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2013 OIG Work Plan: HHS Targets Three Areas
For The Record

From a coding perspective, mechanical ventilation, cancelled surgeries, and Medicare’s transfer policy take top billing in the OIG work plan for 2013.

Last October, the Office of Inspector General (OIG) released its work plan for fiscal year (FY) 2013, an event that sometimes can trigger anxiety among health care organizations. Published annually, the work plan outlines the OIG’s enforcement priorities, enabling health care facilities to better identify compliance risks and more accurately gauge their chances of meeting the requirements.

According to the OIG, the work plan is part of “a dynamic process, and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available. We assess relative risks in the programs for which we have oversight authority to identify the areas most in need of attention and, accordingly, to set priorities for the sequence and proportion of resources to be allocated.”

In creating the work plan, the OIG evaluates several factors, including mandatory requirements by law, regulation, or directive; congressional, Health and Human Services (HHS), or Office of Management and Budget requests and concerns; management and performance challenges facing HHS; collaborative work performed with partner organizations; and management’s responsiveness to results from previous reviews. Among OIG’s areas of focus for 2013 are coding related to payments for mechanical ventilation and cancelled surgeries as well as Medicare’s transfer policy.

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Cardiology: 93010 Is Sometimes the Right Choice on Cardiac ?ť?ŠCath ?ť?ŠDay

The Coding Institute

ECGs are bundled into cardiac catheterizations. But if you overlook opportunities to report ECGs on cardiac catheterization days, you could be shortchanging your practice. ?ť?ŠMedicare offers rules for reporting ECGs on the same date as cardiac catheterizations. The gist is that routine ECGs performed during cardiac caths are not billable in addition to the cardiac cath. But you may bill separately for diagnostic ECGs performed before or after the cardiac cath service. Here’s a closer look.

During cath: Medicare’s Correct Coding Initiative (CCI) manual, Chapter 11, Section I.4, indicates that because ECG monitoring is routinely used during cardiac catheterization, ECG codes aren’t reportable in addition to cardiac cath codes.

(The manual is available from the Downloads section at Coding/NationalCorrectCodInitEd/index.html.)

Note the Diagnostic Exception

Although ECGs that are an integral part of the cardiac cath aren’t separately payable, the patient may have diagnostic ECGs before or after the cath session. Those diagnostic ECGs are separately payable by Medicare when you append modifier 59 (Distinct procedural service) to the ECG code.

The CCI manual, Chapter 11, Section I.16, supports this by stating, “Cardiac catheterization procedures or a percutaneous coronary artery interventional procedure may require ECG tracings to assess chest pain during the procedure. These ECG tracings are not separately reportable. Diagnostic ECGs performed prior to or after the procedure may be separately reportable with modifier 59.”

Note: Don’t confuse standardized patient care with diagnostic ECGs. Some physicians will routinely order an ECG before and after a cardiac catheterization and/or interventional procedure. This is considered standardized patient care.

Helpful: If you’re having trouble determining whether the service performed meets the definition of diagnostic, consider the requirements listed in the National Coverage Determination (NCD) for Electrocardiographic Services (Section 20.15). The NCD manual is available by clicking the link for Publication 100-03 at Regulations-and-Guidance/Guidance/Manuals/Internet- Only-Manuals-IOMs.html.

Use the Appropriate Code for Diagnostic ECG

Once you’ve determined that a patient had a reportable ECG on the same date as a cardiac cath, you need to choose the correct code. For interpretation and report of a typical 12-lead diagnostic ECG performed in a facility, the appropriate code is 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). Recall that to override the cardiac cath/ECG edit, you must append a modifier to the ECG code.

Tip: The code definition refers to “at least 12 leads.”?ō For proper coding, you should know that a “lead”?ō and an “electrode”?ō are not the same thing. For instance, providers may refer to 10 electrodes placed on a patient for a 12-lead ECG. To simplify, think of a lead as an electrical view or snapshot of the heart from a particular perspective, creating what the provider sees on the graphic representation. A combination of electrodes can provide a single lead.

The use of “at least”?ō in the 93010 code definition is also important because it means the code is appropriate for 12 or more leads. ?ť?ŠConsequently, 93010 is correct when documentation shows 10 electrodes for a 12-lead ECG or 14 electrodes for a 15- lead ECG because in both cases there are 12 or more leads.

Bottom line: On cardiac cath days, experts advise only coding ECGs ordered/documented as diagnostic and performed before or after the cardiac cath. Baseline screenings or monitoring ECGs are not considered diagnostic.


Gastroenterology: How to Have Stress-Free GI Pressure, Transit Measurement Reporting

The Coding Institute

You can improve your CPT?ę 2013 code 91112 claims success if you focus on whether or not the procedure was complete and concentrate on who owns the equipment for the procedure. These codes replaced the former Category III codes 0242T.

Check Payer Rules for 91112

When your gastroenterologist performs a wireless capsule test for GI pressure and transit measurement, you will report the procedure and the interpretation of results using 91112 (Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report).

Note: Many payers still consider the procedure of using a wireless capsule to measure GI pressure and transit as investigational and might not provide coverage for the procedure. Many payers also mention that this procedure needs pre-authorization, so check with payers’ coverage policies to avoid the risk of denials.

Append Suitable Modifiers for Discontinued Procedures

Your gastroenterologist may attempt a capsule study for pressure and transit measurement but may need to discontinue the procedure. One such scenario is when the patient has difficulty swallowing the capsule. In such a situation, you will have to append modifier 53 (Discontinued procedure) to 91112 to indicate the incomplete work. Another situation that warrants you to report this modifier is when the capsule gets retained in the stomach.

If your gastroenterologist repeats the procedure by placing the capsule endoscopically in the duodenum for the repeat procedure, then you need to report the procedure using 91112 and the modifier 52 (Reduced services) to the code to indicate that your gastroenterologist used the wireless capsule to measure pressure and transit in the areas beyond the stomach.

Reminder: Don’t forget to report the endoscopy that your gastroenterologist performed to place the capsule. You will have to report it with 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Separate Components When Appropriate

When reporting 91112 for GI transit and pressure measurements, you will have to check who owns the equipment that is being used. If your gastroenterologist owns the recording device and provides the capsule for the procedure, you will just have to report the entire procedure and the interpretations along with the report using 91112.

However, if your gastroenterologist is only providing interpretations and prepares the report for the GI transit and pressure measurements, and the hospital owns the equipment, you will have to report components of 91112 separately. In such a scenario, you will have to report the services of your gastroenterologist using 91112 with the modifier 26 (Professional component) and the hospital will report its part using 91112 with the modifier TC (Technical component).


Internal Medicine: Injection Administration Coding Edits–New?ŠBundling Policies

The Coding Institute

The latest update from the Correct Coding Initiative (CCI) brings some limited–but good–news for internal medicine physicians: approximately 30 edits involving immunization administration and evaluation and management (E/M) services now have a modifier indicator of 9, meaning that the previous bundles have been deleted and are no longer valid. The changes took place April 1, 2013, when CCI 19.1 became effective, and the deletion date is January 1, 2013, indicating the change is retroactive to the first of the year.

The explanation for the changes falls under “CPT?ę manual or CMS manual coding instructions.”?ō

Six immunization administration codes are part of the reversed edits:

– ?ť?Š90460 –?ŠImmunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered

– ?ť?Š+90461–?Š?Š…each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)

– ?ť?Š90471 –?ŠImmunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

– ?ť?Š+90472?Š1–?Š?Š…each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

– ?ť?Š90473 –?Š?ŠImmunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)

– ?ť?Š+90474 –?Š?Š…each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure).

You can now report these administration codes in conjunction with any level of inpatient consultation without the necessity of appending a modifier to the inpatient consultation code to get both services paid, according to specialists. The affected codes are:

“Unfortunately, the other edits bundling office, outpatient, and preventive E/M services with vaccine administration codes in the absence of a valid modifier remain in place,”?ō a coding specialist notes. “That means you’ll need to continue appending a modifier, such as 25, to an affected E/M code provided at the same encounter as a vaccine administration to get paid for both services under the CCI edits.”

Exception: The one exception is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services.). Code 99211 is bundled with a vaccine administration code, regardless of whether you include a modifier.

Recoup: The deletion date for these edits is January 1, 2013, which suggests that the change is retroactive to that date. If you had any services denied on the basis of these particular edits for dates of service between January 1 and April 1, 2013, you may want to consider appealing the denials on the basis of CCI release 19.1.


Neurology: 4 Tips for Conquering Carpal Tunnel Coding Challenges

The Coding Institute

A lack of definitive results from diagnostic tests can complicate carpal tunnel coding. Take care not to jump to a definitive diagnosis code. But this does not mean you will compromise on payment. Follow these tips to ensure you earn what you should for carpal tunnel cases.

1. Don’t Jump to a Diagnosis Too Soon

When your neurologist treats carpal tunnel syndrome (CTS), you usually report diagnosis code 354.0 (Carpal tunnel syndrome).

Note: Your neurologist may document “suspected”?ō CTS in the clinical record. If so, don’t report the definitive diagnosis code 354.0 just yet. While your neurologist is waiting for test results, you should report the patient’s symptoms in support of any services your physician provides.

Reason: ICD-9 official guidelines instruct you to use signs and symptoms codes in the office setting when your neurologist documents an uncertain diagnosis. According to ICD-9, “Do not code diagnoses documented as ‘probable,’?ō ‘suspected,’ ‘questionable,’ ‘rule out,’?ō or ‘working diagnosis,’?ō or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

You may find the ICD-9 guidelines on the CDC website: icd/icd9cm_addenda_guidelines.htm#guidelines

2. Check for Diagnostic Testing

To establish a diagnosis of CTS, your neurologist may perform nerve conduction studies (NCS) and/or electromyography (EMG). Each one has its own diagnostic significance.

You report 95860 or 95861 only when no NCS is performed. If both NCS & EMG are performed, then you need to look at either add-on code +95885 (Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited [List separately in addition to code for primary procedure]) or +95886 (Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels [List separately in addition to code for primary procedure]).

Watch for the complete limb EMG. Additionally, the 95860 (Needle electromyography; 1 extremity with or without related paraspinal areas) — 95864 (Needle electromyography; 4 extremities with or without related paraspinal areas) codes, as well as the 95886 code is ONLY billed when a complete limb EMG study has been performed — testing performed on five or more muscles studied, innervated by three or more nerves or four or more spinal levels’ otherwise the code would be 95870 (Needle electromyography; limited study of muscles in 1 extremity or non- limb [axial] muscles [unilateral or bilateral], other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters) if no NCS are performed.

Count nerves for NCS: You select from codes 95907 (Nerve conduction studies; 1-2 studies) — 95913 (Nerve conduction studies; 13 or more studies) depending upon the total number of separate nerves that are tested.

3. Submit Single Code Once Diagnosis Is Established

When your neurologist has established the diagnosis of CTS, focus on code 354.0. In this case, you do not report the codes for the signs or symptoms, such as numbness, tingling or finger pain. According to ICD-9, “Signs and symptoms that are integral to a disease process should not be assigned as additional codes.”

Reason: Your neurologist may be doing nerve conduction studies and/or electromyography to confirm the diagnosis of CTS. In this case, do not report the signs and symptoms as secondary diagnoses as these are integral to the primary definitive diagnosis.

4. Code for the Treatment Provided

Your neurologist may begin with noninvasive, conservative treatments in the early stages of CTS and include injections in later stages of the disease.

Initial treatment may include pain-relieving medications and a wrist brace or splint.

When pain-killers, splints, and physical therapy have failed or cannot be used for one or more reasons, your neurologist may administer injections into the carpal tunnel to perform a nerve block and relieve the symptoms. If so, submit 20526 (Injection, therapeutic [e.g., local anesthetic, corticosteroid]; carpal tunnel). Depending upon what option your payer prefers, you report either modifier 50 (Bilateral procedure) or modifiers LT (Left side) and RT (Right side) when your neurologist injects both carpal tunnels.

If the symptoms still persist, your neurologist may refer the patient for surgical treatment to relieve the pressure on the median nerve.

Note: Ensure all treatment steps are documented in the treatment plan, or payers may reject your claim based on lack of medical necessity.


Obstetrics: Troubleshoot Your Pregnant Patient Transfer Claims by Counting Visits

The Coding Institute

Prepare for coding your OB-GYN’s services up to the date of the patient’s move depending on how many antepartum visits the physician provides — here are tips for one to three and four to six visits:

1-3 Visits Mean Office E/M Codes

If your OB-GYN sees a pregnant patient for only one to three antepartum visits, how should you report it?

Answer: You need to report the appropriate E/M codes for payment. You won’t have a set E/M code for the patient’s first visit. Your patient could be new to the practice, or the first visit may meet the criteria for a level-five established visit. Therefore you should look to the entire code series (99201-99205 for new patients, 99211-99215 for established patients) as possible options.

Second and third visits: Now your coding options are more limited.

When Medicare and ACOG were developing the relative value units for antepartum care, the follow-up visit was estimated to be a 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...), so this code is your best bet for each of these visits in the absence of documented problems.

Note: In some rare circumstances, such as when the patient has absolutely no problems during the visit, however, the documentation might support reporting only 99212 (Office or other outpatient visit for the evaluation and management of an established patient … Physicians typically spend 10 minutes face-to-face with the patient and/or family) for each visit.

If the patient’s pregnancy is without complication, your diagnosis would be either V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy).

Watch out: Because you do not have a specific antepartum code for one to three visits and have to report E/M codes, payers sometimes will deny these claims and tell you to “include in the global.”?ō You are forced to appeal these decisions. Explain to the payer that you cannot report a global code because you are no longer the patient’s OB care provider.

4-6 Visits Mean Antepartum Code

Your ob-gyn sees a pregnant patient for four to six antepartum visits. How should you report this?

Answer: Four to six visits means you?ů‘ťľ‘šůll be flipping through your book to the maternity care and delivery section — particularly the antepartum codes. You should report 59425 (Antepartum care only; 4-6 visits), which represents the total services rendered by your ob-gyn. This means that you’ll report only one unit of this code.


Opthalmology: Focus Your Cataract Coding With This Tip

The Coding Institute

With several possible surgical treatments for cataract procedures, which you probably code more often than any other surgery, there’s a lot of room for error — with over $800 at stake for complex cataract procedures in 2013.

Use this tricky scenario as a guide:

Document Necessity for Planned Vitrectomy

Scenario: During the course of a cataract removal, the vitreous collapses and the ophthalmologist finds it necessary to perform a vitrectomy.

Question: Can you code separately for the vitrectomy?

Answer: The answer depends on whether the vitreous collapse was an iatrogenic (inadvertently introduced) complication. Ophthalmologists often have to perform a vitrectomy during cataract surgery due to vitreous collapse in the course of removing a dense, senile cataract. In these cases, Medicare considers the vitrectomy a component of the cataract surgery, and thus not separately payable.

The National Correct Coding Initiative bundles vitrectomy codes 67005 (Removal of vitreous, anterior approach [open sky technique or limbal incision]; partial removal) and 67010 (…subtotal removal with mechanical vitrectomy) into cataract surgery ?Šcodes 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification], complex …) and 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]).

Rationale: When procedures are performed together that are basically the same, or performed on the same site but are qualified by an increased level of complexity, the less extensive procedure is included in the more extensive procedure. The column 1 code generally represents the comprehensive service, and the column 2 code is the component that is part of the more extensive column 1 procedure.

Exception: If a prolapsed vitreous exists and is known in advance — and documented in the patient medical record — it is not considered a complication of the cataract surgery. Therefore, the physician who plans to perform a vitrectomy during the same operative session of cataract surgery could code separately for the vitrectomy using modifier 59 (Distinct procedural service): 67005-59 or 67010-59.

Key: Use 379.26 (Vitreous prolapse) for the vitrectomy and the appropriate cataract diagnosis (366.x, Cataract) for the cataract removal.

Be prepared to provide documentation in case you receive denials when using the cataract and vitrectomy codes together, despite using modifier 59. Payers are aware of the potential for abuse of 59 and may want you to go through the review process to prove you’ve met the definition of “distinct procedural service.”?ō

Provide the chart notes to show that you knew about the vitreous collapse in advance and that you made plans to repair it prior to the surgical session of another service. Also, you should provide the operative report with clear documentation showing that there was another condition, besides the cataract surgery, that made the vitrectomy medically necessary.

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Yesterday we posted the first part of our Denial Management Quiz so that you could see how well you scored on your knowledge of techniques for improving your denial rates. Now let‘«÷s move on to Part 2 with some more sophisticated techniques. Ready? (Missed Part 1? Read it here.)

1. Now that we‘«÷ve established that you should track denials, what exactly should you track?

A.?Š Total claims denied for your practice; Total claims filed to a payer; Number and dollar value (charge) of denied line items;

B.?Š Total claims filed to a payer; Number and dollar value (charge) of denied line items; Calculate percentage denied (B divided by A)

C.?Š B above, plus calculate these percentages for your entire medical practice and also by payer, reason, provider, specialty, and location (if you have more than one office)

D. A, B & C


2. When you‘«÷re notified that a claim has been denied, what is your next action?

A. Refile the claim as is; the insurer clearly didn‘«÷t review it

B. Write it off and move on to other claims; if the claim could have been approved, it would have been the first time

C. Investigate; approximately 75% of denials can be resolved without an appeal

D. Appeal; the insurer may need additional information to approve the claim

E. C and D


3. In order to prevent future denials, you should:

A. Fire the person responsible immediately

B. Return denials to their origin (for example, registration errors to front office)

C. Establish a feedback loop with providers by listing top denials at provider meetings; attach EOB examples

D. Educate billing staff on denials, but don‘«÷t bother the providers with the details

E. B and C


4. Your practice should appeal:

A. Every claim, every time

B. Establish a minimum amount for claims to be appealed across the board

C. Different types of denials at different amounts. Establish a protocol for different types of denials and different amounts



1. C; To correctly track the number of claims that are denied for your practice, you‘«÷ll want to measure the following:

i)?Š Total claims filed to a payer (number and total charge amount)

ii)?Š Number and dollar value (charge) of denied line items

iii)?Š Calculate percentage denied (B divided by A)

iv)?Š And calculate these percentages for your entire medical practice and also by payer, reason, provider, specialty, and location (if you have more than one office)


2. E; When a claim is denied, you want to investigate to see if the denial can be resolved without an appeal, but if not, then APPEAL! 75% of appeals result in denied claims being overturned and paid.


3. E; In order to prevent future denials, you should return denials to their origin and establish a feedback loop with providers.


4. C; Your practice should appeal different types of denials at different amounts. Establish a protocol for different types of?Šdenials and different amounts, and test the results. There are ‘«£soft‘«ō denials that can be easily corrected, and ‘«£hard‘«ō denials that require more effort. A $20 ‘«£hard‘«ō denial may not be worth the $25-30 it costs most practices to appeal.


How Have You Scored in Part 2?

4 Correct: You‘«÷re a Denial Champ!

3 Correct: You‘«÷re doing well, but take note of the explanations above to improve your score.

2 Correct: Keep learning!

1 Correct: Hmm‘«™you may need some help with your medical billing. Consider hiring a medical billing service like, which allocates over 50% of its billing costs to the successful collection of the last 20-30% of charges that typically do not get paid on first submission. These are the claims your staff probably doesn‘«÷t have either the time or expertise to collect on‘«Ųbut we do, and we do it every day.

On average, our physician clients get paid faster than 75% of multi-specialty group practices nationwide as surveyed by the Medical Group Management Association and Healthcare Billing Management Association for Days Revenue in AR.

Contact us today to find out how we can help improve your medical billing results and free your staff to focus on patient care.

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Do you know the top 3 reasons medical claims are denied? Want to find out how well you know the world of denial management‘«Ųa key part of medical billing? Let‘«÷s have a little fun during this holiday week: Take our easy quiz now, and see how you score!

1. The top 3 reasons claims are denied are:

A. Coverage terminated, Incorrect and/or incomplete patient identifier information, Incorrect provider information

B. Incorrect and/or incomplete patient identifier information, Coverage terminated, Services non-covered/Require prior authorization or precertification

C. Incorrect?Šdiagnosis and procedure codes, Coverage terminated, Incorrect provider information

D. None of the above


2. The Medical Group Management Association (MGMA) found that better-performing medical groups average aclaims denial rate of:

A. 10%

B. 2%

C. 4%

D. 6%

E. They found it was a waste of time to track it


3. The best way to avoid denials is:

A. To undercode so it‘«÷s obvious the claim should be paid

B. To code the diagnosis to the absolute?Šhighest level for that code, meaning the maximum number of digits for the code being used

C. To make friends with as many people at the insurance companies as possible.

D. Don‘«÷t provide too much documentation so that the insurance company can‘«÷t determine if you‘«÷ve coded correctly or not


4. When developing a process for improving your practice‘«÷s denial rate, the first step in the process is:

A. To contact all your payers and ask them for the top reasons your claims are denied

B. To contact your specialty society and get statistics from them for your specialty

C. To measure the practice‘«÷s baseline denial rate, and then determine and categorize the reason for each denial

D. Look in your medical billing software for a report



1. B; The top 3 reasons claims are denied are Incorrect and/or incomplete patient identifier information, Coverage terminated, Services non-covered/Require prior authorization or precertification

i) Incorrect and/or incomplete patient identifier information?Š(e.g., name spelled incorrectly; date of birth or SSN; subscriber number missing or invalid; insured group number missing or invalid)

Solution:?ŠVerify patient demographic and insurance information before EVERY visit. Ask permission to photocopy the patient‘«÷s state-issued identification (passport, driver‘«÷s license, etc.) and insurance card, so that you are sure to have the proper spelling, group numbers, etc., on hand.

ii) Coverage terminated

Solution:?ŠVerify insurance benefits?Šbefore?Šservices are rendered.

iii) Services non-covered/Require prior authorization or precertification

Solution:?ŠAgain, contact the patient‘«÷s insurance and confirm coverage before services are rendered. You‘«÷ll end up with angry customers if you bill a patient for non-covered charges without making them aware that they may be responsible for the charges before their procedure.

Read More


2. C; The Medical Group Management Association (MGMA) found that better-performing medical groups average just a?Š4% claims denial rate.

Here are some average denial rates by specialty (note that these are for all practices, not better-performing groups):

2011 Denial Rates by Specialty
Category Denial Rate
Primary Care 7%
Cardiology 8%
Surgeons/Ambulatory Surgical Centers 8%
Radiology 9%
Physical Therapy 10%
Chiropractors 13%
Durable Medical Equipment 14%


3. B; The best way to avoid denials is to code the diagnosis to the absolute?Šhighest level for that code, meaning the maximum number of digits for the code being used.


4. C; When developing a process for improving your practice‘«÷s denial rate, the first step in the process is to measure the practice‘«÷s baseline denial rate, and then determine and categorize the reason for each denial. Although if you can get a report from your medical billing software on the most common denial reasons, that will certainly help speed the process.


How Have You Scored in Part 1?

4 Correct: You‘«÷re a Denial Management Champ!

3 Correct: You‘«÷re doing well, but take note of the explanations above to improve your score.

2 Correct: Keep learning!

1 Correct: Hmm‘«™you may want to read up on our blog. Here are some other articles we‘«÷ve published on denial management:

Reduce Denials in Your Medical Practice for an Improved Bottom Line

Fast Billing/Practice Management Tips to Improve Profitability

Medical Billing Reporting: Don‘«÷t be Kept in the Dark About Your Practice

Join us tomorrow for Part 2 of our Denial Management Quiz!

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Medical Billing Resource CenterHave questions on how to prepare for ICD-10?

Wonder how your practice denial rate and collection rates compare with other practices?

Whether you need some help with improving your bottom line or getting started with ICD-10, we can now offer you an online resource center to help. Our Resource Center is now open, featuring:

White papers on improving your bottom line, how to evaluate medical billing services, ICD-10 and more

– All issues of our monthly enewsletter, Monitor, filled with medical billing and coding news and tips

Infographics including our popular infographic on avoiding CMS penalties for eRX & PQRS

– A Practice Revenue Analysis Tool that will help you compare your results to industry standards

– And of course, links to this blog

We‘«÷ve had many requests for these useful tools, so we wanted to gather them in one place where they‘«÷d be easy to access. They‘«÷re now available to you 24/7, to help bring more to your medical practice bottom line.

Take a moment now to review the Resource Center and tell us what you‘«÷d like us to add. We want this Resource Center to meet your medical billing and coding needs.

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The Coding Institute
Here are some excellent tips from a leading resource for coding training and information.

CMS Clarifies 99495 and 99496 Use: Answers to Place and Date of Service Questions

CMS offered some new insights into how Medicare payers expect you to use 2013‘«÷s new transitional care management (TCM) codes during the agency‘«÷s March 12 Open Door Forum, noting several important points about the TCM codes to keep in mind when completing your claims.

The new TCM codes are:

99495, Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge, medical decision-making of at least moderate complexity during the service period, and face-to-face visit within 14 calendar days of discharge

99496, Transitional care management services?Š with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge, medical decision-making of high complexity during the service period, and face-to- face visit within seven calendar days of discharge.

The codes are intended to apply when a physician oversees a patient whose health issues necessitate moderate to high complexity medical decision making (MDM) during the shift from a healthcare facility setting back to the patient‘«÷s community (home) setting.

‘«£A face-to-face visit is required within a specific time frame after the patient‘«÷s discharge, depending on which code you‘«÷re reporting,‘«ō said David A. Ellington, MD, an AMA CPT?ę Editorial Panel member who presented E/M changes at the CPT?ę and RBRVS 2013 Annual Symposium ( ‘«£The initial interactive contact ‘«Ų face-to-face, phone call, or email ‘«Ų should be within two business days of discharge. If you make two attempts to contact the patient or caregiver within that time but are unsuccessful, CPT?ę states that you can still report transitional services if the other criteria are met.‘«ō

Additional Pointers
During the March 12 CMS forum, CMS‘«÷ Ryan Howe emphasized the following areas:

– When determining which place of service (POS) code to use on your TCM claim, you should use the location that ‘«£required the face-to-face visit.‘«ō

– The 30-day TCM period begins on the date of discharge and continues for the next 29 days. Your date of service should be the thirtieth day of care‘«Ų not the first, Howe said during the CMS call.

– CMS will reject any claims with dates of service prior to Jan. 30, 2013, because the codes became effective on Jan. 1 and only cover 30-day periods.

– You can report TCM codes for both new and established patients, Howe said, which is a departure from CPT?ę rules. ‘«£CPT?ę guidance suggests that the codes are only for established patients, but for Medicare purposes, they can be reported for new patients as well,‘«ō he said.

– If 30 days pass between discharge and the initial communication with the TCM practitioner, you cannot report TCM codes, Howe said during the call.

– Medicare will pay only the first TCM claim received per beneficiary in one 30-day period beginning on the date of discharge, so if more than one practitioner reports the code for the same patient, only the doctor whose claim is received first will get paid.

– If the patient dies before the thirtieth day of TCM, you cannot report the TCM codes because they cover a full 30 days. Instead, you‘«÷d report the appropriate E/M code.

For more on the TCM codes, read the FAQs at


Reduce ‘«£Ordering/Referring‘«ō Edit Losses with These Quick Steps

Key: Double check physician NPI is individual and not group practice NPI.

If you have been postponing updating your ordering/referring physician info, take action or you may have begun seeing losses starting in May.

Phase 2 of the ‘«£ordering/referring‘«ō edits hit May 1 and CMS indicated they would issue costly denials as opposed to less burdensome returned claims when practices have invalid ordering/referring physician information. The system will deny claims when the doctor isn‘«÷t in the Provider Enrollment, Chain, and Ownership System (PECOS) file or when the name doesn‘«÷t match.

Smart practices will take these six steps to minimize cash flow delays and financial losses due to ‘«£ordering/referring‘«ō edit denials:

1. Check and recheck. CMS posts a ‘«£Medicare Ordering and Referring File‘«ō on its website with the full list of ‘«£the National Provider Identifier (NPI) and legal name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS),‘«ō CMS explains on the site. The website is at CMS updates the report weekly, it says in newly?Šrevised MLN Matters article SE1305.

Now is the time to step up PECOS file checking. Pay attention to which physicians are sending referrals and ordering services and verify that those physicians are eligible to do so and are currently enrolled in PECOS.

2. Spur enrollment. If you find your docs don‘«÷t have a record in PECOS, you‘«÷ll need to get them to enroll in it or you won‘«÷t be able to get paid.

Resource: Links to educational Medicare articles about enrolling in PECOS are in the ‘«£Additional Information‘«ō section at the end of the MLN Matters article at

3. Match the PECOS file exactly. If your claim calls a physician ‘«£Jack‘«ō and he‘«÷s listed as ‘«£John‘«ō in the PECOS file, it will get shot down. Also, don‘«÷t use credentials such as ‘«£Dr.‘«ō in the name field, CMS advises.

Key: On paper claims, be sure to list first name first and last name last in item 17.

Don‘«÷t let software differences trigger unnecessary edits. Make sure that the physician information that is on file in the providers‘«÷ software systems and is being coded on the claim for enrolled physicians matches the PECOS information, including both the NPI and physician name.

4. Use the right NPI. ‘«£Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to an individual physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral,‘«ō CMS instructs.

5. Know the rules for exceptions. Use the teaching physician‘«÷s information for interns and residents, CMS directs. The exception is for docs in states that license their residents. State-licensed residents may enroll in PECOS on their own to order and/or refer and may be listed on claims.


Separate Problem Can Be Billed During a Well Check Visit

When a patient comes to your office for a preventive wellness visit, if the patient mentions a health problem or other concern during the preventive visit, the encounter might qualify for two codes.

Checkpoint: If the problem ranks as ‘«£significant,‘«ō you can report your work to address it in addition to the preventive care. This may take the form of a problem- oriented E/M code (e.g. 99201-99215), a procedural service, or both.

Key: Although poorly covered in the past, many payers now recognize and pay for these separate, significantly identifiable services addressed during preventive medicine visits. Of course, those additional services, if covered, may also result in a patient financial obligation (e.g. deductible, copay, or coinsurance) that would not accrue with a simple preventive visit. ?ŠManaging patient expectations in this situation is important.

3 Tips: If you‘«÷re still unsure whether you‘«÷re justified in billing a problem- based E/M code along with the preventive visit, keep a few criteria in mind:

1. If the problem is significant enough that it would require or justify the patient to come back for another visit if the internal medicine physician doesn‘«÷t address it, that could be a clue that you‘«÷re dealing with a problem-based E/M situation.

2. Check whether the problem has its own ICD-9 diagnosis code. If so, that means addressing the issue could be a stand-alone (and separately reportable) service.

3. Look for additional evaluation and treatment options, such as X-ray or lab tests, or written prescriptions. These can be other signs that the physician is addressing a significant problem.


Penalties Could Be Coming Your Way for Illegible Documentation

If your physician‘«÷s handwriting is really difficult to read, you should be worried–because payers are getting stricter about illegible documentation and he may face penalties, advises The Coding Institute.

Physicians could actually have problems with payers in the future if the payers cannot read their notes. Billers should stress the importance of legible notes to their providers and may even want to suggest that they print, use dictation, or invest in an electronic medical record (EMR) system to ensure legibility.

Many coders shake their heads when they hear that some physicians maintain incomplete notes, and that auditors ask those physicians for money back since their documentation didn‘«÷t support the codes they billed. But have you ever thought that writing illegibly could make you qualify for CMS‘«÷s interpretation of incomplete notes?

‘«£When determining the medical necessity of an item or service billed, Medicare‘«÷s review contractors must rely on the medical documentation submitted by the provider in support of a given claim,‘«ō CMS says in MLN Matters article SE1237. ‘«£Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS [fee-for-service] claim payment denials.‘«ō

To read the MLN Matters article, visit

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This month we have a number of useful articles on coding that will help you avoid errors and code more precisely.

The G-Codes Are Here for Payment Claims – Ready Or Not
Effective July 1, the Centers for Medicare & Medicaid Services will begin rejecting claims received for Medicare Part B patients that do not include the new requirement of G-coding.

G-coding is a claims-based coding system that CMS plans to “collect and analyze”?ō the data to better understand patient outcomes. It also is meant to be used towards the various conversations surrounding the healthcare reform options floating around…?ŠRead More

CMS Releases Clarification on Reporting External Cause Codes and Unspecified Codes
On May 17, 2013, the Centers for Medicare & Medicaid Services (CMS) released several important clarifications in their ICD-10 Industry Update email. There has been some confusion and frustration regarding the codes in Chapter 20, External Causes of Morbidity (V, W, X, and Y codes), which will replace the current ICD-9-CM E-Code section. Read More

In Sync With ICD-10
In the race to prepare for the new codes, will providers and payers be able to successfully cross the finish line together?

It’s been said that a chain is only as strong as its weakest link. As the timeline for the health care industry’s mammoth ICD-10 implementation marches forward, industry professionals are becoming increasingly aware that if all stakeholders are not ready for the October 1, 2014, deadline, calamity could ensue.

“Everyone is wondering about everyone else…”?ō Read More

2013 OIG Work Plan: HHS Targets Three Areas
From a coding perspective, mechanical ventilation, cancelled surgeries, and Medicare’s transfer policy take top billing.

Last October, the Office of Inspector General (OIG) released its work plan for fiscal year (FY) 2013, an event that sometimes can trigger anxiety among health care organizations. Published annually, the work plan outlines the OIG’s enforcement priorities, enabling health care facilities to better identify compliance risks and more accurately gauge their chances of meeting the requirements…?ŠRead More

Coding for Acute Coronary Syndrome
Acute coronary syndrome (ACS) is classified to ICD-9-CM code 411.1, which is the same code assigned for unstable angina. It is vital to review the entire medical record to make sure the information presented supports the final code assignment. Therefore, if the record contains evidence that the patient may have experienced an AMI but only ACS is documented, then it may be appropriate to query the physician for clarification of the final diagnosis. Final code assignment always is based on physician documentation…?ŠRead More

Dual Coding: An ICD-10 Jump-Starter?Š
By adopting this tactic, health care organizations can accelerate the transition process.

There has been a palpable shift in the conversation surrounding the transition to ICD-10. No longer is it focused on whether the Centers for Medicare & Medicaid Services (CMS) will extend the deadline yet again (it won’t). Instead, it centers on just how soon organizations should start coding in ICD-10 to minimize operational and financial impacts once the October 1, 2014, deadline hits.

For early adopters, the opportunity to code in a dual ICD-9/ICD-10 environment can generate benefits that outweigh negatives such as productivity declines and revenue cycle slowdowns…?ŠRead More

Read Between the Lines: Saving Your Physicians from Copy-and-Paste Problems
Identifying harmful copy-and-paste documentation can help curb serious coding errors.

Like any good story, a medical record should be consistent and relatively easy for the reader to follow, presenting events in a logical sequence. However, as physicians begin to document in the EHR, the patient’s story–the crucial element necessary for coding–can become jumbled and sometimes even unreadable. Coders may begin to see nonsequential dates on progress notes…?ŠRead More

The Coding Corner: Avoid Common Place-of-Service Coding Errors
Place of Service (POS) codes identify where a health care service is provided, which directly affects payment. As explained in MLN Matters?ę Number: SE1104, “To account for the increased practice expense that physicians generally incur by performing services in their offices and other non-facility locations, Medicare reimburses physicians at a higher rate for certain services…?ŠRead More

Appending Modifiers 58, 78, and 79
Modifiers identify procedures that have been altered in some way without changing the fundamental components. In this article, we will examine the modifiers that can be appended to procedure codes for services performed within the global period…?ŠRead More

Updated Codes for Claims Adjustment, Remittance Advice Under HIPAA Released
The Council for Affordable and Quality Healthcare has released updated code combinations for its CORE 360 rule, which is a part of the operating rules for electronic transfer of healthcare funds and remittance advice under HIPAA, according to an AHA News Now report…?ŠRead More

HCPCS Update: Prepare for Medicare’s July Coverage Changes to Zometa and Doxil Codes
Add 2 new Q codes to your system to keep your coding compliant.

The July 2013 HCPCS update has coding changes in store for both liposomal doxorubicin HCl and zoledronic acid. Pay attention both to the new codes available and the coverage changes Medicare will make to existing codes…?ŠRead More

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Is your practice ready for the influx of patients expected with the launch of healthcare insurance exchanges mandated by ACA for Jan. 1, 2014??ŠFourteen million U.S. residents will join the ranks of the newly insured on Jan. 1, 2014, according to the Congressional Budget Office.

‘«£Definitely!‘«ō you might think‘«Ų‘«£I‘«÷m ready for more revenue.‘«ō

Yes, but what about your practice: your staff and your processes? Are they ready?

Right now your office probably chugs along fairly well (or maybe not‘«Ųyou decide). But if the volume of patients you‘«÷re seeing increases rapidly, what will happen to your systems?

– Will no shows go through the roof because staff doesn‘«÷t have time to make reminder calls?

– Will patients wait interminably because check-in isn‘«÷t smooth (and meanwhile, your Yelp ratings plummet)?

– Will you be seeing patients whose coverage isn‘«÷t confirmed because staff didn‘«÷t have time to verify eligibility? (And not everyone will be covered, in spite of the mandate.)

– Will your denial rates rise and your appeal success drop because billing staff are simply overwhelmed?

These are all possibilities‘«Ųif you don‘«÷t review your office processes now, tighten up where needed and plan ahead for the increase.

Here are some steps you should take now:

1. Do an audit of your office. Where are the bottlenecks? How can they be eliminated?

2. Verify eligibility electronically. If you‘«÷re not already verifying eligibility electronically, there will never be a better time to make that change. You can‘«÷t afford having staff spend hours on the phone or even an hour visiting different insurers‘«÷ websites‘«Ųthey need a one-stop method of checking. Many billing software solutions offer this now, and your staff will need it.

3. Take patient histories electronically. By taking patient histories electronically via a patient portal or a tablet in the office, you‘«÷ll reduce wait times for patients (a major source of dissatisfaction) and eliminate the need for a staff member to enter the data into the EHR. This is vital with an increased patient flow; if you have patients sitting, filling in patient histories by hand, your scheduling is going to be shot within the first 2 hours. And you know many of them will forget to fill in the patient history ahead of time or forget to bring it if they do fill it in.

4. Use electronic check-in. Either through a patient portal or in-office kiosks, you need to have patients check themselves in. This will save your front office staff a great deal of time and reduce waiting time. It also offers patients the opportunity to cancel and reschedule easily in advance‘«Ųwhich means you won‘«÷t have holes in your schedule you have to juggle at the last minute.

5. Evaluate your billing processes. With more patients to bill and file claims for, your billing staff could easily be overwhelmed. Then think about the denial management and appeals‘«Ųwill your staff be able to handle the increased volume? Plus get ready for ICD-10?

Even if your billing staff is able to handle the volume of billing your practice currently sees, with the increased number of patients, they may soon be overwhelmed. Plus, they may be seeing new types of denials and problems as payers sort out how they‘«÷ll handle the new coverage.

That‘«÷s why now may be the time to consider turning to a medical billing service‘«Ųan organization that will be up to speed on all of the new regulations and requirements, able to staff up quickly and handle the increase in claim volume. This is what a medical billing service‘«Ųparticularly a nationwide medical billing service like‘«Ųdoes every day.

Find out how we can insure that your medical billing runs smoothly‘«Ųand brings more to your bottom line‘«Ųeven in the face of changes such as the health insurance exchanges and ICD-10.

We‘«÷re ready; we‘«÷ll make sure you‘«÷re ready.

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Medical practice profitability survey reveals less than 9% of physicians are very confident in their medical billing.Two very interesting pieces of news caught my eye this week, and the implications for medical practices from each of these pieces of news is rather staggering, in my opinion.

1. A survey on physician profitability just released by social learning and collaboration platform ?ŠQuantiaMD and EHR/PMS company CareCloud found that only 9% of physicians are ‘«£very confident‘«ō in their current staff, tech and processes for getting paid.

2. A recent blog post on Healthcare IT News discussed the fact that payers are changing their systems from a ‘«£pay-and-chase‘«ō post-payment recovery model to efforts to prevent overpayments. ‘«£Some are implementing analytical technologies to identify possible claim discrepancies at the time a claim is adjudicated. These tools combine predictive, data-driven, integrated code edits and clinical aberrancy rules to identify claim outliers. Unlike rules-based systems, data-driven analytical solutions examine hundreds of variables, and can detect previously unknown and emerging patterns that rules-based analytics may not recognize,‘«ō the article says.

The article goes on to say that ‘«£An additional layer that can deliver savings to a multi-faceted payment integrity program is to reduce billing overpayments that result from improper coding. This can be achieved by supplementing analytics with clinical code edit technologies backed by nationally recognized coding guidelines as they are designed to find coding errors, unbundled treatments, unusual and inconsistent treatment patterns, and inappropriate diagnoses.‘«ō

What these two pieces of news mean to me is that while 91% of physicians are less than ‘«£very confident‘«ō about their billing processes, they are about to face increased scrutiny from payers with finely tuned analytics software, which means that every coding error, unbundled treatment, unusual and inconsistent treatment pattern and inappropriate diagnosis could cause their claim reimbursements to, at best, be delayed, and at worst, to be denied.

This is a recipe for disaster for many practices.

In addition, when asked in the survey how much of their time was spent on ‘«£coding, documentation and administration,‘«ō rather than patient care, the majority of physicians?Š(59%)?Šsaid they sacrificed more than?Š(20%)?Šof their time this way. This is the equivalent of one day per week for a full-time physician spent at a desk rather than in an exam room. About?Š(30%)?Šof physicians spend one-third of their time ‘«Ű or more ‘«Ű on administrative tasks.

So what this picture reveals is that physicians are spending way more time than they want to‘«Ųor should‘«Ųtrying to oversee billing processes they were never trained to manage, with staff who have varying levels of training and experience.

No wonder 91% of them are less than ‘«£very confident‘«ō about their billing‘«ŲI‘«÷m sure an even higher percentage are less than ‘«£very happy‘«ō about this situation!

Plus, a key finding of the PPI survey was that the 5,012 physician participants were two-thirds more likely to foresee a downward trend in profitability for the year ahead than a positive one (36% negative vs. 22% positive). That means it‘«÷s even more hazardous to have billing processes that they‘«÷re not confident in‘«Ųthey need every dollar they can get on the bottom line.

Add all of this together, and it becomes more clear than ever that now is the time for medical practices to change their approach to billing and entrust it to trained professionals who have the technology, processes and experience to handle the current requirements and challenges that lie ahead.

Medical billing is an exceptionally complicated and convoluted process, and only becoming more so. Why would you want less than expert help to manage the lifeblood of your practice?

Find out today how you can have full confidence in your billing processes and bring more to your bottom line. Contact at 800-966-9270 for a complimentary review of your billing.

“Medical Billing made all the difference for my practice. They eliminated all the frustrations associated with insurance reimbursements and increased my revenues by 100%.” ?Š–Janice

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Review these articles from a variety of sources to insure your coding is up to date on E/M, LCD, and other techniques.

Wolves at the Door: E/M Coding Now

Barbara Aubry, a regulatory analyst for 3M Health Information Systems, reports that in the last few weeks, she has read some startling news:

1. The University of Illinois Hospital and Health Sciences System and Mount Sinai Hospital in Chicago owe CMS $145 million in disproportionate share Medicaid overpayments “because they had overcharged poor patients,” according to a FierceHealthFinance news report Feb. 27. What’s even more startling is the alleged overcharges took place 13 years ago.

2. Another stunning article reported Feb. 14 by HealthLeaders Media discussed the case of a respected surgeon who was found guilty of fraudulent coding on claims submitted between August 2002 and October 2003. The doctor was “acquitted of two counts of Medicare fraud but convicted of two counts of making false statements in connection with surgical (CPT) codes submitted” on old claims. He is now serving a 10-month prison sentence.

The Association of American Physicians and Surgeons (AAPS) warns, according to the article, “physicians will now need to practice ‘defensive documentation,’ taking more time away from patient care in order to double and triple check operative notes.” Barbara prefers to call it clinical documentation improvement (CDI), but agrees with the AAPS: Documentation is more important than ever. Read More


Modifier Minute: Modifier 32

Modifier 32?ŠMandated services?Šapplies when a third party, such as an insurer or government agency, specifically requests/requires a service on a patient‘«÷s behalf. For instance‘«™ Read More


Follow New CMS Guidelines ?Što Keep Record Amendments Updated

No practice ‘«Ű or physician ‘«Ű is immune to documentation that needs to be updated; maybe the physician left out an important piece of information, such as the amount of time spent counseling the patient, or the patient‘«÷s diagnosis. When records need to be amended, advises The Coding Institute, be sure your practice follows the latest CMS rules, which were revised on Dec. 7, 2012, in Transmittal 442.

When adding, correcting, or entering information after the date of service, you should identify it as an amendment, and the physician should sign and date it. Never delete the original entry‘«Ųinstead, ensure that all original content is identifiable. You can do this on a paper record by using a single strike line through the original content. For electronic records, you must ‘«£provide a reliable means to clearly identify the original content, the modified content, and the date of authorship of each modification of the record,‘«ō CMS says in the transmittal.

If an auditor ever reviews your files, CMS directs them to consider your amended entries‘«Ųbut only if you follow the rules. Auditors ‘«£shall not consider undated or unsigned entries handwritten in the margin of the document,‘«ō for instance, the Transmittal advises.

CMS advises MACs and auditors that see potential fraud in the documentation to refer those cases to the ZPIC auditors. To read the complete transmittal, visit


CMS corrects edit 84, deletes modifiers reports in an April 30 article that 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‘«™ Read More


Denials Management: With MUE Claim Denials, Appeal, and Appeal Again
If you receive a claim denial due to MUEs, you can appeal, according to a recent article by The Coding Institute.

You should follow three steps during the appeals process:

Step 1: Determine the reason for the denial. First, figure out if you made a coding or billing error. If you find a coding error

‘«Ų?Š?Š?Š such as the wrong number of units entered in the units box

‘«Ų?Š submit a corrected claim. If you don‘«÷t find a coding or billing error, move on to the next step.

Step 2: Decide if you have a legitimate reason to appeal. If you believe there is medical necessity for the services over and above the allowable under the MUE, you should appeal to the contractor. ‘«£If there is no medical necessity, take a look

again at coding,‘«ō Harrington says. ‘«£Make sure service is coded properly, and appropriate modifiers have been assigned.‘«ō

Step 3: Appeal the claim. File an initial appeal with your carrier and follow the standard five-level Medicare appeals process. ‘«£If appealing the claim due to a clinical reason, you may wish to employ clinical expertise when putting together your appeal letter,‘«ō Harrington suggests.


Healthcare News: CMS Adds Codes to Conditionally Bilateral List

Also from CMS added seven CPT codes to the conditionally bilateral list as part of the April update to the Integrated Outpatient Code Editor. When a provider performs a conditionally bilateral service bilaterally, coders must append modifier -50 (bilateral procedure) to the code. Read More


Local Coverage Determinations Provide the Missing Link to Complement Coding Guidelines

The missing link to correct coding, according to an article in, is coder knowledge and practical application of Local Coverage Determinations (LCDs). LCDs are integral to complete documentation governing accurate ICD-9 diagnoses coding. LCDs in essence complement official coding guidelines and Coding Clinic advice. Few coding staff actually know and apply?Šofficial LCDs in their region to complement official coding guidelines and policies. Read More


Observation Services: Many Shades of Gray

This recent article in For the Record states that unique challenges give hospitals and physicians little room for error when it comes to correctly documenting these encounters. According to Betsy Nicoletti, MS, CPC, coauthor of, one complicating factor is that while a hospital ultimately determines the category of a patient‘«÷s admission status, the rules are clear that a patient‘«÷s observation stay begins and ends with a physician‘«÷s order‘«™ Read More

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Coding for Pediatric Chronic Lung Disease
Update your knowledge of chronic lung disease and how to code it in this article from For the Record. Read More

Cardiology Coding: +92973 Coding Is Limited to Mechanical Thrombectomy

The Coding Institute reports in The Cardiac Coding Alert that the aspiration thrombectomy question has finally received an answer with the 2013 addition of the term ‘«£mechanical‘«ō to thrombectomy code +92973:

2012: +92973, Percutaneous transluminal coronary thrombectomy

2013: +92973, Percutaneous transluminal coronary thrombectomy mechanical.

There has been a lot of confusion in the past about whether coders could use +92973 for more than mechanical thrombectomy, specifically whether the code applied tor aspiration thrombectomy, according to Julie Graham, BA, CPC, cardiology coder and compliance specialist for Concentra.

By specifying ‘«£mechanical,‘«ō the code definition change resolves that confusion, says Graham. Be sure to check the guidelines, too, she adds. The 2013 guidelines state, ‘«£Non-mechanical, aspiration thrombectomy is not reported with 92973, and is included in the PCI code for acute myocardial infarction (92941), when performed.‘«ō

The language change aligns with an article in CPT?ę Assistant (March 2002) from the year when the code was created. CPT?ę Assistant stated that +92973 was added to describe a catheter-based angiojet ‘«£procedure using a unique method of fragmenting and removing clots from the coronary artery‘«ō lumen. A vignette in the article describes?Š a reportable thrombectomy that includes advancing the thrombectomy catheter distal to the lesion, activating the catheter using a foot pedal, and then manually withdrawing the catheter to remove the thrombus (repeating as needed).


Gastroenterology Coding: Don‘«÷t Automatically Use 44705 For Fecal Bacteriotherapy
In the Gastroenterology Coding Alert, The Coding Institute advises that if your gastroenterologist performs fecal bacteriotherapy as a treatment for Clostridium difficile infections, you shouldn‘«÷t forget to look at payer policies before you report the assessment and preparation of the fecal microbiota sample with the newly introduced CPT?ęcode 44705. For fecal bacteriotherapy services reporting, turn to two codes: one for the preparation and assessment of the fecal microbiota sample and the other for the instillation in the patient‘«÷s gut.

Use code 44705 (Preparation of fecal microbiota for instillation, including assessment of donor specimen) to cover your gastroenterologist‘«÷s work developing the microbiota sample that will be instilled in the patient‘«÷s digestive tract and for assessing the sample. To indicate the medical necessity for performing fecal bacteriotherapy, you will have to support documentation using the ICD-9 code 008.45 (Intestinal infection due to clostridium difficile).

In addition to reporting 44705, you‘«÷ll report an additional code, depending on the method your gastroenterologist uses to introduce the fecal sample in the patient‘«÷s digestive tract.

Coding for Ovarian Cancer
Get a good review of ovarian cancer in this article, which reviews key issues including coding functional activity. Read More

Internal Medicine and OB/GYN Coding: Bone Density or DEXA Scan Coding: Tips to Help You Out

The restrictions Medicare sets for bone density tests can keep even the most conscientious coders guessing about whether they‘«÷ve met the medical necessity and frequency guidelines. The Coding Institute‘«÷s experts offer real-world advice that will keep you on track and strengthen your chances of success in a recent article:

Tip 1: Gather the Supporting Documentation

Documentation for the bone scan must include an order from a physician or qualified non-physician practitioner who is treating the beneficiary and an interpretation of the test results (Medicare Benefit Policy Manual, Chapter 15, Section 80.5.4). Signing the machine printout doesn‘«÷t count as an interpretation.

The physician also needs to document a complete diagnosis. Medicare doesn‘«÷t offer a national list of covered ICD-9 codes, but it does state that an individual qualifies for coverage when she meets one of five conditions (Medicare Benefit Policy Manual, Chapter 15, Section 80.5.6).

Check your payer‘«÷s local coverage determination (LCD) for the specific ICD-9 codes it says support medical necessity. For example, Aetna lists several diagnoses that may prove medical necessity, such as 627.2 (Symptomatic menopausal or female climacteric states) and 733.90 (Disorder of bone and cartilage, unspecified).

Tip 2: Go With Documented Diagnosis
Only report the documented diagnosis ‘«Ų never choose a diagnosis simply because you know you‘«÷ll get paid for it.

Tip 3: Get the Frequencies Straight
Medicare will pay for bone mass measurements on qualified individuals every two years, but does offer exceptions. (Medicare Benefit Policy Manual, Chapter 15, Section 80.5.5).

Coding for Cognitive Disorders
For the Record offers a good overview of coding for cognitive disorders, from attention-deficit disorder to traumatic head injury. Read More

Neurology Coding: Earn Payment for Psychotherapy Services with Add-On Codes
While managing a chronic debilitating illness like multiple sclerosis, your physician may engage with the patient and/or family to help improve quality of life for the patient. When psychotherapy is part of the treatment that your neurologist provides, a recent article from The Coding Institute advises that you don‘«÷t ignore that component when it‘«÷s time to code. Here‘«÷s their expert advice on how to submit the right codes for situations when your neurologist may provide psychotherapy ‘«Ű and get the pay you deserve.

Determine Duration of Psychotherapy
Your first step to success is to determine the psychotherapy treatment‘«÷s duration. Choose between three codes, depending on how long the session lasted: ?Š90832 ‘«Ű 30 minutes; 90834 ‘«Ű 45 minutes; 90837 ‘«Ű 60 minutes. Be careful, the article notes, as each code now has a specific amount of time.

Look for E/M Services
Check the clinical note to verify whether the psychotherapy was done in conjunction with an evaluation and management (E/M) service. If so, you need to again confirm the duration of the psychotherapy before assigning a code: +90833 ‘«Ű 30 minutes; +90836 ‘«Ű 45 minutes; +90838 ‘«Ű 60 minutes. ?Š(Each should be listed separately in addition to the code for primary procedure.)

Note that all options are add-on codes. Report the appropriate one with the applicable E/M code, such as 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ‘«™) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ‘«™).

Confirm the Family Involvement
Your neurologist might schedule a psychotherapy session to discuss how family interactions can benefit the patient and how the care provided can affect the patient‘«÷s course of illness. The patient may or may not be present for the session, which guides your coding.

Depending upon whether the patient was present, you‘«÷ll report 90846 (Family psychotherapy [without the patient present]) or 90847 (Family psychotherapy [conjoint psychotherapy] [with patient present]). ‘«£It is important it remember that the family psychotherapy codes are not based on the amount of time but rather whether the patient was present or not,‘«ō says Hammer. ‘«£The family psychotherapy codes should be reported only once for the patient, not for each of the family members in attendance.‘«ō

Ophthalmology Coding: Show Blepharoplasty Procedures Aren‘«÷t Always Cosmetic
Many ophthalmologists are not claiming legitimate reimbursement for medically necessary blepharoplasty, advises a recent article from The Coding Institute. Most insurers, the article says, including Medicare carriers, are predisposed to denying payment, and to assuming the procedure is cosmetic. However, they offer expert advice for successful claims such as:

Blepharoplasty Procedures Are Not Always Cosmetic

Whether or not a blepharoplasty procedure is cosmetic depends on the procedure and the patient‘«÷s main complaint. Procedures to remove excess skin and fat from the eyelids are frequently done due to medical necessity ‘«Ų but to support medical necessity and convince Medicare, you need to submit the correct codes and airtight documentation.

For blepharoplasty procedures, look to CPT?ę codes 15820-15823 (Blepharoplasty‘«™). Insurers cover blepharoplasty procedures 15822 (Blepharoplasty, upper eyelid) or 15823 (‘«™ with excessive skin weighting down lid) when the patient suffers from decreased vision or other specific medical problems.

But remember that CPT?ę codes 15820 (Blepharoplasty, lower eyelid) and 15821 (‘«™ with extensive herniated fat pad) are almost never covered. Insurers believe that excessive skin or fat in the lower eyelids do not usually obscure vision.

Keep Everything Documented
Keep this documentation in your blepharoplasty patient‘«÷s file:
– history and physical which documents the patient‘«÷s complaint extensively to support problems with performing activities of daily living (e.g., driving, reading, chronic eye irritation, etc.)
– operative report
– visual fields (taped and untaped)
– photographs (taped and untaped).

The visual field (VF) tests (92081-92083, Visual field examination, unilateral?Š or bilateral, with interpretation and report …) show the extent of the patient‘«÷s decreased vision. Most carriers want two sets of visual fields ‘«Ų one with the upper eyelid at rest and one with the eyelid taped up to demonstrate an expected improvement. Be sure to document both sets of results with the physician‘«÷s interpretation and report. Many LCDs state that the visual fields ‘«£must demonstrate a minimum 12 degrees or 30 percent loss of upper field of vision.‘«ō

Orthopedic Coding: Refine Your Post-Op Infection Coding with These 3 Examples
You could be sabotaging your claims for post-op infections if you aren’t well-versed on individual payers’ global policies and unsure of what modifiers to append, according to a recent article from The Coding Institute. Here are three common scenarios the article offers to facilitate better reporting of postsurgical infection billing:

Coding example 1: Several days following an open repair of distal fibular fracture, 27792 (Open treatment of distal fibular fracture [lateral malleolus], includes internal fixation, when performed), the patient develops a stitch abscess with drainage at the site of the incision. The patient schedules an unplanned visit to the office of the orthopedic surgeon. The surgeon prescribes antibiotics and a follow-up.

For a private payer that follows the AMA CPT?ę guidelines for post-operative complications, you would report an E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient …) appended with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period), if the payer requires you to do so. The modifier is usually needed because any service in the global is automatically denied within payer software systems.

Tip: Use the abscess as the diagnosis, not the reason for the open repair. You report this with code 998.59 (Other postoperative infection). The abscess diagnosis shows the ‘«£unrelated‘«ō reason for the E/M service. The modifier indicates that the payer does not include the service in the initial surgery‘«÷s global fee. Had the patient been covered by Medicare, however, the office visit counts as a part of the global package, and you cannot file an additional claim.

Coding example 2: A week following surgery, the surgeon readmits the patient to the hospital for IV antibiotics but does not take the patient back to the operating room. Once again, in this case, you may not report a separate service to Medicare, even though the orthopedist readmitted the patient. CMS guidelines specify that when the physician readmits the patient within the original surgery‘«÷s global period for complications of the original surgery, you cannot charge evaluation and management services for the readmission or for other E&M services if another physician admits the patient.

But for payers not following CMS guidelines, and follow the AMA CPT?ę guidelines, you may be able to report an appropriate admission code (for example, 99221, Initial hospital care, per day, for the evaluation and management of a patient …) with modifier 24 appended.

Coding example 3: The patient from example 1, who developed a stitch abscess, goes on to require an incision and drainage in the OR, for example, 10180 (Incision and drainage, complex, postoperative wound infection).

In this case, you should report 10180-78 for both Medicare and private payers. Don‘«÷t forget the diagnosis to consider is 998.59, to any CPT?ę codes you report.

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