Coding Strategy

If the doctor does not circle a diagnosis, it may be up to you to find one.

Don’t let an incomplete superbill damage your chances of submitting an accurate claim. If the doctor in your office fails to indicate the ICD-9 code for the condition that he treated, you should read through his documentation to find which diagnoses you should report.

Open the Notes When You Have to — and Even When You Don’t

Suppose your physician hands you a superbill with the procedures circled and the diagnosis left blank.

You could ask the physician which diagnosis to report, or you could examine the documentation yourself. If your office has a policy that includes “coding by abstraction” by certified/qualified coders, then submitting charges based on what is supported (documented) in the note is appropriate, says Barbara J. Cobuzzi, MBA, CPC, CPCH,CPC-P, CENTC, CHCC, with CRN Healthcare Solutions in Tinton Falls, N.J. The physician should be signing off on these charges as part of your internal policy.

Some practices choose to review the documentation and compare it against any diagnoses recorded on the superbill, even when they aren’t required to. This ensures that the documentation matches the code selection every time.

When in Doubt, Confirm With the Physician

If you are new at coding diagnoses from the physician’s notes, you should doublecheck your code selections with the practitioners before submitting your claims.

“Until a coder feels comfortable with the ICD-9 books and the codes used more often in their office, it’s a good idea to run the choices by a clinician,” says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with the Physician Services Division of UPMC in Pittsburgh. “You never want to give a patient a disease or symptom they don’t have  ” or one more severe (or less) than what they have. This is also beneficial to the physicians, as if you select unspecified codes a lot they may learn how to better document the patient’s condition into their notes.”

Tip: Make sure your office creates a policy in writing that spells out what you should do when you encounter a superbill with no diagnosis listed. Some physicians prefer that you ask them for information, while most others rely on their coders to select an accurate code.

Check the Notes for Clues

Consider this example of a situation in which the coder must fill in the gap when the doctor has not written a diagnosis on the patient’s superbill.

Example: The physician’s superbill shows a level-three office visit with a patient wearing a lumbar orthosis. It also shows a date of injury of three days prior to the date of service and is missing the diagnosis code.

First step: You refer to the dictation, which reads: “The patient is a 13-year-old female being evaluated as a consultation at the request of Dr. Jones for lumbar pain. The low back pain started on 12-9-09 when she did splits during cheerleading.” The physician completes the remaining history, review of systems (ROS), past family and social history (PFSH), and exam.

Moving down through the chart note, you see that the patient brought an MRI and x-ray with her, which demonstrated a hairline fracture to the patient’s third lumbar vertebra (L3).

Under a separate heading, the doctor has given his assessment, which states: Closed L3 fracture, benign.

Next step: You look up “fracture” in Vol. 2 of the ICD-9 book and the most specific body area listed is “vertebra, lumbar (closed),” which is 805.4 (Fracture of vertebral column without mention of spinal cord injury; lumbar, closed).

You turn to Vol. 1 and read the information under the “fracture of vertebral column” heading to check for exclusions and see that none apply in this case. You search under 805.4 to see if by chance the book lists codes for benign or traumatic fractures, which it does not.

In addition, ICD-9 does not instruct you to add a fifth digit to 805.4. Therefore, you know that 805.4 is the most accurate code for your doctor’s visit.

@ Part B Insider (Editor: Torrey Kim, CPC).

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If you performed a consult in 2006, the auditor will use 2006 guidelines — not today’s rules.

Most Part B practices have grown accustomed to tucking consult regulations into the backs of their minds, since Medicare no longer pays for these services. However, if an auditor comes calling and wants to review your consult notes, he will be judging you based on the Medicare rules as of the date of service.

Some practices assume that any audits taking place in 2010 or thereafter that involve consult notes will be based on CPT consult rules, and not Medicare’s, since Medicare does not recognize consult payment as of 2010. Because Medicare’s consult regulations were generally more strict than CPT’s, practices consider this a small victory. But this is inaccurate, experts say.

“If the auditor is reviewing services you performed in 2009, CMS rules from 2009 will apply,” confirms Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC with CRN Healthcare Solutions in Tinton Falls, N.J.  “In 2006, Medicare changed the rules — so if they audited 2005 consult services, it would be a different standard than 2009 services as well,” she says.

Requests for Notes May Follow

The Medicare auditor may not just want to read your physician’s notes, but may even request notes from other practitioners if it’s necessary to back up your claims.

“In evaluating consults, I have even experienced one audit where they also requested the referring physician’s documentation to substantiate the reason for the consult,” says Devona Slater, CHC, CMCP, president and compliance auditor with Auditing for Compliance and Education Inc. in Leawood, Kan.

“Medicare’s definition of a consult and the CPT definition have always been different and a reason for confusion,” Slater says.
Slater says she has seen auditors who find that practices don’t have adequate consult documentation “downcode the consults to new or established patient visits and request a refund for the difference.”

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6 tips show you the do’s and don’ts of using 88387 and +88388.

When your pathologist performs sterile macroscopic dissection to prep tissue for molecular diagnostics tests, you didn’t have a way to capture the service — until now. Take advantage of this new payment opportunity by learning when you can and can’t use the 2010 codes, how to document the service, and what you need to know for correct billing.

Tip 1: Know the ‘Macro’ Service

CPT 2010 introduces two new codes to describe surgical pathology tissue prep for certain ancillary tests:

• 88387 — Macroscopic examination, dissection, and preparation of tissue for nonmicroscopic analytical studies (e.g., nucleic acid-based molecular studies); each tissue preparation (e.g., a single lymph node)
• +88388 — … in conjunction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (e.g., a single lymph node) (List separately in addition to code for primary procedure).

“These codes describe macroscopic examination and processing of the target tissue such as a sentinel lymph node for non-microscopic molecular analysis,” says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

The processing includes work such as “dissecting an appropriate portion of the tissue away from the main specimen, and cutting and labeling thin sections under sterile conditions,” Padget explains.

Tip 2: Apply Codes to Pre-Analytic Work

You should not report 88387 or +88388 when the pathologist retrospectively selects a tissue block for molecular analysis based on initial slide review.

You have to think “pre-analytic” and “macroscopic” when deciding whether to use one of these codes, Padget says. “Early indications are that some labs are using them incorrectly — if you’re selecting tumor cells from paraffin embedded material or cutting sections from a block for send-out, that’s not covered by 88387 or +88388.”

Tip 3: Ban 88387-88388 for Microbiology or Flow Cytometry Prep

CPT 2010 states that you should not report 88387-88388 “for tissue preparation for microbiologic cultures or flow cytometric studies.”

“That rules out reporting 88387 or +88388 as prep for any microbiology codes or 88182-88189 (Flow cytometry …)”, says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

The work involved in prepping tissue for microbiology cultures or flow cytometry studies are part of those respective codes.

Tip 4: Avoid 88387-88388 for Microscopy Prep

Because the code descriptors specifically reference “non-microscopic analytical studies” you should not report 88387 or +88388 for tissue prep for special stains or immunohistochemistry-based tumor morphometry analysis, according to Padget.

In other words, don’t report 88387-88388 when the pathologist preps tissue solely for any of the following microscopy-based ancillary studies:

• Special stains (88312-88319)
• Immunohistochemistry (IHC) (88342, 88360-88361)
• Immunofluorescent study (88346-88347)
• Electron microscopy (88348-88349).

Tip 5: Use Codes With Ancillary Molecular Diagnostics

You should report 88387 or +88388 for special tissue prep for “nucleic-acid based molecular studies,” according to the code definition. That would include any codes from the range 83890-83913 (Molecular diagnostics …).

“The definition allows you to use 88387-88388 when the pathologist performs a macroscopic exam and dissection to prepare tissue for molecular diagnostics tests such as polymerase chain reaction (PCR),” Slagle says.

For instance: The pathologist might process a sentinel lymph node biopsy and provide distinct sterile macroscopic examination and sectioning for T or B clonality evaluation, according to Sophia Hauxwell,MT-ASCP, laboratory scientist in the University of Nebraska Medical Center Molecular Diagnostics Laboratory in Omaha.

“You need to be discriminating here,” Padget warns.Don’t use 88387-88388 to separately charge for the conventional gross exam/dissection that takes place with all tissue specimens prior to microscopic examination. And don’t automatically bill the codes every time you order a molecular study. “The pathology report must document a distinct macroscopic exam to identify tumor-containing areas, with dissection of thin sections, all under sterile conditions. This level of work is above and beyond the usual work that occurs at the grossing bench,” he explains.

What about FISH? “Our understanding of 88387-88388 would allow using the codes when the pathologist preps tissue for fluorescence in situ hybridization (FISH),” Slagle says. “FISH meets the criteria of non-microbiology, non-flow cytometry testing involving nucleic acids.”

Warning: “I agree that FISH should qualify because it’s clearly a DNA or RNA test,” Padget says. But without an automated imager, you’ll use a microscope to see the probe staining, which might mean FISH doesn’t pass the “non-microscopic” test, he cautions. “As long as you fulfill other criteria for using 88387 or +88388, I’d report one of those codes with a manual FISH test until I’m told otherwise by an authority like the AMA or CMS,” Padget concludes.

Avoid cytogenetics: “I don’t think traditional cytogenetics fits the requirements for use with 88387-88388,” Padget says. Although cytogenetics testing as an ancillary service to surgical pathology involves DNA or RNA, it also typically involves microscopic examination of tissue cultures.

Tip 6: Identify Unit of Service

The unit of service for codes 88387 and +88388 is “each tissue preparation.” That means you can list two units of 88387 or +88388 if the pathologist separately preps two distinct sentinel lymph nodes for molecular testing.

No TC billing: “Although codes 88387 and +88388 have distinct technical components under the Medicare physician fee schedule, no authoritative source has indicated that you can bill a separate technical fee when a pathologist doesn’t also perform the professional component,” Padget says.

@ Pathology Coding Alert, Editor: Ellen Garver, CPC

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Medicare won’t pay 69210 alone, so here’s how to unlock payment.

Impacted cerumen removal is a fairly straightforward procedure, but billing for the procedure is not always so simple.

The problem: Most payers, including Medicare,consider 69210 (Removal impacted cerumen [separate procedure], one or both ears) to be a minor procedure. But unlike with other minor procedures, they only pay for an E/M service as well as the removal of the impacted cerumen when you have two unrelated diagnoses — one for the E/M service and 380.4 (Impacted cerumen) for the removal of impacted cerumen.

The solution: By learning just three simple steps, you can ensure your physician is getting the reimbursement he deserves for this common procedure.

Step 1: Look for Second Diagnosis

A patient does not usually present for impacted cerumen alone. Another condition, such as ear pain or hearing loss, will usually prompt the visit. When your physician documents that additional diagnosis, you can report two codes to represent the work for both services, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls,N.J., and senior coder and auditor for The Coding Network.

First, you would report one code for the significantly separately identifiable E/M service, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient …). Then, you could report 69210 for the impacted cerumen removal. Documentation must support the medical necessity basedon symptoms and diagnosis; otherwise, the insurer will bundle the E/M service into 69210.

Note: CMS has a list of conditions for allowing you to separately bill an E/M code and 69210. They will allow separate billing when all of the following are met: The nature of the E/M is for anything other than cerumen removal.

During an unrelated encounter, the physician observes impacted cerumen or the patient complains about his ears Otoscopic examination of the tympanic membrane TM is not possible due to impaction

Removal of the impaction requires the expertise of the physician and is personally performed by him The procedure requires a significant amount of time and is clearly documented as such.

Crucial point: “Removal of impacted cerumen is not an ear wash; it takes instruments and the skills of the physician,” Cobuzzi says.

Step 2: Append Modifier 25

To receive separate reimbursement for the E/M service — and to code properly — you will need a modifier.Append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code.

Tip: Always provide separate documentation for the impacted cerumen removal procedure “so that you are demonstrating that the E/M is a separate procedure from the removal of the impacted cerumen,” Cobuzzi says. Do not bury your procedure note in the E/M note. Proper documentation of the patient’s complaint, his medical history, an examination beyond the ear, and a medical decision to remove the cerumen as well as a treatment plan for the second diagnosis, can legitimize a separate E/M procedure and thus support the use of the 25 modifier.

Step 3: Understand the Patient’s Insurance

Some payers do not consider 69210 to be inclusive or mutually exclusive of an E/M procedure. Others have strict guidelines for how the physician executes the procedure, or they put a cap on how often the service is paid for. Check your payer’s regulations on cerumen removal before billing this service.

Take note: Medicare does not pay for an audiologistto remove impacted cerumen. Therefore, if you are billing Medicare you need to send confirmation that the impacted cerumen removal on the day of audiological services was performed by the physician.

The catch: Medicare will not pay for 69210 and an audiology service on the same day. They require the recoding to G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing service as audiologic function testing) indicating that a physician performed the removal on the day of audiology services. Some private payers also pay this G code.

@ Medical Office Billing & Collections Alert, Editor: Joshua Thines

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Medicare’s elimination of payment for consultation services has caused mass confusion throughout the coding community, not just due to the changes it has caused in your billing procedures, but also due to lack of information from CMS.

In an apparent attempt to quell those issues, CMS has released MLN Matters article SE1010, which offers several questions and answers regarding how to report your services now that Medicare no longer recognizes consult codes (99241-99255).

For example, CMS addresses the often-asked question of whether the agency will release a crosswalk of  consult codes to E/M codes. “No,” CMS responded in the article. “Providers must bill the E/M code (other than a CPT consultation code) that describes the service they provide in order to be paid for the E/M service furnished.” In other words …

You must report the E/M code that best matches your provider’s documentation, rather than attempting to find the appropriate consult code and matching it to an office or hospital visit code.

Plus: Many providers have been concerned about what will happen if  they report a subsequent hospital care code (99231-99233) for a physician who hasn’t first billed an initial hospital care code (99221-99223).

CMS responds that it has instructed MACs “to not find fault with providers who report a subsequent hospital care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met,” even if that provider is seeing that patient for the first time during his or her hospital stay.

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AUDIO: What surgical specialties need to understand about the new consult rules. With Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC.