Coding Strategy

These edits took effect April 1, so start observing them yesterday.

The latest version of the Correct Coding Initiative (CCI) has an edit that family practice coders should note – especially if the practice treats newborn patients.

Get to know the new CCI 16.1 edit and get ready to observe it with this expert breakdown. Check Column 1 on These Hospital E/Ms According to CCI 16.1, these codes are in column 1 of the mutually exclusive edits:

• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …)
• 99232 (… an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity …)
• 99233 (… a detailed interval history; a detailed examination; medical decision making of high complexity …).

Column 2 of these edits includes these codes:

• 99460 (Initial hospital or birthing center care, per day,for evaluation and management of normal newborn infant)
• 99461 (Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center)
• 99462 (Subsequent hospital care, per day. for evaluation and management of normal newborn).

Translation: An FP may not report both normal newborn care and subsequent hospital care for a newborn on the same date of service. If the FP performs normal newborn services (99460-99462) on the same date that the newborn later becomes ill and receives subsequent hospital care (99231-99233), you should only report a code from the 99231-99233 code set, explains Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

The services are mutually exclusive because the newborn care codes (99460-99463) are for “normal” newborns (i.e., newborns without medical problems); whereas the subsequent hospital care codes (99231-99233) are for problem-oriented services, Moore says.

Since both sets of services are designated as “per day,”coders must choose between them for a given patient on a given date. “Consistent with the mutually exclusive nature of these services, CCI does not permit a modifier to override the edits,” Moore continues.

Bottom line: Never report 99460-99262 and 99231-99233 for the same patient on the same date of service.

@ Family Practice Coding Alert. Editor: Chris Boucher, CPC

Sign up for the upcoming live audio conference, Modifier 59 and NCCI Edits, 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.

Reading 44373’s code descriptor is key to getting your G Tube claim right.

Question: The gastroenterologist goes to the hospital to treat a patient that had recently been admitted because his gastrojejunostomy tube had migrated to his stomach. After performing a problem focused interval history and exam, the gastroenterologist decides to perform an EGD to reposition the tube. I cannot find a code for repositioning a G tube; how should I code this scenario?

Answer: Judging by your encounter description, the patient’s percutaneous jejunostomy tube (J tube) slipped and became a percutaneous gastrostomy tube (G tube). On the claim, report the following:

• 44373 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneousgastrostomy tube to a percutaneous jejunostomy tube) for the EGD;
• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …) for the E/M;
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99231 to show that the E/M and tube fix were separate services; and
• 536.42 (Disorders of function of stomach; gastrostomy complications; mechanical complication of gastrostomy) appended to 44373 and 99231 to represent the patient’s condition.

Explanation: The descriptor for 44373 might be a bit misleading, but it mentions only “tube conversion.” The tube does not necessarily have to be new.

@ Gastroenterology Coding Alert

Become a gastroenterology coding hero by attending Jill Young’s Things You Shouldn’t Have to Swallow in Gastroenterology Billing audio conference. Reserve your spot today!

Related articles:

1. Gastroenterology Coding Education: Bravo Cap Placements Question: A new patient reports to the gastroenterologist with complaints...
2. How Should I Code a Fibrinolytic Agent Instillation Via Chest Tube?Different calendar dates matter, but multiple instillations the same day...
3. Winter Laceration Repair: How Do I Code For Dermabond?Warning: Your coding will vary depending on who’s getting the...

87 percent error rate leads to drastic measures.

If you think CMS is only watching your E/M codes when it comes to the office or hospital, think again. One MAC recently reviewed nursing facility care claims and was stunned at the findings.

NGS Medicare, a Part B payer in four states, announced on Jan. 26 that it had recently audited claims for code 99310 (Subsequent nursing facility care, per day), and found that only 13 percent of these claims were billed correctly.

Based on the outcome of the audit, NGS said that it “will be implementing a prepay edit for CPT code 99310.”

Know these quick facts before you report this nursing facility care code in the future.

1. Check documentation for comprehensive interval history, comprehensive exam, and/or highcomplexity medical decision-making. CPT requires documentation of at least two of these criteria before you can bill 99310.

“I imagine that doctors are habitually visiting all their nursing home patients at one time and not documenting enough to meet the level-three code,” suggests Crystal S. Reeves, CPC, CPC-H with The Coker Group in Alpharetta, Ga. Indeed, the NGS report indicates that “most errors occurred because the services were billed at a higher level than was substantiated by the documentation.”

2. If you’re coding based on time, be sure to document the pertinent details.

Ever since 2008, CPT has published average time spent on the nursing facility codes, allowing you to report them based on time. However, in order for you to bill these visits based on counseling and coordination of care time, the patient must be present during the visit, and you must document the amount of time spent in counseling.

“Documentation must include time spent face-to-face (or on the floor/unit) counseling and/or coordinating care, as well as the total time of the encounter,” says Wendy Owens-Frierson, CHM, CHI, CPC with PRSS, Inc. in Miami, Fla.

Resource: To read the results from the NGS audit, go here.

Look for an in-depth article about time-based E/M coding in next week’s Part B Insider. Download 2 FREE sample issues here.

Available on CD: The biggest mistakes that coders make with nursing facility E/M codes.

Related articles:

1. The Truth About Self-AuditsAnd one crucial step you should never miss. How many...
2. E/M Challenge: Can I Report 99214 and +99354?Counseling representing more than 50 percent of E/M visit? Choose...
3. CMS Will Offer New Modifier to Denote Admitting Physician on ClaimsPop the champagne cork & get ready for brand new...