Reporting modifier 78 for a staged procedure? Expect denials.
When it comes to appending CPT® modifiers to your codes, the rules can be daunting, and Medicare’s regulations only compound the confusion. But if you’re up to speed on these key modifier billing practices, you’ll be raking in deserved pay.
Check out the following five tips to ensure that you aren’t missing any opportunities.
Modifiers and test results are among the ‘instant denial’ triggers for these codes.
Whether you search under medical oncology, hematology, or hematology/oncology, J0881 and J0885 rank first and third on the lists of the top 10 codes reported to the CMS database (2009). These J-codes for erythropoiesis stimulating agents (ESAs) carry a heavy load of very specific reporting requirements and volatile reimbursement rates. To be sure your claims for these frequently reported codes are as clean and accurate as possible, apply the tips below.
Use this cheat sheet to aid your non-congenital valve disorder coding
|Code||Descriptor||Role of ‘Rheumatic’|
|MITRAL VALVE ONLY|
|394.0||Mitral stenosis||Use if specified as rheumatic or unspecified. If specified as non-rheumatic, use 424.0.|
|394.1||Rheumatic mitral insufficiency||Specific to rheumatic cases. For others, use 424.0.|
|394.2||Mitral stenosis with insufficiency||Use if specified as rheumatic or unspecified. If specified as non-rheumatic, use 424.0.|
|394.9||Other and unspecified mitral valve disease||Use if specified as rheumatic or unspecified. If specified as non-rheumatic, use 424.0.|
|424.0||Mitral valve disorders||Use if specified as non-rheumatic. Also use for mitral insufficiency of unspecified cause.|
|AORTIC VALVE ONLY|
|395.0||Rheumatic aortic stenosis||Specific to rheumatic cases. For others, use 424.1.|
|395.1||Rheumatic aortic insufficiency||Specific to rheumatic cases. For others, use 424.1.|
|395.2||Rheumatic aortic stenosis with insufficiency||Specific to rheumatic cases. For others, use 424.1.|
Get the lowdown on when to code separately for fluoroscopy.
If your physician performs interventional pain management (IPM) services, you’ll need to be up to speed on four top IPM procedures to make sure you’re earning full deserved reimbursement for your claims.
Difference: Pain management specialists are physicians who study pain and perform less invasive injections (soft tissue, peripheral nerve, and joint injections) and medication management to help relieve patients’ pain. One common pain management procedure is trigger point injection (20552, Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) or 20553, single or multiple trigger point[s], 3 or more muscle[s]). An interventional pain management specialist’s scope includes spinal diagnostic and therapeutic procedures and other invasive techniques like nerve stimulator or opioid pump insertion, says Scott Groudine, MD, an anesthesiologist in Albany, N.Y. When submitting claims, you’ll use specialty designation 72 for pain…
Tip: A diagnosis that falls under an ICD-9 ‘other’ code may have its own ICD-10 code.
Under ICD-9, when the manual doesn’t offer a code specific to your diagnosis, you usually choose one of the catch-all “other specified” codes available, such as 425.4 (Other primary cardiomyopathies). When you start applying ICD-10 codes in October 2013, you may find that your catch-all code has been divided into more specific options. Here’s how the ICD-10 counterparts for 425.4 will look.
Question: In the CMS DRG datasheet, what is the difference between the column titled “Geometric Mean LOS” and the one labeled “Arithmetic Mean LOS”?
Answer: The geometric mean length of stay or (GMLOS) is the national mean length of stay for each diagnostic related grouper (DRG) as determined and published by CMS. The arithmetic mean length of stay (ALOS) is the average length of stay experienced by a patient within a chosen DRG. The geometric mean reduces the effect of very high or low values, which might bias the mean if a straight average (arithmetic mean) is used.
Hospitals can use GMLOS and ALOS to analyze reimbursement impacting areas. For instance, a hospital analyst could collect their hospital’s ALOS for hospital inpatients in a particular DRG admitted on a particular day of the week to the GMLOS. Variations in the length of stay relative…
Question: I’m looking for the anesthesia code for a tympanostomy of the left ear, performed on a 10-month-old child. What’s the correct choice?
Check whether your group might fall into one of four new categories.
The push toward e-prescribing is in full swing, with physicians possibly being subjected to a one percent payment hit on CMS claims in 2012 if you don’t successfully participate in e-prescribing this year (and larger hits in 2013 and 2014). If your physicians haven’t yet met e-prescribing criteria, take hope: CMS has proposed four additional ways that eligible professionals (EPs) can potentially avoid the adjustment in 2012.
12, 24, and 48 hour services all have roles in this coding shake-up.
Cardiology codes are always changing, trying to keep pace with technology and current practice. For this reason, Holter monitor codes saw big changes this year. Here’s what you need to know.
Start With a Nutshell Holter Service Description
Dynamic electrocardiography (ECG), also called Holter monitoring, involves ECG recording, usually over 24 hours. The goal is to obtain and analyze a record of the patient’s ECG activity during a typical day. The medical record usually will include the reason for the test, copies of ECG strips showing abnormalities or symptomatic episodes, the patient’s diary of symptoms, statistics for abnormal episodes, the physician’s interpretation, and documentation of recording times.
Verify evidence of previous treatments for successful claims.
If you’re coding for a patient’s carpal tunnel syndrome (CTS) injection, double check for previous, less invasive CTS treatments before getting too far with your claim. If the physician administers an injection during the patient’s initial visit for CTS, you could be facing a denial. Some payers allow CTS injection therapy only when other treatments have failed. Check out these FAQs to make each CTS coding scenario a snap.
Should the Physician Try Other Treatments Before 20526?
Yes. The FP would likely try less invasive treatments before resorting to CTS injection (20526, Injection, therapeutic [e.g. local anesthetic, corticosteroid], carpal tunnel), confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. These treatments might include, but are not limited to: