Coding Strategy

Bonus: Get exposure to ICD-10 coding equivalents.

Question: A mentally-challenged patient who delivered at home was admitted to the hospital for postpartum care. The patient delivered the placenta at home, and once admitted, she had no complications, but the ob-gyn did perform a first degree laceration repair. I’m not sure what diagnosis code to report. Should I look at routine postpartum care or pregnancy complications? And if I use a complication code, what would the fifth digit to a “1″ or “0?”

Texas Subscriber

Answer: Under most situations where the ob-gyn treated no problems during the admission, you would code V24.0 (Postpartum care and examination; immediately after delivery) on the admission date and V24.2 (Routine postpartum follow-up) for any subsequent routine care.

But in this case, your physician also repaired a first degree laceration (CPT code 59300, Episiotomy or vaginal repair, by other than attending physician). Therefore, you may consider this to be an admission for a postpartum condition and instead report 664.04 (First degree perineal laceration). The fifth digit cannot be “1″ or “0″ because the patient delivered prior to her admission and of course you know her delivery status. In this case, the fifth digit must be “4″ to indicate a purely postpartum condition. You may optionally report V24.0 and V24.2 as your secondary diagnoses, but they are not required in this case.

ICD-10: In the near future, you will replace ICD-9 codes V24.0 and V24.2 with ICD-10 codes Z39.0 (Encounter for care and examination of mother immediately after delivery) and Z39.2 (Encounter for routine postpartum follow-up), respectively. Code 664.04 will be replaced by O70.0 (First degree perineal laceration during delivery).

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Focus on form and drug to pinpoint the correct asthma supply code.

Are you clear on how to report asthma procedures and inhalers? Follow this advice, and you’ll breathe easy when it comes to asthma related claims.

Propellant-Driven Inhaler Falls Under 94664

If there’s confusion in your office over whether to use 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler, or IPPB device) to report education/training with the Advair diskus, look no further for your answer.

Code 94664s descriptor specifies demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device. Part of teaching the proper technique in using an inhaler (either propellant-driven [Advair Diskus] or dry powder) is to demonstrate and evaluate. In this respect, the code would seem appropriate to use for demonstration and evaluation, say sources with the Joint Council of Allergy, Asthma & Immunology.

The drawback: Not all payers will reimburse 94664. If practices abuse 94664, probably fewer payers will pay. To support reporting 94664, documentation should include an indication of medical necessity.

Clear Up Inhaler Code Confusion

Patients sometimes need multiple nebulizer treatments in the office to control acute asthma. If you’ve wondered whether to bill 94640 and J7613 multiple times, one time, or one time with modifiers for additional treatments, follow this advice and youll breathe easier.

Submit 94640 for Each Treatment

When a patient receives multiple aerosol treatments on the same date, you should use 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device]) for the first treatment.

Subsequent treatments will require modifier 76 (Repeat procedure by same physician), CPT says. Therefore, you would code three nebulizer treatments as:

• 94640 — First treatment
• 94640-76 x 2 — Two subsequent treatments.

A dose of coding: For the inhalation solution, report three units of J7613 (Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg). Because J7613 represents one unit dose, you should report per nebulizer treatment or, in our example, J7613 x 3.

E/M Might Also Be Acceptable

If the allergist meets the criteria, you should report the appropriate-level E/M code (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient …).

If the physician performs and documents a significant, separate E/M from the treatment (94640), append the E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Time is a factor: If the asthma treatment lasted at least an hour, you’d code it with 94644 (Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour). Report code 94640 for intermittent or one-time treatments.

Clue In to 5th Digit for Asthma Diagnosis

When you submit an asthma diagnosis, don’t forget that ICD-9 requires you to use a fifth-digit sub-classification with asthma codes (493.xx, Asthma). If you submit four digits for an asthma diagnosis, payers will probably reject the ICD-9 code as incomplete.

Correct method: Assign the fourth digit based on the asthma category:

• 493.0x, Extrinsic asthma
• 493.1x, Intrinsic asthma
• 493.2x, Chronic obstructive asthma
• 493.8x, Other forms of asthma
• 493.9x, Asthma, unspecified.

Then, identify the asthmas current state with the appropriate fifth digit:

• 0, unspecified
• 1, with status asthmaticus
• 2, with (acute) exacerbation.

For patients who do not have status asthmaticus or acute exacerbation, use a fifth digit of 0. Code 493.x0 is appropriate when the patients asthma is controlled. A final digit of 1 indicates that the patient has status asthmaticus, which is a medical emergency and is usually treated in the emergency department. You should assign a 2 when something has caused the condition to flare up.

Why it matters: Without this level of specificity, the payer may deny your claim for lack of medical necessity.

Example: An extrinsic asthma patient has an acute exacerbation that requires a nebulizer treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device]). In this case, you should link 94640 to 493.02. Reporting a 2 as the fifth digit helps the payer understand why the patient needs the treatment. Without the final digit (or a fifth-digit of 0), the payer may assume that the patients asthma is under control, making the coded treatment unnecessary.

Reinstate Old J Codes to Get Claims Paid

If you flagged J7611-J7614 as invalid for CMS, you can green light the codes with a valid as of April 1, 2008, notation.

The spring-quarter updates to HCPCS 2008 deleted albuterol/levalbuterol codes J7602 (Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 1 mg [albuterol] or per 0.5 mg [levalbuterol]) and J7603 (& unit dose …). HCPCS reinstated:

• J7611 — Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 1 mg
• J7612 — Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 0.5 mg
• J7613 — Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 1 mg
• J7614 — Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 0.5 mg.

The CMS fee schedule Web site recognizes J7611-J7614 and not J7602-J7603.

Switch Back to Drug-Specific Codes

You may recall that CMS once replaced J7611-J7614 with Q4093 (Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 1 mg [albuterol] or per 0.5 mg [levalbuterol]) and Q4094 (& unit dose …)

Both Q4093 and Q4094 were deleted effective Jan. 1, 2008, however. HCPCS introduced new albuterol-levalbuterol combination codes J7602-J7603 to take the place of those deleted Q codes for 2008.
Medicare decided it was better to use the four codes that separated albuterol from levalbuterol, rather than the combined drug codes J7602-J7603.

Focus on 2 J7611-J7614 Factors

You can get the correct noncompounded solution supply code if you zoom in on two items:

• Form- concentrated (J7611, J7612) or unit dose (J7613, J7614).
• Drug- albuterol (J7611, J7613) or levalbuterol (J7612, J7614).

A revised GA and new GX hope to clarify some of Medicare’s non-coverage policies.

At least one aspect of dealing with Advance Beneficiary Notice of Non-Coverage (ABN) forms is about to get a little simpler, thanks to two modifiers.

CMS is now giving you two HCPCS level 2 modifiers to distinguish between voluntary and required uses of liability codes, according to release CR6563.

Know when you need an ABN with this expert advice:

Background: When your physician provides a service that Medicare does not cover, your practice must provide an ABN to the patient. The patient should then examine and complete the form before your providers administer that service or procedure.

When you have a patient sign an ABN, you also need to append the appropriate modifiers on your claim. ABN modifiers tell the Medicare carrier that you have an ABN on file for services that won’t be covered.

Luckily, modifiers GA (Waiver of liability on file) and GX (Notice of liability issued, voluntary under payer policy) should add more tools to your belt that will help you fend off denials.

Good practice: “It is in the provider’s best interest to discover which procedures need ABNs in their offices, and flag accounts prior to the patient coming in,” says Melinda Brown, CMBS, insurance biller with H. Matt Smith, MD in Kennewick, Wash.

Don’t Waver on Modifier GA Use

CMS redefined modifier GA to be a “waiver of liability statement.” You should only use modifier GA “to report when a required ABN was issued for a service, and should not be reported in association with any other liability-related modifier and should continue to be submitted with covered charges,” CMS says.

Simply put, “the GA indicates that you have a signed ABN on file,” Brown explains.

Unfortunately, using GA does not mean you’ll get automatic reimbursement. According to the CMS guidelines, a GA modifier indicates the possibility that a service may be denied for medical necessity only, and that the physician may bill the patient after the claim is denied.

Example: A patient presents for lesion destruction (freezing) of seborheic keratosis(es). In this case, you would bill 17000 (Destruction [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [eg, actinic keratoses; first lesion) and 17003 (second through 14 lesions, each) times three units of service, for four total lesions with a diagnosis code of 702.19 (Other seborrheic keratosis). You’ll need to obtain an ABN from the patient and then use modifier GA since Medicare may deny 17000 with any diagnosis except 702.0 (actinic keratosis), for medical necessity, says Brown.

Use GX for a Voluntary ABN

When your practice issues a voluntary ABN for a particular service, you’ll instead turn to modifier GX. CMS defines modifier GX as “notice of liability issued, voluntary under payer policy.” You will use modifier GX when you need a denial remittance advice to submit for secondary insurance, when Medicare does not pay as primary, but the secondary insurance does pay with a denial explanation of benefits (EOB).

Old way: Before CMS revised the ABN last year, you would have used a Notice of Exclusion of Medicare Benefits (NEMB) form for these cases. CMS eliminated the NEMB, however, so modifier GX helps you tell the payer you have a voluntary ABN on file.

You might also use the ABN for a never covered service if a patient does not believe the service is not covered and insists that you submit the claim to Medicare. You would have the patient sign the ABN and submit the service to Medicare with a GX modifier so that the patient receives the denial remittance advice.

Watch for: If you append GX on the same line as many liability-related modifiers, including EY (No doctor’s order on file), GA, GL (Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN), and others, Medicare will likely deny your claim.

Example: A patient needs a hearing aid, which Medicare never covers, but the patient has secondary insurance that will pay. The patient signs an ABN. You should submit the claim to Medicare with a GX modifier. Your practice may then submit to the secondary insurance, which will pay for a part of the hearing aid based on the denial from Medicare.

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You may need to append modifier 25, depending on payer policies.

Question: Our physician billed 90634, 90710, and 90606 for vaccines given to a 5-year-old patient. The insurance company denied payment and said they required a modifier. What should we have done differently?

New Hampshire Subscriber

Answer: According to standard CPT coding, vaccine codes do not require modifiers on the associated E/M code. However, you might need to include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) if your insurance company requires it — which might be why you received a denial.

Well check: If your physician administered vaccines on the same day as a well visit, code the well visit with the appropriate code such as …

… 99393 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood [age 5 through 11 years]). You might need to append modifier 25 if vaccinations are given, depending on the payer’s guidelines.

Sick visit: If the child visits because of another problem and receives immunizations during the visit, report the vaccines with the appropriate office visit code from 99212-99214 (Office or other outpatient visit for the evaluation and management of an established patient …).

Then report the vaccine codes: 90634 (Hepatitis A vaccine, pediatric/adolescent doage-3 dose schedule, for intramuscular use), 90696 (Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated -D-TaP-IPV], when administered to children 4 through 6 years of age, for intramuscular use), and 90710 (Measles, mumps, rubella, and varicella vaccine [MMRV], live, for subcutaneous use).

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Medicare’s elimination of payment for consultation services has caused mass confusion throughout the coding community, not just due to the changes it has caused in your billing procedures, but also due to lack of information from CMS.

In an apparent attempt to quell those issues, CMS has released MLN Matters article SE1010, which offers several questions and answers regarding how to report your services now that Medicare no longer recognizes consult codes (99241-99255).

For example, CMS addresses the often-asked question of whether the agency will release a crosswalk of  consult codes to E/M codes. “No,” CMS responded in the article. “Providers must bill the E/M code (other than a CPT consultation code) that describes the service they provide in order to be paid for the E/M service furnished.” In other words …

You must report the E/M code that best matches your provider’s documentation, rather than attempting to find the appropriate consult code and matching it to an office or hospital visit code.

Plus: Many providers have been concerned about what will happen if  they report a subsequent hospital care code (99231-99233) for a physician who hasn’t first billed an initial hospital care code (99221-99223).

CMS responds that it has instructed MACs “to not find fault with providers who report a subsequent hospital care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met,” even if that provider is seeing that patient for the first time during his or her hospital stay.

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