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.
Because of the increase in the number and type of outpatient services provided, more patients are being impacted by noncoverage of self-administered drugs. Kimberly Hoy, JD, CPC, and Valerie Rinkle, MPA, explain why CMS sometimes--but not always--covers self-administered drugs.
Our coding experts answer your questions about how to determine the correct units for drugs, billing for fluoroscopy, therapy caps under OPPS, and payment for critical care and separately reported services
Q: It appears that one requirement for using CPT ® codes 15002–15005 with application of negative pressure wound therapy (NPWT) is that the wound must be healing by primary intention. Can you explain this? We have never used these codes with preparation for vacuum assisted closure (VAC) placement, but it doesn't make sense, as NPWT is almost always used for wounds healing by secondary intention. Our physicians appreciate any clarification.
The rules for coding for facilities and physicians are basically the same for most services, but coders follow different rules for appending certain modifiers. Christi Sarasin, CCS, CCDS, CPC-H, FCS , Kimberly Anderwood Hoy, JD, CPC , and Peggy Blue, MPH, CPC, CCS-P, separate physician and facility rules for using modifiers -26, -TC, and -79.
QUESTION: I work for a gastrointestinal (GI) practice and I have a question regarding the correct sequence for adding diagnosis codes to a claim. I have advised our physicians and billers that the primary diagnosis code is always the reason for the visit. I am a little confused about the remaining diagnosis codes the physician will write down in no specific order. Billers will report codes in the order the physicians write down the diagnoses and not always the reason for the visit. For example, a patient is referred for a consult due to weight loss. The patient comes for the consult and the physicians may put down 787.29 (other dysphagia), 401.1 (benign hypertension), 783.21 (abnormal loss of weight), 787.99 (change in bowel habits) in this order and leave it up to the person entering the info to figure it out. I would report 783.21 first since that was the reason for the visit but then I’ve been putting the GI codes next and then anything else last. What is the correct sequence when adding diagnosis codes to a claim?
