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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 ??Cath ??Day

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. ??Medicare 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.”? For proper coding, you should know that a “lead”? and an “electrode”? 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”? in the 93010 code definition is also important because it means the code is appropriate for 12 or more leads. ??Consequently, 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? 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?Bundling 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? manual or CMS manual coding instructions.”?

Six immunization administration codes are part of the reversed edits:

– ??90460 –?Immunization 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

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

– ??90471 –?Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

– ??+90472?1–??…each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

– ??90473 –??Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)

– ??+90474 –??…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,”? 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”? 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,’? ‘suspected,’ ‘questionable,’ ‘rule out,’? or ‘working diagnosis,’? 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.”? 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?ll 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 ?codes 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.”?

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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Some excellent articles on protecting and improving your practice profitability have been published recently; heres a selection of some we thought would be useful to you.

The Top 3 Reasons Your Claims Get Denied
There are plenty of reasons an insurer might deny your claims, but the most common billing errors are also the simplest and easiest to correct. Here are the top 3Ǫ Read More

Protect Your Practice from Reimbursement Rates and Abusive Payment Tactics
Financial challenges are the top concern in practices today. One of these challenges lies in the obligations defined through physician contracts. If you are one of those practices hard pressed to find a file drawer with all of the original agreements, addenda, and rates associated with reimbursement, you may end up with rates that do not even cover the cost of bringing patients through the doorǪ Read More

Keep Your Patients Safe from Banned Healthcare Workers
The U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) wants to be sure you dont employ excluded individuals to care for government-insurance patients. They are cracking downǪ Read More

Dont Overlook an Opportunity for Loss
Every practice has its opportunity for loss.?Keeping track of your money is a big job, and who is going to make sure its handled honestly? You can hope for employees with the highest integrity and for those who would do anything to make sure your office is as successful financially as it can be.

Still, theft happensǪ Read More

Fighting For Provider Revenue
In this insightful article, author Ken Congdon discusses the fact that healthcare reform, reimbursement cuts, sequestration, and RAC and Meaningful Use audits are new financial challenges cutting into provider revenue. He looks at ways to cope, advising physicians that:

1. Lean management is essential to reshaping financial processes
2. Focus on perfecting front end collection

He writes that ǣOf all the financial pressures currently facing healthcare providers, it seems like the biggest concern among many is effectively addressing the expected rise in patient financial responsibility.

Read the full article now at

Stop Losing Revenue From 5 Common ASC Billing Mistakes
Here are five common mistakes made in ambulatory surgery centers (many applicable to other specialties as well) that result in increased denials and decreased revenue:

1. Mismatching fee/service invoices.
2. How to bill hardware or implant removals.
3. Not knowing coding changes, such as for excision of skin and soft tissue lesions.
4. Not filing claims on time.
5. “Defaulting” to 100 percent in-network participation.

Read the full article at

CMS: Clearinghouses Can Provide Limited ICD-10 Assistance
CMS released information to clarify the role of clearinghouses in assisting the transition to ICD-10, saying that clearinghouses should not be expected to provide the same level of support for ICD-10 as they did for the HIPAA Version 5010 upgradeǪ Read More

4 Reasons ICD-10 is Important to Healthcare
As the burden of the ICD-10 transition wears on, CMS reminds providers of the new code set’s importance to medicine, offering four reasons why ICD-10 matters:

1. It advances healthcare and eHealth initiatives. ICD-10, along with other federal programs, aims to provide greater interoperability, data sharing, quality measurements and clinical outcomes.
2. It captures medical advances.
3. It improves data for quality reporting. The more detailed code set naturally provides better data to measure outcomes and quality.
4. It improves public health research, reporting and surveillance.


5 Tips to Negotiate More Beneficial ASC Payor Contracts for Ophthalmology
Stephen Rothenberg, JD, a consultant with Numerof & Associates, Inc., discusses how ambulatory surgery center leaders can negotiate more beneficial payor contracts for ophthalmology procedures and the outlook for eye surgery as a specialty in the futureǪ Read More

Is Your A/R Costing You More Than You Realize?
As more employers adopt insurance plans with higher deductibles as a way to better manage and save on employee healthcare cost patients seeking surgical procedures are facing higher out-of-pocket costs, including increased co-pays and deductibles. Although billing patients and maintaining accounts receivable has been a widely used and accepted method of helping patients manage fees, it can cost your ambulatory surgical center more than you may realizeǪ Read More

4 Tips for Finding Overlooked Revenue Sources in Healthcare
At the Becker’s Hospital Review Annual Meeting in Chicago May 10, Vince Pryor, CFO of Edward Hospital in Naperville, Ill., and Bruce Shapiro, senior vice president of operations at The CCS Companies, parent company of CCS Revenue Cycle Management, discussed commonly overlooked revenue sources.

“I don’t think you can go into a revenue cycle and not find at least 1 or 2 percent,” Mr. Pryor said. “There’s always something you can work on.” Read More

37 Statistics on What Providers Think About Bundled Payments
The majority of physicians and hospitals say bundled payments have the most potential to improve healthcare affordability rather than patient-centered medical homes or accountable care organizations, according to survey results from Booz & Company. ?Read More

6 Biggest Reasons Provider Business Strategy Will Fail
Scott Regan, Founder and CEO of AchieveIT, gave a presentation at the Becker’s Hospital Review Annual Meeting in Chicago on May 10, 2013, titled “The 6 Biggest Reasons Your Strategy Will Fail.” Review those reasons nowǪ Read More

Are Your Vendors Violating HIPAA? Why Internal HIPAA Compliance May Not Be Enough
We have recently assisted several healthcare provider clients that have discovered that their business associates had allowed protected health information of the provider’s patients to be improperly disclosed in violation of the Health Insurance Portability and Accountability Act of 1996. Specifically, the providers entrusted their patients’ PHI to a business associate, and the business associate did not appropriately protect itǪ Read More

Get Your 10 Electronic Prescriptions (eRx) Done Before June 30th to Avoid a 2% Cut in Medicare Payments in 2014
The deadline is fast approaching for both individual eligible professionals (EPs) and group practices participating in the Group Practice Reporting Option (GPRO) to complete their required number of electronic prescriptions. If you are an EP or an eRx GPRO participant, you must successfully report as an electronic prescriber before June 30, 2013 or you will experience a payment adjustment in 2014 for professional services covered under Medicare Part Bs Physician Fee Schedule (PFS.) Read More

Credit Card on File in Action: Changes for Patients and Employees
At Manage My Practice, we are big proponents of the credit card on file system as a road to financial viability. This program changes your patient collections from a back-end collection program to a front-end collection program, effectively collecting 95% of the patient responsibility within 45 days of the service. 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 ǣmechanical 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 ǣmechanical, the code definition change resolves that confusion, says Graham. Be sure to check the guidelines, too, she adds. The 2013 guidelines state, ǣNon-mechanical, aspiration thrombectomy is not reported with 92973, and is included in the PCI code for acute myocardial infarction (92941), when performed.

The language change aligns with an article in CPT? Assistant (March 2002) from the year when the code was created. CPT? Assistant stated that +92973 was added to describe a catheter-based angiojet ǣprocedure using a unique method of fragmenting and removing clots from the coronary artery lumen. A vignette in the article describes? 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: Dont 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 shouldnt forget to look at payer policies before you report the assessment and preparation of the fecal microbiota sample with the newly introduced CPT?code 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 patients gut.

Use code 44705 (Preparation of fecal microbiota for instillation, including assessment of donor specimen) to cover your gastroenterologists work developing the microbiota sample that will be instilled in the patients 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, youll report an additional code, depending on the method your gastroenterologist uses to introduce the fecal sample in the patients 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 theyve met the medical necessity and frequency guidelines. The Coding Institutes 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 doesnt count as an interpretation.

The physician also needs to document a complete diagnosis. Medicare doesnt 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 payers 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 never choose a diagnosis simply because you know youll 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 dont ignore that component when its time to code. Heres their expert advice on how to submit the right codes for situations when your neurologist may provide psychotherapy and get the pay you deserve.

Determine Duration of Psychotherapy
Your first step to success is to determine the psychotherapy treatments duration. Choose between three codes, depending on how long the session lasted: ?90832 30 minutes; 90834 45 minutes; 90837 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 30 minutes; +90836 45 minutes; +90838 60 minutes. ?(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 Ǫ) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient Ǫ).

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 patients 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, youll report 90846 (Family psychotherapy [without the patient present]) or 90847 (Family psychotherapy [conjoint psychotherapy] [with patient present]). ǣIt 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, says Hammer. ǣThe family psychotherapy codes should be reported only once for the patient, not for each of the family members in attendance.

Ophthalmology Coding: Show Blepharoplasty Procedures Arent 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 patients main complaint. Procedures to remove excess skin and fat from the eyelids are frequently done due to medical necessity but to support medical necessity and convince Medicare, you need to submit the correct codes and airtight documentation.

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

But remember that CPT? codes 15820 (Blepharoplasty, lower eyelid) and 15821 (Ǫ 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 patients file:
– history and physical which documents the patients 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? or bilateral, with interpretation and report …) show the extent of the patients decreased vision. Most carriers want two sets of visual fields 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 physicians interpretation and report. Many LCDs state that the visual fields ǣmust demonstrate a minimum 12 degrees or 30 percent loss of upper field of vision.

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? 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 ǣunrelated reason for the E/M service. The modifier indicates that the payer does not include the service in the initial surgerys 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 surgerys 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? 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. Dont forget the diagnosis to consider is 998.59, to any CPT? codes you report.

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Weve gathered an assortment of coding and billing tips from expert sources in a variety of specialties to help insure youre receiving the maximum reimbursement available.

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2013 New and Revised CPT Codes: Here Are the Changes Most Likely to Affect the Most Practices

Texas Medical Association

Here are some of the changes noted by the Texas Medical Association:

– Getting paid for time-based codes now requires passing the midpoint of the time specified in the code. For example, for a code that requires one hour, 31 minutes must be met to bill the time-based code, and it must be documented.

– Multiple new laboratory and pathology (81400-81408 and 81500-81599) codes have been added and coding descriptions for Tier II procedures revised.?Check the patients benefits and carrier medical policies for coverage, as some of the new codes are for screening a patient for the potential of developing specific conditions.

– Nerve conduction codes (95905-95913):?Several codes have been deleted and new codes added.

These are only portion of the changes for 2013.?Be sure to review the CPT 2013 guidelines for the above sections carefully and the sections with codes you use most often.? In addition, check with carriers for coverage requirements of the new codes and the patients benefits.



Avoid Surgery Center Claim Denials: 5 Expert Tips

Beckers ASC Review

Here are five tips from ambulatory surgery center experts on optimizing billing operations and reducing claim denials from commercial payors, including:

1. Look out for bundled codes
2. Make sure no information is missing
3. Do not misuse modifiers.
4. Check for problem with the payor’s system
5. Work with coding professionals.

Read More



Check CCI Bundling for Motility Studies and Capsule ?Endoscopy; Catch Pairing with Anesthesia and Injection Services

The Coding Institute

When your gastroenterologist performs a gastrointestinal transit and pressure measurement (91112, Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report) using a wireless capsule, you cannot report any other motility studies or a capsule endoscopy procedure that is performed concurrently. The latest round of Correct Coding Initiative edits (19.0) include a host of codes that you cannot report when you are reporting 91112:

– 91020 Gastric motility [manometric] studies
– 91022 Duodenal motility [manometric] study
– 91111 Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus with interpretation and report
– 91117 Colon motility [manometric] study, minimum 6 hours continuous recording [including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed], with interpretation and report

Avoid Reporting Therapeutic or Diagnostic Injections with 91112
The Coding Institute also advises that when your gastroenterologist performs gastrointestinal transit and pressure measurement, you cannot report any injection procedures that are performed in the same session, according to CCI edits 19.0, and provides a list of the codes you cannot report along with 91112 when these procedures are performed in the same session.



37211-37214 Focus on Initial, Subsequent, and Final Day for Non-Coronary Thrombolysis Coding

The Coding Institute

Thrombolysis coders trained to find 75898 reporting opportunities will need to develop new habits for 2013. As part of the non-coronary thrombolysis code update, related services all fall under 37211-37214. Here are the details:
2013: Base Code Choice on Vessel and Day
CPT? 2013 deletes 37201 and 37209, and replaces them with new options that include S&I. Because the new infusion codes include S&I, 75900 has been deleted for 2013. Codes 75896 and 75898 have not been deleted, but they have been revised to specify they apply to transcatheter therapy infusion ǣother than for thrombolysis, says Julie Graham, BA, CPC, cardiology coder and compliance specialist for Concentra in Texas.

Youll also notice that the new codes apply to an entire day of treatment. Use a ǣmidnight to midnight time period, stated Sean P. Roddy, MD, FACS, of the Society for Vascular Surgery and member of the AMA CPT? Advisory Committee, in the ǣVascular Surgery and Interventional Radiology presentation at the AMAs CPT? and RBRVS 2013 Annual Symposium.



2013?Brought New CCI Bundles, Many Targeting New CPT? Codes

The Coding Institute

Among their advice on the 2013 coding changes, The Coding Institute advises that OB/GYN coders pay attention to the modifier indicator to determine which ones you can override and which you cant.

CCI 19.0, which took effect on January 1, 2013, added 37,587 new bundles and deletes 16, 716. Not surprisingly, many of the new CCI edits target new 2013 CPT? codes, and OB/GYN wasnt spared any changes. Among those you should watch for:

Add These Column 2 Codes to 52287

You will find new Botox bladder injection CPT? code 52287 (Cystourethroscopy with injection[s] for chemodenervation of the bladder) has a variety of new codes that you should consider included in this service. These column 2 codes include:

– Anesthesia 00910 and 00916
– Category III codes 0213T, 0216T, 0228T, and 0230T
– Wound closure codes 12001-12057, 13100-13153
– Intravenous codes 36000, 36405-36406, 36410, 36420-36430, 36440, 36600, 36640
– Transcatheter therapy code 37202
– Gastic tube placement code 43752
– Catheterization codes 51701-51703
– Cystoscopic codes 52000, 52001, 52310, 52315
– Urethrotomy and meatotomy codes 53000-53025
– Urethral dilation codes 53600-53665,
– Pelvic exam under anesthesia code 57410.
– Injection codes 62310-62311, 62318-62319, 64400-64530
– Microsurgical technique code 69990
– Fluoroscopic codes 76000-76001, 77001-77002
– Echocardiography codes 93000-93010, 93040-93042, 93318
– Ventilation and oxygen codes 94002, 94200-94250, 94680-94770
– EEG codes 95812-95955
– Intravenous codes 96360-96365
– Therapeutic injection codes 96372-96376
– Moderate sedation codes 99148-99150
– Lidocaine HCL injection code J2001
– Catheterization for collection of specimen code P9612

Some of these noted edit pairs have a modifier indicator of ǣ0, which means you cannot separate these edits with a modifier. Others, like the wound closure codes, intravenous and venous codes, and 52001 (Cystourethroscopy and evacuation of multiple obstructing clots), have a modifier indicator of ǣ1. That means that you can use a modifier to override the bundling under specific clinical circumstances.



Immunization Coding Affected By Latest CCI Changes; Pay Special Attention to Influenza Vaccines

The Coding Institute

New restrictions to vaccine coding are the biggest area of interest to internal medicine physicians in the latest Correct Coding Initiative (CCI) edits. Here is the lowdown on CCI 19.0 and what you can and cant report together during the same encounter:
Watch Whether Vaccine Is Reported or Ignored

Physicians often administer multiple vaccinations during the same encounter, but that doesnt mean CCI edits allow you to bill for each immunization.

More than 30 mutually exclusive edits under CCI 19.0 involve pairs of immunization codes particularly those for influenza and hepatitis.

A closer look shows that many of the edits involve two influenza codes and do not permit a modifier to override the edit. This is because it would not be clinically appropriate to administer two different influenza vaccines to the same patient on the same date. If you inadvertently report two influenza vaccines for the same patient on the same date, which one will be paid will depend on the pair that you report. For example, new code 90672 (Influenza virus vaccine, quadrivalent, live, for intranasal use) will be paid instead of other influenza vaccine codes 90653 90668 if reported with any of them. Note also that several of the codes are pending FDA approval:

– 90653 Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use
– 90661 Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
– 90666 Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use
– 90667 Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use
– 90668 Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use.

Careful: Some of the same influenza vaccine codes that are a Column 2 code in one edit may be a Column 1 code in other situations. Codes 90654-90668, for example, will always be paid instead of 90653 if listed for the same patient on the same date of service.

Hepatitis look: Edits also clarify that some hepatitis vaccines should not be administered (and reported) on the same day as other hepatitis vaccines. For instance, based on the CCI edits, physicians should not administer hepatitis B vaccine 90739 (Hepatitis B vaccine, adult dosage [2 dose schedule], for intramuscular use) during the same encounter as the following hepatitis vaccines:

– 90636 Hepatitis A and hepatitis B vaccine (HepA- HepB), adult dosage, for intramuscular use
– 90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use
– 90740 Hepatitis B vaccine, dialysis or immuno- suppressed patient dosage (3 dose schedule), for intramuscular use
– 90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
– 90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
– 90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
– 90747 Hepatitis B vaccine, dialysis or immuno- suppressed patient dosage (4 dose schedule), for intramuscular use
– 90748 Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use.

ǣLike the influenza vaccine edits above, these edits make sense clinically. In each case, the Column 1 code already includes the Hepatitis B vaccine, and there is no clinical indication for administering two Hepatitis B vaccines to the same patient on the same date, states Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, Ks.



Guidance for Heel Spur Treatment Claims Success

The Coding Institute

If youre reporting heel spur excision as a lone procedure, you could be leaving money on the table. Your surgeon may be doing more than just an excision and not capturing those services means lost pay. Let the advice that follows guide you to accurate and complete claims. You report code 28119 (Ostectomy, calcaneus for spur, with or without plantar fascial release) if your surgeon excises a calcaneal spur. You report this code regardless of whether your surgeon makes release incisions on the stressed or irritated plantar fascia. You may read in the operative note to confirm any fasciotomy done by your surgeon.

If your surgeon removes a part of the calcaneus, you report code 28118 (Ostectomy, calcaneus).

Look for Casts and Devices
Check the procedure notes for details on any casts applied. Your surgeon may apply a walking cast at the time of the heel spur surgery. Keep in mind that the first cast applied at the time of surgery is a part of the global package; you may report subsequent casts, if any. For instance, for a short leg cast, you would report 29425 (Application of short leg cast [below knee to toes] walking or ambulatory type

Note: A change of cast in the global period requires you to confirm if there was a cause for the change. For example, your surgeon may decide to change the cast due to a pressure ulcer. In this case, you report 29425 for the cast and append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the cast application code. In addition, you also report the diagnosis code 707.06 (Pressure ulcer, ankle), 707.07 (Pressure ulcer, heel), or 707.09 (Pressure ulcer, other site) depending upon where the pressure ulcer is located. If your surgeon documentation does not support the location of the ulcer, you may report code 707.00 (Pressure ulcer, unspecified site).

Cast applied later? You may read that your surgeon did apply a cast but only after the surgical excision of the heel spur was completed. For example, your surgeon may choose to defer the cast application due to excessive swelling, although this is fairly rare.

In this case, youd append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to report the application of a cast in the physicians office during the postoperative period. You may bill separately for a cast put on in the office.



92225-92226 Coding: Get to Know These Guidelines for Extended Ophthalmoscopy

The Coding Institute

Many ophthalmology coders arent clear on when its appropriate to report 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) or 92226 (…subsequent). The procedure pays about $27 each time, so mistakes can add up. Read on to see if one of the following EO myths could be taking money out of your practices pockets.

EO Is Not Always Included in Eye Exam

Routine ophthalmoscopy is included in a comprehensive eye exam (92004 and 92014), but according to the National Correct Coding Initiative, extended ophthalmoscopy isnt. CPT codes 92225 and 92226 are not bundled into 92004 or 92014, as of the latest set of NCCI coding edits.

You might still see denials, however. Some carriers have a longtime edit in place not to pay for extended ophthalmoscopy when billed with 92014. If this is the case in your area, you will either need to bill the services and end up in the review and appeal process proving medical necessity.

Bilateral EO Requires Documentation
Despite what some coders may assume, carriers will not automatically pay twice the fee schedule amount for one eye if you report EO bilaterally.

Reality: Carriers will not pay double for bilateral EO unless you can justify medical necessity for performing EO on both eyes. If youve diagnosed a problem in one eye, dont assume the other eye has the same diagnosis although chances are it will. You must report ICD-9 codes showing medical necessity in each eye you performed EO on. The diagnoses dont have to be different for each eye, but they do have to demonstrate medical necessity for the EO.



Faced with ADHD Claim Denials? Focus on These Strategies for Improved Results

When you report a follow-up visit for ADD (Attention Deficit Disorder) or ADHD (Attention Deficit Hyperactivity Disorder), do you submit an office visit code or a pharmacological management code? ǣOffice visit is the correct answer and your ticket to avoiding denials and earning your deserved payment. Heres why:

Remember E/M Is an Essential Component

When the neurologist spends time discussing complaints with the patient and/or family and does a physical examination before prescribing medication for ADHD, report an E/M code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components Ǫ Typically, 10 minutes are spent face-to-face with the patient and/or family) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components Ǫ Typically, 40 minutes are spent face-to-face with the patient and/or family).

Tip: Carefully check the follow-up components. A neurologist will often do a medical examination prior to renewing a prescription. The patient may or may not be on psychotherapy in this case.

We hope you find the tips from these leading sources helpful. For additional help improving your medical billing and coding results, contact at 800-966-9270.

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2013 Medicare Physician Fee Schedule Final Rule Includes Additional 3 Percent Cut for Ophthalmology

James A. McNally, CPC, New Jersey Ophthalmology Assn.

The 2013 Final Rule on the Medicare Physician Fee Schedule was released with a number of significant changes. As a result, the American Academy of Ophthalmology (AAO) has provided a summary of key changes that will impact the practice of Ophthalmology:

  • 3 percent payment cut for Ophthalmology as a result of CMS’ implementation of cuts in reimbursement for eye codes when two or more diagnostic services are billed by the same physician on the same day for a patient.
  • Changes in work values for cataract and complex cataract surgery will also contribute to this 3% reduction.
  • Ophthalmologists face an additional 27 percent cut on January 1, 2013 unless Congress acts to derail the sustainable growth rate formula currently used to calculate Medicare physician pay. The final rule includes a conversion factor of $25.08, which reflects the SGR cut.

Read the entire article at


Avoid Coding Errors with Diabetic Retinopathy Coding

By The Coding Institute

Your practice could lose $1500 if you report 67210 or 67228 incorrectly. To navigate the DR maze, you first have to determine the kind of DR the patient has. Background–or nonproliferative–diabetic retinopathy (BDR or NPDR) is represented by ICD-9 code 362.01 (Background diabetic retinopathy).

Although BDR may never require treatment, in severe cases ophthalmologists use a focal laser (67210) to treat areas of edema resulting from leaking blood vessels. Using a grid pattern, the focal laser aims directly at the leaky sites to seal them off.

In most cases, the ophthalmologist is treating the edema, not the diabetes. Link 67210 to ICD-9 code 362.83 (Other retinal disorders; retinal edema) instead of 362.01.

Proliferative diabetic retinopathy (PDR) (362.02, Proliferative diabetic retinopathy) usually requires treatment. Instead of using the focal laser to seal off one site at a time, ophthalmologists use PRP (67228) to target the entire retinal area. Code 362.02 is the appropriate ICD-9 code for these cases.

Code Initial Treatment Bilaterally

Although BDR and PDR occur often in both eyes, the treatments for these conditions are inherently unilateral. If the ophthalmologist treats only one eye, report the laser code only once. But when the ophthalmologist treats both eyes during one session, report the laser code twice, either on one line (67210-50) or two lines (67210-RT, 67210-50-LT), for example, depending on the payer’s preference.

Medicare has assigned both 67210 and 67228 a bilateral status of “1” meaning that if you report them bilaterally, carriers will reimburse 150 percent of the fee schedule amount for a single code (or your total actual charge for both sides, if it’s lower).

For example, in 2012, payment for a bilateral PRP performed in an office setting would be 150 percent of Medicare’s fee schedule amount for a single 67228 ($1041.89), leading to approximately $1500 in reimbursement.

Avoid Reporting Repeat Sessions

Subsequent treatments of 67210 or 67228 on the same eye within the 90-day global surgical period are not separately billable, due to the “one or more sessions”?? verbiage in the code description.

Append Modifier 79 for Treatment in Different Eye

When a subsequent treatment within the postoperative period is in a different eye, you should code and bill this service with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period).

Important note: As is the case with modifier 79, the eye modifiers (LT and RT) are crucial. If modifier LT had not been used for the first procedure and modifiers 79 and RT used for the second procedure, the second procedure would look like an additional treatment on the same eye to Medicare and would be denied.

Posted on September 14, 2012 by · Leave a Comment
Filed under: Ophthalmology  

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Epilation, as you all know, is the removal of ingrown eyelashes. As such, most coders are unable to distinguish between the epilation per eye lid and epliation per eye. Let me tell you folks, you need to be very careful when performing the ophthalmology coding process for the same. For epilation per eye, you can use two important codes. The first one is 67820, which reports the correction of trichiasis and eipation. The mode of procedure is done through the forceps only. You can use the code 67825 to report the correction of trichiasis, but this time using components other than forceps. Cryotherapy, laser surgery and electrosurgery are some of the common examples of the latter process. In the absence of any national Medicare policy, most Medicare carriers recommend coders to code per lid. This trend is also accepted by the HCFA officials. It is strongly recommended to use the eyelid modifiers in order to maximize the reimbursement from Medicare carriers.

Ophthalmology coding: differentiating between Medicare and non-Medicare carriers

Lets take an example to understand the epilation coding for private carriers. Imagine that two eyelashes were epilated by the ophthalmologists. One of them was performed in the lower left lid. At the same time, three were performed in the upper left lid and six in the upper right lid using the forceps. In this case, you need to append the code 67820-LT on the first line. On the second line, code 67820-51-RT should be appended. Since they are the same, it doesnt matter where you append the modifier -51. This modifier reports the multiple procedures during the session. During the ophthalmology coding process, we normally use the first line to list the highest paying procedure. In any case, you will get half fee for the second procedure and full fee for the first. Industry experts also agree that this is the best way to handle ophthalmology coding routines for epilation procedures and associated payments. Coming back to the ophthalmology coding procedures for Medicare carriers, the same scenario is coded in different way. The code 67520-E2 is used for the lower left eyelid and 67820-E1-51 for upper left eye lid. You can use the code 67820-E3-51 for upper right lid during the ophthalmology coding routines.

Hope the above article was interesting to read and contained useful information. Good day folks!

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