Q: In ICD-9-CM we only have one type of Excludes note. ICD-10-CM uses Excludes1 and Excludes2. What is the difference between the two types of Excludes notes and how do they relate to Excludes notes in ICD-9-CM?
When coders hear the words "interventional radiology," many think of vascular procedures. However, interventional radiology encompasses additional, nonvascular procedures, such as nephrostomy tube placement and drainage of abscesses.
Our coding experts answer your questions about physician supervision for chemotherapy, billing injectable drugs, Addendum B and coverage, new transitional care management codes, and stent placement with other procedures.
The AMA added five new nuclear medicine codes to the radiology section of the 2013 CPT Manual , while revising and deleting a number of codes that represented outdated technology or were bundled into placement procedures.
As more patients are being impacted by noncoverage of self-administered drugs, coders and billers need to know when and how to report drugs and drug administration services. Kimberly Anderwood Hoy, JD, CPC, and Valerie Rinkle, MPA, discuss the differences in how drugs are paid under Medicare Part A and Part B.
Q: The rule our institution has followed with respect to HCPCS coded medications without a local coverage determination (LCD) is to limit prescribing to the FDA-approved indications. The question that arises is how closely do the physicians need to follow the package insert? For example, the drug basiliximab does not have an LCD and the FDA indication is: For acute kidney transplant rejection prophylaxis when used as part of an immunosuppressive regimen that includes cyclosporine and corticosteroids. Generally, physicians performing transplants at our institution do not use steroids or cyclosporine. They use tacrolimus, sirolimus, mycophenolate mofetil, and/or mycophenolate sodium. If the physician performs a transplant without cyclosporine or steroids, do we need to have the patient sign an advanced beneficiary notice?
CMS defines self-administered drugs as drugs patients would normally take on their own. In general, Medicare will not pay for self-administered drugs during an outpatient encounter or for drugs considered integral to a procedure. Kimberly Anderwood Hoy, JD, CPC, and Valerie Rinkle, MPA, explain how to determine whether a drug is integral, self-administered, or both.
Q: A patient went to the operating room under anesthesia for cataract extraction and repair of retinal detachment of the same eye. The surgeon successfully removed the cataract. The surgeon then accessed the back of the eye to begin to repair the detachment. After reviewing the condition of this eye area, the surgeon determined that the eye was in such bad shape it could not be saved, so the detachment was not repaired and surgery was ended. The patient was under anesthesia and the retinal detachment repair procedure was begun (although barely) but then cancelled. Should we report this procedure since the facility incurred expenses for the surgical attempt at repair?
As part of the 2013 OPPS Final Rule, CMS made major changes to how it will reimburse facilities for separately payable drugs and how it will calculate APC relative weights. Jugna Shah, MPH, and Valerie Rinkle, MPA, review the most significant changes in the final rule.
One of the major changes to the 2013 CPT Manual is the replacement of the term "physician" with "physician or other qualified healthcare professional" (QHP) in a wide range of codes.
Physicians and other providers practice in many different areas within a hospital. To accurately code physician and provider services, coders must know and understand the place of service (POS) codes.
CMS announced changes to reporting therapy services—the biggest operational change for 2013—in the Medicare Physician Fee Schedule final rule instead of the OPPS final rule. Jugna Shah, MPH, and Valerie Rinkle, MPA, explain the changes to therapy reporting and molecular pathology coding.
Q: How should we bill for the physician in the following situation? A patient who has end-stage renal disease (ESRD) comes into a hospital’s emergency department (ED) with an emergent condition (dialysis access clotted or chest pain that is ruled out), but misses his or her dialysis treatment. Part of the treatment is dialysis performed in the ED or as an outpatient. The hospital bills G0257 (unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility) as per CY 2003 OPPS Final Rule guidelines and Pub 100-04, Chapter 4, section 200.2
As part of the 2013 OPPS final rule, CMS finalized a clarification to 42 CFR 419.2(b) that could cause confusion in the future if hospitals are audited by third-party payers or by Medicare contractors who do not fully understand the intent of the language or how CMS develops payment rates, says Jugna Shah, MPH, president of Nimitt Consulting based in Washington, D.C.
The biggest operational change for outpatient facilities for 2013 does not appear in the 2013 OPPS final rule. Instead, CMS announced changes to reporting therapy services in the 2013 Medicare Physician Fee Schedule (MPFS) final rule.
Hospitals earned a big win with drug payments this year in the 2013 OPPS final rule, released November 1. CMS decided to finalize its proposal to follow the statute and reimburse facilities at the average sales price (ASP) plus 6%.
As part of the 2013 OPPS final rule, CMS finalized a clarification to 42 CFR 419.2(b) concerning packaged services. Jugna Shah, MPH, and Valerie Rinkle, MPA, explain how this clarification could cause confusion in the future if hospitals are audited by third-party payers or by Medicare contractors who do not fully understand the intent of the language or how CMS develops payment rates.
Q: Is nursing documentation of completion of physician-ordered procedures, such as splinting/strapping, Foley catheter insertion, etc., sufficient to assign a CPT ® code for billing the procedure on the facility side in the ED?
Q: CPT ® code 85660 (sickling of RBC, reduction) has a medically unlikely edit of one unit. We test blood for transfusion for sickle cell before we provide it to a sickle cell patient. If we test three units of blood prior to administering the blood to the patient, which modifier is more appropriate: -59 (distinct procedural service) or -91 (repeat laboratory test)?
Our coding experts answer your questions about observation orders, sequencing additional diagnoses, coding for wound care with no-cost skin substitute, and reporting cardiac rehabilitation and physical therapy together.
The Hospital Outpatient Payment Panel recommended CMS change the supervision requirements for 15 HCPCS and CPT codes during its second meeting this year in August. CMS released details of the meeting September 24.
Misusing modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) can be an expensive proposition. Just ask Georgia Cancer Specialists I, a leading oncology practice in Atlanta.
Q: What CPT ® code best describes the Bier block procedure? We are toiling over this and the most recent CPT Assistant says to use 64999 (unlisted procedure, nervous system). But the article referenced is from 2004. We just want to make sure there is nothing more recent.
Because of the increase in the number and type of outpatient services provided, more patients are being impacted by noncoverage of self-administered drugs. Kimberly Hoy, JD, CPC, and Valerie Rinkle, MPA, explain why CMS sometimes--but not always--covers self-administered drugs.
Our coding experts answer your questions about how to determine the correct units for drugs, billing for fluoroscopy, therapy caps under OPPS, and payment for critical care and separately reported services
The rules for coding for facilities and physicians are basically the same for most services, but coders follow different rules for appending certain modifiers. Christi Sarasin, CCS, CCDS, CPC-H, FCS , Kimberly Anderwood Hoy, JD, CPC , and Peggy Blue, MPH, CPC, CCS-P, separate physician and facility rules for using modifiers -26, -TC, and -79.
Q: It appears that one requirement for using CPT ® codes 15002–15005 with application of negative pressure wound therapy (NPWT) is that the wound must be healing by primary intention. Can you explain this? We have never used these codes with preparation for vacuum assisted closure (VAC) placement, but it doesn't make sense, as NPWT is almost always used for wounds healing by secondary intention. Our physicians appreciate any clarification.
QUESTION: I work for a gastrointestinal (GI) practice and I have a question regarding the correct sequence for adding diagnosis codes to a claim. I have advised our physicians and billers that the primary diagnosis code is always the reason for the visit. I am a little confused about the remaining diagnosis codes the physician will write down in no specific order. Billers will report codes in the order the physicians write down the diagnoses and not always the reason for the visit. For example, a patient is referred for a consult due to weight loss. The patient comes for the consult and the physicians may put down 787.29 (other dysphagia), 401.1 (benign hypertension), 783.21 (abnormal loss of weight), 787.99 (change in bowel habits) in this order and leave it up to the person entering the info to figure it out. I would report 783.21 first since that was the reason for the visit but then I’ve been putting the GI codes next and then anything else last. What is the correct sequence when adding diagnosis codes to a claim?
Accurate reporting of observation services depends on a lot of factors. Deborah K. Hale, CCS, CCDS, and Cheryl Staley, RHIA, CCS, walk though five case studies to explain the ins and outs of observation coding.
CMS proposed extending the delay on enforcement of physician supervision rules for critical access hospitals and small and rural hospitals with 100 or fewer beds for one final year as part of the 2013 OPPS proposed rule. Debbie Mackaman, RHIA, CHCO, and Jugna Shah, MPH, detail some of the more significant proposals for 2013.
Inpatient-only procedures are those that CMS has determined providers must perform on an inpatient basis because they are invasive and require at least 24 hours of postoperative recovery time or monitoring.
Our coding experts answer your questions about coding for hysteroscopy prior to ablation, appending modifier -59 for MRI and MRA, charging for venipunctures, therapy caps under OPPS, reporting limits for Provenge®, modifier -59 and infusion therapy, Reporting TEE pre- and post-operativley, coding for toxic metabolic encephalopathy
When the AMA revised the instructions for reporting ancillary services with critical care in 2011, facilities knew they wouldn't see an immediate increase in payment. CMS determines payment amounts through use of claims data from two years earlier, meaning the earliest facilities could expect additional reimbursement is 2013.
CMS is proposing two major changes as part of the 2013 OPPS proposed rule, released July 6. One has to do with how CMS proposes to calculate APC relative weights; the other addresses the reimbursement level for separately payable drugs and biologicals without pass-through status. Jugna Shah, MPH, and Debbie Mackaman, RHIA, CHCO, discuss the proposed changes for OPPS payment.
QUESTION: I work in an urgent care setting and need to know if we can bill an administration code for injection of Toradol. For example, a patient comes in, and the provider performs an E/M and administers 60mg Toradol intramuscular. I have not been charging for it, thinking it’s bundled into the E/M.
Physicians and facilities use the same codes to report evaluation and management (E/M) levels for emergency department (ED) services, but follow different rules. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, and Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, explain how to correctly choose the most appropriate E/M code for ED services.
Our coding experts answer questions about reporting dialysis for ESRD patient in ED, coding for sequential infusions, procedures on the inpatient-only list, replacement code for C9732, and new drug HCPCS codes.
CMS is proposing two major changes as part of the 2013 OPPS proposed rule, released July 6. One has to do with how CMS proposes to calculate APC relative weights; the other addresses the reimbursement level for separately payable drugs and biologicals without pass-through status.
Q. When is it appropriate to append modifier -74 (procedures discontinued after anesthesia administration or after the procedure has begun) or -73 (procedures discontinued prior to anesthesia) instead of to modifier -52 (reduced service)? Is there more than anesthesia that determines their use? The report below was coded with CPT ® 62311 (injection[s] of diagnostic or therapeutic substance[s]…; lumbar or sacral [caudal]). I asked the coder if modifier -74 should be appended, and the coder said that -52 should be appended. Is this correct? Procedure: Attempted lumbar midline interlaminar epidural steroid injection L5-S1 with fluoroscopy After identifying the L5-S1 interlaminar space fluoroscopically, the skin was sterilely prepped and draped. The skin and subcutaneous tissue were anesthetized with 1% lidocaine. Utilizing a loss of resistance technique and intermittent fluoroscopic guidance, an 18 gauge Tuohy needle was utilized to approach the epidural space. I was not able to successfully identify the epidural space secondary to encountered resistance. The needle depth was checked on lateral views and noted to be superficial to the epidural space when resistance was encountered. We were going to utilize a caudal approach, however skin breakdown was noted. At this point, I elected to have her return for care in 2 weeks and get the skin breakdown in the caudal area treated.
Some wounds and conditions don’t respond to conventional therapies and treatment modalities. In those cases, providers may consider hyperbaric oxygen therapy (HBO). Gloria Miller CPC, CPMA, and Todd Sommer, DO, DPM, CWS, review the conditions eligible for HBO therapy and correct code assignment for these services.
QUESTION: A patient complained of intractable pain from compression fracture (sustained the day prior to admission). The guidelines state if pain is not documented as acute or chronic, don't assign codes from the 338 category. Should we query the physician if the pain was acute or chronic rather than just using the fracture code if it appears that pain control was the main reason for the visit?
