CMS added new guidance to the CPT Manual to clarify imaging documentation for codes that include both procedural and imaging guidance. This article outlines these regulatory changes and implications for outpatient coders and providers.
Outpatient coders and billers must be able to interpret potentially confusing documentation elements for drug administration services and know what to do when key elements, such as infusion time, are missing from an order. Review CMS guidance on the accurate reporting and billing of intravenous drug administration services for calendar year 2019. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Prostate cancer is the second most common form of cancer in American men, according to the American Cancer Society. Shelley C. Safian, PhD, RHIA, CCS-P, CPC-I , writes about CPT coding for rectal exams and a new prostate specific antigen (PSA) immunoassay test used to detect early indications of prostate cancer, as well as ICD-10-CM codes used to support medical necessity for these services.
Arthroscopic procedures allow surgeons to use minimally invasive arthroscopic techniques to treat conditions which previously required more intensive, open surgery. Learn about orthopedic anatomy and terminology and CPT guidelines for reporting arthroscopic hip and knee procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Review advice from experts on accurate documentation and CPT coding for chronic care management, knee injection services, and health and behavior assessments.
In 2018, most organizations held the line on coder productivity, according to the results of sister publication HIM Briefings’ 2018 coding productivity survey.
Pay close attention to new CPT documentation and coding guidance for reporting radiological imaging. For example, a new paragraph titled “Imaging Guidance” in both the surgery and medicine guidelines advises that even when imaging guidance or supervision are included in a surgical procedure code, you must still follow the radiology documentation requirements in the CPT manual.
Modifier -JW is used to describe drug amounts that are discarded and not administered to any patient. This does not reduce the payment for the drugs, so this is an informational modifier, but it is a mandatory modifier.
In the current healthcare climate the issue of medical necessity documentation, or lack thereof, is one of the most common reasons for claim denials. Review medical necessity guidance from CMS and learn how to prevent repeated denials due to improper documentation of medical necessity. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS has downgraded the supervision requirements for services performed by radiologist assistants working in medical practices, imaging centers, and radiology offices. Read about these 2019 changes to ensure accurate documentation and reporting for radiology services.
The beginning of a new year typically brings new resolutions to deal with weight-related issues. Shelley C. Safian, PhD, RHIA, HCISPP , writes about ICD-10-CM coding for common weight-related diagnoses such as obesity and anorexia, and CPT coding for interventions used to treat them.
The ICD-10-CM Manual was recently updated with new codes for peritonitis in association with acute appendicitis and the CPT Manual now includes new codes for gastrostomy tube replacements. Familiarize yourself with these changes to ensure accurate reporting of digestive diagnoses and treatments. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , reviews common CPT and ICD-10-CM coding and documentation errors, such as unbundling, inappropriate modifier usage, and missing information, to help coders reduce their risk from audits.
The 2019 CPT code update includes 19 code additions and three revisions to the cardiovascular section of the CPT Manual. These changes reflect advances in surgical treatment for cardiovascular conditions such as heart failure and aortic stenosis.
Take cues from the revised NCCI Policy Manual for Medicare Services to polish your coding and billing efforts in 2019 and avoid common infractions tied to modifier -50 (bilateral procedure).
A variety of therapeutic services can be used to treat patients suffering from debilitating mental health conditions. Clear up confusion surrounding CPT coding for these initial office visits, psychiatric diagnostic evaluations, and psychotherapy visits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Reporting and billing hospital observation services can be confusing, particularly when the observation stay lasts more than one day. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes about CPT coding for observation services based on time and the key components of the history, exam, and medical decision making of a patient.
The 2019 CPT code update will impact reporting for dermatologic biopsies. Shelley C. Safian, PhD, RHIA, HCISPP, CCS-P, COC, CPC-I , reviews updated reporting guidance and CPT codes for these common types of biopsies.
CMS hit the brakes on making imminent changes to the oft-used E/M code set that’s tied to billions of dollars in medical practice revenue. Review updates to E/M payment and documentation requirements effective January 1 and the extensive changes planned for implementation in 2021 under the 2019 Medicare Physician Fee Schedule final rule.
