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92082 or 92083? Choose The Most Appropriate Code with Expert Help

Even small ophthalmology practices are likely to have a Humphrey visual field analyzer, yet many ophthalmologists don’t know the secrets for securing adequate reimbursement for these services — and they even go so far as to put themselves at risk for costly audits due to lack of documentation.

CPT lists three different visual field examinations — and the higher the code, the higher the reimbursement.:

  • 92081 — Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (e.g., tangent screen, Autoplot, arc perimeter or single stimulus level automated test, such as Octopus 3 or 7 equivalent)
  • 92082 — … intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33)
  • 92083 — … extended examination (e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2 or 30/60-2).

A common mistake ophthalmologists make is billing 92082 when they could legitimately bill 92083.

The key to choosing the correct VF code is in the code descriptors themselves. For example, if the ophthalmologist plots only two isopters on the Goldmann perimeter, CPT would call that “intermediate,” based on its description of 92082. If you plotted three isopters, however, that would be an “extended” examination that would qualify for 92083.

Rule of thumb: An intermediate test is one of the screening tests that you would use if you suspect neurological damage. But ophthalmologists use the threshold exam (92083) when they suspect something that causes a slow, progressive dimming of peripheral vision, like glaucoma. Glaucoma causes a loss of vision like a light bulb slowly becoming…

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Emergency Reporting: Know When To Use +99140 With These Tips

Reporting any qualifying circumstances (QC) codes for anesthesia can be tricky, but knowing when to classify a situation as a true emergency can be a real challenge unless you’re well-versed in the emergency conditions guidelines. Check coding definitions and your provider’s documentation to know whether you can legitimately add two extra units for +99140 (Anesthesia complicated by emergency conditions [specify] [List separately in addition to code for primary anesthesia procedure]) to your claim.

CPT includes a note with +99140 stating that “an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body parts.” Your key to knowing a case meets emergency conditions lies in your anesthesiologist’s notes.

“Quite a number of cases come in where the anesthesiologist marks ‘emergency’ but many times the ‘emergency’ isn’t all that clear,” says Leslie Johnson, CCS-P, CPC, director of coding and education for Medi-Corp., Inc., of New Jersey. Documentation supporting an emergency will depend on each case, so read the chart thoroughly when your provider indicates an emergency.

Solution: Talk with your anesthesia providers to clarify what constitutes an emergency and when you can include +99140. If there’s a real reason to report an emergency (such as a ruptured appendix, 540.0), your physician should clearly document the reason. Another diagnosis code to indicate a problem (such as unstable angina, 411.1) could help show the payer you’re reporting an unusual situation. The second diagnosis can also help in an appeal if a payer that ordinarily recognizes +99140 denies the claim.

“An OB patient who comes in for a cesarean section isn’t automatically an emergency,” explains Scott Groudine, M.D., professor of anesthesiology at Albany Medical Center in New York. “However, a diagnosis of fetal distress and prolapsed cord virtually always…

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Switch to 43327, 43328 for Esophagogastric Fundoplasty

Open or laparoscopic, through chest or abdominal wall, with or without hiatal hernia repair, with or without mesh … these are the various ways your surgeon might perform an esophagogastric fundoplasty. And these are the factors you’ll need to take into account when you try to pick the proper code(s) from among nine new choices in CPT 2011.

Let our experts show the way with four how-to tips for paraesophageal hiatalhernia repair and fundoplication coding for 2011.

Tip 1: Understand Pathophysiology

“When a patient is described as having a hiatal hernia, it usually means that part of the stomach has herniated through the opening in the diaphragm [esophageal hiatus] into the chest and is usually associated with esophageal reflux disease,” according to Gary W. Barone, MD, a physician and associate professor at the University of Arkansas for Medical Sciences in Little Rock.

The hernia repair typically involves the surgeon reducing the stomach back into the abdomen and suturing the enlarged diaphragmatic hiatus, explains M. Tray Dunaway, MD, FACS, CSP, a general surgeon and an educator with Healthcare Value Inc. in Camden, S.C.

During the fundoplication procedure, such as Nissen, the surgeon additionally wraps part of the fundus (top) of the stomach around the esophagus and sutured in place. This creates a “valve” that allows food to reach the stomach from the esophagus but prevents reflux back to the esophagus.

“I would say the Nissen fundoplication is the most common surgical procedure to treat gastroesophageal reflux disease (GERD),” Dunaway adds. Watch for gastroplasty: Sometimes the esophagus is shortened and the surgeon can’t reduce the hernia. “The surgeon might perform a gastroplasty, forming a tube of stomach to effectively elongate the distal esophagus,” Dunaway says. An example of such a procedure is a Collis gastroplasty.

Tip 2: Use 43332-43337 for Open…

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Watch Changes to EEG, Joint Injection Guidelines

You report several EEG codes such as 95812 (Electroencephalogram [EEG] extended monitoring; 41-60 minutes) and 95813 (… greater than 1 hour) based on the amount of recording time. But what constitutes recording time?

Jeffrey Cozzens, MD, professor and chair of the neurosurgery division of Southern Illinois University School of Medicine and a presenter at the AMA’s CPT and RBRVS 2011 Annual Symposium in Chicago, addressed the issue during his presentation about neurosurgery and neurology changes for 2011. Keep two things in mind when calculating recording time for these EEGs:

  • Recording time is when the recording is underway and the healthcare provider is collecting data.
  • Recording time excludes set-up and take-down time.

Other EEG codes, however, focus on the amount of physician time rather than recording time. Watch for that specificity in guidelines for 95961 (Functional cortical and subcortical mapping by stimulation and/or recording of electrodes or brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance) and +95962 (… each additional hour of physician attendance [List separately in addition to code for primary procedure). If the physician is in attendance for a total of 30 minutes or less, only report 95961 and append modifier 52 (Reduced services) to indicate he didn’t fulfill the full hour represented by the code.

Two codes for special EEG tests now specify who attends during the procedure:

  • 95953 — Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, unattended
  • 95956 — Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours, attended by a technologist or nurse.

According to information on the…

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Pay Attention To These Revised Codes for Colon Motility and Manometric Studies

If you’ve been looking for a code on colon motility study and being frustrated for the lack of it, your search is over. CPT 2011 debuts a new code for a manometric study, along with two revised codes for esophageal pH monitoring.

For gastroenterology, you have a lot of changes to sort through — many involving deletions on low use codes or clean-up work.

Here’s How to Use New Manometric Study Codes

You should pay attention on two new codes for a manometric study: 91117 (Colon motility [manometric] study, minimum 6 hours continuous recording [including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed], with interpretation and report), and 91013 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report; with stimulation or perfusion during 2-dimensional data study [e.g., stimulant, acid or alkali perfusion] [List separately in addition to code for primary procedure]).

CPT 91117 is just for the study itself, not for the same session with catheter placement. The radiologist may place the catheter in a prior procedure and the gastroenterologist may come in and out to supervise the testing and any provocations that are performed. Thus, you should include the provocations in the study and report 97117 only once no matter how many times the testing is done.

You can use 91013 in cases like assessment of the effect on the measured esophageal motility when the patient’s esophagus is exposed to different stimulant liquids, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA’s CPT Advisory Panel. The code also applies when intravenous medications are administered to try to produce symptoms. CPT 91010 is included in 91013 and would not be billed separately, he adds.

Use 91034, 91035 in a New Way

Aside from debuting…

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Simplify Ear Coding With These Expert Tips

With more patients turning in for a variety of ear conditions, you cannot afford to lose any reimbursement. Look to our expert advice to ensure you’re coding correctly for all of the ear associated diagnoses.

1. Verify Documentation for E/M With 69210

Cerumen removal can present several coding challenges for your practice, particularly if the physician performs the service as a gateway to visualize the ear. Knowing when you can report 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) is key to collecting for this service.

Example: Suppose a patient presents with ear pain, but the physician has to remove impacted cerumen before he can visualize the tympanic membrane. He subsequently diagnoses an ear infection. Your practice wants to bill an office visit and modifier along with 69210 – is that acceptable?

Key: “Whether to report 69210 is always a value judgment because if you just flick a little wax aside to visualize the eardrum, you shouldn’t bill for cerumen removal,” says Charles Scott, MD, FAAP, with Advocare Medford Pediatric and Adolescent Medicine in New Jersey. “Typically, I’ll use that code if I have to use a special device that allows me to curette the ear before I can visualize the tympanic membrane,” he advises.

The July 2005 CPT Assistant states that cerumen is considered “impacted” in several circumstances, one of which is, “cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.” Therefore, if the cerumen is blocking the physician’s view and he has to use special instrumentation to remove it above and beyond irrigation, most payers allow you to report 69210.

You should ensure that you have separate documentation of the E/M service and procedure to support reporting both codes. Some practices overuse 69210, which means many…

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Switch From 92135 to New Location Based SCODI Codes

 These terms nail down your diabetic retinopathy imaging code choice.

In CPT® 2011 in the place of your old familiar SCODI code, you’ll find three area specific codes. Check out these tips on finding the correct code for imaging as well as DR services.

Code 92135 is being split into three more specific codes. The scanning computerized ophthalmic diagnostic imaging or SCODI code got used a lot in 2010 and was a high volume code. CPT 2011 deletes the code. Pick the new code based on the particular area the imaging is performed on as follows:

Area CPT 2011 Code Descriptor
Front of the eye 92132 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral
Optic nerve 92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
Retina 92134 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

 

92227 Vs. 92228: Look at DR Status

Diabetic retinopathy is the leading cause of blindness. Yet early detection makes the condition correctable 95 percent of the time. Imaging retina center technicians can easily look at a photo and read it. The ophthalmologist can then determine if the patient has DR, the stage it’s in, and the proper course of treatment.

Equate the term “Detection” that’s in new diabetic retinopathy imaging code 92227 (Remote imaging for detection of retinal diseases [e.g., retinopathy in a patient with diabetes] with analysis and report under physician supervision, unilateral or bilateral]) with “screening” for diabetic retinopathy. “Use this…

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ICD-9 2011: 752.3x, V13, V91 Offer Obs More Anomaly, Status Options

Three scenarios show you where to brush up before Oct. 1 hits.

October 1 means it’s time to apply the new 2011 diagnosis codes affecting your obgyn practice, which include new uterine anomaly, placenta, and personal history diagnoses. Are you ready? Take this challenge to find out.

Add Uterine Anomalies to Your Diagnosis Arsenal

Scenario 1:

A) 752.31

B) 752.33

C) 752.35

D) None of the above.

E) All of the above.

Solution 1: E. The American Society of Reproductive Medicine (ASRM) identified seven types of uterine anomalies: agenesis, unicornuate, didelphus, bicornuate, septate, arcuate, and DES related anomalies. Of these, only didelphus and DES related anomalies have unique ICD-9 codes prior to Oct. 1: 752.2 and 760.76, respectively. For the other anomalies, you have no specific diagnosis recourse.

However, as of Oct. 1, you’ll be able to differentiate between these different types, and payers will translate these codes into specific gynecologic and obstetric implications and management. They are:

  • 752.31 – Agenesis of uterus
  • 752.32 – Hypoplasia of uterus
  • 752.33 – Unicornuate uterus
  • 752.34 – Bicornuate uterus
  • 752.35 – Septate uterus
  • 752.36 – Arcuate uterus
  • 752.39 — Other anomalies of uterus.

Multiple Placentae? Make Use of New Dx

Scenario 2: The ob-gyn delivers dichorionic/diamniotic twins vaginally. After October 1, how should you report this?

A) 59400, 59409-51, 651.01, V91.00, V27.2

B) 59400, 59409-51, 651.01, V91.01, V27.2

C) 59400, 59409-51, 651.01, V91.02, V27.2

D) 59400, 59409-51, 651.01, V91.03, V27.2

E) 59400, 59409-51, 651.01, V91.09, V27.2

Solution 2: D. You would report 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or forceps]; Multiple procedures) for the second. To support these CPT codes, you’d link each to 651.01 (Twin pregnancy; delivered) and…

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92541 + 92544 Will Soon Be OK

AMA corrects vestibular test codes to allow partial reporting.

The Correct Coding Initiative (CCI) came down hard on practitioners who perform vestibular testing earlier this year, but a new correction, effective Oct. 1, should ease the restrictions and help the otolaryngology, neurology, and audiology practices that report these services.

The problem: CCI edits currently restrict practices from reporting 92541, 92542, 92544, and 92545 individually if three or less of the tests are performed, notes Debbie Abel, Au.D., director of reimbursement and practice compliance with the American Academy of Audiology.

The solution: Starting October 1, 2010, “if two or three of these codes are reported for the same date of service by the same provider for the same beneficiary, an NCCI-associated modifier may be utilized to bypass the NCCI edits,” CMS wrote in a decision to alter the edits.

The American Speech-Language-Hearing Association (ASHA) has requested “clarification regarding the correct NCCI-modifier to use when reporting the codes to Medicare,” noted Lemmietta G. McNeilly, PhD, CCC-SLP, CAE, chief staff officer of Speech-Language Pathology with ASHA, in a July 29 announcement.

Look for Changes to Vestibular Testing Descriptors

The root of the CCI problem began when the 2010 CPT manual was published, including new code 92540 (Basic vestibular evaluation …) and the subsequent codes following it, which make up the individual components of 92540. “The clarification that resulted in the NCCI edits being lifted should be included in upcoming versions of the manual,” Abel tells Part B Insider.

According to the AMA’s Errata page, code descriptors should read as follows, effective Oct. 1:

  • 92540 — Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and

…

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