Archive for 'Hot Coding Topics'

Can a Sleep Study Code Describe an Awake Test?

Posted on 29. Nov, 2009 by .

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Question: A sleep study was ordered for a patient diagnosed with hypersomnolence. The neurologistincluded a multiple wake test in the sleep study. What CPT code should I use for the multiple wake test?

Answer: You should use 95805 (Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness). Code 95805 is the only sleep study code (95803-95811) that mentionswakefulness testing. Check if you need a modifier on 95805.

Sleep services codes (95805-95811) include recording, interpretation, and report. For cases when the neurologist does only the interpretation, use modifier 26 (Professional component) on the sleep study code.

All sleep studies must have a minimum of six hours. If the sleep study does not last that long, append modifier 52 (Reduced services) to your code.

The multiple wake test measures the patient’s ability to stay awake during a time when she is normally awake. During the wakefulness test the physician or technologist records the time it takes the patient to fall asleep during a course of four to five 20-minute nap opportunities provided during the testing period in the sleep lab.

The patient does not need to be asleep during the tests.

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Urology CPT 2010: 3 New Codes, 2 Deletions Change Your Urodynamics Coding

Posted on 22. Nov, 2009 by .

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Urodynamics income will go down by half, experts calculate.

You will have three new urodynamics codes to learn starting Jan. 1. CPT 2010 adds the following codes:

• 51727 — Complex cystometrogram (ie, calibrated electronic equipment); with urethral pressure profile studies (ie, urethral closure pressure profile), any technique

• 51728 — … with voiding pressure studies (ie, bladder voiding pressure), any technique

• 51729 — … with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique.

To make room for these three new codes, the AMA deleted urodynamics codes 51772 (Urethral pressure profile studies) and 51795 (Bladder voiding pressure studies). “To reduce costs and payments, CPT combined several of the urodynamic codes into one of several new codes,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook. “So doctors will not be able to bill each individual urodynamic procedure as they have in the past.” What you must know about +51797 …

(more…)

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Surgical Coding Mysteries: The Case of the Separate Mesh

Posted on 22. Nov, 2009 by .

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Beware Separate Mesh Removal

Question: The surgeon performed the following: Made 10 cm supraumbilical transverse incision with 15-blade scalpel carried down through subcutaneous tissue using Bovie. Used combination electrocautery and blunted dissection to isolate area of scar tissue on patient’s right side. Noted sutures from previous umbilical hernia repair and mesh from right-lower abdominal hernia repair.

Excised mesh and surrounding scar tissue to level of fascia using combination Bovie and blunt dissection. Closed with 30 Vicrylc and interrupted nylons. Can we bill separately for abdominal exploration (49000), mesh removal (+11008), and scar revision (13101) based on this operative note?

Answer: No, you should not code three separate procedures. You should report 22999 (Unlisted procedure, abdomen, musculoskeletal system) alone for the service described by this operative note.

Here’s why: You should not list +11008 (Removal of prosthetic material or mesh, abdominal wall for infection [e.g., for chronic or recurrent mesh infection or necrotizing soft tissue infection] [List separately in addition to code for primary procedure]) because there is no indication of a post-op infection or a more extensive debridement for necrotizing soft tissue infection.

Although you are correct that complex repair codes such as 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm) describe scar revision, you should not use that code in this case. The service you describe goes deeper than the skin, and the surgeon does not document the length of repair or closure in layers as required for complex repair codes.

You cannot bill 49000 (Exploratory laparotomy, exploratory deliotomy with or without biopsy[s]  [separate procedure]) because the surgeon did notperform a laparotomy — he did not document entering the abdomen, only working to the fascia level. The correct service is a foreign body removal from the abdominal wall. Although there are a number of codes that describe foreign body removal, none describe foreign body removal on the abdominal wall, so you must use the unlisted code. For pricing, you could refer to codes 13101 and 11008 if your surgeon feels that correctly represents his effort.

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Lab Fee G Codes Crosswalk to CPT

Posted on 18. Nov, 2009 by .

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Question: Did you get any info at the CPT 2010 conference about the “Table of Drugs and the Appropriate Qualitative Screening, Confirmatory, and Quantitative Codes” on page 386 CPT? This is brand new, and I need to learn about it.

Answer: CMS created lab fee G codes to substitute for CPT codes due to concern about how the CPT codes were being used. “I thought the descriptions were the same,” said Kenneth Simon, MD, MBA, FACS, CMS for the hospital and ambulatory policy group senior medical officer in “Medicare Physician Payment Schedule 2010 Changes and Beyond” at the CPT and RBRVS 2010 Annual Symposium in Chicago on Nov. 11, 2009. “It was supposed to be a straight cross walk.”

AUDIO: 2010 Pathology/Lab Coding Update. With Peggy Slagle.

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AMA Symposium Report: Low-Level Consult Reporting in 2010

Posted on 18. Nov, 2009 by .

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Dawn in Chicago. And a new day for consult coding.

Dawn in Chicago. And a new day for consult coding.

Hey, Coding News readers! It’s your turn to weigh in on the consult controversy.

Question: What should you do for Medicare 2010 coding if an inpatient consult on a patient’s initial hospital day does not support 99221?

Answer: Kenneth Simon, MD, MBA, FACS, CMS, senior medical officer at the CPT symposium was very adamant that you would have to use 99221. When questioners kept asking “But how could you use 99221 if the documentation didn’t support that level?” he continued to say, “On day 1, use 99221-99223.” His blunt repetition angered many attendees.

Ken, however, based his idea on data that Medicare used for the consult elimination that indicated most consult are coded as high-level consult. Therefore, he seemed to think the low levels would not be problematic.

How many of you currently are using low level consults (99251, 99252)? Let us know in a reply to this question.

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Medicare’s Consult Rule Trickle Down Effect

Posted on 18. Nov, 2009 by .

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Our Chicago reporter's trusty CPT book & conference bag.

Our Chicago reporter

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 .

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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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Pain Management Coding: Endoscopic Lumbar Nerve Decompression

Posted on 15. Nov, 2009 by .

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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 .

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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 .

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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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