The American Medical Association (AMA) made a number of CPT® code changes in 2013 that affect evaluation and management services. AAPC’s Managing Editor G. John Verhovshek, MA, CPC, recently highlighted some of the main changes in an article published by the California Medical Association.
“Eighty-two evaluation and management (E/M) codes in the range 99201-99467 have been revised to allow a physician or other qualified health care professional to provide services,” he says. “The revisions clarify that each state’s scope-of-practice laws (not CPT® descriptor language) determine the services an individual provider is qualified to perform.”
Read the full article.
February 9th, 2013
Your surgeon has excised three skin lesions from the patient’s left shoulder, and now must close the wounds. Should you report both the excisions and repairs? If so, which is primary?
CPT® guidelines instruct that all benign (11400-11471) or malignant (11600-11646) skin lesion codes include simple wound closure, but you may separately report intermediate (12031-12057) and complex (13100-13153) repairs. Medicare and payers who follow National Correct Coding Initiative (NCCI) edits are more restrictive, and will bundle intermediate and complex repairs for excisions of benign lesions of 0.5 cm or less (11400, 11420 and 11440). You may separately report intermediate and complex repairs for malignant lesions of any size.
Here a quick decision tree to help you decide when it’s appropriate to report repair separately:
• Is it a simple repair (e.g., involving “primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures”)?
• If yes, do not report the repair separately.
• If no, was the lesion malignant?
• If yes, report the repair separately.
• If no, does your payer observe NCCI edits?
• If no, report the repair separately.
• If yes, was the lesion larger than 0.5 cm?
• If yes, report the repair separately.
• If no, do not report the repair separately.
When reporting both the excision and repair, list as primary that service having the highest relative value units.
When repair is performed using an adjacent tissue transfer, however, excisions at the same location (whether for benign or malignant lesion) are always included in the repair. CPT Assistant (July 2008) provides the following example:
A physician excises a 1.5 cm lesion on the cheek with an excised diameter of 1.8 cm (primary defect, approximately 3.2 sq. cm.) and performs an adjacent tissue transfer (flap dimension of 1.4 x 3.0 cm., which equals a 4.2 sq. cm. secondary defect). Based on the total area of the primary and secondary defects (7.4 sq. cm.) and the location (cheek), the correct code is 14040. The lesion excision is included in the tissue transfer and is not separately reported.
November 28th, 2012
by Ronda Tews, CPC, CHC, CCS-P
Inadequate documentation is not new to coders, but as offices transition from paper to electronic health records (EHR) coders have a new opportunity to educate physicians when they say, “Oh, that’s documented, it’s just in a previous visit.”
The EHR must follow the same documentation requirements as the paper chart. It is not true that if the information is located “somewhere” in the EHR, that it may be counted toward the documentation requirements for any and all dates of service. The provider must reference within her note for that date of service if she has reviewed any information within the EHR to get credit for the information.
Here’s how Medicare carrier Wisconsin Physician Services (WPS) addresses this topic in a Q&A:
Q 17. This question pertains to an Electronic Medical Record (EMR.) We have always been taught that the progress note “stands alone.” When we are auditing physician’s notes to determine if they are billing the appropriate level of service, what parts of the EMR can be used toward their levels without requiring them to reference it? We are referring specially to Growth charts, Past, Family, & Social History, Medication Listings, Allergies, etc.
A 17. If the physician were not referencing previous material in the EMR, then the information would not be used in choosing the level of E/M service.
The old adage still applies to the EHR: If it’s not documented, it wasn’t done.
Templates are beneficial, but can create problems if documentation begins to look the same for each patient. The Office of Inspector General (OIG) has warned, “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries…. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter.” This does not mean that providers cannot use templates, but appropriate changes need to be made to the template based on the patient being seen and the treatment provided.
And remember: The volume of documentation doesn’t determine coding, medical necessity does. National Medicare policy asserts, “It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed” (CMS Transmittal 178, Change Request 2321, May 14, 2004).
When you report a CPT® “unlisted procedure” code, or one of the new technology (Category III) codes, you may be required to enclose a special report with your claim. Additionally, the CPT® codebook provides instruction regarding special reports in the Radiology Guidelines, which specify, “A service that is rarely provided, unusual, variable, or new may require a special report. Pertinent information should include an adequate definition or description of the nature extent, and need for the procedure; and the time effort, and equipment necessary to provide the service.”
The special report should also provide information about the time, effort, and equipment necessary to provide the service. Additional information that may be helpful to the carrier includes: The complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures performed, concurrent problems, and planned follow-up care. This data gives the payer a better understanding of what the procedure is, what was required to perform it, and how it should be reimbursed.
by Nancy Clark, CPC, CPMA, CPC-I
Understanding the difference between routine and medical eye examinations will guide you to properly code these services and prevent your patient from receiving an unexpected bill. Coding eye examinations is different than coding physical examinations, which have separate CPT® codes for routine and medical visits.
CPT® codes 92002-92014 indicate new and established eye exams, and are used for both routine and medical visits. The primary diagnosis code makes the distinction.
• 92002 Ophthalmological services; medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient
• 92004 ...comprehensive, new patient, 1 or more visits
• 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
• 92014 …comprehensive, established patient, 1 or more visits
A routine visit is indicated by a primary diagnosis code of V72.0 Special investigations and examinations; examination of eyes and vision, followed by any additional diagnostic findings. For example, if an eye exam is coded as 92002 with a primary diagnosis of V72.0, it is considered a routine exam; however, 92002 with a primary diagnosis of 379.91 Pain in or around eye would be considered a medical exam.
When a patient presents for an eye exam due to poor eyesight, he may believe this service to be covered by insurance. But insurers do not consider refractive errors (e.g., nearsightedness and farsightedness) to be medical diagnoses, and many do not cover routine vision exams. Consequently, there may be confusion on the patient’s part if his insurance company denies the service.
Clear up the confusion before the service is rendered by contacting the patient’s health insurance and determining if routine vision services are covered, the frequency of coverage, and if the patient has met or exceeded his limit of routine services. Ask the patient if he has separate vision coverage under another carrier. Ensure that your patient understands the difference in exams and what his insurance covers.
Nancy Clark, CPC, CPMA, CPC-I
November 2nd, 2012
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