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* Should we wait for a subpoena?
* Coding for three procedures with unexpected results
* Pay-per-view article: Poor training can spell disaster for covered entities

Compliance Monitor, April 3, 2003

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Should we wait for a subpoena?

Q: We received a verbal request from the insurance commissioner for copies of a patient's medical record. Under the Health Insurance Portability & Accountability Act (HIPAA), can we release it to the commissioner or should we wait for a subpoena?

A: Generally speaking, you do not have to wait for a subpoena, but remember to take some precautions. Ask why the insurance commissioner is requesting the record. If it's because the commissioner wants to investigate the health plan for possible fraud or abuse, then you can legally release it under HIPAA, especially if it's related to a criminal or civil investigation. Still, ask the commissioner's office to put the request in writing. In most situations, your insurance commissioner is allowed to review the record. You can find details about this in the "operations" section of the HIPAA regulation.

Also, remember to check your state's administrative codes and other state laws. If your state's privacy laws are more stringent than the federal HIPAA regulation, then you must abide by the state laws. If you choose to release this information, you may also want to request that the patient sign an authorization form. That said, each situation varies, so always check with your legal counsel.

This question was answered by Claudia M. Davis, RN, LHRM, LNC, Risk Reducers, Inc.

Go to "Poor training can spell disaster for covered entities" for the rest of this article. The cost is $10. Subscribers to the online version of Briefings on HIPAA have free access to this article. Subscribers to the print edition can find it in their March issues.

A $30 steal!

You can read this article—and much more—in the entire March issue of Briefings on HIPAA. Your cost: Seven stories for only $30! You'll learn how to include some Security Rule topics into your privacy training, and how to make HIPAA part of your facility's PR efforts. Choose between a PDF or HTML version for just $30. Online subscribers have free access to this issue. Print newsletter subscribers can find it in their mailboxes.

Q: If physicians document that they did a procedure that did not have the expected results, should the procedure be coded with a modifier, or should it be coded normally since it was actually completed? Here are three examples we've recently encountered:

1. A physician performs an "incision and drainage" procedure, but no drainage resulted. Since "drainage" is in the description, is it correct to code this procedure?
2. A physician performs a lumbar puncture, but she was not able to obtain any spinal fluid. Should we code this procedure?
3. In a central venous pressure (CVP) line placement, a physician put the line in incorrectly and immediately infiltrated. How should we code this?

A: Always try to consider how clinical issues affect coding, and look for specific data in the patient record to support your coding decisions. Consider these solutions for each of the specific scenarios mentioned above:

1. I would code this one normally since the incision and drainage procedure was performed and the physician expected to obtain exudate.
2. There are a couple coding options for the lumbar puncture.

   If the physician needed to repeat the procedure to obtain fluid, I would only code the procedure once. I would use a -76 modifier with the CPT if the same physician repeated the procedure. Use a -77 modifier if a different physician does the repeat.

   If the physician didn't obtain any fluid, and didn't repeat the procedure, you can code it, and use the -53 modifier since it represents the physician's time and expertise. In this case, however, an auditor reviewing the chart for medical necessity might wonder why the lumbar puncture was medically necessary since the physician didn't repeat it when no fluid was obtained on the first try.

3. For the central venous pressure (CVP) line, the logic is the same as the lumbar puncture. Use the correct modifier to identify the first and subsequent procedure. However, code for only one procedure since the first was discontinued. If a physician does not insert a CVP line, I would want to see clinical documentation supporting the reason; otherwise, an auditor could question the medical necessity of the first attempt.

This question was answered by Barbara Aubry, RN, CCM, CPC, DABQAURP, clinical business analyst with Info-X-Inc.

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