Coding Strategy

Code 31575 includes 92511 and 31231 except under these conditions.

Singling out the correct endoscopy code when your otolaryngologist examines multiple areas in the sinuses and throat isn’t always easy, but in most cases it’s imperative to settle on one, according to National Correct Coding Initiative (CCI) edits. You can adhere to these edits and avoid payback requests if you stick to these guidelines.

3 Rules Guide the Way

Rule #1: Never report 92511 (Nasopharyngoscopy with endoscope[separate procedure]) and 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) together, says Stephen R. Levinson, MD, otolaryngologist and coding consultant based in Easton, Conn. Code 92511 is a component of Column 1 code 31231. The bundle has a modifier indicator of “0” — thus, no modifier can break this bundle.

Rule #2: Code 92511 is a component of Column 1 code 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) but a modifier is allowed in order to differentiate between the services provided (that is, you may append modifier 59 [Distinct procedural services] if there are separate and identifiable services with separate medical indications). Report 92511 in conjunction with 31575 for the same encounter, says Levinson, only if the following conditions are met:

• there are separate medical indications for examining each area (for instance, 784.49 for hoarseness with 31575 in an adult patient with a hyperactive gag reflex and 381.4 for a unilateral or bilateral middle ear effusion with 92511, which would be a rare occurrence), and
• the ENT uses a different scope for each, separate procedure because there is a documented reason that the fiberoptic scope did not provide adequate visualization of the nasopharynx. “This would be highly unlikely,” emphasizes Levinson.

Rule #3: Code 31231 is a component of Column 1 code 31575 but a modifier is allowed in order to differentiate between the services provided. The need to coreport these services for the same encounter, however, would also occur very infrequently. The combination of 31575 with 31231 would similarly call for separate, sufficient medical indications and the medically indicated use of separate endoscopes, says Levinson.

Think Before Appending 59

Some coders mistakenly think that appending modifier 59 to an endoscopy bundle will result in dual payment when the ENT visualizes more than one area. Using 59, however, is incorrect in most instances.

When CCI created the endoscopy bundles, it realized that the bundled codes described different sites, points out Barbara J. Cobuzzi, MBA, CPC, CPCH, CPC-P, CENTC, CHCC, president of N.J.-based CRN Healthcare Solutions. So attempting to break the endoscopy bundle based on the ENT examining two different sites is not appropriate.

Exception: If the ENT performed the two endoscopies at two different encounters on the same day for two distinct medical reasons, you would be safe in reporting 59, explains Cobuzzi. This scenario would be uncommon.

Example: If the ENT performed a laryngoscopy (31575) in the office in the morning for postnasal drip (784.91), and in the afternoon she performed a nasal endoscopy (31231) for unrelated epistaxis (784.7), you may append 59 to the column 2 code 31231.

@ Otolaryngology Coding Alert. Editor: Stacie Borrello, MA

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Modifier 59 sometimes will rescue your reimbursement.

Just when you’re finally getting a handle on all the 2010 coding changes, here comes round two of the Correct Coding Initiative (CCI) edits. Version 16.1, which took effect April 1, will tie your hands when coding many common urology procedures, including prostate biopsies and urethral dilations.

Heads up: CCI 16.1 includes 2,054 new active pairs and 1,947 modifier changes, says Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions Inc. in Clearwater, Fla.

“For urology, there will be 78 edit pair additions and two edit pair deletions,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.To ensure you get paid appropriately for your urologist’s services this quarter, here’s the rundown of the most important changes.

Say Goodbye to Biopsy with Several Prostate Procedures

You can no longer report prostate biopsy codes 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) or 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance) with 52630 (Transurethral resection; residual or re-growth of obstructive prostate tissue including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]). Your payer will reimburse you for 52630 but deny the biopsy codes, and you cannot use a modifier to separate these new edits.

“I have a major issue with the bundling of 55700 and 52630,” laments Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. Kater says her urologists perform a good number of prostate biopsies transrectally and 55700 is what she uses because the descriptor says “any approach.” When you are performing two separate procedures utilizing two different approaches, how can they be bundled?”

Silver lining: CCI also bundles 55705 (Biopsy, prostate; incisional, any approach) into 52630, but the edit carries a “1” modifier indicator. Therefore, you can break that bundle if clinical circumstances warrant separate reporting.

Additionally: As of April 1, transurethral resection of the prostate (TURP) code 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) and laser prostatectomy codes (52647-52649) are mutually exclusive with saturation biopsy of the prostate under anesthesia (55706).

The 52601/55706 and 52648/55706 bundles have a modifier indicator of “0” so you can never bill those codes together. On the other hand, the 52647/55706 and 52649/55706 bundles both have a modifier indicator of “1,” which means you can report the codes together underspecific clinical circumstances using a modifier such as modifier 59 (Distinct procedural service), Ferragamo says.

You will also find prostate biopsy listed as a column 2 code (55706), forming mutually exclusive edits with the following column 1 codes:

• Transurethral destruction of prostate tissue (53850-53852)
• Prostatectomy (55801-55845, 55866)
• Cryosurgical ablation of the prostate (55873).

The modifier indicator for all of these above edits is “1.” You can break the bundles when clinical circumstances warrant.

Beware Multiple Urethral Dilation Edits

CCI 16.1 hits urethral dilation coding hard. To find out what edits you need to apply to your urology practice pronto, subscribe to the Urology Coding Alert.

Editor: Leesa A. Isreal, CPC, CUC, CMBS

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Keep signature, modifier 59, and ‘Incident To’ guidelines front and center.

If you’ve been worrying that the oncologist’s illegible signature on an order is going to come back to haunt your practice in an audit, CMS has offered
answers on when you’re in the clear and when that untidy scrawl could have reviewers requesting additional information.

1. Get Signature Guidelines Down Pat

With few exceptions, Medicare requires a signature for services and orders. CMS updated the rules and added e-prescribing language to the mix in Transmittal 327, CR6698. The rules instruct contractors reviewing claims on what counts as a signature and when the services or orders must have signatures.

One important exception to the signature requirement is that “diagnostic orders need not be signed by the physician,” says Kelly Loya, CPC-I, CPhT, consultant with California-based Sinaiko Healthcare Consulting Inc. Still, the medical record must include information verifying the ordering physician intended the test to be performed, and “a progress note in the medical record must be signed,” Loya explains.

A very helpful feature of the transmittal is a chart that “gives very specific facts as to what meets the requirements or requires follow up with the provider to meet the requirements,” says Loya. For example, if you scan the chart, you can quickly see that an illegible signature written above a typed name is OK, but contractors won’t count just an unsigned typed note with a typed name. “The reviewer can explore alternate methods in order to verify the signature requirement,” Loya notes. “Not complying with an attestation request (within 20 days of the request)” could lead to a denial, she warns.

If you’ve been reporting G8553 (At least one prescription created during the encounter was generated and transmitted electronically using a qualified ERX system), be sure to give the transmittal a close look. The new e-prescribing language solidifies that for non-controlled substances, “as long as a ‘qualified’ e-prescribing system (per Medicare Part D requirements) is used, a pen and ink copy” of the signed prescription order is not required, Loya says. But physicians can’t e-prescribe controlled substances — for example, addictive pain medications — so CMS requires a pen and ink order for these.

Watch for change: The Drug Enforcement Agency recently released its interim final rule on e-prescribing controlled substances. If your oncologist is willing to jump through the multi-step authentication hoops, e-prescribing controlled substances may be a possibility in the future.

Transmittal 327 is effective March 1 with an April 16 implementation date.

2. OIG Is Watching Mod 59; Are You?

In other news, the OIG released its 202-page “Compendium of Unimplemented OIG Recommendations,” which revealed that many OIG suggestions have been ignored.

Case in point: In 2003, the OIG found a 40 percent error rate on claims that contained modifier 59 (Distinct procedural service) when used to separate Correct Coding Initiative (CCI) edits, resulting in Medicare paying $59 million in improper payments.

The OIG encouraged carriers to institute prepayment and postpayment reviews of the use of modifier 59, and suggested that CMS should update carriers’ claims processing systems so they pay claims with modifier 59 “only when the modifier is billed with the correct code,” the OIG report indicates. The OIG now says that CMS has not yet instituted such system edits, and notes that it will “continue to monitor CMS’s efforts to implement edits to ensure correct coding.”

What this means: “The OIG lists modifier 59 as a priority nearly every year, and it’s possible that the agency feels that CMS should be looking more closely at its use,” says Randall Karpf with East Billing in East Hartford, Conn. “The bottom line is that if all of these entities are watching modifier 59, make sure you’re using it properly.”

In particular, past OIG investigations have shown that one of the more common modifier 59 mistakes is incorrectly unbundling 38220 (Bone marrow; aspiration only) and 38221 (… biopsy, needle, or trocar), so be sure you keep a careful eye on this code pair.

Plus: The OIG examined services billed using the “incident to” guidelines, which you should know well if you report oncology services to Medicare. As a result of the OIG scrutiny, CMS is revising its incident to policies to reflect the fact that “no one except licensed physicians perform the services or nonphysicians who have the necessary training, certification, and/or licensure, pursuant to state laws, state regulations, and Medicare regulations perform the services under the direct supervision of a licensed physician.”

Although many practices already follow this rule, the OIG “wants an explicit rule rather that the current implicit rule,” says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

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

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This quick quiz will show you where you fall.

Want to stay polished on your coding and billing skills to ensure stellar reimbursement and compliance? Give this quiz a whirl, and then turn to page 21 for the answers — where the experts chime in with their two cents.

Questions:

1) Which of the following is an example of a skilled AND billable therapy service?

• a) A patient is exercising on a bike while you monitor him, and you code for therapeutic exercise (CPT 97110).
• b) A patient is exercising on a bike while you actively coach the patient on technique and muscles he needs to strengthen to reduce knee pain. You code for therapeutic exercise (CPT 97110).
• c) A patient is doing self stretching exercises for the shoulder using the pulleys while you are performing manual therapy on another patient.

2) You get a new Medicare patient who needs occupational therapy for two unrelated diagnoses from different physicians. How should you charge for your initial eval?

• a) Put everything under one evaluation code. Code 97003 once, and append modifier 76 (Repeat procedure or service by the same physician).
• b) Code 97003 twice, appending modifier 59 (Distinct procedural service).
• c) Bill 97003 once if you’re doing both evals on the same day; bill 97003 twice if you do the second eval on a different day.

3) What should you do if you’re in a non-hospital outpatient setting, your patient exhausts a therapy cap, and she still needs skilled therapy services?

• a) Bill for the services with the KX modifier, and make sure you have documentation to support the medical necessity.
• b) Make the patient sign an ABN form and have her agree to pay out of pocket.
• c) Do not bill for further services. Allow the patient to pay out of pocket or refer her to the nearest hospital outpatient facility.

4) You perform separate and distinct therapy procedures on one patient on the same day that fall under a column 1-column 2 CCI edit. What should you do?

• a) Apply modifier 59 to one of the codes; it doesn’t matter which one.
• b) Apply modifier 59 to the column 1 code of the edit.
• c) Apply modifier 59 to the column 2 code of the edit.

5) Your rehab department has speech therapy orders for a patient suffering from post-stroke dysphagia. What should you code as the patient’s primary diagnosis?

• a) 434.91 (Cerebrovascular accident)
• b) 438.x (Late effects of cerebrovascular disease)
• c) 438.82 (Dysphagia due to late effect of cerebrovascular accident) and 787.2x (Dysphagia)

6) How should you charge for a TENS set up and application in the clinic setting?

• a) 97014 or G0283
• b) 97032
• c) 64550.

Outpatient Billing, quiz answers:

1) Answer: B. Even if a code is reimbursable, like 97110, bill it only for skilled services. Billing 97110 when you’re just watching a patient won’t fly — because anyone can watch a patient.

“When selecting codes, remember that we are paid for what we are doing, not for what the patient is doing” says Ken Mailly, PT, of Maily & Inglett Consulting in Wayne, N.J. Also, when you’re deciding, for example, between therapeutic exercise versus neuromuscular re-education codes, etc., keep in mind you should bill for the intent of what you’re delivering, he adds.

Note: Bill for the patient education and training component of 97110. Once that’s done, the rest of the time would not be billable.

2) Answer: C. Medicare won’t accept modifier 79 from a therapist since it is intended for physician services, and modifier 59 is not appropriate because this case is not a CCI edit.

“If both evaluations are done on the same day, regardless of the payer, bill only one unit of the evaluation CPT code since it is un-timed,” says Rick Gawenda, PT, director of finance for Kinetix Advanced Physical Therapy, Inc. and President/CEO of Gawenda Seminars & Consulting. “If done on separate days, the Medicare program will reimburse for a second evaluation for the second diagnosis.”

Chapter 15 in the Medicare Benefit Policy Manual supports billing for two evaluations if a second condition arises during the episode of care, points out Joanne Byron, LPN, BSNH, CHA, CMC, CPC, CPC-I, MCMC, PCS, president and CEO of HCCS, Inc. in Medina, Ohio. “After the second condition is evaluated, then the plan of care is adjusted to include new treatments and everything is done under one plan of care, according to Medicare.”

Remember: “Most insurance providers follow Medicare guidelines, but not all,” Byron says. So check your patient’s individual coverage guidelines.

3) Answer: C. The therapy cap exceptions process expired at the end of 2009. So you cannot bill for an exception with modifier KX. Also, you’re not required to issue an ABN form since services above the therapy caps are statutorily excluded from Medicare coverage.

For answers 4-6, subscribe to the Physical Medicine & Rehab Coding Alert, Editor: Lindsey Rushmore.

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Overlooking these new Interstim and hemorrhoid destruction bundles could mean denial headaches.

Payers like Noridian Part B will cover the female stress urinary incontinence treatment code 0193T, but before you submit a 0193T claim, you’ll have to check with the correct coding initiative (CCI) version 16.1’s edits. For instance, as of April 1, the work represented by 0193T will include that of cystourethroscopy codes 52000-52001 and 52281.

Don’t let CCI version 16.1’s lack of ob-gyn mutually exclusive edits lull you into a false sense of security. Here’s what you need to know to prevent a denial from landing on your desk.

1. Look For 0193T in Both the Column 1, Column 2 Position

In 2009, CPT added 0193T (Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence) to your possible stress urinary incontinence (SUI) treatment coding options. This code includes the Renessa® transurethral collagen radiofrequency denaturation procedure. Ob-gyns typically perform this nonsurgical, minimally invasive alternative for women who have failed other nonsurgical treatments or who aren’t good candidates for surgery.

What happens: The ob-gyn uses controlled heat at low temperatures and targets tissue in the woman’s lower urinary tract. The heat changes the structure of the patient’s natural tissue collagen. This helps the firmness of tissue and improves her continence. Although the ob-gyn may use heat on multiple sites and document multiple cycles, you should report 0193T once to represent all the treatment cycles performed during an encounter.

As of April 1, 0193T will include the work represented by 52000-52001 (Cystourethroscopy …) and 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female)

Reaction: “These edits don’t surprise me at all because 0193T says ‘transurethral’ which implies the use of the scope,” says Jan Rasmussen, CPC, AGS-GI,ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis. For instance, you should always include “inserting the scope (52000) into the major procedure.” As for 55281, “that is a little less obvious,” but CCI “probably bundled that because these services may be part of the approach,” Rasmussen adds.

You should also include 53660-53666 (Dilation of female urethra …) and 90901 (Biofeedback training by any modality). CCI describes these edits as “misuse of column 2 code with column 1 code” (0193T).

All of these edits carry a modifier indicator of “1,” meaning you can use a modifier (such as 59, Distinct procedural service) to separate them — but make sure your documentation supports the modifier.

Additionally, as of April 1, you should do the opposite and bundle 0193T into the following services:

• 51845 — Abdomino-vaginal vesical neck suspension, with or without endoscopic control (e.g., Stamey, Raz, modified Pereyra)
• 51990 — Laparoscopy, surgical; urethral suspension for stress incontinence
• 51992 — … sling operation for stress incontinence (e.g., fascia or synthetic)
• 57160 — Fitting and insertion of pessary or other intravaginal support device
• 57288 — Sling operation for stress incontinence (e.g., fascia or synthetic)

CCI describes these bundles as “misuse of column 2 code” (which is 0193T) “with column 1 code.” Again, all of these edits carry a modifier indicator of “1,” meaning you can use a modifier to separate it — but make sure your documentation supports the modifier, or you’ll face a denial.

2. Take Note of New Fluoroscopy Bundle With Interstim Procedure

If your ob-gyn tests electrodes for the Interstim procedure, you’re probably used to reporting 64561 (Percutaneous implantation of neurostimulator electrodes; sacral nerve [transforaminal placement]).

What you may not be used to is including fluoroscopy codes (76000-76001, Fluoroscopy …; 77002-77003, Fluoroscopic guidance …). CCI 16.1 tacks these codes as column 2 codes with a modifier “1” indicator, which means you’ll have to append — and justify — a modifier onto the fluoroscopy code to separately report both procedures.

Reaction: Notice how 64561 contains the term “percutaneous.” The physician “has to have some way to visualize the placement,” Rasmussen points out.

3. Count 46930 as Part of More Extensive Hemorrhoid Procedure

Do you report 46930 (Destruction of internal hemorrhoid[s] by thermal energy [e.g., infrared coagulation, cautery, radiofrequency]) with any regularity? If so, then you should be wary of reporting this code with 46255-46258 (Hemorrhoidectomy …), which are “more extensive procedures,” according to CCI.

You cannot separate these bundles with a modifier under any circumstance — except for the case of 46258 (Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including fissurectomy, when performed) with 46930. In this one case, you can use a modifier if necessary, but you have to have documentation to back this up.

You shouldn’t report 46930 with 46500 (Injection of sclerosing solution, hemorrhoids) — a code combination you shouldn’t be reporting anyway. Because this edit carries a modifier indicator of “0,” you cannot separate this bundle with a modifier under any circumstance.

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

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Want to know more about obgyn coding? Check out these upcoming conferences from The Ob-gyn Coding Alert consulting editor, Melanie Witt: The Ins and Outs of Colposcopic Billing and Documentation and Coding Musts for NSTs, CSTs, and BPPs.