Question: A doctor recently told me that appending modifier GY to the refraction code would guarantee payment by a secondary insurer when Medicare denies it. Is this true?
Answer: Modifier GY (Item or service statutorily excluded or does not meet the …
Question: One of our physicians likes to sign everything with just his initials, or sometimes an illegible scrawl. Do we need some type of documentation to support what an auditor might not be able to read?
Answer: Yes, you would be wise to keep a sign…
Question: What codes would you use for lower anterior resection with anal anastomosis and divered ileostomy with mobilization of splenic flexure, which was converted to an open procedure?
Answer: You’ll report the open procedure codes for this case. …
Question: We have always reported A4556 for the electrodes our urologist uses during urodynamics procedures. This year, however, DMERC has refused reimbursement, stating we should instead be using code A4595 or A4557. Those two “replacement” code…
CPT Assistant offers ECG recording checklist.
Question: May we report 93270 even when the only transmission was the test transmission?
Answer: You should be able to report 93270 (Wearable patient activated electrocardiographic rhythm derived event reco…
Question: Documentation reads, “The cyst was excised after performing a central incision directly on the cyst. All the material was expressed, then cyst capsule was removed completely and excised completely. Packing was performed.” Should I code the procedure as an I&D or an excision?
Answer: You should look at the pathology report and any further excision description to reach the correct code set. “Excision is defined as full thickness [through the dermis] removal of a lesion …,” according to CPT’s Excision-Benign Lesions guidelines. The documentation you provided does not indicate what tissue levels the excision involved. A cyst can be epidermal or sebaceous (706.2). A lesion that is removed from the epidermis (top skin layer) does not meet CPT’s excision definition.
The sebaceous gland extends through the dermis. Excision that deep would qualify for an excision code. An excision code (such as 11400, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) requires further documentation detailing the lesion’s morphology, size (including margins), and anatomical location. Without this information, the I&D code (10060, Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) may be more appropriate. The physician made a cut to drain the cyst and then drained (expressed) all the material. The cyst capsule removal is part of the treatment of the I&D to prevent the blockage from reoccurring.
Take more coding challenges with Family Practice Coding Alert. Written by Jen Godreau, BA, CPC, CPEDC, content director of Supercoder.com, Family Practice Coding Alert, Volume 12, Number 6.
Hint: Abnormal versus insufficient cells mean different diagnosis codes.
When a patient returns to your office for a repeat Pap smear, you’ve got to weigh your options of E/M and specimen handling codes, as well as diagnosis codes. Take this challenge to see how you fare and prevent payment from slipping through your fingers.
Question 1: When a patient comes in for a second Pap smear, what CPT code(s) should you apply and why?
Question 2: Will you receive reimbursement for handling the repeat Pap smear? Why or why not?
Question 3: If the patient comes back in for a Pap smear due to abnormal results, what ICD-9 code(s) should you use and why?
Question 4: If the patient has a repeat Pap because the lab did not have enough cells in the specimen to interpret the results, what ICD-9 code(s) should you use and why?
Answer 1: Here’s What CPT Codes
When the patient comes in for a second Pap smear, submit the appropriate E/M office visit code (99211-99215). You will probably be able to report 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) for this visit becausethe patient likely will come in only for the Pap smear and CPT does not include a specific code for taking the Pap. Code 99212 carries 1.08 relative value units (RVUs), unadjusted for geography. That translates to about $31 for this visit (using the new conversion factor of 28.3868).
Answer 2: Handling the Specimen Depends on Payer
Some private payers will reimburse for handling the repeat Pap smear specimen (99000, Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory). But Medicare carriers consider the collection and handling part of a problem E/M…
Incident-to services are on auditors radar. To prevent paybacks, you’ve got to know when to use incident to – and capture full pay, and when to bill services directly – and lose the standard 15%. Test your incident to savvy with this question:
Qu…
With multiple ways to denervate the sensory nerve/nerve branches, pain management coders may argue about which 64xxx code is right. You’ve got to dig into the chart note to identify the method used. See if you’re up to the challenge with this Supercoder Forum Insight.
Question: A provider is doing RFA’s of the left L4, L5, S1, S2, S3 and SA. He is billing 64622 x 1 and 64623 x 4. The other pain provider states this is incorrect and that he should be billing 64640 for S1, S2, S3 and SA. Which coding is correct?
Answer: This is a complex coding issue because there are several different methods to denervate the sensory nerve/nerve branches that provide innervations from the SI joint. Because of this, the coding will depend somewhat on the method used.
However, I can say that reporting 64622 and 64623 x 4 is incorrect. The “paravertebral facet joint nerves” that provide innervations to the facet joints in the cervical, thoracic, and lumbar regions are the medial branches off the dorsal ramus. In the sacrum, there are indeed medial branches, but – as their name indicates – the path for these nerve branches is to the midline to provide innervations to the multifidus muscles and not laterally to the SI joint. So, following the published CPT Instructions for Use of the CPT Codebook – “Do not select a CPT code that merely approximates the service provided”, even though they are similar, procedures performed on the lateral branches of the sacral nerves should not be reported as paravertebral facet joint nerve procedures (i.e., paravertebral facet joint injections or destructions).
A few of the more common techniques are:
…
Here are the pros and cons to help guide your decision.
Question: Our practice is considering accepting patients with PFFS plans. We’re heard that some patients are starting to have them, but we’re not sure whether we’re going to accept them or not. Are PFFS plans beneficial for us?
Answer: PFFS are Private Fee-for-Service plans, which are non-network plans. These plans let members receive care from any doctor or hospital that accepts the plan’s payment terms and conditions.
If your practice decides to accept these terms, you would become a “deemed” provider. Plan members can receive covered services from any deemed provider in the U.S. However, member patients must confirm that the provider is deemed every time a service is provided.
PFFS plans are different from Medicare Advantage plans because they do not require a doctor or hospital to contract with a health plan to provide services. This means that doctors or hospitals that do not agree to the PFFS plans’ terms and conditions may choose not to provide health care services to a plan member, except in emergencies.
Coming soon: Starting in 2011, PFFS plans will have to measure and report on their providers’ quality of care. But the catch is that they’ll also have to form provider networks with contracts.
In counties where there are two or more non-PFFS plans, PFFS plans will no longer be able to simply “deem” providers into the plan without a contract. Under current law, PFFS plans don’t have to prove they can meet access standards if they allow any willing qualified Medicare provider to participate, and they pay as traditional Medicare would pay.
One argument is that the network requirement would provide better access to care because there would be contracts between the providers of services and the plan. On the…