HCPro.com - APCs Weekly Monitor

Tip: CPT Chapter 11 codes take precedence in OB/GYN cases

Fri, 20 Nov 2009 19:20:00 GMT

When coding OB/GYN procedures, remember that ICD-9 codes 630–679 in Chapter 11 (Complications of Pregnancy, Childbirth, and the Puerperium) of the ICD-9 Manual take sequencing priority over other chapters.

Report codes from Chapter 11 in the ICD-9 Manual for conditions that appear in the maternal record only. Refer to code series 764–779 to assign codes for conditions that appear in the baby’s chart, if applicable. Remember that the baby does not have its own chart until its mother gives birth.

This tip was adapted from the article “Examine codes for complex OB/GYN procedures” in the December issue of Briefings on APCs.

Q/A: Billing telemetry daily monitoring

Fri, 20 Nov 2009 05:23:00 GMT

Q: Can our hospital code and bill telemetry daily monitoring in conjunction with a chest pain patient in observation?

A: No CPT code exists for cardiac telemetry daily monitoring, but revenue code 732 does. Consider revenue code 732 an ancillary revenue code, and use it in conjunction with these services when provided by a separate department with specially-trained staff.

Typically, separate department staff members do not perform cardiac telemetry monitoring. Instead, a facility installs telemetry monitors on a specific nursing floor, enabling staff members there to observe. Medical staff members usually admit patients to that particular nursing floor because telemetry is medically necessary and a physician orders it. This means that most patients on that floor receive telemetry.

The typical nursing cost center includes the cost of equipment and staff on this unit. This means that the telemetry is a routine cost, as confirmed by administrative decisions by the Medicare Provider Reimbursement Review Board (PRRB). Because it's a routine cost, you may not bill this service with an ancillary revenue code, such as 732.

Hospitals have has two choices when billing routine costs:

Include the charge in the room and board rate (or hourly observation rate) for that nursing unit.
Separately bill a charge with a recognized routine cost revenue code, such as 230. This allows hospitals to separately bill a line item charge on both inpatients and outpatients. However, note that this particular revenue code is not allowed on outpatient claims. Therefore, depending on the capabilities of an individual hospital’s billing system, it may be able to include charges in the observation hourly charge under revenue code 0762 if the units of service equal the documented hours of observation. Alternatively, establish an observation hourly rate for this area that includes the telemetry charge reported under revenue code 230 for inpatients plus the observation charges reported under revenue code 762.

Master modifiers to ensure accurate reimbursement

Fri, 20 Nov 2009 05:14:00 GMT

Proper modifier use is a critical part of coding, billing, and reimbursement. Currently, coders may choose among 13 CPT modifiers and 39 HCPCS Level II modifiers. With so many choices, even seasoned coders can experience problems when assigning modifiers.

Modifiers allow facilities to indicate that a specific circumstance altered a performed service or procedure without changing the procedure’s definition or code, says Kim LeBlanc, MS, RHIA, CPC, coding manager at Lafayette Health Ventures,Inc., in Lafayette, LA.

Continue reading “Master modifiers to ensure accurate reimbursement” on the HCPro Web site. Briefings on APCs subscribers have free access to this article in the December issue.

Trivia

Fri, 20 Nov 2009 05:11:00 GMT

How many flowers are in the design stamped on each side of an Oreo cookie?

Think you know the answer? Managing Editor Michelle Leppert. If you are one of five randomly selected readers to answer correctly the day you receive your issue, you’ll win a free three-month trial subscription to the HCPro newsletter of your choice.

Last week’s question

What type of jungle animal was Shere Khan in Rudyard Kipling’s The Jungle Book?

Cobra
Lion
Mongoose
Tiger

The correct answer is D. Shere Khan was a tiger.

Q/A: Documenting lesion size

Fri, 13 Nov 2009 05:18:00 GMT

Q: A surgeon excises a lesion on a patient’s back, but fails to document its size or the margins in the operative report. The pathology report lists the total size of the excised specimen, including the lesion size. May we use the pathology report as documentation for the lesion size and the margins excised?

A: CPT Manual introductory notes for this section state “The measurement of lesion plus margin is made prior to excision.” This requires physicians to provide the size before removing a lesion.

Using the pathology report as documentation for coding purposes may result in reporting of an incorrect size. CPT Assistant, August 2000, p. 5, states that pathology reports usually provide specimen size rather than size of the lesion or the excised specimen. Specimens shrink when added to formalin or other preservative. Therefore, measurements in pathology reports are not accurate and don’t provide accurate information for proper CPT procedure code assignment.

Query physicians when they remove a lesion but fail to document its size. Specifically, request the size of the lesion and margins. Physicians need this information to submit accurate bills for their professional services.

Tip: Don't overlook small-dollar savings

Fri, 13 Nov 2009 05:16:00 GMT

When considering ways to reduce revenue loss at your facility, don’t look just for big-dollar savings. Small-dollar savings can add up to a significant amount.

Also, be sure to inform coworkers of changes—large and small—that you implemented. If you don’t tell them about the potential additional revenue, they won’t know.

This tip was adapted from the article “Eliminate missed charges, errors to reduce lost revenue” in the December issue of Briefings on APCs.

Examine codes for complex OB/GYN procedures

Fri, 13 Nov 2009 05:13:00 GMT

Operative notes for OB/GYN procedures can be long and complex, and coders must know how to sift through the detailed information to ensure accurate code assignment.

When coding OB/GYN procedures, remember that ICD-9 codes 630–679 in Chapter 11 (complications of pregnancy, childbirth, and the puerperium) of the ICD-9 Manual take sequencing priority over other chapters.

Continue reading “Examine codes for complex OB/GYN procedures” on the HCPro Web site. Briefings on APCs subscribers have free access to this article in the December issue.

Trivia

Fri, 13 Nov 2009 05:09:00 GMT

What type of jungle animal was Shere Khan in Rudyard Kipling’s The Jungle Book?

Cobra
Lion
Mongoose
Tiger

Think you know the answer? E-mail Managing Editor Michelle Leppert . If you are one of five randomly selected readers to answer correctly the day you receive your issue, you’ll win a free three-month trial subscription to the HCPro newsletter of your choice.

Last week’s question

What are Captain Hook's last words in Peter Pan?

Carpe Diem
Floreat Etona
Hinc lucem et pocula sacra
I die

The correct answer is B. In the play Peter Pan, Captain Hook’s final words are the Eton College motto, Floreat Etona. Playwright J.M. Barrie implies in the text that Hook attended Eton College, then confirmed it in a speech he delivered there in 1927.

Q/A: May we bill an E/M code for a wound care first visit

Fri, 06 Nov 2009 05:41:00 GMT

Q. Several of our facilities that include hospital-based outpatient wound care clinics have requested guidance in the following scenario.

A patient arrives at the clinic with a physician order for wound debridement. This is the patient’s first visit, and the patient meets the CPT new patient definition. The nurse performs the debridement and documents a history and physical.

Because this is a first visit, may we bill for an E/M level and the debridement? Should we bill only for the debridement in subsequent visits?

A. Medicare “incident to” guidelines for hospitals state that nurses must carry out orders from treating physicians and not add to or take away from any order. Just because the patient presents for an initial visit, you may not automatically report an E/M service.

In this case, the answer depends on how the physician ordered the first wound care visit. If the physician order is for wound debridement only, the hospital should bill for wound debridement. Bill the services described with one of the wound management codes—97597, 97598, or 97602. Each of these CPT codes’ descriptors includes the term “wound assessment” so wound evaluation is included when reporting the documented procedure.

After assessing the patient’s presenting condition, the wound care nurse might think that additional services are necessary or that a new issue has arisen since the patient saw the physician. In either situation, the wound care nurse should contact the ordering physician to determine whether further or different medically necessary services are indicated. You may bill an E/M service in addition to the wound care service only if it represents a medically necessary, significant, separately identifiable service ordered by the treating physician and provided by the hospital.

Tip: Determine the number of specimens to code surgical pathology correctly

Fri, 06 Nov 2009 05:39:00 GMT

If you perform a level IV surgical pathology (88305) on more than one specimen from the same patient, the unit of service for this code is the number of specimens requiring individual exam and pathologic diagnosis. Use modifier -59 to indicate tests provided for different specimens.

If you test a single specimen, report only the code that describes the highest level of specificity within a group of related codes if the tests are performed on a specimen with the same end result. For example, within the code range of 88104–88112, report only one code. If you perform multiple tests on multiple specimens, use modifier -59.

This tip was adapted from the article “Q&A: Determining the proper use of modifier -59” in the November issue of Briefings on APCs.

Eliminate missed charges, errors to reduce lost revenue

Fri, 06 Nov 2009 05:34:00 GMT

As more services shift from the inpatient to the outpatient setting, coders are under more pressure to ensure that facilities receive appropriate reimbursement for services provided.

Operational inefficiencies and outdated technology can result in lost revenue. Silo thinking—such as “it’s not my area”—throughout the facility also can contribute to lost revenue.

Continue reading “Eliminate missed charges, errors to reduce lost revenue” on the HCPro Web site. Briefings on APCs subscribers have free access to this article in the December issue.

Trivia

Fri, 06 Nov 2009 05:25:00 GMT

What are Captain Hook's last words in Peter Pan?

Carpe Diem
Floreat Etona
Hinc lucem et pocula sacra
I die

Think you know the answer? E-mail Managing Editor Michelle Leppert. If you are one of five randomly selected readers to answer correctly the day you receive your issue, you’ll win a free three-month trial subscription to the HCPro newsletter of your choice.

Last week’s question

Which phobia do you suffer from if you have an intense fear of Halloween?

Nyctophobia
Phasmophobia
Samhainophobia
Triskaidekaphobia

The correct answer is c. Samhainophobia refers to an abnormal and persistent fear of Halloween. Nyctophobia is an abnormal fear of night or the dark, while phasmophobia is an abnormal and persistent fear of ghosts. Triskaidekaphobia is an abnormal fear of the number 13.

Tip: Develop protocols for enforcing direct supervision requirements

Fri, 30 Oct 2009 18:25:00 GMT

All diagnostic tests require some level of physician supervision. Staff members need to know the level of supervision required for each test and they must ensure that the tests receive the proper level of supervision.

Facilities can assist staff members by creating department protocols for each direct supervision test and establishing a protocol that requires the presence of a physician on campus. For facilities with multiple campuses, this means ensuring that the supervising physician is on the campus where the procedure will occur.

Sometimes, a physician may be involved in another procedure or en route to the department when a test is scheduled to begin. An established protocol for enforcing supervision requirements will help department staff members who may be asked to start a procedure without the physician present.

Once protocols are in place, the facility must communicate this information to every physician. Protocols and their enforcement will help staff members work with physicians to ensure that the appropriate level of supervision is provided.

This tip was adapted from the article “Hospital outpatient departments need to know who is supervising” in the November issue of Briefings on APCs.

Q/A: Calcium gluconate administration: Infusion or hydration?

Fri, 30 Oct 2009 05:27:00 GMT

Q. A patient who has undergone a kidney transplant and has plasmapheresis intravenously receives IV immune globulin (IVIG) and calcium gluconate. The calcium gluconate consists of 3000 mg in 250ml of normal saline.

Should we code the administration of the calcium gluconate as a therapeutic infusion or as hydration?

A. Bill the calcium gluconate administration as a therapeutic infusion, not as hydration. According to the 2009 CPT Manual, codes 96360–96361 “are intended to report a hydration IV infusion to consist of prepackaged fluid and electrolytes (e.g., normal saline, D5-1/2 normal saline +30mEq/liter), but are not used to report infusion of drugs or other substances.”

Calcium gluconate is considered an electrolyte in the treatment of hypocalcemia in conditions requiring a prompt increase in plasma calcium. This is not usually a prepackaged solution, so it would not qualify as hydration, according to CPT Manual instructions.

Assuming that the calcium gluconate is started first, the appropriate 2009 CPT code for the infusion of calcium gluconate is 96365 for the first hour and 96366 for each additional hour. Code the second infusion (IVIG), if administered through the same IV site, with 96367 (sequential infusion) or 96368 (concurrent infusion) based on documentation in the record.

I/OCE quarterly update: CMS addresses condition code 44, billing for radiopharmaceuticals and nuclear medicine

Fri, 30 Oct 2009 05:24:00 GMT

As part of Medicare Claims Processing Manual (MCPM) Transmittal 1803—the October 2009 update to OPPS—CMS supplies additional information about condition code 44 and instructions for billing radiopharmaceuticals and nuclear medicine. The changes became effective October 1.

Hospitals use condition code 44 when they change a patient’s initial status from inpatient to outpatient for purposes of billing and payment. This generally occurs when utilization review (UR) personnel determine that the patient does not meet Medicare’s inpatient guidelines.

Continue reading “I/OCE quarterly update: CMS addresses condition code 44, billing for radiopharmaceuticals and nuclear medicine” on the HCPro Web site. Briefings on APCs subscribers have free access to this article in the November issue.

Trivia

Fri, 30 Oct 2009 05:22:00 GMT

Which phobia do you suffer from if you have an intense fear of Halloween?

Nyctophobia
Phasmophobia
Samhainophobia
Triskaidekaphobia

Think you know the answer? E-mail Managing Editor Michelle Leppert. If you are one of five randomly selected readers to answer correctly the day you receive your issue, you’ll win a free three-month trial subscription to the HCPro newsletter of your choice.

Last week’s question

Where in California did the last Pony Express ride end?

Bakersfield
Los Angeles
Modesto
Sacramento

The correct answer is D. The Pony Express was a rapid mail service crossing the North American continent from St. Joseph, MO, to Sacramento, CA, from April 1860 to October 1861. From March 1861, the Pony Express delivered mail only between Salt Lake City and Sacramento. The Pony Express announced its closure on October 26, 1861.

Q/A: Proper coding for multiple wounds at different sites

Fri, 23 Oct 2009 05:16:00 GMT

Q: A patient with multiple wounds at different sites receives active wound management at one wound site, but receives different treatment for the other wounds. May we bill an active wound management code and an E/M level for the other area or areas?

A: The answer depends on what the physician ordered, what was performed, and what is documented for each wound.

Most FI/MACs have Local Coverage Determinations (LCD) that specify what providers must document to support the service that was rendered. Documentation requirements are very specific concerning the type of tissue present, type of tissue removed/treated, and the requirements for each method of treatment. NCCI edits also dictate code pairs that may be reported for the same date of service—even if multiple wound sites are present. For example, if a clinician performed a nonselective debridement on one wound and active management on another wound, then you may report only an active management CPT code (97597 or 97598). These codes are mutually exclusive with a CCI indicator of 0, which means you may never report them together during the same session or visit.

CMS has said that reporting an E/M code is inappropriate when a CPT code describes the service provided. (Refer to the Federal Register, November 24, 2006, for the Final Rule for CY 2007 OPPS.) For example, don’t report an E/M level when nonselective debridement is provided because CPT code 97602 describes the service.

Tip: Distinguish between therapeutic and diagnostic tests

Fri, 23 Oct 2009 05:14:00 GMT

Facilities need to have a clear understanding of when a procedure is diagnostic and when it is therapeutic.

Some procedures are diagnostic but are considered therapeutic for the purpose of supervision. For those types of procedures, physicians often provide the required level of supervision by being present in the surgical suite. Any procedures that involve injection of contrast or other type of radiological substance clearly require direct supervision.

Facilities need to understand how services are classified to ensure the proper level of supervision. Consult the Medicare Physician Fee Schedule and review codes by level to determine the necessary level of supervision.

This tip was adapted from the article “Hospital outpatient departments need to know who is supervising” in the November issue of Briefings on APCs.

Bill and charge for supplies correctly to reduce risk and lost revenue

Fri, 23 Oct 2009 05:10:00 GMT

Hospital departments may be losing revenue for supplies because they don’t understand how billing and payment rules differ.

CMS, FIs, and MACs give coding, billing, and payment guidance, but it’s not always clear which guidance they’re discussing, said Keith Siddel, MBA, PhD(c). Siddel is founder, president, and CEO of HRM, a national healthcare financial service organization in Creede, CO. Siddel and Valerie A. Rinkle, MPA, revenue cycle director at Asante Health System in Medford, OR, were the speakers at HCPro’s September 16 audio conference, Billing for Hospital Supplies: Minimize Compliance Risks and Revenue Loss.

Continue reading “Bill and charge for supplies correctly to reduce risk and lost revenue” on HCPro’s Web site. Briefings on APCs subscribers have free access to this article in the November issue.

Trivia

Fri, 23 Oct 2009 05:08:00 GMT

Where in California did the last Pony Express ride end?

Bakersfield
Los Angeles
Modesto
Sacramento

Think you know the answer? E-mail Managing Editor Michelle Leppert. If you are one of five randomly selected readers to answer correctly the day you receive your issue, you’ll win a free three-month trial subscription to the HCPro newsletter of your choice.

Last week’s question

Which one of the following is not considered a bone of the cranium?

Ethmoid
Frontal
Parietal
Spheroid

The correct answer is D. A spheroid is an object of approximately spherical shape.