Coding Strategy

Get ready for the dawn of new jaw pain, BMI codes, among others.

If you’ve got high hopes that you’ll benefit from many new ICD-9 codes starting this fall, CMS delivers, with over 130 new diagnosis codes debuting on Oct. 1. CMS published the full listing of codes in a 1,000+ page Federal Register file, but we’ve reviewed the list, and it offers a few surprises.

Over one-third of the new codes can be found in the “V” code section, which describe “supplementary classification of factors influencing health status and contact with health services,” according to the ICD-9 manual.

BMI Info Is Now Clearer

“They’ve expanded the body mass index (BMI) codes to demonstrate higher BMIs with five new codes,” notes Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC with CRN Health-care Solutions in Tinton Falls, NJ.

Whereas in the past, you had just one V code to represent a BMI index over 40 (V85.4), the new edition of ICD-9 will offer additional categories, ranging from a BMI of 40.0 to 44.9 (V85.41) through a BMI of 70 and over (V85.45).

“BMI has become an important health tool, and those codes will also provide more data,” says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, CEO of Healthcare Consulting & Coding Education, LLC. “There are seven vital signs that count for the constitutional bullet in the E/M review of systems coding, and there are those who are of the opinion that BMI should be an eighth option, especially in bariatrics and orthopedics/sports medicine.”

If that eighth bullet does gain traction and come into play for coders, the new V codes could help considerably.

New Jaw Pain Code Debuts

Pain code: You’ll find new code 784.92 (Jaw pain) effective Oct. 1. According to notes made by the ICD-9-CM Coordination and Maintenance Committee in Sept. 17, 2009, “it was suggested to somehow differentiate temporomandibular joint disorders and this code, perhaps using an excludes note.”

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A revised GA and new GX hope to clarify some of Medicare’s non-coverage policies.

At least one aspect of dealing with Advance Beneficiary Notice of Non-Coverage (ABN) forms is about to get a little simpler, thanks to two modifiers.

CMS is now giving you two HCPCS level 2 modifiers to distinguish between voluntary and required uses of liability codes, according to release CR6563.

Know when you need an ABN with this expert advice:

Background: When your physician provides a service that Medicare does not cover, your practice must provide an ABN to the patient. The patient should then examine and complete the form before your providers administer that service or procedure.

When you have a patient sign an ABN, you also need to append the appropriate modifiers on your claim. ABN modifiers tell the Medicare carrier that you have an ABN on file for services that won’t be covered.

Luckily, modifiers GA (Waiver of liability on file) and GX (Notice of liability issued, voluntary under payer policy) should add more tools to your belt that will help you fend off denials.

Good practice: “It is in the provider’s best interest to discover which procedures need ABNs in their offices, and flag accounts prior to the patient coming in,” says Melinda Brown, CMBS, insurance biller with H. Matt Smith, MD in Kennewick, Wash.

Don’t Waver on Modifier GA Use

CMS redefined modifier GA to be a “waiver of liability statement.” You should only use modifier GA “to report when a required ABN was issued for a service, and should not be reported in association with any other liability-related modifier and should continue to be submitted with covered charges,” CMS says.

Simply put, “the GA indicates that you have a signed ABN on file,” Brown explains.

Unfortunately, using GA does not mean you’ll get automatic reimbursement. According to the CMS guidelines, a GA modifier indicates the possibility that a service may be denied for medical necessity only, and that the physician may bill the patient after the claim is denied.

Example: A patient presents for lesion destruction (freezing) of seborheic keratosis(es). In this case, you would bill 17000 (Destruction [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [eg, actinic keratoses; first lesion) and 17003 (second through 14 lesions, each) times three units of service, for four total lesions with a diagnosis code of 702.19 (Other seborrheic keratosis). You’ll need to obtain an ABN from the patient and then use modifier GA since Medicare may deny 17000 with any diagnosis except 702.0 (actinic keratosis), for medical necessity, says Brown.

Use GX for a Voluntary ABN

When your practice issues a voluntary ABN for a particular service, you’ll instead turn to modifier GX. CMS defines modifier GX as “notice of liability issued, voluntary under payer policy.” You will use modifier GX when you need a denial remittance advice to submit for secondary insurance, when Medicare does not pay as primary, but the secondary insurance does pay with a denial explanation of benefits (EOB).

Old way: Before CMS revised the ABN last year, you would have used a Notice of Exclusion of Medicare Benefits (NEMB) form for these cases. CMS eliminated the NEMB, however, so modifier GX helps you tell the payer you have a voluntary ABN on file.

You might also use the ABN for a never covered service if a patient does not believe the service is not covered and insists that you submit the claim to Medicare. You would have the patient sign the ABN and submit the service to Medicare with a GX modifier so that the patient receives the denial remittance advice.

Watch for: If you append GX on the same line as many liability-related modifiers, including EY (No doctor’s order on file), GA, GL (Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN), and others, Medicare will likely deny your claim.

Example: A patient needs a hearing aid, which Medicare never covers, but the patient has secondary insurance that will pay. The patient signs an ABN. You should submit the claim to Medicare with a GX modifier. Your practice may then submit to the secondary insurance, which will pay for a part of the hearing aid based on the denial from Medicare.

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Discover these subsequent reconstruction codes.

Question: The surgeon treated a patient with a large choledochal cyst. The procedure involved an open cholecystectomy with en bloc excision of extrahepatic bile ducts (roux-en-Y reconstruction) with hepaticojejunostomy. What are the correct CPT and ICD-9 codes?

Answer: The correct ICD-9 code will depend on whether the patient has an acquired or congenital choledochal cyst. You would expect to see the congenital cyst more commonly in pediatric patients. Assuming that the patient has an acquired cyst, the correct diagnosis code is 576.8 (Other specified disorders of the biliary tract). On the other hand, if your surgeon is treating a patient with a congenital choledochal cyst, you should report the diagnosis as 751.69 (Other anomalies of gallbladder, bile ducts, and liver).

CPT does not provide a specific code to describe excision of extrahepatic bile ducts, but …

you will find some codes that describe the subsequent reconstruction.

For the cholecystectomy, you should report 47600 (Cholecystectomy). If the duct excision represents significant extra work, you can append modifier 22 (Increased procedural services) to 47600. The surgeon’s documentation should specify extra time and procedural steps that support using this modifier.

In addition to 47600, you should report the appropriate Roux-en-Y reconstruction code. Assuming that the surgeon anastomosed the intrahepatic ducts subsequent to removing the extrahepatic ducts, you should report 47785 (Anastomosis, Roux-en-Y of intrahepatic biliary ducts and gastrointestinal tract) for the repair.

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Wonder if there’s a method to the 76001 madness? Here’s where to look for answers.

The silver lining to the 18,000 Correct Coding Initiative (CCI) that just came rumbling in with CCI 15.3. Analyzing them can help you master radiology coding essentials — including follow-up CTs, fluoro, and more. Apply these five lessons to keep your claims looking their best.

Remember: The latest round of edits, version 15.3, went into effect Oct. 1. You can download the updates at the beginning of each quarter from the CMS Web site, suggests Alice E. Wonderchek, CMBS, CPC, billing and coding specialist with Franklin & Seidelmann Subspecialty Radiology in Beachwood, Ohio. You can download the CCI manual here, as well.

1. Proceed With Caution When Coding 76380

Randomly choose a code for computed tomography (CT) or computed tomography angiography (CTA), and odds are that CCI 15.3 bundles 76380 (Computed tomography, limited or localized follow-up study) into it.

Example: The radiologist performs calcium scoring and a follow-up CT. You should report only 0144T (Computed tomography, heart, without contrast material, including image postprocessing and quantitative evaluation of coronary calcium). You should not add 76380 for this claim, according to the new edits.

These additions join edits in place since 1997, bundling 76380 into 71260 (Computed tomography, thorax; with contrast material[s]) and 74150-74170 (Computed tomography, abdomen …). These edits have a modifier indicator of “1,” which means you may override them with a modifier when appropriate.

You may not use 76380 often, but CPT Assistant (July 2007) states that for a limited CT, 76380 is an alternative to using a procedure-specific CT code with modifier 52 appended, says Stacie L. Buck, RHIA, CCS-P, RCC, CIC, president and senior consultant of RadRx in Stuart, Fla.

Example: ACR’s July/August 2006 Radiology Coding Source demonstrates a potential use of 76380, depending on payer preference, Buck says. In the example, the patient’s condition warrants an abdominal CT as well as a limited pelvic CT. You should choose the appropriate abdominal CT code (74150-74170, Computed tomography, abdomen …) and then report the limited pelvic CT based on the payer’spreference. Two possibilities include (1) 76380 or (2) a pelvic CT code (72192-72194, Computed tomography, pelvis…) with modifier 52 (Reduced services) appended.

2. Keep 76001 for Fluoro-Assist

CCI 15.3 continues the trend of adding bulky lists of fluoro edits to the file. This round the focus is on 76001 (Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy).

The logic: This code refers to “assisting a nonradiologic physician” — meaning you report this code when the radiologist provides the fluoro but doesn’t perform the procedure. So it makes sense that you wouldn’t have the procedure codes and the bundled fluoro (76001) on the same claim.

And remember that the edits don’t apply when your radiologist reports 76001 and another physician reports the procedure for the same patient: “the National Correct Coding Initiative Policy Manual for Medicare Services and NCCI edits have been developed for application to Medicare services billed by a single provider for a single patient on the same date of service,” according to the CCI manual’s introduction.

3. Sedation Codes Are Nothing to Snooze At

The fluoro edits are lengthy, but they’re nothing compared to the moderate sedation additions. Roughly 80 percent of the new bundles relate to moderate sedation codes 99148-99150 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports …), states the Sept. 11 “NCCI 15.3 Update” by Frank Cohen, MPA, senior analyst with MIT Solutions Inc. in Clearwater, Fla. These edits carry a modifier indicator of “0,” which means you can’t override the edit with a modifier.

Example: CCI edits bundle 99148-99150 into renal procedure codes 50390-50398.

But don’t start counting the dollars you’ll be losing. As the descriptors indicate, the codes describe sedation by a second physician — not by the physician performing the diagnostic or therapeutic service. So the edits shouldn’t change how you code your claims for procedures.

You’ll also see some bundles for +99145 (Moderate sedation services … provided by the same physician … each additional 15 minutes intra-service time). For example, CCI bundles +99145 into 36561 (Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older). But your CPT manual or software should alert you that CPT considers moderate sedation already included in this service, meaning you shouldn’t be reporting +99145 with 36561 anyway.

4. Always Expect Anesthesia Bundles

If your interventional radiology practice includes pain management procedures, don’t miss CCI’s bundling of numerous anesthetic injection codes (623xx and 64xxx) into G0260 (Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography).

CCI already bundles these sorts of codes into similar sacroiliac (SI) code 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid).

Basic idea: “Medicare Anesthesia Rules prevent separate payment for anesthesia services by the same physician performing a surgical or medical procedure,” states the CCI manual, Chapter 1, Section C.2.

The edits are Medicare’s way of preventing physicians who perform surgical procedures (such as SI joint injection) from reporting any form of anesthesia, including nerve blocks, explains Marvel Hammer, RN, CPC,CCS-P, ACS-PM, CHCO, of MJH Consulting in Denver. Check the modifier indicator to see if you can override the edit when the physician performs the nerve block as a separate and distinct procedure rather than as anesthetic or an analgesic block for the SI injection, she advises.

5. Heed CPT Instructions on Proper S&I Code

Sometimes CCI offers a little nudge to be sure you follow directions, as you can see by new edits for “extremity” code 36005 (Injection procedure for extremity venography [including introduction of needle or intracatheter]) and “caval” codes 75825-75827 (Venography, caval …).

CPT’s directions with 36005 instruct that “extremity” codes 75820-75822 (Venography, extremity…) are the proper codes for extremity venography supervision and interpretation (S&I).

The new edits address an ongoing problem, as the CCI manual, Chapter 9, Section H.19, reveals: “CPT code 36005 … should not be utilized to report venous catheterization unless it is for the purpose of an injection procedure for extremity venography. Some physicians have misused this code to report any type of venous catheterization.”

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CT/CTAs and MRI/MRAs: Coding, Compliance and Documentation Secrets Revealed in an audioconference with Becky Zellmer.

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