Coding Strategy

Decipher why you should include a seconding diagnosis.

Question: A 38-year-old patient presents to the emergency room with complaints of wheezing, coughing, and trouble catching her breath. After the nonphysician practitioner (NPP) performs a problem-focused history, the physician performs a detailed history and exam and discovers focal ronchi. The physician orders a two-view chest x-ray to check for upper respiratory infection (URI) The chest x-ray results reveal acute URI, and the ronchi clears up upon reevaluation. The patient is treated with antibiotics. How should I code this scenario?

Answer:You’ll submit two of each for this claim: CPT codes, modifiers,and ICD-9 codes. On the claim, report the following:

• 71020 (Radiologic examination, chest, 2 views, frontal and lateral) for the x-ray
• Modifier 26 (Professional component) appended 71020 to show that you are coding for the physician’s services only
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination;and Medical decision making of moderate 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 99284 show that the E/M and the x-rays were separate services
• 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site) appended to 71020 and 99284 to represent the patient’s URI
• 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) appended to 71020 and 99284 to represent the patient’s focal ronchi.

Secondary Dx decoded: Even though the focal ronchi cleared up on reexamination, you should still include 786.7 on the claim. It will help paint a more lucid portrait of the patient’s condition, and can only strengthen your medical necessity case for the chest-x-ray.

@ Part B Insider. Editor: Torrey Kim, CPC

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Don’t be caught asleep: Patient history is one element of proper Dx coding.

Many coders hesitate to report V codes, or simply use them incorrectly, but sometimes this section of ICD-9 most accurately describes the reason for the patient’s condition. In fact, V codes are often essential to reporting an anesthesia patient’s medical history.

If you’re not clear on the importance of V codes, check out these expert-approved answers to some often-asked questions:

Why Should I Use V Codes?

To determine if you should use a V code, look for documentation in your anesthesiologist’s report that will support physical status modifiers or use of Monitored Anesthesia Care (MAC), says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Knowing that a patient has a history of certain problems (such as a history of sudden cardiac arrest) could affect how your provider delivers anesthesia or monitors the patient. The personal history might also help justify having anesthesia services available (either already providing service or with the anesthesiologist on stand-by) for procedures that might not normally need anesthesia.

Important: V codes are not only appropriate as secondary codes. You may occasionally encounter a situation where a V code is necessary as the primary diagnosis. In some cases, reporting a V code might be the only way you’ll be paid for a service.

“If there are chronic conditions that affect the physical status, such as diabetes, lung disease, or cardiovascular disease, then these should be coded in addition” to the current diagnosis codes, says Julee Shiley, CPC, CCS-P, ACS-AN, a coding professional in North Carolina.

Example: A gastroenterologist requests your anesthesiologist at a colonoscopy because the patient has been resistant to moderate sedation in the past. Using V15.80 (History of failed moderate sedation) could justify why the anesthesiologist was at the colonoscopy.

Look for Symbols Indicating V Code Use

“Coders that are not aware of the ICD-9 history codes often err and report the ICD-9 code(s) indicating that the patient has the active or ongoing condition, rather than reporting the compliant and associated patient history code,” Dennis says.

If you find it tricky to distinguish primary from secondary V codes, ICD-9 gives you some helpful hints. Many versions of the ICD-9 manual use a symbol, such as a “1” or a “2” inside a circle, to indicate in what order you should report the code (such as “first listed or primary Dx,” “first listed or additional,” or “additional or secondary Dx only”). You’ll find these indicators next to the code descriptor.

Example: An anesthesiologist provides MAC to a patient with a history of transient ischemic attack (TIA), an episode in which a person has stroke-like symptoms for less than 24 hours. According to ICD-9, you may report V12.54 (Stroke [cerebrovascular]) as the primary diagnosis and the reason for the surgery as the secondary diagnosis.

How Do I Use V Codes For Anesthesia?

Use of V codes for anesthesia can be very different from other specialties’ use of the codes. Find out how by subscribing to the Anesthesia & Pain Management Coding Alert.

Editor: Joshua Thines

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Have your documentation ready for reporting level P4 and higher.

Physical status modifiers, also referred to as P modifiers, PS modifiers, ASAs or ASA P codes, are an important element of your anesthesia coding. If you don’t use them correctly, you could dash your reimbursement opportunities, or risk a payer audit.

Skip P Modifiers With Medicare, But Check Private Payers

If your anesthesiologist works with a number of Medicare patients, you probably haven’t spent much time learning the finer points of anesthesia’s Physical Status Modifiers. Why? Because Medicare does not pay for them.

End of story, right? Not if your practice contracts with private payers. Many private payers will often reimburse for P modifiers if you follow the guidelines.

“Reporting is dependent on the carrier and can be dependent on whether the group negotiated for it in their contract. Most government payers do not allow reporting or payment of PS modifiers,” says Debbie Farmer, CPC, ACS-AN, coder with Auditing for Compliance & Education in Leawood, Kan.

Example: A 2001 Aetna anesthesia policies memo states, “When these modifiers/codes are reported, additional ASA units may be allowed and combined with the base unit value for the anesthesia service performed.” While the trick is in meeting those conditions, you don’t have to shy away from P modifiers if you know the basics.

Use 6 Levels to Define Patient’s Status

The American Society of Anesthesiologists (ASA) developed physical status modifiers to allow coders to distinguish between different levels of complexity of anesthesia service. These levels are based on the patient’s condition, as follows:

• P1 — Normal healthy patient
• P2 — Patient with mild systemic disease
• P3 — Patient with moderate systemic disease which can be a threat to life
• P4 — Patient with severe systemic disease that is a constant threat to life
• P5 — Moribund patient who is not expected to survive with or without the operation
• P6 — Declared brain-dead patient whose organs are being removed for donor purposes.

The ASA does not provide concrete definitions for physical status modifiers because their use is based on clinical decisions the anesthesia provider makes for each patient.

Hint: Most of your anesthesiologist’s services require a P1, P2, or P3 modifier. To use P4 or higher, you need clear documentation in the medical record to support its use. Even if your anesthesiologist classifies a patient as P3, many payers will want more information to support the claim.

How it works: A patient with stable angina would be considered a P3 status. This patient has a systemic disease that could kill him, but he is stable and expected to do well.

A patient with a P4 status has his life constantly threatened by his disease. “ASA 4’s are patients who are not expected to die in the perioperative period, although it wouldn’t be totally unexpected if they do,” says Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York. Someone with unstable angina, or in congestive heart failure who needs surgery, would be a 4.

Make Sure You Clarify Dx and Documentation

In its “Revised Hospital Anesthesia Services Interpretive Guidelines,” CMS offers clarification on minimum accepted standards of what should be included in a pre-anesthesia evaluation of a patient, including “notation of anesthesia risk according to established standards of practice (e.g. ASA classification of risk).”

Why it’s important: The preop note should regularly include PS classification, Groudine says. If it doesn’t, your practice may not be complying with CMS rules.

The best way to ensure you’re using the proper PS code is to check, and double-check, your physician’s documentation. In many cases you can find the ASA classification included in the operating room nurse’s notes.

Heads up: “Many times I see that a claim went in without a diagnosis to support the underlying condition for reporting the PS modifier and the carrier will not allow the additional unit,” Farmer says.

Note: You cannot use a PS code with an add-on code such as +01953 (Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area [TBSA] treated during anesthesia and surgery; each additional 9% total body surface area or part thereof).

@ Anesthesia Coding Alert, Joshua Thines

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Upcoming policy change will slash your payments by half.

Big changes are on the horizon if you participate with insurance provider Horizon Blue Cross Blue Shield (BCBS) of New Jersey.

In a recent memo, BCBS states that effective May 17, 2010, they will cut reimbursement by half on many modifiers, regardless of the circumstances surrounding their use. Your practice might stand to lose thousands of dollars. Take a look at the policy details.

Beware a New Reimbursement Trend

The February 2010 memo offers a list of modifiers that BCBS states “will be considered nonstandard — that either the full service was not performed or that the service in question was performed in conjunction with another service or procedure.”

If the policy proceeds as planned, the move will create logistical migraines for those submitting to Horizon BCBS in NJ, experts warn. Many industry watchers hope that this policy will not set a deeply troubling precedent across the country.

Expect the Worst for Modifiers 25, 59

Of the modifiers being cut, the effects on modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and modifier 59 (Distinct procedural service) may have the greatest impact for your practice.

Important: The memo states that evaluation and management (E/M) services that are appropriately appended with modifier 25 will pay “at 50 percent of the applicable Horizon BCBSNJ fee schedule amount. This recognizes that the service in question was rendered in conjunction with a separately identifiable E&M service performed on the same day by the same practitioner.”

“In general, it’s becoming tougher every day to get payers to pay with a 25 modifier,” says Karla Westerfield, COPM, business manager at Southeast Wyoming Ear, Nose and Throat Clinic in Cheyenne.

Modifier 59 will also receive the same drastic 50 percent reduction. “I feel that even though the 25 modifier is going to hurt practices, it will not be as much of a ‘hurt’ factor as the situation with the 59 modifier,” says Brian Fornutaro, a billing professional with Medi-corp in Cranford, NJ.

Reasoning: Horizon’s memo states that it is following CMS Correct Coding Institute (CCI) guidelines for appropriate use of the modifiers. CCI edits do not allow a reduction on modifier 25, however. They do allow a modifier 59 reduction as part of the multiple procedure reduction rules.

@ Medical Office Billing & Collections Alert

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Don’t let ‘wrong surgery’ modifier mistakes stall your reimbursement.

You use modifier TC for the technical component of a test. So logically, you should use modifier PC for the professional component, right? Wrong. But many coders are making that mistake and causing their practices unnecessary denial hassles. Here’s what you need to know.

Get ‘Wrong Surgery’ Modifiers Right

When practitioners perform erroneous surgeries, CMS requires the hospital outpatient department, ambulatory surgical center (ASC), physician, or other entity to append one of the following three modifiers to codes for services related to the erroneous procedure effective Jan. 15, 2009:

• PA — Surgical or other invasive procedure on wrong body part
• PB — Surgical or other invasive procedure on wrong patient
• PC — Wrong surgery or other invasive procedure on patient.

“Unfortunately, the introduction of these new modifiers has caused much confusion and they are often being submitted incorrectly,” says Sandra Jongebreur, CGSC,CPC, CPC-H, PCS, FCS, coder for Raafat Abdel-Misih, MD, in Wilmington, Del.

Pause Before Appending PC

In particular, beware of confusing wrong surgery modifier PC with the modifier for the professional component of a procedure: 26 (Professional component). For example, if you want to report that the radiologist performed the professional component of 75966 (Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation), be sure you append modifier 26 and not modifier PC. If you append modifier PC, the payer will review the claim to see if the service was related to angioplasty performed on a patient in error and therefore not payable.

The source of confusion for these modifiers is easy to see. “People often think of the professional and technical components as PC and TC,” explains Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in New Jersey. The modifier for the “technical component” is TC, so many coders accidentally append PC (instead of 26) forthe professional component.

The problem is so widespread, that CMS issued MLN Matters article 6718 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM6718.pdf) warning providers about the issue and announcing that contractors will review all claim lines with modifier PA, PB, or PC.

If the contractor determines the provider used one of the modifiers incorrectly, the contractor will return the claim as unprocessable and ask for submission of a new claim.

Resource: To read CMS’s transmittal on the use of these modifiers, visit www.cms.hhs.gov/transmittals/downloads/R1867CP.pdf.

@ Radiology Coding Alert

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