Coding Strategy

Remember to describe all the circumstances surrounding a push to get full reimbursement.

Question: If a non-Hodgkin’s lymphoma patient has an adverse reaction to Rituximab less than 15 minutes into the ordered hour-long infusion, should I report a push?

Answer: Experts suggest the most appropriate way to report a discontinued infusion is to append modifier 53 (Discontinued procedure) to the appropriate chemotherapy infusion code, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

You should use modifier 53 when a physician stops a procedure “due to extenuating circumstances or those that threaten the well-being of the patient,” according to CPT.

Modifier 53 describes an unexpected problem, beyond the physician’s or patient’s control, that necessitates ending the procedure. The physician doesn’t elect to discontinue the procedure as much as he is forced to do so because of the circumstances.

Push: CPT guidelines include “an infusion of 15 minutes or less” as one definition of a push, but 96413-53 describes the ordered and provided service more accurately than a push code (such as 96409, Chemotherapy administration; intravenous, push technique, single or initial substance/drug).

HCPCS: Your documentation should describe the circumstances, the administration start and stop times, and the amount of drug delivered and discarded. If you’re coding for the drug (J9310, Injection, rituximab, 100 mg), you should be able to report the entire amount, assuming you discarded the amount not administered.

ICD-9: Remember also to report the appropriate ICD- 9 codes, such as V58.12 (Encounter for antineoplastic immunotherapy) and 202.8x (Other lymphomas), and a code to indicate why the procedure stopped, such as V64.1 (Surgical or other procedure not carried out because of contraindication) or E933.1 (Drugs, medicinal, and biological substances causing adverse effects in therapeutic use; antineoplastic and immunosuppressive drugs).

Also watch for E/M services performed to care for the patient.

@ Oncology & Hematology Coding Alert. Editor: Deborah Dorton, JD, MA, CPC

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Keep signature, modifier 59, and ‘Incident To’ guidelines front and center.

If you’ve been worrying that the oncologist’s illegible signature on an order is going to come back to haunt your practice in an audit, CMS has offered
answers on when you’re in the clear and when that untidy scrawl could have reviewers requesting additional information.

1. Get Signature Guidelines Down Pat

With few exceptions, Medicare requires a signature for services and orders. CMS updated the rules and added e-prescribing language to the mix in Transmittal 327, CR6698. The rules instruct contractors reviewing claims on what counts as a signature and when the services or orders must have signatures.

One important exception to the signature requirement is that “diagnostic orders need not be signed by the physician,” says Kelly Loya, CPC-I, CPhT, consultant with California-based Sinaiko Healthcare Consulting Inc. Still, the medical record must include information verifying the ordering physician intended the test to be performed, and “a progress note in the medical record must be signed,” Loya explains.

A very helpful feature of the transmittal is a chart that “gives very specific facts as to what meets the requirements or requires follow up with the provider to meet the requirements,” says Loya. For example, if you scan the chart, you can quickly see that an illegible signature written above a typed name is OK, but contractors won’t count just an unsigned typed note with a typed name. “The reviewer can explore alternate methods in order to verify the signature requirement,” Loya notes. “Not complying with an attestation request (within 20 days of the request)” could lead to a denial, she warns.

If you’ve been reporting G8553 (At least one prescription created during the encounter was generated and transmitted electronically using a qualified ERX system), be sure to give the transmittal a close look. The new e-prescribing language solidifies that for non-controlled substances, “as long as a ‘qualified’ e-prescribing system (per Medicare Part D requirements) is used, a pen and ink copy” of the signed prescription order is not required, Loya says. But physicians can’t e-prescribe controlled substances — for example, addictive pain medications — so CMS requires a pen and ink order for these.

Watch for change: The Drug Enforcement Agency recently released its interim final rule on e-prescribing controlled substances. If your oncologist is willing to jump through the multi-step authentication hoops, e-prescribing controlled substances may be a possibility in the future.

Transmittal 327 is effective March 1 with an April 16 implementation date.

2. OIG Is Watching Mod 59; Are You?

In other news, the OIG released its 202-page “Compendium of Unimplemented OIG Recommendations,” which revealed that many OIG suggestions have been ignored.

Case in point: In 2003, the OIG found a 40 percent error rate on claims that contained modifier 59 (Distinct procedural service) when used to separate Correct Coding Initiative (CCI) edits, resulting in Medicare paying $59 million in improper payments.

The OIG encouraged carriers to institute prepayment and postpayment reviews of the use of modifier 59, and suggested that CMS should update carriers’ claims processing systems so they pay claims with modifier 59 “only when the modifier is billed with the correct code,” the OIG report indicates. The OIG now says that CMS has not yet instituted such system edits, and notes that it will “continue to monitor CMS’s efforts to implement edits to ensure correct coding.”

What this means: “The OIG lists modifier 59 as a priority nearly every year, and it’s possible that the agency feels that CMS should be looking more closely at its use,” says Randall Karpf with East Billing in East Hartford, Conn. “The bottom line is that if all of these entities are watching modifier 59, make sure you’re using it properly.”

In particular, past OIG investigations have shown that one of the more common modifier 59 mistakes is incorrectly unbundling 38220 (Bone marrow; aspiration only) and 38221 (… biopsy, needle, or trocar), so be sure you keep a careful eye on this code pair.

Plus: The OIG examined services billed using the “incident to” guidelines, which you should know well if you report oncology services to Medicare. As a result of the OIG scrutiny, CMS is revising its incident to policies to reflect the fact that “no one except licensed physicians perform the services or nonphysicians who have the necessary training, certification, and/or licensure, pursuant to state laws, state regulations, and Medicare regulations perform the services under the direct supervision of a licensed physician.”

Although many practices already follow this rule, the OIG “wants an explicit rule rather that the current implicit rule,” says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

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

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Relying on the physician’s encounter form could be a big mistake.

Question: I used 491.9 to report a patient’s bronchitis, but the payer denied my claim and requested additional information. What was wrong?

Vermont Subscriber

Answer: Your claim may have been denied because you chose an unspecified chronic bronchitis code (491.9, Unspecified chronic bronchitis) instead of a more specific ICD-9 code.

Here’s how to avoid “diagnosis coding” denials next time: Don’t rely on the physician’s encounter form, which usually lists nonspecific diagnoses to maximize space. Your physician’s documentation may actually be more specific.

For instance, your physician has recorded that treatment for an “acute exacerbation” of chronic bronchitis was provided. The term “acute” under 491.21 (Obstructive chronic bronchitis; with [acute] exacerbation) appears in the diagnosis definition. Therefore, if the physician sees a patient with an exacerbation of chronic bronchitis, you may report 491.21.

Snag: You may find your doctor unaware that proper documentation is critical. You should suggest that the pulmonologist be more specific on the terms and descriptions used in the chart when appropriate, and that, without proper documentation, unspecified codes may delay and/or reduce payment.

Smart: ICD-10-CM will prompt you for more specified coding. It’s important to incorporate specificity into your coding and documentation — as early as now.

@ Pulmonology Coding Alert

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Bonus: Get exposure to ICD-10 coding equivalents.

Question: A mentally-challenged patient who delivered at home was admitted to the hospital for postpartum care. The patient delivered the placenta at home, and once admitted, she had no complications, but the ob-gyn did perform a first degree laceration repair. I’m not sure what diagnosis code to report. Should I look at routine postpartum care or pregnancy complications? And if I use a complication code, what would the fifth digit to a “1″ or “0?”

Texas Subscriber

Answer: Under most situations where the ob-gyn treated no problems during the admission, you would code V24.0 (Postpartum care and examination; immediately after delivery) on the admission date and V24.2 (Routine postpartum follow-up) for any subsequent routine care.

But in this case, your physician also repaired a first degree laceration (CPT code 59300, Episiotomy or vaginal repair, by other than attending physician). Therefore, you may consider this to be an admission for a postpartum condition and instead report 664.04 (First degree perineal laceration). The fifth digit cannot be “1″ or “0″ because the patient delivered prior to her admission and of course you know her delivery status. In this case, the fifth digit must be “4″ to indicate a purely postpartum condition. You may optionally report V24.0 and V24.2 as your secondary diagnoses, but they are not required in this case.

ICD-10: In the near future, you will replace ICD-9 codes V24.0 and V24.2 with ICD-10 codes Z39.0 (Encounter for care and examination of mother immediately after delivery) and Z39.2 (Encounter for routine postpartum follow-up), respectively. Code 664.04 will be replaced by O70.0 (First degree perineal laceration during delivery).

@ Ob-gyn Coding Alert

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Insurers might want to see a clear explanation as to why the E/M was necessary.

Question: An established patient with a plan of care in place for her gastroesophageal reflux disease (GERD) reports to the gastroenterologist; two weeks ago, the gastroenterologist started her on Nexium (esomeprazole). One of the practice’s nonphysician practitioners (NPPs) evaluates the patient, taking blood pressure and other vitals. She also asks the patient if she has experienced any nausea, diarrhea, vomiting, or any other side effects since she started Nexium. The patient reports that she’s “thrown up three or four times” since starting the medication, but reports no other side effects. The patient’s record indicates that the gastroenterologist scheduled this visit specifically to check how the patient’s adjustment was going. What can I report for this encounter?

Answer: It will depend on the encounter specifics, but this sounds like a 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 are spent performing or supervising these services …) service.

No matter what E/M code you choose, append the following diagnosis codes:

• 530.81 (Other specified disorders of esophagus; esophageal reflux) to represent the patient’s GERD
• 787.03 (Vomiting alone) to represent the patient’s vomiting

Explanation: The gastroenterologist will often order a patient to report soon after starting a new medication regimen; these scheduled visits are typically 99211 encounters, though they can theoretically be higher-level if complications arise.

For medication checkup encounters, insurers might want to see a clear explanation as to why the E/M was necessary. Cut off any payer queries by including the following documentation on medication checkup E/Ms:

• a record of patient’s blood pressure, if relevant, and other vital signs
• a note indicating the clinical reason for checking blood pressure or other vital signs
• a list of the patient’s current medications (include level of patient compliance, if possible)
• proof that the gastroenterologist evaluated the clinical information the NPP obtained and made a  management recommendation for the patient.

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