The guiding principle is the definitive methodology used for all risk adjustment medical record reviews. Successful Medicare Advantage (MA) plans focus on early disease detection, coordination of care, and accurate reporting of members’ chronic conditions by primary care physicians, retrospective and prospective pursuits to drive and improve health outcomes. Holly J. Cassano, CPC, guides coders through the principles of risk adjustment for MA plans.
QUESTION: When would you use the table labeled as not otherwise classified drugs at the end of the HCPCS Level II Table of Drugs and Biologicals? Many other drugs are not assigned a HCPCS code and are not in this table.
Cardiac catheterization is a common procedure performed to study cardiac function and anatomy and to determine if a patient is a candidate for intervention. Terry Fletcher, CPC, CCC, CEMS, CCS-P, CCS, CMSCS, CMC, and Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, MHP, explain how to code the different catheterization procedures.
Providers will soon be reimbursed by Medicare for a new, less-invasive aortic valve replacement procedure. Medicare Acting Administrator Marilyn Tavenner announced CMS’ decision to pay for transcatheter aortic valve replacement under specific conditions.
QUESTION: We are a small anesthesia group and we are concerned about the specificity for ICD-10-CM. If we submit a claim with an unspecified code and the surgeon submits a claim with more specificity, will we still get paid?
With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. To help coders prepare for the upcoming transition, we will provide an occasional article about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, takes coders on a trip through the digestive system.
Coders will need very specific information in order to code for fractures in ICD-10-CM, including the type of fracture, specific bone fractured, and whether the patient is seen for an initial or subsequent visit. Robert S. Gold, MD, Sandy Nicholson, MA, RHIA, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, detail the information physicians must document for accurate fracture code assignment.
Coders and clinicians often seem to speak different languages. What a clinician considers important information may not be what a coder needs to assign the correct code. Clinicians may not document a piece of information that is vital to the coder. Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, Joseph Nichols, MD, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, explain how clinicians and coders can work together to improve communication.
The American Health Information Management Association (AHIMA) continues to advocate for no delay in the implementation date for ICD-10-CM and ICD-10-PCS.
The Bishop’s Score is primarily a scoring system to assess the viability and/or success of an induction of labor, odds of a spontaneous pre-term delivery, or whether a cesarean section should be considered instead of a vaginal delivery. Lori-Lynne Webb, CPC, CCS-P, CCP , explains how physicians tally the Bishop’s Score and what coders should look for in the documentation.
QUESTION: Can you explain the difference between modifier -80 (assistant at surgery by another physician) and –AS (physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery)? Medicare requires us to use both modifiers for our physician assistants. We have been instructed to use -AS first and -80 second for all Medicare claims submissions. Is this correct?
CMS instructed fiscal intermediaries (FI) and Medicare Administrative Contractors (MAC) to hold claims containing CPT ® code 33249 (insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead[s], single or dual chamber) and HCPCS code C1882 (cardioverter-defibrillator, other than single or dual chamber [implantable]).
When a physician determines the patient has a coronary artery blockage, the physician can choose from several options for treating the patient, depending on exactly what is wrong. John F. Seccombe, MD, and Betty Johnson, CPC, CPC-I, CPC-H, CPCD, CCS-P, PCS, CCP, CIC, RMC, discuss invasive and non-invasive treatments, as well as the heart’s anatomy.
CMS did not discuss drug administration services in the 2012 OPPS final rule, but the AMA did make significant additions to the CPT ® coding guidelines in the 2012 CPT Manual . Jugna Shah, MPH, and Kimberly Anderwood Hoy, JD, CPC, review the guidelines and explain the nuances to keep coders up to date.
QUESTION: I would like to know the correct codes to use when a patient comes into the ER after smoking synthetic marijuana and has symptoms of palpitations, seizure, or anxiety. Some physicians document ingestion, while others document abuse. What is the proper way to code considering we do not have a specific code for this new drug on the market?
A physician or clinical provider of care may have a completely different understanding, interpretation, and definition of medical necessity than the patient or a third-party insurance. Lori-Lynne A. Webb, CPC, CCS-P, CCP, COBGC, CHDA, explains the differences in the definition and application of the term medical necessity.
To correctly assign codes for any surgical procedure, coders need to have an operative (OP) report. But simply having an OP report isn’t enough. Coders also must be able to read the OP report and pick out the important information. Lynn Pegram, CPC, CEMC,CPC-I, CGSC, breaks down the OP report to help coders find the information they need.
As charges become more specific to provide additional concrete and transparent cost data, providers must consider what procedures they routinely provide to patients and what procedures are specifically related to the patient's condition. Denise Williams, RN, CPC-H, and Kimberly Anderwood Hoy, JD, CPC, reveal tips for determining when to separately bill for ancillary bedside services provided to inpatients.
Knowing spinal anatomy provides the foundation necessary to assign codes both before and after the switch to ICD-10-CM. Shelley C. Safian, Kim Pollock, RN, MBA, CPC, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, guide coders through the anatomy and common coding situations in ICD-9-CM and ICD-10-CM.
