Posts Tagged ‘CPT’

The American Medical Association (AMA) recently posted on its website updates to several CPT® Category I codes and a listing of Category III codes that extends into 2014.

Category I Code Additions

• 90664  Influenza virus vaccine, pandemic formulation, live, for intranasal use
• 90666  Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use
• 90667  Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use
• 90668  Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use

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Physician office and hospital coding are sometimes two different worlds.

By Dorothy Steed, CPC-H, CHCC, CPC-I, CPUM, CPUR, CPHM, CCS-P, CEMC, CFPC, ACS-OP, RCC, RMC, PCS, FCS, CPAR

When physician coders/billers transition to a hospital environment, they frequently encounter difficulty without a clear understanding as to why. Hospital managers have positions to fill, but the required skill levels of hospital coders are often different from that expected of physician coders.

Know What Skills Hospital Coding Requires

To prepare for a physician coder/biller hospital position, you need to know the following 10 differences in the two work environments:

1. Physician coders are proficient in coding and billing specific services their physician group provides whereas hospital coders need reasonable proficiency in multiple specialty areas.

2. Hospital coders have to identify the principal diagnosis and properly sequence codes. In the hospital arena, the principal diagnosis is determined as the “reason, after study, that occasioned the admission.” When a patient has multiple co-existing conditions, the coder needs to identify the condition requiring inpatient admission.

3. Hospital coders must be able to select co-morbidities and major co-morbidities correctly. Medicare reimburses most hospitals based upon Medicare Severity Diagnosis-Related Groups (MS-DRG) methodology. Detailed physician documentation is critical in capturing these co-morbidities, which affect the hospital’s reimbursement. Very general statements regarding conditions without further details often do not equate to a complication/co-morbidity (CC) for reimbursement purposes. Other payers may reimburse on a slightly different methodology, depending upon the current contract, but the expectations of the coder are the same regardless of the payer. When diagnosis statements are lacking detail, the coder should query the physician for clarification.

4. The physician billing form contains only four fields for diagnosis codes; whereas a hospital coder commonly selects 10, 15, or 20 diagnosis codes. Whether all will fit onto the UB-04 is not relevant. Due to the collection of disease data reported by hospitals, it is necessary for hospitals to capture all codes for applicable conditions that require physician management or affect the physician’s management of the patient.

5. Inpatient coders must report the correct Present on Admission (POA) indicator for conditions managed during the inpatient admission. The purpose of the POA indicator is to report whether a condition was present at the time of the inpatient admission order. Conditions such as catheter-related infections that occur during the admission may not generate additional revenue for the hospital even though they use additional resources to treat the hospital-acquired condition.

6. CPT® codes are not reported on hospital inpatient claims. Procedures are reported using codes from ICD-9-CM’s Volume 3. These codes are not a direct crosswalk to CPT®; often, when a CPT® code describes multiple steps, more than one code from Volume 3 are required to describe the procedure adequately. For example, 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) describes both cataract extraction and intraocular lens implant. Volume 3 will require that two codes be reported; one for the cataract extraction (13.3 Extracapsular extraction of lens by simple aspiration (and irrigation) technique; Irrigation of traumatic cataract, 13.41 Phacoemulsification and aspiration of cataract, or 13.43 Mechanical phacofragmentation and other aspiration of cataract, depending upon technique), and a second code for the lens implant (13.71 Insertion of intraocular lens prosthesis at time of cataract extraction, one-stage).

7. In general, hospital coders are required to meet both productivity and accuracy standards. For example, they may be required to process inpatient records in an average of  18 to 20 minutes each; ambulatory surgery records, eight-10 cases per hour; emergency department (ED) records, 20 per hour; diagnostic referrals such as lab and radiology, 30 per hour. Standards for accuracy are likely to be in the 92 to 95-percent range (this is up to the coding manager, but most require accuracy well into the 90 percent range).

8. Charges are entered onto a hospital claim through a charge master, which is a large file containing all services, supplies, and drugs the hospital uses to treat the patient. Departments providing services to the patient are responsible for their services’ charges, and these appear on the UB-04 under the revenue codes applicable to the area in which the service was provided.

Hospital billers need to view the charges, determine if errors are present, and have any errors corrected prior to releasing the claim to the payer. Common errors include incorrect units reporting and missed charges.

Operation room (OR) time and anesthesia time are typically reported in 15 minute increments by the hospital. For example, reporting of 4 units = patient in OR for one hour. The number of units for OR and anesthesia should either be the same, or there should be no more than one anesthesia unit more than OR units (to allow for sedation to begin a few minutes prior to the start of the surgical procedure). More than one unit should be considered an error requiring the biller to correct the charges.

9. Although similarities exist between physician coding and hospital outpatient coding, hospital staff needs to understand and correctly use the facility modifiers:

• 27 Multiple outpatient hospital E/M encounters on the same day
• 73 Discontinued outpatient procedure prior to anesthesia administration
• 74 Discontinued outpatient procedure after anesthesia administration

Medicare outpatient reimbursement for most hospitals is based on Ambulatory Payment Classifications (APC) rather than the physician fee schedule or Resource-Based Relative Value Scale (RBRVS), and managed care payers also may reimburse on a form of APCs.

10. Understand that hospital coding managers may not have the option to staff based on just outpatient coders. Although it is relatively common for the most experienced coders to handle the inpatient claims, when short staffed or during vacation time, all staff is expected to assist in completing the work. Likely, there will be a time when you need to code inpatient claims.

Weigh Your Skills Against Hospital Expectations

If your goal is to transition into the hospital environment, review your skills against these requirements and determine your readiness for change. Many coding/billing managers in large urban markets hire only those applicants who demonstrate skills in at least some of the 10 listed areas. Be realistic as to what your current skill level is and how it can be utilized by a hospital. When you think you are ready to take that leap, consider the fact that there are generally more employment opportunities in rural locations due to the shortage of qualified coders in remote areas. Also, consider that managers will usually require you to take a pre-employment test applicable to their needs, regardless of geographical location. If you score well, you have a good chance of being the selected candidate.

Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, COBGC, CPCD, CCS-P
Vice President, Strategic Development
American Academy of Professional Coders

Recently, I traveled to Washington and was given the privilege to attend and participate representing the AAPC in listening session with various industry leaders in December in the country including AHIP, AHA, AMA, Blue Cross Blue Shield, CMS, and many other organizations regarding the problems and challenges the industry faces when implementing ICD-10. Every organization present during the session was asked to identify key challenges when facing the enormous task of ICD-10 implementation.  The most concerning area is that most organizations including health plans, hospitals, physicians and medical practices and many others assume that HHS will push back the implementation date and most have not begun to start the process of discovery and understanding of ICD-10 with their organization.  In fact the consensus from the industry that most were ignoring the ICD-10 mandate for now. One of the most significant areas of concern was business process changes which will impact every organization and ICD-10 training.  Getting ready for ICD-10 is the most significant change that our industry will experience in decades. Read more »

The 2010 Medicare Physician Fee Schedule (MPFS) final rule was posted in the Federal Register over a month ago, giving you plenty of time to review policy changes before the Jan. 1 implementation date. The only question that remains is: Did you review the most recent version? There are a number of technical and typographical errors that have since been identified and corrected. Read more »

As Democrats tout the American Medical Association’s endorsement of their health care overhaul, critics are pointing to their studious sidestepping of a little-known monopoly that sends millions into the trade group’s coffers each year, saying it’s no surprise the Democrats were able to gain the AMA’s support.

Read the full article.

Common documentation and coding errors undermine anesthesiology reimbursement.

By Pam Linton, CPC

Anesthesia groups must take the appropriate steps to reduce or eliminate common documentation and coding mistakes if they are to collect every dollar to which they are entitled.

Reducing errors requires a detailed, up-to-date understanding of anesthesia coding, a working knowledge of anatomy, and open channels of communication between coders and physicians. A process allowing coders to follow up with physicians on specific case questions while offering real-time feedback regarding incomplete or inaccurate documentation can go a long way toward strengthening the anesthesia revenue cycle.

Understand Procedure Details

Many of the most common under-coding errors affecting anesthesia reimbursement result from a lack of detail and clarity about a surgical procedure’s underlying nature and location. Here are some primary examples:

Anterior Lumbar Interbody Fusion: A regular spinal fusion pays eight base units if located in the lumbar region, but pays 10 base units if located in the cervical region. If the fusion involves instrumentation—such as the installation of a cage, plate, or screws—the anesthesia portion pays 13 base units. Financially speaking, it’s worthwhile to determine and document the exact nature and location of the fusion.

Abdominal Cavity: Location, likewise, is important in surgical procedures involving the abdominal cavity. If the procedure involves the lower abdomen, it is worth six units. If it is in the upper abdomen, it is worth seven units.

Cardiac Bypass Surgery: The key question for coders here is: Was the procedure on-pump or off-pump? If a bypass machine is used during the procedure and the heart is stopped to facilitate bypass installation, the procedure is worth 18 units. If the heart is not stopped, the procedure becomes more complex for both anesthesiologist and surgeon. Off-pump bypass surgery pays 25 units. A coronary artery bypass grafting (CABG) redo occurring more than 30 days from the original surgery pays 20 units.

Interstitial Radioelement Application or Biopsy – Prostate: In my experience with auditing outside anesthesia groups, this procedure is under-coded approximately 80 percent of the time. If the procedure is done without ultrasound, it is worth three base units. But if trans-rectal ultrasound is used, it is worth five base units.

Thoracostomy/Thoracotomy: If one lung is deflated (one-lung ventilation) in the course of a thoracostomy/thoracotomy, the case is worth either 11 or 15 base units. That compares to eight or 12 base units if one lung is not deflated. Some of the minor thoracostomy procedures have either eight base units (when one-lung ventilation is not used) compared to 11 (when one-lung ventilation is used). The thoracotomy and some extensive thoracostomy procedures have either 12 base units (when one-lung ventilation is not used) compared to 15 (when one-lung ventilation is used).

Epigastric Hernia Repair: The key here is whether the hernia is strangulated and involves the intestines. If so, the procedure is worth seven base units. If not, the rate is four base units.

Hysterectomy: In the case of radical hysterectomies, wherein lymph nodes may be removed and additional biopsies performed, anesthesiologists are entitled to eight base units. That compares to six base units for a standard, abdominal hysterectomy.

Kidney Stone: Specific anatomical location can also be a key factor in determining how many units the case is worth. If the kidney stone is actually in the kidney, or in the upper one-third of the ureter, payment is seven base units. If the stone is located further down in the ureter, it pays five base units.

Hip Replacement and Revision: A total hip replacement pays eight base units. If the patient has had a prior replacement, however, and the procedure is a revision, anesthesiologists receive 10 base units.

Shoulder Arthroscopy: A simple diagnostic shoulder scope pays four base units. It is rare, however, that a diagnostic scope is not done with surgical repair or debridement. If surgery is performed, the scope is worth five units. It’s important to determine whether the scope was performed with surgery.

Knee Arthroscopy: If diagnostic-only, the scope pays three base units. If done with surgery, the scope pays four base units. Although diagnostic-only knee scopes are more common than diagnostic-only shoulder scopes, they remain a common area of under-documentation.

Education is Key

Year after year, anesthesiology groups leave significant dollars on the table as a result of under-coding errors. In today’s difficult economic environment, such errors are no longer acceptable. That is why continuing education is vital. A comprehensive education program can help to ensure coders clearly understand the nuances, codes, and reimbursement levels associated with a wide range of specific surgical procedures.

Physicians likewise should be provided with ongoing education to make sure they are documenting as accurately and completely as possible. Periodic internal audits can provide insight into where the most significant problems lie, and help focus educational efforts for both coders and physicians.

Anesthesia practices should establish a robust system for real-time interaction between coders and physicians to address issues or questions that arise regarding specific procedures. This process strengthens reimbursement both by reducing under-coding and by limiting potential denials before the claim is filed.

UnitedHealthcare recently announced an important policy change whereas all network physicians will be required to participate in the health plan’s Radiology Notification Program, effective Feb. 15, 2010.

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The Centers for Medicare & Medicaid Services (CMS) is making two code changes to the initial 2010 therapy code list update—adding one code and removing another. These changes will affect physicians, therapists and providers of therapy services billing Medicare.

Effective Jan. 1, 2010, CMS is updating the therapy code list with the “Sometimes Therapy” CPT® code 92520 Laryngeal function studies (ie, aerodynamic testing and acoustic testing). This code always represents therapy services when performed by a therapist and requires a therapy modifier.

CMS is also deleting CPT® code 95992 Standard Canalith repositioning procedure(s), (eg, Epley maneuver, Semont maneuver), per day, effective Jan. 1, 2010.

CMS Transmittal 1850, Change Request 6719 provides the official instruction regarding this change and may be viewed on the CMS Web site.

When your physician documents a service involving placement of interstitial devices for radiation therapy guidance, remember to look in the medical chart for any supplies that may have been used. In addition to the procedure code for implanting the device, your physician can also separately report the implantable tissue markers used to perform the service, according to the Centers for Medicare & Medicaid Services (CMS).

Implantable tissue markers are separately billable and payable when used in conjunction with CPT® 55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple.

An implantable tissue marker incorporates a contrast agent sealed within a chamber in a container formed from a solid material. The contrast agent is selected to produce a change, such as an increase, in signal intensity under magnetic resonance imaging (MRI). An additional contrast agent may also be sealed within the chamber to provide visibility under another imaging modality, such as computed tomographic (CT) imaging or ultrasound imaging.

Effective Feb. 26, 2010, Medicare will separately reimburse HCPCS Level II code A4648 Tissue marker, implantable, any type, when supplied on the same date as the procedure and reported on the same claim.

This policy, specified in Pub. 100-20 of the Medicare Claims Processing Manual, applies only to physicians paid under the Medicare Physician Fee Schedule (MPFS) payment system. No separate payment for HCPCS Level II A4648 will be made to hospitals, ambulatory surgical centers (ASCs) or other facilities paid under the Inpatient Prospective Payment System (IPPS) or Outpatient Prospective Payment System (OPPS)/ASC payment system.

CMS communicated this one-time notification in Transmittal 604, Change Request (CR) 6579 on Nov. 27.

Wondering what CPT® 2010 holds in store for laboratory and pathology coding? “From chemistry to surgical pathology, you’ll find new codes in CPT 2010 that you need to know,” Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha recently told Pathology/Lab Coding Alert. Fifteen to be precise.

In the Chemistry subsection, look for three new codes and one revised code that will allow for more accurate test reporting.

CPT® 2010 adds new Chemistry codes:

• 83987 pH; exhaled breath condensate;
• 84145 Procalcitonin (PCT); and
• 84431 Thromboxane metabolite(s), including thromboxane if performed, urine.

Also for 2010, the description for pH code 83986 has been revised, replacing “except blood” for “not otherwise specified.”

In the Immunology subsection of CPT® 2010, you’ll find three new codes that will also allow more specificity when reporting certain tests.

The new Immunology codes are:

• 86305 Human epididymis protein 4 (HE4);
• 86352 Cellular function assay involving stimulation (eg. mitogen or antigen) and detection of biomarker (eg, ATP); and
• 86780 Antibody; Treponema pallidum.

Beginning Jan. 1, for example, you can use 86305 for HE4 rather than generic code 86316 Immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549], each, advises William Dettwyler, MTAMT, president of Codus Medicus in Salem, Ore.

In the Tissue Typing subsection, you’ll find two new codes effective Jan. 1, 2010 that describe newer types of crossmatching tests.

The new Tissue Typing codes are:

• 86825 Human leukocyte antigen (HLA) crossmatch, noncytotoxic (eg, using flow cytometry); first serum sample or dilution; and
• 86826 Human leukocyte antigen (HLA) crossmatch, noncytotoxic (eg, using flow cytometry); each additional serum sample or sample dilution (List separately in addition to primary procedure).

The Surgical Pathology subsection in CPT® 2010 also sees two, fresh new codes. Capture your lab work using the following codes for ancillary study tissue preparation:

• 88387 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); each tissue preparation (eg, a single lymph node); and
• 88388 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies) each tissue preparation (eg, a single lymph node); in conjunction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (eg, a single lymph node) (List separately in addition to code for primary procedure).

Other new additions to the Laboratory and Pathology section include Microbiology codes 87150 Culture typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed; 87153 Culture typing; identification by nucleic acid sequencing method, each isolate (eg, sequencing of the 16S rRNA gene); and 87493 Clostridium difficile, toxin gene(s), amplified probe technique.

Lastly, you’ll find new code 88738  Hemoglobin (Hgb), quantitative, transcutaneous in the In Vivo (eg, Transcutaneous) Laboratory Procedures section; and 89398 Unlisted reproductive medicine laboratory procedure in the Reproductive Medicine Procedures section.

 Guidelines Change, Too

The introductory language in the Organ or Disease-Oriented Panels subsection of the Pathology and Laboratory section was also revised to clarify that users should not report multiple panel codes that include any of the same constituent analytes performed from the same patient collection. In accordance with this change, the parenthetical notes following panel codes 80047, 80053, and 80076 were deleted; and in the guidelines, the term “analytes” was changed to “tests,” and the phrase “(eg, do not report 80047 in conjunction with 80053)” was added. All references to code 82310 found in the panel codes were corrected to state, “Calcium, total.” One final change of which you should be aware: Code 80055 now includes a cross reference note to clarify that when syphilis screening is performed using a treponemal antibody approach (86780), code 80055 Obstetric panel should not be assigned.

Sources: Coding News, ACOG