Posts Tagged LCD
By Kim Cohee, PT, MS, MBA, DPT, OCS
Physical therapy (PT) and occupational therapy (OT) service modalities are divided into two categories: “supervised” and “constant attendance.” Modalities are typically defined as physical agents intended to effect therapeutic changes (using thermal, acoustic, mechanical, or electric energy). To report these services properly, you must understand the difference between the two types of modalities, as well as the specific requirements for each applicable CPT® code.
Supervised modalities may be billed one unit per date of service. Supervised modalities require neither direct, one-on-one provider-to-patient contact, nor constant supervision. Several of the most familiar supervised modalities include:
97010 Application of a modality to 1 or more areas; hot or cold packs
A hot or cold pack often is used in the beginning or end of a therapy treatment to address pain related to a surgery, injury, or overuse condition. Be sure to document the reason for treatment, the treatment location, and the treatment time in minutes. Medicare designates 97010 as a Status B code, meaning it is always bundled to other provided services. Medicare does not reimburse this code, but other insurers might.
97012 Application of a modality to 1 or more areas; traction, mechanical
Mechanical traction includes cervical and lumbo-pelvic traction. The patient is typically harnessed into a device that applies a distracting force intended to unload a patient’s spinal column. Common diagnoses for traction include cervical and lumbar radiculopathies or disc pathologies. The length of treatment in minutes, the location of treatment, and the traction parameters used must be documented.
97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)
Electrical stimulation (unattended) includes Russian, high-volt pulsed galvanic (HVPG), and transcutaneous electrical nerve stimulation (TENS). Therapists use unattended electrical stimulation to alleviate pain as well as to re-train muscles inhibited due to swelling, pain, and immobilization. Common diagnoses would be post surgical conditions such as anterior cruciate ligament (ACL) reconstruction and rotator cuff repair.
Code 97014 is a Status I code; meaning, it is not valid for Medicare. Rather, the Medicare code for unattended electrical stimulation without wound care is G0283 Electrical stimulation (unattended), to one or more areas, for indication(s) other than wound care as part of a therapy plan of care. Documentation is the same as for manual electrical stimulation (see below in the Constant Attendance section); electrode placement also should be outlined in the unattended treatment.
97016 Application of a modality to 1 or more areas; vasopneumatic devices
Vasopneumatic device describes a sleeve placed over a swollen limb, such as an ankle, knee, or an upper extremity. The sleeve intermittently fills with air, creating a brief compressive force, with the goal to reduce effusion or edema related to injury or surgery when appropriate. This modality is also useful in treating lymphedema when using a lymphedema-specific pump. Documentation should include the parameters with which the device was set to compress and release pressure and the total treatment time. One example of this type of pump is the Jobst pump, but other manufacturers make similar devices.
97018 Application of a modality to 1 or more areas; paraffin bath
Paraffin bath is typically for pain relief in the hands and feet, and uses superficial heat to reduce discomfort in conditions such as arthritis. This service is often provided initially for patient training for use of home devices. It is important to provide documentation regarding medical necessity of this intervention, and why it requires the unique skills of an occupational or physical therapist.
97022 Application of a modality to 1 or more areas; whirlpool
This code includes both wet and dry whirlpools. The modality is intended to decrease pain and muscle spasm, to increase circulation to an injured area (such as the hand, ankle, or wrist), or to clean a wound. Documentation should include the water temperature, the area being treated and time in the water, the type of dressing applied, and any chemicals added to the water.
97036 Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes
Larger whirlpools, called Hubbard tanks, can be used for the full body, when necessary. This service is reported using 97036. Note that this service requires constant attendance.
Coding for Supervised Services
Clinical Example 1: Patient presents with a diagnosis of right ankle sprain. The therapist chooses to use a Jobst pump for 10 minutes, followed by manual therapy (15 minutes) and therapeutic exercise (15 minutes) for range of motion while in a cold whirlpool. Total treatment time is 40 minutes. Total timed treatment, however, is 30 minutes because only one unit per session can be charged for an unattended modality (and does not include the untimed code time, which is constant attendance, explained below). You should still record the time for the treatment, however. Thirty minutes equals two units of timed treatment, within the time frame of ≥23 minutes to ≤38 minutes.
The therapist cannot bill both the whirlpool and the therapeutic exercise because they are being performed at the same time. One unit of vasopneumatic device, one unit of therapeutic exercise, and one unit of manual therapy are billable, according to the Centers for Medicare & Medicaid Services (CMS) “eight-minute rule.”
Documentation should include the patient’s position (patient is supine with ankle elevated on bolster), Jobst sleeve placement, compression on and off times (compression for 30 seconds, release for 30 seconds), and total time (10 minutes). Manual therapy should include descriptions of the treatment type (such as grade III joint mobilization), location (right talocrural joint), and for how long.
The constant attendance modality is billed in 15-minute increments and requires direct, one-on-one provider-to-patient contact. Such treatments may be billed in multiple units. Examples include:
97032 Application of modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
Electrical stimulation (manual) may involve treatment using a handheld unit for a condition such as Bell’s palsy, which affects nerves in the face (note that per National Coverage Determination (NCD) 100-03, section 160.15, Medicare does not cover electrical stimulation for Bell’s palsy). TENS placement for the purpose of showing a patient how to use the unit also may be billed with 97032. Documentation should include specifically where the therapist applies the stimulation on the body, treatment time, on and off time if intermittent, intensity/frequency, and patient instructions.
97033 Application of modality to 1 or more areas; iontophoresis, each 15 minutes
Iontophoresis is the use of an electric current to introduce medication into the tissues to reduce pain and edema. The most common medication is dexamethasone—a controlled substance. A physician must write the prescription because therapists are not licensed to distribute controlled substances. The patient gets the medication at the pharmacy and brings it to the therapy visit. The therapist may use the medication as prescribed by the doctor.
Common diagnoses for which iontophoresis is prescribed may include tendonitis, tendonopathies, and bursitis. This is also a constant-attendance modality, but you can’t bill for the unit’s run time because only one-on-one time with the patient may be billed, and the therapist does not supervise the patient throughout the entire treatment. The total billable time includes only the time spent educating patients about the treatment, prepping them for the treatment, set-up time, and skin check before and after the running of the unit.
97035 Application of modality to 1 or more areas; ultrasound, each 15 minutes
Ultrasound uses high-frequency sound waves to decrease pain, muscle spasm, and joint stiffness with the intention of increasing flexibility. The scientific evidence supporting the efficacy of ultrasound for this purpose is in question, according to the medical evidence using randomized controlled trials. Documentation for ultrasound ideally includes the size of the used ultrasound head, length of treatment time, continuous versus pulsed, intensity, depth of penetration (1 or 3 MHz), and the medication name if doing phonophoresis.
Coding for Constant Attendance Services
Clinical Example 2: A patient is being treated for biceps tendonitis and is experiencing shoulder pain, swelling, and stiffness. The therapist chooses to treat the patient initially with iontophoresis with passive range of motion and postural re-education. A possible billing scenario may be 15 minutes of passive shoulder range of motion, followed by 12 minutes of postural training with exercise instruction, and ending with iontophoresis consisting of five minutes of setup and explanation to the patient, as well as 12 minutes of run time.
The total treatment time is 44 minutes, but based on Medicare’s eight-minute rule, only 32 minutes are billable. The therapist should bill for one unit of therapeutic exercise (97110) and one unit of neuromuscular re-education (97112). Per Medicare rules, the iontophoresis is not billable because the setup time is not equal to or greater than eight minutes (even though the run time is).
If the therapist spends 20 minutes on posture re-education, you may bill for two units of neuromuscular re-education and one unit of therapeutic exercise. Because the total timed treatment exceeds 38 minutes, the therapist can bill Medicare three units for 40 minutes (including the five minutes of iontophoresis setup) of total timed treatment.
Documentation for this example needs to include the names of any exercises performed, number of sets and reps, amount of resistance used, position of the patient during each exercise, goal of each exercise, caregiver training and education, and time spent doing the exercises. The iontophoresis documentation should include the name of the medication used, total dose used and the time period, where the electrodes were placed, and the length of the treatment.
Remember: The above example is based on the CMS’ eight-minute rule, which may not apply in all cases. Coders should be aware of individual insurance practices regarding therapy billing (iontophoresis is a Status A code for Medicare, and may be paid depending on your payer’s local coverage determination (LCD)).
Reimbursement for all of the services mentioned here can vary greatly from payer to payer, and from state to state. Knowing your local policies is critical to getting paid for the care given by providers. On a final note, all modalities should include documentation regarding patient response to treatment.
Kim Cohee, PT, MS, MBA, DPT, OCS, is the manager of the University of Utah Orthopaedic Center Therapy Services. She graduated from the University of Utah with undergraduate and doctorate degrees in physical therapy and a Master of Science in Exercise Physiology. She received her Master of Business Administration from Western Governors University in 2009, and achieved Orthopedic Clinical Specialist (OCS) designation in 2006.
November 1st, 2012
Today is the day remittance for 5010 begins. You will find improvements over the old 4010 system of remittance advice.
Version 5010 introduces some significant improvements over ASC X12 version 4010. For example, in version 5010, the Health Policy Segment will report the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). In addition, the 835 will have a website where the specific LCD or NCD code is explained. You will have access to the code as well as the code description. The 5010 version of the 835 also will contain technical contact information not currently in version 4010. Version 5010 contains new segments such as coverage expiration date and claim received date, which will help providers access important information without manual intervention.
Let your Medicare contractor know you want to receive the version 5010 835.
For more information on ASCX12 version 5010 and NCPDP version D.0, please visit CMS’ Versions 5010 and D.0 website.
July 30th, 2012
By Susan M. Edwards, CPC, CEDC
Correct coding and billing for durable medical equipment (DME) raises many questions, such as:
- What constitutes DME?
- Besides the order and physician signature, what other information do I need to submit a claim?
- Are there modifiers?
To shed some light on ambiguous areas, we’ll answer these questions and more.
What Is DME?
Per Centers for Medicare & Medicaid Services (CMS) guidelines, DME is “medically necessary durable medical equipment, prosthetics, orthotics, and disposable medical supplies (DMEPOS), which includes oxygen and related supplies, parenteral and enteral nutrition, and medical foods.”
DME is also medical equipment that:
- Can withstand repeated use
- Is primarily and customarily used to serve a medical purpose
- Is generally not useful to a person in the absence of illness or injury
- Is appropriate for use in the home
- May include a rigid or semi-rigid device
- May be designed to support weak or deformed body part by eliminating motion
- May be used to immobilize a part to decrease pain and inflammation
- May be rented or purchased
What Do I Submit with Claims?
Providers must submit DME claims in accordance with Healthcare Common Procedural Coding System (HCPCS) Level II coding guidelines and national and local coverage determinations (NCDs and LCDs). Providers may only bill for the actual number of medical necessary units dispensed or delivered to a patient, regardless of the number of units allowed by policy and/or prior authorization.
Orders are required for any DME equipment to be covered under Medicare. To bill Medicare for DME, the ordering physician must be a Medicare enrolled physician.
Requirements on the orders include:
- Dispensing order
- Description of item
- Name of beneficiary
- Name of ordering physician and signature
- Date of order
- Quantity delivered
- Item brand name and serial number (if not custom)
Documentation should include detailed descriptions of the item, as well as any accessories and upgrades that will be used. Written orders for custom fabrications must specifically state “custom fabrication,” or the brand name being used. Custom fabrication involves more than trimming, bending, or making other modifications to a substantially prefabricated item. Prefabricated items are factory processed without a patient in mind, but may be altered to fit the patient.
Products and services must be medically necessary, safe, and appropriate for the course and severity of the condition using the least costly and equally effective alternative to meet the recipient’s needs. For all DME items, refer to your state’s Medicare policy.
To support medical necessity, include chart notes, surgery notes, and all supporting documentation for the product. You will need to verify that:
- The patient is eligible and meets the coverage criteria.
- Ask the patient about the items being dispensed. For example, “Have you had a wheelchair before?” or, “Do you receive any diabetic supplies from anyone else right now?”
- There is a supporting diagnosis.
- The beneficiary has signed and dated the forms.
- The physician has signed and dated the forms.
- The physician has provided his or her National Provider Identifier (NPI) number.
Note that some DME services or items will require prior authorization. It is critical to submit complete and accurate clinical documentation on prior authorization requests.
When a claim is received, Medicare will determine if the ordering/referring provider is required for the billed service. If the provider is not on the claim, Medicare will not pay. If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and eligible to order and refer.
Modifiers are frequently used on DME claims. The most common include (Note: These are not the full descriptions.):
RT/LT – Right/left
NU – New equipment
GY – Non-covered item
KX – Required for knee and ankle-foot orthoses
RR – Rental
UE – Purchase of used equipment
CG – May or may not have a specific LCD in place
GA – Does not meet medical necessity and ABN signed
GZ – Does not meet medical necessity and ABN not signed
GY – Item statutorily not covered
RA – Replacement of DME, orthotic, or prosthetic item
EY – No physician order
Use a Form to Be Sure You’ve Got All Relevant Information
Perhaps the best way to ensure you’ve documented all the necessary information is to use a specialized DME intake form. You can find a sample DME Intake Form at Noridian Administrative Services (NAS): www.noridianmedicare.com/dme/forms/docs/intake_form.pdf.
Any person in the office can use the form to ensure all the right questions are asked.
Lastly, remember to always check your DME Medicare administrative contractor (MAC) websites often for LCD revisions. Educating your physicians of documentation requirements and coverage guidelines will help you as the coder/biller make submitting claims for DME an easier process.
Ask the Patient to Sign an ABN if Coverage Is in Doubt
When ordering DME, determine whether you should ask the patient to sign an Advanced Beneficiary Notice (ABN). The ABN is a standard form to inform a patient that Medicare may deny coverage for a recommended or desired item or service. It explains why Medicare may deny the item or service, provides a cost estimate for the item or service, and notifies the patient of his or her responsibility to pay for the non-covered item or service if he or she chooses to receive it. In many cases, a provider cannot seek payment from the patient for unpaid Medicare services if he or she did not properly issue an ABN.
The ABN must be verbally reviewed with the beneficiary or his or her representative and any questions raised during that review must be answered before the patient signs and dates the ABN. CMS requires the provider present the ABN “far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice.” A copy of the completed, signed form must be given to the beneficiary or representative, and the provider must retain the original notice on file for seven years.
When filing your claim, apply modifier GA Waiver of liability statement issued as required by payer policy, individual case on file when the provider believes the service is not covered and the office has a signed ABN on file.
Modifier GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit applies when Medicare excludes the item or service from coverage. When you report modifier GY, Medicare will generate a denial notice that the beneficiary may use to seek payment from secondary insurance, for instance.
If the provider fails to issue an ABN for a potentially uncovered service, append modifier GZ Item or service expected to be denied as not reasonable and necessary to the claim. This indicates the provider cannot hold the patient financially responsible if Medicare denies the service, but will reduce the risk of fraud or abuse allegations for claims deemed “not medically necessary.”
The ABN CMS-R-131 form and instructions may be downloaded from the CMS website: www.cms.gov/BNI/02_ABN.asp.
Susan Edwards, CPC, CEDC, is a coding specialist at Copley Hospital in Morrisville, Vt. She is the president of the Newport, Vt. chapter, and she teaches Medical Terminology at the local adult learning center. Ms. Edwards is Northeast region one representative for AAPCCA, and secretary on the Board of Directors. She is also on the AAPC Ethics Committee.
July 1st, 2012
2012 introduces new codes for both diagnostic and surgical VATS.
By Laurette Pitman, RN, CPC-H, CGIC, CCS
Due to advances in surgical procedures, video-assisted thoracoscopic surgery (VATS) has an increasing role in the diagnosis and treatment of a wide variety of thoracic disorders that previously required sternotomy or open thoracotomy. Patients who undergo this procedure have the advantages of less postoperative pain, fewer surgical complications, a shortened hospital stay, and reduced costs.
The procedure is performed with the use of small fiber optic cameras that allow the surgeon to look inside the chest, usually via a monitor. Similar to a laparoscopic procedure, small incisions are made in the chest allowing the surgeon to introduce the thoracoscope and other small instruments, which may be used for cutting, stitching, or stapling. Following the VATS, a chest tube may be left in the operative pleural cavity for drainage and/or lung re-expansion.
Multiple procedures can be performed using VATS to treat an assortment of disorders. For example:
- Lung nodules
- Interstitial lung disease
- Mediastinal lymph nodes
- Mediastinal masses
- Pleural abnormalities
- Chest wall masses
- Esophageal tumors
- Lung nodules
- Lung biopsies
- Apical blebs
- Mediastinal lymph nodes
- Mediastinal masses
- Pleural effusion
- Lung abscess
- Reflex sympathetic dystrophy
- Limited stage lung cancer in high-risk patients
CPT® codes for reporting VATS procedures are found in the 32601-32609 series for diagnostic procedures, and 32650-32674 for surgical procedures. New codes were introduced this year for both diagnostic and surgical VATS procedures.
CPT® codes 32607 Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral, 32608 Thoracoscopy; with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral, and 32609 Thoracoscopy; with biopsy(ies) of pleura identify thoracoscopic biopsy procedures. A diagnostic biopsy or biopsies of lung infiltrate—whether by wedge or incisional technique—is reported using 32607. If the thoracoscopic biopsy is performed on a lung nodule or mass (again, either wedge or incisional), select 32608. Both 32607 and 32608 are unilateral codes, reported only once per lung; procedures performed on both lungs require the use of modifier 50 Bilateral procedure.
Clinical Coding Example: A 75-year-old male smoker presents with a growing pulmonary nodule in the left lung.
Description of Procedure: A small incision is made in the initial trocar site on the left chest and the pleural cavity is entered. The thoracoscope is advanced into the pleural cavity. Visual exploration is performed. Additional trocar incisions are made for access ports. Adhesions between the lung and chest wall are freed. The chest and lung are explored. The pulmonary nodule is identified and a stapled wedge biopsy is obtained. The biopsied lung tissue is placed in a sterile bag and removed. Hemostasis is performed with endoscopic electrocautery. A chest tube is inserted through a separate interspace incision. All trocar incisions are assessed for hemostasis. Sponge and needle count are accurate. Each incision is closed with multiple layers of suture for muscle and the skin re-approximated with a subcuticular stitch. The biopsy specimen is sent for pathological analysis.
CPT® code assignment for this example is 32608-LT. Modifier LT Left side is an anatomic modifier that indicates the area or part of the body on which the procedure was performed.
For patients with exudative pleural effusions, pleural thickening, or pleural tumors, a thoracoscopic biopsy may be performed to obtain a definitive diagnosis. This procedure is reported with 32609, one time only, even if multiple biopsies are obtained. Per the Medicare Physician Fee Schedule Database (MPFSDB), modifier 50 does not apply to this code.
Surgical VATS codes include pleurodesis, resections, lobectomy, segmentectomy, pneumonectomy, and lung volume reduction. Medicare has designated these as inpatient-only procedures (status indicator C); you would not expect to see these procedures in the outpatient setting.
Pleurodesis is accomplished to artificially obliterate the pleural space and prevent the recurrence of pneumothorax or pleural effusions. This procedure can be done either chemically or mechanically. In a chemical pleurodesis, a substance such as bleomycin, tetracycline, povidone iodine, or a talc slurry is introduced into the pleural space. This results in an irritation between the pariental and visceral layers of the pleura and closes off the pleural space. In the mechanical method, the pleura are irritated, typically with a piece of rolled-up Marlex mesh mounted at the end of an endoscopic grasper. Performed chemically or mechanically, the procedure is reported with 32650 Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical).
CPT® codes 32666-32668 describe diagnostic and therapeutic wedge resections. A wedge resection involves the surgical removal of a wedge-shaped portion of tissue from one or both lungs, and is usually performed for the diagnosis or treatment of small lung nodules. CPT® 32666 Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass, nodule), initial unilateral is reported for an initial unilateral therapeutic wedge resection of a mass or nodule. Modifier 50 is appended for bilateral procedures. Add-on code +32667 Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary procedure) describes additional thoracoscopic therapeutic wedge resections performed during the same operative session.
When a VATS diagnostic wedge resection is followed by an anatomic lung resection, add-on code +32668 Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) is reported. Pay special attention to the parenthetical note following 32668, which identifies allowable primary procedure codes.
Clinical Coding Example: A 68-year-old female smoker is found to have a growing pulmonary nodule in the lower lobe of her left lung. Diagnostic tests do not indicate metastatic disease. Pulmonary function is normal. Plan is for resection by VATS.
Description of Procedure: Trocar sites are identified. A small incision is made and the initial trocar is inserted followed by the thoracoscope. The thoracoscope is advanced into the pleural cavity and initial visual exploration is performed. Additional trocar incisions are made. Access ports are placed for the passage of instruments. Adhesions between the lung and chest wall are freed. The chest and lung are explored via thoracoscope. The target pulmonary nodule is located with mobilization of the lung as necessary for exposure. Using an endoscopic tissue stapler, a wedge resection of the nodule is performed removing the nodule, along with a 1-2 cm margin of normal lung tissue. The specimen prior to removal is placed in a sterile bag and sent for frozen section. Hemostasis is secured with electrocautery and staple lines are checked.
Frozen section results are positive for carcinoma. It is decided to proceed with VATS lobectomy.
The lung is retracted superiorly and the inferior pulmonary ligament is divided with electrocautery. The mediastinal pleura is dissected away from the inferior pulmonary vein. Care is taken to dissect the inferior pulmonary vein from the superior pulmonary vein. The endoscopic vascular stapler is then used to divide the inferior pulmonary vein. Following this, the lower lobe is retracted inferiorly and dissection is performed in the fissure to separate the upper and lower lobes. The pulmonary artery is identified and freed. The arterial branches to the lower lobe are divided with the endoscopic vascular stapler. The lower lobe bronchus is then identified and divided utilizing the endoscopic tissue stapler. The resected lobe is endoscopically placed in a sterile bag and removed from the chest cavity via an accessory incision.
All staple lines are assessed for hemostasis and air leakage. The lung is deflated and chest cavity irrigated. A chest tube is inserted through a separate interspace incision. The anesthetist is instructed to inflate the operative lung so that re-expansion can be visually confirmed. The thoracoscope is removed. Each trocar incision is closed in multiple layers and dressings applied.
CPT® code assignment in this example is 32663 Thoracoscopy, surgical; with lobectomy (single lobe), along with add-on code +32668 Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure). Modifier LT is appended to indicate the procedure was performed on the left lung.
Codes for lobectomy, segmentectomy, and pneumonectomy are assigned dependent on the amount of tissue or anatomic area removed. VATS lobectomy is a surgical procedure that removes one lobe of the lung that contains cancerous cells. As in a lobectomy performed via thoracotomy, the VATS procedure dissects, ligates, and divides the pulmonary artery, pulmonary vein, and bronchus to the involved pulmonary lobe. Typically, endoscopic stapling devices are used to accomplish the ligation and division of the vessels and bronchus. The surgical specimen is placed into a watertight bag and removed from the chest.
CPT® 32663 Thoracoscopy, surgical; with lobectomy (single lobe) is reported for removal of a single lobe and 32670 Thoracoscopy, surgical; with removal of 2 lobes (bilobectomy) is reported for removal of two lobes (bilobectomy).
Segmentectomy involves the removal of a larger portion of the lung lobe than a wedge resection, but does not remove the whole lobe. Pay careful attention to physician documentation to differentiate the procedures. Report 32669 Thoracoscopy, surgical; with removal of a single lung segment (segmentectomy) for removal of a single lung segment.
Removal of an entire lung is called pneumonectomy. It is most commonly performed for cancer of the lung that cannot be treated by removal of a smaller portion. VATS pneumonectomies are rarely indicated because most tumors needing a pneumonectomy are either T3 or large hilar tumors (Mastery of Cardiothoracic Surgery, Larry R. Kaiser, Irving L. Kron, Thomas L. Spray, October 2006).
When performed, VATS pneumonectomies are similar to open pneumonectomy. The pulmonary vein, pulmonary artery, and main stem bronchus are dissected and divided sequentially using endosocopic stapling devices. For VATS pneumonectomy, report 32671 Thoracoscopy, surgical; with removal of lung (pneumonectomy).
Lung volume reduction surgery (LVRS) is indicated in patients with moderate to severe emphysema. The purpose of the surgery is to remove parts of the lung that do not work, allowing the remaining lung tissue to work more effectively. During VATS LVRS, 30-40 percent of each upper lobe may be removed, allowing expansion of the remaining lung. By reducing the lung size, airways are opened, making breathing easier.
In the VATS procedure, endoscopic stapling is used to cut out diseased lung tissue from healthy lung tissue. Report 32672 Thoracoscopy, surgical; with resection-plication for emphysematous lung (bullous or non-bullous) for lung volume reduction (LVRS), unilateral includes any pleural procedure, when performed for a VATS unilateral lung volume reduction procedure. Append modifier 50 if the procedure is performed on both lungs. Code 32672 is also inclusive of any pleural procedure performed during the LVRS.
Note: A national coverage determination (NCD) for the LVRS procedure, published by the Centers for Medicare & Medicaid Services (CMS), includes specific criteria that must be satisfied for the procedure to be covered for the Medicare beneficiary (Medicare National Coverage Determinations Manual, chapter 1, part 4: 240.1).
As always, thorough and accurate physician documentation is the key to correct CPT® code assignment. Carefully read the operative note and review all CPT® instructional notes to aid in accurate code assignment, substantiation of the billed procedure, and proper reimbursement.
Laurette Pitman, RN, CPC-H, CGIC, CCS, is a senior outpatient consultant for Spi Healthcare. She has over 30 years’ experience in the health care field including ED and OR nursing, coding, and DRG and APC auditing. For more information, please reference www.spihealthcare.com or contact Laurette at firstname.lastname@example.org.
June 1st, 2012
The benefits of taking on a new specialty are worth the initial extra legwork.
By Pam Brooks, CPC
The trend toward comprehensive patient care will create a demand for many new multi-specialty practices. As practices expand, the need for specialty coders will, too. But these jobs won’t come without challenges. Even experienced coders can become overwhelmed when learning a new medical specialty, with all the unfamiliar procedures, terminology, and payer guidelines. With a fair amount of organized and careful front-end prep work, coders can overcome the obstacles of learning a new specialty and reap the rewards.
Review the Data and Do Your Homework
If your new medical specialist has recently worked in another practice setting or facility, you may be able to get a list of his or her coding activity over the past year. When a provider joins a new group, the accounting department usually has access to this historical data to determine the return on investment (ROI) they can expect based on past performance. This list can provide you with insight as to the kind of work your specialist will do at your site.
If possible, sort the list of CPT® codes from the most- to least-commonly performed procedures. This will give you an idea of the scope of the new provider’s practice, and where you’ll need to focus your efforts in terms of learning new coding guidelines. You should also review the list against the most up-to-date version of CPT® to make sure the codes are still current. Keep in mind, however, that any previous coding and billing should be viewed as “suspect.” That is not to say you should assume the provider was billing incorrectly or fraudulently; rather, only use this historical data as a guideline. After careful review, move forward. This will help to ensure your own correct coding.
It’s unlikely that diagnosis coding will be included in the financial data because physician coding and billing is not reimbursed based on diagnosis. It’s a good idea, however, to research the conditions and illnesses for the procedures you’ve identified and to learn about the related anatomy, pathophysiology, and typical treatment plans. Familiarizing yourself with common courses of treatment will enable you to recognize when your provider has gone over and above what is expected. If you come across unfamiliar terminology or concepts, look them up. This is an excellent way to learn about your new specialty or to refresh your memory.
Meet with Your Doctor
To better familiarize yourself with your new specialty, secure a time to meet with your new provider to learn about the types of services she provides. Ask if there are any videos or books you could review that would give you a visual perspective of her work. Alternatively, there are a fair amount of surgical procedures available on YouTube. Or, you can Google any of the procedures you are unfamiliar with.
To prevent billing errors, ask your provider what procedures she will perform in the office verses in an outpatient surgery or inpatient operating room setting.
If part of your responsibility is charge capture, you can also use this meeting to decide which services belong on an office fee ticket, and which services might need to be on billing cards or order sheets for work done in the facility setting. If your provider will be using an electronic health record to document her work, you can offer your expertise as a coder to become a part of the template development team by offering advice on documentation guidelines.
After you’ve gotten a pretty solid idea of your provider’s scope of practice and the procedures you can expect to see, start doing compliance research to support your correct coding. Access the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule (PFS) to determine if any of the identified procedures or diagnostics will require you to bill globally or with modifier 26 Professional component. This is also where you can determine whether an assistant surgeon is allowed, what the global days are, and what the associated relative value units (RVUs) are.
Note: For more information about the Medicare Physician Fee Schedule (MPFS) database, see “Use the PFS RVF to Expand Your Coding Knowledge,” April 2011 Coding Edge, pages 42-44.
Know Specialty-specific Code Guidelines
To make sure you’ll recognize which codes cannot be bundled, run commonly-used codes through the National Correct Coding Initiative (NCCI) edits, and take the time to revisit the modifier lists and definitions to determine if any modifier use would be required in certain circumstances. You’ll want to make sure your chargemaster reports the appropriate fees associated with those modifiers that affect reimbursement, so you aren’t under- or overcharging.
If any unlisted codes show up as part of your new provider’s scope of practice, you will have to investigate the most appropriate comparable listed code. You should also review HCPCS Level II and Category III codes to make sure none of these are being overlooked regarding your new provider’s billable services, equipment, or new technology.
Visit the websites of both CMS and your local carrier to identify any national and local coverage determinations (LCD) related to the list of CPT® codes you’ve identified. It can be helpful to gather all of this information into either a notebook or on your desktop as a virtual procedures manual for later reference. Just remember to update it every year.
Expand Your References
Medicare isn’t your only payer, of course, so visit all of your payer websites or contact your provider representatives to learn if they have any specific coverage determinations based on your list of identified CPT® codes. Depending on your new specialty, some procedures or surgeries may be considered experimental, cosmetic, or non-covered, or require payer-specific modifiers or other billing guidelines.
Professional associations your providers are affiliated with are useful resources for finding this specialty-specific information. For example, American College of Obstetricians and Gynecologists (ACOG), Society of Thoracic Surgeons (STA), and American Association of Orthopedic Surgeons (AAOS) all have websites with valuable information for practice management and coding. Often, these resources provide specialty-specific coding and billing workshops, newsletters, or coding services that can help you navigate the ins and outs of your new specialty.
AAPC is also a significant resource for specialty coders. By logging onto the member forum, you can pose questions or search for previously asked questions in a number of specialty areas, with answers usually provided by senior coders who routinely provide links to regulatory guidance. Most importantly, you can obtain additional training and specialty certification through AAPC’s conferences, workshops, and specialty certification examinations.
Networking through your local AAPC chapter can help introduce you to coders who may have experience in your new specialty. You can also arrange to be on the mailing lists of neighboring local chapters, so if they are holding a meeting regarding your specific specialty, you can attend, learn, and network.
Learning a new coding specialty can be a fun and interesting challenge if you’re motivated and apply a systematic and careful approach to setting up your coding and billing protocols. You can also use this approach to prepare for a job interview in a new and exciting specialty. Take advantage of available resources to add value to your current employer and add experience to your resume.
Pam Brooks, CPC, is the physician services coding supervisor at Wentworth-Douglass Hospital in Dover, N.H. She holds a Bachelor of Science degree in Adult Education and Workplace Training from Granite State College, and is working on her master’s in Health Administration at St. Joseph’s College of Maine. She is a past secretary of the Seacoast-Dover N.H. AAPC local chapter.
April 1st, 2012
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