Choosing the correct E/M level can be difficult enough, but coders may also face scenarios where it’s necessary to append a modifier to the code. Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, reviews when to report modifiers -25 and -27 and instances when the modifiers would not be appropriate.
Choosing an E/M level code depends on three components—history, exam, and medical decision-making. History itself has four further components that coders will need to look for in physician documentation. Review what comprises these components to aid in choosing the correct levels.
Q: We operate a partial hospitalization program (PHP) and just heard from our billing office that there are new requirements for submitting claims. They want us to close out accounts weekly in order for them to bill them. We have done 30-day accounts prior to this and don’t see why they want to change things. Is there a certain timeframe required for billing these services? This is a huge inconvenience to make this work for the business office.
Comprehensive APCs (C-APC) have added another complication to coding and billing for outpatient services. Valerie A. Rinkle, MPA, writes about recent changes that could impact the reporting of physical and occupational therapy and speech-language pathology services provided in support of or adjunctive to a C-APC.
In addition to laterality modifiers for right and left (-RT and –LT, respectively), coders can also report bilateral procedures with modifier -50. Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, analyzes the guidelines for these modifiers and offers tips on how and when to report them.
CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule, though the agency has pushed the start date back a year and worked to ease administrative burden based on public comments.
Q: A patient has multiple labs on the same date of service. We receive the following NCCI edit: “Code 80048 is a column two code of 80053. These codes cannot be billed together in any circumstances.” Should we only bill code 80053?
ICD-10-CM has brought codes to more specifically report obesity and related conditions. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, describes these codes and when to report them, while also taking a look at operative reports for bariatric surgeries.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, looks at the different types of bariatric surgical procedures and documentation details providers may include for them. She also reviews which CPT codes can be used to report these procedures
CMS recently announced changes to require providers to report modifier -JW (drug amount discarded/not administered to any patient) when appropriate. Jugna Shah, MPH, looks at when providers will need to use the modifier and how to remain compliant.
Providers should already be aware they will have to report more specific ICD-10-CM codes when CMS ends its grace period for physicians later this year, but the agency will also be excluding certain unspecified codes from reporting in 2017.
Anatomical CPT modifiers aren’t used just to distinguish laterality. Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, reviews how to report modifiers –LC, -LD, -LM, -RC, and –RI for percutaneous coronary interventions.
The value modifier is having an increasing effect on physician payments and coding each patient’s severity is key to accuracy. Richard D. Pinson, MD, FACP, CCS, writes about how the value modifier impacts payment and conditions coders should be aware of that quality scores.
Q: Are there any new HCPCS codes for recently released biosimilar products on the horizon? Our physicians and pharmacists are being contacted by the manufacturer about purchasing and using them, but we want to be sure we can report them appropriately.
Obesity is a condition that can complicate coding for other diagnoses in a patient’s record. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about how to report BMI and what must be documented in order to link it with other conditions.
CMS’ April I/OCE update includes numerous code and status indicator changes, as well as corrections to its January release. Kimberly Anderwood Hoy Baker, JD, CPC, looks at the changes providers should review to ensure claims including these codes are processed correctly.
Coders can choose from a variety of anatomic modifiers to report procedures performed on specific toes. Review how to properly apply these modifiers and which codes they cannot be reported with.
CMS recently released its seventh maintenance update for National Coverage Determinations to incorporate ICD-10 and other coding updates, which may require providers to contact Medicare Administrative Contractors regarding previously submitted claims.
Sepsis isn’t the only clinical condition with an updated definition that could impact coding and documentation. A task force of the National Pressure Ulcer Advisory Panel recently changed terminology related to pressure ulcers that includes new terms that are not yet part of ICD-10-CM.
Which services should clinical documentation improvement (CDI) specialists target in outpatient facilities? Anny Pang Yuen, RHIA, CCS, CCDS, CDIP , writes about how outpatient CDI differs from inpatient CDI and how it can be applied in hospitals or physician practices.
CMS’ coding modifiers are not always used to report clinical components of a service. Sometimes they can be used in a hospital to provide information about how a service relates to Medicare coverage policies.
Modifier –GA isn’t the only modifier available to report how services may relate to Medicare coverage policies in hospitals. Learn more about how to properly report modifiers –GX, -GY, and -GZ.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about terminology coders will encounter in documentation for Pap tests and other cervical cancer screening report
Jugna Shah, MPH, looks at CMS’ new proposal to implement a new drug payment model for certain providers and how they can comment in order to the agency about its impact on their facilities.
CMS released a list of the thousands of new ICD-10-CM and ICD-10-PCS codes set to be activated October 1, 2016, as part of the 2017 IPPS proposed rule.
Q: Our providers are reluctant to document a correlation between symptoms and a true diagnosis. Do you have any good ways to get them to do this? For example, our providers document "diabetes" but they often don't include additional details that should be there (e.g., gestational diabetes or type II diabetes mellitus in pregnancy).
CMS allows, and sometimes requires, providers to report certain modifiers in order to identify when a service has been provided by different types of therapists. Review the requirements for reporting modifiers –GN, -GO, -GP, and –KX.
Q: Can CPT® code 76700 (ultrasound, abdominal, real time with image documentation; complete) be coded with 76770 (ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; limited) on the same date of service during the same session?
E/M services resulted in a projected $4.5 billion in improper Medicare payments in 2014, according to the April 2016 Medicare Quarterly Compliance Newsletter, accounting for 9.3% of the overall Medicare fee-for-service improper payment rate.
CMS has proposed a new drug payment model that could impact providers nationwide. Jugna Shah, MPH, reviews the multiple stages of the rule and how providers can comment to CMS about the proposed changes.
Pregnant patients with other health issues can lead to complicated coding scenarios. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the clinical documentation necessary to identify certain complications and how coders can report these diagnoses. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Respondents to HCPro’s 2016 ICD-10 survey share their challenges and successes since implementation, while Monica Pappas, RHIA, and Darice M. Grzybowski, MA, RHIA, FAHIMA, offer their thoughts on the impact of ICD-10.
Q: What is the proper ICD-10-CM coding for bilateral hip pain? Should we report M25.551 (pain in right hip) and M25.552 (pain in left hip) or M25.559 (pain in unspecified hip)?
The Centers for Disease Control and Prevention released new guidance last week with updated clinical recommendations for patients exposed to the Zika virus and also announced a registry for pregnant women infected with the virus.
ICD-10 implementation represented an unprecedented challenge for the U.S. healthcare system. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, writes about the impact of the change by looking at survey results that compare ICD-10 productivity benchmarks to ICD-9-CM.
Providers need to keep more in mind than just diagnosis and procedure coding when performing sterilizations for men and women. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews the requirements for sterilizations and the part coders can play in avoiding denials.
The Zika virus has become a major concern over the last couple months and new information about treatment and symptoms seems to emerge daily. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the latest information regarding the Zika virus and how coders can report it.
Reporting modifier –PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments) only recently became mandatory, but new rules and regulations could change the requirements in certain settings. Kimberly Anderwood Hoy Baker, JD, CPC, reviews recent legislation that could have an impact on modifier –PO and looks ahead to when CMS intends to offer more guidance.
Q: When a foreign body is removed from the eye, does it matter what instrumentation is used to remove it? We recently had two cases in which the ED physician stated that the foreign body was easily removed with a cotton swab. She is questioning whether we should charge (facility and professional) for this type of removal or whether it should just be considered when determining the E/M level.
Implementation of electronic health record (EHR) systems can reduce queries and create more standardized documentation for providers, but now, according to a study published by the Journal of Patient Safety , EHRs are also linked to fewer in-hospital patient complications.
Drug administration services follow a hierarchy for reporting, but coding can become complex when providers administer multiple drugs. Review these tips to help tackle tough injection and infusion scenarios.
CMS recently announced a delay in the anticipated system release of outpatient and inpatient quality reporting data due to the relocation of the Health Care Quality Information System Data Center responsible for the Hospital Quality Reporting programs.
CPT codes for drug administration follow a hierarchy that is unique to those procedures. Review the hierarchy in order to understand how to apply codes for any type of scenario.
Q: If a physician orders a consultation for a patient who is experiencing a headache due to hypertension, which ICD-10-CM codes would be assigned? Would hypertension be coded since headache is a common sign and symptom of hypertension, or would both the headache and hypertension be coded?
Accurate coding and billing data is important for both providers and CMS. Jugna Shah, MPH, writes about challenges providers have faced with providing that data to CMS and what the agency can do to ease provider burden.
Specialty groups are often able to move faster on creating guidelines for new procedures and codes than other ruling bodies. But sometimes this guidance can create conflicts between physician and facility coders. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about how to avoid these scenarios and come to the best resolution for providers, payers, and patients.
As the healthcare industry acclimates to using ICD-10, coders can rest assured it will still be several years until ICD-11 becomes a reality. Originally pegged for a 2015 release to the World Health Assembly, the World Health Organization (WHO) has quietly pushed ICD-11’s debut to 2018.
Q: Our radiation oncology department is having some angst about some updated guidance provided by CMS regarding reporting of planning services. These services are provided prior to the actual intensity-modulated radiation therapy (IMRT) service in order to know how to deliver the IMRT. We are not sure if we have been reporting this correctly.
Post-traumatic stress disorder isn’t only reported for military personnel. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about when PTSD may be reported and which diagnosis and procedures codes should be included.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Peggy Blue, MPH, CPC, CEMC, CCS-P, explain when to report the new codes introduced in the 2016 CPT Manual for genitourinary procedures.
The AMA introduced new CPT codes for 2016 to report intracranial therapeutic interventions. Stacie L. Buck, RHIA, CCS-P, CIRCC, RCC, reviews the changes and provides examples on how to use them in a variety of procedures.
CMS audits for meaningful use could mean collecting information across the coding and HIM departments. David Holtzman, JD, CIPP, and Darice Grzybowski, MA, RHIA, FAHIMA, review what auditors could request and how to prepare your facility.
Hospital coders can choose multiple modifiers to apply to a procedure code if the service was discontinued. Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, provides an overview of these codes and in which instances to use them.
The improper payment rate for oxygen equipment and supplies to the Medicare program was 62.1% with projected improper payments of approximately $952 million during the 2014 reporting period, according to a Comprehensive Error Rate Testing (CERT) program study detailed in the January 2016 issue of the Medicare Quarterly Compliance Newsletter.
Q: Our radiology department is requesting that we add a new modifier to their charge description master (CDM), modifier –CT (computed tomography [CT] services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association [NEMA] XR-29-2013 standard). They want this added to the CT scan line items, but they are not sure if it is for all of the items or only certain ones. Can you provide more information that might help us know how to proceed?
The government recently approved changes for physician payment systems. Is your clinical documentation improvement (CDI) team ready to tackle these challenges? More importantly, are your physicians ready?
Perhaps recognizing the massive undertaking for coding and HIM departments in 2015 with the implementation of ICD-10, the latest CPT® update includes a relatively small 367 changes for 2016. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Peggy Blue, MPH, CPC, CEMC, CCS-P, review updates to the digestive system and E/M codes.
Jennifer Avery, CCS, COC, CPC, CPC-I, writes about how the increased specificity in ICD-10-CM changes pregnancy coding and how to use gestational weeks in physician documentation to report trimesters.
While providers are still awaiting further guidance on the four modifiers CMS introduced as subsets of modifier -59 (distinct procedural service), the latest NCCI Manual does include clarification for certain scenarios involving the modifier.
Q: What can we report for the physician if circumcision is done during delivery? Do we bill that on a separate claim for the infant? Is this a covered procedure?
Modifier -52 is used to report procedures that are partially reduced or eliminated at the provider’s discretion. Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, looks at how the modifier should be applied in hospitals and tips for compliance.
Before the new year begins, Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, recommends taking a look at post-implementation risks CMS and third-party payers have identified. She also offers solutions on auditing and reviewing these risks. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Providers will only have to report one data collection modifier related to a C-APC in 2016. Jugna Shah, MPH, and Valerie A. Rinkle MPA, examine the requirements behind the modifier and how APCs will also be restructured next year.
Outpatient coding and billing errors lead to more than half of all automated denials by Recovery Auditors, according to the latest RACTrac survey from the American Hospital Association.
Jugna Shah, MPH, and Valerie A. Rinkle, MPA, review new comprehensive APCs (C-APC) CMS added in the 2016 OPPS final rule as well as the negative payment update due to a CMS overestimation in 2014.
In addition to updating procedures for 2-midnight rule reviews, the 2016 OPPS final rule includes new guidance on coding and billing issues, including reporting certain CT scan services. Jugna Shah, MPH, examines the changes and what providers need to do before 2016.
CMS recently released an ICD-10-CM resource for specialties and specific conditions and services that collects varied educational tools, including webcasts, case studies, and clinical concept guides.
Nearly half a million patients receive dialysis services each year. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, writes about the ICD-10-CM and CPT® codes providers will need to know in order to report these services accurately.
Q: How many times should Glasgow Coma Scale information be captured? If you have the ambulance, ED physician, and attending physician all recording the score, should each be reported?
CMS is introducing multiple new modifiers that providers may need to report beginning January 1, 2016. Jugna Shah, MPH, reviews the modifiers and the conditions for reporting them.
In the second part of her Q&A series, Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, answers coder questions about OB topics including modifier usage, services bundled in the package and when to use specific ICD-10-CM Z codes.
CMS and Medicare Administrative Contractors are aware of certain issues regarding National Coverage Determinations and Local Coverage Determinations related to ICD-10 and working to resolve them as soon as possible, according to CMS.
Jugna Shah, MPH, and Valerie A. Rinkle, MPA, review newpolicies and regulations from CMS in the 2016 OPPS final rule, including a new comprehensive APC for observation.
Q: A patient fractured all metatarsals last year and had open reduction and internal fixation. The patient now has a nonunion of the fracture sites and is going back to the OR for an amputation. What would be the appropriate ICD-10-CM seventh character to report?
Providers need to be careful when reporting multiple services with status indicator J1 on the same claim. Dave Fee, MBA, reviews potential concerns with reporting multiple comprehensive APCs as well as new codes and APCs introduced in the October 2015 I/OCE update.
Q: We are an independent outpatient end-stage renal disease clinic. When we administer a blood transfusion (we do not bill for the blood) can we bill HCPCS code A4750 (blood tubing, arterial or venous, for hemodialysis, each) for the tubing used in the procedure and also A4913 (miscellaneous dialysis supplies, not otherwise specified) for miscellaneous supplies pertaining to administering the blood?
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, answers questions from coders about OB diagnoses and procedures, including what’s bundled in the global package and how to report multiple births.
CMS introduced several new HCPCS codes and added comprehensive APCs (C-APC), including one for observation, in the 2016 OPPS final rule, released October 30.
Extensive changes in ICD-10-CM terminology and codes for cardiovascular diseases often frustrate coders, says Cindy Basham, MHA, MSCCS, BSN, CCS, CPC . She provides an overview of the changes and notes what must be documented so coders can select the appropriate code.
Kelly Whittle, MS, and Monica Pappas, RHIA, provide methods for determining the impact ICD-10 is having on your department’s productivity and strategies for minimizing losses.
Q: I have a question about coding infusion/injections in the ED prior to a decision for surgery. A patient comes into the ED with right lower abdominal pain. The physician starts an IV for hydration, gives pain medication injections, then does blood work and an MRI to rule out appendicitis. The blood work comes back with an elevated white blood count, so the patient is started on an infusion of antibiotics. Then the MRI results come in with a diagnosis of appendicitis. So a surgeon is called in to consult and take the patient to surgery. Can we bill the infusions/injections prior to the decision for surgery? I realize that once the decision is made, then the infusion/injections are off limits and are all included in the surgical procedure. But up until that time, can the ED charge the infusions/injections? They are treating the patient’s symptoms and can’t assume the patient will have surgery until the decision is made by the surgeon.
Insufficient documentation is the leading cause of improper payments for claims involving referring providers, according to a Comprehensive Error Rate Testing (CERT) program study detailed in the October 2015 Medicare Quarterly Compliance Newsletter .
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about terms coders will see in physician documentation for ulcers and how to code related conditions in ICD-10-CM.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, provided documentation and coding examples for reporting breast care procedures and ICD-10-CM diagnoses.
ICD-10 is undoubtedly affecting coder productivity, but Bonnie S. Cassidy, FAHIMA, RHIA, FHIMSS, CPUR, NAHQ, and Reid Conant, MD, FACEP, provide strategies for increasing proficiency and leveraging technology to reduce the effects of changing to a new code set.
In addition to updated procedure codes in 2015, ICD-10-CM added new codes for reporting mammography and breast MRIs and ultrasounds. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, writes about how to identify which codes to use to meet Medicare requirements and where third-party payer requirements may diverge.
Q: Our business office wants us to start using modifier -PO (services, procedures, and/or surgeries furnished at off-campus, provider-based outpatient departments) for services that are provided in some of our outpatient departments, but not all. We want to hard code this to our charge description master but are not sure why some services will get this modifier and some won't.
Charlotte L. Kohler, RN, CPA, CVA, CRCE-I, CPC, ACS, CHBC, discusses how modifiers -59 and -91 differ and what coders need to know to use them when reporting laboratory services.
Recovery Auditors have identified numerous potential duplicate claims from Medicare Part B providers, according to the October 2015 Medicare Quarterly Compliance Newsletter . These claims are send to MACs for further action, which could include overpayment recovery.
Most improper payments for diagnostic nasal endoscopies reviewed during a Comprehensive Error Rate Testing (CERT) special study occurred due to insufficient documentation, according to the latest Medicare Quarterly Compliance Newsletter .
Coders can no longer rely on the muscle memory and cheat sheets they developed working with ICD-9-CM for so long. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, reviews ways coders can update their processes for reporting certain OB/GYN services in ICD-10-CM.
Providers have to create their own ED E/M guidelines, which can present a variety of challenges for facilities. For coders, this means an understanding of how to calculate critical care and other factors in order to report the correct visit level.
