[CCO] Certification Coaching Organization LLC http://www.cco.us Medical Certifications - Learn It - Get Certified - Stay Certified Sat, 28 May 2016 10:10:01 +0000 en-US hourly 1 ICD-10-PCS Code for ALIF (Anterior Lumbar Interbody Fusion Procedure) http://www.cco.us/icd-10-pcs-code-for-alif-anterior-lumbar-interbody-fusion/ http://www.cco.us/icd-10-pcs-code-for-alif-anterior-lumbar-interbody-fusion/#respond Sat, 28 May 2016 10:10:01 +0000 http://www.cco.us/?p=21157 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’m getting confused trying to code for ALIF in ICD-10-PCS. It seems so different from ICD-9-CM volume 3 codes.” A: It is very different. First thing we need to know is, what does ALIF stand for? ALIF is an Anterior Lumbar Interbody Fusion Procedure, and so, an additional question […]

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Q: “I’m getting confused trying to code for ALIF in ICD-10-PCS. It seems so different from ICD-9-CM volume 3 codes.”

A: It is very different. First thing we need to know is, what does ALIF stand for? ALIF is an Anterior Lumbar Interbody Fusion Procedure, and so, an additional question that was written similar to this, because when you guys send in the question we try to combine them, so it’s unique that more than one came in, it says: “How do you code an ALIF with a dx of grade 3 annular tear on L5-S1: grade 2 annular tear on L4-L5?”

They were wanting to know also the PCS portion of this, which is the ICD-10-PCS that replaced the volume 3 ICD-9 codes. Let’s talk about the procedure really quick. I actually found some fantastic information from Spine Health. It’s on spinehealth.com and there is a link that you can use from this answer sheet. One of the things that you need to know about ALIF procedures, and again we shortened everything down to an abbreviation because nobody wants to have to say Anterior Lumbar Interbody Fusion, but ultimately what you’re doing is you’re fusing the vertebrae together because it has wear and tear on it, and that cushioning that’s between the vertebrae has worn out, and so they have pain.

Now that we know that that’s what is being done, there are two approaches that are used, and when you’re doing PCS you need to know the approach. And commonly there’s an anterior, or in the front they actually go through the abdominal wall, and go to the spine. They actually move aside the abdominal contents because actually all of your intestines and all those organs are in a sac, so they just bypass that, pull that out to the side, and then they go right into the spine.

VIDEO: ICD-10-PCS Code for ALIF (Anterior Lumbar Interbody Fusion Procedure) 

Or they could do a posterior fusion, but really they like to go in from the front because that’s where the damage usually is the front of the vertebrae and then anterior, they’ll go in and theycould put pins and do some other things. I’ve got some more visuals for you, but know that they can do an anterior and posterior fusion, so that’s going to make picking the proper PCS code important.

In the case when there’s not a lot of stability, this is actually a type of degenerative disk disease, so when you’re coding out for regular ICD-10 code that’s probably what you’re dealing with but for the ALIF procedure itself, the first thing is anterior or posterior fusion, or both.

As we scroll down and we know now what the procedure is, let’s break it down because PCS is actually brilliant the way it’s set up. To me, it’s a lot easier to use than volume 3. Once you get the hang of it, PCS is like taking those little wooden blocks that your children played with, with the letters and stuff, and just putting the blocks in order to write a code to tell a story. It’s so much fun.

The first thing you need to know is: What is operation? What is the procedure that’s being done? Well, we’re doing a fusion. When you go to look in the index of the PCS, you’re going to look under fusion, you’re actually going to fuse something together. Then they want to know what body system are you working with? This is considered a joint, a lot of people don’t realize that. Then you have to know if it’s a body system it’s considered a joint. What is it? Well, you have five lumbar vertebrae and then you have five sacral vertebrae, they’re actually fused together, but they count out as five. They start 1, 2, 3, 4, 5 lumbar and then it goes to the sacrum 1, 2, 3, 4, 5, but they’re fused.

That’s important when you go to take care of making the code, putting all the pieces together, not necessarily for PCS; where is L5 or whatever. But asking yourself where you’re at in the joint. Then you need to know if there’s going to be a device used, and there’s usually a device, so three choices of the devices are Interbody Fusion Device, where they actually go in and put a cage, a titanium cage that hold that vertebra in place.

Then they can also take a bone graft from the iliac crest of the pelvis, which is like the heart-shaped part of the pelvis – you need to know the bones of the body if you’re doing coding – so that iliac crest is, how they can tell if it’s a male or female skeleton by the shape. They actually tap in there, pull out part of the pieces of the pelvis and they graft in that substitute tissue to make new bone fusion, and then they also have something that’s not from the body. “Auto” means that it’s coming from your body, and then if it’s not from your body they’re getting it from someplace else.

Here we’re showing the lumbar and sacral joints, I guess you can say part of the vertebra, and you see where the facets are. We’re dealing with this procedure, like I said they’re come in from the front, so see the blue areas which is that it says it’s the intervertebral disk area, and that’s the part that’s deteriorated and being squished. Then the spine, all the nerves and stuff are involved here, but see, where it says the facet of the joint, that’s where you’re getting that these are joints.

This is a picture of the lumbar and the sacral area that we were just talking about. They’re going to come in from the front which would be the blue area that you’re seeing. It was very difficult to find a picture that we could actually get permission to use, but this was absolutely perfect to show you what they do. We know what the basis of our code is, let’s look at how this will be coded, so if you have a PCS manual, and you can keep up with me, you can follow along. The first thing we’re going to be is in section 0 and that’s Medical & Surgical, so think of that as your first little wooden block then they want to know what –

Chandra: Zero.

Alicia: Yes, thank you. This is another thing, when you’re dealing with ICD-10 it’s always a good idea to strikethrough 0’s to keep them in shape. Thank you, Chandra. What body system is our next little block and that would be an “S” for lower joint and then the root operation is going to be a fusion, and as you’re looking in the table to fill in these blocks that would be a “G.”

The next portion is to go into more depth of what actual body part are we dealing with? The one that I choose to just simplify everything, Lumbar Vertebral Joints two or more. That’s a “1” but there are other choices that you can use, so we’re going with that one. Then, the approach. It would be open because what they do is they literally open you up, pull everything to the side and go into the spine like we saw in that picture towards the little blue areas, that’s the front of the anterior part of the spine, and then where you see the little knobs that’s the posterior part of the spine.

What I did was I actually pulled out a Find-A-Code from this point. The code that I picked so that we can have an example was 0SG10, that’s where we’re showing right there that we’ve got as our basis of our code. But then we have some other choices that we’ve got to make. This is where the options open up and this is where a lot of the confusion can happen, and as you’re more familiar with the procedures and how the terminology is used and the different ways they do these procedures, this is where this part of the code starts to pop for you.

If we use this 0SG1070 you’ve got a fusion of 2 or more Lumbar Vertebral Joints with this tissue from your own body substitute. Anterior Approach (that means from the front), Anterior Column, Open Approach; that’s the 70. This was again, so much information that I wanted you to get to see, so it’s small.

Just really quickly, look at all of your options though. We go from 70 all the way down to a ZJ, which is fusion of 2-4 lumbar joints post approach. Anyway, you may be able to see it better than I have, I would have to put my glasses back on. See all of the options that they’re giving you here off of this one code. Don’t let this freak you out though because it’s all right there in the manual. What you have to do is just pick the right block piece to go to fill out this code and it’s going to be in your terminology that you find in the procedure itself, in the op report.

Again, when you get to a new base code, like I said before the 70 then you get another list of these. Did I write something else under after that? I think maybe. Then I said, “here is an example,” we were talking about lumbar, but what if they also did part of the sacrum then that would be 0SG as that foundation part of the code with 504Z, which would – again I just pulled this out as one of them there are several options, but here we’re doing a fusion, part of the sacrum, and it’s an internal fixation device open approach. That’s another option that’s given to you.

Its’ very fascinating, it’s a lot of fun to work with PCS, but until you get in there and start doing it, those little blocks can get very confusing. The hardest part though is, by far, figuring out what the first term to look up is, and it’s a fusion for this particular PCS code, and then the blocks all start to fall into place literally for you. This was a fun one.

Related ICD-10-PCS Code for ALIF Posts:

ICD-10-PCS Code for ALIF (Anterior Lumbar Interbody Fusion Procedure)

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Modifier 24 — E/M During Post-Op Period (GSP) http://www.cco.us/modifier-24-em-post-op-period/ http://www.cco.us/modifier-24-em-post-op-period/#respond Thu, 26 May 2016 13:53:16 +0000 http://www.cco.us/?p=21148 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: “Provider billed with a modifier 24 with a diagnosis code for trigger thumb only. Does this justify modifier 24? Is it significant enough to warrant payment of E/M within the global period?” A: Really what this question came down to is, what do we have to have to use […]

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Q: “Provider billed with a modifier 24 with a diagnosis code for trigger thumb only. Does this justify modifier 24? Is it significant enough to warrant payment of E/M within the global period?”

A: Really what this question came down to is, what do we have to have to use that modifier 24? How do we clearly indicate in the documentation that the service is unrelated to the surgery that they had, that they’re coming in for?

The answer to this question is: the documentation is key. The scenario that they gave, we see that the surgery that the patient had was for her shoulder, they had a shoulder replacement, or a repair of some sort. While they were in for their postop visit they said, “Oh by the way, I have this trigger thumb that…” if you don’t know what a trigger thumb is, their thumb gets stuck like this; you could get trigger finger, and all those types of things.

This patient said, “I have a trigger thumb that you treated before and it’s starting to give me trouble again,” so the physician put trigger thumb down as their E/M diagnosis for an unrelated encounter, put the E/M code on, and put a 24 modifier on it. Said, “OK I want to send it out separate from their post op,” and the question that the coder had was “Alright, is that enough? Is just the separate diagnosis alone?” My answer is a separate diagnosis alone is not sufficient. What it comes down to is the documentation.

VIDEO: Modifier 24 — E/M During Post-Op Period (GSP)

The thing that I recommend using is what I call a “bucket analogy” and this is the way that E/M and separately reportable things were taught to me when I first started working as auditor, and looking at some of these things. The physician that I worked under said, “OK. If you have a patient coming in for a postoperative visit and you’re trying to figure out if something is reportable in addition to that postop visit. Take their documentation, make a copy of it and highlight everything that’s related to the postoperative care.”

Everything that they would normally do as routine workup postop; everything they checked the history around it and all of that. If it’s not related to that surgical care, don’t highlight it. Then you look at everything you have left that’s not highlight, or some people highlight it in a different color, and see if you have enough to justify a separate E/M service. It’s two buckets because if you put it in the postop bucket you can’t use it for the separately reportable. You can’t double dip; it has to be completely separate.

Most of the time what I find is my doctors that are doing this, they have tons of stuff that’s related to the postop care, and they might have a couple of things that are separately reportable related specifically just you, in this case the trigger finger. Oftentimes, they have a hard time getting above a 99212 or a 99213 for an established patient in the office with that modifier-24, but it all comes down to the documentation. Yes, a separate diagnosis is going to support it from a medical necessity perspective. They’re not here for their shoulder, they’re here for their thumb now, so that supports me from a medical necessity perspective, but you’ve got to have the documentation to back it up to show that you went above and beyond what you normally would have done for the postop on the shoulder.

If we can scroll on I actually put in what this person that send in the question said the documentation contained. What I did is I put a strikethrough through the things that in my opinion would have been related to the shoulder. They’re here 60 days postop, they’re also doing their physical therapy, but oh they mentioned that they have trigger thumb injected 16 months ago, and it’s starting to bug her. That don’t have anything to do with the shoulder.

We didn’t examine the shoulder, that’s all postop, but the triggering is noted in the right thumb, so we did look at the thumb. And we scroll down a little bit farther they go on, and say what they told them to do in follow-up for the shoulder, and they’re here for the rotator cuff repair, and here’s what we did. We did a trigger thumb injection 16 months ago, she’s still off work, that’s all related to the shoulder, and then we said, OK we gave her options for what she could do for this time. We gave her a prescription for medication, we told her to come back in a month.

My only issue here is the Daypro that they prescribed. He doesn’t really make it clear is that for the thumb or the shoulder? It’s going to be for both. Well, he has already prescribed it for the shoulder; if so, do we count it, or do we not? It comes down to looking at this, and if whether we count that prescription or not, basically because we say we’re going to do a cortisone injection if she comes back, it’s a new problem. At most, I probably would have been able to get a 99212 out of this one because we only looked at one body system, and we only had one element in history, and you’re not going to get very high in your level of E/M but it all comes down to the documentation. So the diagnosis alone is not enough to use that modifier-24 to unbundle something from a global surgical package, so that’s a recap of the question that came through.

Related Modifier 24 — E/M During Post-Op Period (GSP) Posts:

Modifier 24 — E/M During Post-Op Period (GSP)

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Coding Aftercare — Can a Z code be a Primary / Admitting Dx? http://www.cco.us/coding-aftercare-can-a-z-code-be-a-primary-admitting-dx/ http://www.cco.us/coding-aftercare-can-a-z-code-be-a-primary-admitting-dx/#respond Mon, 23 May 2016 10:08:43 +0000 http://www.cco.us/?p=21125 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 a Z code be a Primary / Admitting Dx? “Can I use a Z code as a primary/first listed diagnosis? I am struggling with coding aftercare especially.” A: The answer is yes. You can use a Z code for a first listed diagnosis. The thing to understand and […]

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Q: Can a Z code be a Primary / Admitting Dx? “Can I use a Z code as a primary/first listed diagnosis? I am struggling with coding aftercare especially.”

A: The answer is yes. You can use a Z code for a first listed diagnosis. The thing to understand and this second question that came in was that they were getting confused going from ICD-9 to ICD-10 and that not all the codes translate and the thing to remember is that ICD-9 doesn’t translate into ICD-10 perfectly. Not always. But one code that is fun to remember is the Z00.00 code which I like to fondly refer to as the ZOO code and that is for an encounter for general adult medical examination without abnormal findings. Or you can use this for an encounter for adult health check-up, it’s not otherwise specified.

But remember, when you have this code, the Z00 code, that it is for no abnormal findings when they come in. That’s the key there. Then, there is an additional code that isn’t Z00 there after the point, you’re going to have other characters for abnormal findings. That wasn’t the intent when they came in, this particular encounter code, but they do find something.

If you want to look at these in your manuals, in your ICD-10 manuals, if any of you have them with you, I’m sure you all carry them around with you wherever you go. The guidelines for this particular code is section 1; C.21.c13. Looking at 13, it says routine and administrative examinations. This is a lot of information and so I actually made it in a smaller font because we really don’t have to go over all of it; you can go over it in your own leisure here now that you know where it’s at.

What it is expressing is that it’s for a general check-up and this could be for an administrative purpose or maybe even for pre-employment physical. When you go in for a pre-employment physical, they don’t expect to find that you have diabetes or hypertension, so it would be without any abnormal findings. Or if they go in and they say, “Hey, you’ve got hypertension,” then that would be with abnormal findings. But, this is a code that you are going to use in such cases where a diagnosis is found during a routine exam, what you should do is use the diagnosis or if the condition is discovered, it should be coded in addition to this Z code. That’s the basis of how this particular Z code works, and it’s a common first-listed diagnosis code.

VIDEO: Coding Aftercare — Can a Z code be a Primary / Admitting Dx?

Let’s look at how this is found also for encounters for general medical examinations with abnormal findings. The difference is that the last character is not going to be “0” it is going to be different and there are options and that’s why you’ll see a little hyphen there stating there’s options. If you have an abnormal finding, just remember that the Z00 code is with abnormal findings and without abnormal findings.

If you have abnormal findings, what should you do? Well, it says right here in this guideline. Should a general medical exam result in an abnormal finding, the code for general medical examination with abnormal findings should be assigned (just like we did before)diagnosis. A secondary code for the abnormal finding should also be coded.

You come in for your pre-employment exam and they say, “Hey, you’ve got hypertension,” then you will have with abnormal findings and hypertension. That is what could happen with this common Z code.

As we move along, what other Z codes can be used? There’s actually quite a few. Don’t forget, this is where the guidelines are but let’s look at this particular guideline that we looked at before, but look at 16. As you’re looking at your guidelines, it keeps indenting at an outline; 16 state a Z code that may only be principal/first-listed diagnosis. What are the guidelines there? What I did was I actually went in to Find-A-Code and I took all of the Z codes down to the smallest level before the decimal and gave you a list of what the possible options are of codes that could be principal or first listed. I’m assuming most encoders do this for you, but Find-A-Code does.

I’m not going to read all of those because actually there’s more than a dozen, but the main ones, the one that always pops into my head is the Z00 codes. Then, as you look at some of these, the Z01 is for a special examination without complaint, suspected or reported diagnosis; administrative examination is Z02. As we scroll down let’s jump and look at some of these others here.

This would make sense; look we’ve got Z31.84 is encounter for fertility preservation procedure. Below that, we’ve got supervision of normal pregnancy. Because when you’re in a pregnancy, you start out coming in every month and then you come in every two weeks and then it becomes weekly. And what code is the principal diagnosis for that? It’s a Z34. Your encounter is supervision of this normal pregnancy. Then, it goes on for postpartum care as well.

Let’s see, they’ve got plastic and reconstructive surgery. These are things that are going to take multiple visits; however, you’re coming in mainly for the same thing unless you have a complication that is involved.

One of the ones that I forget that exist is Z52 – donors of organs and tissues. This always made me think of a friend of mine, her brother had had multiple kidney transplants and siblings were not always a good match. Now, as we’ve advanced with that, my friend, his sister is going to be a match, so she’s prepping to be a donor for him. Ultimately, this Z52 would fall into that.

Then we get down to the last one, Z99.12 – encounter for respirator [ventilator] dependence during power failure. So, they’ve got everything. Anything that you can think of could possibly be in there. Again, I found this off of Find-A-Code when I looked up the Z codes and you’re able to go back and look at a list of them in order.

It was mentioned, the question about aftercare. I want to highlight that quickly. If you’ve got the category Z00 – Z99 and these codes, why do we have them? There are for occasions when circumstances other than a disease, injury, or external cause classifiable to categories A00-Y89 (huge range) are recorded as diagnoses or problems. This is going to be stated at least in Find-A-Code; on every Z code this is going to be a statement.

Two main ways this arises when you’re looking at the Z codes, and the first one it’s when a person may or may not be sick when they come in; thus, when you have a person that’s coming in because they’re pregnant, they’re getting their routine care, they’re not sick and yet it’s routine care for this pregnancy. See how that works? Then, it goes on to explain more about the donor tissue and some other things like prophylactic vaccinations, immunizations; if you bring your child in to be vaccinated. Or, maybe you’re going in to have a flu shot and now they have a pneumonia shot. That would fall under that category.

The second part of that would be when some circumstances or problem is present which

influences the person’s health but is not in itself currently an illness or injury. Again, that’s the pregnancy that is in there. This is straight out of the guidelines and that’s all listed in Find-A-Code. I believe that’s about it. Again, when you get your transcript, those links on Find-A-Code there, Find-A-Code has a free version which you should be able to pull those up.

But Z codes, if you’re coming in for follow up, it mostly depends on why you’re doing the follow up. If there is a diagnosis, if they’ve fractured their hip and they’re coming in for follow up of that in a skilled facility, it’s follow-up for the fracture care, then you’re looking at a diagnosis code other than a Z code. Don’t forget that you’ve got the Z codes available to you, they can be first listed if they fall in that list; however, if there is a diagnosis that is the reason they’re being treated, of course that’s going to go as the first listed diagnosis. Z codes are a lot of fun, guys.

Related Coding Aftercare Z Code Posts:

Coding Aftercare — Can a Z code be a Primary / Admitting Dx?

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Review of X Modifiers (EPSU) | Modifier 59 Alternatives http://www.cco.us/review-of-x-modifiers-epsu-modifier-59-alternatives/ http://www.cco.us/review-of-x-modifiers-epsu-modifier-59-alternatives/#comments Mon, 23 May 2016 01:12:32 +0000 http://www.cco.us/?p=21132 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: Review of X Modifiers (EPSU) (modifier 59 alternatives) — “Can you review the X modifiers implemented January 1, 2015?” A: Honestly, there really hasn’t been that much of a change. In fact, CMS Medicare hasn’t given us much feedback or examples that consultants and coders have been looking for. […]

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Q: Review of X Modifiers (EPSU) (modifier 59 alternatives) — “Can you review the X modifiers implemented January 1, 2015?”

A: Honestly, there really hasn’t been that much of a change. In fact, CMS Medicare hasn’t given us much feedback or examples that consultants and coders have been looking for. But these new modifiers, XE, XP, XS and XU were created to define subsets of modifier 59 which describes Distinct Procedural Services. That just basically means that Medicare had overpaid 40% of claims because of misuse of modifier 59 so they created these very explicit X codes. But I have a feeling that ICD-10 implementation took more of their time and this has been put on the back burner because we really don’t have that much more and they haven’t even come forward with examples to help clarify things.

  • XE – modifier is Separate Encounter for a Service That’s Distinct because it occurred during a Separate Encounter on the same day.

  • XS – Separate Structure, also a Distinct service because it was performed on a Separate Organ/Structure.

  • XP – Separate Practitioner and that represents a Service that is Distinct because it was Performed by a Different Practitioner.

  • XU – Unusual Non-Overlapping Service is the Use of a Service that is Distinct because it does Not Overlap Usual Components little bit ambiguous to me.

Any of these codes whether it’s -59 of the X modifiers documentation must support a different session, surgery or procedure, different sites or organ systems, or any encounters not ordinarily performed on the same day.

Some of the facts are modifiers 59 and X modifiers are never to be appended to an E/M code, only procedures or services. CMS will continue to recognize modifier 59 in many instances and be selective when requiring the X modifiers where specific procedure codes represent a higher risk for coding abuse or CMS over payment. That, I have not seen happen but I would anticipate somewhere in the near future it will.

VIDEO: Review of X Modifiers (EPSU) | Modifier 59 Alternatives

You only want to use modifiers if they adhere to the National Correct Coding Initiative status indicators. That is “1” meaning that the code can be billed with modifiers 59, X (EPSU) on the Column 2 Code. “0” status indicator means it can never be billed together. Basically, that is, is that they are used on the second and additional procedures on the claim form.

The very first procedure on the claim form would never, ever show a modifier -59 or X code. It’s always the lesser valued procedure. With Column 2 procedure codes, they are listed in the National Correct Coding Initiative. If it says “1” then you can add the modifier -59 or any of the X modifiers to the second column procedure code. And you also would use them if there was no other acceptable modifier and I’ll show that as we move forward, what that would mean.

You never want to code a modifier 59 and an X modifier on the same procedure code and on the same date of service on a claim form. That’s not CMS’ rules. I happened to see some blurb on a Blue Shield on one of the Carolinas and it said you should have them both together. We’re focusing on CMS, but I cannot stress enough that if you venture forth into these other payers, make sure you know what the guidelines are.

If a more appropriate modifier can be used opposed to a 59 of the X modifiers, by all means use it. In other words, if a modifier -50 is more appropriate, you would use that as a bilateral instead of listing the procedure twice with the modifier -59 or an X on the second procedure. XE (Separate Encounter) is exactly that. It’s distinct because it occurred during a separate encounter on the same date of service. I extracted different examples from different payor sites from Medicare and just different places to just give you an example.

A physician performs a cardiovascular stress test (93015) and also a rhythm ECG (93040) at a different encounter on the same day. What I did is I took these two procedure codes and I use SuperCoder.com and I entered them into the system. What came forward was the CCI validation saying that the code 93040 which is the ECG is a column 2 code for 93015. If it was appropriate, you could add a modifier to code 93040. I’m sure the other softwares do it as well, but with SuperCoder it will tell you with an asterisk, you would attach a modifier X to the 93040.

If you move down, you’ll see this is what they give you on SuperCoder. These are all the related modifiers so that if for any reason any one of these whether it’s left, right, TA or T1 for a toe, whatever, that takes precedence. But in this case, this the XE would work so you would use 93015 first and then the second column, code 93040-XE.

The next example is the XP and this is basically very basic. It’s two services/procedures performed by two different practitioners performed by two different practitioners on the same date of service in a group using the same tax id#. It does not have to be at the same encounter; one could be in the morning, one in the afternoon and they don’t even have to be the same specialty, but they can be.

XS is the Separate Structure, which is pretty self-explanatory and that is the service that is distinct because it was performed on a separate organ or structure. As an example, a complex repair of the forehead measuring 2.5 cm (13131) as well as a complicated incision and removal of a foreign body, subcutaneous tissue in the arm.

When I entered these two CPT codes, the 13131 and the 10121, SuperCoder came out with a CCI saying that 13131 is a Column II code for 10121, and you would add the modifier to the 13131, the XS modifier and then you can just see it as we move up, you can see the example. The 10121, and then you would append the 13131 XS.

Again, if any of these other codes apply, if they happen to apply, you could use that instead of the XS but this is definitely a good example of how that would work.

XU (Unusual Non-Overlapping Service) is a service that is distinct because it does not overlap usual components of the main service. I’ll tell you, I see so many examples and none of them make sense to me, so I use this one. I don’t know, laparoscopy, surgical ablation, of one or more liver tumor(s) radiofrequency (47370). And, Ultrasonic Guidance for needle placement (e.g. biopsy, aspiration, injection, localized device), imaging supervision and interpretation for Phlebitis and thrombophlebitis of superficial vessels of right lower extremity (76942).

When I put these codes in, 76942 as the column 2 code for 47370, and it did say to append it to the 76942. But I wanted to stress that one of the things that I did see that jumped out at me and I saw two similar examples of this, is that if the 76942 was related to the laparoscopic liver tumor ablation, no modifier would have been required, you would add the modifier if it was unrelated to the laparoscopic liver tumor ablation.

Honestly, everyone that gave these examples with XU in particular have complained that Medicare has not given one example to allow consultants or anyone to really get a handle on what these means, so I apologize if it’s not coming across clear. But I spent a lot of time trying to find something that was clear cut on this particular modifier. Since I had two similar, I used this one as an example but I’m waiting and the day that I see it, I’ll make sure that it shows up on the webinar even if we touched on that XU; but for now, that’s really the best that I could do.

Lastly, I had just one final thing, is something to think about when you’re actually coding and using these X modifiers. That if a physician excises 2 cysts on the left breast on the same day, would you use a modifier 59? The answer would be no, because the CPT code is for a male or female, one or more lesions, and there’s no distinct modifier required because it’s in the description of the CPT.

However, if it was 2 cysts on the left and right breast on the same day, would we use an XS modifier -50 bilateral or left or right? Because that is two structures, the left breast and the right breast; but in this case as I had mentioned earlier, this modifier -50 would take precedence over those XS because in the guidelines it states that that code, you would report a modifier -50 for bilateral cases and it’s right there in the guidelines of CPT.

In summary, coders have to remain diligent in their quest for correct use of these X modifiers. Many payers and Medicare contractors do not offer solutions nor do they accept the X Modifier in certain or all cases. I had mentioned one of the Blue Shields in the Carolinas said they wanted the 59 with an XS on the same line. And coders who had asked about my examples, the last time I presented this a year ago, in Massachusetts, my Blue Shield plan scenario that I offered was actually accurate, but in Medicare and in other cases it wasn’t and that’s why we came back and we visited the X codes because there really has a lot of different questions out there and Medicare has yet to come forward and really help coders and other companies understand better. For now, we just do our homework and when things really start happening, we’ll be able to address it again.

Review of X Modifiers (EPSU) Posts:

Review of X Modifiers (EPSU) | Modifer 59 alternatives

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Modifiers, Global Surgical Package and Bundled Services Explained http://www.cco.us/modifiers-global-surgical-package-bundled-services-explained/ http://www.cco.us/modifiers-global-surgical-package-bundled-services-explained/#respond Fri, 20 May 2016 09:21:02 +0000 http://www.cco.us/?p=21120 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 you explain a little bit about modifiers, global surgical package and bundled services?” A: There’s a lot of information in one question. When we start to talk about these, a lot of times you’re going to hear the phrases “global surgical package” and “bundled services.” When you hear […]

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Q: “Can you explain a little bit about modifiers, global surgical package and bundled services?”

A: There’s a lot of information in one question. When we start to talk about these, a lot of times you’re going to hear the phrases “global surgical package” and “bundled services.” When you hear those things, basically what’s happening is the insurance company is wrapping all of the services related to a specific procedure into the payment for that one CPT code. While there may be several CPT codes that could be broken up to represent the different pieces, they say bill us the big one and we’re going to bundle everything in there. Sometimes things are bundled and sometimes they’re bundled into what we call a global surgical package.

Now, there are different types of surgical packages. We’ve got major surgical packages and your minor surgical packages. Those all differ based on the number of global service days. Think about the procedures that they’re having performed. A patient has a major surgical procedure. Think about anything from restoring an open fracture, lining the bone back up, closing that was created when the bone popped through the skin, to removing organs.

VIDEO: Modifiers, Global Surgical Package and Bundled Services Explained

Maybe the patient had a hysterectomy. Those are major surgeries. They oftentimes take a long period of time to heal well beyond ten days and they have what’s called the 90-day global package, which means for 90 days everything that that surgeon does is bundled in to that major surgical package. All those follow-up visits, anything that’s related to the surgery gets bundled up. That’s a shortened version of what a major surgical package is.

I did include some links. I included the links to the Medicare website that show you the difference between major and minor. We talked about major being major, 90 days; minor is 10 days, it can actually be zero days or ten days. Again, those are going to be procedures that don’t take quite as long to heal, and the difference between a zero and 10 days is going to be what all is being performed. Things like scopes. Think about colonoscopy, those usually have a zero-day global because you’re only going to see the patient that one day and everything you do that one day is going to be included. That’s considered a zero day global.

Maybe you have sutures and a laceration, that’s probably going to have a 10-day global period because that skin has to heal and you’ve got to see the patient back in 7-10 days to remove those sutures. That’s all considered part of that surgical procedure of repairing the laceration.

The other type of surgical package that we have and it’s not really a surgical package, but it’s another type of package that we see and that’s the obstetrical package. A lot of people forget that this is another packaging or another bundling. When we talk about major surgery and minor surgery, we were talking about a procedure that was being performed and all the services associated with it were lumped in. Talk about the obstetrical package, we’re talking about a patient who’s pregnant and all of the care related to the pregnancy is lumped in to what we call their obstetric package.

Billing for an obstetric package is a little bit different and each carrier has different rules. The link that I gave you here is actually a link to ACOG (The American Congress of Obstetricians and Gynecologists), a lot of the stuff on their site is pay only. You have to be a member to get it and you have to be a physician to get to it. This is one of the free articles that they put out there.

They actually talk about when that package begins, and it begins when the confirmation of pregnancy is documented. It bundles all of these things together, and you’re going to see if you look at the CPT codes specific to the OB package, that typically that OB package includes 13 antepartum visits, anything before the baby is born. It includes labor and delivery, and it includes the follow-up care with mom. You’re probably going to see her for a day or two while she’s in the hospital before you discharge her and let her go home. Then you’re going to see her back six weeks after delivery to make sure she’s healed OK. Babies acclimating to the household, mom doesn’t have any major postpartum issues that we need to deal with. All of that. That’s another type of package that they’ve bundled that payment together.

Surgical packages were one piece, bundling is another thing. Surgical package includes bundled services, but sometimes bundling is simply saying this procedure is part of this bigger procedure. Maybe when I go in and let’s say I do a partial colectomy, if you go in and do a partial colectomy you’re removing part of the colon. Depending on which part you remove, there may be a specific part to say, “Oh, I did just the sigmoid colon,” or “I did just the transverse colon.” But if you did multiple pieces, a larger code that you can use in place of the one that says I did this piece and this piece. That’s holy cow bundle. Says you can’t bill them separately.

Now, sometimes they bundle things together that are usually performed together and if they’re performed separately or they’re not interrelated to one another, that’s where your modifiers come in. Modifiers are used to unbundle packages. It’s to unbundle surgical packages, to unbundle the obstetric package, and to unbundle bundled procedures.

I do give you the link there to NCCI Edits on the Medicare website. If you’re not familiar with NCCI, this is the National Correct Coding Initiative. This is what Medicare uses as their basis for determining which procedures are bundled with one another; which ones can be billed together, which ones can’t be billed together and which ones can be billed together if we use a modifier.

This is actually a nifty little document that takes you through how to use the database of NCCI Edits, what the different pieces mean, because when you put in two codes together, you’re going to get them to get to show up one right next to the other. They explained what a column 1 code is, what a column 2 code is; and you’ve got little numbers next to it, a 0, a 1, a 9, and it explains to you if it has a zero there, that means you can’t ever bill those two procedures together. They’re mutually exclusive; it’s one or the other. If it’s got a “1” it means “Oh, well, sometimes they go together,” and you might need a modifier to unbundle that. That sort of thing.

They give you, like I said here an example of the difference. If you have a “0” you cannot put a modifier on. It’s not allowed, you can’t unbundle them, it’s not going to happen. A “1” means you can put a modifier on it if it’s appropriate. The “9” means a modifier is not really applicable, it doesn’t have anything to do with that, so they take you through all of the different pieces.

If you go back to the answer sheet, we’re going to talk about which modifiers affect bundling in the packages. There are lots of different modifiers that may unbundle certain services. The first two I talked about are modifiers 24 and 25; 24 and 25 are E/M modifiers. They can only go in your evaluation and management code. These two cannot ever go on a surgical procedure. This go on the evaluation and management.

Modifier-24 says, “Hey, the patient was here but I saw him for something completely unrelated to the surgery they had done.” We see this a lot in family practice. Maybe we have a patient who is pregnant, and she comes in for something unrelated to the pregnancy. Maybe she has an ankle sprain. It has nothing to do with the fact that she’s pregnant. We’re not seeing her for the pregnancy, that she sees her OB for the pregnancy. We’re seeing her follow-up on her ankle sprain.

Oftentimes that’s a modifier-24 and states unrelated, totally separate. Modifier-25 is used for some of those minor surgical procedures that it’s decided we’re going to do it today after we’ve already seen them for E/M. They came in for an office visit we didn’t know we were going to need to do a minor procedure. Minor procedure could be anything from a lesion removal, a laceration repair; those types of things. Again, the documentation has to be clear that it was separate, but a -25 says “Hey, it’s separate and we could pull that E/M out separately.”

The last five modifiers are all surgical modifiers; these would go on your procedure code. This usually fall in the 10,000 to 60,000 series of CPT. These modifiers, the first three 54, 55, and 56 are used to break up the surgical package. Maybe your physician has the surgeon but here she’s only doing part of the care. Maybe somebody else did the preop and the postop, they’re only doing the surgery itself. They bill that CPT code with a 54 on there, so I just did the surgery. That’s all I need paid for, don’t pay me for the preop and the postop.

If they only did the postop they’re only seeing the patient after surgery for all that followup you use a 55. If they only did the preop you use the 56. Now it’s important to say that these are the coding rules. Every payor is a little bit different. For example, Medicare really doesn’t like that preop modifier and doesn’t recognize it in a lot of situations, so you need to be familiar with the carrier rules if you’re using these from a billing prospective.

Modifiers 57 and 59 are two additional ones that you see. 57 says that we made the decision for surgery today. 57 is also an E/M modifier but then on the E/M code to say that the service we provided today is separately reportable from the surgery because we’re going to do surgery today or tomorrow, but we just figured out we needed to do it, and decided to do it today, and the doctor has to be clear to say we made that decision during today’s encounter.

Modifier 59 says it’s a Distinct Procedural Service. This is what unbundles two surgical procedures from one another and this is one of the biggest abused modifiers. People think, “Oh, I get an NCCI Edit, it says these two don’t go together and I have “1” that says I can put a modifier on it.” Just because you can doesn’t mean you should. They have to be separate. There has to be something different to use that 59.

Oftentimes it’s a different surgical site, maybe it was an arm and a leg, maybe it’s a different surgical session. We took him to surgery in the morning, we took him to a different surgery in the afternoon, but there’s got to be some distinct service there. There’s got to be a separate piece before you blow those apart.

Just to recap, global surgical packages could be either a major surgery, a minor surgery, or an obstetric package and those bundled together payment for the type of procedure the patient received. Bundling is not limited just to packages, sometimes CPT codes, one CPT code is bundled into another because it’s a more extensive CPT code, and modifiers are used to break apart those packages, or those bundled services, so that’s a synopsis of those three different concepts.

Related Modifiers, Global Surgical Package and Bundled Services Posts:

Modifiers, Global Surgical Package and Bundled Services Explained

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Chiropractic Billing vs. Medical Billing http://www.cco.us/chiropractic-billing-vs-medical-billing/ http://www.cco.us/chiropractic-billing-vs-medical-billing/#respond Tue, 17 May 2016 09:42:15 +0000 http://www.cco.us/?p=21068 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: Chiropractic Billing vs Medical Billing – “I recently switched from coding & billing with a 97.5% collection rate to billing for a chiropractic group. Now, 50% of my claims are being denied – particularly with Medicare, and I’m not doing anything differently than I did at my prior job.” Jo-Anne — […]

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Q: Chiropractic Billing vs Medical Billing – “I recently switched from coding & billing with a 97.5% collection rate to billing for a chiropractic group. Now, 50% of my claims are being denied – particularly with Medicare, and I’m not doing anything differently than I did at my prior job.”

Jo-Anne — A: Chiropractic billing is very, very different than medical billing for a physician, and the most important task at hand is to research each payer rule for chiropractic, and that goes for other specialties, too, like, podiatry and so forth.

There are limitations with some specialties. Coding should not be an issue with this specialty but knowledge of the guidelines is imperative. Many health insurance plans do not offer chiropractic benefits and other plans offer this as an additional coverage for a fee for patients, but please note that anyone on Medicare, Medicare has stringent guidelines, and offers minimal coverage for services provided.

What does Medicare pay for? Chiropractic care has limited coverage. Medicare covers manipulations only of the spine if medically necessary to correct a subluxation. Office visits are not covered. X-Rays are not covered. Manipulation of extremities, hands and feet are not covered. A subluxation which is an incomplete or partial dislocation of the vertebrae must be the primary diagnosis always followed by a secondary neuromusculoskeletal condition.

VIDEO: Chiropractic Billing vs. Medical Billing

The subluxation must be demonstrated in the patient documentation in the event of an audit, and it, by either an x-ray, or a physical exam, and the specific vertebrae must be documented. Chiropractic manipulation codes must be appended with a modifier AT to indicate the care is active or corrective. Omission of this modifier will result in an automatic denial with no patient responsibility.

That’s very important, but again this is Medicare, and if you’re not using that modifier or you’re billing for an office visit like you would for a doctor, or medical doctor that’s why your collections are so poor because it’s just very specific rules.

On the CMS-1500 Form, block 14 must have a date, and not necessarily a date of injury or first symptom, but the date of the first visit for the current episode. If the patient just came in that day to start her treatments, that would be the date of service. Block 19 must indicate an x-ray date if there was an x-ray taken and used to identify the subluxation.

There were only three codes that Medicare accepts for billing and that’s the 98940, which is 1-2 regions, 98941 3-4 regions of the spine, and 98942 for 5 regions of the spine. If you look in the CPT manual you’ll actually see a 98943 for extremities because I’m talking about Medicare, those are the only three that are accepted.

As far as Advanced Beneficiary Notices, all other services, the chiropractic with Medicare, such as exams, x-rays, therapies are not statutorily covered services when performed by a chiropractor, so therefore you’re not required to give your patients an ABN to sign. If a doctor, a chiropractic who gives out an ABN is strictly voluntary, and all the rules are chiropractic coverage, which is listed below here.

How Do Other Payers Reimburse for Chiropractic? You really have to visit your payers’ websites and search for the Chiropractic Billing Guidelines, and you also have to know your patient eligibility. Some Blue Shield plans will pay for an initial evaluation with a manipulation only. No massage, no heat, nothing. Subsequent visits for Blue Shield they may only pay for manipulation and a massage, but definitely no visit, so these are things that you’re billing like an office visit with the manipulation even as a subsequent that’s why you’re getting denied.

Other carriers will pay for an office visit, manipulation and a modality, but most of these plans do have limitations, so it is to your advantage to know them, so that may be the biggest reason is not understanding what the plans and the billing rules are for each one and why your collection is so low.

In terms of your accounts receivable of you saying that they are poor, just keep in mind that, number one, you want to collect your co-payments at the time of service because even if the insurance allows $57 for the service, the doctor may only receive $17 from the insurance company because the co-payment is 40.

If you’re not collecting that copayment, your receivables are just going to inflate, you really have to pay attention to the rules of chiropractic because it definitely is different than billing for any type of medical profession, so that’s probably why you’re down so much and your collection rate is so low. That’s it for chiropractic, and believe me I know my husband is one, so I see all the little things that go along with that, and it’s a pain.

Related Chiropractic Billing vs Medical Billing Posts:

Chiropractic Billing vs. Medical Billing

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May 2016 CCO Graduates and Exam Passers http://www.cco.us/may-2016-cco-graduates-and-exam-passers/ http://www.cco.us/may-2016-cco-graduates-and-exam-passers/#respond Mon, 16 May 2016 09:07:03 +0000 http://www.cco.us/?p=21084 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

“A goal is a dream with a deadline.” — Napoleon Hill To our new CCO graduates and CPC Exam Passers, congratulations! You have proven your determination, brains, and willingness to learn. We’re wishing you the best things in life. Here’s to new opportunities open to you with the certificate you now hold as proof of diligence, […]

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May 2016 CCO Graduates and Exam Passers

“A goal is a dream with a deadline.” — Napoleon Hill

To our new CCO graduates and CPC Exam Passers, congratulations! You have proven your determination, brains, and willingness to learn. We’re wishing you the best things in life. Here’s to new opportunities open to you with the certificate you now hold as proof of diligence, knowledge, and skills. You did it! Soar high and follow your dreams because the best is yet to come!!! BIG CONGRATS to:

  • Leslie Elliott – 03/19/2016 – Completed CPC Course (PBC)

  • Jessica Galley – 04/14/2016 – Completed CPC Course (PBC)

  • Janice Boylan – 04/02/2016 – Completed CPC Course (PBC)

  • Dawn Crothy – 03/26/2016 – Completed CPC Course (PBC)

  • Myrna Jackson – 05/03/2016 – Completed CPC Course (PBC)

  • Rockeisha Clarke – 05/09/2016 – Completed CPC Course (PBC)

  • Renee Holl – 05/10/2016 – Completed CPC Course (PBC)

  • Kathleen Vawter – 04/12/2016 – Completed CPC Blitz

  • Sandy Martin – 04/25/2016 – Completed CPC Blitz

  • Ashley Brown-Pacheco – 05/07/2016 – Completed CPC Blitz

  • Merlin Samson – 04/21/2016 – Completed CPC Practice Exam

May 2016 CCO Graduates and Exam Passers

Twelve (12) of our CCO graduates are among the 2016 COC and CPC Exam Passers. Huge congratulations to all of you!!! So proud of you on this great achievement. You dreamt, you planned, you believed, you worked hard, and you conquered. Congratulations for achieving this milestone. Get ready for a whole new adventure because another one starts as you venture on to achieve your dreams. Congratulations graduates, you aced your exams!!! BIG THUMBS UP to:

  • Anjee Brazelton – 04/19/2016 – Passed COC Exam

  • Leslie Elliott – 03/19/2016 – Passed CPC Exam

  • Janice Boylan – 04/02/2016 – Passed CPC Exam

  • Kathleen Vawter – 04/02/2016 – Passed CPC Exam

  • Jessica Galley – 04/14/2016 – Passed CPC Exam

  • Rockeisha Clarke – 05/09/2016 – Passed CPC Exam

  • Merlin Samson – 04/21/2016 – Passed CPC Exam

  • Dawn Crothy – 03/26/2016 – Passed CPC Exam

  • Sandy Martin – 04/25/2016 – Passed CPC Exam

  • Myrna Jackson – 05/03/2016 – Passed CPC Exam

  • Renee Holl – 05/10/2016 – Passed CPC Exam

  • Ashley Brown-Pacheco – 05/07/2016 – Passed CPC Exam

Related May 2016 CCO Graduates and Exam Passers:

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EM Codes 99201 99205 – EM Coding Question http://www.cco.us/em-codes-99201-99205-em-coding-question/ http://www.cco.us/em-codes-99201-99205-em-coding-question/#respond Sat, 14 May 2016 10:22:25 +0000 http://www.cco.us/?p=21064 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Q: EM Codes 99201 99205 –  “What E/M code should I use when a new patient comes in to the physician office and the doctor documents the 99201-99205 codes along with the preventive codes, or well visit codes? I believe the 99201-99205 would be appropriate even though the physician states […]

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Q: EM Codes 99201 99205 –  “What E/M code should I use when a new patient comes in to the physician office and the doctor documents the 99201-99205 codes along with the preventive codes, or well visit codes? I believe the 99201-99205 would be appropriate even though the physician states he did the well visit too.”

A: Basically, it should actually start with the reason for the visit, so did they schedule a well visit and then a problem was found during that visit, if that’s the case then the preventive visit would be really the main code you’d want to use, and then you’d have to decide if the work was significant enough to warrant a regular E/M, and if it was then you’d want to do modifier-25.

In this case, the questioner was specifically mentioning new patient codes, so maybe the patient is not sick, maybe they’re coming in to get established as a new patient, they just moved to the area. For me personally, I would still use the preventive visit codes, but you really want to go by how the payers want you to do it, but there’s no illness, and in my book if there’s no illness that’s a preventive visit.

If you scroll down a little bit more, I did a little grab of our coding manuals on preventive medicine, these are just some of the annotations that I’ve got in there. For Preventive Medicine I write asymptomatic patient, they’re not sick, and the guidelines tell us that these codes are based on age and risk, which is normally what you’re doing when you’re getting established and they’re running test and doing things that would be considered comprehensive in nature for your particular age. If it’s a well-baby visit they’re going to be doing all those pediatric test talking about immunizations and all that sort of thing.

VIDEO: EM Codes 99201 99205 – EM Coding Question

But if you notice the third paragraph down it says: “If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive service, and the problem or abnormality is significant enough,” that’s key, so I have that highlighted “to require additional work…” then it tells you to use the codes from the 99201-99215 range.

If it’s minor they’re saying, “just include and bundle it in.” If you scroll down a little bit more where I have it underlined, “an insignificant or trivial problem… should not be reported.” That’s how I would go about it. The question we’re saying that their physician wanted to code both – a new office visit and preventive – I don’t think that would fly with most payers. My colleagues can chime in if they agree or not, but I feel that that would be a preventive visit.

One recommendation in cases where you do have a preventive visit and you have what I call a problem-based, keep the notes separate because if you get audited and you have to send in documentation and you’ve got your preventive medicine visit and you’ve got your problem visit separately documented then you have a much better chance that both of them getting reimbursed. And, I’d like to say if you don’t have a HEM (history, exam, medical decision making) then you can’t bill an E/M, so if you don’t have something significant enough that it could even be written separately then you probably should just bundle it in with the preventive medicine code.

Related EM Codes 99201 99205 Posts:

EM Codes 99201 99205 - EM Coding Question

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Path and Lab 80300 80304 CPT Codes http://www.cco.us/path-lab-80300-80304-cpt-codes/ http://www.cco.us/path-lab-80300-80304-cpt-codes/#respond Fri, 13 May 2016 09:58:06 +0000 http://www.cco.us/?p=21049 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

Path and Lab 80300 80304 CPT Codes Laureen: Q: “Can you go over Path & Lab coding for Presumptive Drug Class Screening 80300 80304 CPT Codes?” A: This one, Ruth Sheets who’s on the CCO team prepared for us, so thank you Ruth, and she did a great job. She […]

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Path and Lab 80300 80304 CPT Codes

Laureen: Q: “Can you go over Path & Lab coding for Presumptive Drug Class Screening 80300 80304 CPT Codes?”

A: This one, Ruth Sheets who’s on the CCO team prepared for us, so thank you Ruth, and she did a great job. She gives really good visual aids and for those who have been following CCO for a while you know we’re visual teachers and learners, and so this falls right in line with it.

For this, let’s start with some key terms, and the beginning of your Path & Lab manual were these codes come they used to be a small little section, and now it’s pages and pages long, and it could be very overwhelming, but once you can get the terminology down and you understand how it’s divided up, it really isn’t as bad as it seems.

First of all, what is an Assay? It’s an analysis to determine the presence or the absence, or quantity of one or more components. Sometimes, they’re just looking to see, is it present in the person’s body, or they might want to know exactly how much is in the patient’s body.

The next two terms Quantitative and Qualitative, you’ll see a lot in the pathology section.

Quantitative is just how it sound, you’re adding it up. They want to know how much of a particular substance; whereas Qualitative is really, you’re trying to figure out, is it there, is it present, so looking to identify the existence of a particular substance.

VIDEO: Path and Lab 80300 80304 CPT codes

The next term that we wanted to find is the word presumptive, so that means you’re looking to identify the possible use or nonuse of a drug. That was a change in 2015. The CPT manual used to just say Qualitative for that, now they say Presumptive, and that’s what it means. They’re presuming there might be some drug use, and they’re going to go in and try through testing, and to figure out if that’s true. Whereas, definitive is they’re looking to identify an individual drug specifically to distinguish between structural isomers but not necessarily stereo isomers, so real techie there.

Drug Class, this is important and to understand because the CPT codes are divided by drug class. It’s a grouping of chemically related drugs. An example here is barbiturates. You’re going to have a lot of different types of barbiturates and they can be tested using similar method, so that would be in one drug class. CPT has determined two distinctive lists and technically three, two that are distinctive and one that’s a catch-all for everything else.

Drug Class List A are going to be things like alcohol, barbiturates, cocaine, opiates, etc. and you can say a whole long list on page 493 of your CPT Professional version.

Drug Class B, which is a little more complicated are your acetaminophen, nicotine/cotinine, salicylate, tramadol, etc. Again, that list is on page 493 of your CPT manual as well.

The reason for the division is that just like other things in CPT some things are more expensive than others, so there’s more work involved than others. The note here says, “It typically takes less resources to identify the drugs in Class List A than it does in Class List B.”

We want to talk about the general types of Assays. A Therapeutic Drug Assay, just like in other parts of CPT, therapeutic is more of the fixing type of thing; so the person is already on a drug, or something, so they’re monitoring a clinical response to a prescribed medication. Those are reported with CPT codes 80150 through 80299.

The Presumptive Drug Class Drug Assay is to identify possible use or nonuse of a drug, or drug class, and that’s that range 80300 to 80304, and so your co-choice in that range is going to depend on that first bullet there, what drugs you’re looking for, is it a Class A, or Class B, or is it fall in the other category? Then, second, the methodology of the test being used, so those are things that as a coder you want to pull out of the documentation to be able to code.

Really follow the instructions in your Path & Lab section for those to code it correctly. There are some specifics and we’ve got a little chart at the end that Ruth did that I’ll share with you.

Definitive Drug Testing to identify the individual drugs. This is where we’re really getting down very specific, what is that drug in the blood stream, or the urine, or whatever, and distinguish between the arrangement of the atoms in those. Those tests are very precise and they’re represented by CPT codes 80320 to 80377 and the note here is that presumptive drug class assays are often followed by a definitive.

The first thing, is it present, test is going to be done, then maybe they found the person unconscious with an empty bottle of pills, or whatever, and they presumed that it’s in it, yup it’s there. Now, they’re going to do a definitive and be more precise on the exact type or the quantity of it; and so, therefore, if you do both per CPT you’re allowed to report both.

Here is the lovely chart that Ruth did for us. The way this works, it’s like a decision tree, so start, the question is, is it a presumptive drug screen? I love how it says “No. Stop, this chart won’t help you.” A little CCO humor there. Yes, then you’re going to scroll down a little bit and we want to figure out what the drug class is, and we just reviewed that there’s two definitive types, or two – I probably shouldn’t use definitive since that’s one of the definitions here.

There’s two clear types A or B, and then there’s a catch-all, everything else. If its Class List A, that’s the first screen box there, we’re going to go over, and ask ourselves the question, is it non-TLC, capable of direct optical observation, yes or no? If yes, you go to the right you’re going to code the 80300 for any number of drug classes per date of service.

If the answer is no, then we need to figure out, was it TLC method? If it’s yes, then we’re going to go to the right, and we’re going to code 80303 for any number of drug classes, single or multi drug class method per date of service. If the answer is no, then we’re going to say by instructional test system, for example, multichannel chemistry analyzer using immunoassay or enzyme assay.

These are the methods, what’s the method here? If it’s yes, if the answer is yes to that then you’re going to code it as an 80301. If the answer is no, it’s not otherwise specified, presumptive procedure, very good. The second green box, if it’s not class B, if its class B then our first question is, by immunoassay or non-TLC chromatography without mass spectrometry. If the answer is yes to that question, then we’re going to code it as 80302 for each single drug class procedure.

If the answer is no, then we’re going to be is it the TLC method; if yes then we’re going to code it the 80303. If the answer is no, then it’s not otherwise specified. And then finally the last screen box is other classes. We’re going to ask ourselves again, is it the TLC method, yes or no. If it’s yes, we’re going to code it an 80303. If no, we’re going to code it a not otherwise specified.

Isn’t that a great chart? I love that, so kudos to Ruth for putting that together for us. Also she didn’t stop there; she gave us a little table to help us to understand for each of the classes, Presumptive Testing for Class List A. We want to ask ourselves if the methodology is: Non-TLC devices or procedures, and capable of being read by direct optical observation then we code it 80300. How many times? Once per date of service. It doesn’t matter how many drug classes.

The second row, single drug class method, by instrumented test systems like a discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay, then those methods would warrant 80301, and you can report that once per date of service no matter how many drug classes. Then finally for class A, TLC procedure for single and multiple drug class method is reported with 80303, once per date of service no matter how many drug classes.

For class B, if the methodology is by immunoassay or non-TLC chromatography without mass spectrometry you’re going to code it 80302. How many times, once for each single drug class procedure and they have to be from drug class B. If the methodology is TLC procedure for single or multiple then you’re going to report it as 80303, and that one is once per date of service, and that’s no matter how many drug classes.

Finally, presumptive testing for any number of drug classes. If the methodology is TLC procedure for single or multiple, it’s going to be 80303. How many times? Once per date of service no matter how many drug classes; and then all that other methodology, all those different ways of testing stuff would be an 80304, and you report that once per procedure.

This answer sheet is available to our Replay Club members. I gave you access to the chart but if you want the whole kit and caboodle that’s part of the benefit of joining the Replay Club $19.95 per month, it’s a real bargain, and those are just extra resources on this. You could go look up if you really needed to know more about it. I think that really put it together very well, so thank you Ruth.

Related Path and Lab 80300 80304 CPT Codes:

Path and Lab 80300 80304 CPT codes

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Introduction to Risk Adjustment — HCC Coding http://www.cco.us/introduction-risk-adjustment-hcc-coding/ http://www.cco.us/introduction-risk-adjustment-hcc-coding/#respond Thu, 12 May 2016 09:47:29 +0000 http://www.cco.us/?p=20817 Visit [CCO] Certification Coaching Organization LLC for more articles about [CCO] Certification Coaching Organization LLC - Medical Certifications - Learn It - Get Certified - Stay Certified.

In today’s discussion, we’re going to talk about what Risk Adjustment (RA) is, what’s the purpose of it, where it originated from, which plans are Risk Adjustment plans, and the history and development of Risk Adjustment. We will also talk about why do you want to know about Risk Adjustment? Why […]

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Introduction to Risk Adjustment HCC Coding

In today’s discussion, we’re going to talk about what Risk Adjustment (RA) is, what’s the purpose of it, where it originated from, which plans are Risk Adjustment plans, and the history and development of Risk Adjustment. We will also talk about why do you want to know about Risk Adjustment? Why should it even be crossing your purview?

You’re going to find that Risk Adjustment is essential and we’re going to talk through why, and what we’re beginning to see Risk Adjustment plans affecting. We’ll talk about how Risk Adjustment reporting is different from traditional coding and why there is an increasing number of Risk Adjustment plans?

Let’s get started!

What Is Risk Adjustment?

Well, let’s break the term down. In this case, I went out and I looked for definitions of those two terms, and yeah, they’re kind of dry, they’re kind of boring definitions but let’s actually apply them to the world of insurance billing and reporting for medical services.

A risk is a situation where the probability of a variable (such as burning down of a building) is known but when a mode of occurrence or the actual value of the occurrence (whether the fire will occur at a particular property) is not known.

For example, the probability of a variable, they give us the example of burning down of a building. Well, in our world it could be a patient who has diabetes, and the variable is not knowing whether or not they’re going to require services or what services they’re going to need over the case of a year, that’s a risk.

The adjustment piece is where we’re taking fiscal and monetary policies and we’re adjusting them to balance out that payment allotment and get rid of the unknowns and try to level the playing field.

When we talk about leveling payment, that’s the whole purpose behind Risk Adjustment.

What Is Risk Adjustment - HCC Coding

For traditional Fee-for-Service Plans, I’m not talking about Risk Adjustment, but traditional insurance payment that we’ve seen for years, the way that insurance carriers are compensated for their services it’s the same way that the physician is compensated for the services rendered. They’re both paid for services, services provided to the patient, and those services are paid typically either on a fee schedule.

Why Do I Need To Understand Risk Adjustment?

The slide above gives you a great indication as to why you may need to understand Risk Adjustment. The slide is a picture of the United States showing the number of Medicare Advantage Plan patients or beneficiaries by state. This is actually something that we pulled from the Kaiser Family Foundation; Kaiser Permanente being one of the largest Risk Adjustment insurance plans across the entire country. They provide services in a variety of different states. But they published this information annually on their website and show how much has changed and how many are in each state.

The vast majority of states, every state with I think the exception of Alaska, has some number of beneficiaries enrolled in a Medicare Advantage Plan and several states have well above 15, 20, 25% of their Medicare population. Now, some of you are going “25% is nothing.” That’s a quarter of your Medicare population, and especially if you’re working in a practice that is predominantly elderly patients, aged, disabled, those over 65, those who are eligible for Medicare, this could potentially be a very large subset of your practice population. So, this could make a huge difference when we start looking at this.

Why Do I Need to Understand Risk Adjustment

So, this is just the Medicare Advantage Plans. We don’t have data yet on how many patients are enrolled on those ACA Marketplace Plans that risk adjust. We also don’t have a very good way of tracking how many patients are enrolled in Medicaid Risk Adjustment Plans, but if they are anywhere like these numbers, think about that, your total population depending on your state. It could be a quarter of your patient population, it could be 50% of your patient population, and it could be even more than that. Not just based on state, it’s based on specialty, based on the name, type of insurance plans that you accept; all of that sort of thing.

What’s the Purpose of Risk Adjustment? (Level Payment & Expectations)

We take this and we start thinking about how they apply this in a real day-to-day world. Think we have four patients. I got them on the screen. I labeled them patients A through D. Patient A is our normal healthy patient. Normal healthy patient may or may not receive services throughout the course of the year. We certainly hope that they’re going to come in for services particularly their annual wellness visit or annual preventive exam, their immunizations, any mammogram or colonoscopy or whatever those screening services are that are age appropriate, gender appropriate that they should be coming in for. But overall, we don’t anticipate requiring a vast number of services for that patient because they’re healthy. They don’t have any long term chronic comorbidities, anything like that we need to worry about.

Patient B on the other hand, let’s say this is a patient who’s pretty much healthy, but the patient is a diabetic. Well, just to compare to patient A, we know that patient B is likely to receive more services throughout the course of a year than patient A, simply because patient B is a diabetic. They’re more prone to complications. It’s going to take them longer to heal after illnesses or injuries. They may require medications to control their diabetes depending on the type of diabetes that they have, their activity level, their age, a number of factors; but it’s likely that they’re going to come in more frequently on a more routine basis for services than patient A is.

So, in the world of Risk Adjustment, the insurance plans would get paid a little bit more for patient B than they would for patient A. 

What Is The Purpose of Risk Adjustment Coding

Then, we look at Patient C, and we say, “OK.  Well, the difference between patients B and C, we’re already getting paid a little bit more for this patient because they’re a diabetic.” But this diabetic has developed a complication or a related illness; in this case, they’ve got retinopathy. Retinopathy ups the level of service that the provider is going to need to provide; patients are going to require seeing additional physicians, right? Maybe they were seeing either their endocrinologist, or their primary care doctor for their diabetes. They developed this retinopathy, now we have an ophthalmologist involved in the services provided. And the ophthalmologist and the primary care doctor have to coordinate services and that patient is going to require more diagnostic testing, perhaps more therapeutic treatment. They’re going to require an additional level of services over and above Patient B who is simply a diabetic.

Then we look at Patient D. Well, we’re already paying a little bit more because that patient is a diabetic, we’re paying a little bit more because that patient’s got retinopathy, and now they’ve got an ophthalmologist involved and they require additional services. But then we say, “Uh-oh! This patient has developed even more illnesses that are going to affect their long-term care,” and in this case the patient’s got chronic kidney disease stage III. Well, now we’re going to have to have some additional care involved, right? Chances are they’re seeing a nephrologist. They’re requiring some additional services to make sure that we keep that CKD under control; that it doesn’t exacerbate or worsen. Checking their kidney functions on a regular basis, there’s additional lab test that they’re going to need, potentially additional diagnostic test whether it’s an ultrasound, whether it’s an MRI. Things like that, that may be required over the course of the year, so we pay more for patient D.

If you compare the amount that they would receive for patient D, to the amount that they would receive for patient A, you’re going to see it’s going to be a pretty drastic difference in how much money that insurance plan is going to get. Justifiably so, it’s just going to cost them more to cover patient D than it is to cover patient A. Risk Adjustment isn’t anything new. When we start talking about this, you’re going to find that Risk Adjustment has been around for years, and the easiest thing to compare it to, think about your car insurance, we all know that car insurance, not everybody pays the same amount to the insurance carrier for their car insurance, right? It’s going to cost more to insure a 16-year-old boy in a sports car than it is to insure a 40-year-old female in that same sports car, and the color of the car is going to make a difference, and all of those different factors factor in. So, Risk Adjustment applies in lots of different arenas, we’re just seeing it become more prevalent in how we report insurance services from medical services nowadays.

Where did Risk Adjustment (RA) Plans Originate?

Where Did the Risk Adjustment Plans Originate

When we start looking at these plans, and I say that it’s not new, it’s really not new. Risk Adjustment Plans have been around for years, the first, the original Risk Adjustment Plans for Medicare actually originated in the 1980s. Now, a lot of people who already know about Risk Adjustment are like “No, no, no, no. That didn’t come until the late 1990s and it was all about legislation.” No! We’ve actually had Risk Adjustment plans dating back to the 80s.

Then the 1980s we had some Medicare and Medicaid plans that paid in a Risk Adjustment model. It’s just not Risk Adjustment like you and I know about Risk Adjustment today. Back then, the Risk Adjustment only included about four things. It included the patient’s age, the patient’s gender, whether or not they were eligible for Medicaid services, or whether or not they were a nursing home resident. Those different factors could adjust payment back then.

Is Risk Adjustment (RA) Really Increasing?

Are we really seeing the number increase for this Risk Adjustment plans? Well, this is another slide from the Kaiser Family Foundation. This is when where if you ask me that question, I’m going to say, “You tell me. You look at this slide and tell me.” In ten years since 2005, the number of Medicare managed care, health plan patients has more than tripled.

Is Risk Adjustment Really Increasing

So, yes, we are seeing a huge increase in the number of Risk Adjustment plans. It’s tripled in the last ten years and this only takes into account Medicare Advantage Plans, their Special Needs Plans, all those different things that factor under Medicare Advantage Plans. We haven’t even addressed how many patients do we have on Medicaid Managed Care Plans, how many patients do we have on those ACA Marketplace Managed Care Plans.

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