers
• Contacting qualified health care professionals for specific problems of patient
• Review of discharge information
• Need for follow-up care review based on tests and treatments
• Patient, family and caregiver education

Note that the non-physicians who may bill TCM codes are Nurse Practitioners (NPs), Physician Assistants (PAs), Clinical Nurse Specialists (CNSs), and Certified Nurse Midwives (CNMs), unless they are otherwise limited by their state scope of practice.
Physicians reporting TCM codes are most likely to be primary care physicians, however other specialties may report them. Both CPT and Medicare prohibit a physician who reports a service with a global period of 10 or 90 days from also reporting the TCM service.
Examples of non face-to-face services provided by staff under the guidance of physicians and non-physician providers included in TCM codes are:

• Caregiver education to family or patient, addressing independent living and self-management
• Communication with patient and all caregivers and professionals regarding care
• Determining which community and health resources would benefit the patient
• Providing communication with home health and other patient-utilized services
• Support for treatment and medication adherence
• The facilitation of services and care

These TCM codes do not include (and may be billed separately):

• E/M services after the first face-to-face visit
• Tests and procedures

The following services cannot be billed during the time period covered by transitional care:

• care plan oversight services (99339, 99340, 99374 – 99380)
• prolonged services without direct patient contact (99358, 99359)
• medical team conferences (99366 – 99368)
• end stage renal disease services (90951 – 90970)
• online medical evaluation services (98969, 99444)
• education and training (98960 – 98962, 99071, 99078)
• anticoagulant management (99363, 99364)
• telephone services (98966 – 98968, 99441 – 99443)
• preparation of special reports (99080)
• analysis of data (99090, 99091)
• complex chronic care coordination services (99481X – 99483X)
• medication therapy management services (99605 – 99607)

99495 – Transitional Care Management Services (Medicare reimburses $163.99 for non-facility) with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
• Medical decision making of at least moderate complexity during the service period
• Face-to-face visit within 14 calendar days of discharge

99496 – Transitional Care Management Services (Medicare reimburses $231.36 for non-facility) with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
• Medical decision making of high complexity during the service period
• Face-to-face visit within 7 calendar days of discharge (note that discharge and TCM may not be billed on the same day.)

What questions do you need to answer in your practice to insure you are correctly using the TCM codes?

1. Have you spoken with all payers to determine which ones will reimburse you for TCM codes?
2. If you do not see your patient in the hospital, how will you know your patient is in the hospital? Most hospitals/facilities should call you to schedule a follow-up visit for the patient, triggering a TCM event. If this is not being done, how will you know your patient has been discharged? Hospitals have a vested interest in making this work as they want to prevent readmissions, so they should be helpful in working on a communication plan.
3. Who in your practice has primary responsibility for managing the discharged patients and triggering the first contact and face-to-face visit within the time frames? What manual or electronic tickler system will be used to alert staff?
4. What forms for a paper chart or templates for an EMR will be needed for documentation of all services provided?
5. Do your providers know the difference between moderate and high complexity medical decision making? If not, get them up to speed.
6. Will your billing system flag the claim with the TCM code to be dropped at 30 days, or will you need an alert system to be sure the claim is dropped appropriately? Can your billing system be programmed to hold charges to review for TCM patients that will not be paid during the TCM period in addition to the TCM code? If not, what’s your plan?

source
http://managemypractice.com/do-you-understand-the-new-medicare-transitional-care-management-service-codes/

PRINCIPLE XI. POISONING AND ADVERSE EFFECTS OF DRUGS AND E CODES

1. ICD-9-CM provides codes to differentiate betwe en poisoning and an adverse
reaction to a correct substance properly prescribed and administered correctly. (See
principle XIV for poisoning.)

2. The World Health Organization has proposed a definition of an adverse drug
reaction as any response to a drug "which is noxious and unintended and which occurs
at doses used in man for prophylaxis, diagnosis, or therapy".

3. Terms frequently used in diagnostic statements to identify adverse drug reaction to
a correct substance properly administered are : accumulative effect, allergic reaction,
idiosyncratic reaction, hypersensitivity, paradoxical reaction, and side effects,
synergistic reaction and antagonistic drug interactions.

4. Categories E93-E949 provide means to identify the drug responsible for a n
adverse reaction to a substance correctly administered. These E Code subcategories
provide the same specificity in identifying the drug involved in causing the adverse
reaction as do categories 96 -979 in identifying the drug involved in poisoning. Not e
that codes 96-979 cannot be used in combination with codes E93-E949. One
identifies a substance causing poison, and the other identifies a substance causing an
adverse reaction in therapeutic use.

5. The adverse reaction to a correct substance prop erly administered is classified to
the manifestation or the nature of the adverse reaction, such as gastritis, lymphadenitis,
urticaria, psychosis, etc.

6. Two codes are required to code an adverse reaction to a correct substance properly
administered. First code the adverse reaction using a code from 1-799 categories;
second, code the drug or substance which caused it, using an E code from the
Therapeutic column of the Table of Drugs and Chemicals. If the reaction is unknown,
use code 995.2 and the E code.

7. Codes E93-E949 can never be used as a solo code. The adverse reaction code is
always sequenced first. The E code can never be the principal diagnosis.

8. Code 995.2 will be used for unspecified nature of allergic or idiosyncratic reactions
to a correct substance properly administered (drug allergy, NOS). It is provided for
those cases in which a code from 1-799 cannot be assigned because the nature of
the reaction is not known/stated. In these cases 995.2 is sequenced first, and the E
code is an additional code

Correct Coding for Excision of Malignant Skin Lesions

Correct coding of malignant skin lesion excisions can be very complex. Several factors need to be taken into account when choosing the correct codes. These factors include the size of the lesion, the size of the excision, the depth of the excision (skin subcutaneous, fascia, muscle), the location on the body of the lesion and the closure. An understanding of the distinction between the 116XX malignant lesion excision codes and the 2XXXX radical excision malignant codes allows the best prospect for reimbursement if the requirements of each specific code are met and appropriately documented.
Excision malignant lesion codes 11600 to 11646 indicate full thickness excision of a skin lesion including margins. This margin is determined by the diameter of the lesion plus the most narrow margin required to excise the lesion. Since most skin lesions are excised in an elliptical fashion to facilitate an esthetic closure, it is the narrow margin that determines the adequacy of the excision (Example A). These codes are stratified by location in the body and by the dimension of the excision (Table). The malignant lesion excision Current Procedural Terminology (CPT) Codes 11600 to 11646 include simple closure of the wound.

If the diameter of the lesion and the most narrow margin totals more than 4 cm, a 22 modifier should be included and the charge increased appropriately.

When the excision site is closed using an adjacent tissue transfer, whether that involves undermining in order to facilitate the closure, mobilization and placement of a local flap or Z-plasty, the 14000--14350 CPT Codes (adjacent tissue transfer or rearrangement) should be used. These codes include the excision of the defect so that an excision code is not used in addition to the 14XXX Codes.

When the excision site is closed by intermediate or complex closures such as fascia and/or subcutaneous closure, both the excision code and the closure code should be used (Example B).
When the excision extends deep to the subcutaneous tissues involving either fascia or underlying muscle, the radical excision CPT codes in the musculoskeletal section would be appropriate. For example, wide excision of melanoma of the back including subcutaneous tissues and underlying fascia would be coded 21935. If the excision site is covered with a split or full-thickness skin graft, the appropriate graft code should be used in addition to the appropriate excision code (Example C).

Example A A 1 cm basal cell carcinoma is excised from the arm of a patient. The narrowest margin is 0.5 cm on either side of the lesion. The total narrowest margin measures 2 cm (1 x 0.5 x 0.5). This skin excision deeply extended only down to the subcutaneous tissues. The appropriate code would be 11602. With a simple skin closure, no other code would be appropriate.

Example B Excision of a basal cell carcinoma from the skin of the neck results in an elliptical excision with a narrowest margin of 2.5 cm. The deep margin of excision included the platysma muscle. A two-layer closure was carried out, including a deep platysma layer and a skin layer. We would recommend an 11623 as the excision code and 12041 as the closure code.

Example C A 2.5-cm melanoma is excised from the leg. Lateral margins result in a total excision defect of 6 cm with a depth of excision that includes the fascia of the underlying muscle. The defect is closed with a split-thickness skin graft. Correct coding for this procedure would be 27615 (radical excision-malignant lesion, leg or ankle) and 15120 for the split thickness skin graft.

Comment One of the aggravating aspects of these malignant excision codes is the complexity and difficulty of selecting the correct code or set of codes for any particular situation. In Example B, an excision code and the closure code is one option; if deep margin of excision extends to the underlying muscle fascia, the radical excision codes would be appropriate.

Updates on CPT Codes for RF Ablation of Uterine Fibroids by AMA

Halt Medical announced that the American Medical Association (AMA) Current Procedure Terminology (CPT) Panel has established a new CPT® code specifically for Radiofrequency (RF) Ablation of Uterine Fibroids.


CPT codes used by medical practitioners; including physicians, hospitals, and others healthcare providers to report healthcare services to insurers for the purpose of reimbursement. This standardized nationwide system of identification provides a uniform language for reporting medical services.

"The existence of this unique code will simplify the process, for both providers and insurers, of submitting and processing claims on behalf of their patients," according to Russ DeLonzor, President and COO of Halt Medical, Inc. Jeffrey M. Cohen, CEO of Halt Medical added that, "Category III CPT Codes are reserved for important new and emerging technologies, such as the Acessa™ Procedure, and are intended to recognize and capture reported services and procedures. As a healthcare manufacturing company, we are incredibly pleased with this development. We look forward to working with our customers and insurers to continue improving access to this procedure for those women suffering from symptomatic uterine fibroids." 

The Acessa Procedure is a minimally invasive laparoscopic procedure that delivers radiofrequency energy to destroy the fibroids. After treatment, the fibroid is re-absorbed by the surrounding tissue. Acessa allows the surgeon to treat only the fibroids, while preserving normal function of the uterus. Patients typically go home the same day with little pain, and enjoy a rapid return to normal activities. More than 300 women have been successfully treated with Acessa.

CMS Leaves ICD-10 Testing Up to the Industry

The Centers for Medicare & Medicaid Services (CMS) announced in
April it will not perform end-to-end tests of ICD-10-CM and PCS fee-for-service (FFS) claims with providers before October 2014. This means providers, facilities, and EMR vendors must make sure they are ready for the mandatory implementation.

The federal agency explains end-to-end testing was already done when its 5010 data standard was implemented last year, and ICD-10-CM and PCS are code sets rather than mechanisms to manage the data. CMS says providers and payers are pretty much on their own to assure ICD-10 codes will be reportable and payable. End-to-end testing is a process-wide testing of electronic claims submission, adjudication, and “payment” to iron out bugs before a change is made to Medicare and commercial payment.

The agency is doing internal testing, but it won’t be providing a lot of support to providers, Rhonda Buckholtz, vice president of ICD-10 education for AAPC, explained. She said this presents a challenge to both providers, who must assure their systems can handle ICD-10-related claims, and payers, who must retool and test their systems in time for the transition. The biggest worry is guaranteeing the process works from provider to payer and back.

Medicare administrative contractors (MACs) are encouraging providers to begin testing, but also won’t be providing much support. Lack of a cohesive national effort means chaos, Buckholtz fears. “We can’t have another 5010,”  she said, referring to the delayed and confusing implementation of the data standard now used for Medicare and commercial claims. She and others in the industry are working to change CMS’ mind before it becomes too late. Buckholtz said, “this is not just a technology issue, it’s how that code actually hits systems and if it can get paid.”

In the meantime, she advises, providers should communicate with their electronic health care system vendors and payers to assure claims and revenue will not be held up by systems not ready for the new code set’s implementation.

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