Archive for 'Hot Coding Topics'

Radiology Coding Education: Is 76705 OK for Back?

Posted on 03. Nov, 2009 by .


Question: For a lower back ultrasound of a soft tissue mass, which CPT code is appropriate?

Answer: Code 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]) is appropriate for this lower back ultrasound.

Although the code descriptor states “abdominal” and not “back,” CPT Assistant (May 2009) clarifies that 76705 is appropriate for a lower back or abdominal wall soft tissue mass ultrasound.

Bonus tip: You might be surprised to discover these other not-so-obvious anatomy/code pairings that CPT Assistant supports:

• chest wall, upper back: 76604 (Ultrasound chest [includes mediastinum], real time with image documentation)

• pelvic wall, buttock, perineum: 76857 (Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles])

• upper extremity, axilla, groin, lower extremity: 76880 (Ultrasound, extremity, nonvascular, real time with image documentation).

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Nonphysician Providers & Incident To Checklist

Posted on 01. Nov, 2009 by .


Check state laws PLUS this crucial document.

In last week’s Coder’s Cranium, we started a checklist of 3 things you should know to correctly bill for a nonphysician practitioner’s services — and stay compliant. This week, we complete the checklist with advice for items 4, 5 & 6.

4. Have You Distinguished Auxiliary Personnel From NPP Services?

NPPs can supervise auxiliary personnel (registered nurses [RNs], licensed practical nurses [LPNs] and technicians) for incident-to services just as a physician would supervise the NPP.

The catch: You must bill the auxiliary personnels services under the NPPs number, and you may only receive 85 percent reimbursement. For example, the physician is out of the suite doing rounds in a hospital while a PA sees patients in the suite under her provider number. A patient comes in for a blood draw, which a nurse on staff performs. The nurse should bill 36415 (Collection of venous blood by venipuncture) under the supervising PA’s provider number.

Watch out: State license laws determine the scope of practice under which NPPs can operate. So be sure to check your states licensure policy on incident to as well as other services (such as their ability to prescribe) because the scope of practice may not align with Medicare. The stricter set of laws takes precedence. (more…)

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Neurosugery Coding: 3 Easy Steps Distinguish Between 61790 & 61791

Posted on 01. Nov, 2009 by .

Trigeminal Nerve, in yellow.

Trigeminal Nerve, in yellow.

Anatomy know-how points you in the right direction every time.

How do you tell the difference between 61790 (Creation of lesion by stereotactic method, percutaneous, by neurolytic agent [e.g., alcohol, thermal, electrical, radiofrequency]; gasserian ganglion) and 61791 (… trigeminal medullary tract)?

That’s the question a Neurosurgery Coding Alert reader posed when she wrote, “What is the difference between the gasserian ganglion and trigeminal medullary tract, and how do you determine which code to use?” The answer lies in knowing your anatomy so you can assign codes accordingly.

1. Know Your Nerve Anatomy

Understanding the nerve branches and how they relate to each other is your first step in distinguishing between 61790 and 61791. Here’s what you need to know:

• The trigeminal nerve provides sensation to the face. It’s the fifth (and largest) cranial nerve, also called the fifth nerve (or “V.”) (more…)

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Ophthalmology Coding: GDX, VF, & Temp Plugs — How Many Modifiers?

Posted on 01. Nov, 2009 by .


Question: A patient came in for a GDX and visual field (VF) tests. During the same visit, the ophthalmologist put in temporary plugs. Can we get paid for all services on the same day? I know the office visit needs a modifier. Do I need to put one on the GDX & VF, too?

Answer: Provided the ophthalmologist made the decision to perform the tests during this visit, you may bill for the office visit and the testing. You should be able to get paid for all services using four modifiers — one on the office visit as you indicated, one on each plug code, and one on the GDX. You do not need a modifier on the VF (92081-92083, Visual field examination, unilateral or bilateral, with interpretation and report …).

Warning: If the patient was scheduled to come in for the GDX and VF testing as the result of a previous office visit, you should bill only the GDX and VF testing.

Unless there is a need for the physician to perform another office visit evaluation (worsening symptoms, new symptoms), do not report the office visit. Inserting a plug (68761, Closure of the lacrimal punctum; by plug, each) is a minor procedure that includes related evaluation and management work. You should only report an E/M when documentation supports the service as significant and separately identifiable from the plug insertion. In these cases, you need modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the office visit (99201-99215, Office or Other Outpatient Services).

Make sure to use separate diagnoses for the problem and for the primary reason or diagnosis for the visit. (Please click ‘read more’ for a money-saving tip and how you should code for an insurer that doesn’t recognize E modifiers.) (more…)

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Pain Management Coding Update: Facet Joint Injection CPT Changes for 2010

Posted on 29. Oct, 2009 by .


Pain management, anesthesia, orthopedic, physiatry & neurology coders get ready for a facet joint codes shift that preps for ICD-10.

The 2010 version of CPT attempts to organize the facet joint injection codes by deleting 64470-64476 and debuting 64490- 64495 in their place, as follows:

• 64490 — Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

• 64491 — … second level

• 64492 — … third and any additional level(s)

• 64493 — Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

• 64494 — … second level (more…)

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Does My E/M Coding Have to Match Hospital’s E/M Coding?

Posted on 29. Oct, 2009 by .


Question: My physician removed a catheter in an outpatient hospital exam room. Should I include this removal as part of the E/M? If E/M is appropriate, will the hospital also report an E/M? And, if so, do the physician and hospital E/M codes need to match?

Answer: You should include simple Foley catheter removal as part of an E/M service. These follow-up visits will often be low-level visits (such as 99212, Office or other outpatient visit …). Inpatient E/M codes would also be appropriate when your physician performs these services in the hospital (for example, 99231, Subsequent hospital care, per day, for the evaluation and management of a patient …).

The hospital sometimes may have the option of whether or not to report an outpatient E/M code for an outpatient ambulatory payment classifications (APC) reimbursement. For example, if the patient has another procedure during the same encounter as the catheter removal, then the hospital would not report its E/M service separately from the other procedure.

In most cases, the physician’s outpatient E/M level will determine the hospital APC and any other outpatient procedure reported on the same day. The 2009 Outpatient Prospective Payment System (OPPS) final rule states that “while awaiting the development of a national set of facility-specific codes and guidelines, we have advised hospitals that each hospital’s internal guidelines that determine the levels of clinic and emergency department visits to be reported should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes.”

Translation: The hospital E/M code choice should reflect the hospital’s resource use, not the physician’s. You  may see a difference in new versus established code choices, as well. For hospitals, “beginning in CY 2009, the meanings of new and established patients pertain to whether or not the patient has been registered as an inpatient or outpatient of the hospital within the past 3 years,” the rule states.

2010 E/M Coding Update comes to audio. Your entire office can learn from Dr. Duane Abbey for one low price!

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New CPT Codes for Cardiac CT, Imaging Appear for 2010

Posted on 27. Oct, 2009 by .


Plus: Say goodbye to two perfusion codes.

If you’ve ever wondered whether Medicare actually pays attention to CPT’s Category III codes, the AMA offers an answer with the release of the new codes included in CPT 2010.

First and foremost, CPT will delete the Category III cardiac computed tomography (CT) imaging codes 0144T-0151T and replace them with new, permanent Category I codes, as follows:

• 75571 — CT, heart, without contrast material, with quantitative evaluation of coronary calcium

• 75572 — CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) (more…)

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Does CNS Count as NP for Time-Based Coding?

Posted on 27. Oct, 2009 by .


CNS = NP = PA for CPT, but Check State Law

Question: Does a certified nurse specialist (CNS) count as a nurse practitioner (NP) for reporting 99213 based on time?

Answer: Yes, for CPT purposes, a certified nurse specialist billing under his own provider number counts the same as a nurse practitioner or physician assistant. So if the office visit meets the requirements for time-based billing — counseling and/or coordination of care comprises more than 50 percent of the face-to-face CNS-patient encounter and documentation indicates the encounter’s total face-to-face time, the counseling minutes, and a discussion summary — the CNS can choose the office level using time, such as 15 face-to-face minutes for 99213 (Office or other outpatient visit for the evaluation and management of an established patient …) as the sole criteria.

Be careful: Check your state law. State scope of practice laws may restrict services and procedures that nonphysician practitioners may provide.

AUDIO: Maximize Reimbursement with Time-Based Coding and CLIA Waived Tests.

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Nonphysician Providers and Incident-To: Your Coding Questions Answered

Posted on 25. Oct, 2009 by .


Here’s why you should keep your physicians’ work schedules on file.

Correctly billing your nonphysician practitioners (NPPs) incident-to services means the difference between 85 and 100 percent reimbursement. But if you bill incident-to haphazardly, you’re just waving a red flag at auditors.

And those auditors are jonesin’ to find incident to billing problems. Just check out this recent report from the HHS Office of Inspector General to learn the kinds of mistakes they’re looking for.

But have no fear. If you use the following list of questions to evaluate your incident-to claims for all the must-have components, and be sure the documentation includes the same, you’ll have nothing to worry about if auditors come knocking.

1. Do the Services Involve Direct Supervision?

Direct means that the supervising physician must be in the immediate office suite while incident-to services are being provided. But if you’re too conservative with the word direct, you could be giving up the extra reimbursement that comes with billing incident to. Direct doesnt mean that the physician has to be supervising the work elbow-to-elbow with the NPP. (more…)

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Will a CLIA Waiver Help Our Practice’s Bottom Line?

Posted on 25. Oct, 2009 by .


Question: During a practice meeting last week, the subject of Clinical Laboratory Improvement Amendments (CLIA) waivers came up. We are currently not CLIA-waived, and we will discuss it again at next month’s meeting. I was wondering if you could offer any input? Should we apply for a CLIA waiver?

Answer: Whether or not the waiver is worth it is up to your individual practice. However, a practice is not allowed to perform many basic laboratory services without CLIA-waived status. So if your practice does not get the waiver, you could be missing out on possible pay for some simple screens.

Example: Here are a few of the tests that have CLIA-waived status to help you decide:

• 81002 — Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy

• 82270 — Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection) (more…)

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