Monday, December 21, 2009

Consultation Changes for 2010

Happy Holidays... Not much may change for me here in Idaho, but in the world of coding... things are changing fast and furious..... Below is a quick "down and dirty" of the changes that are on the horizon for the 2010 consultations. This came to me by way of Gail Eldridge (Coding Goddess extraordinaire!) so I am sharing with all of my Blogging friends! E-mail me if you have ??'s or concerns... networking is one of the best ways to problem solve!!! Enjoy your holiday and keep on coding!

What's Coming for Consultations in 2010

There are some major changes to inpatient consultation codes coming Jan.1st, 2010. Unfortunately I still have unclear guidance on exactly what the changes will mean to you. Stay tuned next month for more information

What we do know

- As of January 1st, 2010 Medicare will no longer pay for the inpatient or outpatient consultation codes (99241-99245 and 99251-99255)

- Outpatient consultations will be billed with the new patient E&M codes (99201-99205)

- Inpatient consultations will be billed with either an Initial hospital Care code(99221-99223) or a subsequent hospital care code (99231-99233)

- Medicare will now pay for more than 1 provider to bill the Initial hospital care code (99221-99223) multiple specialties will now be able to bill this code

- An unknown modifier will need to be appended to the Initial hospital care code(99221-99223) of the admitting physician

- Work RVU values will be increased for new patient E&M codes (99201-99205) and Initial hospital and subsequent hospital care codes (99221-99223 and 99231-99233)

- The 2010 CPT description of the consultation codes actually loosens the language of when you can bill a consultation. New language states "recommend care or assume ongoing management" it also states that the request for the consult can now be documented by the requesting or the rendering provider

- Telemedicine consultations will still be paid with the appropriate G-Codes

What we don't know- We have no idea which other payors will be paying for these codes if any or what RVU value will be assigned. It is suspected that several Idaho payors may continue to allow use of the inpatient and outpatient consultation codes

- The only payor that has announced they will pay for the consultation code set is on the east coast with no active members in Idaho

Sunday, December 20, 2009

The "infamous" Christmas Letter.........

Yes..... It's that dreaded Christmas "letter"! So pour yourself a BIG glass of your favorite wine and settle in for lots of bragging. (I do have the cutest grandson EVER!!!) Oh yeah, and I didn’t win the lottery. ha ha ha...

Not much changes here @ our place in Idaho, so I really don't have a lot to "update" you on. So to spare you the gory details, and not bore you outta your mind... I'll just wish you a


Remember to say "I love you" to your family, friends, and all the wonderful people that we have in our lives. May God help you "fill in your dash" with the things that make you happy!

Oh, Yeah…..about that glass of wine…. Celebrate and toast to a really good 2009 and to the promise of 2010.

Love Always...


Tuesday, December 8, 2009

Surgical Coding Basics - Free Webinar

Surgical Coding Basics FREE WEBINAR....

Tomorrow - will be hosting a free webinar on Surgical Coding Basics. If you are interested, please access their site, and join, then log in tomorrow for some really great information.

I have posted the majority of the info below... but you'll need to sign up to view from your own computer!



Date: Wednesday December 09, 2009

Time: 12:00 ET (Please log in at least five minutes before the start of the presentation).

Weblink (to view and listen on your computer):

All course materials are available online.

Can't make the live event?
All sessions are archived after the air-date for you to view on-demand. Follow the weblink above to access the webinar at you convenience.

Spread the word:
Feel free to invite your colleagues to join you. Please be sure to let us know the total number of participants from your office on the webinar so that we can accurately track the response to this program.

Technical assistance:
If you experience any problems during the webinar or are unable to log into the session, please email

Minimum Technical Requirements

We appreciate your time, and hope you will join us for future webinars. Questions? Ask Amanda at 410 818 2704, e-mail, or visit

Tuesday, December 1, 2009

CPT Modifiers – Know Them by Family

HI TO ALL!!! With the Holiday season upon us, it has been a very busy few weeks. However, I came across this article and thought I would share out to all of you. This is from the "Coding Compliance Advisor Newsletter - November 2009"
(put out by WoltersKlewer) I know that modifiers can be so very difficult, but this brief article really helps put it into perspective... ENJOY!

CPT Modifiers – Know Them by Family
By Laureen Jandroep, CPC

To better choose what modifier to use follow these steps:

1. Identify your situation

2. Match it to that family of modifiers

3. Pick the modifier in that family that best describes you situation

Modifiers and Compliance

Modifiers help tell the rest of the story when it comes to coding. As with all coding, any modifiers appended to a code need to be substantiated in the medical record. Due to the nature of many modifiers bypassing computer edits on the payers side that would otherwise block a line item or entire claim from being paid the coder has to be especially careful about the selection of modifiers.

Global Package Modifier Family

If you need to submit a claim for service that occurred in a global period that is not for routine follow up consider one of the “Global Package” modifiers. First you have to determine if the patient is in a global period. Most payers follow Medicare guidelines which are published in the Medicare Physician Fee Schedule Database ( There is a column for each CPT and HCPCS Level II labeled “Global Days” and will contain one of the following:

000 This means there are no global days assigned to this code. These will generally be assigned to endoscopic or minor procedures.

010 For minor procedure with expected normal follow up in a 10 day period.

090 For major surgery with a 1-day preoperative period and a 90-day postoperative period included in the fee.

MMM For maternity codes where the usual global period does not apply.

XXX For codes where the global concept does not apply

YYY For codes where the carrier is to determine whether the global concept applies.

ZZZ The code is related to another service and is always included in the global period of the other service.

Once you determine that you are indeed in a global period for this patient you need to apply one of these modifiers for your claim to even be considered for reimbursement. Most of these modifiers don’t adjust the fee—it just gets the claim through the door for consideration.

Global Package Modifier Family

Brief Description
How to Use

Unrelated E/M service by the same physician during a post-op period
Use this modifier when you have an E&M visit that has nothing to do with the surgery that has put the patient into a global period. Per CPT Assistant May 1997 “"Modifier -24 is used when a physician provides a surgical service related to one problem and then during the period of follow-up care for the surgery provides an evaluation and management service unrelated to the problem requiring the surgery." Note it does not say unrelated to the surgery itself.

Decision for surgery
For surgeries with a 90-day global period you also have a 1-day preop period that is bundled in. This is for the preop visit after the decision for surgery has been made. If the visit where the decision for surgery was made happens to be the day of or before the surgery it will get bundled in to the surgery code unless you append this modifier.

Staged or related procedure
Use this modifier when you are providing another non EM procedure that is related to the procedure putting the patient in the global period. Without it your claim will be kicked back.

Repeat procedure by same physician
Use this modifier when you need to report the same CPT code within the global period of the first. This will identify the procedure as not being a data entry error and will also get it through the door to even be considered.

Repeat procedure by another physician
Same as for -76 but with a different physician performing the service.

Return to OR for a related procedure during the postop period
Typically this modifier is used when the patient has complications and needs to return to the operating room for treatment.

Unrelated procedure or service by the same physician during the postop period
Use this modifier when you are providing another non EM service that is not related to the surgery that has put the patient in the global period.

Surgical care only
These three modifiers are designed to break up the global package in its relative pieces of one surgical CPT code. There would need to be a documented transfer of care between the physicians sharing the surgery CPT code. Most payers bundle the preop with the surgical care piece so it is rarely used.

Postoperative management only

Preoperative management only

Bundling Modifier Family

In this family of modifiers you’re dealing with codes that could be bundled into other codes or represent a portion of a service represented by a code.

Brief Description
How to Use

Significant separately identifiable E/M service
When ever you bill an E&M service with a procedure you will need to append this modifier to the E&M code or else it will not get paid. The payer considers each procedure code to have an inherent E&M component so unless you append modifier -25 they will think the E&M is this inherent component and will bundle it into the procedure code. Your E&M code should be clearly separate from the procedure note. A different diagnosis helps to show the E&M is truly separate from the procedure but is not required.

Professional component
Many codes when reported represent a global code – most of your radiology codes fall into this category. If reported without a modifier the full fee will be paid. If your physician only provided the professional component (interpretation and report) append -26. If your practice owns the equipment and employs the staff to run it but you did not provide the professional component append –TC.

Distinct procedural service
This modifier is used when you have multiple procedures and one is usually considered a component of another. The National Correct Coding Initiative edits ( are used by Medicare and many other payers to determine this. If you have two codes that are considered bundled together but they were done at separate times, separate locations on the body, etc. you can override the edit by using -59.

Thursday, November 19, 2009


Hi to all my blog-spot friends... This was sent to me to send out and get the word out regarding HAI's. As I look at this, the more committed we need to be to reduce these infections. In addition to some GREAT information, (and websites) they also have CE credits available.

Please take the time to read and learn about HAI's.

Thanks!!! L : )

(reproduced in part from with consent from

When someone develops an infection at a hospital or other patient care facility that they did not have prior to treatment, this is referred to as a healthcare-associated (sometimes hospital-acquired) infection (HAI).Healthcare-associated infections (HAIs) are a global crisis affecting both patients and healthcare workers.According to the World Health Organization (WHO), at any point in time, 1.4 million people worldwide suffer from infections acquired in hospitals.A Centers for Disease Control (CDC) report published in March-April 2007 estimated the number of U.S. deaths from healthcare associated infections in 2002 at 98,987.The risk of acquiring healthcare-associated infections in developing countries is 2-20 times higher than in developed countries.

Afflicting thousands of patients every year, HAI often leads to lengthening hospitalization, increasing the likelihood of readmission, and adding sizably to the cost of care per patient.Financially, HAIs represent an estimated annual impact of $6.7 billion to healthcare facilities, but the human cost is even higher.Until recently, a lack of HAI reporting requirements for healthcare facilities has contributed to less-than-optimal emphasis being placed on eliminating the sources of healthcare associated infections. However, growing public anxiety regarding the issue and resulting legislation on state and local levels demanding accountability is serving to accelerate initiatives to combat HAIs.To learn more about the impact of healthcare-associated infections for both medical professionals and patients, please visit
About Not on My Watch Prevention Campaign.

To protect patients by reducing the risk of HAI, healthcare professionals must continually update their knowledge of infection management.
As part of an ongoing commitment to quality care and infection prevention, nationwide doctors and hospitals are partnering with Kimberly-Clark to deliver continuing education programs on healthcare-associated infection (HAI) prevention to staff and management. As simple as education sounds, busy doctors and nurses on the front lines of delivering care can find it difficult to find the time to take advantage of scheduled programs within their hospitals.

The HAI Education Program is part of a national infection awareness campaign for healthcare professionals called “Not on My Watch” and will provide the facility with a toolkit that contains informational flyers, patient safety tips and posters.

The "Not on My Watch" campaign provides accredited continuing education (CE) programs based on best practices and guidelines as well as research available on reducing the incidence of healthcare-associated infections.

For details about the "Not On My Watch" campaign, and the HAI Education Bus please visit

Saturday, October 24, 2009

Interesting Week... H1N1 at the forefront of the news.....

This has really been an interesting week... with H1N1 being at the forefront of the news, I am sure you have had coding issues come up surrounding it!

According to "Beckers Hospital Review"

The American Medical Association has expedited the publication of a new code specific to vaccine administration and revised existing code 90663 to include the H1N1 vaccine, according to an AMA news release.
The new codes will streamline the reporting and reimbursement procedure for physicians and healthcare providers administering the vaccinations and help to report and track immunization and counseling services related to the H1N1 vaccine throughout the healthcare system, according to the release.

Codes were created in consultation with the Department of Health and Human Services. Code 90470 was created to report H1N1 immunization administration and counseling. Code 90663 was revised by the CPT Editorial Panel to refer specifically to the H1N1 vaccine product. Both codes are effective immediately.

For reference, the two CPT codes are:

* 90470-H1N1 immunization administration (intramuscular, intranasal), including counseling when performed

* 90663-Influenza virus vaccine, pandemic formulation, H1N1

Your ICD-9 Driver should be codes

* 487.0 Influenza w/pneumonia
* 487.1 Influenza w/other respiratory manifestations
* 487.8 Influenza with other manifestations

* 488.0 Influenza due to identified avian influenza virus
* 488.1 Influenza due to identified novel H1N1 influenza virus

* V04.81 Influenza (Need for prophylactic vaccination/innoculation)
* V04.89 Other Viral Diseases (Need for prophylactic vaccination/innoculation)

Keep in mind too, that if you are giving additional vaccinations at the same time, you will need to review the criteria in your CPT books.

Stay Healthy and next week I'll post the Audit criteria for Medical Decision Making!

Saturday, October 17, 2009

Auditing Basics: EXAM (aka... touch)

Exam also known as touch

The exam criteria for auditing has 2 different methodologies to choose from. CMS allows us to choose either the 1995 guidelines or the 1997 guidelines to choose from.

Lets explore the 1995 exam guidelines. The 1995 guidelines allow us to recognize either a "body area" or a body "organ system" These are broken down below.

the following body areas are recognized:

• Head, including the face

• Neck

• Chest, including breasts and axillae

• Abdomen

• Genitalia, groin, buttocks

• Back, including spine

• Each extremity

you can choose to utilize body "organ systems" (do not intermix and confuse the two)

the following organ systems are recognized:

•Constitutional (e.g., vital signs, general appearance)
* Ears, nose, mouth and throat
• Cardiovascular
* Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric

When utilizing the 95 guidelines for "body systems" or "body areas" to determine the level to be met CMS has outlined the criteria as:

1995 Guidelines = Problem Focused exam is limited to the affected body area or 1 organ system

1995 Guidelines = Expanded Problem Focused exam is to examine the affected body area + other symptomatic or related organ systems for a total of between 2-4 body areas, or organ systems examined

1995 Guidelines = Detailed exam is to examine the affected body area + other symptomatic or related organ systems for a total of between 5-7 body areas, or organ systems examined

1995 Guidelines = Comprehensive exam is to completely examine the affected body area + other symptomatic or related organ systems for a total of 8 or more body areas, or organ systems examined.

Interestingly, the 1995 guidelines published from CMS was a document of aproximately 15 pages, where the 1997 guidelines were closer to 60 pages. So, from that perspective you have more "choices" in the 1997 bullet points, but less confusion with the 1995 exam criterias.

Now.. Let's explore the 1997 examination guidelines or "bullet points" as they are commonly known as. These "bullet's" are encompassed and "bulleted" to make it easier to "count" which areas have been examined. These bullet points have been broken down as a "multi-system" examinination with a comprehensive laundry list of body areas that can be examined, or you can choose to utilize the 1997 "single system" examination bullet points to meet the criteria. The table below outlines the "multi-system" exam bullet points.

1997 Problem Focused = 1-5 elements denoted by a "bullet"

1997 Expanded Problem Focused = 6-11 or more elements denoted by a "bullet"

1997 Detailed = 12-17 elements denoted by a "bullet" OR at least 2 elements identified from six areas/systems

1997 Comprehensive = 18 or more bullets OR all bullets in 9 or more "systems/areas"

**Separate criteria for Single sytem exam - found within the 1997 CMS guidelines (see link)

System/Body Area

Elements of Examination


• Measurement of any three of the following seven

vital signs: 1) sitting or standing blood pressure,

2) supine blood pressure, 3) pulse rate and

regularity, 4) respiration, 5) temperature, 6)

height, 7) weight (may be measured and recorded)

• General appearance of patient e.g. development,

nutrition, body habitus, deformities, attention to



• Inspection of conjunctivae and lids.

• Examination of pupils and irises e.g. reaction to

light and accommodation, size and symmetry.

• Ophthalmoscopic examination of optic discs e.g.

size, C/D ration, appearance and posterior segments

e.g. vessel changes, exudates, hemorrhages.

Ears, nose,

• External inspection of ears and nose e.g. overall

mouth & throat

appearance, scars, lesions, masses.

• Otoscopic examination of external auditory canals

and tympanic membranes.

• Assessment of hearing e.g. whispered voice,

finger rub, tuning fork.

• Inspection of nasal mucosa, septum and turbinate

• Inspection of lips, teeth, and gums

• Examination of oropharynx: oral mucosa, salivary

glands, hard and soft palates, tongue, tonsils and

posterior pharynx.


• Examination of neck e.g. masses, overall

appearance, symmetry, tracheal position, crepitus.

• Examination of thyroid e.g. enlargement

tenderness, mass.


• Assessment of respiratory effect e.g. intercostal

retractions, use of accessory muscles,

diaphragmatic movement.

• Percussion of chest e.g. dullness, flatness,


• Palpation of chest e.g. tactile fremitus

• Auscultation of lungs e.g. breath sounds,

adventitious sounds, rubs.


• Palpation of heart e.g. location, size, thrills

• Auscultation of heart with notation of abnormal

sounds and murmurs.

Examination of:

• Carotid arteries e.g. pulse amplitude, bruits.

• Abdominal aorta e.g. size, bruits

• Femoral arteries e.g. pulse amplitude, bruits.

• Pedal pulse e.g. pulse amplitude

• Extremities for edema and/or varicosities


• Inspection of breasts
e.g. symmetry, nipple



• Palpation of breasts and axillae e.g. masses or

lumps, tenderness.


Examination of abdomen with notation of


presence of masses or tenderness.

• Examination of liver and spleen

• Examination of presence or absence of hernia.

• Examination when indicated of anus, perineum

and rectum, including sphincter tone, presence of

hemorrhoids, rectal masses.

• Obtain stool sample for occult blood test when indicated.


• Examination of the scrotal contents e.g.


hydrocele, spermatocele, tenderness of cord.

• Examination of the penis.

• Digital rectal examination of prostate gland e.g.

size, symmetry, nodularity, tenderness.


Pelvic examination (with or without specimen


collection for smears and cultures) including:

• Examination of external genitalia e.g. general

appearance, hair distribution, lesions and vagina

e.g. general appearance, estrogen effect, discharge,

lesions, pelvic support, cystocele, rectocele.

• Examination of the urethra e.g. masses,

tenderness, scarring.

• Examination of the bladder e.g. fullness, masses,


• Cervix e.g. general appearance, lesions, discharge.

• Uterus e.g. size, contour, position, mobility,

tenderness, consistence, descent or support.

• Adnexa/parametria e.g. masses, tenderness,

organomegaly, nodularity.


Palpation of lymph nodes in two or more areas:

• Neck

• Axillae

• Groin

• Other


• Examination of gait and station.

• Inspection and/or palpations of digits and nails

e.g. clubbing, cyanosis, inflammatory conditions,

petechiae, ischemia, infections, nodes.

Examination of joints, bones and muscles of one or

more of the following six areas 1) head and neck, 2)

spine, ribs and pelvis, 3) right upper extremity, 4) left

upper extremity, 5) right lower extremity, 6) left lower

extremity. The examination of a given area.

• Inspection and/or palpation with notation of

presence of any misalignment, asymmetry,

crepitation, defects, tenderness, masses.

• Assessment of range of motion with notation of

any pain, crepitation or contracture.

• Assessment of stability with notation of any

dislocation (luxation), subluxation or laxity.

• Assessment of muscle strength and tone e.g.

flaccid, cog wheel, spastic with notation of any

atrophy or abnormal movements.


• Inspection of skin and subcutaneous tissue e.g.

rashes, lesions, ulcers.

• Palpation of skin and subcutaneous tissue e.g.

induration, subcutaneous nodules, tightening.


• Test cranial nerves with notation of any deficits.

• Examination of deep tendon reflexes with notation

of pathological reflexes e.g. Babinski.

• Examination of sensation e.g. by touch, pin,

vibration, proprioception.


• Description of patient's judgment and insight

Brief assessment of mental status including:

• Orientation to time, place and person

• Recent and remote memory

• Mood and affect e.g. depression, anxiety, agitation.

If you’re still confused regarding exam criteria, please e-mail me or contact me, and I’ll do my best to help!