RACs are just another tool in the government’s arsenal to collect improper payments.

You’ve got so many compliance acronyms flying at you every day that you may not be able to differentiate your RAC from the OIG. Know these quick facts about RACs to stay better informed.

• Recovery audit contractors (RACs) detect and correct past improper payments so CMS and the MACs can prevent such problems in the future
• RACs are hired as contractors by the government, and they can can collect “contingency fees,” which means that they get a percentage of the amount that they recover from providers who were paid inappropriately The maximum RAC lookback period is three years, and they cannot review claims paid prior to Oct. 1, 2007
• Between 2005 and 2008, RACs involved in the original demonstration project recovered over $1.03 billion in Medicare improper payments, but referred only two cases of potential fraud to CMS, according to a February OIG report on the topic, which noted that “because RACs do not receive their contingency fees for cases they refer that are determined to be fraud, there may be a disincentive for RACs to refer potential cases of fraud.”
• Unlike RACs, the OIG is a government entity. Although the OIG also performs reviews and audits and seeks improper payments, the OIG does not collect contingency fees.

For more on the RAC program, visit www.cms.gov/rac.

@ Part B Insider. Editor: Torrey Kim, CPC

Sign up for the upcoming live Webinar, You Can Use the Appeals Process Like a Pro, 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.

Image by Stephen Woods.

You have two options depending on how the physician performed the procedure.

Question: Our orthopedist administered a hip injection under fluoroscopy. Can I report both codes?

Wyoming Subscriber

Answer: You can code both the injection and fluoroscopy, but the correct choices depend on how your physician completed the procedure.

Option 1: If your orthopedist injected radiopaque dye and performed the arthrography concurrently, code the procedure with 27093 (Injection procedure for hip arthrography; without anesthesia).

Option 2: If he completed the guidance and injection as separate procedures, submit 20610 (Arthrocentesis, aspiration, and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) for the injection. Include 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) for the fluoroscopic guidance.

Remember to append modifier 26 (Professional component) to 77002 because your physician performed the service but doesn’t own the fluoroscopy equipment.

SI change: If the physician injects the sacroiliac joint instead of the hip joint, choose either 20610 (Arthrocentesis, aspiration, and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) or 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid).

@ Orthopedic Coding Alert. Editor: Leigh DeLozier, CPC

Sign up for the upcoming live audio conference, Coding Tips for Hip Procedures, 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 you have a question, be sure to ask your physician.

Question: A patient reports to the ER at 8 a.m. on a Sunday morning. He reports a horrible toothache that started on Friday; he says he planned to “tough it out” over the weekend and see his dentist Monday, but the pain was too severe; he reports 10 on a 10-point pain scale. The ER physician performs an “inf. Aveo block,” according to the notes. What condition do the notes reflect, and how should I code this scenario?

Massachusetts Subscriber

Answer: You should double-check with the physician before filing the claim, but the shorthand appears to indicate that he performed an inferior Aveolar block, which is a type of dental block. If the physician confirms this procedure, report the following:

• 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch) for the block
• 525.9 (Unspecified disorder of the teeth and supporting structures) appended to 64400 to represent the patient’s condition.

@ Emergency Department Coding Alert, Editor: Chris Boucher, CPC

Want to know more? Sign up for the upcoming live audio conference, Take the Sting out of Coding Infusion and Injection Services, 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 incorrect Fee Schedule calculation could have cost your practice precious dollars.

Earlier this month, President Obama helped you avert a 21 percent pay cut by signing the “Continuing Extension Act of 2010” — but one MAC let several claims slip through the system using the discounted payment formula, and the payer is in the process of correcting its error.

Just before the president signed the law on April 15, MACs had been holding all claims for dates of service between April 1 and April 14. Even though the pay freeze was retroactive to April 1, some practices…… worried that their MACs might process claims using the 21 percent reduced fee during the period on April 15 after the claims hold expired but before the president signed the law.

In one case, those fears may have been warranted.

According to an April 26 notification from Highmark Medicare Services (a Part B payer in five states), several claims for dates of service on or after April 1 and received between April 1 and April 7 “potentially paid at the incorrect -21 percent reduced fee schedule.”

Highmark indicated that it had “identified the universe of claims impacted by the use of the incorrect fee schedule,” and made a mass adjustment. “Our goal is to have initiated 95 percent of all adjustment claims by Wednesday, May 5th,” Highmark indicated, promising to provide additional updates as the adjustments are made.

For more on this issue, visit www.highmarkmedicareservices .com.

Get the latest provider news by subscribing to the Part B Insider. Editor: Torrey Kim, CPC

Sign up for the upcoming on-demand Webinar, 5 Steps to Optimize Your Office’s Coding & Billing Practices, 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.

Did you factor in a foreign body removal code?

Question: During an open hernia repair for a reducible umbilical hernia, the surgeon finds a sizeable gallstone embedded in the omentum extending into the preperitoneal fat. The surgeon excises the gallstone granuloma with cautery. Patient history indicates cholecystectomy eight years ago. What are the correct ICD-9 and CPT codes?

Utah Subscriber

Answer: The proper procedure code for this scenario is 49585 (Repair umbilical hernia, age 5 years or older; reducible). If the gallstone resection represents a significant amount of extra time and effort, modifier 22 (Increased procedural services) would be appropriate.

Watch out: You should not report the omentum gallstone resection (49255, Omentectomy, epiploectomy, resection of omentum [separate procedure]) in addition to the 49585 hernia repair. As a designated “separate procedure” code, you should only list 49255 if it is the only procedure the surgeon performs at the site. Because you indicate that the gallstone is imbedded in the omentum and extends only partially into the peritoneum, you should not code the service as a peritoneal foreign body removal (49402, Removal of peritoneal foreign body from peritoneal cavity).

As to ICD-9 codes, the documentation can make a big difference. If your surgeon indicates that he thinks the gallstone was dropped and left in the omentum during the previous surgery, you should consider it a foreign body left during surgery and code 998.4 (Foreign body accidentally left during a procedure). Otherwise, the best diagnosis choice is 568.9 (Unspecified disorder of peritoneum). Report the umbilical hernia as 553.1 (Umbilical hernia).

@ General Surgery Coding Alert, Editor: Ellen Garver, CPC

Do you have surgery global periods down pat? Find out at this upcoming audio conference: To Bill or Not: What’s in the Global Surgery Period. Sign up, or order a transcript/CD!

Be a hero. Sign up for Supercoder.com and the Supercoder.com Facebook Fan Page.

Speed your coding for ABVD chemotherapy coding with this handy summary of the codes most likely to appear on your claim.

But remember: Base your final code choices on the services, drugs, and diagnosis documented.

@ Oncology Coding Alert

Want to know more? Check out Brenda Childester’s upcoming Tackle Oncology Drug Waste and Off-Label Use audio conference. You can also order a transcript and/or CD.

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

Discover why coding a myofascial flap twice is a big mistake.

Question: Our surgeon performs an abdominal closure using left and right myofascial advancement flaps. I believe we should code one unit of 15734 because flap codes refer to the recipient area — not donor site. But the surgeon believes we should code 15734 x 2 because he uses two flaps to perform the defect closure. What is the correct coding?

Arkansas Subscriber

Answer: You should not report 15734 (Muscle, myocutaneous, or fasciocutaneous flap; trunk) for this service — either once or twice. Instead, you should list the procedure using an adjacent tissue transfer code such as 14000 (Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less) or 14001 (… defect 10.1 sq cm to 30.0 sq cm) depending on the defect size.

Here’s why: Adjacent tissue transfer rearrangement includes repair by advancement flaps, according to CPT instruction in the introduction to those codes. On the other hand, 15734 does not specifically include myofascial flaps and does not describe advancement flaps for closure.

Size matters: Rather than coding this twice, you should code the entire size of the primary and secondary defects (including secondary defects for both flaps). If the defect is larger than 30.0 cm, you can still use the adjacent tissue transfer or rearrangement codes by listing 14301 (Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm) and adding +14302 (… each additional 30.0 sq cm, or part therof [list separately in addition to code for primary procedure]) as needed.

@ General Surgery Coding Alert

Be a hero. Join the medical coding community at Supercoder.com and get the latest updates at the Supercoder Facebook fan page.

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

Want to be ahead of the game? Attend the ICD-10 Issues: Get Ready for the Conversion ASAP audio conference.

Also, when’s the last time you tuned up your internal auditing process? Check out this upcoming Jacqueline Stack audio conference: Do Your Own Auditing – Spot Problems Without Outsourcing.

Be a hero. Join Supercoder.com and be a part of your coding community at the Supercoder.com Facebook Fan Page.

Make sure your documentation supports the additional substantial complexity of the hernia repair and mesh.

Question: A patient presented for a colectomy for colon cancer. The physician also discovered that the patient had a ventral incarcerated hernia that required a complex repair using mesh. Because of the separate work, we reported 44140 and then reported 49561 with modifier 59. The payer denied the claim. Were we wrong to append modifier 59?

Mississippi Subscriber

Answer: You might think you can append modifier 59 (Distinct procedural service) to the hernia repair code and bill it separately. After all, the hernia repair seems to qualify as a different reason for surgery than the colectomy — for example, if the patient has a recurrent hernia. But modifier 59 tells the payer the hernia repair happened at a separate session, which isn’t true in your case.

If the physician’s documentation proves justification, you might try …

… appending modifier 22 (Unusual procedural services) to the colectomy code because of the extra complexity, time, and effort required by the complex hernia repair with mesh.

The Correct Coding Initiative (CCI) considers hernia repair code 49561 (Repair initial incisional or ventral hernia; incarcerated or strangulated) to be part of partial colectomy code 44140 (Colectomy, partial; with anastomosis) because the hernia repair is integral to the closure. You may have to appeal for the additional money. So make sure the documentation supports the additional substantial complexity of the hernia repair and mesh implantation before appending modifier 22.

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

Be a hero. Join the coding community at Supercoder Fan Page.