Get ready for another year of nail-biting to find out if your Medicare payments will be slashed. “The calendar year 2011 Physician Fee Schedule conversion factor is $25.5217,” notes the 2011 Medicare Physician Fee Schedule Final Rule, printed in th…
Medically unlikely edits ignorance could be causing you medical coding claim denials.
Ensure you’re not letting medically unlikely edits (MUEs) wreak havoc on your urology practice’s coding and reimbursement by uncovering the truth about four aspects of these edits.
Myth 1: MUE Edits Don’t Affect Your Practice
Some practices feel that they don’t need to worry about MUEs.
Reality: “They limit the frequency a CPT code can be used,” says Chandra L. Hines, business office manager at Capital Urological Associates in Raleigh, N.C. “With our specialty of urology, we need to become aware of the denials and not let every denial go because the insurance company said it was an MUE. We should all be aware of MUEs as they occur, and we cannot always control whether or not we will receive payment.”
The MUE list includes specific CPT or HCPCS codes, followed by the number of units that CMS will pay. CMS developed the MUEs to reduce paid claims error rates in the Medicare Program. The first edits were implemented in January 2007, although some of the edits themselves became public in October 2008.
Some MUEs deal with anatomical impossibilities while others edit automatically the number of units of service you can bill for a service in any 24-hour period. Still others limit codes according to CMS policy. For example, excision of a hydrocele, bilateral (55041) has a bilateral indicator of “2,” so you should never bill two or more units of this code. Additional edits focus on the nature of the equipment for testing, the study or procedure, or pathology specimen.
Anatomical example: The MUEs edit out and deny an erroneously coded claim for a circumcision (54161, Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age) for a patient…
You can sit back and enjoy the fall foliage spectacle — SuperCoder.com’s got your ICD-9-CM 2011, National Correct Coding Initiative 16.3, and October Medicare Physician Fee Schedule medical coding updates covered.
Go ahead and search for th…
Treatment plans are a must, experts say.
You’ve treated your chiropractic patient, you’ve selected the correct codes, and you’ve submitted your claim. All set, right? Not quite. Check out this common mistake that chiropractors make.
“Many chiro…
Sometimes CCI compliance requires looking beyond the edit pairs.
Correct Coding Initiative (CCI) edits don’t bundle SPECT (78803) and planar (78070) parathyroid imaging codes, but coding experts often tell you not to code the two together for SPECT and planar parathyroid imaging on the same date.
Add some method to this madness by looking at the information offered by two coding resources, the Society of Nuclear Medicine (SNM) and the NCCI Policy Manual for Medicare Services (CCI Manual).
1. SNM Singles Out 78803
SNM’s online Practice Management Coding Corner features a Q&A that recommends reporting 78070 (Parathyroid imaging) for planar imaging alone, but 78803 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; tomographic) for parathyroid SPECT imaging with or without planar, says Jackie Miller, RHIA, CCS-P, CPC, vice president of product development for Coding Metrix Inc. in Powder Springs, Ga.
Support: “Choose the single code that describes the protocol and procedure performed,” states the Q&A, located at http://interactive.snm.org/index.cfm?PageID=2442&RPID=1995. SNM “would NOT recommend coding both CPT codes,” the article notes.
2. CCI Makes the Case for SPECT Code
Although there is notyou won’t find any a specific edit bundling 78070 and 78803, CCI does address the SPECT/planar issue in the CCI Manual, says Miller.
CCI Manual, Chapter 9, Section E.2, explains that you may not report a SPECT study and planar study of the same limited area because “Single photon emission computed tomography (SPECT) studies represent an enhanced methodology over standard planar nuclear imaging. When a limited anatomic area is studied, there is no additional information procured by obtaining both planar and SPECT studies.”
Bonus tip: The manual indicates you may report both planar and SPECT codes only when the size of the scanned area makes both sets necessary, such as with whole body bone scans with…
Remember frequency rules differ for average, high risk.
Getting Medicare to pony up for colorectal cancer screenings is not difficult provided you follow its frequency guidelines and eligibility requirements to the letter. A coding slip up on one of these items will knock you out of the saddle, and Medicare won’t accept the claim at all.
Rope in all the coding info you’ll need via this Medicare colorectal cancer screening FAQ.
Who’s Eligible for Average-Risk Test?
If the Medicare patient is 50-plus years old, he is eligible for a covered Medicare screening, confirms Dena Rumisek, CPC, biller at Michigan’s Grand River Gastroenterology PC.
However: These patients are considered average risk, and can have a colorectal cancer screening only once every 10 years, says Cheryl Ray, CCS, CPMA, of Atlantic Gastroenterology in Greenville, N.C. Ignore Medicare’s frequency guidelines at your peril, experts warn.
“Medicare is very stringent on the date … it has to be 10 years or longer — it can’t be 9 years and 360 days,” between covered screening colonoscopies, assures Rumisek.
Example: A 68-year-old established Medicare patient reports for a screening colonoscopy on Dec. 5, 2009. The patient’s records indicate that he last had a covered screening on Sept. 15, 1998. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).
What ICD-9 Codes Are In Play for G0121?
Just one, provided there is no need for any therapeutic intervention during the colonoscopy. Medicare requires V76.51 (Special screening for malignant neoplasms; colon) on all G0121 claims. You might list other identified conditions secondarily, including diverticulosis (562.10) or hemorrhoids (455.0).
Always list the V code first for an average-risk screening, however.
What if the Patient Had a Recent Flexible Sig?
The frequency rules differ depending on whether other related…
Plus: The OIG recovered over $1.5 billion in fiscal year 2009, and is on the lookout to collect more.
With less than two weeks to go before Medicare payments once again threaten to decrease by 21 percent, a new report sheds light on the financial outcome of Congressional actions.
Although the 2010 Physician Fee Schedule originally included a conversion factor that would have been 21 percent lower than the 2009 level, practices haven’t felt that cut yet this year,because legislators have voted several times to freeze payments, which now use the conversion factor of $36.0791. That freeze will expire on May 31, after which your Medicare payments will drop considerably unless Congress steps in once more.
However, one government entity’s calculations show that the freeze is costly. According to a May 7 Congressional Budget Office report, freezing payments at the current levels for the rest of 2010 would cost the government… … $6.5 billion. The AMA has turned up the heat on Congress to replace the current payment method, releasing a print ad aimed at Congress to demonstrate that “more delays of permanent reform now increase the cost for taxpayers,” and that the association “calls on Congress to fix the flawed Medicare physician payment formula now.”
Congress has not yet introduced a bill to extend the payment freeze past May 31. Keep an eye on the Insider for more information as this story develops.
To read the Congressional Budget Office’s calculation sheet,visit www.cbo.gov/budget/factsheets/2010b/SGR-menu.pdf.
@ Part B Insider. Editor: Torrey Kim, CPC
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