Archive for 'Hot Coding Topics'

Medicare’s Consult Rule Trickle Down Effect

Posted on 18. Nov, 2009 by .

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And what it means for pediatric practices. A report from AMA in Chicago.

Although CPT clarifies the transfer of care definition, the fix came too late for Medicare, meaning your private payers may follow suit.

Continued Errors Result in E/M Boon

The Office of Inspector General found a high error rate on consultation codes. Different opinions on when a transfer of care occurs versus a consultation caused $1.1 billion in incorrect payments. “We couldn’t even all agree on some scenarios,” admitted William J. Mangold, Jr., MD, JD, Noridian Administrative Services’ (Arizona, Montana, Utah, Wyoming) Medicare contractor medical director in the carrier response section to Day 2′s opening session at the CPT and RBRVS 2010 Annual Symposium in Chicago.

Pediatricians who don’t regularly code consults could gain from Medicare getting fed up with the inconsistency and invalidating the codes for payment in 2010. CPT still maintains the codes. CMS, however, will take the payments for 99241-99255 (Consultations) and redistribute them to office visits (99201-99215), hospital care (99221-99233), and nursing home (99304-99310) codes. This will create a 6 percent boost for primary care in E/M reimbursement from private payers that adopt the 2010 Medicare Physician Fee Schedule.

Get ready for ‘Dante’s Inferno,’ says one veteran coder. (more…)

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ED Coding Question: Observation or Other E/M Code?

Posted on 17. Nov, 2009 by .


Question: A 42-year-old patient reports to the ED early on Tuesday morning for evaluation of uncontrollable shaking in her extremities and severe pain in her neck. The EP admits the patient to observation at 7 a.m. and orders blood tests and a CT scan — however, the shaking continues to worsen. The EP consults with a neurologist, who recommends hospitalization. The neurologist then admits the patient to the hospital as an inpatient at 6:25 p.m. Tuesday for more examination. Notes indicate a comprehensive history and exam, along with moderate medical decision making. Should I code this as an observation, or some other E/M service?

Answer: The ED physician could use an initial observation code in this situation.

On the claim, report 99235 (Observation or initial hospital care, …) for the E/M with 781.0 (Abnormal involuntary movements) and 723.1 (Cervicalgia) appended to represent the patient’s symptoms. ED physicians do not admit patients to hospital inpatient status (though they can recommend hospitalization); the neurologist will code for those services.

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AUDIO TRAINING EVENT: Caral Edelberg, CPC, CCS-P, CHC tells ED coders all they need to know — and only what they need to know — for 2010. STAT.

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Pain Management Coding: Endoscopic Lumbar Nerve Decompression

Posted on 15. Nov, 2009 by .


Hint: Think ‘unlisted procedure.’

Question: One of our physicians is looking into “endoscopic lumbar spinal nerve decompression.” One of the medical device representatives indicated he could bill it like the lateral extraforaminal approach for lumbar decompression, but I haven’t found much information. What’s your advice?

Answer: Despite what you physician might have heard, your most appropriate choice probably is 64999 (Unlisted procedure, nervous system).

Many pain management providers are being introduced to different endoscopic approach systems. The AMA confirms that the descriptors for lumbar decompression procedures, such as those mentioned to your physician (63055-+63057, Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disc], single segment …) do not include an endoscopic technique and should not be used to report this type of approach.

If the provider doesn’t complete the laminectomy (hemilaminectomy) required to meet the criteria for reporting 63020-+63035 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial  facetectomy, foraminotomy and/or excision of herniated intrevertebral disc, including open and endoscopically-assisted approaches …), the AMA directs you to report the “unlisted” procedure code.

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PQRI: No Coumadin Due to Fall Risk

Posted on 13. Nov, 2009 by .


Plus, experts at the AMA meeting in Chicago tell you what to do if you can’t get H1N1 vaccine for PQRI Measure 110 or other vaccine measures.

Question: My internist decided not to put a patient on Coumadin because the patient has a higher risk of falling than from having a stroke. Our group participates in PQRI easure 33 for risk of clotting. How can I indicate performing the measure wasn’t appropriate so that the physician isn’t penalized for not prescribing the anti-blood clotting medication?

Answer: You should report the measure and append the denominator exclusion indicator 1p. This indicator shows the physician chose not to prescribe the drug due to the art of medicine, or factors that make performing the measure not clinically appropriate.

If, however, the internist prescribed Coumadin but the patient isn’t taking it because she can’t afford the medication, you instead would use 2P. Your group can then have the patient referred to a social worker to help the patient figure out her financial hardship and find a way to obtain the medically necessary drug.

The third denominator exclusion in this group is 3p, which shows the medication was not available. Read on to learn what to do when you can’t get H1N1 vaccine supply … (more…)

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2010 Tumor Excision Coding: Lesion Vs. Chunk Size

Posted on 13. Nov, 2009 by .


Straight from the AMA in Chicago — answers to your lesion excision coding questions for 2010.

Question: A thigh lesion measures 2 cm but requires a resection down to the subcutaneous layer of 4 cm. Which lesion excision code should I use?

Answer: “You should use the larger of the subcutaneous codes,” says Albert E. Bothe, Jr, MD, FACS, with the American College of Surgeons in “Excision of Soft Tumors/Bone Tumors” on the final day of the AMA CPT and RBRVS 2010 Annual Symposium. The size of the lesion is the lesion. “The defining size is the size of the resection” or the mass that’s taken out, Bothe stressed.

If all that the surgeon takes out is the lesion, you would use the lesion size or 2 cm as the lesion excision. But if the surgeon indicates the larger size of the tissue he also has to take out, you assign the excision code based on the resection size. You mention that the resection size is 4 cm, which is more than the 3-cm cut point stipulated in 27327′s new 2010 description (Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less than 3 cm). Therefore, you would use 27337 (… 3 cm or greater). Don’t miss this documentation must … (more…)

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Medicare 2010 CPT Consultation Code Changes

Posted on 12. Nov, 2009 by .


New rules for consult coding straight from the AMA Meeting in Chicago — plus where your practice will gain and lose reimbursement.

If you can’t figure out how to match a low level consult to an initial hospital care code, you’re not alone.

Code 99251 doesn’t crosswalk to 99221, agreed William J. Mangold, Jr., MD, JD, Noridian Administrative Services’ (Arizona, Montana, Utah, Wyoming) Medicare contractor medical director in the carrier response section to Day 2′s opening session at the CPT and RBRVS 2010 Annual Symposium in Chicago. “They don’t have the same criteria.”

Medicare will consider the consult codes (99241-99255) invalid codes for payment, effective Jan. 1. Experts expect some large carriers, including Blue Cross Blue Shield, Aetna, and Humana to adopt the same policy for uniformity. For carriers and private payers that no longer recognize consult codes, let these examples help you decide what code to instead use.

1. Apply Patient Status Rules to Outpatient Encounters

“CMS is saying the consult codes are going away,” Mangold explains. Instead, you should choose the appropriate code based on the applicable guidelines. (more…)

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Is 30901 Your Nosebleed Code? Not So Fast?

Posted on 12. Nov, 2009 by .


Hint: Look for these keywords in the note to select the correct nosebleed code.

Question: The internist stops a patient’s nosebleed. Is this always a procedure?

Answer: No, if a patient reports with a nosebleed and the physician stops the bleeding with basic methods, you’ll typically opt for the appropriate-level E/M code.

E/M methods: Code minimal attempts at stoppage — including ice or brief, direct pressure — as an E/M service. CPT does not consider these types of treatments separately billable procedures, so an E/M is the way to capture the services the physician provides.

For example, a 62-year-old established patient reports to the internist with an active right-nostril nosebleed that has lasted for three hours. The internist performs a problem focused history and exam, then uses ice and pressure to treat the nosebleed. Read on for how to code this scenario … (more…)

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From the AMA in Chicago: CPT 2010 Out of Order Codes

Posted on 11. Nov, 2009 by .


Here’s where you can find a full list of resequenced codes.

Notice that new sign in your CPT book? No, that hash mark’s not to delete a message or to sign into a conference; it’s to alert you to an out of order code.

The “#” works like a flashing yellow light: Slow down, there might be something unexpected. Rather than moving groups of codes to new sections, the AMA has created another option. “Resequencing makes a lot of sense to avoid renumbering the codes,” explained William T. Thorwarth, Jr., MD, in “CPT 2010 Overview” at the CPT and RBRVS 2010 Annual Symposium’s opening session in Chicago.

Watch for the Out of Order Placard

When you’re coding a lesion excision, you usually assume the code increases by one as the excision’s size class goes up. But that truism will no longer hold true. Fortunately, watching for # will alert you to these inconsistencies. Read more for examples … (more…)

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Infusion Coding Education: Remicade

Posted on 10. Nov, 2009 by .


Coding Hint: Watch for ‘add-ons’ during Remicade sessions

Question: An established patient with a plan of care in place for his Crohn’s disease of the ileum reports to the gastroenterologist for a Remicade infusion. The infusion started at 10:00 a.m. and ended at 11:42. The patient reported nausea during the infusion, so the gastroenterologist administered 200 mg of Benadryl from 10:41 to 10:52. How should I report this encounter?

Answer: This claim has a lot of moving parts; you can code for both the Remicade and the Benadryl administrations. Because your Benadryl infusion time was so short, however, you should not report an infusion code for that service.

Follow this two-step guidance on how to ethically maximize this claim:

Step 1 — Remicade: The total infusion time for the Remicade treatment was an hour and 42 minutes. Represent this time with the following: (more…)

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Cardiology Coding Question: Separate Reporting for 37204

Posted on 08. Nov, 2009 by .


Question: Should I separately report right and left bronchial artery embolization?

Answer: You should report 37204 (Transcatheter occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method, non-central nervous system, non-head or neck) twice for right and left lung embolization at the same encounter.

In addition, if the cardiologist provides supervision and interpretation (S&I), you should report 75894 (Transcatheter therapy, embolization, any method, radiological supervision and interpretation) twice.

Support: CPT Assistant (October 1998) states you should report 37204 once “for each operative field addressed.” When the cardiologist embolizes the right and left bronchial arteries, he addresses two separate operative fields (right and left lung). CPT Assistant suggests appending modifier 59 (Distinct procedural service) to the codes for the second and subsequent fields.

Bonus tip: You should report one pair of codes (37204, 75894) per field even if the physician treats multiple vessels in that field or uses many coils or other embolic materials in a single vessel, states CPT Assistant (September 1998).

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