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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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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”?ť?ō 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.

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