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.
Cardiology: 93010 Is Sometimes the Right Choice on Cardiac ?ť?ŠCath ?ť?ŠDay
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 www.cms.gov/Medicare/ 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 www.cms.gov/ 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
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 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
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.”
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
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
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.