Cardio Challenge: Discover Event Monitor Disconnect Date’s Proper Place

Posted on 22. Mar, 2010 by suzanne.leder.

Find out where to report date of services on your claim form.

Question: Which date(s) of service should I report for 30-day cardiac event monitoring?

Washington Subscriber

Answer: For Noridian Medicare, your Part B administrator for Washington, you’ll need to know both (1) the date the staff hooked up the patient and (2) the day they disconnected the patient. But knowing which dates to report is only half the battle — you also need to know where to report them. (more…)

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Separate Sleep Study Coding from Your H&P Coding

Posted on 22. Mar, 2010 by suzanne.leder.

Don’t separately report a cursory H&P from the sleep code.

Question: If a nurse practitioner (NP) performed an H&P (history and physical exam) or a subsequent visit with a patient prior to a sleep study, can you bill the H&P with modifier 25 and the sleep study code? Is the H&P included in the sleep study?

Florida Subscriber

Answer: (more…)

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Surgery Challenge: Ensure a Clean Claim by Interpreting Detailed Central Line Note

Posted on 15. Mar, 2010 by suzanne.leder.

Find out which you can report separately: a tunneled or a non-tunneled line.

Question: What code should we bill when we remove a central venous pressure (CVP) line and insert a Hickman catheter at a different site?

New York Subscriber

Answer: You can’t determine the proper code based on type of catheter (such as CVP line or Hickman).

Selecting the proper code depends on the patient’s age, whether the surgeon places the catheter centrally or peripherally, where the catheter tip is at the end of placement, and whether the catheter is tunneled or non-tunneled. (more…)

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Surgery Coding: Look at Service Date Before Appending Modifier 59

Posted on 12. Mar, 2010 by suzanne.leder.

Make sure your documentation supports the additional substantial complexity of the hernia repair and mesh.

Question: A patient presented for a colectomy for colon cancer. The physician also discovered that the patient had a ventral incarcerated hernia that required a complex repair using mesh. Because of the separate work, we reported 44140 and then reported 49561 with modifier 59. The payer denied the claim. Were we wrong to append modifier 59?

Mississippi Subscriber

Answer: You might think you can append modifier 59 (Distinct procedural service) to the hernia repair code and bill it separately. After all, the hernia repair seems to qualify as a different reason for surgery than the colectomy — for example, if the patient has a recurrent hernia. But modifier 59 tells the payer the hernia repair happened at a separate session, which isn’t true in your case.

If the physician’s documentation proves justification, you might try … (more…)

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Ob-gyn Coding Challenge: Deliver Postpartum V Codes With Care

Posted on 10. Mar, 2010 by suzanne.leder.

Bonus: Get exposure to ICD-10 coding equivalents.

Question: A mentally-challenged patient who delivered at home was admitted to the hospital for postpartum care. The patient delivered the placenta at home, and once admitted, she had no complications, but the ob-gyn did perform a first degree laceration repair. I’m not sure what diagnosis code to report. Should I look at routine postpartum care or pregnancy complications? And if I use a complication code, what would the fifth digit to a “1″ or “0?”

Texas Subscriber

Answer: Under most situations where the ob-gyn treated no problems during the admission, you would code V24.0 (Postpartum care and examination; immediately after delivery) on the admission date and V24.2 (Routine postpartum follow-up) for any subsequent routine care. (more…)

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Ensure Multi-Vaccine Payment With This Coding Advice

Posted on 09. Mar, 2010 by suzanne.leder.

You may need to append modifier 25, depending on payer policies.

Question: Our physician billed 90634, 90710, and 90606 for vaccines given to a 5-year-old patient. The insurance company denied payment and said they required a modifier. What should we have done differently?

New Hampshire Subscriber

Answer: According to standard CPT coding, vaccine codes do not require modifiers on the associated E/M code. However, you might need to include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) if your insurance company requires it — which might be why you received a denial.

Well check: If your physician administered vaccines on the same day as a well visit, code the well visit with the appropriate code such as … (more…)

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EM Coding: Should I Select 99211 for Most Med Checks?

Posted on 06. Mar, 2010 by suzanne.leder.

Insurers might want to see a clear explanation as to why the E/M was necessary.

Question: An established patient with a plan of care in place for her gastroesophageal reflux disease (GERD) reports to the gastroenterologist; two weeks ago, the gastroenterologist started her on Nexium (esomeprazole). One of the practice’s nonphysician practitioners (NPPs) evaluates the patient, taking blood pressure and other vitals. She also asks the patient if she has experienced any nausea, diarrhea, vomiting, or any other side effects since she started Nexium. The patient reports that she’s “thrown up three or four times” since starting the medication, but reports no other side effects. The patient’s record indicates that the gastroenterologist scheduled this visit specifically to check how the patient’s adjustment was going. What can I report for this encounter?

Answer: (more…)

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E/M Coding: Use Current Diagnosis to Support E/M Visit

Posted on 05. Mar, 2010 by suzanne.leder.

Don’t forget to include the code for the arthrocentesis.

Question: A new patient sees the orthopedist because of shoulder problems. The physician schedules an MRI and the patient returns the following week to discuss the findings. The physician had already reviewed the films and goes over them in depth with the patient. He also administered a shoulder joint injection to help relieve the patient’s pain.

What diagnosis should we report with the E/M service to reflect the amount of time spent reviewing films and counseling the patient and to distinguish it from the injection?

West Virginia Subscriber

Answer: Select a diagnosis based on your provider’s documentation, such as rotator cuff tear (840.4, Sprains and strains of shoulder and upper arm; rotator cuff [capsule], or 727.61, Rupture of tendon, nontraumatic; complete rupture of rotator cuff). Include that diagnosis with … (more…)

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Ob-gyn Coding Challenge: EM End-Result Tells You What ICD Code To Go For

Posted on 03. Mar, 2010 by suzanne.leder.

Check out these ICD-10 ob-gyn diagnosis coding equivalents.

Question: A patient presented for an initial OB visit. Another clinic confirmed her pregnancy, but she has never received prenatal care. The patient got her usual initial OB service (i.e. lab orders), Pap smear, and chlamydia trachomatis (CT)/neisseria gonorrhoeae (GC) screening. After discussing some concerns with the patient, the ob-gyn ordered another pregnancy test which came out negative. He ordered an ultrasound (US) which showed no intrauterine pregnancy. The ob-gyn noted bilateral polycystic ovaries, however. In short, the office completed the initial OB visit prior to knowledge of a negative pregnancy test (given the confirmation documentation of a positive pregnancy test). I’m not sure whether to bill it as an initial or an office visit. What code should I use for the first diagnosis?

California Subscriber

Answer: Your clue is to code what you know at the end of the visit. Since the patient was not pregnant, you should report … (more…)

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Ob-gyn Challenge: Take the Pressure Out of a 3D US Coding

Posted on 28. Feb, 2010 by suzanne.leder.

No severe problems? You may have trouble with reimbursement.

Question: The ob-gyn performed and OB ultrasound (US) on a patient. Can I bill 76376 in addition to the ultrasound if the ob-gyn used 3D?

Montana Subscriber

Answer: Yes. You can report a 3D procedure with 76805 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester [> or = 14 weeks 0 days], transabdominal approach; single or first gestation) and 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation). (more…)

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Counseling Must Dominate Exception Claims For Seamless Payment

Posted on 26. Feb, 2010 by suzanne.leder.

Choose the service level using the documented history, exam, and MDM.

Question: A new patient with a chronic gastric ulcer meets the gastroenterologist for management of her condition. The gastroenterologist meets for 34 minutes with the patient, and performs an expanded problem focused history and exam and straightforward medical decision making. The note also indicate that she spent 21 minutes advising the patient on proper diet and medication management. Is this an instance where I can code based on total encounter time?

New Jersey Subscriber

Answer: Maybe. Go back and double-check both the total encounter time and the amount of time the spent on counseling by either the physician or any NPP.

If the provider spends at least half (16 min) of the total session time counseling the patient, then report … (more…)

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Surgery Coding: Narrow Your Options for Birmingham Hip Procedure

Posted on 24. Feb, 2010 by suzanne.leder.

Image by Stephen Woods.

Include this term in Box 19 to indicate the type of implant.

Question: One of our surgeons says we should use a total hip code for Birmingham resurfacing even if he doesn’t complete a total hip procedure; another physician says to use an unlisted code . What’s the correct answer?

Washington Subscriber

Answer: Both of your physicians could be right depending on the situation, so check with the payer before submitting your claim following one of these options: (more…)

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Migraine ICD-9 Codes: How Do I Get My 5th Digits Right?

Posted on 18. Feb, 2010 by suzanne.leder.

Discover what the 5th digit represents and why you need it on your claim.

Question: A presents to the ED with complaints of a headache that’s worsening daily. He is experiencing visual blurring and nausea but no vomiting. This is the third headache of this nature in three weeks, and it has lasted “four or five days.” Documentation indicates a detailed examination and history; after performing the assessment and speaking to the patient, the physician documents migraine with typical aura and status migrainosus Treatment options include acute intervention with prescription, but the physician feels the patient needs to add prophylactic medicine treatments, since the headaches appear to be reoccurring. What migraine ICD-9 code represents this patient’s headache?

Tennessee Subscriber

Answer: This sounds like a migraine with status migrainosus. On the claim, report the following: (more…)

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Burn Coding: Calculate Total Body Surface Area (TBSA)

Posted on 17. Feb, 2010 by suzanne.leder.

Investigate your physician’s documentation to determine the body area percentage actually debrided.

Question: My anesthesiologist administered anesthesia for a burn excision on the leg of a middle-aged adult male, but he didn’t give clear notes on the patient’s affected body surface area. How do I code for this?

Kansas Subscriber

Answer: You will start by coding 01952 (Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area [TBSA] treated during anesthesia and surgery; between 4 percent and 9 percent of total body surface area) and add +01953 ( . . . each additional 9 percent total body surface area or part thereof [List separately in addition to code for primary procedure]) as necessary.

Next, you’ll need to don your Sherlock Holmes hat. You’ll need find documentation of the patient’s affected total body surface area (TBSA). The attending surgeon typically … (more…)

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Neurosurgery Coding: Previous Injury Means Multiple Dx Options

Posted on 15. Feb, 2010 by suzanne.leder.

Find out what additional information V codes provide to the payer.

Question: We have a patient with previous spinal injury that is now causing neck pain. How should I code the diagnosis?

North Carolina Subscriber

Answer: Document and code prior conditions that contribute to a patient’s current complaint — if they affect the management of the current condition. Prior trauma, such as a previously broken bone or other injury, can cause patients to experience back pain. If the patient’s pain stems from a previous condition, you may code that diagnosis to justify pain management procedures your neurosurgeon performs. Depending on the situation, there may be late-effect codes or V codes that you may report in addition to the current complaint that show a late effect or a personal history of trauma.

Option 1: (more…)

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Oncology Coding: Day 1 of FOLFOX4 Regimen

Posted on 12. Feb, 2010 by suzanne.leder.

Here’s the key to concurrent infusion coding.

Question: What are the appropriate codes for the first day of the FOLFOX4 regimen?

Answer: You should base your final coding decision on the documentation and the exact services your practice provides. But as a starting point, the FOLFOX4 regimen typically involves the patient receiving Oxaliplatin and folinic acid concurrently over two hours, followed by a 5-FU bolus on day one.

That same day, the patient begins a 22-hour infusion of 5-FU, often using an ambulatory pump. In this scenario, your day one claim would include: (more…)

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Surgical Coding: Capture Extra Work for Choledochal Cyst

Posted on 10. Feb, 2010 by suzanne.leder.

Discover these subsequent reconstruction codes.

Question: The surgeon treated a patient with a large choledochal cyst. The procedure involved an open cholecystectomy with en bloc excision of extrahepatic bile ducts (roux-en-Y reconstruction) with hepaticojejunostomy. What are the correct CPT and ICD-9 codes?

Answer: The correct ICD-9 code will depend on whether the patient has an acquired or congenital choledochal cyst. You would expect to see the congenital cyst more commonly in pediatric patients. Assuming that the patient has an acquired cyst, the correct diagnosis code is 576.8 (Other specified disorders of the biliary tract). On the other hand, if your surgeon is treating a patient with a congenital choledochal cyst, you should report the diagnosis as 751.69 (Other anomalies of gallbladder, bile ducts, and liver).

CPT does not provide a specific code to describe excision of extrahepatic bile ducts, but … (more…)

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Gastroenterology Coding Challenge: Repositioning a G Tube

Posted on 07. Feb, 2010 by suzanne.leder.

Reading 44373’s code descriptor is key to getting your G Tube claim right.

Question: The gastroenterologist goes to the hospital to treat a patient that had recently been admitted because his gastrojejunostomy tube had migrated to his stomach. After performing a problem focused interval history and exam, the gastroenterologist decides to perform an EGD to reposition the tube. I cannot find a code for repositioning a G tube; how should I code this scenario?

Answer: Judging by your encounter description, the patient’s percutaneous jejunostomy tube (J tube) slipped and became a percutaneous gastrostomy tube (G tube). On the claim, report the following:

• 44373 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneousgastrostomy tube to a percutaneous jejunostomy tube) for the EGD; (more…)

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Why Is the Co-Pay I Collected Short By $20?

Posted on 06. Feb, 2010 by Editor.

Verify co-pay early to save time, money

Question: A patient came to our office for a routine exam with the same insurance card she’s had for years. We charged her the standard copay of record. Then I found out her employer changed the terms of the insurance, so the copay she paid was short by $20. What went wrong?

Answer: You might easily assume that when a patient has the same insurance company, the copay is the same as it has always been. But unless you check first, you won’t know the patient’s coverage has changed until after the fact.

Best practice … (more…)

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Is E/M Possible Pre-Colonoscopy?

Posted on 03. Feb, 2010 by Editor.

Question: A local family physician refers a patient to our gastroenterologist for a diagnostic colonoscopy. The patient reports to the practice and meets the gastroenterologist for the first time. After answering some patient questions during a brief introduction, the gastroenterologist performs a diagnostic colonoscopy with brushing. The patient had never met the gastroenterologist before. Is the time he spent with the patient pre-screening a separate E/M?

Explanation … (more…)

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