Decipher why you should include a seconding diagnosis.

Question: A 38-year-old patient presents to the emergency room with complaints of wheezing, coughing, and trouble catching her breath. After the nonphysician practitioner (NPP) performs a problem-focused history, the physician performs a detailed history and exam and discovers focal ronchi. The physician orders a two-view chest x-ray to check for upper respiratory infection (URI) The chest x-ray results reveal acute URI, and the ronchi clears up upon reevaluation. The patient is treated with antibiotics. How should I code this scenario?

Answer:You’ll submit two of each for this claim: CPT codes, modifiers,and ICD-9 codes. On the claim, report the following:

• 71020 (Radiologic examination, chest, 2 views, frontal and lateral) for the x-ray
• Modifier 26 (Professional component) appended 71020 to show that you are coding for the physician’s services only
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination;and Medical decision making of moderate complexity….) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 show that the E/M and the x-rays were separate services
• 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site) appended to 71020 and 99284 to represent the patient’s URI
• 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) appended to 71020 and 99284 to represent the patient’s focal ronchi.

Secondary Dx decoded: Even though the focal ronchi cleared up on reexamination, you should still include 786.7 on the claim. It will help paint a more lucid portrait of the patient’s condition, and can only strengthen your medical necessity case for the chest-x-ray.

@ Part B Insider. Editor: Torrey Kim, CPC

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This modifier is key to E&M and counseling codes cohabiting on your claim.

Question: Can I report alcohol cessation counseling codes along with E/M codes, or do I have to choose one or the other?

Idaho Subscriber

Answer: You can, and in most cases will, report counseling codes along with E/M services. The behavior change intervention codes are intended to be reported in addition to an E/M service when the provider furnishes them. Most counseling sessions occur after the provider performs some sort of E/M. Consider this case study:

A new patient presents to the gastroenterologist reporting intense heartburn and “vomiting bile” for about a week. The patient’s skin is a splotchy yellow, and he reports experiencing generalized fatigue “for as long as I can remember.” Due to the smell of alcohol and the patient’s symptoms, the physician asks the patient if he has been drinking. The patient says “Yes,” so the physician decides to conduct the CAGE test to gauge alcohol abuse

Based on the test results, the physician determines that the patient is at least moderately dependent on alcohol; she performs extensive counseling and recommends the patient start attending Alcoholics Anonymous or some other community support group for alcohol-addicted individuals.The physician then finishes her patient exam.

She also recommends that the patient schedule a follow-up visit for a cirrhosis screening. The alcohol counseling lasted 18 minutes, and notes indicate the physician also performed a level-two E/M.

In this instance, the gastroenterologist performs both an E/M service and alcohol counseling. On the claim, you would report the following:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decisionmaking…) for the E/M;
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99202 to show that the E/M was a separate service from the counseling;
• 787.04 (Bilious emesis) appended to 99202 to represent the vomiting;
• 787.1 (Heartburn) appended to 99202 to represent the heartburn;
• 782.4 (Jaundice, unspecified, not of newborn) appended to 99202 to represent the skin condition;
• 780.79 (Other malaise and fatigue) appended to 99202 to represent the patient’s fatigue;
• 99408 (Alcohol and/or substance [other than tobacco] abuse structured screening [e.g., AUDIT, DAST], and brief intervention [SBI] services; 15 to 30 minutes) for the counseling service; and
• 305.00 (Alcohol abuse; unspecified) appended to 99408 to represent the patient’s alcohol dependence.

@ Gastroenterology Coding Alert. Editor: Chris Boucher, CPC

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When an EM service occurs during a postop global period for reasons unrelated to the original procedure, use this modifier.

Question: If the cardiologist performs a pacemaker insertion in the hospital and later visits the patient in observation, should I code the observation visit?

Georgia Subscriber

Answer: You should not charge this visit separately. Pacemaker insertion code 33208 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial and ventricular) has a 90-day global period.

For payers applying Medicare rules, that means that payment for the pacemaker insertion service includes the following services (among others) for 90 days following the procedure:

• Services related to complications following surgery, not requiring additional trips to the operating room
• Postoperative visits (follow-up visits) related to recovery from the surgery
• Postsurgical pain management by the surgeon.

FYI: Medicare specifies certain visits that are not included in the global package, meaning you may report them separately:

• Visits unrelated to the diagnosis that prompted the surgical procedure (unless the visits occur due to complications)
• Treatment for the underlying condition or an added course of treatment which is not part of normal surgery recovery
• Diagnostic tests and procedures
• Clearly distinct surgical procedures which are not re-operations or treatment for complications
• Treatment for complications which requires a return trip to the operating room.

When an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code.

Source: You can find the definition of the global surgical package in Medicare Claims Processing Manual, Chapter 12, Section 40.1.A.

@ Cardiology Coding Alert. Editor: Deborah Dorton, JD, MA, CPC

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You have two options depending on the next step.

Question: Our vascular office performs blooddraws and analysis for a local hospital. Can we bill for a lab draw in an office setting, and if so, what codes should we use?

Georgia Subscriber

Answer: If you’re sending your patients to an outside lab for both the blood draw and testing, you cannot report any blood draw codes. If your office collects the blood, you have two coding options, depending on the next step.

Option 1: Since it sounds like your practice has its own laboratory to perform blood tests, you can report 36415 (Collection of venous blood by venipuncture) for the venipuncture, assuming that the lab has Clinical Laboratory Improvement Amendments (CLIA) certification.

Option 2: If the collected blood specimen goes to an outside lab for testing, you should report 36415 for the blood draw and add modifier 90 (Reference [outside] laboratory).

Also keep in mind that most Medicare carriers allow one collection fee for each patient encounter, regardless of the number of specimens drawn. If an E/M service is provided and billed, most payers will bundle 36415 into the E/M service.

Finally, be sure to document the blood draw. All services administered to the patient, including the blood draw, must be documented in the patient’s medical record.

@ Medical Office Billing & Collections Alert. Editor: Leesa A. Israel, CPC, CUC, CMBS

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Use these FAQs to achieve level 5.

A patient reports to the emergency department in such severe respiratory distress that she cannot communicate during the history of present illness (HPI) portion of the E/M service. The patient also presents to the ED alone via ambulance, meaning there was no one else to speak for her.

How can a coder decide on the history level for this ED E/M service? Knowing an important exception to the HPI rules in ED settings will help you accurately report these incidents.

When a physician documents that an HPI [history of present illness] is unobtainable due to patient condition, you can invoke the caveat, explains Lori Bettencourt, CPC, PCS, coder at Pro-Medbill LLC in Hampton N.H.

Benefit: The ED caveat can prevent E/M downcoding based on the E/M HPI component. Follow this FAQ to get the lowdown on all the ED caveat rules you’ll need to code correctly each time.

What Are the Caveat Basics?

“In real life, ED physicians are not always able to obtain a complete history from a patient. Of course the physician should always document any history they can obtain from the patient, family or friends, EMS, nursing home, etc.,” says Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass. If the history is limited, however, the caveat “allowsthe physician to receive ’full-credit’ for even a comprehensive history – if you document why the history could not be obtained,” Lemanski stresses.

“The caveat is a CPT exception unique to emergency medicine 99285 services. It provides an exception to the E/M content requirements when the physician is unable to obtain the required [history] information,” relays Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La. This could be due to the urgency of the patient’s condition or the physician’s mental status.

For instance: The ED physician performs a comprehensive exam and high-complexity medical decision making for a patient, but she cannot get enough information from the patient for a comprehensive history. If you invoke the ED caveat in this instance, you might be able to report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity …).

How About a Clinical Example?

Consider this potential ED caveat scenario, courtesy of Edelberg:

A 64-year-old patient presents to the ED with altered mental status and left-sided facial droop. The physician examines the patient, but the patient cannot provide any useful history information. The physician orders a CT scan of the head, the patient is admitted to rule out a stroke. Notes indicate that the physician performed a comprehensive exam and high MDM.

In this scenario, you might be able to invoke the ED caveat if the physician documented her inability to obtain a full history, and report 99285 for the encounter.

How Can I Spot Potential Caveat Claims?

In a perfect world, the physician would stamp “ED caveat” on each relevant claim, but coders will have to be good spotters to make the caveat work for them.

How? Coders might be able to identify caveat situations based on terms the physician uses, says Bettencourt. Some terms that could indicate a caveat if they appear in the notes include:

• history unobtainable
• history obtained by family member due to altered mental status.

Other possible keys: Lemanski offers these terms that might indicate a patient that is unable to fully communicate:

• unresponsive
• obtunded
• comatose
• aphasic
• paralyzed and intubated
• incoherent due to intoxication or drugs.

How Do I Document the Caveat Situation?

In order to submit a successful caveat claim, however, you need to include two specific pieces of information. Find out what they are by subscribing to the ED Coding Alert.

Editor: Chris Boucher, CPC

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Even though Medicare no longer accepts consult codes, you can still apply modifier 57.

Question: In our ob-gyn office, we used to apply modifier 57 to inpatient consult codes. Now that Medicare doesn’t accept consult codes, how should we use this modifier?

Kentucky Subscriber

Answer: The short answer is that you should appendmodifier 57 (Decision for surgery) to the non-consult inpatient E/M code that the documentation supports.

Suppose the ob-gyn performed a 2009 level-three inpatient consult in which the ob-gyn determined the patient required an exploratory laparotomy later that sameday due to severe abdominal distention and pain as well as some uterine bleeding. Adding the modifier to the E/M code will help show payers why you’re reporting an EM in addition to the major surgery performed later that day, 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]).

For 2010, the exact E&M code you choose will depend on the circumstances specific to the visit, such as whether the visit is the first or second ob-gyn visit during the admission. But as an example, suppose you’re coding the ob-gyn’s first visit to an inpatient. Your documentation may support 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity …), which has requirements similar to 99253 (Inpatient consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity).

You should append modifier 57 to the E/M code. If, instead, the ob-gyn is the principal physician — the one overseeing the patient’s care and the one who is admitting the patient — be sure to append modifier AI (Principal physician of record), as well. This would be the case if the ob-gyn admitted the patient for observation for the abdominal pain and bleeding but later made the decision to take her to surgery that same day.

@ Ob-gyn Coding Alert, Editor: Suzanne Leder, BA, M. Phil., CPC, COBGC

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Sicker patients may not always mean higher MDM.

If your physician bills a lot of high-level office visits, he may be at risk of an audit — which may not be cause for concern — if his documentation justifies his code choices.

“Some physicians believe their patients are sicker than others’, so they feel they’re justified using more 99215s, when in fact that may not be the case,” says Crystal S. Reeves,CPC, CPC-H, consultant with Coker Group in Alpharetta, Ga. “The CPT manual outlines the requirements of the E/M codes, there are clinical examples in the back of CPT, and CMS publishes a Table of Risk that can help guide you, so use all of those resources to determine whether you’re billing properly,” she advises.

Training is Key: If you advise your physician that he is overbilling the high-level codes and he says, “But all of our patients are really sick,” show the doctor CMS’s Table of Risk, “which can be an eye opener for physicians,” Reeves says.

When it comes to MDM for high-level E/M services, “look for how many diagnoses or management options the doctor is treating,” Reeves says. “If a patient presents with a brain tumor and is on chemotherapy but is doing well, his condition may ultimately be terminal but this visit may not qualify for a level five. But if a patient has COPD, hypertension, degenerative disc disease, pneumonia, and diabetes, there will be more data to review, which may qualify for a higher MDM level.”

Make diagnosis coding a priority: If your claim doesn’t convey the status or complexity of the condition, an auditor won’t be able to infer it, advises Stephanie L. Fiedler, CPC, ACS-EM, director of revenue management with YAI in New York, N.Y. “The best way to do this is to report your diagnosis codes to the highest level of specificity.”

If a diagnosis code isn’t listed on your superbill, research to find it rather than just using one that you do list on your encounter form.

“Certain diagnoses may not be listed on a physician’s superbill, so the doctor may just circle the closest unspecified code,” Fiedler says. For instance, a physician might circle the standard controlled diabetes code on a superbill because it’s there, “but any time there are renal, peripheral vascular, or ophthalmic complications, those are the ones they have to go back to the coding book for — and oftentimes, they don’t,” she says.

“Without the more specific code, the physician isn’t conveying the acuity of what he’s doing, so the diagnosis may not support the claim.”

@ Part B Insider, Editor: Torrey Kim, CPC

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If your radiologist performs adjustments during the bariatric surgery’s global period, do this.

Question: Our radiologists perform percutaneous LAP-BAND adjustments. We report S2083 for the service and 77002 for the fluoroscopy. Is this the correct fluoroscopy code?

Connecticut Subscriber

Answer: Code 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) is appropriate for fluoro used for gastric band adjustment in the outpatient setting, according to the American Hospital Association’s Coding Clinic for HCPCS, Vol. 9, No. 3, 2009. Of course, the code is only appropriate when the physician uses and documents the fluoroscopic guidance.

The procedure: LAP-BAND adjustment involves passing a needle into the port of a band placed around the patient’s stomach as part of bariatric surgery. The radiologist uses the needle to add or remove fluid to change the width of the stoma (the outlet the band creates between the two parts of the stomach), according to CPT Assistant (April 2006).

The physician typically performs the adjustment through a subcutaneous port. If it’s palpable, the physician may not require guidance. But for patients who need to lose a lot of weight or for patients who have already lost weight and have a lot of extra skin, the radiologist may need guidance to find the port.

Keep in mind that adjustments performed during the bariatric surgery’s global period are included in the surgical fee, so you should not report them separately. You may report adjustments performed after the global postoperative period ends. For those (non-Medicare) payers who accept S codes, you may report S2083 (Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline). Otherwise, you may have to include the service in the appropriate E/M code, depending on payer preference.

@ Radiology Coding Alert, Editor: Deborah Dorton, JD, MA, CPC

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Plus: CMS reps cite current Medicare law and advise that practices should report just one inpatient care code per patient, per day.

Although CMS has eliminated payment for consult codes, it will continue to honor split/shared visits — as long as they are billed using E/M codes and follow the payment rules already in place.

That’s the word from CMS, where staffers aimed to straighten out confusion stemming from the January MLN Matters article SE1010, which offered several questions and answers regarding how to bill Medicare following the elimination of consult code payment.

In the article, CMS noted that “the split/shared rules applying to E/M services remain in effect, including those cases where services would previously have been reported by CPT consultation codes.”

“We understand that this has caused some confusion, as there were — and are — different split/shared rules for consultation services compared to E/M services,” noted CMS’s Rebecca Cole noted during during an April 13 CMS Open Door Forum.

“We’d like to clarify that Q&A,”Cole said. “As we’re no longer recognizing the consultation CPT codes for purposes of payment under Part B, the split/shared rules regarding consultation services are no longer applicable. Since E/M visit codes are being billed for services that were previously reported by the CPT consultation codes, the split/shared rules pertaining to E/M services apply when billing E/M CPT codes,” Cole stressed.

Remember: You can still report shared/split visits according to the regulations using E/M codes, but you cannot collect from Medicare for any consultation codes.

CMS is considering issuing a clarification in writing to dispel any confusion regarding the shared/split billing rule, Cole noted.

CMS Advises Practices to Rein in Initial Inpatient Billing

One caller wanted clarification on billing for hospital care now that consult codes aren’t payable. She asked whether a physician can report two initial hospital care codes for the same patient on the same date — for instance, if the physician saw the patient prior to surgery for one reason, and then saw the patient after surgery for another reason.

“I think you should consult the CPT rules as well as the manual, but I think our reaction to that is no,” said CMS’s William Rogers, MD,during the call. The initial hospital care codes refer to that physician’s first visit with the patient, Rogers said. Later evaluations should be billed using subsequent hospital care codes, he advised.

However, CMS reps indicated that they will look into the issue further to determine whether physicians should be able to report a second initial hospital care code if specifically requested to review a different condition. “We can consider this further and decide what our next steps will be,” Rogers said. Until then, CMS staffers urged practices to continue billing according to published rules.

In black and white: “Both initial inpatient hospital care codes and subsequent hospital care codes are ‘per diem’ services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice,” notes CMS Transmittal 1545.

Use Current Bone Density Codes

One caller was delighted that, thanks to the new health care reform legislation, CMS will be raising payment for bone density tests, but noted that the legislation listed old bone density test codes 76075 and 76077.He asked whether MACs will be requesting those codes going forward, or whether practices should continue reporting newer codes 77080-77082.

Advice: You should use the current codes 77080-77082, not the old codes, said CMS’s Amy Bassano.

@ Part B Insider, Editor: Torrey Kim, CPC

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Medicare won’t pay 69210 alone, so here’s how to unlock payment.

Impacted cerumen removal is a fairly straightforward procedure, but billing for the procedure is not always so simple.

The problem: Most payers, including Medicare,consider 69210 (Removal impacted cerumen [separate procedure], one or both ears) to be a minor procedure. But unlike with other minor procedures, they only pay for an E/M service as well as the removal of the impacted cerumen when you have two unrelated diagnoses — one for the E/M service and 380.4 (Impacted cerumen) for the removal of impacted cerumen.

The solution: By learning just three simple steps, you can ensure your physician is getting the reimbursement he deserves for this common procedure.

Step 1: Look for Second Diagnosis

A patient does not usually present for impacted cerumen alone. Another condition, such as ear pain or hearing loss, will usually prompt the visit. When your physician documents that additional diagnosis, you can report two codes to represent the work for both services, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls,N.J., and senior coder and auditor for The Coding Network.

First, you would report one code for the significantly separately identifiable E/M service, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient …). Then, you could report 69210 for the impacted cerumen removal. Documentation must support the medical necessity basedon symptoms and diagnosis; otherwise, the insurer will bundle the E/M service into 69210.

Note: CMS has a list of conditions for allowing you to separately bill an E/M code and 69210. They will allow separate billing when all of the following are met: The nature of the E/M is for anything other than cerumen removal.

During an unrelated encounter, the physician observes impacted cerumen or the patient complains about his ears Otoscopic examination of the tympanic membrane TM is not possible due to impaction

Removal of the impaction requires the expertise of the physician and is personally performed by him The procedure requires a significant amount of time and is clearly documented as such.

Crucial point: “Removal of impacted cerumen is not an ear wash; it takes instruments and the skills of the physician,” Cobuzzi says.

Step 2: Append Modifier 25

To receive separate reimbursement for the E/M service — and to code properly — you will need a modifier.Append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code.

Tip: Always provide separate documentation for the impacted cerumen removal procedure “so that you are demonstrating that the E/M is a separate procedure from the removal of the impacted cerumen,” Cobuzzi says. Do not bury your procedure note in the E/M note. Proper documentation of the patient’s complaint, his medical history, an examination beyond the ear, and a medical decision to remove the cerumen as well as a treatment plan for the second diagnosis, can legitimize a separate E/M procedure and thus support the use of the 25 modifier.

Step 3: Understand the Patient’s Insurance

Some payers do not consider 69210 to be inclusive or mutually exclusive of an E/M procedure. Others have strict guidelines for how the physician executes the procedure, or they put a cap on how often the service is paid for. Check your payer’s regulations on cerumen removal before billing this service.

Take note: Medicare does not pay for an audiologistto remove impacted cerumen. Therefore, if you are billing Medicare you need to send confirmation that the impacted cerumen removal on the day of audiological services was performed by the physician.

The catch: Medicare will not pay for 69210 and an audiology service on the same day. They require the recoding to G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing service as audiologic function testing) indicating that a physician performed the removal on the day of audiology services. Some private payers also pay this G code.

@ Medical Office Billing & Collections Alert, Editor: Joshua Thines

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