Coding Strategy

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).

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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).

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If your radiologist performs adjustments during the bariatric surgery’s global period, do this.

Question: Our radiologists perform percutaneous LAP-BAND adjustments. We report S2083 for the service and 77002 for the fluoroscopy. Is this the correct fluoroscopy code?

Connecticut Subscriber

Answer: Code 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) is appropriate for fluoro used for gastric band adjustment in the outpatient setting, according to the American Hospital Association’s Coding Clinic for HCPCS, Vol. 9, No. 3, 2009. Of course, the code is only appropriate when the physician uses and documents the fluoroscopic guidance.

The procedure: LAP-BAND adjustment involves passing a needle into the port of a band placed around the patient’s stomach as part of bariatric surgery. The radiologist uses the needle to add or remove fluid to change the width of the stoma (the outlet the band creates between the two parts of the stomach), according to CPT Assistant (April 2006).

The physician typically performs the adjustment through a subcutaneous port. If it’s palpable, the physician may not require guidance. But for patients who need to lose a lot of weight or for patients who have already lost weight and have a lot of extra skin, the radiologist may need guidance to find the port.

Keep in mind that adjustments performed during the bariatric surgery’s global period are included in the surgical fee, so you should not report them separately. You may report adjustments performed after the global postoperative period ends. For those (non-Medicare) payers who accept S codes, you may report S2083 (Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline). Otherwise, you may have to include the service in the appropriate E/M code, depending on payer preference.

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

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Grasping 93010’s effect on new vs. established patient status could bring a $58 reward.

Whether you call them ECGs or EKGs, chances are you see a lot of electrocardiograms in your practice. That means that even the tiniest coding errors can add up quickly. Brush up on the 93000-93010 basics with this review of the service, the code components, and the role ECGs can play in choosing the proper E/M code.

1. Count on These Codes for Proper ECG Reporting

There are three codes for routine ECG:

• 93000 — Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
• 93005 – … tracing only, without interpretation and report
• 93010 — … interpretation and report only.

The service these codes describe typically involves placing six leads on the patient’s chest and additional leads on each extremity, says Christina Neighbors, MA, CPC, CCC, ACS-CA, charge capture reconciliation specialist and coder at St. Joseph Heart & Vascular Center in Tacoma, Wash. The procedure “picks up and traces the path of electrical activity sent from the SA [sinoatrial] node through the heart and puts it onto paper,” Neighbors says.

The external skin electrodes can pick up electrical current because the heart’s electrical activity generates currents that spread to the skin, explains CPT Assistant (April 2004).

2. Prevent Denials With This Modifier 26 Rule

Just say no to modifier 26 (Professional component) with your ECG code, warns Kim Huey, CPC, CCS-P, CHCC, an independent coding consultant in Auburn, Ala. Similarly, you should not append modifier TC (Technical component).

Reason: Codes 93000-93010 are already broken down into professional and technical components, Huey says:

• 93000: global (professional and technical components)
• 93005: tracing (technical component)
• 93010: interpretation and report (professional component).

In other words, if the cardiologist provides only the interpretation and report for an ECG performed at a hospital, you should report 93010, not 93000-26.

Helpful: If you ever need a reminder about whether a code accepts modifiers 26 and TC, the Medicare physician fee schedule (MPFS) can help. According to the MPFS, 93000 has a PCTC (professional component, technical component) indicator of “4,” meaning “global test only” code. Code 93005’s PCTC indicator is “3,” which indicates “technical component only” code. And 93010’s indicator of “2” means the code is a “professional component only.” You can search the MPFS at www.cms.hhs.gov/pfslookup/.

3. Pinpoint Whether 93010 Patients Are ‘New’

Your cardiologist’s role in an ECG interpretation could dictate whether you choose a new or established patient E/M code at the patient’s next visit.

Rationale: “An interpretation of a diagnostic test, reading an x-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient,” states Medicare Claims Processing Manual, Chapter 12, Section 30.6.7 (www.cms.hhs.gov/Manuals/).

You just need to be sure you understand the definition of a new patient, says Betsy Nicoletti, MS, CPC, founder of Medical Practice Consulting in Springfield, Vt. A new patient is one who has not received professional service from that physician (or another physician of the same specialty in the same group) during the past three years.

Medicare’s decision to no longer cover consult codes makes mastering new versus established even more important. Your consult code choice did not differ based on whether a patient was new or established, but the codes you use to replace the consult might. For example, consult codes 99241-99245 specify: “Office consultation for a new or established patient …” In contrast, office/outpatient E/M codes 99201-99205 are for new patients only and 99211-99215 are for established patients only.

Payoff: If documentation supports coding a visit previously reported as a consult as a level-five E/M service, for example, knowing the difference between new and established has an impact on your wallet. The Medicare nonfacility national rate for a level-five new patient visit (99205) pays $58 more than a level-five established patient visit (99215).

@ Cardiology Coding Alert

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Help is here: One troublesome, confusing edit is no longer an issue.

You may still be getting to know your CPT 2010 manual, but the new edition of CCI, effective April1, is already looking to make some code pairings impossible.

The Correct Coding Initiative (CCI) released version 16.1 earlier this week, revealing 2,054 new active pairs and 1,947 modifier changes, said Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions, Inc., in a March 22 announcement.

Deletions: CCI version 16.1 attempts to untangle several troublesome sets of edits in its next round with the announcement that 142 code pair bundles will be deleted, Cohen noted. For instance, CCI previously bundled 93610 (Intra-atrial pacing) and 93612 (Intraventricular pacing) into 93651 (Intracardiac catheter ablation …), but effective retroactive to Jan. 1, that bundle has been deleted.

Swapped pairs: In the past, CCI used to bundle shoulder arthroscopy code 29806 into shoulder surgery code 29825. Essentially, CCI denied 29806 when billed with 29825, unless you appended a modifier. However, CCI has just announced that it plans to “swap” the pairs, and will now bundle 29825 into 29806.

“I believe this edit makes sense,” says Ruby Woodward, BSN, ASC-OR, coding and research specialist for Twin Cities Ortho-pedics, PA in Minneapolis, Minn. “Generally, if we are doing a capsulorrhaphy, we are doing it for instability, which is probably a greater issue. If a patient has a true ‘frozen shoulder,’ which would be the primary reason to do 29825, they wouldn’t be unstable.”

Modifier changes: CCI will now allow you to append a modifier to separate the edits bundling 64450 (Injection, anesthetic agent, other peripheral nerve or branch) into hundreds of other codes, such as debridement codes 11004-11006. The modifier indicator in these code pairs used to be “0,” indicating that nothing could separate the edits, but with CCI version 16.1, the indicator is now “1,” meaning you can append a modifier (such as 59, Distinct procedural service) to the code.

Although most of the modifier indicator changes involve 64450, CCI also changes the modifier indicator bundling new code 88738 (Hemoglobin) into 85025-85027 (Complete CBC). Effective April 1, you can use a modifier to separate these bundles.

@ Part B Insider

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