Here are the pros and cons to help guide your decision.

Question: Our practice is considering accepting patients with PFFS plans. We’re heard that some patients are starting to have them, but we’re not sure whether we’re going to accept them or not. Are PFFS plans beneficial for us?

Answer: PFFS are Private Fee-for-Service plans, which are non-network plans. These plans let members receive care from any doctor or hospital that accepts the plan’s payment terms and conditions.

If your practice decides to accept these terms, you would become a “deemed” provider. Plan members can receive covered services from any deemed provider in the U.S. However, member patients must confirm that the provider is deemed every time a service is provided.

PFFS plans are different from Medicare Advantage plans because they do not require a doctor or hospital to contract with a health plan to provide services. This means that doctors or hospitals that do not agree to the PFFS plans’ terms and conditions may choose not to provide health care services to a plan member, except in emergencies.

Coming soon: Starting in 2011, PFFS plans will have to measure and report on their providers’ quality of care. But the catch is that they’ll also have to form provider networks with contracts.

In counties where there are two or more non-PFFS plans, PFFS plans will no longer be able to simply “deem” providers into the plan without a contract. Under current law, PFFS plans don’t have to prove they can meet access standards if they allow any willing qualified Medicare provider to participate, and they pay as traditional Medicare would pay.

One argument is that the network requirement would provide better access to care because there would be contracts between the providers of services and the plan. On the other hand, private FFS plans may limit the number of providers who participate, actually resulting in poorer access to care.

@ Medical Office Billing & Collections Alert (Editor: Joshua Thines).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Plus: CMS has proposed freezing the ICD-9 codeset after next year.

If you were hoping that the Oct. 1, 2013 ICD-10 implementation date wasn’t set in stone, you are out of luck. That’s the word from CMS during a June 15 CMS Open Door Forum entitled “ICD-10 Implementation in a 5010 Environment.”

“There will be no delays on this implementation period, and no grace period,” said Pat Brooks, RHIA, with CMS’s Hospital and Ambulatory Policy Group, during the call. “A number of you have contacted us about rumors you’ve heard about postponement of that date or changes to that date, but I can assure you that that is a firm implementation date,” she stressed.

Brooks indicated that the rumor about a potential delay in the implementation date continues to persist throughout the physician community, and recommended that practice managers alert their physicians to the fact that that the rumor is untrue.

The Oct. 1, 2013 date will be in effect for both inpatient and outpatient services. Keep in mind that the ICD-10 implementation will have no impact on CPT and HCPCS coding, Brooks said. You will still continue to bill your CPT and HCPCS procedure codes as before.

You’ll Find Nearly 55,000 Additional Codes

Currently, CMS publishes about 14,000 ICD-9 codes, but there are over 69,000 ICD-10 codes. The additional codes will allow you to provide greater detail in describing diagnoses and procedures, Brooks said.

If you’re wondering which specific codes ICD-10 includes for your specialty, you can check out the entire 2010 ICD-10 codeset, which CMS has posted on its Web site. “Later this year, we’ll be posting the 2011 update,” Brooks said during the call.

@ For more details on CMS’ upcoming plans, subscribe to Part B Insider (Editor: Torrey Kim, CPC).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

MACs won’t process June claims until today, in hopes that Congress will act.

The Senate’s delays could mean serious payment crunches for your practice.

Last month, the freeze that has been keeping the Medicare conversion factor at 2009 levels expired, meaning that Part B practices were due to face a 21-percent cut effective for dates of service June 1 and thereafter. Because Congress had not yet intervened to stop those cuts, CMS initially instructed MACs to hold claims for the first 10 business days of June while lawmakers could deliberate whether to eliminate the looming cuts.

When the Senate reconvened on June 7, many analysts expected its members to vote on H.R. 4213, “The American Jobs and Closing Tax Loopholes Act of 2010,” which was expected to increase your payments through the end of this year, according to the text listed on the House Ways and Means Committee Web site. However, the bill has not passed, leading CMS to extend the MACs’ claims hold through June 17.

According to a June 14 CMS notification, the agency directed its contractors “to continue holding June 1 and later claims through Thursday, June 17, lifting the hold on Friday, June 18.”

CMS acknowledged in its June 14 notification that the lengthened claims hold period “may present cash flow problems for some Medicare providers. However, we expect that the delay, if any, beyond the normal processing period will be only a few days.”

The impact of the 17-day claims hold will vary, depending on the practice and how many Medicare patients it sees, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Those practices with large Medicare populations could face a cash flow crisis, 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.

“The claims hold effectively cuts off their Medicare pay for that period,” Cobuzzi says. “This has been happening almost monthly this year (with a few exceptions that gave us multiple month extensions).”

Avoid Holding Claims on Your Own

Some practices do not count on Medicare to do the claims hold correctly, so they are holding the claims themselves, Cobuzzi says. “In May, the MACs released payments before the fix was in, at the 21-percent reduction, and then those claims had to receive corrections,” she notes. “The practices that are holding their own claims figure that kind of mistake will not happen to them. But their delay will be even longer because they are not submitting to Medicare until the fix is voted on and then they have to wait the time period for Medicare processing.”

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

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Don’t let 2006 DXA code references lead you to use wrong codes.

Which codes should you use to reap the benefit of CMS’s new calculations for bone scan payment? During an April 13 CMS Open Door Forum, that’s what one caller wanted to know.

Good news: He was delighted that, thanks to the new healthcare 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. The caller asked whether MACs will be requesting those old codes going forward, or whether practices should continue reporting current codes 77080-77082 (Dual-energy X-ray absorptiometry [DXA] …).

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

Added support: CMS transmittal 700, effective Jan. 1 and implemented June 1, announces increased payment for DXA scan imaging, making the new non-facility total relative value units (RVUs) 2.70. The original 2010 fee schedule listed the transitioned non-facility total RVUs for this code as 1.71.

When combined with the conversion factor of $36.0791, that makes DXA pay about $97.00, a $36.00 increase over the previous payment of approximately $61.00. The calculation for the new rates depended on 2006 values, which is why the now-deleted codes are referenced. The transmittal notes that 77080 and 77082 replaced the 2006 codes.

@ Optometry Coding Alert (Editor: Jerry Salley, CPC).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Despite disadvantages, a new tax ID is a must when physicians leave your group.

Question: One of our optometrists wants to stop billing under the group’s tax ID and start billing under his own tax ID. I’m concerned that doing so will confuse the insurance companies and slow down his income, even though he has personally called some to notify them of the change and the effective date. Some payers are now asking for new W9 forms. Is there an easy way to do it?

Answer: Your optometrist can change his tax ID at any time, but you must submit a new W9 to your payers, in addition to a letter explaining that he will no longer be practicing under the group’s tax ID.

Downside: Yes, the optometrist’s income will be slowed. You also run the risk that the payer’s enrollment department does not handle the paperwork properly. Other billers have reported instances of the income being paid to the old tax ID or not being paid at all. Claims can also be lost even though the correct paperwork has been submitted multiple times.

If your optometrist is currently part of a group, and he is leaving the group, he needs his own tax ID. Many legal issues will arise from this. For example, if he is staying in the same office suite, he will have to pay market rent for the offices and staff that he is using. When patients move between the old practice and his new practice, questions will arise about which patients are considered new and which are considered established patients.

Much of this will have to be determined by the legal structure that is set up as he leaves the group. This can be a much more complex change than it appears on the surface. Your best bet is probably to consult a healthcare attorney.

@ Optometry Coding Alert (Editor: Jerry Salley, CPC).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

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).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Study frequency guidelines before you bill for counseling services.

Question: A 60-year-old established Medicare patient with a confirmed diagnosis of vanishing lung (emphysema) reports to the family physician (FP) for a medication check and blood work; the patient is a moderate smoker. During the medication check and blood work, which took about 5 minutes, the patient tells the practice’s non-physician practitioner (NPP) “I think I’m ready to quit smoking; can you help?” The NPP spends the next 7 minutes providing smoking cessation counseling for the patient. Can I report a cessation code and an E/M?

Answer: Provided the patient meets Medicare’s requirements for cessation counseling, you can report the following:

• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes or less are spent performing or supervising these services.) for the E/M

• 492.0 (Emphysema; emphysematous bleb) appended to

• 99211 to represent the patient’s emphysema

• 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) for the smoking cessation counseling

• 305.1 (Tobacco use disorder) appended to 99406 to represent the patient’s tobacco dependency.

Know the rules: According to Medicare, its patients are entitled to smoking and tobacco use cessation counseling provided the patient is either:

• a tobacco user who has an illness caused or complicated by tobacco use or

• taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on Food and Drug Administration-approved information.

Additionally, note these two frequency guidelines for spot-on 99406 and 99407 (… intensive, greater than 10 minutes) claims:

• Medicare will cover up to two counseling attempts per year for the first 12-month period of counseling (Each attempt can include up to four counseling sessions).

• Medicare will cover up to eight more sessions during a second or subsequent 12-month period of counseling after 11 full months have passed since the first Medicare covered cessation counseling session was performed. For example, if the first of eight covered sessions was performed in April 2009, a second series of eight sessions may begin in April 2010.

@ Family Practice Coding Alert (Editor: Chris Boucher, CPC).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

If patient’s critical care and visit satisfies time regs, 99291 is the better bet.

When scouring the notes for evidence of an emergency department caveat scenario, coders can easily forget to ask themselves one simple question: Can I report a critical care code for this scenario?

The answer’s yes more often than you might think, says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La.

“Many patients who qualify for the caveat may also be candidates for critical care. If the condition is severe enough that the patient’s ability to provide this information is impaired, then the condition may be critical,” she explains.

Critical Care Omits Specific History Component

Considering critical care and the caveat simultaneously can make your head spin, as the ED caveat does not even apply to 99291 (Critical care, evaluation and management of the critical ill or critically injured patient; first 30-74 minutes) or +99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

Why? “There are not the same bullet-counting requirements for documentation of history, physical examination, or MDM [medical decision making] for critical care,” explains Edelberg. The descriptors for critical care concern only E/M of the critically ill or injured patient.

So when your physician invokes the emergency department caveat for a patient, check to see if the patient was critically ill or injured; if she was, and the physician documents at least 30 minutes of critical care, consider 99291.

Payout: The only level of service you can invoke the emergency department caveat on is 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 …).

The 99285 code pays about $171 nationally (4.74 transitioned facility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.0846), whereas 99291 garners about $217 (5.99 RVUs multiplied by 36.0846).

Check Out This Critical Caveat Scenario

We asked Michael Lemanski MD, emergency department billing director at Baystate Medical Center in Springfield, Mass., to describe a scenario in which the physician provides critical care to a patient who also qualifies for the emergency department caveat:

Emergency medical services (EMS) presents with two teenage girls that were involved in a high-speed motor vehicle crash with roll-over. One of the girls has been extricated, has a traumatic amputation of her left arm, and lost vital signs en route to the ED. The other has a head injury, is hypotensive, and appears too intoxicated to provide any history for either patient. The girl who lost vitals en route is clearly critically injured, but the only history available to the physician is when the collision occurred, where, and how. Details about past medical history, social history, family history and review of systems (ROS) are unavailable. The physician spends a total of 64 minutes providing critical care services for the patient.

Caveat achieved, but …: In this instance, the emergency department physician could reasonably invoke the emergency department caveat — but it is unnecessary, as you should report 99291 for this encounter.

@ Emergency Department Coding Alert (Editor: Chris Boucher, CPC).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Maximize 11040-11044 pay with modifier 51.

In most cases, your practice won’t report debridement separate from wound repair codes. But when exceptions arise, follow these three tips to choose the appropriate wound repair code.

If you’re considering reporting debridement separate from a wound closure, make sure your physician’s notes clearly document that the wound was contaminated and required saline or other substances or instrumentation to cleanse and debride the wound.

Don’t miss: If you report a debridement code with your wound closure codes, append modifier 59 (Distinct procedural service) to the debridement code. This informs the payer that you recognize that debridement is generally bundled into wound repair, but that clinical circumstances required the physician to perform debridement as a separate service.

1. Look for Wound Repair With the Debridement

CPT specifies that you may also report debridement codes independently of repair codes when the physician removes large amounts of devitalized or contaminated tissue or when the physician performs debridement without immediate primary repair of a wound, notes Pamela Biffle, CPC, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas.

The physician may clean debris from the wound without repairing the wound because it was either not deep enough to require repair or the physician delayed the repair due to an extenuating circumstance.

In the case in which the dermatologist excises a lesion, debridement is included in the procedure. However, when the dermatologist only performs debridement or performs the debridement in addition to the wound repair, such as the case when a wound is excessively dirty or contaminated with debris, you would also code the debridement code with the wound repair/excision code, appending modifier 51 (Multiple procedures) for the multiple procedure.

Example: A patient returns to the dermatologist several days after a chemical peel to her forehead, cheeks and chin. The areas on her chin are weeping a purulent material, and the wound is infected. The dermatologist debrides the infected areas of her chin and applies an antibiotic ointment.

You should report this scenario using codes 11640 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less) and 11040 (Debridement; skin, partial thickness) also with modifier 51.

2. Make Sure Debridement Doesn’t Justify a Higher Level Repair

Although physicians most commonly clean a wound immediately before they repair a wound, you wouldn’t report a debridement code separately. Don’t miss: The debridement procedure may also necessitate a repair procedure that will affect your billing report.

@ To learn more about debridement pay, including the reimbursement difference between simple and intermediate repair codes and which supplies net you cash, subscribe to Dermatology Coding Alert (Editor: Jerry Salley, CPC).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

The reason your patient is visiting is key.

Question: We have a patient who came in for a routine eye exam, but reported retinal damage from a BB-gun incident six years ago. What would be the best way to code this? This is a new patient, and I do not have any old records.

Answer: Unless the BB-gun injury six years ago has something to do with why the patient is there, it may not have any bearing on your coding. The diagnosis code always depends on the reason for the visit. If the patient decided to see an optometrist because of eye pain, eye pain (379.91, Pain in or around eye) — or whatever the optometrist found that was causing the pain — would be the diagnosis. If the eye pain is indeed the late effect of the BB-gun injury, you could report 906.0 (Late effect of open wound of head, neck and trunk) as a secondary diagnosis.

“When reporting late effects of an acute injury,” instruct the ICD-9 guidelines, “code the residual problem/condition as the primary diagnosis and record the appropriate late effects code as a secondary diagnosis.” In the above example, 379.91 would be the primary diagnosis, and 906.0 would be the secondary diagnosis.

However: If this was truly a routine exam, and the patient denies any current complaints, you would have to use V72.0 (Examination of eyes and vision) as the diagnosis. Unless the patient has vision insurance that covers routine exams, most carriers won’t reimburse you for this visit.

@ Ophthalmology Coding Alert (Editor: Jerry Salley, CPC).

Sign up for the upcoming live audio conference, Risk Management Strategies for Healthcare Providers, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.