In December 2014, CMS posted a document on its Advisory Panel on Hospital Outpatient Payment (HOP Panel) website outlining the hospital outpatient therapeutic services that were recently evaluated for a change in supervision levels. The three-page document contains a chart that includes the HCPCS code, the level of supervision required for coverage, and the effective dates of the changes for various services.
Q: When would we use codes from ICD-10-CM category E13 (other specified diabetes mellitus)? If it's secondary diabetes but not due to an underlying condition or drug and is not chemically induced, what kind of diabetes could it be?
CMS expanded packaging and finalized Comprehensive APCs in the 2015 OPPS final rule. Jugna Shah, MPH, and Valerie Rinkle, MPA, analyze the changes and the potential impact on providers.
In a concerted effort to move healthcare payments to a system of "quality over quantity," CMS finalized policies that greatly expanded packaging for outpatient providers in the 2015 OPPS final rule. It also introduced complexity adjustments with comprehensive APCs (C-APCs).
As CMS pushes the OPPS from a fee-for-service program toward more of a true prospective payment system, financial impact analysis of changes, departmental budgeting, and forecasting has become more complicated each year.
Q: If the physician does not perform a formal myelography and just administers an injection before the patient goes straight for computed tomography (CT), which CPT ® code would we report in 2015? The 2015 combination codes are for use when the same radiologist or physician who performs the injection reads his or her own study.
Q: I have a question regarding CPT ® code 99184 (initiation of selective head or total body hypothermia in critically ill neonate, includes appropriate patient selection by review of clinical, imaging, and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling) in the 2015 CPT Manual . What if the neonate is in the hospital for several weeks? The total body hypothermia is performed, the baby improves, but remains in the hospital and then needs the procedure performed a second time. Can we report it a second time if several weeks have elapsed?
Beginning January 1, 2015, physicians will no longer need to provide certification for an inpatient admission unless the admission is expected to last for at least 20 days or the case is an outlier.
Q: We have a patient diagnosed with neuropathy due to poorly controlled insulin-dependent Type 1 diabetes mellitus. What should we report in ICD-10-CM?
Q: I work in a large, provider-based orthopedic clinic with a rheumatology department that has many patients who are very ill with several comorbid conditions. Does the physician need to document every comorbid condition that impacts his or her medical decision making for each encounter? Do we need to code every comorbidity each time in order to meet hierarchical condition category (HCC) requirements?
Nearly 30% of Medicare patients are enrolled in Medicare Advantage (MA) programs, which come with specific coding and documentation challenges. Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA, and Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, highlight key requirements for reporting diagnoses that map to Hierarchical Condition Category codes, the basis of MA plans.
Editor's note: Jugna Shah, MPH, president and founder of Nimitt Consulting, writes a bimonthly column for Briefings on APCs, commenting on the latest policies and regulations and analyzing their impact on providers.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
Steven Espinosa , CCS , AHIMA-approved ICD-10-CM/PCS trainer, and Denise Williams, RN, CPC-H, outline the anatomy of the upper gastrointestinal system and how anatomical details, along with the provider's approach and intent, help determine the proper procedure code.
Q: Do any general guidelines exist for queries on outpatient services? We are beginning the process of developing such a query system for our hospital outpatient services and clinical documentation team.
When is a mammogram a screening procedure and when does it qualify as a diagnostic test? Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, outlines the differences between the two and what to look for in the documentation.
Q: A patient was in a hyperbaric oxygen chamber for eight minutes and the physician had to abort the treatment because the patient was feeling anxious. Which HCPCS/CPT ® code should the hospital bill: HCPCS code C1300 (hyperbaric oxygen under pressure, full body chamber, per 30 minute interval) or an E/M code? Which code should the supervising physician bill: CPT code 99183 (physician or other qualified healthcare professional attendance and supervision of hyperbaric oxygen therapy, per session) or an E/M code?
CMS has instructed MACs to reprocess claims and providers to reimburse beneficiaries due to a miscalculated copayment for stereotactic radiosurgery, according to the October update to the OPPS and Integrated Outpatient Code Editor (I/OCE).
Editor's note: Andrea Clark-Rubinowitz, RHIA, CCS, CPCH , has more than 30 years of experience working with healthcare professionals, information systems, hospital coding, and operational and compliance training. She founded and led Healthcare Revenue Assurance Associates from 2001 to 2014. Contact her at 954-465-0968 or aclark5678@gmail.com .
Q: What if the provider states that diabetes is due to the adverse effects of a drug, but doesn't tell us which drug? How do we report that in ICD-10-CM?
The ICD-10-CM delay has at least one silver lining: the ability to spend more time on coding and documentation requirements before implementation. Providers may want to also think about aligning their ICD-10-CM efforts with outpatient clinical documentation improvement (CDI) during this time. Elaine King, MHS, RHIA, CHP, CHDA, CDIP, examines the benefits and challenges of outpatient CDI programs.
Evaluation and management (E/M) services are one of the top areas of review by federal auditors. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes about common errors found in audits and how providers can take steps to correct them.
The 2015 OPPS proposed rule includes new Comprehensive APCs, increased packaging, and many other changes. Kimberly Anderwood Hoy Baker, JD, and Jugna Shah, MPH , review the proposed rule and policies that may be finalized by CMS.
Q: We're not sure what to report in this situation: A patient comes to the ED and goes into respiratory failure. The respiratory therapist comes in to put patient on a vent in the ED, then the patient is transferred to another facility. We can’t report CPT ® code 94002 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day) because it is for inpatient/observation, per the definition. We wondered about using 94660 (continuous positive airway pressure ventilation [CPAP], initiation and management) for the CPAP. The lay description seems to be basically the same as 94002, except for “applies to ventilation assistance using adjustments in volume and pressure on the initial day…" Would 94660 be appropriate?
When CMS releases rules, the length can be intimidating. But even at a relatively slim 700 pages, the 2015 OPPS proposed rule isn't able to include details on each of the changes CMS is planning. This is probably a good thing?otherwise the rules could be thousands of pages long. Updates like codes being moved around or status indicators changing often aren't described in full in the narrative text, necessitating a deeper look at the addenda CMS releases as Excel® files on its website.
Modifier -25 (significant, separately identifiable E/M service by the same physician on the day of a procedure) is used to distinguish visits from procedures on the same day. It is not used to distinguish observation from a visit service on the same day.
CMS refined and updated its Comprehensive APC policy in the 2015 OPPS proposed rule released July 3, adding a new complexity adjustment factor. CMS also proposes significantly expanding the packaging of ancillary services. Additionally, the proposed rule includes a significant change to requirements related to inpatient physician certification.
Q: We're wondering about how to use CPT ® code 73225 (magnetic resonance angiography [MRA], upper extremity, with or without contrast material) in our hospital. When providing an MRA of an upper extremity with and without contrast material, should we bill this service twice (since CPT indicates with or without contrast material) or only once?
Q: My physicians perform procedures in the office such as angioplasties, catheter insertions, venograms, and repairs of grafts and fistulas. What is the proper way to code the medications they administered during the procedures?
Hospitals will still use CPT ® codes to report procedures after ICD-10 is implemented, but some will also code with ICD-10-PCS. Andrea Clark, RHIA, CCS, CPC-H , reviews the advantages and challenges outpatient facilities may face when using ICD-10-PCS.
The July quarterly I/OCE update from CMS brought few new APCs or edit updates, but did deliver new modifier -L1. Hospitals will use the new modifier to submit outpatient laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) in certain circumstances to claim separate payment.
"Sometimes the questions are complicated and the answers are simple." ?Dr. Seuss This quote seemed an appropriate way to begin a discussion about outpatient encounters and ICD-10-PCS. You see, outpatient procedures will still be coded using CPT ® /HCPCS?the HIPAA-approved code set for reporting hospital outpatient procedures?regardless of when ICD-10 is implemented.
The July quarterly I/OCE update from CMS brought few new APCs or edit updates, but did deliver a new modifier. Debbie Mackaman, RHIA, CHCO, Jugna Shah, MPH , and Denise Williams, RN, CPC-H , explain how to use the modifier, as well as the impact of APC changes.
Q: A patient comes into the ED with sickle cell crisis and is in a lot of pain. The physician states the patient needed “aggressive” pain control for treatment, because what was given in the beginning provided only minimal relief. Could I code using CPT ® code 99285 (ED visit for evaluation and management of a patient, including a comprehensive history, comprehensive exam, and high complexity medical decision making)?
Q: We are coding for pain management procedures and have been doing dual coding in ICD-9-CM and CPT ®. With a medial branch block ablation at two levels for L3-L4 and L4-L5 for a bilateral injection, we are coding: ICD-9-CM procedure code 04.2 (destruction of cranial and peripheral nerves) CPT codes 64635 (destruction by neurolytic agent, paravertebral facet joint nerve[s], with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single facet joint) and 64636 (destruction by neurolytic agent, paravertebral facet joint nerve[s], with imaging guidance [fluoroscopy or CT]; lumbar or sacral, each additional facet joint [List separately in addition to code for primary procedure]), each with modifier -50 (bilateral procedure) appended. What would be your recommendation for the ICD-10-PCS code? Currently we are coding 015B3ZZ (destruction, lumbar nerve, percutaneous) twice. We are not sure if we should be picking this code up twice or only once.
Documentation and billing for observation stays has come under increased scrutiny from the OIG, though many hospitals have struggled with changing regulations and frequently updated guidance.
Q: I work for general surgeons. Here is a common scenario: The surgeon is called in to see patient in the ED for trauma or consult. The patient is admitted, but our physician is not the admitting physician. I would tend to bill the ED code set, but do I have to use the subsequent hospital care codes instead?
Q: If the clinical impression is physical assault, vomiting, blunt injury to abdomen, and head injury with loss of consciousness, can I code the history of hypertension, diabetes mellitus, headache, bipolar disorder, and depression?
On July 1, CMS will implement a variety of changes to current supervision requirements as recommended by the Hospital Outpatient Payment Panel. Debbie Mackaman, RHIA, CHCO , reviews the panel's recommendations, and which CMS plans to accept or reject.
CMS made relatively few changes in the April quarterly I/OCE update, introducing four new APCs, deleting one, and reclassifying several skin substitute codes.
Hospital outpatient therapeutic services, such as ED or clinic visits, that are paid under the OPPS or to critical access hospitals (CAH) on a cost basis must be furnished "incident to" a physician's service to be covered.
The April quarterly I/OCE update brought relatively few changes, though CMS has continued to refine skin substitute reporting. Dave Fee, MBA, reviews the updated skin substitute categories, as well as updates to laboratory billing.
Q: I read that CPT ® code 20680 (removal of implant; deep, e.g., buried wire, pin, screw, metal band, nail, rod, or plate) is commonly used for deep hardware removal. What would be the proper code for removal on one screw that has already made its way out, is not under any muscle, and is easy to visualize?
Q: My office often has denials of evaluation and management (E/M) visits with our OB patients when using HCPCS modifier -GB (claim being resubmitted for payment because it is no longer covered under a global payment demonstration). Would coding with V22.2 (pregnant state, incidental) as a secondary diagnosis possibly alleviate this issue?
In January, I wrote about the perfect storm that led to the release of the 2014 OPPS final rule. We endured a later-than-usual release, errors in the data files and a release of updated files, a government shutdown, and a vastly shortened window between the release of the final rule and implementation on January 1. Judging by the confusion among providers?and corrections and clarifications coming from CMS on what seems like a weekly basis on a wide range of issues?we're still not in the clear.
Since January, providers have been struggling to reconcile conflicts between CMS' rules and regulations and those published by the CPT® Manual and other AMA publications.
Providers struggle to reconcile conflicts between recent CMS regulations and the CPT® Manual and other AMA publications. Jugna Shah, MPH , Valerie A. Rinkle, MPA , and Linda S. Dietz, RHIA, CCS, CCS-P , look at specific areas of confusion and how to code them accurately.
Q: I have been told to use the general surgery CPT ® codes in the 20000 series for reporting excisions of sebaceous cysts when the surgeon must cut into the subcutaneous layer. I don’t agree with this, since the 20000 codes do not give ICD-9-CM code 706.2 (sebaceous cyst) as a billable diagnosis code. Because a sebaceous, epidermal, or pilar cyst begins in the skin and may grow large enough to press into the subcutaneous layer, I think we should report an excision code from the 11400 series, and if need be, the 12000 codes for closure.
Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews which diagnosis codes, in both ICD-9-CM and ICD-10-CM, Medicare recently approved to provide medically necessary for inserting pacemaker systems.
Q: My question is about the time interval requirement of the CPT ® add-on code 96376 (each additional sequential intravenous push of the same substance/drug provided in a facility [list separately in addition to code primary procedure]), which says that more than 30 minutes must pass between administrations of same substances in order to report it. In our ED, cardiac patients are frequently started on heparin—a bolus given for less than 16 minutes and a drip given over several hours. These are frequently charted in the electronic record as having been given at the same time. In this case, is it still appropriate to report 96365 (intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour) for the first hour of drip and 96376 for the bolus, or must the administration be given greater than 30 minutes apart?
The January 2014 quarterly I/OCE update included nearly 400 new HCPCS Level II codes, but the most significant changes for providers may center on relatively few codes, as a result of modifications CMS made in the 2014 OPPS final rule.
Our experts answer questions on payment rates for scans, bronchodilator treatment, the inpatient-only list, stereotactic radiosurgery, bill exposure with arthrodesis, and more.
While many of the code changes in the 2014 CPT® Manual surgical sections involve bundling together common procedures, the major changes in the Radiology and Laboratory sections involve updates for newly recognized technologies and drugs.
Changes implemented by the 2014 OPPS Final Rule resulted in the addition and deletion of many codes in the January I/OCE update. Dave Fee, MBA , reviews some of the most important modifications, including changes to evaluation and management services and device reporting.
Hierarchical Condition Category (HCC) coding may be a foreign concept for some coders, but making sure documentation for Medicare Advantage patients supports it can be critical. Holly J. Cassano, CPC , discusses what criteria needs to be met for complete documentation.
Q: When coding excision of a breast mass with needle localization using stereotactic guidance, we report CPT ® code 19125 (excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion) and new code 19283 (placement of breast localization devices, percutaneous; first lesion, including stereotactic guidance). The 3M system says Medicare NCCI edits consider this separate reporting of codes that are components of the comprehensive procedure if billed for services provided to the same beneficiary by the same physician on the same day. These codes will be rebundled by the Medicare payer and payment will be based on code 19125 only. Does that mean to only report 19125 for this kind of case? If there is an excision of a lesion by one surgeon and needle localization done by a radiologist, can we report 19125, with 19283 and modifier -59 (distinct procedural service)? We can’t find any official reference for this issue for 2014. How do we code excision of a breast mass with needle localization now?
Q: I am auditing a note for a fusion. The note lacks detail, therefore is hard to justify. The patient had a prior hardware placement. The note describes dissecting down, debridement of necrotic bone, and tissue work done. This is the entire note, after describing dissection, “Vigorous irrigation with 10 liters of saline and antibiotics was carried out. Hemostasis was maintained. The right S1 screw and rod portion was removed as it was notably loose. Additional decortication and onlay bone grafting was performed at L1-S1. Drains were placed…” They coded: 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) Add-on code 22614 (each additional vertebral segment) x4 22852 (removal of posterior segmental instrumentation) In the procedures performed area of the note, they state: Hardware removal, lumbar Revision fusion L1-S1 with onlay bone graft Irrigation and debridement of lumbar spine wound Since there is nothing in the note regarding autografting, I assume this is an allograft? Should this be coded? Also is that documentation enough to justify arthrodesis? Modifier -GC (this service has been performed in part by a resident under the direction of a teaching physician) was appended, although the language was not added for this. I can only assume a resident dictated this.
When an NCCI edit occurs on a claim, providers can go directly to CMS’ website and download the latest edits to pinpoint why the edit occurred and what codes may be conflicting.
CMS has been making it clear over the years that packaging would become a larger and larger part of OPPS, and in calendar year (CY) 2014 CMS made good on this.
Debbie Mackaman, RHIA, CPCO, and Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS, discuss the purpose of medically unlikely edits (MUEs) and how they are calculated by CMS.
Q: Can we report CPT ® code 32609 (thoracoscopy; with biopsy of pleura) with 32666 (thoracoscopy, surgical; with therapeutic wedge resection, initial unilateral)? We have researched thoroughly and were not able to find a clear answer.
Jugna Shah, MPH, and Valerie A. Rinkle, MPA, examine the 2014 OPPS Final Rule and explain which services are now packaged, including drugs and biological that function as supplies when used in diagnostic or surgical procedures, clinical diagnostic lab tests, and device removal procedures.
Q: I have a question regarding CPT® code 22558 (arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; lumbar). I perform this exposure as a vascular surgeon, with the orthopedic surgeon preforming the spinal surgery. If I perform an anterior exposure for a spine deformity using code 22808 (arthrodesis, anterior, for spinal deformity, with or without cast; two to three vertebral segments), do I bill 22558 for the exposure?
In addition to increased packaging and collapsing of E/M clinic visit level CPT ® codes in the 2014 OPPS -Final Rule, CMS made additional changes that will have an immediate impact on reimbursement or require operational changes for providers.
One of the most radical changes CMS proposed in this year’s OPPS was to collapse the five levels of E/M CPT ® codes and replace them with three new HCPCS G-codes, including one APC for all clinic visits, one for all Type A ED visits, and one for all Type B ED visits.
In the 2014 OPPS Final Rule, CMS offered the following -example for billing a laboratory test on the same date of service as the primary service, but ordered for a different purpose than the primary service by a practitioner different than the practitioner who ordered the primary service.
Q: I am looking for information about to how to bill for a transnasal-endoscope approach in removing a skull-base tumor. I have never been comfortable with the doctors wanting to use CPT ® 61600 (resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; extradural) to bill a non-invasive procedure. I am perplexed about which CPT code(s) to report for this type of procedure.
Skin and dermatology coding includes unique challenges with its extensive terminology and the need to calculate wound and lesion sizes. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , discusses common documentation problems and how coders can improve their efficiency and proficiency.
Q: A patient presents with lower back pain and the physician documents findings of stenosis, degenerative “changes,” and mild facet arthropathy. Which diagnosis codes should we report? I would code 724.02 (stenosis, lumbar region, without neurogenic claudication) and 721.3 (lumbosacral spondylosis without myelopathy) for the facet degeneration. Another coder has stated that I cannot code 724.02, as the 721.3 diagnosis code will exclude the use of 724.02. Can you help with this scenario?
CMS did not finalize a proposal to collapse all evaluation and management visits into three codes, but did change clinic visit level coding. Jugna Shah, MPH, and Valerie A. Rinkle, MPA, review some of the major changes to E/M levels for 2014 and the new codes introduced. introduced.
Our experts answer questions on port reassessment, laparoscopies, reporting multiple biopsies, rejected drug claims, post-reduction film, nipple revisions, and more.
The number of patients using Medicare Advantage (MA) is rapidly growing, making Hierarchical Condition Categories (HCCs) an increasingly important concept for revenue cycle staff to understand in order to guarantee reimbursement.
Q: When we send in a claim for CPT ® code 29898 (arthroscopy, ankle, surgical; debridement, extensive) to Aetna with modifier –AS (non-physician assisting at surgery) for our physician’s assistant, Aetna will deny the claim saying “assistant not covered.” However, that procedure code says it is covered for an assistant surgeon. I have sent appeal after appeal and printouts from the American College of Surgeon’s (ACOS) Coding Today website showing this procedure code is payable to Aetna, and Aetna still denies the claim. Medicare pays on this claim, why wouldn’t Aetna?
Q: How does CPT ® define "final examination" for code 99238 (hospital discharge day management; 30 minutes or less)? Does the dictation have to include an actual detailed examination of the patient? We have been coding 99238 for discharges that include final diagnosis, history of present illness, and hospital course along with discharge labs, medicines, and home instructions. Very few contain an actual exam of the patient. Have we been miscoding all this time?
Jugna Shah, MPH, and Valerie A. Rinkle, MPA, look at drug administration coding, beginning with documentation, in order to highlight the information coders need to ensure accuracy. They also review the hierarchy coders must follow when coding for injections and infusions.
Healthcare providers are used to regularly changing guidelines and regulations that drastically alter their processes for coding and billing. Despite few guideline changes since 2008, drug administration still frequently causes confusion because of all the necessary factors to properly document, code, and bill the services.
During the January injections and infusions audio conference, Jugna Shah, MPH, president and founder of Nimitt Consulting in Washington, D.C., and Valerie A. Rinkle, MPA, associate director with Navigant Consulting in Seattle, reviewed these scenarios.
Q: When a procedure is performed by laparoscopy, but only a code for the open approach is listed, do you use the unlisted procedure code? For example, the physician documented: laparoscopic pyloromyotomy, hypertrophic pyloric stenosis. We used CPT ® code 43520-22 (pyloromyotomy, cutting of pyloric muscle, Fredet-Ramstedt type operation, with the increased procedural services modifier) but the coding department corrected with 43659 (unlisted laparoscopy procedure, stomach). We are a pediatric surgical practice. I feel because the procedures are very common and performed often, our revenue will drop by using unidentified procedure codes, but I want to code them correctly.
Q: We recently had a situation where a patient had come in to have his port re-assessed. He had been complaining of the port being difficult to access. Preliminary x-ray showed the port accessed, with great blood return. Patient has an allergy to IV contrast, so we just flushed the port, and did not give the contrast. The port remained accessed. How do we code this? Do we use 36598 (contrast injection[s] for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report) with a modifier -52 (reduced services)? The other option is a modifier -73 (discontinued outpatient procedure prior to anesthesia administration) or -74 (discontinued outpatient procedure after anesthesia administration). However we have no documentation regarding anesthesia, and I'm not sure the patient would even get anesthesia for a procedure such as this.
Our experts answer questions about followup visits in the ED, skin substitutes, flu vaccines, osteoporosis and fractures in ICD-10-CM, ICD-10-CM external cause code, modifier for discontinued cardioversion, and modifier -25
Coders select E/M levels based on criteria developed by their organization. CMS has proposed a significant change to E/M coding-replacing the current 20 E/M levels for new patients, existing patients, and ED visits with three G codes-but that change would only apply to Medicare patients and only to the facility side.
Some of the most sweeping changes in OPPS history were proposed in the 2014 rule, including new packaging rules, quality measures, and changes to evaluation and management. Jugna Shah, MPH, and Dave Fee, MBA, look at some of the changes and how they could impact providers.
Q: The patient has had a previous bilateral mastectomy and is now coming in for a revision of bilateral areola with a dermal fat graft to the left nipple and excision of excessive skin and subcutaneous tissue from both breasts. This would be CPT ® code 19380 (revision of reconstructed breast) with modifier -50 (bilateral procedure) and 19350-50 (nipple/areola reconstruction) for both procedures. I cannot locate information that tells me if the nipple revision on the reconstructed breast is part of the 19380 or can be separately coded with 19350.
