Q: We get an NCCI edit when billing an intramuscular/subcutaneous injection (CPT® code 96372) during the same encounter as billing an injection, infusion, or hydration. Should we append modifier -59 (distinct procedural service)? Does it matter if an IV line is already in place before intramuscular/subcutaneous administration?
Coders use the same CPT ® codes to report outpatient services whether they are coding physician or facility services. Jaci Johnson, CPC,CPC-H,CPMA,CEMC,CPC- I, and Judy Wilson, CPC, CPC-H, CPCO, CPC-P, CPPM, CPCI, CANPC, CMRS, examine the similarities and differences between coding in the two settings.
Providers were glad to see CMS' ruling (CMS-1455-R) released March 13 (published in the Federal Register on March 18), which allows full Part B payment for inpatient stays that had been denied as not reasonable and necessary. The ruling had very few details on how the process would work, but on March 22, CMS published Transmittal R1203OTN instructing contractors and providers on the details.
Our experts answer questions about hydration, excludes notes in ICD-10-CM, L codes for neurostimulator devices, physician supervision for hyperbaric oxygen therapy, E/M service with wound care, and pass-though drugs.
Q: A patient suffered a nontraumatic intracerebral hemorrhage six months ago and is now being seen for long-standing aphasia as a result of the stroke. How would we code this in ICD-10-CM?
CMS corrected edit 84, added five APCs to the I/OCE, deleted two APCs, and changed the description of another as part of the April updates to the I/OCE. In addition, CMS deleted all of the genetic testing modifiers, retroactive to January 1.
Gloria Miller, CPC, vice president of reimbursement services for Comprehensive Healthcare Solutions, Inc., located in Tacoma, Wash, created this quick reference for HCPCS Level 1 modifiers commonly used in wound care coding.
Our experts answer questions about modifiers for diagnostic interventional procedures, Medicare recognition of CPT ® code 9066, reporting add-on code for psychotherapy with interactive complexity, reporting G0378 for all payers, and wound care coding.
Successful appeals can actually lead to CMS policy changes. Facilities have been successfully appealing to receive Part B payments after a Medicare review contractor denied a Part A stay as not medically necessary. As a result, CMS is changing its policy on rebilling for Part B services.
CMS corrected edit 84, added five APCs, deleted two APCs, and changed the description of another as part of the April updates to the I/OCE. Dave Fee, MBA, reviews the most significant changes CMS implemented
Q: If a patient has a spinal deformity on L5-S1 and we use the appropriate codes from 2280X and then the physician performs an arthrodesis/fusion on the same level, can we bill the appropriate fusion codes (225XX-226XX) as well? My impression is no, but I would love to get some insight into this question.
Q: A physician's office collects a pap specimen and sends the specimen to the hospital lab for processing. The physician's office lists ICD-9-CM code V72.31 (general gynecological examination with or without Papanicolaou cervical smear) as the diagnosis for this service. What is the proper diagnosis code for the hospital to use for billing when only processing the specimen?
CMS is making a significant change to the Medically Unlikely Edits (MUE) by changing some of them from line-item edits to date-of-service edits, effective April 1. Jugna Shah, MPH, Kathy Dorale, RHIA, CCS, CCS-P, John Settlemyer, MBA/MHA, and Valerie Rinkle, MPA, explain how the change could affect coding and reimbursement.
Q: We received an outpatient radiology report (exam performed 7/11/12) where the radiologist states: CLINICAL INDICATION: LUMBOSACRAL NEURITIS EXAM: LUM SPINE AP/LAT CLINICAL STATEMENT: LUMBOSACRAL NEURITIS COMPARISON: MAY 23, 2012 FINDINGS: There is posterior spinal fusion L-3-L-5 with solid posterolateral bridging bone graft. Pedicle screws and rods are stable in position. There are bilateral laminectomy defects at L3-L-4. The vertebral body and disc space heights are preserved. The spinal alignment is maintained without evidence of spondylolisthesis. No acute fracture is identified. No lytic or blastic lesions are seen. The sacroiliac joints are unremarkable. IMPRESSION: Stable postsurgical changes with solid posterolateral fusion graft. Would you use the following ICD-9 codes: V67.09, 724.4. or 724.4, V45.4? Our coders disagree.
With no national guidelines in place for facilities to use to determine evaluation and management (E/M) level, coders must apply their facility’s guidelines when coding an outpatient visit. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, and Joanne M. Becker, RHIT, CCS, CCS-P, CPC, CPC-I, use three ED case studies to highlight potential pitfalls for ED E/M leveling.
Our experts answer questions about, modifier -25, cardioversion performed during an ED code, denials for multiple port film line items, and procedure discontinued after administration of anesthesia.
CMS is making a significant change to the Medically Unlikely Edits (MUE) by changing some of them from line-item edits to date-of-service (DOS) edits, effective April 1.
CMS added 410 new codes and seven new therapy and patient condition modifiers to the Integrated Outpatient Code Editor (I/OCE) as part of the January 2013 update. Dave Fee, MBA, highlights the key changes to the I/OCE.
In the coding world, it’s a never-ending clash that can cause compliance concerns—facility vs. professional. Kimberly Anderwood Hoy, JD, CPC , and Peggy Blue, MPH, CPC, CCS-P, explain how coders in each setting use different codes for the exact same services based on the payment systems, the rules, and how each setting applies those rules.
Q: A patient received Toradol 30 mg IV and Zofran 4 mg IV at 14:38. He also had normal saline wide open with documented start of 14:30 and stop of 15:40. Is the hydration chargeable as 96361 (intravenous infusion, hydration; each additional hour) even though the initial service is not 90 minutes? Is the hydration a concurrent service?
Q: In ICD-9-CM we only have one type of Excludes note. ICD-10-CM uses Excludes1 and Excludes2. What is the difference between the two types of Excludes notes and how do they relate to Excludes notes in ICD-9-CM?
The AMA added five new nuclear medicine codes to the radiology section of the 2013 CPT Manual , while revising and deleting a number of codes that represented outdated technology or were bundled into placement procedures.
When coders hear the words "interventional radiology," many think of vascular procedures. However, interventional radiology encompasses additional, nonvascular procedures, such as nephrostomy tube placement and drainage of abscesses.
Our coding experts answer your questions about physician supervision for chemotherapy, billing injectable drugs, Addendum B and coverage, new transitional care management codes, and stent placement with other procedures.
As more patients are being impacted by noncoverage of self-administered drugs, coders and billers need to know when and how to report drugs and drug administration services. Kimberly Anderwood Hoy, JD, CPC, and Valerie Rinkle, MPA, discuss the differences in how drugs are paid under Medicare Part A and Part B.
CMS defines self-administered drugs as drugs patients would normally take on their own. In general, Medicare will not pay for self-administered drugs during an outpatient encounter or for drugs considered integral to a procedure. Kimberly Anderwood Hoy, JD, CPC, and Valerie Rinkle, MPA, explain how to determine whether a drug is integral, self-administered, or both.
Q: The rule our institution has followed with respect to HCPCS coded medications without a local coverage determination (LCD) is to limit prescribing to the FDA-approved indications. The question that arises is how closely do the physicians need to follow the package insert? For example, the drug basiliximab does not have an LCD and the FDA indication is: For acute kidney transplant rejection prophylaxis when used as part of an immunosuppressive regimen that includes cyclosporine and corticosteroids. Generally, physicians performing transplants at our institution do not use steroids or cyclosporine. They use tacrolimus, sirolimus, mycophenolate mofetil, and/or mycophenolate sodium. If the physician performs a transplant without cyclosporine or steroids, do we need to have the patient sign an advanced beneficiary notice?
As part of the 2013 OPPS Final Rule, CMS made major changes to how it will reimburse facilities for separately payable drugs and how it will calculate APC relative weights. Jugna Shah, MPH, and Valerie Rinkle, MPA, review the most significant changes in the final rule.
Q: A patient went to the operating room under anesthesia for cataract extraction and repair of retinal detachment of the same eye. The surgeon successfully removed the cataract. The surgeon then accessed the back of the eye to begin to repair the detachment. After reviewing the condition of this eye area, the surgeon determined that the eye was in such bad shape it could not be saved, so the detachment was not repaired and surgery was ended. The patient was under anesthesia and the retinal detachment repair procedure was begun (although barely) but then cancelled. Should we report this procedure since the facility incurred expenses for the surgical attempt at repair?
Physicians and other providers practice in many different areas within a hospital. To accurately code physician and provider services, coders must know and understand the place of service (POS) codes.
One of the major changes to the 2013 CPT Manual is the replacement of the term "physician" with "physician or other qualified healthcare professional" (QHP) in a wide range of codes.
Q: How should we bill for the physician in the following situation? A patient who has end-stage renal disease (ESRD) comes into a hospital’s emergency department (ED) with an emergent condition (dialysis access clotted or chest pain that is ruled out), but misses his or her dialysis treatment. Part of the treatment is dialysis performed in the ED or as an outpatient. The hospital bills G0257 (unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility) as per CY 2003 OPPS Final Rule guidelines and Pub 100-04, Chapter 4, section 200.2
CMS announced changes to reporting therapy services—the biggest operational change for 2013—in the Medicare Physician Fee Schedule final rule instead of the OPPS final rule. Jugna Shah, MPH, and Valerie Rinkle, MPA, explain the changes to therapy reporting and molecular pathology coding.
The biggest operational change for outpatient facilities for 2013 does not appear in the 2013 OPPS final rule. Instead, CMS announced changes to reporting therapy services in the 2013 Medicare Physician Fee Schedule (MPFS) final rule.
Hospitals earned a big win with drug payments this year in the 2013 OPPS final rule, released November 1. CMS decided to finalize its proposal to follow the statute and reimburse facilities at the average sales price (ASP) plus 6%.
As part of the 2013 OPPS final rule, CMS finalized a clarification to 42 CFR 419.2(b) that could cause confusion in the future if hospitals are audited by third-party payers or by Medicare contractors who do not fully understand the intent of the language or how CMS develops payment rates, says Jugna Shah, MPH, president of Nimitt Consulting based in Washington, D.C.
As part of the 2013 OPPS final rule, CMS finalized a clarification to 42 CFR 419.2(b) concerning packaged services. Jugna Shah, MPH, and Valerie Rinkle, MPA, explain how this clarification could cause confusion in the future if hospitals are audited by third-party payers or by Medicare contractors who do not fully understand the intent of the language or how CMS develops payment rates.
Q: Is nursing documentation of completion of physician-ordered procedures, such as splinting/strapping, Foley catheter insertion, etc., sufficient to assign a CPT ® code for billing the procedure on the facility side in the ED?
Q: CPT ® code 85660 (sickling of RBC, reduction) has a medically unlikely edit of one unit. We test blood for transfusion for sickle cell before we provide it to a sickle cell patient. If we test three units of blood prior to administering the blood to the patient, which modifier is more appropriate: -59 (distinct procedural service) or -91 (repeat laboratory test)?
The Hospital Outpatient Payment Panel recommended CMS change the supervision requirements for 15 HCPCS and CPT codes during its second meeting this year in August. CMS released details of the meeting September 24.
Our coding experts answer your questions about observation orders, sequencing additional diagnoses, coding for wound care with no-cost skin substitute, and reporting cardiac rehabilitation and physical therapy together.
Misusing modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) can be an expensive proposition. Just ask Georgia Cancer Specialists I, a leading oncology practice in Atlanta.
Q: What CPT ® code best describes the Bier block procedure? We are toiling over this and the most recent CPT Assistant says to use 64999 (unlisted procedure, nervous system). But the article referenced is from 2004. We just want to make sure there is nothing more recent.
