Coding Strategy

Pain management specialties might make use of modifier 52 as well.

The situation is bound to happen: A patient undergoing surgery has complications, and your anesthesiologist must stop his services. Are you prepared to recognize a situation that calls for modifier 53 (Discontinued procedure) or even modifier 52 (Reduced services)? Learn the specific criteria for reporting each modifier to ensure successful coding every time.

Patient Status Often Determines 53 Use

You will use modifier 53 when a procedure ends due to a threat to the patient’s well-being or other extenuating circumstances. For example, the surgeon performs a preop assessment, but during the evaluation he detects a carotid bruit (785.9, Other symptoms involving cardiovascular system), so he delays the surgery indefinitely until a better evaluation can be made.

Documentation clue: You can only use modifier 53 after anesthesia administration and/or a surgical preparation took place, and the procedure was actually started. You should consider the procedure discontinued when anesthesia ends early. “If any modifier is to be used, 53 is the most appropriate,” says Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York.

Example: A patient is being prepared for a routine surgery but has not yet been induced. Another patient develops chest pains and must be induced for surgery immediately, so your anesthesiologist must cancel the first procedure to attend to the second patient’s procedure. You should report 01999 (Unlisted anesthesia procedure[s]) with modifier 53, Groudine recommends.

You should let the payer reduce the fee on services to which you attach modifier 53. Otherwise, you risk additional payment reductions.

Bottom line: When reading the operative report of a discontinued service, simply look at the reason for the discontinuance. If it indicates an extenuating circumstance occurred, use modifier 53.

Facility difference: If you are coding only for facility payment, such as for an ambulatory surgical center (ASC),use modifiers 73 (Discontinued outpatient procedure prior to anesthesia administration) or 74 (Discontinued outpatient procedure after anesthesia administration) instead of modifier 53.

Turn to 52 for ‘Physician Discretion’

Although modifier 52 may not apply to anesthesia, it might apply to pain management specialists. Find out when you should use modifier 52 for your pain management specialist by subscribing to the Anesthesia & Pain Management Coding Alert.

Editor: Joshua Thines

Sign up for the upcoming live audio conference, Anesthesia Coding 101, or order the CD/transcripts.

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Decipher what column 1/column 2 means in this neurosurgery bundle example.

Question: Would you explain what the differences are between mutually exclusive and “column 1/column 2″ edits that come from the Correct Coding Initiative (CCI)?

Florida Subscriber

Answer: Mutually exclusive edits pair procedures are services that the physician could not reasonably perform at the same session on the same beneficiary.

For example, CCI lists 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) as mutually exclusive of 61313 (… intracerebral). The payer would not expect that the neurosurgeon would perform both types of craniectomy on the same date for the same patient because they describe different, exclusive procedures.

Bottom line: If you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser-valued of the two procedures (in the case of 61312 and 61313, the payer would reimburse only 61312).

Column 1/column 2 edits describe “bundled” procedures. That is, CMS considers the procedure code listed in column 2 as the “lesser” service, which is included as a component of the more extensive,-column 1 procedure code.

Example: The CCI contains an edit bundling 61535 (Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue [separate procedure]) with 61320 (Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial).

In this case, 61320 is the more extensive procedure which includes the “lesser” procedure 61535. In theory, removing the electrode array is not significant enough to warrant separate payment when it’s done at the same time as the abscess drainage.

Bottom line: If you were to report bundled (column 1/column 2) procedures for the same patient during the same session, Medicare would reimburse only for the higher-valued of the two procedures (in the case of 61320 and 61535, the payer would reimburse only 61320).

@ Neurosurgery Coding Alert, Editor: Leigh DeLozier, CPC

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Find out what incident-to requirements you have to meet.

Question: Is there any circumstance in which a group can bill all services and all providers (including other physicians) under just the head doctor? I know we can bill NPP services incident-to another physician, but what about other physicians?

Wisconsin Subscriber

Answer: No, you cannot always bill services for all providers under one of the group’s medical doctors. One reason is because …

… you may not bill one doctor incident-to another doctor. Incident-to rules don’t apply here because they pertain to the relationship between a physician and a nonphysician practitioner (NPP).

Bottom line: It is never acceptable to bill services provided by one physician under another physician’s name or national provider identifier (NPI). Billing under the name of a physician who did not perform the service can lead to problems including false claims submission allegations.

You can, however, report NPP services incident-to the medical director if the visits meet all the requirements of incident-to services. The NPP could be a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist — as long as the NPP meets state and federal guidelines to provide the service. The NPP must be “licensed by the state under various programs to assist or act in the place of the physician,” according to the Medicare Benefit Policy Manual, Chapter 15.

Best bet: Check your state and local Medicare Audit Contractor’s (MAC) or Medicare carrier’s regulations for NPP qualifications. If the NPP does not meet one or both sets of guidelines, don’t bill incident-to for physicianlevel services (such as 99212-99215, Office or other outpatient visit …).

For more on incident-to billing, refer to the Medicare Benefit Policy Manual, Chapter 15, Section 60.2.

@ Podiatry Coding Alert

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5 tips help you recover deserved pay.

Collecting money from patients, especially during a recession, can be challenging. If your front desk is responsible for collecting copays and sometimes old balances, its success or failure has a dramatic impact on the practice’s bottom line.

Check out five ways you can improve your front desk collection efforts:

1. When calling to remind patients about their visit date, also remind them of their co-pay amount and any old balances so they come prepared to pay at the visit.

2. When a patient complains about paying a bill, send her to a manager so the bill can be reviewed and explained.

3. Most practice management software will allow front desk staff to view outstanding balances. Your front desk staff can politely remind the patient that there is a balance and say something like, “How would you like to pay your bill today?” Assume that the patient is planning to pay.

4. If the patient has a problem paying their balance or paying for the visit that day, do not discuss this at the front desk. Respect his privacy. Staff may wish to take him to a manager’s office where a payment plan or other arrangement can be established.

5. Ask your manager about offering discounts to patients with no insurance if they pay for the visit at checkout instead of sending them a bill.

And one extra tip: Involve Your Supervisor. Pearl Stafford, front office manager for an internist and gastroenterologist in Naples, FL, who also once worked for a psychiatrist where she assumed the role of the receptionist from time to time, acknowledges that old or really old AR can be difficult to collect. “A lot hinges on the physician,”says Stafford. “In this particular office, my physician provided incentive. Since the AR was so old in many cases, he offered me 25 percent of anything I collected. Most collection agencies charge 50 percent, so this was beneficial to the practice and also worked as an incentive for me.” If something is really old, it’s better to collect some money as opposed to nothing and wipe it off the books.

Carol Gibbons, CEO of CJ Consulting, helps management to set up collection targets for the front desk and then rewards staff when they reach that goal. “In one practice with seven physicians, the front desk as collecting $500 per day at the front desk. After doing training with the front desk staff, we started pushing up their collection goal and then bought lunch each time they reached a new goal. Today, at the front desk, that office collects $2,500 to $3,500 per day in co-payments, co-insurance, and old balances. The manager still buys pizza when they reach a new high in daily collections or rewards individual employees with gift cards.”

Again, your specific role in collections will vary, but these are some ideas that you may wish to present to your manager or physician if they are not yet implemented in your office.

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Verify co-pay early to save time, money

Question: A patient came to our office for a routine exam with the same insurance card she’s had for years. We charged her the standard copay of record. Then I found out her employer changed the terms of the insurance, so the copay she paid was short by $20. What went wrong?

Answer: You might easily assume that when a patient has the same insurance company, the copay is the same as it has always been. But unless you check first, you won’t know the patient’s coverage has changed until after the fact.

Best practice …Set up a process to verify each patient’s insurance information before every visit. The ideal time to verify with a patient or her insurance company is either before the appointment or when she arrives at your office. Devise a plan for how you will obtain patient information early on. Your options include connecting with the patient, a software program, or through the payer directly.

Finally, copy every patient’s insurance card every time. This simple step will put you in the clear for those times when a patient’s terms, copays, or precertification contact numbers have changed.

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