Coding Strategy

Double check POS 11 shouldn’t be 22 — or 24.

Entering your place-of-service (POS) number on your claim form may seem routine, but a recent OIG audit found that practices are not giving POS numbers the care they deserve.

Based on a review of 100 non-facility Part B claims from 2007, the OIG found that only 10 of the sampled claims had the correct POS code assigned to it, resulting in overpayments of over $4,700. Based on the sample, the OIG estimated that Medicare nationally overpaid physicians $13.8 million in POS coding errors, according to the report.

Physicians collect higher payments for services rendered in the physician’s office, a patient’s home, an ASC, a nursing facility, or another non-hospital facility versus those services performed in a facility setting (such as a hospital). The OIG review of 100 sample claims found that 90 of the services were coded as having been performed in a non-facility location, even though “60 were actually performed in hospital outpatient departments and 30 were ASC-approved procedures performed in ASCs,” the report notes.

As a result of the audit findings, CMS indicated that it would institute safeguards to ensure that POS errors are better identified. Therefore, practices should remember to focus just as clearly on POS coding as they do on procedure and diagnosis coding to avoid scrutiny and accusations of miscoding.

Written by Torrey Kim, MA, CPC, editor for Part B Insider: Keeps you up to date, compliant.

CMS announcement is triumph for physicians who haven’t collected in the past.

If you’ve been writing off tobacco cessation counseling as non-payable, it’s time to change your tune.

In the past, CMS only covered 99406-99407 (Smoking and tobacco use cessation counseling visit…) for a beneficiary with a tobacco-related disease or with signs or symptoms of one. But on Aug. 25, CMS announced that “under new coverage, any smoker covered by Medicare will be able to receive tobacco cessation counseling from a qualified physician or other Medicare-recognized practitioner who can work with them to help them stop using tobacco.”

“For too long, many tobacco users with Medicare coverage were denied access to evidence-based tobacco cessation counseling,” said Kathleen Sebelius, HHS secretary, in an Aug. 25 statement. “Most Medicare beneficiaries want to quit their tobacco use. Now, older adults and other Medicare beneficiaries can get the help they need to successfully overcome tobacco dependence.”

The new tobacco cessation counseling coverage expansion will apply to services under Medicare Part B and Part A. “The new benefit will cover two individual tobacco cessation counseling attempts per year,” CMS indicated in an Aug. 25 news release. “Each attempt may include up to four sessions, with a total annual benefit thus covering up to eight sessions per Medicare patient who uses tobacco.”

“We know that older adults and other Medicare beneficiaries can be successful in their struggles to stop using tobacco, as long as they have the right resources available to them,” said HHS’s Howard Koh, MD, MPH in an Aug. 25 statement. “Today’s decision will assure that beneficiaries can access that help from qualified physicians and other Medicare-recognized practitioners.”

To stay up to date on Medicare coverage issues, subscribe to Part B Insider, written by Torrey Kim, MA, CPC.

Improperly coding IOL Masters or A-scans can cost your practice $30 per patient.

Calculating intraocular lens power for patients facing cataract surgery has gotten more precise as A-scan and IOL Master technology has advanced. But to make sure your practice is getting fairly reimbursed each time, you need to understand the bilateral rules for 76519 and 92136.

Could one of these myths be damaging your claims?

Include Bilateral and Unilateral Components in Global Code

Myth: If the ophthalmologist calculates IOL power in both eyes, you should report 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) or 92136 (Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation) twice (e.g., 76519-RT and 76519-LT, or 76519-50).

Reality: You should not report 76519 or 92136 with modifier 50 even if the ophthalmologist calculated the IOL power of both eyes, warns Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director, Best Practices-Network Operations at Mount Sinai Hospital in New York City. To understand why, it’s helpful to know how Medicare’s Physician Fee Schedule values the procedures.

As it does with many other diagnostic tests, CMS divides the A-scan (76519) and the IOL Master (92136) into two components. The technical component (the actual performing of the test) is denoted with modifier TC, and the professional component (viewing and interpreting the results) is denoted with modifier 26.

For most procedures, the technical and professional components have the same bilateral status – for example, 92250-TC and 92250-26 (Fundus photography with interpretation and report) are both considered inherently bilateral, denoted with modifier indicator “2” on the fee schedule. The reimbursement for all components of 92250 is based on both eyes being tested.

Exception: For both 76519 and 92136, the technical component has a different bilateral status from the professional component. You can find the bilateral surgery indicators in the fee schedule, says Sylvia Conrad, insurance coordinator with Your Eye Solution in Jacksonville, Fla. Both 76519-TC and 92136-TC are denoted with modifier indicator “2,” which means that the technical component of the codes is considered inherently bilateral. The work of performing the test on both eyes is included when reporting the CPT codes – you should report 76519-TC or 92136-TC only once, whether the ophthalmologist tests one or both eyes.

Code Components Separately if Both Eyes Tested

The professional components (76519-26 and 92136-26) are denoted with modifier indicator “3,” however, which means that the professional component of the codes are inherently unilateral. When you report a global code, without modifiers, you are telling the insurer that you performed the technical component of both eyes and the professional component of one eye for that service. Therefore, you may be leaving money on the table for performance of the professional component on the other eye, says Mac.

Why? Ophthalmologists usually perform the technical component of the procedure – the actual measurement of the eye – on both eyes at the same time on the same day. But he may only perform the professional component – the IOL power calculation – on the eye that is going to have surgery. For example, if an ophthalmologist performs an A-scan on both eyes, calculating IOL power in the right eye, he would report 76519-RT. That code and modifier tell Medicare that the ophthalmologist performed the (bilateral) technical component and the (unilateral) professional component of the right eye.

If the ophthalmologist calculates IOL power in both eyes, code the technical and professional components separately. For example, for an IOL Master and power calculation in both eyes, code:

• 92136-TC for the bilateral technical component
• 92136-26-50 for the bilateral professional component. Append modifier 50 (Bilateral procedure) to show that you bilaterally performed this usually unilateral component.

Alternatively, some payers require you to report these services as follows, notes Mac:

• 92136-RT and 92136-26-LT

What’s the difference? Medicare rules dictate how bilateral procedures can be reimbursed. Since the global components of both 76519 and 92136 are denoted withbilateral status “2,” Medicare payment policy is to pay the fee schedule amount for only one code if you report it globally without the appropriate use of modifiers or using only modifier 50.

Thus, claiming 92136-50 will only yield $77.80, based on the 2010 fee schedule, unadjusted for geographical location (2.11 RVUs x 36.8729 conversion factor). Reporting IOL measurements in both eyes properly, with 92136-TC and 92136-26-50, however, should bring in about $30 more:

• 92136-TC = (1.31 RVUs x 36.8729) = $48.30
• 92136-26-50 = (0.80 RVUs x 36.8729) x 2 = $58.99
• Total: $107.29
• Check This 76519/92136 Bundle

Myth: If the ophthalmologist has to perform both an A-scan and an IOL Master, report both 76519 and 92136.

Reality: The National Correct Coding Initiative (NCCI) indicates otherwise. CPT codes 76519 and 92136 are in a mutually exclusive bundle. If you report both codes, Medicare carriers will only reimburse you for 92136.

Example: The ophthalmologist performs the technical portion of an A-scan on the left eye, but dense cataracts prevent him from getting a viable result from the right eye. He performs an IOL Master on the right eye and calculates IOL power for the right eye. You should only report 92136-TC and 92136-25-50. Do not report the failed 76518 scan and the 92136 scan together, says Mac. “Some payers may have alternative instructions for reporting the A-scan and/or IOL Master when the physician finds it necessary to perform both on the same day,” she explains. “Check with your local payer guidelines for specific guidance.”

Look for Fifth Digit on Cataract Dx

Myth: ICD-9 code 366 should be enough to justify medical necessity for 76519 or 92136.

Reality: Although 366.x (Cataract) is a good start, it’s not where you should end your ICD-9 quest. Coding rules dictate that you code as specifically as possible. Since the codes under 366.x extend into five digits, you will need a five-digit code, such as 366.02 (Posterior subcapsular polar cataract), to describe the patient’s condition fully.

Tip: Look for helpful notes in your ICD-9 manual. If a code has a “checkmark 4th” or “checkmark 5th” note next to it, look above or below it for a more detailed code or specific instructions on adding the additional digits.

 Get more money saving tips from Ophthalmology Coding Alert’s writer Jerry Salley, BA, CPC.

488.1x Cheat sheet makes fast work of snagging correct code.

Don’t let rumors of few ICD-9 changes in prep for ICD-10 blindside you to top diagnosis changes for 2011. Without the scoop on expansion to the 488, 784, and 787 categories, denials for invalid codes will derail your claims delaying your payments.

In ICD-9 2011, “Codes continue to become more and more specific necessitating a provider to document clearly and thoroughly to allow for selection of the most specific and accurate code,” says Jennifer Swindle, RHIT, CCS-P, CEMC, CFPC, CCP-P, PCS, Director Coding & Compliance Division, PivotHealth, LLC.

Good news: Updating your ICD-9 coding by the Oct. 1, 2010, effective date doesn’t have to be a chore. Start using your new choices in no time flat following these guidelines.

Look at Manifestation When Assigning “Swine Flu” Dx

This fall, when a patient has H1N1 (“swine flu”) pay attention to two details. The medical record will have to identify the correct influenza and you will have to capture the appropriate manifestation to select the codes to the degree of specificity now required, Swindle points out.

With the change “category 488 (Influenza due to certain identified influenza viruses) would mirror the structure of category 487 (Influenza),” according to the Summary of March 2010 ICD-9-CM Coordination and Maintenance Committee Meeting. The current 488.x sub-category didn’t provide the level of detail that category 487 (Influenza) does.

Change: There will be “tremendous expansion of the H1N1 category,” Swindle explains. ICD-9 2011 deletes 488.0 and 488.1 and adds six new five-digit codes. New codes 488.0x (Influenza due to identified avian influenza virus) and 488.1x (Influenza due to identified novel H1N1 influenza virus) allow you “to uniquely capture pneumonia, other respiratory manifestations, and other manifestations occurring with these types of influenza,” states the summary.

Starting Oct. 1, you’ll assign the correct 488.xx code based on the type of comorbid manifestation the avian or H1N1 influenza involves:
Comorbid Manifestation                        Avian         H1N1
Pneumonia                                                  488.01      488.11
Other respiratory manifestations      488.02      488.12
Other manifestations                               488.09      488.19

Don’t forget: As with 487.0, when you code 488.01 or 488.11, you’ll use an additional code to identify the type of pneumonia (480.0-480.9, 481, 482.0-482.9, 483.0-483.8, 485).

Focus on These Fecal Incontinence Symptoms

You’ll get to be a whole lot more specific when reporting fecal incontinence this fall. The single code 787.6 will give way to four new options that describe fecal incontinence problematic symptoms, such as fecal smearing, fecal urgency, and incomplete defecation.

When Oct. 1 rolls around, you’ll no longer be able to report 787.6 (Incontinence of feces). ICD-9 will delete it. Instead, you’ll use one of the following new codes:

• 787.60 — Full incontinence of feces
• 787.61 — Incomplete defecation
• 787.62 — Fecal smearing
• 787.63 — Fecal urgency.

Don’t miss: Incomplete defecation (787.61) is distinct from constipation and fecal impaction. Rectum and anal sphincter problems (including rectoceles) can cause these problems, but currently, you don’t have a way to specify these symptoms.  The 2011 ICD-9 includes a new code, 560.32, for fecal impaction.  Previously, this condition was included in 560.39, “Impaction of intestine; Other.”   

 “The new fecal incontinence code (787.60) is a change that we will have to remember,” says Lisa Selman-Holman, JD, BSN, RN, HCSD, COSC, consultant and principal of Selman- Holman & Associates and CoDR — Coding Done Right in Denton, Texas. The new code for fecal impaction excludes constipation, she says, which can still be reported using a code from the 564.0X series, “Constipation.”

Welcome More Specific Pain Dx in 2011

When the physician diagnoses jaw pain after Oct. 1, coders can choose 784.92 (Jaw pain) for the encounter. Previously, consideration included 526.9 (Unspecified diseases of the jaws), “which does not clearly illustrate the complaint,” relays Sarah Todt, RN,CPC, CEDC, director of education and compliance for Medical Reimbursement Systems, Inc., in Woburn, Mass.

Benefit: The more specific jaw pain code could help “support some complaints that may be related to dental problems,” says Todt.

For more coding changes, check out Family Practice Coding Alert, written by Jen Godreau, BA, CPC, CPEDC.

AMA corrects vestibular test codes to allow partial reporting.

The Correct Coding Initiative (CCI) came down hard on practitioners who perform vestibular testing earlier this year, but a new correction, effective Oct. 1, should ease the restrictions and help the otolaryngology, neurology, and audiology practices that report these services.

The problem: CCI edits currently restrict practices from reporting 92541, 92542, 92544, and 92545 individually if three or less of the tests are performed, notes Debbie Abel, Au.D., director of reimbursement and practice compliance with the American Academy of Audiology.

The solution: Starting October 1, 2010, “if two or three of these codes are reported for the same date of service by the same provider for the same beneficiary, an NCCI-associated modifier may be utilized to bypass the NCCI edits,” CMS wrote in a decision to alter the edits.

The American Speech-Language-Hearing Association (ASHA) has requested “clarification regarding the correct NCCI-modifier to use when reporting the codes to Medicare,” noted Lemmietta G. McNeilly, PhD, CCC-SLP, CAE, chief staff officer of Speech-Language Pathology with ASHA, in a July 29 announcement.

Look for Changes to Vestibular Testing Descriptors

The root of the CCI problem began when the 2010 CPT manual was published, including new code 92540 (Basic vestibular evaluation …) and the subsequent codes following it, which make up the individual components of 92540. “The clarification that resulted in the NCCI edits being lifted should be included in upcoming versions of the manual,” Abel tells Part B Insider.

According to the AMA’s Errata page, code descriptors should read as follows, effective Oct. 1:

• 92540 — Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording (Do not report 92540 in conjunction with 92541, 92542, 92544, or 92545)
• 92541 — Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording (Do not report 92541 in conjunction with 92540 or the set of 92542, 92544, and 92545)
• 92542 — Positional nystagmus test, minimum of 4 positions, with recording (Do not report 92542 in conjunction with 92540 or the set of 92541, 92544, and 92545)
• 92544 — Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording (Do not report 92544 in conjunction with 92540 or the set of 92541, 92542, and 92545)
• 92545 — Oscillating tracking test, with recording (Do not report 92545 in conjunction with 92540 or the set of 92541, 92542, and 92544).