The Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics (NCHS) posted updates Aug. 5 to the ICD-9-CM Official Guidelines for Coding and Reporting. These guidelines for diagnosis coding are effective Oct. 1.

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The Centers for Medicare & Medicaid Services (CMS) is considering changes to the Medicare coverage policy for ventricular assist devices (VAD) as destination therapy in end-stage heart failure patients.

In a proposed decision memo dated Aug. 19, CMS proposes removing the requirement that patients must have a body size greater than 1.5 m² and raising the peak oxygen-consumption threshold from 12 mL/kg/min to 14 mL/kg/min.

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Palmetto GBA recently amended its Cataract Surgery Local Coverage Determinations (LCDs) to reflect a focus on the adult patient and a more complete description of functional status.

In response to comments the J1 Part A/B Medicare administrative contractor (MAC) received, the title of the final policy was amended to appropriately reflect the adult patient population. Palmetto GBA also removed the specific Snellen visual acuity threshold from the final LCD. The reporting requirement of the “best corrected” Snellen visual acuity remains, however. As does the expectation that the medical records supporting the cataract extraction identify the activity limitations (e.g., in self-care and mobility) and participation restrictions (e.g., in interpersonal interactions and relationships and community, social and civic life) are also reported.

These terms may be new to physicians, hospitals, and ambulatory surgical centers (ASCs) providing cataract surgery but are reflective of long-standing concepts included in such well-established instruments like the National Eye Institute’s Visual Functioning Questionnaire – 25 (VFQ – 25).

To provide guidance to physicians, hospitals, and ASCs on how best to communicate functional status for patients requiring cataract extraction, Palmetto GBA has incorporated the concepts of the International Classification of Functioning, Disability and Health (ICF) taxonomy into the final version of the LCD.

Below is a case scenario demonstrating the value of going beyond diagnosis by using the concepts of the ICF. Please note that while Palmetto GBA is encouraging physicians and hospitals providing cataract surgery to consider the conceptual framework of the ICF, Medicare does not require the reporting of the ICF codes. Read more »

Medicare Part B physician payments for transforaminal epidural injection services increased from $57 million in 2003 to $141 million in 2007, according to a recent review conducted by the Office of Inspector General (OIG). That amounts to a 150 percent increase.

A gain in popularity of this magnitude prompted the OIG to conduct a review of this pain management service. In the review, the OIG states that roughly 34 percent of 433 sampled claims for transforaminal epidural injection services performed in 2007 did not meet Medicare requirements. The OIG estimates approximately $43 million in improper payments.

Physicians should prepare themselves for added contractor scrutiny of these types of pain management claims.

Transforaminal epidural injections are a type of interventional pain management technique used to diagnose or treat pain. There are two primary codes used to bill a single injection in the cervical/thoracic or lumbar/sacral area of the spine, and each primary code has an associated add-on code for use when injections are provided at multiple spinal levels. These codes are:

Physician payments vary based on the place of service (office vs. ambulatory surgical center (ASC) or outpatient department) and also the modifiers billed. For example, bilateral transforaminal epidural injections, which are performed on both the right and left side of a vertabrel level should be billed using modifier 50. The use of this modifier would increase payment to 150 percent of the base rate.

According to the OIG, “The reviewer found primarily that physicians improperly used add-on codes and bilateral modifiers.”

Medicare covers transforaminal epidural injections that are reasonable and necessary, which are those used in the diagnosis or treatment of illness or to improve the functioning of a malformed body part. To ensure payment, physicians must:

• Properly document medical care to support the service; and
• use uniform procedure codes to report all services.

Documentation should include a description of the service provided, with details such as location and frequency of injections, as well as outcomes that support subsequent injections. Diagnosis codes also must support medical necessity. Most contractors with local coverage determinations (LCDs) in place for transforaminal epidural injections also require the use of radiographic guidance (such as live X-rays), prohibit multiple pain management services on the same day, and limit frequency.

In response, the Centers for Medicare & Medicaid Services (CMS) says it intends to strengthen program safeguards, which may include medical reviews and system edits.

Read the OIG’s August review for complete details.

The 5010 837I transaction implementation in January 2011 will allow providers, hospitals and skilled nursing facilities (SNFs) to report up to 25 ICD-9-CM diagnosis and 25 ICD-9-CM procedure codes when submitting claims to Parts A and B Medicare administrative contractors (A/B MACs) and/or fiscal intermediaries (FIs) for services to Medicare beneficiaries.

Current claim forms allow for only nine ICD-9-CM diagnosis codes and six ICD-9-CM procedure codes. Medical coding and billing staff should prepare for this change.

Source: MLN Matters MM7004, issued July 30

By: Corrie Alvarez, CPC, CPC-I, CEDC, AAPC educator and PMCC Instructor

Since the AAPC’s annual conference in Jacksonville, I have been wearing my “Ask me about ICD-10” button at chapter meetings. So, what is the most frequently asked question? “How and when should I begin learning about ICD-10?”

It is an obvious question and the answer varies depending on the individual. Those beginning their coding career are worried about learning something new so soon, and those nearer the end of their coding careers don’t think they can learn something new. Whichever group you belong to, I can assure you that if you code now, you will be able to code in ICD-10. You have time to prepare and the key to your success will be in the planning, and staying on track with your plan.  Here are five things you can do now to prepare for ICD-10.

1. Decide where you want to be on October 1, 2013.

ICD-10 will give most of us an opportunity to expand or change our current roles. With the need for more detailed information in the patient’s medical record, there will be an increase to the queries we send to our providers. This will increase significantly the interaction between coders and the medical staff. Are you prepared for this? Training providers takes a different skill set, and if you have a desire to take up this new challenge you need to be prepared for it. Begin work on your communication practices now.

2. Develop an action plan.

The action plan can be a simple excel spreadsheet with your ICD-10 goals and objectives. You also can use your benchmark tracker on the AAPC website to track your progress. Make sure you indicate timelines and have a space to note your progress. This will be a working document that may change over time, but having your goals in writing will not only help keep you focused, it will get you there!

3. Assess your current skill level with medical terminology and anatomy.

ICD-10 represents a significant improvement over ICD-9. There are twice as many categories and currently 69,000+ codes consisting of up to seven alpha-numeric characters. Obviously this will increase the level of specificity required when coding.  If necessary, update your medical terminology and anatomy knowledge within the next year.  Having an in-depth knowledge of anatomy and terminology will help you ease the transition into ICD-10-CM and lessen productivity losses.

4. Research and find useful websites

Look for websites that are providing useful, updated ICD-10 information.

This may be CMS, AMA or AAPC, for example. Don’t forget to search the top carriers in your region as well. Bookmark them and scan them at least monthly for updated information.

5. Find an 1CD-10 partner

Find someone who is looking for the same thing as you. If it’s someone at work, plan to bring your lunch at least twice monthly to share your findings and discuss recent articles. In addition, you can go to the “find a chapter” section on the AAPC website and find local chapters in your region and consider attending their meetings if the topic is on ICD-10.  Find other coders to carpool with. Not only will it make the drive enjoyable, it will make you more comfortable having someone you know with you.

Although the idea of ICD-10 can be confusing and intimidating, it is manageable with proper planning, these five simple tips will help get you started on your journey to the October 1, 2013 implementation date. Remember this is a journey and not an event. By following these steps you will be ahead of the game and be ready to improve the success of your practice, which in turn will help you further your career.  By being prepared, you will find that ICD-10, rather than an object of fear, can be a tool to bring you success.

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that changes how physicians are paid for furnishing dialysis services for patients with end stage renal disease (ESRD) from partial bundled composite rates to a new partial payment system (PPS). The rule also establishes a quality incentive program (QIP) linking a facility’s payments to performance standards. This is the first time a QIP is part of a PPS.

Facilities failing to meet or exceed specified total performance scores will receive reduced reimbursement for dialysis services furnished on or after Jan. 1, 2012.

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A government-led medical record review reveals that 39 percent of Medicare Part B claims allowed for mental health services during non-Part A nursing home stays in 2006 did not meet the program requirements for coverage, according to a July 8 Office of Inspector General (OIG) report. Specifically, the OIG says, services were found to be medically unnecessary, undocumented or inadequately documented or miscoded. These errors resulted in an estimated $74 million in inappropriate Part B payments.

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AAPC member Betty Johnson, CPC, CPC-I, CPC, CPC-I, CCS-P, PCS, RMC, CIC, CCP, CPC-H, CDERC, shares in-depth advice on how to determine the proper codes for pressure ulcers or bed sores. This article is not available online but can be found on page 14 of the June/July issues of BC Advantage.

By John F. Bishop, PA-C, CPC, CGSC, CPRC

Abdominal wall reconstruction has become more common in the past 10 years. Such reconstructions may occur for blunt or penetrating abdominal trauma, abdominal compartment syndrome, wound dehiscence, intraperitoneal tumor resection, or complications of previous abdominal surgery (such as hernias and mesh infections).

Anatomy

The abdomen is comprised of several tissue layers, listed here by location from superficial to deep:

• Skin
• Subcutaneous tissues
• Superficial fascia (scarpa fascia)
• Anterior rectus fascia
• Rectus abdominus muscle
• Posterior rectus fascia
• Extraperitoneal adipose
• Peritoneum

The fascias are layers of elastic, fibrous tissue; adipose is fat; the peritoneum is a membrane that forms the lining of the abdominal cavity, which contains the stomach, intestines, liver, etc. Other abdominal wall structures located lateral to the rectus abdominus muscles are the external oblique fascia and muscle, internal oblique fascia and muscle, and transverses muscle and transversalis fascia. Distinguishing among the abdominal layers is important because the surgeon may close more than one layer of muscle or fascia during reconstruction, and each layer of closure sometimes calls for separate coding.

ICD-9-CM Coding

Diagnostic statements dictated by a surgeon for abdominal wall reconstruction may include:

• Acquired deformity of abdominal wall (738.8 Acquired deformity of other specified site)
• Congenital deformity of abdominal wall (756.70 Other congenital musculoskeletal anomalies; anomaly of abdominal wall, unspecified)
• Loss of upper domain (879.3 Open wound of abdominal wall, anterior, complicated) and/or lower domain (879.5 Open wound of abdominal wall, lateral, without mention of complication)
• Complicated open abdomen (879.3, 879.5, or 879.7 Open wound of other and unspecified parts of trunk, complicated)
• Large, complicated, incarcerated ventral hernia (553.20 Other hernia of abdominal cavity without mention of obstruction or gangrene; ventral hernia, unspecified)
• Large, complicated, incarcerated incisional hernia (553.21 Other hernia of abdominal cavity without mention of obstruction or gangrene; ventral hernia, incisional)
• Diastasis recti (728.84 Disorders of muscle, ligament, and fascia; diastasis of muscle)
• Disruption (dehiscence) of abdominal incision (998.31 Other complications of procedures, not elsewhere classified; disruption of internal operation wound)
• Complication of non-healing surgical wound (998.83 Other specified complications of procedures, not elsewhere classified; non-healing surgical wound)

Although these diagnoses are among the most common, they are not exclusive in prompting abdominal wall reconstruction: Other diagnoses may apply.

CPT® Coding

The various procedures now designed to assist with abdominal wall reconstruction may include a component separation utilizing longitudinal release of the rectus abdominus muscles (15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk).

This release is designed to help relieve the tension in closure of the peritoneum. Most frequently, it is done bilaterally.

The National Correct Coding Initiative (NCCI) and Medicare Physician Fee Schedule (MPFS) Relative Value File do not allow the use of modifiers 50 Bilateral procedure with 15734. Instead, a bilateral procedure may be reported using two units of 15734. Some payers may further require you to append modifier 59 Distinct procedural service to the second unit on a second line entry to indicate a separate anatomic location. Check with your payer for details. There are several appropriate procedures:

• Separate release(s) of the external oblique fascia and muscle (15734; bilateral 15734 x 2—note that second unit may require modifier 59).
• Separate release(s) of the internal oblique fascia and muscle (15734; bilateral 15734 x 2—note that second unit may require modifier 59).
• Separate release(s) of the transverses muscle and transversalis fascia muscle (15734; bilateral 15734 x 2—note that second unit may require modifier 59).
• Application of acellular dermal allograft (such as Alloderm®, Tissuemend®).

The insertion of these allograft materials usually acts as an overlay to strengthen the closure of the rectus and/or fascia. This is reported using 15330 Acellular dermal allograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children for the first 100 sq cm and +15331 Acellular dermal allograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) for each additional 100 sq cm or part.

For example, you would report placement of 351 sq cm of allograft 15330 for the first 100 sq cm, and 15331 x 3 for the additional 251 sq cm.

• Repair of a reducible ventral or incisional hernia (initial 49560 Repair initial incisional or ventral hernia; reducible or recurrent 49565 Repair recurrent incisional or ventral hernia; reducible)
• Implantation of mesh or other prosthesis for open incisional or ventral hernia repair (+49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair))
• Adjacent tissue transfer or tissue rearrangement for the closure of the deep subcutaneous tissues and superficial fascia (scarpa fascia) (14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm and +14302 Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure))
• Following surgery, the skin and subcutaneous tissues may require a complex closure (13100-13102)

Op Report Coding Example

In this procedure, a general surgeon and plastic surgeon work as co-surgeons to repair an incisional hernia and reconstruct the abdominal wall. Each co-surgeon must dictate his or her own operative (op) note. We will be coding for the plastic surgeon’s portion of the procedure only, as represented in the following op note.

Pre-op dx: 1. Incisional hernia 2. Acquired deformity of anterior abdominal wall

Post-op dx: 1. Incisional hernia 2. Acquired deformity of anterior abdominal wall

Procedure: 1. Repair of incisional hernia. 2. Components separation of anterior abdominal wall. 3. Bilateral rectus muscle advancement flaps for anterior abdominal wall reconstruction. 4. Insertion of BioA tissue matrix for reinforcement of anterior abdominal wall reconstruction. 5. Adjacent tissue transfer closure of anterior abdominal wall (20 cm x 30 cm).

Procedure in Detail: The patient was brought to the OR … The abdominal scar was excised. We then elevated anterior abdominal flaps from costal margin to costal margin and down to the pubis. This allowed us to expose the hernia sac.

The operation was then turned over to [general surgeon] for reduction of the hernia and lysis of adhesions and small bowel exploration. After the general surgery team had freed the fascial edges, the plastic surgery team scrubbed back in and began the components release portion of the operation.

Incision was made in the anterior rectus fascial sheath, and we then dissected external oblique muscles bilaterally. We were then able to slide the rectus muscle along with the internal oblique muscles medially … This allowed for tension-free closure of the abdomen along the midline … we plicated and closed the anterior abdominal wall along the midline … [and] implanted a BioA tissue matrix … We used 2 sheets of 15 x 9 and quilted them together … We sutured the BioA in with 2-0 Vicryl along the anterior rectus fascia sheath, along the edges where the incisions then were made for the components separation. This spanned the entire area.

We inserted #19French Blake drains … [and] advanced the skin flaps, trimmed off the excess tissue and the additional scar tissue, and closed in multiple layers … The deep layer was closed with 2-0 Vicryl in simple interrupted fashion. The deep dermis was closed with 3-0 Vicryl in simple inverted interrupted fashion. The skin then was approximated with 4-0 monocryl in a subcuticular fashion. The wound was dressed …

The coding template below represents the aforementioned well-documented, summary op report. Not all op reports are this complex, or use the same number or specific CPT® codes and units. I encourage all coders and surgeons to review the CPT® verbiage and make sure each tissue layer (peritoneum, fascia, muscle, subcutaneous, and skin) is well documented to support appropriate and legal reimbursement.

The plastic surgeon acts as co-surgeon for the hernia repair, performing the approach (including excision of the abdominal scar and exposure of the hernia sack). This would be reported using 49560 with modifier 62 Two surgeons appended, and a primary diagnosis of incisional hernia (553.21). A tissue matrix also is placed to strengthen the repair and may be reported separately using add-on code 49568.

Although we are not coding for the general surgeon, the lysis of adhesions is bundled to the repair—unless it is documented as unusually difficult or time-consuming, in which case modifier 22 Increased procedural services may be appended to the primary procedure code. Similarly, exploration of the small bowel is not reported separately in this case.

The rectus muscle advancement should be coded 15734 and, because this was a bilateral procedure, may be reported twice. Remember that some payers may require modifier 59 on the second unit. A diagnosis of muscle separation (728.84 Diastasis of muscle) is primary to the hernia diagnosis.

The adjacent tissue transfer used in closing measures a total of 600 sq cm (20 cm x 30 cm). Report 14301 for the first 60 sq cm, and 18 units of 14302 for the remaining 540 sq cm (each unit of 14302 specifies 30 sq cm; 30 sq cm x 18 units = 540 sq cm). Here, the reason for the procedure is the open wound (879.3 Open wound of abdominal wall, anterior, complicated).

Tip: Note the use of modifier 51 on 14301 and 14302: Some payers may not require you to append modifier 51 because the payer’s billing software will recognize multiple procedures and order them accordingly. If you don’t already know your payers’ policy, ask for it in writing.

Although not documented here, if the abdomen is open already, or is a difficult case to close, each separate layer may need individual closure. The coder should read the op note carefully to search for the distinction between each separate layer, and what materials and methods are used for final closure. Even if the surgeon states he used a local tissue advancements flap to close the abdomen, he also may dictate something like, “the deep subcutaneous layers were closed with 0-Vicryl, the superficial sub-Q layer closed with 2-0 Vicryl, the subdermal was closed with 3-0 Vicryl, and the subcuticular layer closed with 4-0 Nylon.” This type of dictation may warrant the use of complex closure codes 13100-13132, as appropriate to the length of the wound.

John F. Bishop, PA-C, CPC, CGSC, CPRC, has 36 years experience as a physician assistant, and is a multi-specialty surgical coder with over 25 years in coding, compliance, auditing, and provider/coder education. He is president of Bishop & Associates, Inc., and senior coder/auditor for The Coding Network, LLC.