[CCO] Certification Coaching Organization LLC http://www.cco.us Medical Certifications - Learn It - Get Certified - Stay Certified Wed, 28 Sep 2016 01:50:40 +0000 en-US hourly 1 Sequencing of Codes: Depression and Suicidal Ideation Codes http://www.cco.us/depression-suicidal-ideation-codes/ http://www.cco.us/depression-suicidal-ideation-codes/#respond Mon, 26 Sep 2016 10:45:19 +0000 http://www.cco.us/?p=28562 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: “I have a question about depression and suicidal ideation. Should I code depression first and then suicide?” A: That’s a great question. When we start looking at the ICD 10 guidelines, funny enough, there is not a specific directive as to which one has to go first. If you […]

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Sequencing of Codes: Depression and Suicidal Ideation Codes

Q: “I have a question about depression and suicidal ideation. Should I code depression first and then suicide?”

A: That’s a great question. When we start looking at the ICD 10 guidelines, funny enough, there is not a specific directive as to which one has to go first. If you look these two codes up in ICD-10- CM, the depression code in ICD-9 remember we had that generic code for depression not otherwise specified, it was a 311? In ICD-10, they did away with that depression not otherwise specified, and it now maps to major depressive disorder, single episode, that’s where that goes, so it’s an F32.9.

VIDEO: Sequencing of Codes — Depression and Suicidal Ideation Codes

The suicidal ideation is a sign or a symptom code. It goes to R45.851. Some people go, “Isn’t suicidal ideation a sign or a symptom of depression?” No. Not everyone that is depressed becomes suicidal. That’s why you do want to code them separately when a patient has both, and when it’s documented that the patient has both in their record. But there is not anything in the guidelines that says one has to go in front of the other; instead the guideline that we fall back to is how do we define our principal diagnosis or a first-listed diagnosis?

The difference between those two being principal diagnosis is what we use in the facility setting, in the hospital, they call it a principal diagnosis. In the outpatient environment, we call it the first-listed diagnosis. They both have the same definition, and that definition is that condition, after study, to be chiefly responsible for the services rendered.

So, in determining which one of these goes first, you got to ask yourself, “Why did we wind up seeing the patient that day?” Well, we’re seeing them because they were depressed and during the course of treatment figured out that they do have some suicidal ideation because that’s typical questions that they ask. If you got a patient that’s coming in that’s depressed, we’re going to put them through a questionnaire and we’re going to ask them:

  • “Are you having any suicidal ideation?
  • Do you ever think about hurting yourself?”
  • And if they say, “Yes,” “OK, do you have a plan?” because we need to know how far we need to escalate this, how important, how risky are you to yourself and to others.
  • And the order of the diagnosis would be, “OK, what did you really wind up seeing them for?”

If they’re hospitalized – and I’m going to use principal diagnosis first –if they’re hospitalized for say a week and it’s because they’re depressed and while they’re depressed we ascertain that they had some suicidal ideation, but they don’t have plans, we don’t think they’re really going to act on it, but it’s important they let us know that. The main reason we saw them was because they were depressed; the depression code would go first.

Conversely, if they present and they’re being brought in or they’re presenting themselves to be evaluated because “I’ve been depressed for a while but now I’m having suicidal thoughts and I’m actually starting to work out a plan in my head.” In that situation, why are we seeing them? Well, yeah, they’re depressed but we’re seeing them because acutely they are suicidal and we need to get that addressed and help them overcome that.

So, the answer to this question about which one has to go first between depression and suicidal ideation is it depends on what the circumstances of that encounter were – why were they there? Were they there for the depression or were they there for the suicidal ideation because that will determine which one goes first.

The answer sheet just includes all of the definitions from the guidelines where I show you. And if both situations, maybe the depression and the suicidal ideation are both responsible for the patient being there or equally responsible, then according to the guidelines it doesn’t matter which one goes first and its typically not going to be a payment difference either. They’re both considered medically necessary in most or all situations.

Related Depression and Suicidal Ideation Codes Posts:

Sequencing of Codes: Depression and Suicidal Ideation Codes

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September 2016 CCO Graduates and CPC Exam Passers http://www.cco.us/2016-cco-graduates-cpc-exam-passers/ http://www.cco.us/2016-cco-graduates-cpc-exam-passers/#respond Fri, 23 Sep 2016 10:05:33 +0000 http://www.cco.us/?p=28412 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

 “If you can imagine it, you can achieve it. If you can dream it, you can become it.”  — William Arthur Ward To our recent CCO graduates and 2016 COC, CRC and CPC Exam Passers, CONGRATULATIONS!!! It is true, the exam may not be easy, but what you have learnt all through the years, you […]

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September 2016 CCO Graduates and CPC Exam Passers

 “If you can imagine it, you can achieve it.
If you can dream it, you can become it.
” 

— William Arthur Ward

To our recent CCO graduates and 2016 COC, CRC and CPC Exam Passers, CONGRATULATIONS!!! It is true, the exam may not be easy, but what you have learnt all through the years, you make the best use of it. Today’s achievement tells your success story and we, the CCO family, congratulate you for your win. Don’t limit your knowledge and look outside to extend your talent. Today, you define the success with your hard work and dedication, honesty and courage. Believe in yourself and bring out your best quality to make your journey smoother. BIG THUMBS UP to:

  • Sarah Wood Rodriquez CPC 11/01/2015 Using CPC Blitz

  • Paula Farbolin CPC 08/31/2016 Using CPC Blitz

  • Anna Bulmash CPC 08/27/2016 Using CPC Blitz

  • Kim Reid CPC 08/31/2016 Using CPC Blitz

  • Melissa Orozco CPC 03/12/2016 Using CPC Blitz

  • Renee Davis CPC 09/14/2016 Using CPC Blitz

  • Catherine Adams CRC 09/10/2016 Using CRC Blitz

  • Misty Ferguson COC 09/10/2016 Using COC Blitz

  • Christine Ordonez CPC 08/26/2016 Using CPC Course (PBC)

  • Ella M Vandenlangenberg CPC 08/20/2016 Using CPC Course (PBC), Practice Exams

Related CPC Exam Passers and CCO Graduates:

 

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Wound Care and Laceration Repairs | CPT Coding Tips http://www.cco.us/wound-care-laceration-repairs-cpt-coding/ http://www.cco.us/wound-care-laceration-repairs-cpt-coding/#respond Wed, 21 Sep 2016 14:26:02 +0000 http://www.cco.us/?p=28433 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: Wound Care and Laceration Repairs — “Could you do some scenarios with wound care at the next webinar? I am noticing a lot of those type questions on the CPC practice exams and am weak in that area. For example, an 11 year old girl fell from a chair […]

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Wound Care and Laceration Repairs | CPT Coding Tips

Q: Wound Care and Laceration Repairs — “Could you do some scenarios with wound care at the next webinar? I am noticing a lot of those type questions on the CPC practice exams and am weak in that area. For example, an 11 year old girl fell from a chair and received two 3 cm lacerations to her left arm with embedded glass etc. etc. face, leg and arm needed layered closure wound repair and (whatever) needed superficial repair and (whatever) needed complex repair.”

A: The first thing that I wanted to clarify when we’re looking at this question is, this isn’t really wound care. Wound care is when we are providing care to the actual wound. Things like wound-vacs, packing, and all of that. What this is, is what we call a repair, and this is really a laceration repair. Laceration is just that, it’s a cut open on the skin and it can go multiple layers down, all the way to the bone in some situations.

When we look at coding for repairs, there are really three factors that you have to know. If you were to go in your CPT manual and you go to the repair section in the integumentary section, you’re going to find that there are three factors that determine which repair you need. The three pieces that you need to know. First of all, you’re going to have to know the type of the repair, is it simple, intermediate or complex? When we talk about simple, intermediate or complex, simple is just what it sounds like, simple. We’re just closing that back up. We’re using usually sutures to stitch it back up, sometimes we’re using butterflies, but it can’t be something as simple as Dermabond; if you read through the guidelines, it’s there.

VIDEO: Wound Care and Laceration Repairs | CPT Coding Tips

Intermediate, since it’s a little more complex than that, we may have to do a layered closure, we may have to get some dirt and debris out of there. A complex is just as it sounds, really complex; we had to do a lot of extensive undermining. We had to get all this dirt and all this dead skin and all of this other debris out of there. We got to do a layered closure, maybe we have to do rotations, something like that. Then, in addition to knowing what kind, what level, how big of a deal is it, we need to know where are we repairing, the anatomical location.

The third piece we have to know is the length of the laceration and your providers need to be documenting how big that laceration is. Good question I get a lot of the time is: “What if my provider didn’t say how big the laceration was?” Well, they shot themselves in the foot. It’s not that we can’t code for it, but we have to go with the smallest size available because most of them will say like under “2 cm.” If they didn’t tell us how big it was, all we can do, we know they had a laceration and we know we repaired it, and we usually know what level it was but we don’t know how big it was, we have to go with that small one.

Let’s look, I’ve got a scenario here in my answer sheet that we’re going to talk through, a little farther down in the page:

Laceration Repairs Scenario

We’ve got Martha. Martha is a 75-year- old female, she lost her balance and she fell. When she fell, she fell through the storm door at home. She has glass embedded in her right forearm and then her right hip. She also sustained lacerations to her right cheek, shoulder, and knee. So, we’ve got five different places that were injured; we’ve got the forearm, the hip, the cheek, the shoulder, and knee.

Her cheek laceration was 2 cm in length and we closed it with 6-0 Prolene. Her knee wound was 5.5 cm. Her shoulder wound was 7 cm. For the shoulder wound, we had to layer the closure. That should be, any time you see a layered closure, that should indicate to you that you’re going to have at least an intermediate repair. What that means is they had to layer the closure; they had to close maybe muscle and then skin, so they had to do multiple layers.

Her forearm was 11 cm and her hip laceration was 4 cm, both required cleaning and removal of glass. Again, they had to do more than just a simple closure. The hip laceration was closed using a layered closure of Vicryl and Prolene, and the forearm was a complex closure with some debridement going on there.

How to Code Laceration Repairs

So, when you go to code for this, what you’re going to do is ask those three questions. I had set mine up in a little table so we can talk easily.

  • Where was it?
  • Where were we?
    • We had the cheek, the shoulder, the forearm, the knee and the hip.
  • How big was each of them?
    • So, I read through the note, and I plugged in the link of each one, next to that.
  • What type of closure was each one of them?
    • Simple, intermediate or complex?

Wound Care and Laceration Repairs | CPT Coding TipsYou notice in my table I have two simples, two intermediates, and one complex. When you look at these codes in the CPT manual, they’re grouped. If you do the bubble and highlight thing, they’re grouped into three bubbles and that is because they group different body areas together and they’ll say, “Oh, you code the arms and the legs together. You code the face and certain parts of the face together.” Things like that.

For simple repairs, the cheek falls into the second bubble in your book, and the knee falls into the first one. So what we have, two simple repairs, they’re in two different anatomical locations even according to the CPT groupings, so we have to have two codes. For the intermediate repairs, the shoulder and the hip, both of those get grouped into the trunk or the extremities. My shoulder and my hip are both right off of my trunk before I go to the extremity.

For those purposes for a repair, if they’re in the same bubble, we add them together, we don’t code for them separately. You go, we coded for the first two separately because they were in different bubbles. But in this one they’re in the same bubble, they get added together so we take the 7 cm on the shoulder, the 4 cm on the hip. We add them together to get an 11 cm laceration with intermediate closure and we code the correct code for that, in this case it’s 12034.

We still have another closure left, we have one more, that complex closure. It gets coded all by itself because it’s a different level of closure. Think about it this way, you know where all of them were, you got to look at what was the level of closure – simple, intermediate or complex? So look at all your simples together, you look at all your intermediates together, look at all your complex together. And within each of those, do they all go to the same anatomical grouping for the codes? If so, they get added together. If not, they get coded separately.

What about RVUs?

Based on RVUs, that’s the relative value unit or the weight given to that code, which one pays more, which one is worth more work? And according to RVUs, I listed the answers for you there in the order that they go with, and the complex repair is going to go first, and then you’re going to have those intermediate repairs, then you’re going to have those simple repairs. According to the guidelines we also need a modifier 59, and that is because the guidelines say, “When more than one classification of wounds is repaired, list the more complicated as the primary procedure, and the less complicated as the secondary procedure, using modifier 59.”

Actually, what you would do is that 13121 would go first, and the remaining four codes (12034, 13122, 12011, 12002) would each have a modifier 59 on them to show that they are separate and significant from one another. They’re in different, they meet different requirements and different criteria so that the carrier doesn’t bundle all of them together and say, “You didn’t bill this right.”

That’s what when we talk about those examples that you’re going to see on the CPC exam and the practice exams, those are really repairs and it’s all about those three questions, what part of the body, how significant was the repair – simple, intermediate or complex; and how long, the length of the laceration?

Related Laceration Repairs and Wound Care Posts:

Wound Care and Laceration Repairs | CPT Coding Tips

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Timely Filing for Claims and Appeals | Medical Billing Tips http://www.cco.us/timely-filing-for-claims-and-appeals-medical-billing-tips/ http://www.cco.us/timely-filing-for-claims-and-appeals-medical-billing-tips/#comments Mon, 19 Sep 2016 10:01:12 +0000 http://www.cco.us/?p=28372 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: Timely Filing for Claims and Appeals — “Please explain filing limits with insurance claim processing” for the initial claim as well as the appeal process. A: Basically, we’ll be covering information about how all insurance companies do enforce filing limits for both initial claim submission, as well as for […]

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Q: Timely Filing for Claims and Appeals — “Please explain filing limits with insurance claim processing” for the initial claim as well as the appeal process.

A: Basically, we’ll be covering information about how all insurance companies do enforce filing limits for both initial claim submission, as well as for appealing claims. So, you really need to know your payer filing limits and create a cheat sheet for your demographic area. When filing or appealing a claim, you want to be absolutely sure that you get those claims in early because there were always technical problems or if you’re using snail mail, things get lost in the mail. It happens more often than not, so if a doctor gives you a charge today and expects you to transmit it tonight and thinks it’s going to be OK because the cutoff is tomorrow, I can bet you that it didn’t go through for some reason. There’s always a delay and the insurance companies do look for specific proof of when they received it in order for you to get paid.

You want to pay also attention to notifications of changes regarding time constraints. For years, we were dealing with a year and a half with Medicare and then they changed to one year submission, so pay attention to any of your payer’s notifications because they will send them to you via email if you sign up on their website. Lastly, when you do your aging, the follow-up – I can’t say it enough, just pay attention to your follow-up because you can see trends there, as far as claims not being paid and you can see “Gee, if this whole bunch didn’t get paid, there might be a problem,” and so forth.

VIDEO: Timely Filing for Claims and Appeals | Medical Billing Tips

Filing limit – I can’t stress enough. Below (on the answer sheet) is an example of how this particular payer, which is TRICARE, allows 90 days from the date of service to bill out claim but the biller really has to know all the filing rules! In this particular case, we see at the top that the date of the notice when the doctor got paid was May 15, 2006 and below where the other red arrow is, it shows date of service is April 08, 2006, and it was paid; so it clearly is showing me that the biller had the work and transmitted it right away and TRICARE paid it.

What I do want to point out is that for any reason this claim is denied or there was any type of issue with it, if you were appealing to TRICARE, you would have 90 days to appeal from the date that the explanation of benefit was dated; so you’re not going to go 90 days from the date of service but from the actual notice or EOB. So, the May 15 th , you would tap on 90 days, and if it’s a secondary insurance, it might be 60 days, it could be a year, and whatever it is, you have that amount of time from the date of the original either payment or denial of an EOB.

Timely Filing for Claims and Appeals | Medical Billing TipsWhat I did just so that you all understand is that Google is a wonderful thing, and I just wanted to point out that when you know, when you’re working for a practice, what payers are dealing with, whether it’s California or Massachusetts, go into those payer websites. This example was TRICARE because I showed you that Explanation of Benefits, I just happened to find these guidelines and they were current. It basically said that: TRICARE network providers must file all claims within 90 days of the date of service. Where TRICARE is the secondary payer, the 90 days will begin after the first initial claim paid. If Medicare was primary and they paid today’s date, you would have 90 days from today’s date to bill out TRICARE. If TRICARE denied you would have 90 days from this denial to appeal.

Also, non-network providers may file claims up to one year after the date of service. That really is up to the biller to find out because a lot of doctors that are in networks of particular payers, they are usually affiliated with hospitals that are either involved in the network or not. Only you will know best and that’s why I really stress you have to check it out.

Another example here just to show you very quickly is the Basic Claims Processing Times and the different guidelines with TRICARE. Most clean claims will process within 30 days and generally, if a clean claim goes over the 30 days, they will pay you interest. That’s pretty standard with most insurances. Then they give you the criteria for clean claims: complying with the billing guidelines and requirements. Having no defects or improprieties on a claim, including documentation if it’s applicable, and also do not require a special processing that would prevent timely payment.

If you have any problems with your EOBs, whether you don’t think they paid enough or anything, TRICARE gives you a website that you can register on and you get a username and password and you can access all your doctor’s information, or you can call voice recognition and call a number and speak to someone. That’s just telling you a little bit more about how to process a claim.

Next page, what I did is just showed you an example. There are multiple contractors that process Medicare claims. In my area and another areas in the United States, NGS is one of the contractors. What I wanted to do is just show you that not only do they give you information about where you have to file how many days you have, but if you look here, it gives you all the information on how to appeal a claim and if you look to the left it will say: Who May File An Appeal, Levels of Appeals and Time Limits for Filing, and it even explains Reopening and Redetermination.

Reopening is very basic, you messed up on a diagnosis code, you forgot a modifier, something very basic. Redetermination – you may feel that obstetrical procedure that’s not typically bundled into another procedure, should have been paid or something, and it gives you all the guidelines. If you look to the right of this, you’ll see this in Appeals Timeliness Calculator, which I’ll show you next, as well as appeal forms. That is with any Medicare website and pretty much every other insurance company, it may look different but the information is the same.

Timely Filing for Claims and Appeals | Medical Billing TipsThe next page has to do with just basically the appeals calculator. Again, I won’t go into big detail, but you have your option of picking if it’s a reopening, redetermination, and it tells you the amount of days that you have to appeal, like, 120 days or whatever. Again, all your carriers will give you this information. This is just an example of what’s available on the websites.

The next one is just a very simple explanation of what a redetermination is, and it’s just giving you the filing limits again, how many days, time limit to initiate a redetermination, you have 120 days from the date of receipt of the initial determination, which is the EOB. Once they come up with the determination, you are not happy with it, you have 60 days to apply again, and it just gives you more information. It also tells you, a little bit below on this page, that you just submit your redeterminations online but you can do them on mail.

The next page, you’ll actually see a copy of a form just as an example. I won’t go through it, but it’s basically the beneficiary’s name, ID number, the reason why you are appealing, and so forth.

Laureen: Jo-Anne, Tamika had a question, she said: “Does timely filing policies apply even if you’re not contracted with the payer?”

Jo-Anne: Yes, they do. And I’ve had first-hand experience with that, so yes.

Laureen: Then another related question: “Do coders or billers process claims?”

Jo-Anne: It really depends. In my billing service, all the billers always coded or make sure the coding was appropriate and then they bill it out. When you’re in a big practice management within a hospital setting usually all roles are broken down, so a coder would actually be coding, but the biller they’ll have one that registers, one that does keypunching, one that does coding, one that does payment posting, and one that does problem resolution. My mindset is I like to do it all because oftentimes the left hand doesn’t know what the right hand is doing, and I like to have control when I used to bill all the time, of knowing when my claims went out, that I was responsible to leave notes against the patient’s account. But typically, the coders don’t have anything to do with the appeals process unless there’s an issue with the code that the biller may approach the coder. But that’s why a lot of billers are already coders because you will find out fast enough that you have to understand coding to a certain extent in order to understand why some of the claims are denied.

Laureen: Then we had one more, Charity wants to know: “If Medicare does not pay a clean claim within 30-46 days, what would you suggest doing at that point to get them to pay the interest?” Timely Filing for Claims and Appeals | Medical Billing Tips

Jo-Anne: I’ve never run into a time where they haven’t paid the interest, but sometimes depending, like, when we went through ICD-10, major changes where we anticipated and they tell us ahead of time that there will be delays, I’m not sure if we’ve seen interest on that. But a typical delay in payment I’ve always seen the interest given to the doctor, but again if they haven’t been paid, first of all, you want to make absolutely sure that they’re even in the system and so you can check online one or two just to make they’re there, because if they’re not there and you have a whole list of Medicare claims sitting there, then something may have happened between your office and the clearing house, or the clearing house and the payer, and that’s where I really stress to follow-up and staying on top of your work because the filing limits really do come into play and they’re not as lenient as they were even a year ago. They’re so strict, so you want to make sure that you understand.

The next slide is a cheat sheet and whatever you do, do not go by my numbers, this is strictly an example, but this is what my staff always had and I used to have in a day. I would list all my key insurance companies (Medicare, BlueCross BlueShield, HMO, PPO, Medicare Advantage, one of their plans, Tufts Medicare Preferred). As you can see, the initial claims vary. At one point, BlueCross BlueShield, HMOs we only had 90 days, but their PPOs and indemnities we had a year. Now, everything is 90 days. And, their appeals vary from 90 days to 120 days, 180 days. You really have to go into the insurance companies that your providers are contracted with.

If you have any plans, and I know in Massachusetts we have a few, that a 60 days you stay on those because by the time you get it and it’s transmitted and you get your EOB back, if you get it back, you don’t have a whole lot of time to play there; so those 60 days, make those a priority.

Allow Time for Technical Problems When Filing

Timely Filing for Claims and Appeals | Medical Billing TipsYou just want to allow time for technical problems. I would never submit a claim 1-5 days prior to the filing limit. Clearinghouses and payers have maintenance downtimes when no work can be transmitted. Databases crash, whether it’s the software, the clearinghouses, or the insurance companies. Regardless of when you transmit, payers consider when the claim was received. It does not matter if you sent it one day before; if there was a delay – trust me, there’s plenty of them. Things get lost in cyberspace so there’re problems; claims will be delivered late and they will deny it for over the filing limit. Billers oftentimes can appeal, but like I said, it’s very rare that they pay. If the insurance doesn’t have an electronic acknowledgement saying that they have that claim, they don’t usually work with you.

As far as problems where your claim is denied and you have to file, you have to first ask yourself: Was it the front desk? Was it the patient’s fault? If the patient gave the information but the front desk was negligent, then the practice is liable if we didn’t get the information on time, so you can’t bill the patient. But if the patient came in and did not give updated information and billing companies, office will call the patient, will try to get the office to call the patient, and they finally get around to calling you four months after four bills have gone out, they’re liable.

Again, your office should develop a protocol and stick to it for all your filing limit scenarios because front desk sometimes does not update their files by the time the biller gets the work, and that’s a bad practice to get into. And follow-up on claims is IMPERATIVE. Problems will jump out when you examine the dates of the outstanding claims. A lot of times you’ll see that the transmissions, even though they said they were sent weren’t, so that will keep you in line as well. That will keep you in line as well.

Timely Filing for Claims and Appeals | Medical Billing TipsIn summary, just know your clean claim submission filing limits, as well as the filing limits for your claim appeals. Use designated payer forms, phone calls or online access to appeal claims. Definitely use a cheat sheet for the initial and appeal file limits. Allow time for technical problems and delays and file clean and appealed claims ASAP. Don’t let them sit there. And, monitor your ageing to see if any claims are old- do not allow this to occur after the filing limit because it’s really tough to get that money. And if your billing [or coded] for a surgeon, it’s not $50, you may be talking $2500 and they won’t be happy with you. And that’s it!

Laureen: Very good. I really like the graphics and showing those examples. One thing I wanted to clarify that came up because we do have a lot of newbies on the call, to do coding, you don’t have to do billing and vice versa. They do complement each other, coding is a part of billing; but we don’t normally do a lot of billing topics but we’re starting to because we have a lot more billing students than we ever had and a lot of people want to have multiple skills and even though they might not actually do billing as part of their job. They want to understand all of the pieces because it makes them a more valuable employee.

Some people do coding with auditing or coding and they get into risk adjustment, so there are multiple things that you can do in this industry. And because this call is kind of a hodgepodge of everything, we try and answer questions in all different areas, so for those who are currently taking our coding course and are freaking out thinking now they got to do billing, no you don’t have to. You can, if you want to have multiple certifications, they do complement each other, and it’s neat to know when you code things and off it goes to get paid, all the work that has to be done on the end of that. You’re doing the coding upfront, but then billing has to take over and get it processed and post the payments and all that fun stuff.

Related Timely Filing for Claims and Appeals Posts:

Timely Filing for Claims and Appeals | Medical Billing Tips

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ICD-10-PCS Coding for Measurement and Monitoring with Examples http://www.cco.us/icd-10-pcs-coding-measurement-monitoring-examples/ http://www.cco.us/icd-10-pcs-coding-measurement-monitoring-examples/#respond Wed, 14 Sep 2016 09:51:11 +0000 http://www.cco.us/?p=28244 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: Could you review how to code for measurement and monitoring in ICD-10-PCS with examples? Well, as you know I love ICD-10 and I also really enjoy ICD-10-PCS. Since we do a weekly student webinar for ICD-10-CM and PCS and Risk Adjustment we’ve been working through some of these examples […]

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Q: Could you review how to code for measurement and monitoring in ICD-10-PCS with examples?

Well, as you know I love ICD-10 and I also really enjoy ICD-10-PCS. Since we do a weekly student webinar for ICD-10-CM and PCS and Risk Adjustment we’ve been working through some of these examples and Measurement and Monitoring is very commonly used in ICD-10-PCS.

I have to tell you that I picked this question because it is an awesome question and I love talking about ICD-10-PCS but because of miscommunication, Chandra went in and created this wonderful answer sheet for me. So, again, she did the work and I get to tell you all about it, which is actually the fun part. So, we give kudos to Chandra for putting this together for us.

A: The first thing you have to know about PCS when you’re working with ICD-10-PCS is that it is not like ICD-10-CM and it is not like CPT. What makes PCS different is that it’s not diagnosis coding, so when you see ICD-10 you just automatically think diagnosis. We’re talking about procedure codes, and so of course you think, “OK, CPT,” but we’re not talking about CPT codes. These are things still that you’re doing to a patient in an in-patient facility environment and there are not CPT codes that cover this.

VIDEO: ICD-10-PCS Coding for Measurement and Monitoring with Examples

In the past with ICD-9, this was bundled in into Volume Three – some of you may remember that – but with ICD-10 now ICD-10-PCS has its own manual. So, you can now separate the way that works. You potentially have to get another manual though because you have ICD-10-CM, PCS and everything.

Measurement and Monitoring Examples

The first thing I want to talk about is Measurement and Monitoring. Measurement – when you think of how to divide PCS, you always have to look for the key term, and the key term with PCS is a little different, a little more complicated than CPT or ICD, those are real straightforward, unlike PCS. So, when you’re looking to code something you have to think, “What am I doing?” and with Measurement, you’re determining the level of the physiological or physical function at a point in time – you’re measuring it.

But if you’re Monitoring, you’re doing the same thing repetitively over a period of time. So, if you understand the definition of those then it will help you to determine if that what you’re trying to code is in a measurement or monitoring area. Now, PCS is not really a puzzle, it’s like putting blocks together and it’s done with a graphing system, not like anything with CPT or ICD at all. It’s very unique. So, you have to get the keyword first and it isn’t always the term you’re thinking of.

We’ve got some examples of measurement and monitoring that you may not have thought of as falling into that category. What you have to do first is get the root operation – that’s what they call it in PCS – and you need to find that or I would say the key term to be able to go from that point to put your blocks together to build the code, expand it out, and then you think of a little set of blocks.

I always think of my mother-in-law would purchase those little wooden blocks or the little tiles for your Scrabble games and then she would spell everybody’s name out in the family and put it in this little neat thing that she had. That’s what we’re doing – we’re spelling out the whole procedure.

1. Monitoring of urinary flow.

ICD-10-PCS Coding for Measurement and Monitoring with ExamplesThe first objective is to determine what is the procedure being performed. What’s being done when we’re measuring or monitoring.

Then, the next thing you need to determine is where on the body that you’re going to be working, that’s the next step. So, you take it one step at a time. Chandra found a great graphic here, so let’s start with something simple.

Urinary flow. If you’re in the hospital for any extent of time – lots of people get catheters but even if they haven’t got a catheter they may be monitoring how much urine input and output that they have. So, for monitoring urinary flow, what is the objective of the procedure? We’re monitoring. We’re going to look again and again and again repetitively and monitor.

Then, what body system are we working with? What body part? It’s the urinary system and flow. So, you look up monitoring, urinary and flow – that gives you the blocks. So, the code is going to be 4A1D75Z. Now, how did we come up with that? When you look in your manual, it has an index and a tabular just like the other three manuals but the first term that we looked up was Measurement and Monitoring – it’s all in the same category, so see that’s a four. This is a great graphic that Chandra found.

The next thing is the physiological symptoms, A. So, we have “4A” so far. Then, what are we actually doing? We’re in this section – we got our first block, we’re doing measurement and monitoring. The next is an A – what are the physiological symptoms; and then the next block is a 1 – we’re monitoring and that’s repetitive. Then, we need to know body system. The fourth character is the body system.

Look at all the things that we can measure and monitor. This is where the table comes in – venous, lymphatic, respiratory, gastrointestinal – but we’re doing urinary, so that’s a D that gives us our next block.

Approach – How are we getting this information? How are we monitoring it? Well, via natural or artificial opening. Via natural would be you’re urinating. There’s no artificial opening there but we have several choices, so 7 builds the next block.

Function or Device – This is interesting, so we look at our choices and we go down to Urinary because we’re going across. Once we’re in Urinary, we have to stay on that level of the graph and we’re given a choice – 3, 5, B, D and L and we’re doing flow, wasn’t it? Or was it L, I can’t remember. So 5 – it’s the flow; urinary flow is what we’re doing.

Then, the last character, if we don’t have a qualifier and then you’ll see different examples, if we have nothing in the next block that needs to be filled out it’s a Z, that’s no qualifier. I think of that as an X in ICD-10 – it’s a holding place. They call it “no qualifier” but in my mind that’s how I think of it. You got to have a holding place there and it’s a Z. Sometimes, you’ll have two Z’s but that’s how you put it together.

FINAL CODE: 4A1D75Z

2. Fetal monitoring of cardiac electrical activity via natural opening.

ICD-10-PCS Coding for Measurement and Monitoring with ExamplesNow, let’s look at some other examples. We walked through this one. This time, we’re not going to show you a graph but I’m going to give you the verbiage/the terminology that you need – “Fetal monitoring of cardiac electrical activity via natural opening.” Actually, what they can do with that is ‘fetal’ is going to be the baby and cardiac electrical activity via natural opening.

There are a lots of ways to do fetal monitoring but you have to know fetal is the baby – hasn’t been born yet – so fetus/fetal. Once the baby is born it’s going to put you in another category for monitoring. What they can do, there are several ways they do this, but one of them now is they literally, once the woman’s water broke, they can go up and screw a little device – a little cord into the baby’s head – and it monitors their cardiac output.

What’s the objective? What are we doing? The first thing we need to know, our key term is, we’re monitoring. Now, it’s a little different after that. What are we doing – fetal cardiac; what type – electrical activity. Then, that gives us our first section – right there at the top – 4A1H is going to answer those questions. Then, once we got that, then we’ll go down to the next block, and then to complete the table we’ll just keep filling in the blocks across after we’ve got the H and we’ve got natural opening. What are we doing? Electrical activity. Then last, there’s no qualifier so there’s nothing else that we need.

The code for that particular monitoring is: 4A1H74Z.

Just because I had a student do this the other day on our ICD-10-PCS, be very careful when you get into codes that are zeros – the number 0 – and the letter O because they look different. When you’re typing it can be very confusing so I always do a strikethrough on the number zero if you’re having to write these out, just a little heads up.

Also, just a little hint – a fetus is considered product of conception. That is also a term that we don’talways think of. With PCS, you have to put on a different hat. The verbiage isn’t necessarily the first thing that comes to mind and that’s what people struggle with when they’re working with ICD-10-PCS. The verbiage in CPT isn’t always the PCS verbiage. You have to think, I’m doing in-patient, what boils it down, what am I actually doing? I’m monitoring. What am I monitoring? The products of conception – a fetus,” the baby hasn’t been born yet.

3. Monitoring of respiratory flow, via nose – nasal cannula.

ICD-10-PCS Coding for Measurement and Monitoring with ExamplesHere’s one that’s very common again. The objective: we’re monitoring. What are we doing? Respiratory is the body system. For what? The flow. So, monitoring, respiratory and flow gives us the codes 4A19. So, we’d look in the Index, monitoring, then go into respiratory and flow, that gives us to the section 4A19. Then we go to the Tabular, we open it up, you’ll see a graph like Chandra put in there and that’s when we can fill up the rest of the blocks – via natural or artificial opening. See how the verbiage repeats itself?

So, once you get the idea of the verbiage, PCS becomes a lot easier; but in the beginning it’s a little harsh on you trying to say, “Well, that’s not what it is.” Well, yeah, that’s the verbiage they use. So, that would be a 7, the flow is a 5 and the qualifier is a Z.

So, if a person is monitoring the respiratory flow it’s going to be: 4A1975Z.

4. External measurement of cardiac pacemaker.

I think we have the last one that is also a very common PCS code – “External measurement of cardiac pacemaker.” What’s the objective here? We’re not monitoring anymore, we’re measuring. So, you’re going to go to the index to measurement. What are we measuring? The cardiac is the body system – cardiac. What are we actually measuring in the body system of cardiac? The pacemaker.

So, that’s going to give us our basic code, and then once you fill out the rest of the boxes, you’re going to have: 4B02XSZ.

5. “This 23-week pregnant female is brought to the unit to monitor the cardiac sounds of her child. The sounds were monitored using an endoscopic vaginal monitor.”

ICD-10-PCS Coding for Measurement and Monitoring with ExamplesWe did have one more. These are some that I had come up with that were very common, I thought, that you’ll see in our in-patient setting. “This 23-week pregnant female is brought to the unit to monitor the cardiac sounds of her child. The sounds were monitored using an endoscopic vaginal monitor.” So, what’s the objective? We’re monitoring. That’s where you go in the Index. What are we monitoring? Fetal cardiac – that’s the body system – but what is it? It’s the sounds. It’s the sounds. Now, did you think of that? No.

Then, we start out with our 4A1H, then you go to the Tabular, you go to the section of 4A1H and you fill in the rest of the blocks. You now have a column and it’s like a drop down, then I can answer this column and this column. The next is via natural or artificial opening endoscopic is 8. What is that it again? Sounds. No qualifier, Z.

That gives us a PCS code of: 4A1H8HZ.

I think that was the last one, but to just wrap up PCS, the verbiage, keep in mind, is not like CPT. It’s similar but it’s a little bit different. So, probably the best way when you’re first getting in to PCS is to sit there and go through the Index. Go through the Index and see the options that are going to be given to you. It takes a little time to pick it up but once you get it, it’s so easy. Again, you’re just building the blocks. Think of a Scrabble board and you’re building words or a little scenario that each letter or character explains something else.

Unlike ICD-10 or just CM, where a 9 is usually always unspecified. Some of that happens with PCS where a Z is no qualifier but you may see an H in one section of measurement monitoring but an H may be in another section – the first four digits – of a completely other area and it’s not the same thing. H isn’t always the same thing throughout the Tabular.

Again, you have a graph for each one and once you get going it’s so much fun to do, you’re creating a formula. I love chemistry. It makes me think of that, but that’s it! That’s the basics of how you can put together PCS codes and measurement and monitoring is just used a lot. If you can start there, then you can expand out.

Related ICD-10-PCS Coding for Measurement and Monitoring Posts:

ICD-10-PCS Coding for Measurement and Monitoring with Examples

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How To Locate ECodes — The Best Way to Learn http://www.cco.us/how-to-locate-ecodes-best-way-learn/ http://www.cco.us/how-to-locate-ecodes-best-way-learn/#respond Sun, 11 Sep 2016 10:15:45 +0000 http://www.cco.us/?p=28231 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: How to Locate Ecodes — “What is the best way to ‘learn’ how to locate E codes?” A: I think they’re talking about ICD-9 here because they did a follow-up saying something about injuries. When we talk about E codes, we’ve talking about E codes for years. We’ve been […]

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Q: How to Locate Ecodes — “What is the best way to ‘learn’ how to locate E codes?”

A: I think they’re talking about ICD-9 here because they did a follow-up saying something about injuries. When we talk about E codes, we’ve talking about E codes for years. We’ve been in ICD-9 for 30 years until last year, they are now V, W, X, and Y, so make sure you’re calling them external cause codes or V-Y codes or something because now if we say E codes, those are endocrine, diabetes, that sort of thing.

VIDEO: How To Locate ECodes — The Best Way to Learn

But if we’re talking about external cause codes, which I believe this question was about, the easiest way to learn how to locate the E codes is if you look at the guidelines for the E codes, the very first guideline tells you that these codes serve five purposes. They tell you how the injury happened, like the cause, did we fall down, car accident, whatever. Was it intentional or not? Was it a suicide, was it an assault, or was it an act of terrorism? Where was it, what were they doing, and were they being paid? Those are the five questions that you have to ask yourself to get the right Ecodes.

The best way to do this to find and learn how to locate them is pick a color for everything except the cause and highlight these terms in your manual. So, when we talk about: Was it intentional? Find the word suicide, find the word assault, find the word terrorism and highlight them in one color, because you know that’s what you need for your second code, it’s got to be one of those three.

Where did it happen? Go to the place and highlight the place of occurrence codes back in the external cause index, put them in a different color, then your intentional codes. Find your activity codes, that’s – what were they doing, put them in the third color. Then, go find your status codes, that’s – where they being paid, were they volunteer, that sort of thing, and put them in a fourth color. That way you know anything that’s white has to be a cause code, and that’s the easiest way to find what caused it. Was it a car accident? Was it a fall? Was it striking against an object? Was it getting hit with a sword? What was it? Then, those other four are your supplemental codes. That’s what it makes me think of, that’s the easiest way to work through them.

Related How to Locate Ecodes Posts:

How To Locate ECodes — The Best Way to Learn Ecodes

 

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CPT Code 99211 Nurse Visits | CPT Coding Tips http://www.cco.us/cpt-code-99211-nurse-visits-cpt-coding/ http://www.cco.us/cpt-code-99211-nurse-visits-cpt-coding/#respond Thu, 08 Sep 2016 09:13:25 +0000 http://www.cco.us/?p=28199 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: “Can someone please discuss CPT Code 99211? A: Why, sure, we can. Unlike Alicia, I wanted Chandra to do my answer sheet because I always have best intentions but normally the Thursday of the webinar we’re all running around and I’m like, “Last minute Laureen,” and it’s a very […]

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Q: “Can someone please discuss CPT Code 99211?

A: Why, sure, we can. Unlike Alicia, I wanted Chandra to do my answer sheet because I always have best intentions but normally the Thursday of the webinar we’re all running around and I’m like, “Last minute Laureen,” and it’s a very bad habit. At any rate, answer prepared by Chandra, presented by Laureen but it’s a real quickie so we’ll get right to your chat questions.

First of all, what’s the definition of 99211? We’ve got our new patient codes and we’ve got our established patient codes for evaluation and management. The 99211 is the first code for established outpatient but it’s very unique. It doesn’t have the common three bullets – history, exam and medical decision making – like you see with the other codes and it’s often referred to as the nurse visit code.

VIDEO: CPT Code 99211 Nurse Visits | CPT Coding Tips

Here’s the definition: Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified healthcare professional. Usually the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services. So, the not requiring a physician is why they call it a nurse visit code.

Generally, it’s often ancillary nursing staff that’s going to be providing the services during the encounters and it is an E/M service, so there is some HEM going on – history, exam, medical decision making. But CPT doesn’t specify which areas or the amount like they do with other codes where they have discrete levels of history, exam and medical decision making.

Medicare places further restrictions on reporting 99211 by lumping it into the types of services typically performed “incident to” the physician’s services. What that means is under the “incident to” practice the physician must have established the plan. So, it’s not the nurses just taking over and treating the patient. The physician has established the plan and the nurses during follow-up in relation to that. So, that’s what that “incident to” is talking about and there has to be direct supervision. It means the physician has to be immediately available in the office suite to take over care should the need arise.

There must be a documented need for the services provided and the ancillary staff may not address any new problems or change any portion of the plan of care and order for the service to be considered “incident to.” The physician must also periodically see the patient – that would be nice. Some insurance carriers further specify this by defining “periodically” as at least every third visit.

So, if a patient is coming in for a routine thing that the doctor is aware of, he has established the plan, he’d say, “OK, poke your head in every third visit just to make sure everything’s going well.”

The types of services typically provided during these encounters are evaluation and management services considered minor in nature that do not meet any other code definition, such as blood pressure checks, weight checks, etc.

Some providers feel it is appropriate to report a nurse visit (99211) in addition to venipunctures, immunizations, etc. However, most insurance carriers will deny these… they will bundle them together. The reason is, for immunizations, the provider is already receiving payment for the E/M portion of the service… or, in the case of the venipuncture, the bundle the minimal E/M service provided into the payment for the venipuncture… They don’t want you to double dip.

For more information on CPT® code 99211 and nurse visits, here are a few articles and references that may be helpful. Again, advantage of being in the Replay Club, you get all these links and benefits of our research. That was my quickie question on nurse visits and thank you Chandra for doing that nice answer sheet for us.

Related CPT Code 99211 Nurse Visits Posts:

CPT Code 99211 Nurse Visits | CPT Coding Tips

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August 2016 CCO Graduates and CPC Exam Passers – FINAL http://www.cco.us/august-cco-graduates-cpc-exam-passers-2/ http://www.cco.us/august-cco-graduates-cpc-exam-passers-2/#respond Mon, 05 Sep 2016 10:44:20 +0000 http://www.cco.us/?p=28169 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

 “Good plans shape good decisions. That’s why good planning helps to make elusive dreams come true.”  — Lester R. Bittel Huge congratulations to our new CCO graduates who are among the 2016 CPC Exam Passers.  The achievement you have today is the result of your talent and knowledge. It is your hard […]

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August 2016 CCO Graduates and CPC Exam Passers - FINAL

 “Good plans shape good decisions. That’s why good planning helps to make elusive dreams come true.” 

— Lester R. Bittel

Huge congratulations to our new CCO graduates who are among the 2016 CPC Exam Passers.  The achievement you have today is the result of your talent and knowledge. It is your hard work and dedication the lead you towards the success. We wish you keep this courage up always for what is yet to come. The joy will be all yours, if you always believe in your work. Enjoy the smiles in your lives and earn your respect with hard work. BIG THUMBS UP to:

  • Rosanne Barnett  –  CPC –  08/06/2016 – Using CPC Blitz

  • Phyllis Pfingston  –  CPC  – 08/24/2016  – Using CPC Blitz

  • Stephanie Barr  –  CPC  – 08/20/2016  – Using CPC Blitz

  • Paula Lenard  –  CPC  – 08/20/2016  – Using CPC Blitz

  • Jeanne Geissberger  – CPC  – 08/13/2016  – Using CPC Blitz

  • Shelley Want  –   CPC  – 08/20/2016  – Using CPC Blitz, Practice Exams

  • Mari Flack  –  CPC   – 07/01/2016  – Using CPC Blitz, Practice Exams

  • Susan Loria  –  CPC  –  08/20/2016  – Using CPC Blitz, CPC Course (PBC)

  • Toni R. Porche  –  CPC –   08/27/2016  – Using CPC Blitz, Practice Exams

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Coding Cast & X-ray Application During Post-op | Medical Coding Tips http://www.cco.us/coding-cast-x-ray-application-during-post-op-medical-coding-tips/ http://www.cco.us/coding-cast-x-ray-application-during-post-op-medical-coding-tips/#respond Sat, 03 Sep 2016 10:47:12 +0000 http://www.cco.us/?p=28101 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: Cast & X-ray Application – “When coding for application of a cast, cast supplies, & x-ray, during post op would we append the 58-mod to the application of the cast?” A: I don’t think so. Chandra: Not typically, because typically they only bundle the first one that’s done the […]

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Q: Cast & X-ray Application – “When coding for application of a cast, cast supplies, & x-ray, during post op would we append the 58-mod to the application of the cast?”

A: I don’t think so.

Chandra: Not typically, because typically they only bundle the first one that’s done the same time that you bill fracture care.

Alicia: Yes. The person comes in during post-op, they put pins in the legs or whatever, and they also casted you. When they do that cast the first time, it’s all inclusive. Now, if you come back… a scenario I remember from the ER, a guy broke a tendon and the ligament because he caught his calf on a hook and so he was suspended by this big giant metal hook. Anyway, he was sliced open on his calf this big.

VIDEO: Coding Cast & X-ray Application During Post-op | Medical Coding Tips

The physician sewed the tendon and the ligament and everything together in the ER because it was all exposed; I mean, he was filleted like a fish. It was really exciting, he even pulled them and let me watched the guy’s toes wiggle. That being said, he wanted to cast the patient because when you have a ligament and a tendon tears in the leg, you need them not to be moving at all while they’re healing, they’re like giant rubber bands. You need that healing process. He casted him but he cut out the cast to show the wound because you can’t have stitches like that being covered up in a warm, moist area. So, he did that.

Let’s say that that patient came back a week later because his wound got infected, started oozing. They take the cast off because his leg is swelling and they clean him up and re-apply a different cast. That would get you a modifier 58 because it’s not applicable to the post-op.

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E/M with Diabetes | E&M Coding Tips http://www.cco.us/em-diabetes-em-coding-tips/ http://www.cco.us/em-diabetes-em-coding-tips/#respond Thu, 01 Sep 2016 10:05:43 +0000 http://www.cco.us/?p=28080 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: E/M with Diabetes – “When coding say an E/M encounter and the patient has type 2 diabetes documented in the medical record but the patient is not seeing the provider for her diabetes, is it still listed as a diagnosis?” Alicia A: This one I happen to know as […]

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Q: E/M with Diabetes – “When coding say an E/M encounter and the patient has type 2 diabetes documented in the medical record but the patient is not seeing the provider for her diabetes, is it still listed as a diagnosis?”

Alicia A: This one I happen to know as a risk adjustment point of view. I would tell you any time that a patient comes in that they have a chronic condition especially diabetes that affects all the other body systems, you definitely are going to have it listed as a diagnosis.

One of the things that the providers are struggling with these past few years is because they don’t do this. Let’s say we have a scenario which is really hard for us to find a scenario where diabetes isn’t pertinent. If a person comes in with, just say, a respiratory infection and it’s not that big of a deal but he prescribes antibiotic and let’s say he gives him a little bit of a steroid, it’s starting to get into the lungs. He may not list that the person is a diabetic; however, I look at it as a point of view, if he give a diabetic any type of steroid, it’s going to change their blood sugars.

VIDEO: E/M with Diabetes | E&M Coding Tips

Most usually, the provider will say, “For the next week or the next two weeks, I want you to check your blood sugar twice a day versus once a day or once a week and I want to put you on a sliding scale just in case the steroid affects your blood sugar,” etc., etc., etc. Maybe the person isn’t necessarily on insulin, so they don’t have to do that. Again, it’s probably going to be mentioned, so therefore, it’s listed as a diagnosis.

Now, the thing about it is, don’t think of it in the concept of being a coder for the provider on an individual encounter. Yes, you can list it. That’s the answer to the question; but think of it for the risk adjustment aspect every time that patient comes in and they have a chronic condition, it needs to be listed.

If the person comes in because they stubbed their toe and they’re diabetic, the doctor mentions that they’re diabetic, and because they stubbed their toe and healing… etc., etc., all the disease process for it. But the person also has COPD. He’s not going to list the COPD, he’s not there to see the COPD. So, the traditional coder is saying, “Of course we don’t want him to list COPD because it has nothing to do about this encounter.” But actually it does for a risk adjustment purpose: every time that patient sees a CMS-approved provider face-to-face, every single chronic condition needs to be listed.

Are you going to use it to substantiate a CPT code? No. However, you want that risk adjustment coder to be able to say, “Look, he has COPD and he’s on three inhalers and…” The physician doesn’t have to address it, but you have to have the fact that the chronic condition is listed and I’ve got a line, I’m showing he’s actively being treated by inhalers. So, even if this patient came in for a stubbed toe, I got to collect an HCC for DM and COPD.

So, my answer is, always list them. It doesn’t have to be pertinent to getting paid. You don’t get paid for regular coding on diagnosis coding, you get paid on CPT, so it’s OK to list it.

Is that what you would say, Chandra, or would this change?

Chandra: I’m going to tweak what you said just a little bit. I absolutely agree, especially for diabetes, you’re hard pressed to find an example where the patient comes in for some other condition and the diabetes is not pertinent. Most providers aren’t familiar with risk adjustment and I say that depending on what part of the country you work in. I know when I worked in California all the physicians I worked with were risk adjustment, they knew it inside and out. In Indiana, they look at me like I’m nuts when I start talking about risk adjustment because it’s just a very small portion of our population.

But from a coding perspective, as a physician coder day in and day out, if the provider indicated that a patient came in for an evaluation and management encounter and they were also a diabetic, if that diabetes was potentially going to play a role…I’ll give you an example, a patient comes in, they are following up on a surgery that they’ve had, and, oh by the way, they’re a diabetic. Oh, wow! We want to know they’re a diabetic because it’s going to affect their healing rate and all of that. The physician doesn’t have to be actively treating their diabetes, but the diabetes may have just come into play in the thought process. That needs to be taken into account because there was more medical decision making done around that diabetic encounter, but the documentation has to substantiate it. That’s not to say that it has to have some drawn-out, the patient has diabetes… But it needs to indicate they’re diabetic somewhere, whether it’s the past medical history, hopefully it’s the assessment that they’ve indicated they’re diabetic, it’s being followed by so-and-so.

If they’re on a medication, they need to do a medication reconciliation to identify that not only do I know they’re diabetic, I know what medication they’re on. Hopefully in the assessment they’ve said, “Oh, by the way, here’s who is treating that, here’s who is managing that.” That’s your best documentation to support any kind of audit, whether it be risk adjustment or fee-for-service auditing.

Related E/M with Diabetes Posts:

E/M with Diabetes | E&M Coding Tips

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