Coding Strategy

Study frequency guidelines before you bill for counseling services.

Question: A 60-year-old established Medicare patient with a confirmed diagnosis of vanishing lung (emphysema) reports to the family physician (FP) for a medication check and blood work; the patient is a moderate smoker. During the medication check and blood work, which took about 5 minutes, the patient tells the practice’s non-physician practitioner (NPP) “I think I’m ready to quit smoking; can you help?” The NPP spends the next 7 minutes providing smoking cessation counseling for the patient. Can I report a cessation code and an E/M?

Answer: Provided the patient meets Medicare’s requirements for cessation counseling, you can report the following:

• 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 or less are spent performing or supervising these services.) for the E/M

• 492.0 (Emphysema; emphysematous bleb) appended to

• 99211 to represent the patient’s emphysema

• 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) for the smoking cessation counseling

• 305.1 (Tobacco use disorder) appended to 99406 to represent the patient’s tobacco dependency.

Know the rules: According to Medicare, its patients are entitled to smoking and tobacco use cessation counseling provided the patient is either:

• a tobacco user who has an illness caused or complicated by tobacco use or

• taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on Food and Drug Administration-approved information.

Additionally, note these two frequency guidelines for spot-on 99406 and 99407 (… intensive, greater than 10 minutes) claims:

• Medicare will cover up to two counseling attempts per year for the first 12-month period of counseling (Each attempt can include up to four counseling sessions).

• Medicare will cover up to eight more sessions during a second or subsequent 12-month period of counseling after 11 full months have passed since the first Medicare covered cessation counseling session was performed. For example, if the first of eight covered sessions was performed in April 2009, a second series of eight sessions may begin in April 2010.

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

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Don’t lose 19342 pay for delayed insertion.

Your general surgeon may perform breast reconstruction following cancer, infection, trauma, or burns, or in some cases, strictly for cosmetic reasons. Make sure you capture appropriate implant pay, when that’s part of the surgical scheme, by following our experts’ tips.

Tip 1: Prosthesis’ Purpose Drives Coding

Breast implants commonly serve two functions — cosmetic breast enhancement or breast reconstruction following a disfiguring event such as mastectomy for cancer or a traumatic injury.

CPT divides implant codes based on the function, so that’s the first distinction you need to make when selecting the proper code.

Differentiate augmentation: Use 19325 (Mammoplasty, augmentation; with prosthetic implant) when the surgeon implants a breast prosthesis for breast enlargement. “Code 19325 describes cosmetic implants only,” emphasizes John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates.

When the surgeon implants a prosthesis to reconstruct the breast following mastectomy, you need to look elsewhere for a code. For silicone or saline implants involved in reconstruction, CPT provides the following two codes:

• 19340 — Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
• 19342 — Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction.

Tip 2: Timing is Everything for Implant Placement

CPT provides 19340 and 19342 for breast prosthesis associated with mastectomy or mastopexy. You’ll decide between those two codes based on when your surgeon performs the implant procedure.

How it works: For patients whose physiology will accommodate a full-size saline- or silicone-filled prosthesis, your surgeon may place the implant immediately following the mastectomy. “If the surgeon inserts a breast implant at the same operative session as the mastectomy, you should report 19340,” Bishop says.  “For our mastectomy patients who opt for reconstruction, immediate treatment is the most common choice,” says Lynn Woolard, practice manager for General and Vascular Surgery in Elgin, Ill.

Look for ‘delayed’ code: On the other hand, the surgeon sometimes closes the surgical site following mastectomy and the patient goes home to heal for some period of time. If the patient returns at a later date for a breast reconstruction that involves implant placement, you should list 19342 for the insertion. Using this code correctly is important because the procedure is more complicated and pays significantly more, according to Bishop — $725 for 19340 versus $868 for 19342, based on the Medicare physician fee schedule facility national values using conversion factor 36.0846.

To read the rest of this article, subscribe to General Surgery Coding Alert (Editor: Ellen Garver, CPC).

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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

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On Tuesday evening, the Senate passed H.R. 4691, which freezes the Medicare conversion factor at current levels through March 31.

Because of this vote, you will not face the 21% pay cut until April 1, explains Part B Insider editor, Torrey Kim. Hopefully by that point, a more permanent fix will have been introduced. “The Senate is working on a bill that would extend the current Medicare payment rate until Oct. 1,” reports this article from the AAFP site.

H. R. 4691 is a “hodgepodge” bill that contains a lot of other provisions in addition to this month’s conversion factor freeze, reports The Wall Street Journal. The bill also extends COBRA’s health insurance subsidies.

FREE WEBINAR: Are you home-growing your very own physician pay cuts with faulty E/M coding? Stop shorting yourself on E&M coding levels with this most-often-overlooked medical coding history type.

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AdreView gets its own ‘A’ code, too.

You can leave confusing “not otherwise classified” codes behind for a few more of the contrast agents that you use.

For services on or after Jan. 1, be sure you’re using the product-specific codes detailed below. Not using the proper codes will lead to claim rejection, which means “not receiving the proper reimbursement. And no one wants to start out their new year that way,” points out Lisa Martin, CPC, CPC-IM, CPC-I, an instructor for the AAPC’s Professional Medical Coding Curriculum.

Turn to A958x to See New Options

HCPCS 2010 adds A9583 (Injection, gadofosveset trisodium, 1 ml) to report Vasovist, an intravascular contrast agent designed for MRI.

Eovist, another MRI contrast agent, also will have its own code: A9581 (Injection, gadoxetate disodium, 1 ml). This contrast is aimed specifically at diagnosing liver disorders.

Another new code is A9582 (Iodine i-123 iobenguane, diagnostic, per study dose, up to 15 millicuries) for AdreView, which is a molecular imaging agent that helps physicians detect rare neuroendocrine tumors

Expect a Little Less Stress for Stress Test

In addition to these new codes, Cardiolite’s code gets a little shorter. HCPCS has removed the confusing phrase “up to 40 millicuries,” effective Jan. 1, 2010:

• 2009: A9500 — Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries

• 2010: A9500 — Technetium Tc-99m sestamibi, diagnostic, per study dose.

Caution: As in 2009, verify with your payer what it considers to be a “study.” For example, typically, you should be able to report one dose for a myocardial perfusion imaging’s rest phase and one dose for the stress phase, but a few payers may consider the two phases to be a single study.

Resource: You can download the 2010 HCPCS codes here.

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