Coding Strategy

If the doctor does not circle a diagnosis, it may be up to you to find one.

Don’t let an incomplete superbill damage your chances of submitting an accurate claim. If the doctor in your office fails to indicate the ICD-9 code for the condition that he treated, you should read through his documentation to find which diagnoses you should report.

Open the Notes When You Have to — and Even When You Don’t

Suppose your physician hands you a superbill with the procedures circled and the diagnosis left blank.

You could ask the physician which diagnosis to report, or you could examine the documentation yourself. If your office has a policy that includes “coding by abstraction” by certified/qualified coders, then submitting charges based on what is supported (documented) in the note is appropriate, says Barbara J. Cobuzzi, MBA, CPC, CPCH,CPC-P, CENTC, CHCC, with CRN Healthcare Solutions in Tinton Falls, N.J. The physician should be signing off on these charges as part of your internal policy.

Some practices choose to review the documentation and compare it against any diagnoses recorded on the superbill, even when they aren’t required to. This ensures that the documentation matches the code selection every time.

When in Doubt, Confirm With the Physician

If you are new at coding diagnoses from the physician’s notes, you should doublecheck your code selections with the practitioners before submitting your claims.

“Until a coder feels comfortable with the ICD-9 books and the codes used more often in their office, it’s a good idea to run the choices by a clinician,” says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with the Physician Services Division of UPMC in Pittsburgh. “You never want to give a patient a disease or symptom they don’t have  ” or one more severe (or less) than what they have. This is also beneficial to the physicians, as if you select unspecified codes a lot they may learn how to better document the patient’s condition into their notes.”

Tip: Make sure your office creates a policy in writing that spells out what you should do when you encounter a superbill with no diagnosis listed. Some physicians prefer that you ask them for information, while most others rely on their coders to select an accurate code.

Check the Notes for Clues

Consider this example of a situation in which the coder must fill in the gap when the doctor has not written a diagnosis on the patient’s superbill.

Example: The physician’s superbill shows a level-three office visit with a patient wearing a lumbar orthosis. It also shows a date of injury of three days prior to the date of service and is missing the diagnosis code.

First step: You refer to the dictation, which reads: “The patient is a 13-year-old female being evaluated as a consultation at the request of Dr. Jones for lumbar pain. The low back pain started on 12-9-09 when she did splits during cheerleading.” The physician completes the remaining history, review of systems (ROS), past family and social history (PFSH), and exam.

Moving down through the chart note, you see that the patient brought an MRI and x-ray with her, which demonstrated a hairline fracture to the patient’s third lumbar vertebra (L3).

Under a separate heading, the doctor has given his assessment, which states: Closed L3 fracture, benign.

Next step: You look up “fracture” in Vol. 2 of the ICD-9 book and the most specific body area listed is “vertebra, lumbar (closed),” which is 805.4 (Fracture of vertebral column without mention of spinal cord injury; lumbar, closed).

You turn to Vol. 1 and read the information under the “fracture of vertebral column” heading to check for exclusions and see that none apply in this case. You search under 805.4 to see if by chance the book lists codes for benign or traumatic fractures, which it does not.

In addition, ICD-9 does not instruct you to add a fifth digit to 805.4. Therefore, you know that 805.4 is the most accurate code for your doctor’s visit.

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

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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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Watch those Taxotere units, or kiss 95 percent of your reimbursement goodbye.

A brand new list of HCPCS codes — including docetaxel and bevacizumab updates — goes into effect Jan. 1 and our 8-step superbill maintenance plan will stop denials in their tracks for 2010.

Not using the proper codes will lead to claim rejection, which means “not receiving the proper reimbursement. And no one wants to start out their new year that way,” points out Lisa Martin, CPC, CIMC, CPC-I, who oversees the charge operations for a large, independent community cancer center in central Illinois and is an active instructor for the AAPC’s Professional Medical Coding Curriculum.

1. Docetaxel Do: Swap J9170 for J9171

The most widely used of the new chemotherapy HCPCS codes may prove to be J9171 (Injection, docetaxel, 1 mg), says Martin. Oncologists may prescribe docetaxel (Taxotere) for breast cancer, non-small cell lung cancer, prostate cancer, gastric cancer, and head and neck cancers.

Units alert: HCPCS 2010 deletes 2009 docetaxel code J9170 (Injection, docetaxel, 20 mg). The main difference is how you’ll calculate units. In 2009, you reported 1 unit for every 20 mg. In 2010, you’ll report 1 unit per 1 mg. If you fall into old habits, billing 1 unit for every 20 mg, you’ll only get 5 percent of the reimbursement you’re due, warns Roberta Buell, MBA, in her Nov. 17 E-Reimbursement newsletter for OnPoint Oncology in Sausalito, Calif.

2. Focus on J9155 for Firmagon

Depending on your specialty, you may find J9155 (Injection, degarelix, 1 mg) useful in the new year, says Martin.Oncologists prescribe degarelix (Firmagon) for patients with advanced prostate  cancer.

As with the new docetaxel code, you’ll report 1 unit for every 1 mg of degarelix.

3. Choose J9328 for IV Temozolomide

New code J9328 (Injection, temozolomide, 1 mg) may be of more interest to certain practices, says Martin.

Temozolomide (Temodar) treats particular types of brain cancer, specifically glioblastoma multiforme (coded as a malignant neoplasm based on site) and refractory anaplastic astrocytoma (also coded as malignant neoplasm by site). Remember that J9328 is particular to the intravenous formulation, not the oral drug.

4. Say ‘So Long’ to Short Lived Q2024

Confusion abounded when CMS created Q2024 (Injection, bevacizumab, 0.25 mg), effective Oct. 1, 2009. Oncology coders already had J9035 (Injection, bevacizumab, 10 mg) for bevacizumab (Avastin).

The lower dosage amount (0.25 mg per unit) made Q2024 more appropriate for ophthalmologists who use smaller amounts. But their outcry about payment problems encouraged CMS to delete Q2024, bringing much cheering from oncology and ophthalmology coders alike.

Bottom line: In 2010, continue to use old faithful code J9035 for bevacizumab

5. Move Mozobil Coding to J2562

If you provide plerixafor (Mozobil) injections, be sure you highlight new code J2562 (Injection, plerixafor, 1mg). The FDA approved the drug in 2008 for patients with non- Hodgkin lymphoma and multiple myeloma. When combined with granulocyte-colony stimulating factor (GCSF), plerixafor stimulates stem cells to move out of the bone marrow and into the blood stream so the physician may collect the cells for later autologous transplant.

(“Autologous” means the cells are transplanted back into the same patient.)

Tip: The codes you may use for G-CSF include filgrastim (Neupogen) codes J1440 (Injection, filgrastim [G-CSF], 300 mcg) and J1441 (Injection, filgrastim [GCSF], 480 mcg). Ensure, however, that you choose the most appropriate code based on the strength ordered and administered according to the supporting documentation.

6. Add J2796 for ITP Patients

Practices treating patients for chronic immune (idiopathic) thrombocytopenic purpura (ITP) need to know about J2796 (Injection, romiplostim, 10 micrograms). Romiplostim (Nplate) stimulates bone marrow megakarocytes to produce platelets, helping ITP patients, who have lower than normal platelet counts.

7. Jump to J7185 for Xyntha in 2010

Xyntha antihemophilic factor will get an upgrade from temporary code Q2023 (Injection, factor VIII [antihemophilic factor, recombinant] [Xyntha], per I.U.) to new permanent code J7185, which has the same descriptor.

Because of this change, HCPCS 2010 deletes Q2023 and tweaks the descriptor for J7192, making it a “not otherwise specified” code:

• 2009: J7192 — Factor VIII (antihemophilic factor, recombinant) per IU

• 2010: J7192 — Factor VIII (antihemophilic factor, recombinant) per IU, not otherwise specified.

8. Separate Ferumoxytol Codes by ESRD Use

The iron containing product ferumoxytol (Feraheme) has two new temporary codes for 2010:

• Q0138 — Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)

• Q0139 — Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis).

Note that Q0138 is specific to non-end stage renal disease (non-ESRD) use and Q0139 is for ESRD patients on dialysis.

Currently, the drug has FDA approval for patients with chronic kidney disease. Interestingly, the drug also has potential as an MRI contrast agent and may prove useful in tumor imaging.

Remember: You can download the latest HCPCS file from the CMS Web site here.

AUDIO ON-DEMAND: 2010 Oncology Coding Update.

Oncology Coding Reference CD Collection for 2010.

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