The publication of the final rule officially announcing a change in the ICD-10 compliance date from October 1, 2013 to October 1, 2014, ends the uncertainty surrounding ICD-10 implementation that has plagued the healthcare industry. Sue Bowman, MJ, RHIA, CCS, FAHIMA, details what healthcare organizations should be doing now to prepare.
ICD-10-CM coronary artery disease and myocardial infarction codes will undoubtedly differ from their ICD-9-CM counterparts in some ways, but certain aspects will remain the same. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, explain what coders need to know about reporting these conditions.
QUESTION: I work in an urgent care setting and need to know if we can bill an administration code for injection of Toradol. For example, a patient comes in, and the provider performs an E/M and administers 60mg Toradol intramuscular. I have not been charging for it, thinking it’s bundled into the E/M.
CMS is proposing two major changes as part of the 2013 OPPS proposed rule, released July 6. One has to do with how CMS proposes to calculate APC relative weights; the other addresses the reimbursement level for separately payable drugs and biologicals without pass-through status. Jugna Shah, MPH, and Debbie Mackaman, RHIA, CHCO, discuss the proposed changes for OPPS payment.
Physicians and facilities use the same codes to report evaluation and management (E/M) levels for emergency department (ED) services, but follow different rules. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, and Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, explain how to correctly choose the most appropriate E/M code for ED services.
Providers will now soon need only one unique health plan identifier when billing insurance companies. CMS finalized the Administrative Simplification: Adoption of Standard for Unique Health Plan Identifier rule released August 24.
Coders face many challenges when coding for services provided by teaching physicians, interns, residents, and students. Medicare has specific rules and regulations surrounding what services it will pay for when an intern, a resident, or a student provides services. Lori-Lynne A. Webb, CPC, COBGC, CCS-P, CCP, CHDA, details what coders need to see in the documentation before reporting these services.
When is in appropriate to use modifier -59 to override coding edits? When is another modifier more appropriate? Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, and Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS , explain the appropriate use of modifier -59.
Q. When is it appropriate to append modifier -74 (procedures discontinued after anesthesia administration or after the procedure has begun) or -73 (procedures discontinued prior to anesthesia) instead of to modifier -52 (reduced service)? Is there more than anesthesia that determines their use? The report below was coded with CPT ® 62311 (injection[s] of diagnostic or therapeutic substance[s]…; lumbar or sacral [caudal]). I asked the coder if modifier -74 should be appended, and the coder said that -52 should be appended. Is this correct? Procedure: Attempted lumbar midline interlaminar epidural steroid injection L5-S1 with fluoroscopy After identifying the L5-S1 interlaminar space fluoroscopically, the skin was sterilely prepped and draped. The skin and subcutaneous tissue were anesthetized with 1% lidocaine. Utilizing a loss of resistance technique and intermittent fluoroscopic guidance, an 18 gauge Tuohy needle was utilized to approach the epidural space. I was not able to successfully identify the epidural space secondary to encountered resistance. The needle depth was checked on lateral views and noted to be superficial to the epidural space when resistance was encountered. We were going to utilize a caudal approach, however skin breakdown was noted. At this point, I elected to have her return for care in 2 weeks and get the skin breakdown in the caudal area treated.
Some wounds and conditions don’t respond to conventional therapies and treatment modalities. In those cases, providers may consider hyperbaric oxygen therapy (HBO). Gloria Miller CPC, CPMA, and Todd Sommer, DO, DPM, CWS, review the conditions eligible for HBO therapy and correct code assignment for these services.
QUESTION: A patient complained of intractable pain from compression fracture (sustained the day prior to admission). The guidelines state if pain is not documented as acute or chronic, don't assign codes from the 338 category. Should we query the physician if the pain was acute or chronic rather than just using the fracture code if it appears that pain control was the main reason for the visit?
As part of the July update to the Intergrated Outpatient Code Editor, CMS reinstated HCPCS C1882 to the list of acceptable devices for CPT code 33249. Dave Fee, MBA, explains the implications of the change and reviews code changes included in the update.
Physicians can perform three different types of wound debridement and coders will find different codes for each type. Gloria Miller, CPC, CPMA, and John David Rosdeutscher, MD, discuss the different types of debridement, as well as coding and documentation requirements.
Observation services can generate so much confusion that CMS actually asked for comments on observation and inpatient status as part of the 2013 OPPS proposed rule. Kimberly Anderwood Hoy, JD, CPC, and Deborah K. Hale, CCS, CCDS, help coders unravel the complexities of observation services.
Inpatient facilities received mixed news on proposed changes to the list of complications and comorbidities (CC) and major CCs (MCC) in the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) final rule , released August 1.
The National Center for Health Statistics, the Centers for Disease Control and Prevention (CDC), and CMS have posted updated files for ICD-10-CM for 2013.
Cross-training coders has definitive short-term advantages, such as enhancing staff coverage during holidays and vacations and increasing the department's ability to handle periods of fluctuation in certain bill types. But coding managers might not realize that these benefits can also help hospitals with long-term preparation for ICD-10. Angie Comfort, RHIT, CCS, and Rose T. Dunn, MBA, RHIA, CPA, FACHE, explain the benefits of cross training coders as ICD-10 approaches.
Many coders can quickly quote the code for diabetes mellitus in ICD-9-CM (code 250.00) when the physician only documents diabetes mellitus. But what will coders need in the documentation for diabetes mellitus in ICD-10-CM? Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Jill Young, CPC, CEDC, CIMC, and Donna Smith, RHIT, dissect the differences in coding for diabetes mellitus in ICD-9-CM and ICD-10-CM.
QUESTION: Our laboratory medical director sent out a notification to our medical staff, patient care departments, and order entry personnel that a physician order that read “CBC” or “CBC with differential” would be completed as a CBC with automated or manual differential and coded using CPT ® code 85025 (blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC, and platelet count] and automated differential WBC count). Should we code 85025 when the order just reads CBC and when we do a manual differential with the CBC?
Coders can run into two types of edits that may require them to append modifier -59 (distinct procedural service) to override: National Correct Coding Initiative (NCCI) edits and medically unlikely edits (MUE). Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS, and Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, explain the differences between the edits and how to correctly determine when to override the edit.
Pain is an expected component of injuries, illnesses, and surgical procedures. In some instances, however, the patient's pain is unexpected or is worse than predicted. Sometimes, the pain can last well beyond the time it should have resolved. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, and Susan E. Garrison, CHCA, CHCAS, CHC, PCS, FCS, CCS-P, CPAR, CPC, CPC-H, provide tips and guidance to help coders accurately report pain management diagnoses and procedures.
CMS is proposing two major changes as part of the 2013 Outpatient Prospective Payment System (OPPS) proposed rule , released July 6. One has to do with how CMS proposes to calculate APC relative weights and the other with the reimbursement level for separately payable drugs and biologicals without pass-through status.
An anesthesia provider faces plenty of challenges: cancelled anesthesia, failed medical direction, monitored anesthesia care, time issues, invasive line placement rules, and start/stop times. Judy A. Wilson, CPC, CPC-H, CPCO, CPC-P, CANPC, CPC-I, CMRS, reviews some of the common challenges coders face when reporting anesthesia services.
QUESTION: The vendor for our cochlear implants has stated it’s standard to provide our operating suite with the cochlear device and two external speech processors. Should we report HCPCS Level II code L8614 (cochlear device, includes all internal and external components) for the one device and two external speech processors even though one processor is sent home with the patient? If so this means that we should charge the patient for the device and two processors as one price under revenue code 278.
Chronic kidney disease (CKD) is the permanent alteration in the kidney’s ability to perform filtration and reabsorption functions. Patients with CKD can come into an outpatient clinic or may be admitted as an inpatient, either for the CKD or some other condition. Debra Lawson, CPC, PCS, and Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, explain the ICD-9-CM and CPT ® coding for CKD.
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. This month’s column addresses the anatomy of the eye.
Emergency Departments (EDs) see a wide range of illnesses and injuries, from minor to major, which may require critical care. Lois E. Mazza, CPC, details how critical care is defined, what elements providers must document, and under what circumstances critical care can be coded for ED patients.
CMS reassigned 10 codes to status indicator K (paid under OPPS; separate APC payment) as part of the July update to the Integrated Outpatient Code Editor .
In coding, sometimes it really is brain surgery and coders need a strong understanding of the anatomy of the skull and brain in order to correctly report diagnoses and procedures. Cynthia Stewart, CPC, CPMA, CPC-H, CPC-I, discusses the anatomy of the brain and skull and guides coders through some brain surgery procedures.
The Rh factor of positive and negative can lead to problems between a mother and the developing fetus, a condition known as mother-fetus incompatibility. In some cases, the mother must receive the Rho(D) immune globulin. Lori-Lynne A, Webb, COBGC, CPC, CCS-P, CCP, CHDA , explains the diagnostic and procedure coding options for Rho(D) immune globulin.
QUESTION: I've always coded labile hypertension with ICD-9-CM code 401.9 (unspecified essential hypertension) because I couldn't find a more specific one. My supervisor stated that I must use ICD-9-CM code 796.2 (elevated blood pressure reading without diagnosis of hypertension) because it means the patient's blood pressure was high without a history of hypertension. The physician's diagnosis is labile hypertension. What code would you use?
An absence of start and stop times is one of the more frequent challenges that coders face when reporting injections and infusions. Denise Williams, RN, CPC-H, and Jugna Shah, MPH, highlight some other challenges to help coders determine how to code for injections and infusions.
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.
The transition to ICD-10-CM is coming. The only question is when. Despite the possible delay, coders and other HIM professionals must continue to prepare for the transition. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Sandy Nicholson, MA, RHIA, Robert S. Gold, MD, Jennifer Avery, CCS, CPC-H, CPC, CPC-I, and Kim Felix, RHIA, CCS, provide information on how ICD-10-CM will—and will not—differ from ICD-9-CM.
Just because a physician considers a service or procedure medically necessary doesn't mean insurance carriers will pay for it. When a service or procedure is not covered, facilities must provide patients with an Advanced Beneficiary Notice of Noncoverage (ABN). Judith Kares, JD, CPC, and Jacqueline Woeppel, MBA, RHIA, CCS, explain limits on liability and what modifiers to use with ABNs.
CMS continues to add more screening services to the list of covered preventative services. The newest additions involve screenings for sexually transmitted infections (STI).
The January update to the Integrated Outpatient Code editor generally includes a large number of changes and the January 2012 update is no exception. Dave Fee, MBA, highlights the most significant changes including the addition of modifier –PD, which he calls one of the real sleepers in this release.
Otolaryngology coding covers a wide range of procedures and four parts of the respiratory system—the ears, nose, sinuses, and throat (ENT). Stephanie Ellis, RN, CPC, and Kim Pollock, RN, MBA, CPC, explore some common ENT coding trouble spots.
QUESTION: We have a question in regards to hydration that we are trying to figure out. Does the physician specifically have to state in his or her documentation that the IV is for hydration purposes or can a coder figure it out through critical thinking and using the process of hierarchal injection/infusion coding when reading the record? For example, X IV fluids are being used for an antibiotic and after the antibiotic, the IV fluids continue at 125/hr for hydration. Does the physician need to document "for hydration"? Our physicians do not want to write that. Do you have any good advice on this?
In many instances, payers may consider a drug to be self-administered in some circumstances but not in others. As a result, coders must pay special attention to how these drugs are used within their setting. Kimberly Anderwood Hoy, JD, CPC, and Valerie Rinkle, MPA, offer some tips and suggestions for reporting self-administered drugs and determining when the drug is integral to the service.
Drug delivery implants are designed to provide active pharmaceuticals to a targeted area in into the patient’s body for a certain length of time site. Lori-Lynne Webb, CPC, CCS-P, CCP, COBGC, CHDA, provides what coders need to understand to correctly report drug delivery implant codes and what the physician must document.
To code chemotherapy properly, coders need to understand what the clinical staff actually does for the patient via complete and accurate documentation. Chemotherapy and other injections and infusion present some unique challenges in part because clinical staff members are focused more on patient care than documentation requirements. Paula Lewis-Patterson, BSN, MSN, NEA-BC, and Jugna Shah, MPH, discuss the challenges of compiling complete chemotherapy documentation.
CMS added modifier -PD (diagnostic or related nondiagnostic item or service provided in a wholly owned or wholly operated entity to a patient who is admitted as an inpatient within three days or one day) to the Integrates Outpatient Code Editor (I/OCE) as part of the January updates detailed in Transmittal 2370 .
QUESTION: We are a nondialysis facility, so when a patient is in observation for some other reason and must undergo hemodialysis, we report code G0257 (unscheduled or emergency dialysis treatments for an ESRD [end stage renal disease] patient in a hospital outpatient department that is not certified as an ESRD facility). But how should we code peritoneal dialysis when a patient is in observation or inpatient for other problems? I have received three different codes from different coders. I cannot really find any information on this anywhere.
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, JustCoding will provide an occasional article about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. In this month’s column, Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, addresses the anatomy of the respiratory system.
As hospitals develop more intensive training programs for ICD-10-CM/PCS, coordinators may want to consider how different learning styles will impact the effectiveness of these training sessions. Education has to work for everyone and one size does not necessarily fit all. Victoria Weinert, RHIT, CCS and Lora Ma explain how to get everyone moving in the same direction and prevent coders from going rogue.
Coders will need more information to correctly assign fracture codes in ICD-10-CM, but don’t fear. Most of that information is already in the medical record. Robert S. Gold, MD, Sandy Nicholson, MA, RHIA, and Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, walk through what you need to know to code fractures in ICD-10-CM
We hear about physician engagement across and throughout all healthcare settings almost daily, so it’s nothing new. But it's important for the upcoming transition to ICD-10-CM/PCS. Gloryanne Bryant, RHIA, RHIT, CCS, CCDS, offers suggestions for how to get your physicians engaged in the change.
Coders who are preparing for the upcoming transition to ICD-10-CM should note some significant changes to the coding guidelines for glaucoma coding as part of the 2012 updates to the ICD-10-CM Official Guidelines for Coding and Reporting .
QUESTION: The 2012 CPT ® Manual includes the typical time physicians spend at the bedside and on the patient’s hospital floor or unit for initial observation care codes 99218, 99219, and 99220. Do these codes only apply when the counseling and/or coordination of care support the respective 30/50/70 minutes of time? Do you know if CMS has published any new guidelines related to these times?
CMS decided not to cap outpatient payment rates for cardiac resynchronization therapy defibrillator procedures at the standardized inpatient rate as part of the calendar year 2012 Outpatient Prospective Payment System final rule. In addition, CMS finalized several changes regarding payments for 11 cancer centers, drug payment calculations, and physician supervision. Jugna Shah, MPH, and Kimberly Anderwood Hoy, JD, CPC, explain the changes facilities will see in 2012.
The AMA added a total of 60 new codes throughout the surgery section of the 2012 CPT ® Manual , 18 of which appear in the cardiovascular and respiratory system subsections. The AMA also revised 86 codes and deleted 48 codes in the surgery section. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, and Christi Sarasin, CCS, CCDS, CPC-H, FCS, highlight the significant changes for 2012.
CMS added four new J codes for reporting drugs and biologicals that previously did not have specific codes available as part of the 2012 Outpatient Prospective Payment System updates ( Transmittal 2376 ).
The ultimate goal of fetal surveillance is to prevent fetal death. Part of this process is a fetal non-stress test (FNST), the monitoring of the fetal heart rate in response to fetal movement. Lori-Lynne A. Webb, CHDA, CCS-P, CCP, CPC, COBGC, details what the FNST includes and how to code for it.
