With no national guidelines in place for facilities to use to determine evaluation and management (E/M) level, coders must apply their facility’s guidelines when coding an outpatient visit. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, and Joanne M. Becker, RHIT, CCS, CCS-P, CPC, CPC-I, use three ED case studies to highlight potential pitfalls for ED E/M leveling.
Q: We received an outpatient radiology report (exam performed 7/11/12) where the radiologist states: CLINICAL INDICATION: LUMBOSACRAL NEURITIS EXAM: LUM SPINE AP/LAT CLINICAL STATEMENT: LUMBOSACRAL NEURITIS COMPARISON: MAY 23, 2012 FINDINGS: There is posterior spinal fusion L-3-L-5 with solid posterolateral bridging bone graft. Pedicle screws and rods are stable in position. There are bilateral laminectomy defects at L3-L-4. The vertebral body and disc space heights are preserved. The spinal alignment is maintained without evidence of spondylolisthesis. No acute fracture is identified. No lytic or blastic lesions are seen. The sacroiliac joints are unremarkable. IMPRESSION: Stable postsurgical changes with solid posterolateral fusion graft. Would you use the following ICD-9 codes: V67.09, 724.4. or 724.4, V45.4? Our coders disagree.
CMS is making a significant change to the Medically Unlikely Edits (MUE) by changing some of them from line-item edits to date-of-service edits, effective April 1. Jugna Shah, MPH, Kathy Dorale, RHIA, CCS, CCS-P, John Settlemyer, MBA/MHA, and Valerie Rinkle, MPA, explain how the change could affect coding and reimbursement.
Breast biopsies should be easy to code because coders have so few codes to assign, but it is one area where documentation is lacking. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, reveals what key elements coders should look for in a breast biopsy note.
On March 13, CMS issued a notice of ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim that a Medicare review contractor deemed to be not reasonable or necessary. The revisions are intended as an interim measure until CMS can finalize an official policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward.
Q: A patient received Toradol 30 mg IV and Zofran 4 mg IV at 14:38. He also had normal saline wide open with documented start of 14:30 and stop of 15:40. Is the hydration chargeable as 96361 (intravenous infusion, hydration; each additional hour) even though the initial service is not 90 minutes? Is the hydration a concurrent service?
Evaluation and management (E/M) coding is incredibly subjective. Two coders can look at the same documentation and choose two different E/M levels and both will be able to justify their choice. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA-Approved ICD-10-CM/PCS Trainer , Lori Owens, RHIT, CCS, and Deborah Robb, BSHA, CPC, discuss how electronic medical records can complicate E/M coding even more.
In the coding world, it’s a never-ending clash that can cause compliance concerns—facility vs. professional. Kimberly Anderwood Hoy, JD, CPC , and Peggy Blue, MPH, CPC, CCS-P, explain how coders in each setting use different codes for the exact same services based on the payment systems, the rules, and how each setting applies those rules.
CMS added 410 new codes and seven new therapy and patient condition modifiers to the Integrated Outpatient Code Editor (I/OCE) as part of the January 2013 update. Dave Fee, MBA, highlights the key changes to the I/OCE.
If you think you’ve estimated the right amount of training time for ICD-10-CM, you probably should increase it. Cindy Grant, CHIM , Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, and Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, explain why organizations will need to plan additional hours of training for ICD-10-CM.
Anatomy hasn’t changed in hundreds of years, but with the additional specificity required in ICD-10-CM, coders will need to brush up on their knowledge . Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-Approved ICD-10-CM/PCS Trainer, takes coders on a tour of the respiratory system and compares ICD-9 and ICD-10-CM coding for some respiratory conditions.
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?
CMS is currently updating its ICD-10 implementation guides for practices, small hospitals, and payers. The agency has already posted the updated guide for small and medium practices .
The International Classification of Diseases (ICD) was originally referred to as the Uniform Classification of Causes of Death. Robert S. Gold, MD , reveals why ICD in the United States doesn't correlate well with the systems in other countries and omits various important clinical conditions that can cause fatal outcomes for patients.
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.
Genetic screening is often used to detect abnormal genes or possible fetal anomalies during antepartum care. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, reviews some of the most common genetic tests and what diagnosis codes to report.
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: 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 is making a significant change to the Medically Unlikely Edits by changing the edits from line item edits to date of service edits. The change will become effective April 1.
Interventional radiology cases are often complex with confusing coding rules, especially for radiologic supervision and interpretation. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, and Karna W. Morrow, CPC, RCC, CCS-P, lead you through the maze of coding these procedures.
One of the major changes to the 2013 CPT ® Manual is the replacement of the term "physician" with "physician or other qualified healthcare professional" in a wide range of codes. Marie Mindeman and Andrea Clark, RHIA, CCS, CPC-H, discuss how this change affects code assignment.
CMS rescinded Transmittal 2607 and replaced it with Transmittal 2636 to update the add-on code edit file to include a change in the list of primary codes for CPT add-on code 90785 (interactive complexity).
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.
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?
ICD-10-CM includes separate chapters for diseases of the eye and diseases of the ear, a change from ICD-9-CM, where both diseases are included in the nervous system codes. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, explains how the ICD-10-CM codes for diseases of the eyes and ears are similar to and different from ICD-9-CM codes.
On January 9, the American Medical Association sent out a notification of errata in the 2014 CPT ® Manual . The AMA followed with a January 16 correction saying the errata file is for the 2013 CPT Manual .
The use of dual coding is frequently discussed and debated as a way to prepare for the transition to ICD-10. Donna Smith, RHIA, Thea Campbell, MBA, RHIA, Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, and Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, evaluate the pros and cons of dual coding.
Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, COBGC, CPCD, CCS-P, CDIP, senior manager at Blue and Company in Indianapolis, an industry expert on ICD-10, provides preparation tips and action steps for ICD-10 implementation.
The American Medical Association completely overhauled the CPT ® Manual’s psychiatry subsection for 2013. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, explains the new codes and guidelines associated with psychiatric services.
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
Coders will find plenty of changes throughout the musculoskeletal, respiratory, and cardiac sections of the CPT® Manual for 2013, as well as guidelines changes, deletions, and editorial revisions. Andrea Clark, RHIA, CCS, CPC-H, Georgeann Edford, RN, MBA, CCS-P, and Marie Mindeman walk through some of the major changes for 2013.
Coding for stent placement procedures will look very different in 2013. The American Medical Association deleted the two CPT ® codes used to report nondrug-eluting intracoronary stent placement procedures.
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.
Coders will find significant changes in the medicine section of the 2013 CPT® Manual . Denise Williams, RN, CPC-H, and Georgeann Edford, RN, MBA, CCS-P, review the changes to nerve conduction studies, vaccine administration, ophthalmology, and allergy testing.
The AMA added new CPT ® codes to report transcatheter aortic valve replacement for 2013. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, details these and other code changes for cardiology.
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?
CMS recently posted an updated version of the National Correct Coding Initiative (NCCI) manual to the CMS NCCI website . The manual includes changes identified in red text and will be effective with dates of service January 1, 2013.
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)?
As tempting as it might be to append modifier -59 (distinct procedural service) to a claim in order to get paid, doing so poses a huge compliance risk. Karna W. Morrow, CPC, RCC, CCS-P, Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS , Peggy Blue, MPH, CPC, CCS-P, and Kimberly Anderwood Hoy, JD, CPC, walk through five case studies to help coders chose the correct modifier.
Misusing modifier -25 (significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service) can be an expensive proposition. Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS, and Debbie Mackaman, RHIA, CHCO, explain how to determine when an E/M service is significant and separately identifiable.
Five new CPT ® codes will be used to report services in two new evaluation and management categories: complex chronic care coordination services and transitional care management services. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, details the codes and guidelines for these services.
If you’re worried about getting your physicians trained for ICD-10, you’re not alone. Thea Campbell, MBA, RHIA, Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, Donna Smith, RHIA, and Sue Belley , MEd, RHIA, CPHQ, offer tips and strategies to educate physicians about the new code sets.
Organizations looking for real-world examples of ICD-10 education can check out the plan created by Ginger Boyle, MD, of Spartanburg Regional Healthcare System in South Carolina.
With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. To help coders prepare for the upcoming transition, JustCoding will provide an occasional article about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. This month’s column addresses the anatomy of the shoulder.
External cause codes in ICD-10-CM are intended to provide data for injury research and evaluation of injury prevention strategies. Some are humorous and some are confusing. Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, explains how and when to use these codes.
