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

Posted on 25. Oct, 2009 by in Coding Challenge, Hot Coding Topics.


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…

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Double Ultrasound Codes Spell Double Trouble With Auditors

Posted on 25. Oct, 2009 by in Hot Coding Topics.


Authorities scrutinize medical necessity for 76830 & 76856.

The OIG is watching your ultrasound orders and code combinations — and it doesn’t like what it sees. Take note of these problem spots to keep your claims in the clear.

An OIG audit of ultrasound services billed in 2007 found that nearly one in five ultrasound claims “had characteristics that raise concerns about whether the claims are appropriate,” according to a July 2009 audit report titled “Medicare Part B Billing for Ultrasound.

The most common error: Roughly 17 percent of 2007 Part B ultrasound claims lacked prior service claims by the ordering physician, the OIG indicated.

What this means: Several physicians ordered ultrasounds for patients that they hadn’t treated within the last year. “The OIG would wonder why the doctor would order an ultrasound for a patient who [the ordering physician] hasn’t examined,” notes Allison Larro, Esq., an Atlanta-based attorney.

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Anesthesia Coding Education: Sciatic Nerve Block & Same-Day General Anesthesia

Posted on 22. Oct, 2009 by in Coding Challenge, Hot Coding Topics.


Question: My anesthesiologist performed a sciatic nerve block for a patient with postoperative pain on the same day he provided general anesthesia for that patient’s knee surgery. How should I code this?

Answer: Use modifier 59 (Distinct procedural service) when you need to show that your physician performed two distinct services on the same day. When your physician places a sciatic nerve block for postoperative pain management (for example, 64445, Injection, anesthetic agent; sciatic nerve, single), and on the same day provided general anesthesia for knee surgery (01400, Anesthesia for open or surgical arthroscopic procedures on knee joint; not otherwise specified), your final codes are 64445-59 for the block, along with 01400 for the anesthesia.

AUDIO: Take the billing ache out of postoperative pain. With Joanne Mehmert, CPC, CCS-P.

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Radiology Billing Checklist: Rules for Additional Tests without Treating Physician’s Order

Posted on 22. Oct, 2009 by in Toolkit.


Keep these additional test rules at your fingertips if your want to keep auditors out of your hair.

The Office of Inspector General and Recovery Audit Contractors are out to audit non-compliant ultrasound claims, so knowing the rules is more important than ever. And we’ve got a link and a handy checklist to keep you out of trouble.

If you’re wondering when a radiologist can bill for a test without the treating physician’s order, we’ve got the link where CMS answers your question, plus a handy checklist.

CMS explains when a radiologist can bill for a test without the treating physician’s order in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6.

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Medical Office Billing: 7 Ways to Escape Computer Claim Casualties

Posted on 22. Oct, 2009 by in Hot Coding Topics.


Pay attention to EOBs and keep talking to your MAC.

You could be losing money to a computer glitch and not know it, experts say.

If you don’t nip a computer glitch in the bud, you may be plagued with improper denials and other claim holdups. Here are seven things you can do to seek out and solve glitch-related problems:

1. Eyeball Your EOBs

Watch your explanation of benefits (EOB) forms, and keep your eyes open for denials and downcodes that don’t look correct.

2. Check Your A/R

Always review your accounts receivable (A/R) to ensure that you’ve received the payments you’re due. If a computer glitch kept your MAC from paying you, don’t hesitate to point it out to the payer.

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OIG Auditors to Cardiologist: You’re Billing Medicare Properly

Posted on 20. Oct, 2009 by in Provider News.


Report reveals what he and his billing staff did right. Does your practice have the right stuff?

Turns out the old saying is true:If you haven’t done anything wrong, an OIGaudit is nothing to worry about.

A New York cardiologist who collected over $1.3 million over a three-year period for 5,061 claims caught the OIG’s eye due to a “high volume of Medicare claims in comparison to other cardiologists throughout New York state,”according to the OIG’s report on the topic, which was released on Oct. 14.

The OIGreviewed the cardiologist’s records for the three-year period, but found that the physician, who specialized in non-invasive procedures, complied with Medicare reimbursement requirements. Therefore, the OIG made no recommendations and did not request any fund recovery from the physician.

What your practice can learn: If you have a physician who specializes in a particular condition or…

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Service Doesn’t Meet Incident-To Rules? Report Under NPP’s NPI

Posted on 20. Oct, 2009 by in Hot Coding Topics.


Heads up: These vaccine admin codes are excluded from incident-to requirements.

Incident-to rules don’t always apply to diagnostic services, but many medical practices aren’t aware of that.

And based on a new wave of scrutiny directed toward incident-to claims, you should know physician supervision rules inside and out.

A recent audit from the HHS Office of the Inspector General audit found that unqualified nonphysician practitioners performed 21 percent of incident-to services examined, and that’s sure to have Medicare scrutinizing your incident-to claims even more thoroughly than in the past.

The presumption: Many practices believe that as long as they meet the minimum requirements of incident-to (the physician is on-site and sees patients for any new problems), they can report all types of NPP services incident-to and collect their extra 15 percent of Medicare reimbursement.

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What’s the Correct Diagnosis Code for a Urine Drug Test?

Posted on 20. Oct, 2009 by in Coding Challenge, Hot Coding Topics.


Question: What is the proper ICD-9 code when the lab performs a urine drug test?

Answer: ICD-9 does not provide one specific code for a urine drug test. The correct diagnosis code to report when billing for the lab test depends on the signs, symptoms, patient condition, or other reason for the test, such as screening. The ordering physician will assign a narrative diagnosis or ICD-9 code when requesting a urine drug test from the lab.

For example: A high school student previously diagnosed as marijuana dependent is doing poorly in school. Suspecting marijuana use again, the physician orders a urine drug screen. In this case, the most appropriate code is 304.30 (Cannabis dependence, unspecified).

In another case: A physician might order a general screening urine drug test such as 80100 (Drug screen, qualitative; multiple drug classes chromatographic method, each procedure) for an  elderly patient prior to admission to a…

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Coders: Watch Out for Claim-Denying Computer Glitches

Posted on 18. Oct, 2009 by in Hot Coding Topics.


Don’t wait for your MAC to alert you to an error — be on the lookout for them.

If you’ve been losing reimbursement to computer hiccups at your carrier, you’re not alone. Earlier this year, thousands of Medicare recipients in one state were wrongly told their benefits were being cut by $300 — but the state decided not to notify those affected with a letter. Instead, the state only told those who called in to complain that the notification of benefit cuts they received was the result of a computer glitch.

Glitches can cause erroneous denials, unnecessary rejections, lost crossover claims, and frustrating delays. But if you don’t notice the glitch, you could kiss your reimbursement goodbye. That’s because the MAC won’t always alert you to a mistake that its computers made.

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OB or Not OB: That’s the Ultrasound Coding Question

Posted on 18. Oct, 2009 by in Coding Challenge, Hot Coding Topics.


Question: For an ultrasound, the radiologist documented measurements of the uterus, endometrial complex, and ovaries. She noted no evidence of intrauterine pregnancy, no free fluid in the cul-de-sac, physiologic follicle formation, and positive Doppler flow in the ovaries. The patient had syncope but no confirmed pregnancy. Should I report an obstetric or nonobstetric ultrasound?

Answer: Because the patient has no confirmed pregnancy before the ultrasound, you should report a nonobstetric ultrasound.

The AMA’s CPT Assistant (October 2001) states that when a female patient presents with no confirmed pregnancy, you should report a nonobstetric ultrasound, regardless of whether the ultrasound confirms pregnancy.

On the flip side, if the patient had a confirmed pregnancy and presented for an ultrasound that might be pregnancy related, but the ultrasound does not demonstrate a pregnancy, you would report an obstetric ultrasound code.

ICD-9: Because you don’t have a confirmed diagnosis, you should report the symptom that led to the ultrasound: 780.2 (Syncope and collapse).


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