Q: I work in a pediatrics office and have a question regarding billing for supplies (e.g. slings, ace wraps, tubes, and masks). Is there a certain CPT code we should report? Or should we report a HCPCS A code instead? Our billing department recently began to use a payer path to perform billing functions, and it is rejecting our supply codes and instead generating generic codes on the CMS-1500.

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It happens every day in every kind of healthcare facility: Claims denials. Large and small physician offices, hospitals, specialties, and family practices lose thousands of dollars per year as a result of denied claims. Studies indicate that some hospitals lose $1,000 per day, and some outpatient facilities lose as much as $1,200 per day. Unfortunately, some facilities and practices try to mitigate the loss by passing the debt to the patient or guarantor. Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, provides helpful advice that you can use to successfully overcome denials.

DeAnne W. Bloomquist, RHIT, CCS, and Robert S. Gold, MD, discuss the financial impact that the new hospital acquired conditions will have on hospitals beginning October 1.

Most health information management (HIM) directors think a disaster will never occur at their hospitals. And although channeling positive thoughts is generally laudable, it isn’t a realistic approach when disaster can strike at any moment. A disaster doesn’t necessarily need to take the form of a hurricane, tornado, or pandemic to severely incapacitate an HIM department. What happens when the power goes out? Or how about when the computer system crashes? Glennda Gore, RHIA, and Chris Apgar, CISSP, help prepare your facility for future obstacles.

Q: Two male patients present for the same procedure­—a total hip arthroplasty (CPT code 27130, athroplasty, acetabular and proximal femoral prosthetic replacement, with or without autograft or allograft). One patient pays for the surgery himself, and the other patient has insurance. On both accounts, the primary surgeon charges CPT code 27130, and the assistant surgeon charges CPT code 27130 with modifier -80.  

The charge for CPT code 27130 is $100.00, bringing the total charges for both surgeons to $200.00. However, we know that the insurance company will adjust our reimbursement when we report modifier -80. On the other hand, the self-pay patient will receive a bill in the amount of $200.00. Should we adjust the self-pay patient’s bill to reflect the use of modifier -80? This would equal the adjusted reimbursement from the insurance company.

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CMS released its inpatient prospective payment system (IPPS) final rule for fiscal year (FY) 2009 on July 31, updating Medicare payments to hospitals and providing added incentives for hospitals to improve their quality of care. Changes take effect October 1. CMS will publish the final rule in the August 18 Federal Register.

When Angela Simmons, CPA, director of clinical revenue and reimbursement at the University of Texas’ MD Anderson Cancer Center in Houston, faced the prospect of implementing CMS’ new erythropoietin stimulating agent (ESA) transmittals, she had several goals. At the top of her list was to ensure a smooth transition.

Q: Medicare allows hospitals to separate out any vaccines patients receive during an inpatient stay and bill as a Part B claim along with an administration charge. This applies to three different types of vaccines (i.e., hepatitis B, influenza and pneumonia). To stay compliant, we need to bill all our inpatients the same way (e.g., including both a vaccine and administration charge). Is this correct? Do we bill all vaccines with administration charges, regardless of the type of vaccine or payer, or just these three types?

CMS and the National Center for Health Statistics (NCHS) released the following guidelines for coding and reporting using ICD-9-CM. Coders should use these guidelines as a companion document to the official version of the ICD-9-CM.

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The query process is an effective way to improve clinical detail and coding accuracy. More specific and detailed documentation improves future continuity of care and can potentially lead to improved quality of care. Colleen Garry, RN, BS, offers advice on how your facility can develop compliant physician queries to enhance its clinical documentation improvement program.

Meera Mohanakrishnan, CPC, CPC-H, explains why it’s important for coders and billers to understand that they should only report an unlisted HCPCS code for rarely performed, unusual, or new procedures when a more appropriate code is not available.

How do you define “chronic”? Many medical dictionaries and Web sites describe chronic diseases as long lasting or recurrent. The Agency for Healthcare Research and Quality prefers a more substantial definition; it says that chronic conditions are “expected to last one year and result in limitations in self-care, independent living, and social interactions or in the need for ongoing medical intervention.” Leatrice Ford, RN, BSN, CCS,  and Shannon McCall, RHIA, CCS, CPC, debate the importance of assigning a Y indicator to chronic conditions as well as the need for a universal chronic conditions reference list.

Q: What is the correct CPT code for destroying telangiectasia on the skin via a laser? The dermatologist wants us to report the unlisted code. However, an article in the Derm Coding Consult, Winter 2007, p. 5, states that we should not report CPT codes 17106–17108 for this procedure.

Raynaud’s phenomenon (disease)

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Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, Michael A. Ferragamo, MD, FACS, and Susan Crews, CPC, ACS-UR, PCS, discuss the proper way to code urology procedures. Learn the four catheterization codes, how to report transurethral resection of the prostate, and how to get the reimbursement your facility deserves.

Shannon McCall, RHIA, CCS, CPC, and Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, explain why outpatient coders should pay close attention to changes in diagnostic coding. While ICD-9 coding may not directly affect outpatient payment, it contributes to coding accuracy and to prevention of reimbursement delays.

Glenn Krauss, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, addresses concerns regarding the increased and inappropriate use of radiology imaging in the practice of medicine. Krauss also talks about the single payment principle under composite APC payment methodology. Adhering to this, Medicare proposes five composite APCs based on three imaging modalities that represent higher costs to the Medicare program in the form of higher reimbursement to hospital outpatient providers.

CMS has awarded contracts to the 53 contractors participating in Medicare’s Quality Improvement Organization (QIO) Program and outlined in its 9th Statement of Work (SOW). The SOW, which focuses on improving the quality and safety of healthcare services for Medicare beneficiaries, also promotes the following three national themes:

• Beneficiary Protection
• Patient Safety
• Prevention

QUESTION: What code should I report for a colonoscopy with cannulation of the ileum?

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Chris Simons, RHIA, Elisa Gorton, RHIA, and Nancy Davis discuss the importance of HIPAA training for coding and billing staff. Although these staff members may not have much face-to-face interaction with patients, their constant access to medical records and protected health information still makes them susceptible to potential violations. Our experts give advice on how to provide education.

Stephanie Ellis, RN, CPC, describes the compliance ramifications of coding and billing mistakes. She discusses common errors, such as upcoding and undercoding, as well as the risks and penalties for fraudulent behavior. Stay on the straight and narrow with quick tips from this industry expert.

Do you work in the finance department or business office at your facility? Are you part of a clinical documentation improvement team looking to implement a successful program? Are you a coding manager trying to improve how your staff reports complications and comorbidities (CC) and major CCs? If so, The IPPS PC Pricer software is just what you need. Kimberly Anderwood Hoy, Esq., sings the praises of this little known resource.

In a July 15press release, CMS announced that it paid more than $36 million to health professionals who satisfactorily reported quality information to Medicare under the 2007 Physician Quality Reporting Initiative. More than 109,000 professionals participated in the 2007 program. Of those, more than 56,700 physicians and other eligible professionals met statutory requirements for satisfactory reporting and therefore received an incentive payment.

The mid-year 2008 Medicare Physician Fee Schedule rate of -10.6% has been replaced with a 0.5% update, retroactive to July 1, 2008, according to a July 16 CMS fact sheet.

Q: How should I code a case in which a 16-year-old female has fetal alcohol syndrome? Should I report ICD-9-CM code 760.71?

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On July 15, CMS enacted the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 that extends the use of the cost-to-charge payment methodology for brachytherapy and therapeutic radiopharmaceuticals through January 1, 2010, according to Job Aid (JA) 0826. The change is retroactive to July 1.

For ambulatory surgery centers (ASC) that offer pain management services, it’s important to review AMA guidelines, both past and present. Doing so ensures that you are accurately coding procedures—and not leaving any reimbursement on the table. Lolita M. Jones, RHIA, CCS, and Linda Van Horn, MBA, provide guidelines to help you understand what reimbursement ASCs are eligible to receive.  

If they don’t perform a thorough record review, clinical documentation improvement (CDI) specialists may fail to catch many DRG-changing complications and comorbidities (CCs) and major CCs (MCCs). Glenn Krauss, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, and Deborah Mange, RN, BSN, talk about what it takes to be a savy and successful CDI specialist.

Those in the health information management (HIM) world know that hospital and physician incentives have never been completely aligned because each is reimbursed under a separate payment system. CMS currently pays hospitals a single amount per discharge under the Inpatient Prospective Payment System (IPPS), and physicians receive separate payment per service under the Medicare Physician Fee Schedule. But that traditional model may soon change for some hospitals in Medicare Administrative Contractor (MAC) Jurisdiction 4 (i.e., Texas, Oklahoma, New Mexico, and Colorado), as CMS announces its voluntary Acute Care Episode (ACE) Demonstration project. Herb B. Kuhn, CMS deputy administrator, and Rachel Duguay, CMS project officer, discuss the details.

As the weather turns warmer and people become more active over the summer months and early fall, you may find yourself coding several common injuries such as burns, sprains, dehydration, and fractures. Joe Rivet, CPC, CCS-P, CICA, refreshes your coding knowledge with some helpful scenarios.