Coding Strategy

Treatment plans are a must, experts say.

You’ve treated your chiropractic patient, you’ve selected the correct codes, and you’ve submitted your claim. All set, right? Not quite. Check out this common mistake that chiropractors make.

“Many chiropractors do not create written chiropractic treatment plans for every new patient,” says Marty Kotlar, DC, CHCC, CBCS, president of Target Coding, a chiropractic coding and billing consulting firm. Use this checklist to ensure you send Medicare the information CMS most wants to see included “with every new patient plan of care,” Kotlar says:

__ The history
__ Present illness
__ Family history
__ The past health history
__ The physical examination
__ The diagnosis
__ The plan — This should include:

• Therapeutic modalities to effect cure or relief (patient education and exercise training)
• The level of care that is recommended (the duration and frequency of visits)
• Specific goals that are to be achieved with treatment
• The objective measures that will be used to evaluate the effectiveness of treatment
• Date of initial treatment.

__ Signature/initials to authenticate the records.

@ Part B Insider (Editor: Torrey Kim, CPC).

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Sometimes CCI compliance requires looking beyond the edit pairs.

Correct Coding Initiative (CCI) edits don’t bundle SPECT (78803) and planar (78070) parathyroid imaging codes, but coding experts often tell you not to code the two together for SPECT and planar parathyroid imaging on the same date.

Add some method to this madness by looking at the information offered by two coding resources, the Society of Nuclear Medicine (SNM) and the NCCI Policy Manual for Medicare Services (CCI Manual).

1. SNM Singles Out 78803

SNM’s online Practice Management Coding Corner features a Q&A that recommends reporting 78070 (Parathyroid imaging) for planar imaging alone, but 78803 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; tomographic) for parathyroid SPECT imaging with or without planar, says Jackie Miller, RHIA, CCS-P, CPC, vice president of product development for Coding Metrix Inc. in Powder Springs, Ga.

Support: “Choose the single code that describes the protocol and procedure performed,” states the Q&A, located at http://interactive.snm.org/index.cfm?PageID=2442&RPID=1995. SNM “would NOT recommend coding both CPT codes,” the article notes.

2. CCI Makes the Case for SPECT Code

Although there is notyou won’t find any a specific edit bundling 78070 and 78803, CCI does address the SPECT/planar issue in the CCI Manual, says Miller.

CCI Manual, Chapter 9, Section E.2, explains that you may not report a SPECT study and planar study of the same limited area because “Single photon emission computed tomography (SPECT) studies represent an enhanced methodology over standard planar nuclear imaging. When a limited anatomic area is studied, there is no additional information procured by obtaining both planar and SPECT studies.”

Bonus tip: The manual indicates you may report both planar and SPECT codes only when the size of the scanned area makes both sets necessary, such as with whole body bone scans with SPECT studies, says nuclear medicine coding expert Denise Merlino, MBA, CNMT, FSNMTS, CPC, president of Merlino Healthcare Consulting in Magnolia, Mass. Also keep an eye out for vascular flow studies. If the radiologist performs planar vascular flow studies alongside SPECT studies, you should report the vascular flow combined code, not the flow, planar, and SPECT studies independently, Merlino says.

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

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Remember frequency rules differ for average, high risk.

Getting Medicare to pony up for colorectal cancer screenings is not difficult provided you follow its frequency guidelines and eligibility requirements to the letter. A coding slip up on one of these items will knock you out of the saddle, and Medicare won’t accept the claim at all.

Rope in all the coding info you’ll need via this Medicare colorectal cancer screening FAQ.

Who’s Eligible for Average-Risk Test?

If the Medicare patient is 50-plus years old, he is eligible for a covered Medicare screening, confirms Dena Rumisek, CPC, biller at Michigan’s Grand River Gastroenterology PC.

However: These patients are considered average risk, and can have a colorectal cancer screening only once every 10 years, says Cheryl Ray, CCS, CPMA, of Atlantic Gastroenterology in Greenville, N.C. Ignore Medicare’s frequency guidelines at your peril, experts warn.

“Medicare is very stringent on the date … it has to be 10 years or longer — it can’t be 9 years and 360 days,” between covered screening colonoscopies, assures Rumisek.

Example: A 68-year-old established Medicare patient reports for a screening colonoscopy on Dec. 5, 2009. The patient’s records indicate that he last had a covered screening on Sept. 15, 1998. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

What ICD-9 Codes Are In Play for G0121?

Just one, provided there is no need for any therapeutic intervention during the colonoscopy. Medicare requires V76.51 (Special screening for malignant neoplasms; colon) on all G0121 claims. You might list other identified conditions secondarily, including diverticulosis (562.10) or hemorrhoids (455.0).

Always list the V code first for an average-risk screening, however.

What if the Patient Had a Recent Flexible Sig?

The frequency rules differ depending on whether other related colorectal cancer tests were performed previously; if a patient has had a routine flexible sigmoidoscopy screening (G0104, Colorectal cancer screening; flexible sigmoidoscopy), he is not entitled to a screening colonoscopy for at least 48 months, advises Cynthia Swanson RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP in Omaha, Neb.

Example: An average-risk established Medicare patient reports to the internist for a screening colonoscopy on Dec. 7, 2009. The patient’s medical record indicates that he had a flexible sigmoidoscopy screening on Nov, 17, 2007. This patient is not now eligible under Medicare guidelines for a screening colonoscopy because it has been only three years since his sigmoidoscopy.

What About Coverage for High-Risk Patients?

A patient who is considered at high risk for colorectal cancer is entitled to a screening colonoscopy once every 24 months, Ray says. You’ll list a V code (such as V10.05 [History of Colon Cancer] or V12.72 [Diseases of digestive system; colonic polyps]) as the primary diagnosis for these tests — most of the time.

If the patient already suffers from a condition that automatically put him at high risk for colorectal cancer, list that condition as the primary diagnosis.

Example: A 69-year-old established Medicare patient with a personal history of colonic polyps reports to the internist for a colonoscopy screening on Dec. 1, 2009. The patient record indicates that the patient’s last colonoscopy screening was May 4, 2006. On the claim, report G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) with V12.72 appended.

Can I Bill Private Payers for Screenings?

The answer will vary. Some private carriers pay fully for colonoscopy screenings — their coding practices for these services can differ from Medicare, however. Many U.S. states have passed legislation similar to the Medicare regulations requiring all health insurance carriers to cover routine colorectal cancer screening starting at age 50. Most non-Medicare payers accept 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing; with or without colon decompression [separate procedure]) for a screening colonoscopy, Ray relays.

Caveat: Though 45378 is likely the code you’ll choose for private payer screens, Ray recommends that you still check with the carrier before coding these services; specifically, look for the private payer’s frequency and diagnosis guidelines, which might differ from Medicare’s. “Each carrier pays [for screenings] according to the patient’s policy,” she says.

G codes possible: Other private payers might want you to code the same way as Medicare. For instance, BCBS of Michigan accepts the G codes and follows most of the same diagnosis guidelines as Medicare, according to Rumisek.

What Happens When Screening Turns Diagnostic?

Find out what you should base your CPT code on, by subscribing to the Internal Medicine Coding Alert.

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Plus: The OIG recovered over $1.5 billion in fiscal year 2009, and is on the lookout to collect more.

With less than two weeks to go before Medicare payments once again threaten to decrease by 21 percent, a new report sheds light on the financial outcome of Congressional actions.

Although the 2010 Physician Fee Schedule originally included a conversion factor that would have been 21 percent lower than the 2009 level, practices haven’t felt that cut yet this year,because legislators have voted several times to freeze payments, which now use the conversion factor of $36.0791. That freeze will expire on May 31, after which your Medicare payments will drop considerably unless Congress steps in once more.

However, one government entity’s calculations show that the freeze is costly. According to a May 7 Congressional Budget Office report, freezing payments at the current levels for the rest of 2010 would cost the government… … $6.5 billion. The AMA has turned up the heat on Congress to replace the current payment method, releasing a print ad aimed at Congress to demonstrate that “more delays of permanent reform now increase the cost for taxpayers,” and that the association “calls on Congress to fix the flawed Medicare physician payment formula now.”

Congress has not yet introduced a bill to extend the payment freeze past May 31. Keep an eye on the Insider for more information as this story develops.

To read the Congressional Budget Office’s calculation sheet,visit www.cbo.gov/budget/factsheets/2010b/SGR-menu.pdf.

@ Part B Insider. Editor: Torrey Kim, CPC

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Save this option for when other collection methods have failed.

You’ve offered discounts, payment plans, and more,but you still haven’t received payment from a patient. You may be forced to do a write-off at this point, says Steve Verno, CMMC, CMMB, NREMT-P, a medical billing consultant and educator in Orlando, Fla. Your practice is justified in writing off a patient’s balance in the following situations:

1. The cost of collecting a balance is more than what the patient owes. For example: A patient’s balance due is $3 after all insurance payments. The administrative cost to bill and collect is at least $15 per statement. “You don’t spend $15 to collect $3,” Verno says.

2. The provider uses all available methods to try to collect, including submitting the account to a collection agency.

3. The patient files for bankruptcy. This does not automatically initiate a write-off, however. The court could discharge the debt or establish a payment plan based on available assets. If you do receive a discharge of debtor notice, you can then write off the debt.

4. If the patient has Medicare, but there is no signed Advanced Beneficiary Notice of Non-Coverage (ABN) form on file for the specific date of service, and thus there is no GA (Waiver of liability statement on file) modifier on the claim, you will not be allowed to balance bill. So if Medicare won’t pay the claim due to medical necessity, you will be forced to write off the charges.

5. If the terms of your contract with the insurance company state that you cannot balance bill the patient if a claim is denied. The process may follow a similar outcome as in bullet point 4, resulting in a write-off.

6. The patient proves financial hardship, using the criteria mentioned in part one of “Don’t Let Patients’ Financial Hardship Become Yours” in the Vol. 10, No. 2 issue of Medical Office Billing & Collections Alert. Editor: Joshua Thines.

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