Coding Strategy

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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Forget about incident-to in the facility, but consider this similar billing technique.

ED coders that have never heard of “incident-to” billing have nothing to worry about, as you cannot code for “incident-to” services in the hospital. Coders that don’t understand shared visit billing, however, could be costing their ED practices.

Follow this advice on the “what’s” of shared visit billing.

What’s a Shared Visit?

During a shared visit, a qualified nonphysician practitioners (NPP) and the physician “team up” to provide a complete ED E/M service to the patient, confirms Lynn Anderanin, CPC, CPC-I, COSC, senior coding consultant for Health Info Services in Park Ridge, Ill.

The rub: The ED physician must provide a face-to-face service or you cannot report a shared visit, warns Kimberly Sullivan, CPC, coding specialist at Deaconess Physician Billing Services in Evansville, Ind.

According to the Medicare Claims Processing Manual (MCPM), Chapter 12, Section 30.6.1: “When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or the NPP’s UPIN [unique physician identification number]/PIN number.

“However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP’s UPIN/PIN,” the MCPM states.

What’s the Benefit of Shared Visit Coding?

Medicare payers, and payers that observe Medicare rules, allow you to report shared visits under the physician’s National Provider Identifier (NPI) rather than the NPP’s. When you bill under the NPP’s NPI, you’ll receive 15 percent less for the same service, so ethically bill under the physician’s NPI whenever you can.

Hypothetical example: A physician and NPP provide a service that qualifies for shared visit billing, and pays out at $100. The coder’s in a hurry, doesn’t recognize the shared visit opportunity, and bills under the NPP’s NPI. That $100 service is only worth $85.

What About a Clinical Example?

At 7 a.m. Monday, the NPP performs a detailed history and physical exam on a 66-year-old asthma patient who is wheezing and exhibiting tachypnea. The NPP orders nebulizer treatments and steroids. Following several rounds of nebulizers, the attending physician performs a lung exam and finds that the patient has improved.

The combined documentation of the visit includes a note from the physician demonstrating a clinically meaningful face-to-face encounter. Notes indicate moderate MDM for the encounter, and the physician ultimately diagnoses the patient with an asthma exacerbation and discharges her.

On the claim you would report the following:

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: detailed history; detailed examination; medical decision making of moderate complexity …) for the E/M
• 493.92 (Asthma, unspecified; with [acute] exacerbation) appended to 99284 to represent the patient’s exacerbation.

Explanation: Since the physician documented a face to face encounter the claim could be submitted under the attending physician’s NPI number.

@ ED Coding Alert

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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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Choose the service level using the documented history, exam, and MDM.

Question: A new patient with a chronic gastric ulcer meets the gastroenterologist for management of her condition. The gastroenterologist meets for 34 minutes with the patient, and performs an expanded problem focused history and exam and straightforward medical decision making. The note also indicate that she spent 21 minutes advising the patient on proper diet and medication management. Is this an instance where I can code based on total encounter time?

New Jersey Subscriber

Answer: Maybe. Go back and double-check both the total encounter time and the amount of time the spent on counseling by either the physician or any NPP.

If the provider spends at least half (16 min) of the total session time counseling the patient, then report …… 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity … Physicians typically spend 30 minutes face-to-face with the patient and/or family) for the encounter, based on the total time the provider spent face-to-face with the patient, with 531.7 (Gastric ulcer; chronic without mention of hemorrhage or perforation) appended to represent the patient’s condition.

Don’t stop there: Whenever you invoke the counseling exception for E/Ms, be sure the patient’s medical record has good documentation of the session. For instance, a good note for your scenario might read: “Spent total of 34 minutes with patient. Talked about medication options and possible side effects for 15 minutes, and about diet and ulcer management for 6 minutes.”

Remember: If you cannot enact the counseling exception for this encounter and code based on time, you must code based on the key elements. Choose the service level using the documented level of history, examination, and medical decision making the physician provides. In your case, the visit’s key components would qualify as 99202 (… an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making …).

@ Gastroenterology Coding Alert

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What your pulmonologist writes in the documentation matters.

The pulmonologist’s documentation, along with the patient’s medical record can make or break your chronic obstructive pulmonary disease (COPD) reporting. One key is making sure that your coding accurately identifies the patient’s specific pulmonary condition and any other associated acute condition (if necessary).

Background: According to the National Heart Lung and Blood Institute, COPD is a serious lung disease that, over time, makes it hard to breathe. In people who have COPD, the airways — the bronchial tubes through which air moves in and out of your lungs — are partially blocked, which makes it more difficult to get air out than in.

These hints will help you determine which ICD-9 codes you should report when the patient has other conditions that are related to COPD.

Hint 1: Category 493 Fits COPD and Asthma

Asthma is a disease distinct from COPD. However, the two may co-exist in the same patient. The ICD-9 493 category includes all the asthma codes you might need. If your pulmonologist diagnoses COPD and asthma together, look to the terms he uses in the medical record and use them as your guide to select which code to report.

The asthma codes you’ll choose from are:

• 493.20 — Chronic obstructive asthma, unspecified
• 493.21 — Chronic obstructive asthma with status asthmaticus
• 493.22 — Chronic obstructive asthma with acute exacerbation.

Heads up: You might find some confusion about selecting 493.20, a less-specific code. You should clarify with the pulmonologist if the patient has status asthmaticus or an acute exacerbation before opting to go for the “default” code. If the patient does not have either of these two conditions, only then should you use 493.20. Underdocumented details may affect the most specific ICD-9 code selection.

Additionally, if your pulmonologist documents status asthmaticus with any type of COPD, you should list that diagnosis first. The status asthmaticus diagnosis “supercedes any type of COPD, including that with acute bronchitis or acute exacerbation,” says Deborah J Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, CCP, EMS, president of Indianapolis-based Medical Professionals Inc and author of the American Medical Association’s Principles of ICD-9-CM Coding. You should only assign the fifth digit of “1″ in this case (493.21), not the fifth digit of “2″ (493.22).

Hint 2: COPD + Bronchitis = 491.2x

Chronic obstructive bronchitis is a more specific diagnosis than the non-specific term, COPD (496). If your pulmonologist documents chronic obstructive bronchitis in a patient, you should bill 491.2x (Obstructive chronic bronchitis: 0 without exacerbation, 1 with (acute) exacerbation and 2 with acute bronchitis).

Note: The CPT code 466.0 (Acute bronchitis) is no longer necessary to report in the setting of chronic obstructive bronchitis since the descriptor for 491.2x already mentions “acute bronchitis.”

It is possible that the pulmonologist would document that a patient is having acute bronchitis with COPD which is causing an acute exacerbation. When faced with this scenario, remember that the acute bronchitis causes the exacerbation, thus you should still report 491.22 (Obstructive chronic bronchitis with acute bronchitis), says Alan L Plummer, MD, professor of medicine in the division of pulmonary, allergy, and critical care at the Emory University School of Medicine in Atlanta, Georgia.

On the other hand, if the documentation states that the patient has COPD with acute exacerbation, but doesn’t mention acute bronchitis, report 491.21 (Obstructive chronic bronchitis, with [acute] exacerbation).

Example: A patient with COPD who is not well-controlled is just using an albuterol inhaler. The pulmonologist decides to add a steroid inhaler to current therapy along with a long-acting beta-2 agonist. You could report the encounter using only 496 (Chronic airway obstruction, not elsewhere classified), but a more descriptive code would be 491.21. This code specifically identifies the patient as having chronic obstructive bronchitis and indicates that the patient’s clinical problems are not controlled.

Important: If the diagnoses states only COPD, with no other manifestation or condition associated with it (i.e., chronic bronchitis or emphysema), you should opt for 496. If the patient has emphysema in addition to chronic obstructive bronchitis, you should also code 491.2x since this code also includes emphysema. If the patient does not have chronic bronchitis but does have emphysema, you should code 492.8 (Other emphysema).

Hint 3: Documentation Must Jive With COPD Diagnosis

If you’re going to list a COPD diagnosis code, be sure the documentation supports the physician’s code selection. You should look out for details in the documentation, such as a listing of signs, symptoms and conditions. Play it safe by having enough detail in the history of present illness and the review of systems to support a diagnosis of COPD.

Watch for: Your pulmonologist should also document the tests he orders, such as X-rays (71010-71035), and pulmonary function tests (94010-94621). Document any therapeutic drug treatment associated with the plan of care for the patient. The tests and treatments help support your physician’s diagnosis of COPD.

Don’t miss Jennifer Godreau’s audio: “Ten Tips for Improve Your Pulmonology/Critical Care Coding Right Now.”

@ Pulmonology Coding Alert

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