Archive for 'Coding Challenge'
Posted on 02. Sep, 2009 by .
Answer: A few months ago, Medicare did implement some new regulations for bariatric procedures for diabetic patients.
The rule: If your physicians perform bariatric surgery procedures on diabetic patients you need to take note of the patient’s body mass index (BMI) ” it could be your magic number in determining the patient’s eligibility for Medicare payment, according to MLN Matters article MM6419, which had an implementation date of May 18.
Effective for any services performed on Feb. 12 or thereafter, the following three procedures are not covered for patients with type II diabetes and a BMI under 35:
• Open and laparoscopic Roux-en-Y gastric bypass (43846, Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [150 cm or less] Rouxen-Y gastroenterostomy and 43644, Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy [roux limb 150 cm or less])
• Laparoscopic adjustable gastric banding (43770,Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device [e.g.,gastric band and subcutaneous port components] and
43773, … removal and replacement of adjustable gastric restrictive device component only)
• Open and laparoscopic biliopancreatic diversion with duodenal switch (43845-43847, Gastric restrictive procedure with partial gastrectomy … and 43645, Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption).
The upside: CMS will cover these procedures in patients who have type II diabetes and a BMI of 35 orhigher.
Posted on 31. Aug, 2009 by .
Question: A patient presented in our office and said that his defibrillator was firing. What diagnosis code is appropriate for this?
Answer: You’ll need a little more information on the cause of the firing to choose the proper code. Here are some specifics you need to ask about or look for in the note.
If the firing resulted from an automatic implantable cardiac defibrillator (AICD) malfunction, you should report 996.04 (Mechanical complication of cardiac device,implant, and graft; due to automatic implantable cardiac defibrillator).
Alternatively, the patient may have had a dysrhythmia that caused the defibrillator to fire as it’s supposed to. In that case, you would use the heart condition as the primary diagnosis code, such as a code from the 427 series (Cardiac dysrhythmias). Then you would report V45.02 (Cardiac device in situ; automatic implantable cardiac defibrillator) to indicate that the patient has an AICD.
Posted on 28. Aug, 2009 by .
Question: Which HCPCS code should I use to report Eovist MRI contrast?
Answer: You should verify the appropriate code with your payer, but the most likely option is A9579 (Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified [NOS], per ml).
Here’s why: HCPCS doesn’t currently offer a specific Eovist (gadoxetate disodium) code for physician claims. (Code C9246 [Injection, gadoxetate disodium, per ml] does describe Eovist, but HCPCS guidelines state that C codes “can only be reported for facility [technical] services.”)
Because you don’t have a specific HCPCS code for your physician claim, you should choose a “not otherwise specified” code. CIGNA Government Services, the Part B carrier for North Carolina, for example, lists Eovist on its “Not Otherwise Classified Drug” Part B Fee Schedule under Option 3.
Eovist, used specifically to detect lesions in the liver, is a gadolinium-based magnetic resonance contrast agent, making it a match for code A9579. Remember to include on the claim the drug’s name and exact dosage given.
Potential new code: Eovist had a spot on the April 2009 HCPCS Public Meeting agenda. There was a request for a specific code, and CMS’s preliminary decision was that it would create Axxxx (Injection, gadoxetate disodium, 1ml). We’ll keep you posted.
Posted on 26. Aug, 2009 by .
Question: When I looked up Zevalin, I found out it’s a monoclonal antibody. Does that mean I should report a chemotherapy administration code for Zevalin therapy? CPT guidelines say chemo admin codes are correct for monoclonal antibodies.
Answer: Zevalin is a monoclonal antibody, and CPT does say chemotherapy administration codes are correct for “certain monoclonal antibodies.” But you should not report chemo admin codes for Zevalin therapy.
What to do: You should report 79403 (Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion) because Zevalin is a radiopharmaceutical.
“Code 79403 is specific for radioimmunotherapy with radioactive materials attached to monoclonal antibodies,” states AMA’s CPT Assistant (September 2005).
If you bear the cost of the drug, you also should report A9543 (Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries). Note that A9543 is specific to therapeutic use (as opposed to A9542 [Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries], which is specific to diagnostic use and often paired with 78804 [Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring 2 or more days imaging]).
Check coverage policy: Strict payer guidelines often limit Zevalin coverage to patients who meet specific criteria, such as particular types of non- Hodgkin’s lymphoma, certain platelet counts, and more.
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Posted on 24. Aug, 2009 by .
Question: We’ve gotten denials when we bill 87324 x 2 for two EIA tests for C. diff toxin A and toxin B. Can our lab code for tests for both toxins if we use the same lab method for both tests?
Answer: Yes, you can bill for both Clostridium difficile toxin A and toxin B if a physician orders the tests for medically necessary reasons. C. difficile is a bacterium that can cause diarrhea and can worsen to severe colon inflammation. Although C. difficile occurs in most normal, healthy digestive tracts, the organism can create problems when allowed to grow unchecked, as might happen when a patient takes antibiotics to treat another illness.
C. difficile produces toxins A and B that can cause the diarrhea and colitis. That’s why lab tests focus on identifying the presence of one or both of these toxins.
Labs can detect the toxins by different methods, such as those described by the following codes:
• 87230 — Toxin or antitoxin assay, tissue culture (e.g., Clostridium difficile toxin) (more…)
Posted on 21. Aug, 2009 by .
Question: Our orthopedic surgeon turned in a note that says, “Performed a bilateral hemilaminectomy with discectomy and foraminotomy for nerve decompression.Then I did a lumbar decompression with posterior lumbar interbody fusion and posterior lateral transverse fusion with pedicular screws.”
How should I report this? Is the hemilaminectomy bundled with the fusion?
Answer: No, you shouldn’t consider the hemilaminectomy with decompression part of the fusion (although more payers are beginning to bundle these procedures).
To report both, your physician must document he decompressed the spinal cord and/or nerve roots Report 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar) for this part of the surgery. Be sure to append modifier 50 (Bilateral procedure) to indicate that the hemilaminectomy was bilateral.
Next, report the posterior lumbar interbody fusion (PLIF), in which the vertebral endplates are separated and graft material inserted between them, using 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar). (more…)
Posted on 19. Aug, 2009 by .
Question: What is the difference between a primary and secondary neoplasm? I’m confused about which code to use for a metastatic tumor once the original tumor has been removed.
Answer: Continue to report the metastatic tumor as “secondary” even if the primary tumor has been eradicated.
Primary: A primary neoplasm code indicates the original tumor site.
Secondary: A secondary neoplasm indicates a site to which the cancer has spread.
History of: According to ICD-9 2009 official guidelines, if the patient’s tumor is eradicated and no longer requires treatment, you should use a “history of” code, such as V10.3 (Personal history of malignant neoplasm; breast).
Here’s the exact language: “When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code” (page 24).
Posted on 17. Aug, 2009 by .
Question: The dermatologist treated an established patient with a cut on her lip and used Dermabond to close the 1.8-cm laceration. Should I use a laceration repair code when the only adhesive he used was Dermabond?
Answer: Your code choice will depend on the patient’s insurance. Check out these two coding options:
Patient has Medicare: If the physician uses Dermabond as the only closure material for a simple repair on a Medicare patient, report G0168 (Wound closure utilizing tissue adhesive[s] only) for the service.
Patient has commercial insurance: If the commercial carrier follows Medicare rules, use G0168. However, if the payer does not observe Medicare guidelines, you’ll most likely choose a laceration repair code, even when Dermabond is the only adhesive the physician uses. On the claim, report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less).
Either way: Append 873.43 (Other open wound of head; face, without mention of complication; lip) to the procedure code to represent the patient’s injury.
Posted on 14. Aug, 2009 by .
Answer: The procedure removes adhesions (tags) from the dura to correct any neurological deficits. Physicians often remove a specimen to send for lab review, but that service is included in the primary procedure.
In this situation, you’ll report 63200 (Laminectomy, with release of tethered spinal cord, lumbar) for the cord release and +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) for the microscope use. Don’t report the dural tag removal separately, as it is incidental to the tethered cord release.
Posted on 12. Aug, 2009 by .
Question: Our dermatologist shaved three epidermal lesions that the patient chose not to have submitted to pathology: a 0.4 cm lesion from the patient’s chest, a 0.3 lesion from the patient’s back, and a 0.2 lesion from the patient’s stomach. Will I need to include modifiers?
Answer: Because CPT classifies the shaves with the same anatomic area and size code, you will need a modifier on the second and third shave removal codes. Without the modifiers, the insurer’s software system may throw out the additional shaves as duplicates.
You should technically use modifier 51 (Multiple procedures) on the second shave (11300, Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less). Then separate the third excision from the second with modifier 59 (Distinct procedural service). The claim would contain: 11300, 11300-51, and 11300-59.
If you’re reporting the claim to a Medicare carrier, omit modifier 51. Medicare’s computer editing system automatically considers eligible additional procedures multiple without requiring modifier 51. Because of this, Medicare would deny your line item of 13000-51. You could append modifier 59 (Distinct procedural service) instead: 13000, 13000-59, and 13000-59.