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Radiology Coding: Watch for 4 Key ICD-9 Additions

From head to toe, the new diagnosis codes hold something for everyone.

Whether your patients present with cardiologic, orthopedic, or gynecologic complaints, the next round of ICD-9 codes could hold important changes for you. Here’s the rundown on the new codes most relevant to radiologists — including a new option for retained magnetic metal fragments.

Remember: ICD-9 2011 will go into effect Oct. 1, 2010. The official version will be released in the fall, so the codes below are not yet final.

1. Look Forward to More Specific Ectasia Codes

The proposed changes to ICD-9 2011 add four codes specific to aortic ectasia. These codes are among the most significant changes for radiology coders because you may see that term in your radiologist’s findings, says Helen L. Avery, CPC, CHC, CPC-I, manager of revenue cycle services for Los Angeles-based Sinaiko Healthcare Consulting Inc. “Ectasia” means dilation or enlargement, and aortic ectasia typically refers to enlargement that is milder than an aneurysm. But ICD-9 2010 does not distinguish ectasia from aneurysm, indexing aortic ectasia to 441.9 (Aortic aneurysm of unspecified site without mention of rupture) and 441.5 (Aortic aneurysm of unspecified site, ruptured).

The proposed 2011 codes are specific to aortic ectasia and differ based on anatomic site:

  • 447.70 — Aortic ectasia, unspecified site
  • 447.71 — Thoracic aortic ectasia
  • 447.72 — Abdominal aortic ectasia
  • 447.73 — Thoracoabdominal aortic ectasia.

2. Watch for ‘Claudication’ in Stenosis Report

Another one of the important changes is the proposed addition of 724.03 (Spinal stenosis, lumbar region, with neurogenic claudication), says Avery. The code refers to lumbar spinal stenosis, which is a narrowing of the spinal canal, according to the Sept. 16-17, 2009, ICD-9-CM Coordination and Maintenance Committee meeting proposal (available here). Neurogenic claudication “is a commonly used term for a…

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Collect HPV Pay with Proper Screening vs. Reflex Diagnoses

Align ‘medical necessity’ with ICD-9 instruction.

Ordering a human papillomavirus (HPV) screen with a Pap test isn’t the same as ordering a reflex HPV screen following an abnormal Pap. Although ICD-9 instruction and coverage rules might appear to be at loggerheads, our experts can show you the way out.

Question: Should the physician order a screening and/or reflex HPV Pap test (such as 87621, Infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, amplified probe technique) with V73.81 (Special screening examination for human papillomavirus [HPV])?

What you stand to gain: “Many ‘V’ codes are paid as part of a screening benefit for patients who have those specific benefits,” says Tina Burkhalter, billing manager with SouthEastern Pathology in Rome, Ga. On the other hand,

“tests ordered with diagnostic codes tend to go to the deductible,” she says. “We hear from patients complaining that they must pay for the HPV test because their insurer tells them we used the ‘wrong’ code.”

Medical Necessity Points to 795.0x

Although no national coverage policy exists for screening HPV testing to evaluate cervical cancer risk, many payers follow the consensus guidelines recommended by the American Society for Colposcopy and Cervical Pathology (ASCCP).

A core ASCCP recommendation is to screen for high-risk HPV DNA in patients over the age of 20 years with a Pap cytologic result of 795.01 (Papanicolaou smear of cervix with atypical squamous cells of undetermined significance [ASC-US]). The guidelines also address the role of HPV with other Pap outcomes in special populations, such as recommending reflex HPV testing for postmenopausal women with cytologic findings of 795.03 (Papanicolaou smear of cervix with low grade squamous intraepithelial lesion [LGSIL]).

Key: If your payers have adopted any or all of these guidelines, you’ll need to report the Pap findings, such as 795.01, to show…

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Urology Coding: Capture Kegel Exercise Pay With E/M

Don’t assume 90911 is the correct code choice.

Question: Is there a procedure code for billing for Kegel exercise teaching? Can we use code 90911 or possibly 97110?

Answer: There are no specific CPT or HCPCS codes for the performance of or teaching of Kegel exercises. To bill for teaching a patient how to properly perform these exercises, a nurse or medical technician must document a brief history and physical examination as well as the indications for and the expected goals of the Kegel exercises. Under these circumstances, you can then report 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician …) for this encounter.

About the service: Kegel exercises are voluntary contraction and relaxation of the perineal musculature including the urinary sphincter (pelvic diaphragm). These exercises are usually performed outside of the office without medical staff supervision, and are a non-invasive and non-surgical treatment for female and occasionally male stress urinary incontinence.

Pitfall: You should only use 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) for the teaching of biofeedback therapy with face-to-face supervision in office by a trained member of your medical staff.

Additionally, you should use 97110 (Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) only for pelvic floor muscle rehabilitation (PFMR) performed under one-on-one supervision with a physician, physiotherapist, or ancillary office staff member specifically trained in an accredited physiotherapy program.

@ Urology Coding Alert (Editor: Leesa A. Israel, CPC, CUC, CMBS).

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Ob-gyn Coding: Clue In To These CCI Edits Before You Choose 0193T

Overlooking these new Interstim and hemorrhoid destruction bundles could mean denial headaches.

Don’t let CCI version 16.1’s lack of ob-gyn mutually exclusive edits lull you into a false sense of security. Here’s what you need to know to prevent a denial from landing on your desk.

Payers like Noridian Part B will cover the female stress urinary incontinence treatment code 0193T, but before you submit a 0193T claim, you’ll have to check with the Correct Coding Iniative (CCI) version 16.1’s edits. For instance, as of April 1, the work represented by 0193T will include that of cystourethroscopy codes 52000-52001 and 52281.

1. Look For 0193T in Both the Column 1, Column 2 Position

In 2009, CPT added 0193T (Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence) to your possible stress urinary incontinence (SUI) treatment coding options. This code includes the Renessa transurethral collagen radiofrequency denaturation procedure. Ob-gyns typically perform this nonsurgical, minimally invasive alternative for women who have failed other nonsurgical treatments or who aren’t good candidates for surgery.

What happens: The ob-gyn uses controlled heat at low temperatures and targets tissue in the woman’s lower urinary tract. The heat changes the structure of the patient’s natural tissue collagen. This helps the firmness of tissue and improves her continence. Although the ob-gyn may use heat on multiple sites and document multiple cycles, you should report 0193T once to represent all the treatment cycles performed during an encounter.

As of April 1, 0193T will include the work represented by 52000-52001 (Cystourethroscopy …) and 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female).

Reaction: “These edits don’t surprise me at all because 0193T says ‘transurethral’ which implies the…

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Anesthesia Coding: Find the Missing EGD Reimbursement Link

Warning: Just including EGD diagnosis with your claim doesn’t guarantee reimbursement — here’s help.

Question: Our anesthesiologist provided anesthesia during an esophagogastroduodenoscopy (EGD) procedure, at the request of the attending physician. We coded the anesthesia portion with 00810. A note in the documentation mentions the request was due to the patient’s symptoms, but no other details were provided. The claim we submitted was denied, but we followed all of the other guidelines provided by the payer, including proof that the anesthesiologist administered Propofol. What did we do wrong?

Answer: One key to the denial might be found in the lack of coding for the patient’s condition. Your diagnosis code should indicate the co-existing medical condition that justifies your anesthesiologist’s involvement in the case, not the gastrointestinal condition leading to the endoscopy.

You may want to consult with your anesthesiologist to verify that the patient had a condition such as:

  • Parkinson’s disease (332.0)
  • Heart conditions (such as 410.xx, Acute myocardial infarction or 427.41, Ventricular fibrillation)
  • Mental retardation (318.x)
  • Seizure disorders (such as 780.39, Other convulsions)
  • Anxiety (such as 300.0x, Anxiety states)
  • Pregnancy
  • History of drug or alcohol abuse.

These are just some of the conditions that payers may require to justify the presence of an anesthesiologist at a colonoscopy. ICD-9 2010 also has two codes to describe failed sedation attempts: 995.24 (Failed moderate sedation during procedure) and V15.80 (Personal history of failed moderate sedation).

If your anesthesiologist’s documentation confirms one of these conditions, 995.24 or V15.80 would also justify an anesthesiologist’s involvement to most payers. The conditions listed above constitute the medical necessity of anesthesia with the procedure. If you used a screening diagnosis or treatment of commonly found conditions instead of the clinical condition requiring anesthesia, payers will not pay you for these services.

Also note the…

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Lawsuit Pushes Red Flags Rule Back — Again

Amidst an AMA lawsuit, the FTC appears to take a wait-and-see approach.

After a year’s worth of extensions of the Red Flags Rule, medical practices were ready to buckle down and ensure that their plans were in place, because the rule was set to take effect on June 1.

However, just days shy of that deadline, the Federal Trade Commission (FTC) announced that it would be delaying enforcement until Dec. 31, 2010, “at the request of several Members of Congress,” according to a May 28 FTC news release.

Under the Red Flags Rule, “certain businesses and organizations — including many doctor’s offices, hospitals, and other health care providers — are required to spot and heed the red flags that often can be the telltale signs of identity theft,” according to an article on the Federal Trade Commission’s Web site.

To comply with the Red Flags Rule, covered entities are expected to create a written red flags program to prevent and detect potential identity theft cases.

According to the FTC, the rule applies to businesses that qualify as creditors or financial institutions, and the FTC’s broad definition indicates that it applies to many medical practices. “Health care providers are creditors if they bill consumers after their services are completed,” the FTC Web site says. “Health care providers that accept insurance are considered creditors if the consumer ultimately is responsible for the medical fees.”

However, simply “accepting credit cards as a form of payment does not make you a creditor under the rule.”

Congress requested the delay in part to “pass legislation that will resolve any questions as to which entities are covered by the Rule,” the FTC press release indicated. “Congress needs to fix the unintended consequences of the legislation establishing the Red Flags Rule — and to…

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Medical Coding: 4 Tips To Eliminate Your Breast Implant Coding Challenges

Don’t lose 19342 pay for delayed insertion.

Your general surgeon may perform breast reconstruction following cancer, infection, trauma, or burns, or in some cases, strictly for cosmetic reasons. Make sure you capture appropriate implant pay, when that’s part of the surgical scheme, by following our experts’ tips.

Tip 1: Prosthesis’ Purpose Drives Coding

Breast implants commonly serve two functions — cosmetic breast enhancement or breast reconstruction following a disfiguring event such as mastectomy for cancer or a traumatic injury.

CPT divides implant codes based on the function, so that’s the first distinction you need to make when selecting the proper code.

Differentiate augmentation: Use 19325 (Mammoplasty, augmentation; with prosthetic implant) when the surgeon implants a breast prosthesis for breast enlargement. “Code 19325 describes cosmetic implants only,” emphasizes John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates.

When the surgeon implants a prosthesis to reconstruct the breast following mastectomy, you need to look elsewhere for a code. For silicone or saline implants involved in reconstruction, CPT provides the following two codes:

  • 19340 — Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
  • 19342 — Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction.

Tip 2: Timing is Everything for Implant Placement

CPT provides 19340 and 19342 for breast prosthesis associated with mastectomy or mastopexy. You’ll decide between those two codes based on when your surgeon performs the implant procedure.

How it works: For patients whose physiology will accommodate a full-size saline- or silicone-filled prosthesis, your surgeon may place the implant immediately following the mastectomy. “If the surgeon inserts a breast implant at the same operative session as the mastectomy, you should report 19340,” Bishop says.  “For our mastectomy patients who opt for reconstruction, immediate treatment is the most common…

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Medicare: 21% Cut Continues to Loom, With May 31 Deadline Nearing

CMS instructs MACs to hold claims for ten business days while Congress mulls bill.

Impending cuts to your Medicare pay have been a familiar story this year, but hopefully you won’t face a 21-percent payment drop while you’re trying to enjoy your summer.

Last month, Congress voted to extend freezing the conversion factor at 2009 levels so Part B practices wouldn’t have to face a 21 percent cut to the conversion factor, which was supposed to go into effect on April 1. Once the president signed the extension into law, it meant that practices didn’t have to worry about the Medicare cuts until June 1, in hopes that the government would find a more permanent solution to the pay cut crisis before the conversion factor freeze expires on May 31.

New Bill Could Put Off Cuts

The House Ways and Means Committee published the text of H.R. 4213, “The American Jobs and Closing Tax Loopholes Act of 2010,” on its website on May 20. The bill would increase your payments through the end of this year, according to the text listed on the Committee’s Web site, which states, “In lieu of the update to the single conversion factor … that would otherwise apply for 2010 for the period beginning on June 1, 2010, and ending on December 31, 2010, the update to the single conversion factor shall be 1.3 percent.” The bill also includes provisions that would ensure that additional cuts don’t take place through 2013.

The American College of Physicians posted support for the bill on its website, but the AMA expressed disappointment. “An intervention to delay a looming Medicare physician payment cut will provide temporary stability for seniors and their physicians, but the AMA is deeply disappointed that Congress will once again fail to permanently correct the…

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