News & Media

Posted 05/10/2016

Part B Insider (Multispecialty) Coding Alert

Part B Coding Coach: Mastering Migraines: The Importance of the 4th Character in ICD-10 Coding

– Published on Mon, May 09, 2016

Understanding Character No. 4 is essential to select the right diagnosis code.

When you’re coding for your patient’s migraine headaches, ICD-10 offers a challenge ICD-9 did not: more choices for more specific migraine diagnoses.

Benefit: More specific diagnoses could lead to more specific treatments, which might improve patient outcomes. There is a learning curve to mastering ICD-10 migraine coding, however.

In short, migraine ICD-10 coding goes long. Coding migraine patients correctly often involves coding to the sixth character. Before you get there, however, you must ID the correct fourth character of the ICD-10 code, as these numbers represent the most general migraine classifications.

Check out this primer on choosing the proper fourth digit for your migraine diagnoses, and you’ll end up with the most accurate ICD-10 code possible for each patient’s migraine — as well as a road map to which fifth/sixth character(s) you might need.

‘Prodrome’ Often Equates to Aura

The four-character code for the most common migraine presentation is G43.0- (Migraine without aura…). If a patient does have an aura with the migraine, you’d opt for G43.1- (Migraine with aura…), confirms Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare in Lansdale, Pa.

Aura definition: The term defines “specific nervous system symptoms that occur or begin approximately five to 20 minutes prior to the onset of the headache,” explains Yvonne Bouvier, CPC, CEDC, senior coding analyst for Bill Dunbar and Associates, LLC, in Indianapolis, Ind.

According to Bouvier, these symptoms can include, but are not limited to:

  • Visual field blind spots
  • Patient sees a “zigzag” pattern
  • Blindness that affects half of the visual field, in one or both eyes
  • Visual hallucinations
  • Patient sees flashing lights
  • Patient suffer a pins and needles sensation in his arm or leg
  • Patient has difficulty speaking.

These early migraine symptoms are also called a “prodrome,” reports Falbo. So if you see “prodrome” in the notes for a patient suffering from a migraine, he might also have an accompanying aura.

‘Stroke-Like’ Symptoms Can Come With Hemiplegic Migraines

Another fourth-character subcategory of migraines in ICD-10 is hemiplegic migraines. When a patient has a hemiplegic migraine, you’ll choose a code from the G43.4- (Hemiplegic migraine…) code set.

Definition: “Hemiplegic migraine is a rare condition which has been linked to a genetic abnormality. Symptoms include temporary weakness down one side of the body, which usually lasts between five minutes and one day, but can last for several days,” explains Falbo.

Though all migraines are serious medical conditions, hemiplegic migraines are especially nasty.

Symptoms of a hemiplegic migraine “can range from worrisome to debilitating, and these headaches aren’t easy to treat,” says Falbo. You must identify patients with hemiplegic migraines early, because if they don’t get the care they need quickly, the end result could be disastrous.

“Migraines are unpredictable and unique to each person. You may have a hemiplegic migraine headache with extreme pain and minor paralysis one month,” Falbo says. “Then, the next attack might bring extreme paralysis without much headache pain at all.”

Falbo reports that other symptoms of hemiplegic migraine include:

  • Persistent and severe, throbbing pain. This might only occur on one side of the patient’s head.
  • A pins-and-needles feeling. The feeling might move from the patient’s hand and up his arm.
  • Balance and coordination issues.
  • Patient sees zigzag pattern, or suffers double vision/blind spots.
  • Patient has slurred speech or difficulty with language. For example, he might mix words up in a sentence or have trouble remembering a word.
  • Dizziness/vertigo.
  • Nausea/vomiting.
  • Extreme sensitivity to light, sound, and/or smell.
  • Extreme confusion.
  • Decreased consciousness/coma.

Look to G43.6- When CI Accompanies Migraine

Sometimes, the migraine isn’t the only problem the patient is suffering from when you treat him. One of the complicating factors for patients suffering from persistent migraine with aura can be cerebral infarction (CI), which you’d code with G43.6- (Persistent migraine aura with cerebral infarction…). This condition is often marked in the notes as a “migrainous infarction,” Bouvier relays.

When a patient has a migrainous infarction, it’s a very serious situation. The provider will have to treat the infarction and the migraine, as the combination of conditions could lead to stroke for the patient, Bouvier explains.

However serious migrainous infarctions might be, they are “rare and occur more commonly in patients who have migraine with aura, as opposed to those without aura,” explains Bouvier.

Also: Don’t forget to report the CI as well as the migraine when coding migraines with cerebral infarction. According to notes under G43.6-, you need to select from the I63.- (Cerebral infarction…) family when you code for this type of migraine.

 

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Posted 05/10/2016

Part B Insider (Multispecialty) Coding Alert

Goodbye Meaningful Use, Hello Advancing Care Information

– Published on Mon, May 09, 2016

This new MIPS initiative offers more options and assistance for participating practitioners.

In an effort to simplify the Electronic Health Record (EHR) system, the Department of Health and Human Services (HHS) explained in a notice of proposed rulemaking on April 27, 2016 that they plan to replace the current incentive plan, Meaningful Use, with a new program titled Advancing Care Information.

“In our extensive sessions and workshops with stakeholders, a near-universal vision of health information technology surfaced: Physicians, patients, and other clinicians collaborating on patient care by sharing and building on relevant information,” stated Andy Slavitt, CMS acting administrator and Karen DeSalvo, MD, National Coordinator, Office of the National Coordinator for Health IT in last week’s CMS blog post.

Under this MACRA implementation, MIPS aims to utilize the Advancing Care Information performance plan to “simplify requirements, support patient care, and be flexible to meet the needs of physician practices. The proposal emphasizes measures that support improved patient engagement and connectivity and reduces reporting burden.”

Here’s what’s changing: There are key differences in the new program that move away from the complicated, “one-size-fits-all” policies of Meaningful Use. In a nutshell, Advancing Care Information boosts interoperability between systems, making it easier to exchange information and can be adjusted and tailored to each clinician’s needs. The streamlined system also coordinates the various Medicare reporting programs so “quality measures reporting” is no longer necessary.

Physicians using “certified EHR technology” and reporting a “customizable set of measures that reflects” the practice’s use of the innovations in daily operations would account for 25 percent of the MIPS score upfront. The Advancing Care Information score is comprised of a base, performance, and a possible bonus point that add up to the final composite score.

If mandated, the initial performance period for Advancing Care Information is scheduled to run from January 1, 2017 through December 31, 2017.

Resource: For a detailed look at MIPS’s Advancing Care Information initiative, visit www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Advancing-Care-Information-Fact-Sheet.pdf.

Posted 05/06/2016

Part B Insider (Multispecialty) Coding Alert

Annual Wellness Visits: This MAC Reminds Practices to Use Caution Billing Separate E/M With AWV
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Remember not to overlap history, exam when determining E/M level.

When a patient presents for an annual wellness visit (AWV) or initial preventative physical exam (IPPE), you typically know how to report the visit. But if they have a separate issue that requires a deeper evaluation, that’s when coding can get tricky. One MAC tried to shed some light on this subject last week, and the key is to demonstrate the separate nature of the additional E/M service.

Background: CMS covers an exam for a new Medicare patient called the IPPE (G0402), as well as an AWV (G0438-G0439) once a year, but otherwise does not pay for preventive E/M services. Both the IPPE and AWV have very specific parameters that you must cover when you perform these services, and when patients have additional needs that fall outside of these parameters, physicians might want to address both issues at the same visit, which can lead to a confusing coding scenario.

Part B MAC Palmetto Medicare issued a tip to practices on April 21, reminding them that although you are permitted to report both the E/M code and the IPPE/AWV, you must ensure that you aren’t double dipping by including documentation from the IPPE or AWV when calculating your E/M code.

“When the physician or qualified NPP provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or AWV, CPT® codes 99201-99215 may be reported, depending on the clinical appropriateness of the circumstances,” Palmetto says. “Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be submitted for the medically necessary, separately identifiable, E/M service.”

Make Sure to Use Modifier 25

If you want to be sure to collect payment for both the E/M service and the AWV or IPPE, don’t forget to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to your E/M service code.

In the CMS document The ABCs of the AWV, the agency says, “When you provide a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service in addition to the AWV, Medicare may pay for the additional service. Report the CPT® code with modifier 25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury or to improve the functioning of a malformed body member.”

Don’t forget to bill patients for their portion of the E/M service (copayments, deductibles, etc.) even though they typically won’t owe anything for the AWV or IPPE. “Cost sharing will apply to the E/M service that is furnished during the IPP Exam as the Affordable Care Act only waives the cost sharing requirement for the IPPE and not the E/M service,” said CMS’s Stephanie Frilling during a March 28, 2012 National Provider Call regarding the IPPE and the AWV.

Two Examples Help Guide You

If you aren’t certain when a secondary condition might prompt a separate E/M service along with an AWV, consider the following two examples:

Example 1: “A patient comes in for their AWV and while they are being seen, they tell the doctor about low back pain with pain radiating into their leg,” says Rebecca L. Odell, CPC, CPCO, CPB, CPC-I, billing team leader with Advanced Health Partners, Inc. and AAPC chapter president in New Windsor, NY. “They state the pain started approximately a week ago after gardening and it is happening more and more frequently with occasional numbness in their right foot. The doctor does a complete workup and sends the patient for an MRI or further testing. He wants to see the patient to discuss the results in a week.”

For this visit, you can report both the AWV and an E/M code with modifier 25 appended. “However, the doctor needs to document properly,” Odell says. “To keep the two codes separate, the doctor should write two different notes—one for the AWV and one for the E/M code. The information being used for the E/M code shouldn’t be used in the AWV note. When documenting, it should be treated as if the patient was seen for two separate encounters.”

Example 2: “A condition that could prompt a deeper E/M would be a chronically ill type two diabetic with multiple manifestations that include circulatory issues along with long term use of insulin,” says Geanetta Agbona CPC, CPC-I, of CGS Billing Service. “In this case, those issues would need to be addressed swiftly. If the physician does provide both services on the same day, it should be well documented and the notes should clearly indicate that two separate services were rendered,” she adds.

In these examples, you will report the AWV as well as the additional E/M service. You’ll append modifier 25 to the E/M code.

Resource: To read Palmetto’s April 21 Weekly Tip, visit www.palmettogba.com.

Posted 03/01/2016

Part B Insider (Multispecialty) Coding Alert

E/M Coding: Yes, You Can Report E/M Codes When Talking to Family About Patient Care

– Published on Mon, Feb 29, 2016

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As long as the patient is present, CMS allows you to bill an E/M code based on time.

It happens frequently in Part B practices—a patient presents with her family members, who want to discuss how to care for the patient’s condition. The doctor spends most of his time discussing care with the family rather than the patient, leaving coders to wonder how to report the service—should you bill a counseling code, an E/M code, or some other combination? Fortunately, if you can document time-based services, then you are on the road to reporting family visits when the patient is present.

Watch the Clock

Your best bet when discussing care with a patient and her family is to bill an E/M service (99201-99215) based on time. Because the doctor is performing counseling based on an active condition that the patient has, you are justified in reporting the appropriate E/M code based on the amount of time spent performing face-to-face counseling or coordinating care.

When you’re billing based on time, CPT® defines “face-to-face time” as “only that time spent face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination, and counseling the patient.” Because CPT® uses the language “with the patient and/or family,” it’s clear that you can discuss the care with the patient’s family and not just with the patient to count it toward the time-based E/M code.

Medicare says: When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services.

If you are selecting a code based on time, the medical record should show three pieces of information, says Part B MAC WPS Medicare in its “Time-Based E/M Services” Fact Sheet. “The total time of the visit, the time or percentage of the visit spent in counseling/coordination of care and the nature of the counseling/coordination of care. When the physician uses the total minutes or the clock time is a personal decision. Medicare needs to be able to see the three pieces of documentation as listed above.”

Consider These Examples

Several scenarios below serve to illustrate different options applicable to counseling coding and documentation.

Example 1: A 78-year-old established male patient with Alzheimer’s presents to your practice with her son and daughter-in-law. The doctor counsels them about how to deal with the illness and how to administer appropriate medications. The face-to-face encounter takes 45 minutes, 35 minutes of which is spent counseling the patient, her son and her daughter-in-law.

Coding Solution: For this visit, you can report 99215 (Office or other outpatient visit for the evaluation and management of an established patient … Typically, 40 minutes are spent face-to-face with the patient and/or family) based on the amount of time spent with the patient in counseling/coordination of care, assuming your documentation meets the guidelines (see below).

Example 2: A 75-year-old male patient is hospitalized with a heart attack. His cardiologist meets with the patient and his wife to counsel them on the risks and benefits of different kinds of treatment, including angioplasty. Although the doctor only spent 20 minutes with the patient prior to the wife entering the hospital room, he spent 20 minutes in discussion with her, for a total of 40 minutes. He was at the patient’s bedside the entire time.

Coding Solution: If the patient is in the hospital and the family comes into the room to talk with the doctor, you can count that toward the total visit time. In this case, use code 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient…Typically, 35 minutes are spent at the bedside and on the patient’s hospital floor or unit).

Ensure Crystal Clear Documentation

Before using time as the controlling factor, check off the following requirements that must be documented based on CMS guidelines

1. The total time spent with the patient
2. That more than 50 percent of the face-to-face time the physician spent with the patient/and or family is counseling/coordination of care. For instance, “Saw the patient, her daughter and her son-in-law for 30 minutes face-to-face; 25 minutes of that visit was spent in counseling concerning ….”
3. A description or summary of the counseling/coordination of care provided. For Example One above, you could consider, “Counseled the patient and her family to address coping strategies for the patient’s diagnosis of Alzheimer’s disease and treatment options.”

What If the Patient Isn’t Present?

If the patient’s children or spouse present to the practice to discuss the patient’s condition with the doctor and the patient is not present, you cannot bill Medicare using the E/M codes. Although CPT® rules support reporting the E/M codes without the patient present, CMS sings a different tune. “CMS states that the patient has to be present,” says Coding Consultant Donelle Holle, RN.

Red flag: Provider documentation such as “I had a lengthy discussion…” or “I spent a great deal of time with the patient discussing…” does not support using the dominant counseling/coordination of care as the basis for level of E/M service. You should only select an office visit code based on time when your clinician spends more than 50 percent of the face-to-face time with the patient and/or family member on counseling and/or coordination of care.

Key: Medical necessity must also be a key factor in your code choice. Be sure that the time spent with the patient or her family is warranted. Just because the patient and provider talked for a long time doesn’t mean it was medically necessary to do so.

 

Posted 03/01/2016

Part B Insider (Multispecialty) Coding Alert

Documentation: 3 Recordkeeping Tips That Will Make Auditors Smile

– Published on Mon, Feb 29, 2016

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Instituting these simple strategies ensure that you’re ready for any type of review.

When you think of recordkeeping, you may immediately envision your accounting receipts and A/R books, but the reality is that you should also ensure that your medical records are just as buttoned-up as your financial information.

The following three tips will help you confirm that your documentation is as polished as it can be, so you’ll always be able to support the codes that you report.

Tip 1: Find A Way to Make Notes Legible. If your physician can’t maintain legible documentation, then your records won’t hold up under audit, and could even be compromising the integrity of your code choices. After all, if your coder can’t read the records, he or she can’t select the most appropriate code. If the doctor has messy handwriting, you may want to suggest that he print, use dictation or invest in an electronic health record (EHR) system to ensure legibility.

You certainly don’t want to have to reimburse any money because an auditor can’t read your doctor’s handwriting, and CMS clearly states that this can happen. “When determining the medical necessity of an item or service billed, Medicare’s review contractors must rely on the medical documentation submitted by the provider in support of a given claim,” CMS says in MLN Matters article SE1237. “Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS claim payment denials.”

If an auditor is on the way and you know he won’t be able to read your notes, there are things you can do instead of panicking. “If a provider feels that his/her notes may not be legible, he/she may translate these notes prior to submitting them to Palmetto GBA for review,” says Part B MAC Palmetto GBA. “The note must be translated verbatim and signed by the provider. Both documents must be submitted.” In other words, you should submit your original documentation and the transcribed version to any auditor who requests the records.

Tip 2: Don’t Get Creative With Abbreviations. Your doctor may refer to a fasting blood test as an “FB,” but the coder might know “FB” as a “foreign body.” Confusing acronyms and abbreviations can confuse billing staff members as well as auditors. That’s why you should only use common abbreviations that are universally known.

Anthem Medical’s Medical Record Documentation and Coding Tips policy states, “Use only standard abbreviations, avoid the use of abbreviations in medical record documentation, and do not create your own abbreviations.”

So if your doctors are accustomed to using terms like “rec tkr,” you may want to remind them to expand it out to “recommend total knee replacement” to meet your carrier’s guidelines.

Tip 3: Look for Two Signatures When Scribes Are Involved. A scribe is a person who accompanies the doctor on each patient encounter. The scribe writes or transcribes the doctor’s dictation into the medical record, helping to expedite documentation.

While it helps if the scribe has knowledge of medical terminology and a familiarity with typical encounters, procedures and commonly used medications, there are no set training or qualification requirements since scribes basically function as a human tape recorder. The scribe should not independently document anything other than perhaps the review of systems and past medical, family, and social history, which Medicare documentation guidelines allow to be recorded by ancillary staff members.

When your doctor uses a scribe, ensure that you meet the signature requirements. Noridian Medicare says in its Documentation Guidelines for Medicare Services, “If the physician uses a scribe (an individual taking notes), the scribe needs to fully sign the note, with their own credentials, followed by the physician’s signature and credentials.”

Posted 03/01/2016

Part B Insider (Multispecialty) Coding Alert

Documentation: 3 Recordkeeping Tips That Will Make Auditors Smile

– Published on Mon, Feb 29, 2016

——————————————————————————–

Instituting these simple strategies ensure that you’re ready for any type of review.

When you think of recordkeeping, you may immediately envision your accounting receipts and A/R books, but the reality is that you should also ensure that your medical records are just as buttoned-up as your financial information.

The following three tips will help you confirm that your documentation is as polished as it can be, so you’ll always be able to support the codes that you report.

Tip 1: Find A Way to Make Notes Legible. If your physician can’t maintain legible documentation, then your records won’t hold up under audit, and could even be compromising the integrity of your code choices. After all, if your coder can’t read the records, he or she can’t select the most appropriate code. If the doctor has messy handwriting, you may want to suggest that he print, use dictation or invest in an electronic health record (EHR) system to ensure legibility.

You certainly don’t want to have to reimburse any money because an auditor can’t read your doctor’s handwriting, and CMS clearly states that this can happen. “When determining the medical necessity of an item or service billed, Medicare’s review contractors must rely on the medical documentation submitted by the provider in support of a given claim,” CMS says in MLN Matters article SE1237. “Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS claim payment denials.”

If an auditor is on the way and you know he won’t be able to read your notes, there are things you can do instead of panicking. “If a provider feels that his/her notes may not be legible, he/she may translate these notes prior to submitting them to Palmetto GBA for review,” says Part B MAC Palmetto GBA. “The note must be translated verbatim and signed by the provider. Both documents must be submitted.” In other words, you should submit your original documentation and the transcribed version to any auditor who requests the records.

Tip 2: Don’t Get Creative With Abbreviations. Your doctor may refer to a fasting blood test as an “FB,” but the coder might know “FB” as a “foreign body.” Confusing acronyms and abbreviations can confuse billing staff members as well as auditors. That’s why you should only use common abbreviations that are universally known.

Anthem Medical’s Medical Record Documentation and Coding Tips policy states, “Use only standard abbreviations, avoid the use of abbreviations in medical record documentation, and do not create your own abbreviations.”

So if your doctors are accustomed to using terms like “rec tkr,” you may want to remind them to expand it out to “recommend total knee replacement” to meet your carrier’s guidelines.

Tip 3: Look for Two Signatures When Scribes Are Involved. A scribe is a person who accompanies the doctor on each patient encounter. The scribe writes or transcribes the doctor’s dictation into the medical record, helping to expedite documentation.

While it helps if the scribe has knowledge of medical terminology and a familiarity with typical encounters, procedures and commonly used medications, there are no set training or qualification requirements since scribes basically function as a human tape recorder. The scribe should not independently document anything other than perhaps the review of systems and past medical, family, and social history, which Medicare documentation guidelines allow to be recorded by ancillary staff members.

When your doctor uses a scribe, ensure that you meet the signature requirements. Noridian Medicare says in its Documentation Guidelines for Medicare Services, “If the physician uses a scribe (an individual taking notes), the scribe needs to fully sign the note, with their own credentials, followed by the physician’s signature and credentials.”

Posted 02/10/2015

Part B Insider (Multispecialty) Coding Alert

Patient Privacy: Discover These 3 Common Ways That Practices Violate HIPAA

– Published on Mon, Feb 08, 2016

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Hint: You should train your temps if they aren’t already hip to HIPAA.

Now that HIPAA is part of your practice’s everyday operations, you may not focus as strongly on privacy training as you did a decade ago. However, HIPAA compliance is something that should be part of your daily operations, and letting just one aspect of privacy fall through the cracks could open you up to dozens of violations. Get to know these three ways that practices frequently violate the HIPAA privacy rules without realizing it.

1. Forgetting That HIPAA Rules Follow Charts That Leave the Office

Working in a medical office is like any other job in that employees tend to bring work home with them—and sometimes that translates into private employee information sitting on your kitchen table, where your family or other visitors can quickly see it. To avoid situations like this, which clearly violate patient privacy rules, you should establish a policy on taking charts home. Unless handled very carefully, you could violate HIPAA and face penalties even if you just misplace one superbill in your home.

While HIPAA certainly does not prohibit physicians from taking patient charts home, it’s an issue to consider, and a decision each covered entity will have to make for itself. If you decide to allow physicians, coders, billers or other staff members to take charts out of the office, it’s a good idea to implement a log-out system. That way, you’ll know where each patient’s information is, and there’s some accountability.

You also should have a policy that says your staff members must safeguard any patient information when they remove it from the office, since the HIPAA laws protect the patient’s privacy no matter where the chart happens to be.

2. Train Your Temps

Medical practices hire temporary employees from time to time, whether it’s to fill in while you’re hiring new staff members or to replace an employee who is out on maternity leave. And although it’s not easy to offer HIPAA training to employees who will only be in your organization for a short period of time, failure to do so could open your practice up to enforcement scrutiny.

The reality is that temps must receive the same training as everyone else. If the temp hasn’t already been trained through his or her placement organization, now is the time to nail down that training. You can either bring the temp in on group training if it’s coming up soon, or you can perform one-to-one training followed by self training tools like a PowerPoint presentation with a quiz at the end or a security worksheet. All session documents and training materials are then kept in temporary employees’ files.

3. Don’t Let HIPAA Lapse After Patient Dies

If a patient passes away, that doesn’t make his or her HIPAA agreement null and void. In fact, the HIPAA Privacy Rule protects a patient’s individually identifiable health information for 50 years after the date of death, according to the Department of Health and Human Services.

“During the 50-year period of protection, the personal representative of the decedent (i.e., the person under applicable law with authority to act on behalf of the decedent or the decedent’s estate) has the ability to exercise the rights under the Privacy Rule with regard to the decedent’s health information, such as authorizing certain uses and disclosures of, and gaining access to, the information,” HHS says in 45 CFR 160.103 of the Privacy Rule.

Keep in mind that if a family member needs information about the decedent’s health care specifically for the family member’s own health care treatment, the practice “may disclose a decedent’s protected health information, without authorization, to the health care provider who is treating the surviving relative,” HHS says on its website in a separate question and answer.

Posted 02/10/2015

Part B Insider (Multispecialty) Coding Alert

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QUESTION: Our doctors sometimes see patients for follow-up visits after evaluating a problem that required no treatment, and we are unsure of which ICD-10 code to report for these. Although Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) is close, we’d rather have a follow-up code that describes a service that was not “after treatment.” Can you advise on whether there is such a code?

ANSWER: There is not such a code in ICD-10, and you are correct in selecting Z09 as the most accurate code for this service.

Although the code’s descriptor does say “after completed treatment,” remember that “treatment” can include supportive care, such as fluids, ibuprofen, rest, and monitoring. If you are checking in on a patient who had a bout of vomiting and you want to make sure she’s feeling better following a previous visit during which the physician only prescribed rest and monitoring, you can use Z09.

Posted 02/10/2015

Part B Insider (Multispecialty) Coding ALERT

Reader Question: Don’t Take Chart Amendments Lightly

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QUESTION: One of our physicians made mistakes on several charts and printed out new documentation to replace the old notes. Our office manager isn’t comfortable with this. Can you advise?

ANSWER: Although it is legal to amend your records, you cannot simply throw out the original documentation and replace it with something new, because payers could consider that “record tampering.”

As long as the doctor actually remembers the information, or reads notes or other written information that triggers their memory of the additional information, he can add information at any time. Follow these steps to make sure your corrections will pass a review:

1. Cross out old information rather than deleting it. If you are correcting an incorrect statement in the record, you should draw a line through the statement and put the word “error” next to it. Then sign or initial it (depending on your policy) and put the date. The original information must still be readable and included in the record. Use just a single line to cross it out.

2. Title the late entry. Never try and make a late entry appear like it was there all along. Be sure to clearly mark the correction or supplementation as a late entry with a title such as “Addition to record made on Dec. 15, 2015 by Steve Smith, MD:”

3. Include signature and date. Any late entry should include its date, and corrections or additions to documentation should ideally be made by the documentation’s original author. That person should sign the correction as well as dating it.

4. Add the reason. It’s a good idea to jot down the purpose of the entry — for example, clarification. It’s also helpful to indicate the source of the additional information, such as based on notes jotted during the visit.

5. Remember hard copies. If you make a correction in the electronic health record and there is also a hard copy printed from the electronic record, the hard copy must also be corrected.

Posted 01/25/2016

Part B Insider (Multispecialty) Coding Alert

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Part B Coding Coach: Watch These 4 Group Psychotherapy Myths That Could Prove Costly

– Published on Tue, Jan 19, 2016

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Hint: Use HCPCS codes for group psychotherapy in a partial hospitalization setting.

When reporting a psychotherapy session that your clinician conducts for a group of patients, you will need to focus on how many units of the code you can report on one calendar date of service. You should also be aware of what other services you can or cannot report for the same patient on the same calendar date of service.

Bust these four common myths that will help you achieve reporting success and help you better understand the rules for reporting the group psychotherapy code, 90853 (Group psychotherapy [other than of a multiple-family group]).

Myth 1: Units of Service for 90853 Depend on the Length of the Session

Reality: Unlike many of the time based psychotherapy codes, group psychotherapy code (90853) does not contain a time component to it. So irrespective of the time taken by your clinician in performing the group psychotherapy for a patient, you will not have to worry much about the duration of the session. Instead, you will have to remember that you should report only one unit of 90853 regardless of the length of the session on one calendar date of service.

However, you should not confine to reporting just one unit of 90853 for the entire group that is taking up the session. Instead, you will have to report one unit of the code for each and every member in the group who is participating in the session. Although it is typical for a group therapy session to have about eight to ten patients, the maximum number of patients that is permissible to participate in a group therapy session is 12. “In other words, the number of units of 90853 that you report depends on the number of patients in the group, not the length of time spent with the group,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

As with any psychotherapy service, the documentation should include details about why and how this group psychotherapy is beneficial and medically necessary for the patient’s treatment. To establish the medical necessity of the session, the documentation should include the diagnosis for which the patient is being treated. The documentation should also include how much time was spent on the session (even though that does not impact coding of the service) and the number of sessions your clinician intends to perform for the patients.

Myth 2: +90785 Can be Reported Only Once for Group With Communication Issues

Reality: When your clinician is conducting a group psychotherapy session, it is likely that he may face difficulties in communicating with some patients in the group. In such a scenario, you can get deserved reimbursement to compensate for the additional time and effort your clinician had to spend in performing the group psychotherapy with these patients. For this, you will have to report the add-on code +90785 (Interactive complexity [List separately in addition to the code for primary procedure]) along with the group psychotherapy code.

Again, as with the group psychotherapy code, you will have to report the add-on code +90785 for each patient in the group for which communication difficulties complicated the clinician’s provision of the service. Do not report it once for the entire group. “Also, do not report it for every patient in the group unless it applies to every patient in the group,” Moore adds. So, for instance, if your clinician encountered communication issues with five of the ten patients in the group, you will report +90785 for each of these five patients as an add-on code to 90853.

Reimbursement: According to the Medicare Physician Fee Schedule, the add-on code +90785 carries a total of 0.39 non-facility relative value units [RVUs]. When you multiply the RVUs by the 2016 Medicare conversion factor of 35.8279, you’ll get a national average payout of almost $14. So, watch out for in the documentation to spot instances where your clinician had to spend extra time and effort with the patient in overcoming communication issues, or else you will be foregoing much deserved reimbursement. You can also suggest to your clinician that he/she document in the patient’s chart notes about communication difficulties he/she encountered, so you will not lose out on the additional pay.

Myth 3: 90853 Cannot be Reported With Another Individual Psychotherapy Code

Reality: It may not be uncommon for you to encounter situations where your clinician would have scheduled individual psychotherapy and group psychotherapy on the same calendar date of service for the same patient. So, can both the services be reported on one calendar date of service for the same patient?

You will face Correct Coding Initiative (CCI) edits if you try reporting 90853 with an individual psychotherapy code from the range 90832-90838. However, the modifier indicator to the above mentioned edit is ‘1,’ which means you can overcome the edits with a modifier.

As the individual psychotherapy codes are column 2 codes in the bundling edits with 90853, you will have to append a suitable modifier to the individual psychotherapy codes. The modifier that you will have to use with these individual psychotherapy codes to overcome the bundling is 59 (Distinct procedural service) or modifier XE (Separate encounter), if the payer, like Medicare, recognizes modifier XE.

If your clinician performs an E/M service such as medication management on the same day on which he also performed a group psychotherapy session, you will again look at CCI edits, as you face bundling edits if you’re reporting an E/M code with 90853. Again, as the modifier indicator is ‘1,’ you are allowed to overcome the edit by using a suitable modifier. Here you will have to append the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code you are reporting along with the group psychotherapy code.

Myth 4: 90853 Can Also be Reported for Patients in Partial Hospitalization Programs

Reality: “This depends on the payer,” Moore says. When your clinician performs a group psychotherapy session to a group of Medicare patients in a partial hospitalization program, you cannot report 90853 for these patients. For Medicare patients in partial hospitalization program settings, you will have to use G0410 (Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45 to 50 minutes).

Again, you cannot use +90785 if your clinician encountered difficulties in communicating with these Medicare patients in the partial hospitalization program. For patients in the group psychotherapy session with whom your clinician encountered problems with interaction, you will have to report G0411 (Interactive group psychotherapy, in a partial hospitalization setting, approximately 45 to 50 minutes) instead of G0410. For instance, if your clinician encountered communication issues with four of the twelve patients in the group psychotherapy session, you will have to report G0411 for these four patients and report G0410 for the other eight patients.

For payers other than Medicare, check with the payer to see how it wants you to report group psychotherapy in the partial hospitalization setting. Ask if they prefer you to use the CPT® codes or the “G” codes favored by Medicare.

Don’t forget: When reporting a group psychotherapy session for patients in a partial hospitalization program, you will have to use 52 (Psychiatric facility-partial hospitalization) as the place of service code. This should be true regardless of the payer.

Posted 10/28/2015

Part B Coding Coach: Ask 3 Questions Before Coding for Split Sleep Study

– Published on Mon, Oct 26, 2015

Plus: Watch date of service for reporting bundled codes such as 95811.

Patients suffering from sleep disorders such as sleep apnea can be regular visitors to your neurologist’s office. One of the first steps to reimbursement success in dealing with sleep apnea cases is spot-on diagnosis followed by choosing the correct codes for treatment and care. Ensure maximum returns on your polysomnography (PSG) coding by answering the following questions.

  1. Are You Reporting a Sleep Study or Polysomnography?

Usually, the patient is referred to a neurologist by a primary care physician when he presents with the symptoms. Your physician may schedule a sleep study or polysomnography to confirm or eliminate the diagnosis.

Know the difference: Polysomnography is a sleep study that records many body functions including the brain’s electrical activity (electroencephalogram or EEG), eye movement (electroculogram or EOG), muscle activity (electromyogram or EMG), heart rate (electrocardiogram or ECG), respiratory effort, airflow, and blood oxygen levels (oximetry). Most polysomnography studies consist of about 16 channels and are used to diagnose several sleep disorders. Polysomnography differs from a sleep study in that it includes sleep staging.

In order for you to report polysomnography, sleep must be both recorded and staged. Polysomnography involves monitoring of several activity levels during a minimum numbers of hours of sleep, usually about six. Generally, monitoring will include measuring of heart rate and rhythm, chest bands that measure respiration, and additional monitors that sense oxygen and carbon dioxide levels in the blood. These physiological parameters of sleep must be continuous and simultaneously monitored and recorded for six or more hours with a subsequent physician review, interpretation and report. If a polysomnography is performed, you will report it from the following codes, depending upon the number of parameters tested:

  • 95808 – Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
  • 95810 – Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist.
  1. Did the Procedure Include CPAP?

When suspecting obstructive sleep apnea (OSA), the physician may opt for a split study that involves two steps. First, polysomnography is performed where the patient’s sleep is monitored. Once the patient’s sleep has been monitored and the apnea witnessed and recorded, the second part of the study involves the treatment. The physician initiates continuous positive airway pressure ventilation (CPAP) and then monitors its effect.

Important: You can report the treatment with 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management) but only when the initiation of CPAP does not occur during the course of the split night study, and the patient must be brought back to the office at a later time.

Given the guidelines required by polysomnography, the study may have started, but not enough data may have been collected to allow for the fitting and administering of CPAP during the single encounter. However, if enough data are collected to warrant CPAP initiation during the session, , you will report the split sleep study 95811 (… sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist). This code bundles the polysomnography with the CPAP treatment, appropriate when the two procedures are performed during the same study. Do not report separate components, 95810 on day 1, and 94660 on day 2 in this case.

It is important to have the documentation supporting the code used readily available.

  1. Did the Physician Administer Bilevel Ventilation?

Although central sleep apnea is reported similarly to obstructive sleep apnea, it involves different symptoms and requires a different treatment plan. The patient undergoes a similar split sleep study.

The polysomnography portion must meet the same guidelines as obstructive sleep apnea. However, in central sleep apnea, the second half of the study involves bilevel ventilation rather than CPAP. The same rules apply ­– codes 95810 and 94660 cannot be reported if the procedures are provided during a single sleep study encounter; they would be bundled and you will report only 95811.

Know the difference: CPAP stands for “continuous positive airway pressure;” BiPAP refers to “Bilevel (or two level) positive airway pressure.”  While CPAP generally delivers a single pressure, BiPAP delivers two levels of pressure: one at a higher level when the patient inhales and one at a lower level when the patient exhales. Your physician prescribes the levels of pressure for both types of tests.

Sometimes the neurologist may decide to perform a CPAP study (similar to a split sleep study except the patient uses CPAP for the entire time) if she notices changes in the conditions of patients already on CPAP. For example, they may have an increase in snoring or they may feel sleepier. You would report this service using the same code: 95811.

Posted 09/29/2015

Part B Insider (Multispecialty) Coding Alert

Allergy Immunotherapy: 95165: This Payer Cites Ongoing Problems With Allergy Shot Coding

– Published on Fri, Aug 07, 2015

Hint: Limit number of units you bill to the size of the vial.

Although you might think you’ve got the allergy shot coding rules committed to memory, one Part B MAC is hoping you’ll revise some of those traditions.

On July 31, NGS Medicare distributed a notification to Part B practices alerting them to tighten up their claims for 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]).

“Investigations by the OIG in 2002 and again by the Program Safeguard Contractor in 2015 have demonstrated that claims for CPT® code 95165 are sometimes billed incorrectly,” the alert stated, adding that providers should keep in mind that per CMS guidelines, one unit of 95165 equals one cc of the antigen.

Therefore, if the doctor administers four ccs of a vial, then he should report four units of 95165. “Billing one unit of 95165 per one cc holds true regardless of the number of injections, and/or number of antigens,” NGS said in the alert. “Additionally, once an antigen maintenance mix is created and billed it cannot be further diluted for additional charges.”

However, despite the “one unit per cc” rule, Medicare does have several caveats as follows, according to chapter 12 of the Medicare Claims Processing Manual:

  • If a physician prepares a 20cc multi dose vial, he can bill Medicare for 20 doses, since the practice expense is calculated based on the assumption that the physician will remove multiple one cc doses from the vial. “If a physician removes two cc aliquots from this vial, thus getting only 10 doses, he may nonetheless bill Medicare for 20 doses because the practice expense for 20 doses reflects the actual practice expense of preparing the vial.”
  • If a physician removes multiple ½ cc doses from a 10 cc multi dose vial for a total of 20 doses, he can only bill Medicare for 10 doses, which is the maximum billable for the 10 cc vial. “Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the vial,” CMS says.
  • If, however, a physician prepares two 10cc multi-dose vials, he can bill Medicare for 20 doses. But the doctor can remove as many doses from those vials as he wants. “For example, the physician may remove ½ aliquots from one vial, and one cc aliquots from the other vial, but may bill no more than a total of 20 doses,” CMS says.
  • If a physician prepares a five cc multi-dose vial, he can bill Medicare for five doses. However, if the physician removes ten ½ cc doses from the vial, he can still bill only five doses because the practice expense of preparing the vial is the same, without regard to the number of additional doses that are removed from the vial.

Translation: In essence, the maximum number of units you can report for any vial is the same as the number of ccs included in the vial itself.

Get to Know These Other Allergy Shot Rules

With fall allergy shot appointments already filling your schedule, it’s a good time to refresh your memory on how to report these services in general now that you’ve got the 95165 rules under your belt.

When your physician provides only the injections for the allergy immunotherapy and the allergenic extracts for the injections came from another source, you should code for the injections only, depending on the number of injections provided. If your physician provided only one injection, reach for CPT® code 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection).

If your physician provides more than one injection, use 95117 (Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections) to report the allergy immunotherapy services that your physician performed. The code involves the observation service (to check for allergic reactions) that your physician performed after the injection. Keep in mind that these codes only represent the administration of the extract prepared by your physician or someone from your facility.

Reminder:  If your physician administered the antigens sublingually (i.e., by placing drops under the patient’s tongue), then you cannot claim reimbursement for the service. Note that antigen(s) administration is covered only if it is injected by your provider.

Know the Codes for Allergenic Extract Preparations

Along with knowing the codes to report injections-only, you’ll best capture your provider’s services for allergenic extract prep if you apply the appropriate code. Most payers recognize 95144 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial[s] [specify number of vials]) or 95165 to report the provision of the allergenic extracts, whether the allergenic extracts are mixed or prepared by a person of another facility or by the same individual providing the injections.

Be sure to report the correct code, dependent upon whether or not single dose vials are prepared, or the more common multi-dose vial. For single dose vials, report the total number of vials prepared for the patient. For multi-dose vials, report the number of one cc doses prepared (even if the patient will not be given a one cc dose at a given encounter).

Don’t Forget to Report E/M Services When Performed

You may be unsure about reporting E/M services along with allergy immunotherapy codes. The allergy administration codes include a pre-procedure evaluation to ensure that the patient is able to receive the injection and a post-procedure evaluation period to determine if the patient is in jeopardy of an allergic reaction, so you cannot report an E/M code unless a separate identifiable service is performed. Obtaining informed consent is included in the immunotherapy.

Remember that you have to an appropriate E/M code (such as 99212-99215,  Office or other outpatient visit for the evaluation and management of an established patient…) depending on the level of E/M services provided when a separate service is performed in addition to the allergy immunotherapy. Add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to help the payer know that a separate service has been performed in addition to the allergy immunotherapy. Include documentation of the separately identifiable service that has been performed.

Example:  Your physician assesses a patient suffering from severe pain and fever due to a peritonsillar abscess (475), and the patient receives her scheduled bimonthly series of allergy immunotherapy for allergic rhinitis due to dander (477.2). Your physician performs and documents a level-three E/M service. You should report 99115 and 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components Physicians typically spend 15 minutes face-to-face with the patient and/or family) along with the modifier 25 appended to 99213.

Posted 09/23/2015

Part B Insider (Multispecialty) Coding Alert

Part B Coding Coach: 3 Tips Lead You to Successful Spirometry Claims

– Published on Tue, Aug 04, 2015

Hint: Double check the “medically necessary” codes allowed by your payer.

Spirometry is one of the most frequent diagnostic tests used by pulmonologists to confirm various pulmonary diseases. However, you need to remember two things while reporting the diagnostic codes to support it: specificity and medical necessity.

Background: Pulmonologists use spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation; and 94060, Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) to measure how quickly the patient’s lungs can move air in and out, as well as how much.

The patient breathes into the mouthpiece of a tube connected to the spirometer, which measures the airflow. The procedure is useful to detect obstructive airway diseases, such as asthma and chronic obstructive pulmonary disease (COPD).

  1. Negate Payer Rejection With the Highest Code Specificity

Although the payment for spirometry tests is based on the CPT® codes you report and not on the diagnosis, the payer can easily reject your claim if you can’t establish a credible medical necessity for the procedure by applying the correct diagnosis code. These ICD-9 or ICD-10 codes inform the payer why the pulmonologist had to perform the spirometry. Increasingly, carriers deny payment if the diagnostic codes are not specific enough.

Ensure that you are coding to the highest possible level of specificity by collecting complete information. While you are converting the physician’s encounter information into codes, you need to have complete information at your hands.

For example, if the doctor simply writes “chronic bronchitis” in the patient’s record, you need more information. Chronic bronchitis is a very non-specific diagnosis and most likely to be denied because of missing digits. ICD-9 classifies Chronic bronchitis under the parent family code 491 (Chronic bronchitis). Similarly, chronic bronchitis can be reported in ICD-10 through either of the codes J41 (Simple and mucopurulent chronic bronchitis), J42 (Unspecified chronic bronchitis), or J44 (Other chronic obstructive pulmonary disease) family of codes. You need determine the type of chronic bronchitis (simple, mucopurulent, with/without exacerbation, etc.) and whether it is a confirmed diagnosis. Consequently, you will have to seek out more information on the specific symptoms from the patient’s chart or by querying the physician. Specific diagnosis coding requires clear access to all the necessary information.

Use the code with the highest specificity: No matter how well the pulmonologist communicates the patient data, you must ensure that you use the right code and that it is being carried to the highest digit possible. This involves not only noting any caution or warning symbols in the ICD-9 or ICD-10 manual (some color-coded books use yellow for nonspecific codes and red for those with missing digits) but also having a good working knowledge of the terminology associated with spirometry. From the example above, if the physician sees a patient for chronic bronchitis, you will have to support the diagnosis codes by gathering enough information to know that the patient has obstructive chronic bronchitis with acute exacerbation.

Find the correct and complete code under chronic bronchitis with acute exacerbation (491) in the ICD-9 system and similarly in the ICD-10 manual (J41, J42, J44). The simple rule is: Assign higher-level codes only if there are no sub-codes within that code category. For example, assign four-digit codes only if there are no fifth-digit sub classifications for that category. Otherwise, assign the closest fifth-digit sub classification code for those categories where it exists.

In our earlier example, the specific ICD-9 code to report is 491.21 (Obstructive chronic bronchitis with [acute] exacerbation). The fourth digit indicates that there is an element of COPD present, and the fifth digit clarifies that there is an acute exacerbation of the chronic condition. Under ICD-10, the appropriate code would be J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation)

Although carrying out to the fifth digit is mandatory, you occasionally have to use an unspecific code if no code exists that matches the pulmonologists’ documentation. For example, for unspecified chronic bronchitis, you can always report J42 under ICD-10. “J42 may not be considered “medically necessary” for reimbursement, depending upon the payer’s policy,” informs Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania. It is always best to education the physician about the increased documentation requirements for ICD-10, and increased specificity in payer policy requirements,” she adds.

  1. Ramp up Your Reports for Error-Free Billing

You can stay updated with the latest diagnosis coding by evaluating your regular code reports. As a good practice, you should generate a report of the top 50 diagnosis codes and top 50 CPT® codes each physician used after every two months. Carefully review the reports, noting which nonspecific codes the pulmonologists used and how often. Report this information to the physicians and keep track of each report to benchmark progress and trends.

In addition, updating your encounter forms occasionally is always beneficial for your practice. This should eliminate the potential for using outdated or deleted codes. Your physicians will also be able to choose diagnoses that reflect their current patient population. Pulmonary physicians are frequently unaware of the many diagnostic codes available to them. They only see the small sample presented to them on their billing slip, and many limit their selection to these codes.

You should ensure including all applicable diagnosis codes on the encounter form to give the doctor the full range of options. This is all the more important now as the vastly expanded ICD-10 nomenclature comes into effect from October. If you only include those codes your carriers have indicated as showing medical necessity, you could be accused of coding for payment, which can be deemed fraudulent.

  1. Last Port of Call is Local Policies

Medicare carriers assign each CPT® code a list of diagnosis codes, which according to them show medical necessity for performing the service. The table below lists the most commonly accepted ICD-9 diagnoses and their possible ICD-10 crosswalks for spirometry. Although these are the most frequently allowed ICD-9 codes, each payer has its own take on the codes.

Consequently, you should contact your carriers and get their policies in writing regarding medical necessity for spirometry. You can use them to ensure that the diagnosis you assign will support your pulmonologist’s decision to use the procedure.

However, you should keep in mind that you cannot just pick a diagnosis from the carrier’s policy because it has stated that it will get paid. You must assign diagnostic codes based on the physician’s documentation. Otherwise, you could be an auditing target for deliberately using paying codes.

Posted 09/01/2015

-Part B Insider (Multispecialty) Coding Alert

Pulmonary Coding: 3 PFT Focused Cases Show You How to Report Lung Testing

– Published on Mon, Aug 24, 2015

Bill 94010 and 94060 together at your own peril.

Dealing with pulmonary function test (PFT) codes can be deceptive as you navigate through simple looking codes that may come back to haunt you if make single slip and lose valuable dollars. Familiarize yourself with when to use the right CPT® codes for PFT by busting these myths.

Background: Whenever your pulmonologist treats a patient with suspected or known lung disease (such as emphysema), you are definitely in the mix for a possible use of PFT codes. The physician will need the PFTs along with meticulous history and physical examination for diagnosing the patient’s lung condition and pinpointing the disease from many.

What it is: PFT is a collective term loosely translated to a group of procedures — namely, spirometry, lung volume test, diffusion capacity test, lung compliance test, and exercise tolerance testing.

The fundamental PFT is a spirometry that measures lung volume and function (the rate at which you blow air in and out). You normally report spirometry with code 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation).

Another common test is the bronchospasm test, an extended form of spirometry. First, a spirometry test is performed, then the physician administers a bronchodilator (such as an albuterol inhaler) to dilate the airways, after which another spirometry would be done. The code for this procedure is 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration).

The following case studies illustrate how to code for PFTs:

Insert All Possible Diagnoses to Justify Visit and Tests

Case #1: A patient with chronic obstructive pulmonary disease presents to the office with a variety of symptoms, including shortness of breath, wheezing, and breathlessness. After a thorough patient interaction, the pulmonologist decides to perform numerous in-office tests to properly diagnose the severity of the disease, including bronchospasm evaluation, diffusing capacity test, and thoracic gas volume test. He also orders a chest x-ray.

Code this: In this case, you should report the following:

  • 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity.) along with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) for the office visit. You would use the modifier to indicate that the E/M was a distinct and separate service since the evaluation resulted in the need for additional same-day testing;
  • 94060 for the bronchospasm evaluation;
  • 94729 (Diffusing capacity [e.g., carbon monoxide, membrane] [List separately in addition to code for primary procedure]) for the diffusing capacity test;
  • 94726 (Plethysmography for determination of lung volumes and, when performed, airway resistance) for the lung volume test;
  • 05 (Shortness of breath), 786.07 (Wheezing), and 786.09 (Other respiratory abnormalities) — presenting symptoms [In ICD-10, these will convert into R06.02 (Shortness of breath), R06.2 (Wheezing), and R06.89 (Other abnormalities of breathing)]
  • 21 (Obstructive chronic bronchitis with [acute] exacerbation) linked to the CPT® codes for the diagnostic support code. When ICD-10 goes into effect, you will report J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation) instead.

Caution: “The radiologist should bill for the x-ray (71010, Radiologic examination, chest; single view, frontal), but you should include your informal physician’s review of the x-ray interpretation in your documentation for credit in the complexity of your medical decision making,” informs Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.

Remember to Include Inhalation Solution Codes While Billing

Case #2: A 55-year-old new patient who has been smoking for 30 years with shortness of breath is referred to your pulmonologist for consult. The physician performs a detailed history and an expanded problem-focused exam, and decides that spirometry would help diagnose COPD. The patient has non-optimal readings on the first spirometry, so the physician administers albuterol and re-performs the spirometry. Readings from the second test are greatly improved. The pulmonologist diagnoses the patient with reactive airway disease and probable COPD.

Code this: You should bill:

  • 99241-99245 (Office consultation for a new or established patient office …) for the consult services (if accepted by the payer) or 99201-99205;
  • 94060 for the albuterol-induced spirometry;
  • 12 (Intrinsic asthma; with [acute] exacerbation) because the patient is having an acute exacerbation (shortness of breath). A secondary code is not necessary in this case because shortness of breath is intrinsic to asthma and the COPD is not a definitive diagnosis. When ICD-10 goes into effect, you will report from J45.– (Asthma …) depending upon the quality of the asthma and the acuteness of attack.
  • J7609-J7613 (Albuterol, inhalation solution,…) for the bronchodilator medication, such as Albuterol, if your pulmonologist performs the test in the office.

Hint: The correct code here is 94060 because the spirometry has turned into a bronchospasm test because the physician used an albuterol inhaler during the evaluation. The bronchospasm evaluation (94060) involves spirometry (94010) taken before and after your physician administers bronchodilation (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) to dilate the airways. “This means that although the physician performed both test components, you cannot report either component separately spirometry administration of bronchodilator,” adds Pohlig.

Be Careful in Coding Bronchodilator Administration

Case #3: A new asthmatic patient presents in your office with difficulty breathing. The physician administers peak flow to make sure the problem is not serious. The measurement, however, is high, and the physician gives the patient a bronchodilator to open up his airways and takes another peak-flow measurement.

Code this: Because the peak-flow measurement is such a quick and simple test, it is not reimbursable as a standalone test. Code 94060 cannot be used here because a spirometry was not given before and after the bronchodilator; rather, the pulmonologist performed a peak flow. You should report code:

  • 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:…) for the office visit along with modifier 25;
  • 94640 to represent the bronchodilator administration because it is considered a nebulizer treatment in this case.