CMS’ proposed 2014 OPPS rule is set to introduce many changes, such as more packaged services, including lab tests and add-on codes. Jugna Shah, MPH; Dave Fee, MBA; Kimberly Anderwood Hoy, JD, CPC; and Valerie A. Rinkle, MPA, offer their insight on what effect these changes could have for providers.
Modifiers are sometimes essential to ensure proper payment, but choosing the correct one can be tricky. Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS; Katherine Abel, CPC, CPMA, CEMC, CPC-I; and Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, discusssome confusing modifiers and how to use them accurately.
Q: We have a patient with documented age-related osteoporosis. She bent over to pick up a newspaper from a table and fractured a vertebrae. Should we code the fracture as pathologic or traumatic?
E/M coding and reimbursement for hospital outpatients could change dramatically if CMS finalizes its proposal to replace current E/M CPT ® codes with three G-codes.
Our experts answer questions about billing vasectomy and sperm analysis , coding for ED visit when the patient is admitted for surgery, billing glucose reading before a PET scan, documentation required for the functional limitation codes, and appropriate reporting of observation.
Q: The patient comes in for a cardioversion, but the international normalized ratio results were unsatisfactory. The physicians canceled the cardioversion. Would modifier -73 (discontinued outpatient/hospital ambulatory surgery center procedure prior to the administration of anesthesia) be appropriate?
Evaluation and management (E/M) coding and reimbursement for hospital outpatients could change dramatically if CMS finalizes its proposal to replace current E/M CPT ® codes with three G codes. Dave Fee, MBA, Peggy S. Blue, MPH, CCS-P, CPC, Jugna Shah, MPH, Kimberly Anderwood Hoy, JD, CPC, Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Valerie A. Rinkle discuss the possible impact if CMS finalizes its proposal.
Medical necessity is as simple as it sounds and it isn’t important just for inpatients. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews the importance of establishing medical necessity for outpatient services.
In January 2013, CMS introduced 42 therapy functional reporting G codes (nonpayable), but instituted a six-month trial period. That grace period ended July 1. Denise Williams, RN, CPC-H, Dave Fee, MBA, and Debbie Mackaman, RHIA, CHCO, explain how to report these G codes and their related functional modifiers.
Q: A clinician goes to a patient's home and does not perform an evaluation and management, but performs a catheter replacement. How should we code this encounter?
In January 2013, CMS introduced 42 therapy functional reporting G codes (nonpayable). These G codes are to be reported in conjunction with therapy services (physical, occupational, and speech). CMS also introduced seven complexity/severity modifiers to be used with these G codes.
Providers setting charges based on an understanding of their costs is not a new concept, says Jugna Shah, MPH, president and founder of Nimitt Consulting. However, providers struggle with this or fail to do it correctly, and then stand to deteriorate their future payment rates since CMS relies on provider data to set payment rates not only for inpatient and outpatient services, but also for laboratory services.
Eight CPT ® codes for multianalyte assays with algorithmic analyses (MAAA) procedures are now classified as not covered under OPPS (status indicator E), retroactive to January 1, 2013. These codes are now subject to I/OCE edit 9.
Coders append modifiers to claims every day, but use some modifiers less frequently than others. Lori- Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, discusses the proper use of two less common modifiers, modifiers -62 and -66.
CMS’ July update to the Integrated Outpatient Code Editor features new codes, new APCs, and a new modifier. Dave Fee, MBA, explains the most noteworthy changes for this quarter.
CMS is reexamining inpatient criteria because it has seen a significant increase in the number of patients spending more than 24 hours in observation. Providers are worried that a Recovery Auditor will deny a short inpatient stay for lack of medical necessity and recoup payment years later. So instead, some facilities place patients in observation for longer time periods.
