Sunday, November 14, 2010

BIG NEWS for me & a Podiatry coding issue....

Big news I want to share… (and education too!)

I have received good news from the AAPC this week. I just have to share with all of my blog followers. I have been chosen to speak at the national AAPC conference in April of 2011. It will be held in Long Beach, CA. I will be presenting on the daVinici robotic assist device utilized in a variety of surgeries. This is a presentation that is near and dear to my heart, as the surgeons that I work with, show me what successes they have every day utilizing this incredible robotic system.

I presented this educational session at our local chapter meeting in Boise, and had some GREAT feedback. If you would like to have the opportunity to see my presentation in Long Beach, here’s a quick link to see what the AAPC has out on the website regarding the conference.

I have also submitted this presentation to AHIMA, and am hopeful that I will get the opportunity to bring this to the AHIMA national conference in Salt Lake City in October 2011. I’ve got my fingers crossed that they’ll pick it up too.

And now….. back to our educational blog……..

Tenotomy – Toe: Percutaneous vs/Open procedure codes.

I was coding podiatry op reports, and came across an issue from the podiatrist. He wanted me to code/bill for an “open” hammer toe tenotomy (code 28232) that was performed in the office.

When I reviewed the documentation, it was really a “percutaneous” hammer toe tenotomy (code 28010) that he performed and he noted it as such. He did the release of the tendon with a needle.

The key CPT notation between these two procedures is the “percutaneous” vs/the “incisional” modality in the provider’s documentation. Because the podiatrist stated he did this procedure “percutaneously” I was able to code/bill this correctly. If you are unable to determine how the procedure was performed, do not “guess” or “assume”. Query your provider, then have them amend or update the documentation to clarify the procedure prior to the billing of your claim.

Definition of both procedures are:

Code 28010 Tenotomy, percutaneous, toe; single tendon

“This procedure is performed to correct mallet or hammer toe. The physician makes a small percutaneous incision at the crease of the toe where the tendon is restricted. The tendon is released from the bone and the toe is straightened. The incision is sutured and dressing applied. “

Code 28232 Tenotomy, open, tendon flexor; toe, single tendon (separate procedure)

“This procedure is often done for repair of hammer toe. A small incision is made on the crease of the toe on the bottom of the foot. The skin is reflected and the tendon is exposed. The tendon is released from its attachment site allowing the toe to extend. This is usually is accompanied by other procedures. The incision is closed with sutures and a soft dressing is applied. Report 28234 if the incision is made on the dorsal toe and the extensor tendon is released”

Thanks again for allowing me to share my experiences with you, and I hope that I get the opportunity to meet you in person in Long Beach! HAPPY CODING!

Saturday, November 6, 2010


Tuesday, November 02, 2010

CMS Office of Public Affairs



The Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment period on Nov. 2, 2010 that updates payment policies and Medicare payment rates under the Medicare Physician Fee Schedule (MPFS) for physicians’ services furnished in CY 2011. In addition to payment policy and payment rate updates, the MPFS addresses a number of provisions of the Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the “Affordable Care Act”). Although most of the provisions included in the final rule directly affect payments provided under the MPFS, the rule also addresses a number of policies that are not directly related to this payment system.


Since 1992, Medicare has paid for the services of physicians, NPPs, and certain other suppliers under the MPFS, a system that pays for covered physicians’ services furnished to a person enrolled under Medicare Part B. Under the MPFS, in general, a relative value is assigned to each of more than 7,000 services to capture the amount of work, the direct and indirect (overhead) practice expenses, and the malpractice insurance expenses typically involved in furnishing the service. The higher the number of relative value units (RVUs) assigned to a service, the higher the payment. The RVUs for a particular service are multiplied by a fixed-dollar conversion factor and a geographic adjustment factor to determine the payment amount for each service.

Affordable Care Act Provisions INCLUDED IN THE CY 2011 MPFS FINAL RULE

Primary Care & Prevention

  • Elimination Of Deductible And Coinsurance For Most Preventive Services: Effective Jan. 1, 2011, the Affordable Care Act waives the Part B deductible and the 20 percent coinsurance that would otherwise apply to most preventive services. Specifically, the provision waives both the deductible and coinsurance for Medicare-covered preventive services that have been recommended with a grade of A (“strongly recommends”) or B (“recommends”) by the U.S. Preventive Services Task Force (USPSTF), as well as the initial preventive physical examination and the new annual wellness visit. The Affordable Care Act also waives the Part B deductible for tests that begin as colorectal cancer screening tests but, based on findings during the test, become diagnostic or therapeutic services.
  • Coverage Of Annual Wellness Visit Providing A Personalized Prevention Plan: The Affordable Care Act extends the preventive focus of Medicare coverage, which currently pays for a one-time initial preventive physical examination (IPPE or the “Welcome to Medicare Visit”), to provide coverage for annual wellness visits in which beneficiaries will receive personalized prevention plan services (PPPS). The law states that the annual wellness visit may include at least the following six elements, as determined by the Secretary of Health and Human Services:
  • Establish or update the individual’s medical and family history.
  • List the individual’s current medical providers and suppliers and all prescribed medications.
  • Record measurements of height, weight, body mass index, blood pressure and other routine measurements.
  • Detect any cognitive impairment.
  • Establish or update a screening schedule for the next 5 to 10 years including screenings appropriate for the general population, and any additional screenings that may be appropriate because of the individual patient’s risk factors.
  • Furnish personalized health advice and appropriate referrals to health education or preventive services.

CMS has developed two separate Level II HCPCS codes for the first annual wellness visit (G0438 – Annual wellness visit, including personalized prevention plan services, first visit), to be paid at the rate of a level 4 office visit for a new patient (similar to the IPPE), and for subsequent annual wellness visits (G0439 – Annual wellness visit, including personalized prevention plan services, subsequent visit), to be paid at the rate of a level 4 office visit for an established patient.

  • Incentive Payments To Primary Care Practitioners For Primary Care Services: The Affordable Care Act provides for incentive payments equal to 10 percent of a primary care practitioner’s allowed charges for primary care services under Part B. Under the final policy, primary care practitioners are: (1) physicians who have a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; as well as nurse practitioners, clinical nurse specialists, and physician assistants; and (2) for whom primary care services accounted for at least 60 percent of the practitioner’s MPFS allowed charges for a prior period as determined by the Secretary of Health and Human Services. The law also defines primary care services as limited to new and established patient office or other outpatient visits (CPT codes 99201 through 99215); nursing facility care visits, and domiciliary, rest home, or home care plan oversight services (CPT codes 99304 through 99340); and patient home visits (CPT codes 99341 through 99350).

In the final rule with comment period, CMS excluded consideration of allowed charges for hospital inpatient care and emergency department visits in determining whether the 60 percent primary care threshold is met. These exclusions will make it easier for providers in rural areas to become eligible for the payment incentive program. The incentive payments will be made quarterly based on the primary care services furnished in CY 2011 by the primary care practitioner, in addition to any physician bonus payments for services furnished in Health Professional Shortage Areas (HPSAs).

CMS will determine a practitioner’s eligibility for incentive payments in CY 2011 using claims data and the provider’s specialty designation from CY 2009 for practitioners enrolled in CY 2009. For newly enrolled practitioners, CMS will use claims data from CY 2010 to make an eligibility determination regarding CY 2011 incentive payments. For subsequent years, CMS will revise the list of primary care practitioners on a yearly basis, based on updated data regarding an individual’s specialty designation and percentage of allowed charges for primary care services.

Improving Payment

  • Incentive Payments For Major Surgical Procedures In Health Professional Shortage Areas: The Affordable Care Act also calls for a payment incentive program to improve access to major surgical procedures – defined as those with a 10-day or 90-day global period under the MPFS – that are furnished by physicians in Health Professional Shortage Areas (HPSAs) between Jan. 1, 2011 and Dec. 31, 2016. To be eligible for the incentive payment, the physician must be enrolled in Medicare as a general surgeon. The amount of the incentive payment is equal to 10 percent of the MPFS payment for the surgical services furnished by the general surgeon. The incentive payments will be made quarterly to the general surgeon when the major surgical procedure is furnished in a zip code that is located in a HPSA. CMS will use the same list of HPSAs that it has used under the existing HPSA bonus program
  • Medicare Economic Index (MEI): The MEI is an inflation index for physician practice costs that is used as part of the formula to calculate annual updates to MPFS rates. For CY 2011, CMS is rebasing and revising the MEI to use a 2006 base year in place of a 2000 base year. This update to the MEI is the first time it has been rebased and revised since 2004. In addition, the final rule with comment period announces CMS’ plans to convene a technical advisory panel to review all aspects of the MEI, including inputs, input weights, price-measurement proxies, and productivity adjustment; and indicates that CMS will consider the panel’s analysis and recommendations in future rulemaking.
  • Revisions To The Practice Expense Geographic Adjustment: As required by the Medicare law, CMS adjusts payments under the MPFS to reflect local differences in practice costs. CMS assigns separate geographic practice cost indices (GPCIs) to the work, practice expenses (PE), and malpractice insurance cost components of each of more than 7,000 types of physicians’ services. The final rule with comment period discusses CMS’ analysis of PE GPCI data and methods, and incorporates new data as part of the sixth GPCI update, while keeping the GPCI cost share weights the same pending the results of further CMS and Institute of Medicine studies.

The Affordable Care Act establishes a permanent 1.0 floor for the PE GPCI for frontier states (currently, Montana , Wyoming , Nevada , North Dakota , and South Dakota ). The Affordable Care Act limits recognition of local differences in employee wages and office rents in the PE GPCIs for CYs 2011 and 2012 as compared to the national average. Localities are held harmless for any decrease in CYs 2011 and 2012 in their PE GPCIs that would result from the limited recognition of cost differences. CMS will continue to review the GPCIs in CY 2011, in accordance with the Affordable Care Act provision that requires the Secretary of Health and Human Services to analyze current methods of establishing PE GPCIs in order to make adjustments that fairly and reliably distinguish the costs of operating a medical practice in the different fee schedule areas.

  • Permitting Physician Assistants To Order Post-Hospital Extended Care Services: The Affordable Care Act newly authorizes physician assistants to perform the level of care certification that is one of the requirements for coverage under Medicare’s skilled nursing facility (SNF) benefit.
  • Payment For Bone Density Tests: The Affordable Care Act increases the payment for two dual-energy x-ray absorptiometry (DXA) CPT codes for measuring bone density for CYs 2010 and 2011. This provision requires payments for these preventive services to be based on 70 percent of their CY 2006 RVUs and the 2006 conversion factor, and the current year geographic adjustment.
  • Improved Access To Certified Nurse-Midwife Services: The Affordable Care Act increases the Medicare payment for certified nurse-midwife services from 65 percent of the PFS amount for the same service furnished by a physician to 100 percent of the PFS amount for the same service furnished by a physician (or 80 percent of the actual charge if that is less). The increased payment amount is effective for services furnished on or after Jan. 1, 2011.
  • Extension Of Medicare Reasonable Cost Payments For Certain Clinical Diagnostic Laboratory Tests Furnished To Hospital Patients In Certain Rural Areas: The Affordable Care Act reinstitutes reasonable cost payment for clinical diagnostic laboratory tests performed by hospitals with fewer than 50 beds that are located in qualified rural areas as part of their outpatient services for cost reporting periods beginning on or after July 1, 2010 through June 30, 2011. For some hospitals whose cost reports begin as late as June 30, 2011, this could affect services performed as late as June 29, 2012, because this is the date those cost reports will close.
  • Physician Self-Referral Disclosure Requirement For Certain Imaging Services: The Affordable Care Act amends the in-office ancillary services exception to the physician self-referral law as applied to magnetic resonance imaging, computed tomography, and positron emission tomography, to require a physician to disclose to a patient in writing at the time of the referral that the patient may obtain these services from another supplier. CMS will require that the referring physician provide the patient with a list of five alternative suppliers within a 25-mile radius of the physician’s office location at the time of the referral who provide the imaging services ordered.
  • Adjustments To The Medicare Durable Medical Equipment, Prosthetics, Orthotics, And Supplies Competitive Bidding Program: The Affordable Care Act expands round 2 of the durable medical equipment (DME) competitive bidding program from 70 metropolitan statistical areas (MSAs) to 91 MSAs by adding the next 21 largest MSAs by total population not already selected for rounds 1 or 2. The 2009 annual population estimates from the U.S. Census Bureau are the most recent estimates of population that will be available prior to the round 2 competition mandated to take place in CY 2011.

Improving Payment Accuracy

  • Misvalued Codes Under The Physician Fee Schedule: The Affordable Care Act requires CMS to periodically review and identify potentially misvalued codes and make appropriate adjustments to the relative values of the services that may be misvalued. CMS has been engaged in a vigorous effort over the past several years to identify and revise potentially misvalued codes. The final rule with comment period identifies additional categories of services that may be misvalued, including codes with low work RVUs commonly billed in multiple units per single encounter and codes with high volume and low work RVUs. The final rule also includes CMS’ response to recommendations from the American Medical Association (AMA) Relative Value Update Committee (RUC) for CY 2011 regarding the work or direct practice expense inputs for 325 CPT codes.
  • Multiple Procedure Payment Reduction Policy for Therapy Services: The Affordable Care Act requires CMS to identify and make adjustments to the relative values for multiple services that are frequently billed together when a comprehensive service is furnished. Although not part of the Affordable Care Act, to more appropriately recognize the efficiencies when combinations of therapy services are furnished together, CMS is adopting a multiple procedure payment reduction policy for therapy services that will reduce by 25 percent the payment for the practice expense component of the second and subsequent therapy services furnished by a single provider to a beneficiary on a single date of service. This policy will apply to all outpatient therapy services paid under Part B, including those furnished in office and facility settings.
  • Modification Of Equipment Utilization Factor and Modification of Multiple Procedure Payment Policy For Advanced Imaging Services: The Affordable Care Act adjusts the equipment utilization rate assumption for expensive diagnostic imaging equipment and, as a result, reduces payment rates for the associated procedures relative to 2010. Effective Jan. 1, 2011, CMS will assign a 75 percent equipment utilization rate assumption to expensive diagnostic imaging equipment used in diagnostic computed tomography (CT) and magnetic resonance imaging (MRI) services. In addition, beginning on July 1, 2010, the Affordable Care Act increased the established MPFS multiple procedure payment reduction for the technical component of certain single-session imaging services to consecutive body areas from 25 to 50 percent for the second and subsequent imaging procedures performed in the same session.
  • Revision To Payment For Power-Driven Wheelchairs: As required by the Affordable Care Act, CMS is adjusting the payment schedule for power-driven wheelchairs under the Medicare Part B fee schedule to pay 15 percent (instead of 10 percent) of the purchase price for the first three months of the 13 month rental period and 6 percent (instead of 7.5 percent) for the remaining months. Payment is based on the lower of the supplier’s actual charge and the fee schedule amount.

In addition, the Affordable Care Act eliminates the lump sum (up-front) purchase payment option for standard power-driven wheelchairs. CMS has revised the regulations to conform to this new requirement, which permits payment only on a monthly rental basis for standard power-driven wheelchairs effective for items furnished on or after Jan. 1, 2011. For complex rehabilitative power-driven wheelchairs, the regulations continue to permit payment to be made on either a lump sum purchase method or a monthly rental method.

The Affordable Care Act also specifies that these changes do not apply to payments made for power-driven wheelchairs furnished pursuant to contracts entered into prior to Jan. 1, 2011 as part of the Medicare DMEPOS competitive bidding program.

  • Maximum Period For Submission Of Medicare Claims Reduced To Not More Than 12 Months–; The Affordable Care Act reduced the maximum time period for submission of Medicare fee-for-service claims to one calendar year after the date of service. This change, which applies to services furnished after Jan. 1, 2010, reflects a reduction to the prior maximum timely filing deadline of 15 to 27 months. The Affordable Care Act also mandated that providers and suppliers file claims for services furnished prior to Jan. 1, 2010 no later than December 31, 2010. The final rule revises the timely filing regulations to reflect these new requirements. It also establishes three new exceptions to the timely filing requirements for retroactive entitlement situations, dual-eligible beneficiary situations, and retroactive disenrollment from Medicare Advantage plans or PACE provider organizations.

The final rule with comment period will appear in the Nov. 29, 2010, Federal Register. CMS will accept comments on certain aspects of the final rule with comment period until Jan. 3, 2011, and will respond to them in a final rule to be issued on or about Nov. 1, 2011 that sets forth the policies and payment rates effective for services furnished to Medicare beneficiaries on or after Jan. 1, 2012.

For more information, see:

November Coding Tips

** Here's the buzz for November -- Cerumen Removal(s) and also a quick update on Obsteteric U/sounds trans-vag and trans-abdominal... Enjoy....


Cerumen Removal (69210)

Here is the guidance from CPT-

A major element in determining whether code 69210 should be reported is understanding the definition of impacted cerumen. By definition of the AAO-HNS,

“If any one or more of the following are present, cerumen should be considered ‘impacted’ clinically:

* Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.

* Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.

* Inflammatory considerations: Associated with foul odor, infection, or dermatitis.

* Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.”

Other issues may also require consideration. Removing wax that is not impacted does not warrant the reporting of CPT code 69210. Rather, that work would appropriately be captured by an evaluation and management (E/M) code regardless of how it is removed. If, however, the wax is truly impacted, then its removal should be reported with 69210 if performed by a physician using at minimum an otoscope and instruments such as wax curettes.

To summarize:

  • Only bill for cerumen removal if the cerumen is impacted and there is provider involvement in the removal.

  • If the patient returns at a later date for an ear irrigation performed by the nurse only, a 99211 nurse visit code should be billed.


Billing for Transvaginal and Transabdominal Ultrasound on OB patients at the same session

Per CPT Ultrasound Guidelines: “If transvaginal examination is done in addition to transabdominal obstetrical ultrasound exam, use 76817 in addition to appropriate transabdominal exam code”.

When reporting multiple modalities, and expecting to receive reimbursement,the clinical indications are usually the determining factor if the claims will be reimbursed. Most payers will pay this coding combination when the following criteria have been met:

There must be a clinical indication as to why both modalities are warranted and the diagnosis codes must be linked accordingly.

Example : Complete and Detailed Ultrasound (CPT 76811) was performed due to suspected fetal anomaly OB Transvaginal Ultrasound (CPT 76817) was performed during the same session to evaluate the characteristics of cervix including length and structure for a patient with cervical incompetence.

The documentation must clearly define that both modalities were utilized.

Example : “In addition to the transabdominal approach, a transvaginal ultrasound as utilized to access the cervical length”.

According to Medicare National Correct Coding Policy Edits, October – December 2010 (Version 16.3), there are no current “bundling” edits in place that would not allow payment for both services. However…..some payers may require that the Modifier 59 Distinct Procedural Service) be attached to the transvaginal study when billed in conjunction with a transabdominal study.

Example :

76811 & 76817- 59 Or 76811- 26 & 76817- 26 - 59

If you are unsure about payment, always call the 3rd party payer (insurance carrier) regarding their policy of a specific CPT code and/or diagnosis.

Monday, November 1, 2010

Breast Cancer Awareness - A great website to check out...

Welcome my Friends….

As you know, October is breast cancer awareness month. However, breast cancer knows no season or month, so please continue education and information about this disease.

I received a great resource site from my friend Ava Jacobs on behalf of, a division of Elsevier:

Not only does this site have GREAT information, but also includes the opportunity for CME credit in regard to breast cancer diagnoses.

A short and sweet post today… but VERY IMPORTANT!


Sunday, October 24, 2010

Breast coding update - Understand surgical breast procedures to assign correct CPT codes

Hi to all… I thought it was fitting that I bring back an old article that I wrote in 2006, but updated with the new codes… A lot of good info here, and still as timely today, as it was then… Enjoy

Understand surgical breast procedures to assign correct CPT codes

Coders should understand medical terminology regarding surgical breast procedures to correctly bill the operative procedure that the physician performs. CPT has a complete section devoted to the breast. In this section, it is broken down into the following five core areas:

  • Incision – Surgical opening made with an instrument such as a scalpel or knife -
  • Excision – The surgical act of cutting out, cutting away or taking out
  • Introduction – Directing or placing of a needle, catheter or other medical implement into the body
  • Repair/reconstruction – To surgically correct a defect back to its original state
  • Unlisted procedures – No current CPT code given to a specific procedure that the physician as documented.

Understand incision breast codes

Report the following codes for incision procedures:

  • 19000Puncture aspiration of cyst of breast –

Explanation: A direct access (through the skin) to a cyst or lump within the breast is performed with a needle or trocar, then the fluid or tissue is removed and sent to pathology for analysis. Some clinicians refer to this as a percutaneous breast aspiration. These are most often performed in the office setting.

  • +19001Add on code for each additional cyst (listed separately)

Explanation: A CPT code that is “added on” to the core code but cannot have a 51 modifier attached.

  • 19020Mastotomy w/exploration OR drainage of abscess deep –

Explanation: a surgical opening of the breast with a scalpel or knife so the physician can look around (or explore) the interior of the breast tissue. This code can also be used if the physician surgically opens the breast (incision) to drain a cyst or abscess. This procedure can be performed in the office, but many physicians prefer to do them in a surgical suite, or outpatient setting.

  • 19030Injection procedure for ductogram or galactogram

Explanation: A Physician or technician injects with a needle, contrast dye directly into the breast to image the breast ducts. These diagnostic tests are usually performed for a diagnosis of abnormal nipple discharge.

Understand excision breast codes

Report the following codes for excision procedures:

  • 19100—Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)

Explanation: A biopsy the breast, using a long needle, through the skin, aimed toward the “lump” or “lesion”. X-ray or ultrasound guidance is not used. A core of breast tissue is then removed and forwarded to pathology for diagnosis.

  • 19101—Biopsy of breast; open, incisional

Explanation: An incision is made in the breast near the site of the mass or lump. The mass or lump is identified and a small tissue specimen is removed. This specimen is examined immediately. If the mass or lump is benign, the wound is repaired with layered closure. If malignant, the incision may be closed pending a separate, more extensive surgical session.

  • 19102—Biopsy of breast; percutaneous, needle core, using imaging guidance

Explanation: A biopsy of the breast, using a long needle, through the skin, aimed toward the “lump” or “lesion”. X-ray or ultrasound guidance IS USED. A core of breast tissue is then removed and forwarded to pathology for diagnosis.

  • 19103—Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance

Explanation: A biopsy of the breast, using a long needle, through the skin, aimed toward the “lump” or “lesion” that utilizes vacuum assistance, and rotates. X-ray, fluoroscopy or ultrasound guidance IS USED. A core of breast tissue is then removed and forwarded to pathology for diagnosis.

Add on code :+ 19295—Image guided placement, metallic localization clip, percutaneous, during breast biopsy (List separately in addition to code for primary procedure)

Explanation: An actual metal clip or wire is placed within the breast, and used to delineate the area of the breast that the physician needs to biopsy or perform an open exploration.

  • 19105—Ablation, cryosurgical, of fibroadenoma, including ultrasound guideance, EACH fibroadenoma

Explanation: The physician uses cryotherapy to obliterate a fibroadenoma of the breast. The patient's skin is cleansed and the ablation site is anesthetized. Ultrasound is used to locate the tumor. A cryoprobe is inserted through a small incision and placed within the fibroadenoma under ultrasound. The device initiates ice ball formation. The cryoprobe is warmed before removal from the breast. This code reports treatment of one fibroadenoma.

Radiology codes to consider with codes 19100–19103 include 76095, 76096, 76360, 76393 and 76942.

Understand FNAs

Fine needle aspiration (FNA) is a percutaneous procedure that uses a fine gauge needle (22 or 25 gauge) and a syringe to extract sample fluid from a cyst or to remove clusters of cells from a solid mass. FNA is an integral part of the diagnosis and treatment for many minor breast symptoms. Physicians use it as a tool for the diagnosis of cancerous cells within the breast.

When a physician finds a lump in the breast, he or she will send the patient to have a mammogram or ultrasound of the breast (specialized x-rays of the breasts). Depending on what the diagnostic mammogram/ultrasound reveals, the physician will determine the next course of treatment. Many times, that treatment includes a FNA in the office to determine whether the lump is solid or cystic (fluid-filled). If the FNA does not reveal any diagnostic information, the physician may consider a breast biopsy.

FNA, incisional breast procedure codes, and excisional breast procedure codes are billable for both male and female patients are not age exclusive. However, some local insurance carriers may render a “gender” denial because they view these codes are female-only. However, in men, breast lumps/cancers account for fewer than 1% of all breast malignancies reported, and 80% of all breast lumps found are benign—not malignant—according to the Y-ME National Breast Cancer Organization.©

Report the following codes to indicate a fine-needle aspiration:

  • 10021—Fine needle aspiration; without imaging guidance
  • 10022—Fine needle aspiration; with imaging guidance

Explanation: Fine needle aspiration (FNA) is a percutaneous procedure that uses a fine gauge needle (22 or 25 gauge) and a syringe to sample fluid from a cyst or remove clusters of cells from a solid mass. First, the skin is cleansed. If a lump can be felt, the radiologist or surgeon guides a needle into the area by palpating the lump. If the lump is non-palpable, the FNA procedure is performed under image guidance using fluoroscopy, ultrasound, or computed tomography (CT), with the patient positioned according to the area of concern. In fluoroscopic guidance, intermittent fluoroscopy guides the advancement of the needle. Ultrasonography-guided aspiration biopsy involves inserting an aspiration catheter needle device through the accessory channel port of the echoendoscope; the needle is placed into the area to be sampled under endoscopic ultrasonographic guidance. After the needle is placed into the region of the lesion, a vacuum is created and multiple in and out needle motions are performed. Several needle insertions are usually required to ensure that an adequate tissue sample is taken. CT image guidance allows computer-assisted targeting of the area to be sampled. At the completion of the procedure, the needle is withdrawn and a small bandage is placed over the area. Report 10021 if fine needle aspiration is performed without imaging guidance. Report 10022 if imaging guidance is used to assist in locating the lump.

Sunday, October 10, 2010

OB lacerations - New rules from ACOG & Placenta delivery only's

Well... just when you think you've got the world by the tail... someone changes the rules, and the world whirls around and bites you!!!

with this said... I was working on an appeal for payment of a 3rd degree laceration code that was performed at the time of a delivery. However...... in my research I found out that ACOG (American Congress of Obstetricians & Gynecologists) has bundled 3rd and 4th degree lacerations into the regular delivery code, but you are to append the modifier 22. (Effective as of Jan 1 2010)

My suggestions for getting this paid with the mod 22 attached is to ensure that the documentation from the provider states that the laceration is a 3rd or 4th degree, and clearly states the repair. If possible, have the provider also document the time it took to do this repair, over and above a 1st or 2nd degree repair. (which is also bundled into the delivery, but not separately payable).

So - If you are having the headache of not getting paid for those pesky lacerations.. ACOG put this out in their 2010 ACOG coding manual. If you need or want more info regarding this, please let me know or contact the ACOG for more info. As we all say... we learn more from our mistakes and failures, than we do from our successes. This was a great learning experience for me, so I'm glad to share with you!

Also... I had a situation come up this week, where the OB hospitalist arrived as the baby was being delivered by the nursing staff... and we debated whether or not to bill for a "precipitous delivery" or a "placenta delivery" only.

After much debate, we decided upon the "placenta delivery" only. That way, the OB hospitalists could get paid for the work they performed, and the antepartum care and the postpartum care would be billed by the OB that provided that service.

So what I learned from this last week... is you just never quit learning!!! PS... new ICD-9 codes were effective as of 10.01.2010... so be sure to review the new codes and put them into practice.

... Happy Coding.......... L : )

Saturday, September 18, 2010

Coding/Billing Guidelines for “Family visits/Consultations”

Coding/Billing Guidelines for “Family visits/Consultations”

This came to me this week when a co-worker’s family wanted to meet with the physician regarding a plan of care for dealing with her elderly parents, and their medical, social, and basic living needs. She was shocked to find out they could not just “bill” her Mom’s medicare. So, after some discussion and research this is what I found out we can do. (as a Coder, Provider or family member)

The bottom line from all the research that I did…. is that 3rd party payors do not want to pay for medical counseling unless the benificiary is present when the provider renders this service.

When I started digging, (and numerous phone calls made) the rationale from insurance carriers…to put in layman’s terms; it’s the same as “stolen identity”. Ie… "your credit card has been stolen and is being used to purchase services the cardholder never received or authorized". This made total sense to me once explained . (I also hadn't thought about the HIPPA issues involved too)

Wow!!!!… I guess I never realized that this could be such an complex issue for coders and providers too. CMS and CPT both have rules the providers must follow but do not necessarily mirror each other especially in light of HIPPA, billing criteria, and how to code for these services.

Anyway………Here’s the info I found to share on the subject for coders, providers, medical offices and family members to ponder if you are presented with this situation… I hope this clarifies some of the issues that surround this sticky issue! and as always, feel free to contact me regarding ??'s at

Enjoy! L : )


CPT gives us some direction how to deal with this…(straight from CPT)

99201 (-02, -03, -04, -05) Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family

So, in CPT language, this can be interpreted as

§ The provider can provide care and/or counseling and coordination of care with just the patient

§ The provider can provide care and/or counseling and coordination of care with just the family member

§ The provider can provide care and/or counseling and coordination of care with both together.

Where this gets problematic is the billing issues. These issues encompass the place of service such as Hospital, (Inpatient & Outpatient) Office and Emergency Room…So let’s clarify what we need to do:

Medicare/Medicaid for Office/Outpatient Services:

For Office/Outpatient services, CMS does not allow for payment unless the patient is present at the time the services are rendered. The rationale behind this is Medicare considers this part of the pre-post workup for an E&M service, and is a long standing Medicare Policy.

An ABN cannot be used as the patient was not there and engaged in the face-to face process. rationale: the ABN has to be acknowledged and signed by the beneficiary, which cannot be done if the patient is not in attendance.

Private Payor for Office/Outpatient Services

Again, we can default back to the CPT guidelines, but many private payors have contractual or internal policies regarding this type of service. CPT states we can use the code, but it will be up to the private payor to determine if they will pay for the service. If you plan to bill a private payor for “family counseling” here are a couple of options you can consider:

§ Bill the patient’s carrier with a paper claim, utilizing the standard E&M codes; submit the claim with documentation stating medical necessity of meeting with the family, without the patient present, be sure to use the diagnosis “V” code of V65.19: "Other person consulting on behalf of another person." (i.e. full disclosure of the nature of the visit to the carrier)

§ Schedule an appointment with the family member, as a patient in your practice, and bill his/her insurance payer for counseling coordination of care of themselves in relation to their family members medical issues (such as the stress on you as a care-giver, etcc)

§ Schedule an appointment with the provider for the family member(s) and inform the family members that for xxx amount of time, the charge is $XXX.oo. Disclose to the family members that this will need to be paid in full up front, at the time of visit. You also need to inform the family at the time of scheduling that without the patient’s consent, (or medical power of attorney) the provider/physician may not be able to disclose any information regarding the patient due to HIPPA privacy laws.

Inpatient services:

In regard to the Inpatient side of things, it works just a bit differently. The patient is currently present in the hospital, so this is much easier for the physician to communicate and coordinate care in regard to the patient with the family members. The argument of the patient not being there is irrelevant.

In some cases the patient is so critically ill, that a family member can “speak for” the patient in regard to history, and social issues if the patient cannot speak for themselves, and may have the ability to made medical decision based on a medical power of attorney, living will, or current care-giver or spousal status.

CPT is very specific in regard to code selection for admission and subsequent visits in regard to counseling/coordination of care. 50% (or more) of the time spent. must be documented as counseling and/or coordination of care to bill by time default. Otherwise the guidelines of history, exam and medical decision making must be followed. As the coder you need to carefully read the guidelines set for by CPT in the CPT manual.

Thursday, September 2, 2010

ACOG speaks again: Reporting the Confirmation of Pregnancy Visit

From our friends @ ACOG: Enjoy!

Reporting the Confirmation of Pregnancy Visit

The initial OB visit may be reported as an E/M service under certain conditions. Even if the patient has taken a home pregnancy test, the initial visit may still be billed as an E/M service as you will be officially confirming the pregnancy.

When coding for the “initial ob visit”, there are a few things that have to be taken into consideration. First you have to determine if the patient is there for a confirmation of pregnancy or if the pregnancy has already been confirmed. The second thing that needs to be determined is if the OB record has been initiated. Once this has been established you can determine how the visit should be reported.

Here is an example to help clarify the issue:
If a patient presents with signs or symptoms of pregnancy or has had a positive home pregnancy test and is there to confirm pregnancy, this visit may be reported with the appropriate level E/M services code. However, if the OB record is initiated at this visit, then the visit becomes part of the global OB package and is not billed separately.

If the pregnancy has been confirmed by another physician, you would not bill a confirmation of pregnancy visit.

The confirmation of pregnancy visit is typically a minimal visit that may not involve face to face contact with the physician (for an established patient). The physician may draw blood and prescribe prenatal vitamins during this initial visit and still report it as a separate E/M service as long as the OB record is not started.

Diagnostic Reporting Options:
V72.40 Pregnancy examination or test, pregnancy unconfirmed
V72.41 Pregnancy examination or test, negative result
V72.42 Pregnancy examination or test, positive result

The physician should report V72.40 if the encounter is to test for a suspected pregnancy and the patient leaves without knowing the results. If the pregnancy test is negative, report code V72.41. Report code V72.42 if the pregnancy is confirmed but the obstetrical record is not initiated. This diagnosis code is also used when the physician sees the patient for the confirmation of pregnancy but will not be providing the global obstetric care.

Global obstetrical care begins when the obstetrical record is initiated as part of the physician's comprehensive obstetrics work-up which includes the comprehensive history and physical.

Note that some payers may now view an initial obstetrical ultrasound performed in the office at the initial visit, as part of the comprehensive work up that initiates the global package. If this service is performed, your specific payer may view the initial visit as included in the global OB package even if the visit is reported with an E/M service code.

As not all payers follow CPT guidelines as to the contents of the global obstetrics package, you should always check with your specific payers for their definition of the global obstetrics package. Be sure to keep a written copy of any instructions.

A final point to keep in mind is that not every initial OB visit will be reportable outside of the global package. Deciding when to initiate the global OB care depends on the clinical circumstances, the physicians’ medical judgment, and payer reimbursement policies.

Questions/comments may be sent to ACOG's Coding Staff via email at

OB/GYN - New ICD-9-CM Codes: Effective October 1, 2010

Straight from the ACOG website...

These codes will be of interest to you if you code/bill any OB or GYN services...

New ICD-9-CM Codes: Effective October 1, 2010

Following are the new, expanded, and revised ICD-9-CM codes that are of interest to obstetricians and gynecologists. These codes will take effect October 1, 2010. HIPAA requires providers to use the medical code set that is valid at the time the service is provided. Therefore, physicians must cease using discontinued codes for services after the new codes become effective October 1.

The term “habitual aborter” was used within the descriptions of codes 629.81 and 646.3 for patients with recurrent pregnancy loss. Due to confusion over the use of these codes and patient sensitivity to being referred to as a habitual aborter, the American Congress of Obstetricians and Gynecologists (ACOG) requested the codes be revised to state “recurrent pregnancy loss”... The term “habitual aborter” will still appear in the ICD-9-CM index under code 621 (Disorders of Uterus, Not Elsewhere Classified).

629.8 Other specified disorders of female genital organs
629.81 Habitual aborter Recurrent pregnancy loss without current pregnancy
Excludes: habitual aborter Recurrent pregnancy loss with current pregnancy (646.3)

646 Other complications of pregnancy, not elsewhere classified
646.3 Habitual aborter Recurrent pregnancy loss

Müllerian anomalies include all congenital anomalies of the uterus, cervix and vagina. Congenital uterine anomalies are classified into seven distinct types: agenesis, unicornuate, didelphus, bicornuate, septate, arcuate, and diethylstilbestrol (DES) related anomalies. Of these, only didelphus and DES related anomalies previously had unique ICD-9-CM codes; 752.2 and 760.76, respectively.

Vaginal and cervical anomalies are less common. Prior to this change, there were unique codes only for imperforate hymen (752.42) and embryonic cyst of cervix, vagina, and external female genitalia (752.41).

752 Congenital anomalies of genital organs
752.3 Other anomalies of uterus
752.31 Agenesis of uterus
Congenital absence of uterus
752.32 Hypoplasia of uterus
752.33 Unicornuate uterus
Unicornate uterus with or without a separate uterine horn
Uterus with only one functioning horn
752.34 Bicornuate uterus
Bicornuate uterus, complete or partial
752.35 Septate uterus
Septate uterus, complete or partial
752.36 Arcuate uterus
752.39 Other anomalies of uterus
Aplasia of uterus NOS
Müllerian anomaly of the uterus, NEC
752.4 Anomalies of cervix, vagina, and external female genitalia
752.43 Cervical agenesis
Cervical hypoplasia
752.44 Cervical duplication
752.45 Vaginal agenesis
Agenesis of vagina, total or partial
752.46 Transverse vaginal septum
752.47 Longitudinal vaginal septum
Longitudinal vaginal septum with or without obstruction
752.49 Other anomalies of cervix, vagina, and external female genitalia
Absence of cervix, clitoris, vagina, or vulva
Agenesis of cervix, clitoris, vagina, or vulva
Anomalies of cervix, NEC
Anomalies of hymen, NEC
Müllerian anomalies of the cervix and vagina, NEC

The fecal incontinence code (787.6) has been expanded to allow for the classification of symptoms such as: fecal smearing, fecal urgency and incomplete defecation.

787 Symptoms involving digestive system
787.6 Incontinence of feces
Encopresis NOS
Incontinence of sphincter ani
787.60 Full incontinence of feces
Fecal incontinence NOS
787.61 Incomplete defecation
787.62 Fecal smearing
Fecal soiling
787.63 Fecal urgency

Additionally, a unique code for fecal impaction was created with appropriate instructional notes that distinguish the new symptom codes within the 787.6 series from the codes for fecal impaction and constipation.

560.32 Fecal impaction


To clarify the difference between long term and prophylactic use of medications, many revisions have been made to the tabular and index sections of ICD-9-CM. Changes include revisions to the title of category V07 (Need for isolation and other prophylactic measures) and titles for the codes under subcategory V07.5 (Prophylactic use of agents affecting estrogen receptors and estrogen levels), in addition to revisions to the index entries for prophylactic use of antibiotics.

V07 Need for isolation and other prophylactic or treatment measures
Excludes: long-term (current) (prophylactic) use of certain specific drugs (V58.61-V58.69)
V07.5 Prophylactic uUse of agents affecting estrogen receptors and estrogen levels
V07.51 ProphylacticuUse of selective estrogen receptor modulators (SERMs)
V07.52 Prophylactic uUse of aromatase inhibitors
V07.59 Prophylactic uUse of other agents affecting estrogen receptors and estrogen levels

New codes have been established for personal history of vaginal and vulvar dysplasia. These codes explain the reason for the encounters and parallel the existing code for personal history of cervical dysplasia (V13.22).

V13.23 Personal history of vaginal dysplasia
V13.24 Personal history of vulvar dysplasia

When congenital conditions are corrected, coding guidelines state that “a personal history code should be used to identify the history of the anomaly.” Code series V13.6 has been expanded and additional codes have been added to identify personal history of congenital anomalies by body system.

V13.6 Congenital (corrected) malformations
V13.62 Personal history of other (corrected) congenital malformations of genitourinary system
V13.69 Personal history of other (corrected) congenital malformations

Code V25.1 has been expanded to include both insertion and removal of an IUD. Use of code V25.42 will now be limited to routine surveillance of an existing device. New codes V25.12 and V25.13 can be reported with code V25.42 on a record.

V25.1 Encounter for insertion or removal of intrauterine contraceptive device
Excludes: encounter for routine checking of intrauterine contraceptive device (V25.42)
V25.11 Encounter for insertion of intrauterine contraceptive device
V25.12 Encounter for removal of intrauterine contraceptive device
V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device
Encounter for replacement of intrauterine contraceptive device
V25.42 Intrauterine contraceptive device
Checking, reinsertion, or removal of intrauterine device
Excludes: insertion or removal of intrauterine contraceptive device (V25.11–V25.13)
of intrauterine contraceptive device as incidental finding (V45.5)

The body mass index (BMI) code section has been expanded and additional codes have been added to allow for specificity of BMI over 50. The new codes will allow for tracking patients at increased health and surgical risk.

V85.42 Body Mass Index 45.0-49.9, adult
V85.43 Body Mass Index 50.0-59.9, adult
V85.44 Body Mass Index 60.0-69.9, adult
V85.45 Body Mass Index 70 and over, adult

A new V code category was developed to allow delineation of placenta status when reporting multiple gestations. The new codes indicate the number of placentas and amniotic sacs.

V91 Multiple gestation placenta status
Code first multiple gestation (651.0-651.9)
V91.0 Twin gestation placenta status
V91.00 Twin gestation, unspecified number of placenta, unspecified number of amniotic sacs
V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)
V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)
V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)
V91.09 Twin gestation, unable to determine number of placenta and number of amniotic sacs
V91.1 Triplet gestation placenta status
V91.10 Triplet gestation, unspecified number of placenta and unspecified number of amniotic sacs
V91.11 Triplet gestation, with two or more monochorionic fetuses
V91.12 Triplet gestation, with two or more monoamniotic fetuses
V91.19 Triplet gestation, unable to determine number of placenta and number of amniotic sacs
V91.2 Quadruplet gestation placenta status
V91.20 Quadruplet gestation, unspecified number of placenta and unspecified number of amniotic sacs
V91.21 Quadruplet gestation, with two or more monochorionic fetuses
V91.22 Quadruplet gestation, with two or more monoamniotic fetuses
V91.29 Quadruplet gestation, unable to determine number of placenta and number of amniotic sacs
V91.9 Other specified multiple gestation placenta status
Placenta status for multiple gestations greater than quadruplets
V91.90 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs
V91.91 Other specified multiple gestation, with two or more monochorionic fetuses
V91.92 Other specified multiple gestation, with two or more monoamniotic fetuses
V91.99 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs

Sunday, August 29, 2010

Coding for Smoking Cessation - Info straight from CMS!

Coding Information for SMOKING CESSATION… Info Straight from CMS

Hi to my blog readers... This is just another reminder that CMS now pays for smoking cessation, and that they are committed to helping our patients quit smoking. In addition, these services are billable, (and payable from Medicare) with proper documentation. Please be sure that your providers denote this as "separately identifiable" from your regular E&M visits AND have your time documented of the minutes spent in the smoking/tobacco cessation counseling visit. (time-in/time-out is the best for audit substantiation, but a notation of how much time spent is OK too.)

I've included some websites where this info can be found at the end of the blog.
  • 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes
  • 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
  • Diagnosis code 305.1

CMS smoking cessation guidelines & information:

Smoking is the most preventable cause of disease and death in the U.S. People who continue to smoke after the age of 65 have a higher overall risk of disease and death than those who quit. Smoking contributes to and can exacerbate heart disease, cancer, stroke, lung disease, hypertension, diabetes, osteoporosis, macular degeneration, and cataracts. It can also interfere with the effectiveness of medications that many older adults take, including insulin.

In March 2005, CMS determined that there was sufficient evidence to support Medicare coverage for smoking and tobacco use cessation counseling for beneficiaries who have smoking-related illnesses, or who are taking medications that are affected by tobacco use. Medicare's prescription drug benefit will also cover smoking cessation treatments prescribed by a physician beginning in January 2006.

This section provides information regarding Medicare's smoking and tobacco use cessation counseling benefit, resources to support providers in the delivery of counseling, and organizations promoting cessation to older adults.

General Facts:

• An estimated 9.3% of people ages 65 and older smoke cigarettes.

• Approximately 440,000 people die annually from smoking related diseases, and 300,000 of those deaths occur in people ages 65 and older.

• One study estimated that Medicare spends about 10% of its total annual budget on treating smoking-related illnesses--approximately $24 billion in 2001.

• There are significant benefits to quitting smoking, even after 30 or more years of smoking. Lung function and circulation begin to improve soon after quitting. Smokers who quit have cardiovascular mortality rates similar to those of non-smokers, and this benefit is unrelated to age or the time elapsed since quitting. In one study, older smokers who already had coronary artery disease improved their survival and risk of heart attack by quitting.

• Older adults who smoke have been shown to be more successful at quitting than younger smokers.

What Medicare covers:

Medicare covers 2 types of counseling:

• Intermediate cessation counseling is 3 to 10 minutes per session; and

• Intensive cessation counseling is greater than 10 minutes per session.

Medicare will cover 2 quit attempts per year. Each quit attempt may include a maximum of 4 intermediate or intensive counseling sessions, with the total annual benefit covering up to 8 sessions in a 12-month period. The health care provider and patient have the flexibility to choose between intermediate and intensive counseling.

To be eligible to receive this benefit, a beneficiary must have a condition that is adversely affected by smoking or tobacco use, or that the metabolism or dosing of a medication that is being used to treat a condition the beneficiary has is being adversely affected by his or her smoking or tobacco use.

In addition, Medicare Part D will also cover smoking cessation treatments prescribed by a physician beginning in January 2006. However, over-the-counter treatments, such as nicotine patches or gum, will not be covered.

Other helpful information:

In addition to Medicare's smoking cessation counseling benefit, the Department of Health and Human Services launched a national telephone counseling quit line for all smokers in the U.S. The toll free number 1-800-QUITNOW (1-800-784-8669, TTY 1-800-332-8615) is a single access point to the National Network of Tobacco Cessation Quit lines. Callers are routed to a state-run quit line for assistance. If there is no state-run quit line, they are routed to the National Cancer Institute's quit line.