Sunday, December 11, 2011

Telemedicine: bringing healthcare to rural areas.

Telemedicine has made inroads into the medical area, by bringing specialist care to very rural areas, anywhere in the world.  This type of technology allows a two-way real-time communication between the rural provider and a specialist consultation that is not nearby.

Telemedicine has provided many benefits to those in a rural setting, to have access to specialty care throughout the world.

Coding for telemedine is a new challenge.  CMS (Medicare) will pay for selective telehealth/telemedicine services.  CMS states that they will reimburse for the use of a telecommunication as a substitute for a face-to face encounter.  However, they will only reimburse if the ‘originating’ site is in a rural health professional shortage area (HPSA).  Telemedicine is considered investigational by some 3rd party carriers, and may not be reimbursed.  If that is the case, then the patient would ultimately be responsible for those charges. 

Payment and coverage of telemedine/telehealth services requires an interactive audio and video telecommunication system that allows real-time processing with communication between the provider at the rural health site, and the provider (consultant) at the distant location. 

Below is a listing of the type of services utilizing telemedicine/telehealth.  This is not an all-inclusive listing.
§    Office/outpatient office visits
§    Individual psychotherapy
§    Pharmacologic management
§    Psychiatric diagnostic interview examinations
§    End Stage Renal Disease Services (ESRD)
§    Medical Nutrition Therapy
§    Radiology Interpretation Services
§    Cardiac medicine services

For coding of these services HCPCS provides the most comprehensive listing of service codes to be reported.  However, modifiers also play a part in this too.  As a coder if you are reporting with HCPCS the listing below is a methodology to report consultations, and follow up services in an inpatient setting.

Follow-up inpatient telehealth consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth (new 1-1-2009)
Follow-up inpatient telehealth consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth (new 1-1-2009)
Follow-up inpatient telehealth consultation, complex physicians typically spend 35 minutes communicating with the patient via telehealth (new 1-1-2009)
Social work and psychological services, directly relating to and/or furthering the patient's rehabilitation goals, each 15 minutes, face-to-face; individual (services provided by a CORF qualified social worker or psychologist in a CORF) (new 1-1-2009)
Initial inpatient telehealth consultation, typically 30 minutes communicating with the patient via telehealth (new 1-1-2010)
Initial inpatient telehealth consultation, typically 50 minutes communicating with the patient via telehealth (new 1-1-2010)
Initial inpatient telehealth consultation, typically 70 minutes or more communicating with the patient via telehealth (new 1-1-2010)   
Telehealth originating site facility fee
Telehealth transmission, per minute, professional services bill separately  

If you are in the outpatient setting you need to use the modifiers GT & GQ.
       GQ  Via asynchronous telecommunications system
GT  Via interactive audio and video telecommunication system

As a provider of telehealth services, a GT modifier will need to be appended to the professional fee code (either CPT code(s)  or HCPCS code).  These modifier codes would be added to the standard evaluation and management codes, or to what would normally be billed for a visit that is an actual face-to-face visit with the provider. 

If the evaluation service includes a provider reviewing the medical record(s), then no separate billing may be submitted for a record review.  Medical record review is already included in consultation/evaluation services per CPT guidelines.

If the telecommunications service is provided by asynchronous telecommunications, then the GQ modifier would need to be appended.  An example of the asynchronous technology is a service such as an ultrasound, or MRI performed, then sent to a distant location/provider for interpretation/consultation.  This technology is not actual real time face to face, but “store and forward” for use by the consultant. 

In some cases an insurance payer will pay for the usage of the telecommunication equipment if you are the originating site.  Billing for this service, can be submitted with HCPCS code Q3014 on your claim form.  In addition, some carriers may even pay for telehealth transmission “per minute” by usage of HCPCS Code T1014. 

At this time, telemedicine is still a relatively new process and new codes are emerging all the time. This link below is very helpful -   


Sunday, December 4, 2011

What is involved in Maternal/Fetal Ultrasound Coding

Let’s start at the beginning…

In the world of Obstetrics, Maternal Fetal Medicine (MFM)/Perinatology is a sub-specialty that is focused on the fetus, and it’s growth during the pregnancy.  Perinatology specialists work closely with obstetricians, and genetic counselors to provide care for high risk pregnancies, and to provide screening services for potential fetal anomalies prior to birth.  The perinatal period, is generally defined as the time from 8-12 weeks gestation to approximately 30-45 days after delivery.

MFM/perinatal specialists can provide extensive care for high risk pregnancies, to include such diagnoses as multiple gestation (twins, triplets etc) , in-vitro fertilization pregnancies, advanced maternal age,  and chronic maternal diagnoses (i.e. hypertension, diabetes) . Perinatologists can also perform and provide extensive ultrasound procedures with interpretation of fetal growth and/or anomalies, placenta location, amniotic fluid, and umbilical cord complications during the pregnancy.  They also can provide highly complex surgical fetal procedures performed in-utero.

Coding for obstetric ultrasound can be challenging.  CPT has specific guidelines for each ultrasound code, yet the documentation and interpretation of these codes can be difficult to figure out when looking at the actual documentation or interpretation of the scans. 

CPT has outlined the obstetrical codes within the code series  76801 through 76828.  Not only do these codes include traditional ultrasound, but also include fetal biophysical profiles, doppler velocimetry of the fetal umbilical and middle cerebral artery but also echocardiography of the fetus.

Many Perinatologists practice in their own office, and have their own ultrasound equipment.  If the scan is provided in the office setting,  a global ultrasound code would be billed.  However, in locations that a perinatologist is not readily available, patients will have the scans performed in an outpatient facility.  If that is the case, the facility will bill the ultrasound with a TC (technical component only) modifier.  The facility will forward the scans, to the perinatologist to provide an interpretation of the scan.  The perinatologist will only bill for the written report or interpretation of the scan by adding the 26 (interpretation only) modifier to the cpt code. 

Conquering the Ultrasound code-set
According to the guidelines in CPT all diagnostic ultrasounds require both a permanently recorded image and a final written report.  A coder needs to fully understand if they are billing and coding ultrasound scans as A) Global or complete scan; B)the recorded image or Technical component only, or C) the interpretation/documentation only of the ultrasound scan.

Below are more helpful hints to coding Obstetrical ultrasounds:

§    Review the code definitions to determine if the CPT code itself specifies for the first or single gestatation – such as found in code 76801

§    If the add-on code “Ì” symbol is denoted at the beginning of the CPT code, do not use a 51 modifier with the code, as per the CPT definitions of a ‘add on code’.  Review code 76802 to understand the add on code is used to denote ‘each additional gestation”   

§    If the CPT code set does not specify ‘units”   such as in the code 76815, it states 1 or more fetus’s so only 1 unit would be appropriate.  It should not be billed as 2 units. Only as 1 unit, even though more than 1 fetus may be documented.

§    If the CPT code set does not specify ‘units” as in code 76816, CPT informs the coder to add the modifier 59 for each additional fetus when reporting  If coding for twins, the codes reported would be 76816 for baby a, and 76816-59 for baby b.

§    Review codes carefully to determine if a trimester has been specified within the ultrasound codeset such as in code 76805

§    Review to determine if the ultrasound is performed trans-abdominally, or trans-vaginally. 

Deciphering the Terminology

In MFM/Perinatology medicine, there are many strange words and procedures, that a coder should understand before trying to decipher an ultrasound documentation.  Included below are terms commonly found in MEM/perinatology ultrasound documentations.

A procedure to draw a sample of amniotic fluid which is then analyzed to detect chromosome abnormalities, structural defects and metabolic disorders.
Amniotic Fluid

Amnio Fluid
The fluid in which the embryo or fetus is suspended within the womb (the embryonic sac inside the uterus).

Beats per minute
the number of heartbeats per unit of time (beats per minute)
Chorionic Villus Sampling

An alternative to amniocentesis to detect chromosomal abnormalities. The CVS can be performed earlier in fetal development than amniocentesis, and thereby allows earlier diagnosis.
Congenital Defect

A problem or condition existing at or dating from birth; acquired during development in the womb (uterus) and not through heredity
Crown Rump Length
the ultrasound measurement of a fetus

A minimally-invasive examination of the fetus by a miniature video camera inserted through a small tube
Estimated Date of Confinement
a term for the estimated delivery date for a pregnant woman
Fetal Abnormality

A condition detected in the unborn human that is not the normal or average.
Fetal Echocardiography

A high resolution ultrasound test to detect heart abnormalities in the fetus.
Fetal Pole

a thickening on the margin of the yolk sac of a fetus during pregnancy
Genetic Counseling

Medical guidance concerning inherited (genetic) disorders.
In Utero

Relating to being in the womb
Intra-Uterine Pregancy
the normal location for a pregnancy to occu
In-vitro Fertilization
a process by which egg cells are fertilized by sperm outside the body
Last Menstrual Period
the first day of the menstrual period prior to conceiving, used to calculate Expected Date of Delivery
Magnetic Resonance Imaging
A noninvasive diagnostic technique that produces computerized images of internal body tissue induced by the application of radio waves
Maternal Fetal Medicine
The testing and management of high-risk pregnancies; also called perinatology
Neonatal Intensive Care Unit
An area within a hospital dedicated to the care and treatment of pre-term and   critically ill babies
Neural Tube Defect
an opening in the spinal cord or brain that occurs very early in human development, visualized by ultrasound
Nuchal Translucency
The area around the neck of the fetus, also known as the nuchal fold

Occurring, existing or performed after birth

Occurring, existing or performed before birth
Trans-abdominal ultraound
Ultrasound procedure performed to visualize the pelvic cavity through application of sound waves by a device placed upon the abdomen
Trans-Vaginal ultrasound
Ultrasound procedure performed to visualize the cervix and uterine contents by application of sound waves through a device inserted into the vagina.

the division of pregnancy into three-month sections
A technique involving the formation of a 2D-or 3D dimensional image used for the examination and measurement of bodily abnormalities.
What the documentation reports look like

Included below is a dictation that shows the correct coding and documentation for a twin pregnancy.  Review and test yourself on the codes to be applied.  This documentation was performed as a global procedure in the perinatologists office

The LMP of this 30 year old, G1, P0-0-0-0 patient was unknown, her working
EDC is MAR 8 2011 and the current gestational age is 11 weeks 2 day(s) by
date of assisted reproductive procedure. A sonographic examination was
performed on AUG 19 2010.

A normal gestational sac was documented. The yolk sac was seen, measuring
0.4 cm. The amnion was also documented. A normal fetal pole was noted with
cardiac motion at 169 bpm.
1) 1st Trimester Screening    2) Twins    3) IVF

CPT Coding: 76801   +76802
Diagnosis Code(s)  651.03
Fetus # 1 of 2
Variable presentation
Fetal growth appeared normal
Placenta Location = Posterior
No placenta previa
Placenta Grade = 0
Amniotic Fluid = Normal

* Indicates Measurement Included In Average Gestational Age
CRL 4.5 cm c/w 11 weeks 1 day(s)*
THE AVERAGE GESTATIONAL AGE is 11 weeks 1 day(s) +/- 7 days.

Visualized, Appearing Sonographically Normal:
The uterus was visualized, midplane in orientation.
Twin IUP (Fetus A)
11 weeks 2 day(s) by date of assisted reproductive procedure. (EDC= MAR 8
11 weeks 1 day(s) by this ultrasound. (EDC= MAR 9 2011)
Variable presentation
Fetal growth appeared normal
Chorionicity = Dichorionic, Diamniotic
Repeat ultrasound in one week.

Fetus # 2 of 2
Fetal growth appeared normal
Placenta Location = Posterior
No placenta previa
Placenta Grade = 0
Amniotic Fluid = Normal

* Indicates Measurement Included In Average Gestational Age
CRL 5.2 cm c/w 11 weeks 5 day(s)*
THE AVERAGE GESTATIONAL AGE is 11 weeks 5 day(s) +/- 7 days.

Visualized, Appearing Sonographically Normal:
The uterus was visualized, midplane in orientation. The left ovary was
enlarged, measuring 7.6 x 5.9 x 7.0 cm. The right ovary was enlarged,
measuring 6.1 x 5.5 x 4.0 cm.

Twin IUP (Fetus B)
11 weeks 2 day(s) by date of assisted reproductive procedure. (EDC= MAR 8
11 weeks 5 day(s) by this ultrasound. (EDC= MAR 5 2011)
Fetal growth appeared normal
Chorionicity = Dichorionic, Diamniotic

Patient is seen for first trimester screening.
The CRL is at the lower limits for the NT measurement and it could not be obtained on either twin given patient habitus. Thus patient will need to return for the serum screen and NT measurement. Sequential screening was discussed in detail with regard to the 2 step testing process. Screening for a NTD is only provided when the second serum screen is completed. Cystic fibrosis screening was also discussed. At the conclusion of the discussion, patient wished to return for the NT and serum screen.

Repeat ultrasound in one week.


Wednesday, November 23, 2011

Quick CPT 2012 Update to be on the look out for!

CPT 2012 Changes for Contraceptive Capsule insertion/removal Codes 

CPT 2012 deletes CPT code 11975 (Insertion, implantable contraceptive capsules) and deletes CPT code 11977 (Removal with reinsertion, implantable contraceptive capsules).
With the deletion of these two codes (11975 and 11977) coders should look to use  CPT Code  11981 (Insertion, non-biodegradable drug delivery implant) when the physician or provider inserts an Implanon™ brand for contraception,  For removal you will need to use code 11976 (Removal, implantable contraceptive capsules) 

Some patients still have Norplant™ brand systems that will need to be removed.  Put this info on your 'hot list' of changes...  I'm sure CPT has more changes in-store for us in 2012.  HAPPY CODING!

Sunday, November 13, 2011

OB/GYN Hospitalists – A new sub-specialty that is making a positive impact in OB/GYN Care.

OB/GYN Hospitalists –  A new sub-specialty that is making a positive impact in OB/GYN Care.

As a coder who has worked in OB/GYN for a lot of years, I have had the unique opportunity to be the coder for a new program specialty at our local hospital.  We have implemented a program of OB/GYN Hospitalists into our traditional OB/GYN practice. 

OB/GYN Hospitalists are the ER physicians (so to speak) for all things “Girlie”.  This type of practice model has an OB/GYN specialist available 24 hrs per day.  This practice enables patients to have emergent care for any type of OB/Gyn emergency, when their own physician is unavailable.  We traditionally see those patient who
§    Think they may be in labor, which could be at term, or pre-term
§    Are in labor and is precipitously close to delivery
§    Have been in some type of trauma, and need an OB/GYN’s expertise
§    Are experiencing a miscarriage, or GYN emergency such as ovarian torsion

In addition an OB/GYN hospitalist :
§    Can assist and deliver Vaginal births, V-back delivery, Cesarean Delivery,
§    Be a primary or assistant at surgery for emergent or planned OB/GYN serves
§    Provide ancillary testing services such as Fetal Non-Stress Tests, Fetal Ultrasound, and Maternal support for pre-term labor, or complex Antepartum or post-partum conditions.
§    Be an extension of on-call coverage for the patient’s primary care physician who normally over-sees the care of the obstetric patient.

As for coding and billing of these types of physicians, we use all facets of Inpatient, Outpatient Hospital, Emergency and office codes for our Evaluation and Management side of the practice.  We routinely bill for CPT procedures including surgery, medicine, and radiology/ultrasound services.  These physicians also provide main surgery care for Cesarean Sections, and Trauma care, but also provide care as a surgical assistant to General Surgeons too.

The ultimate goal for our practice model is to provide the utmost care for our pregnant and emergency OB and GYN patients 24/7 in the absence of the patient’s ‘regular OB/GYN physician.  We work in tandem with those primary providers.  

The 3rd party insurance payers have been very receptive to this new sub-specialty as it really does provide top care, and a great price to the payers.  I have had the pleasure to partner with
Rob Olsen, in Seattle Washington and his website:

Feel free to contact me with any questions or concerns you have about billing and coding for this unique specialty!  Who know.. it just might be the ‘area’ your practice is looking to add.

Sunday, October 30, 2011

Certified Nurse Midwifery – an Alternative Ancillary service in an OB/GYN Practice.

Certified nurse-midwives (CNMs) are RNs with advanced training and certification in midwifery.  These advanced practice nurses are recognized in all 50 states as a legal profession.   A CNM licensed RN, can care for expectant mothers and, provide clinical OB/GYN services.  This includes oversight of prentatal care during pregnancy; management of labor; delivery of the infant, and postnatal care of moms & babes, and some even teach breastfeeding techniques, and provide assistance with post-partum depression.   CNM’s also provide preventive health care / wellness visits  to include  pap smear testing, counseling, prescribing of diagnostic & therapeutic medications, conducting clinical research and trials, diagnostic testing such as ultrasound, cytometrogram’s and minor procedures such as lesion removals and biopsy’s.   The value of such an employee is that they can provide nearly identical services as an MD/DO OB/GYN, yet do not raise the practice overhead expense at the same level as a MD/DO OB/GYN employee. 

CNM services encompass a full range of ancillary services that can be incorporated into an OB/GYN practice.  CMS allows  (Center for Medicare/Medicaid Services)  CNM’s to provide full scope of care and in the past have been reimbursed from 65- 85%  allowable of the Medicare Physician based fee schedule.  

Prior to April 1, 2008, if the CNM service was provided as “incident to” an MD or DO, reimbursement was figured and paid at 100% of CMS Medicare/Medicaid allowable fee schedule. However, As of April 1, 2008, Under under H.R.3126,  CNM' s will now be paid at 100% of the Medicare Allowable fee schedule.  The current Medicare fee schedules include all MD/DO’s, chiropractors, optometrists, podiatrists, nurse-anesthetists, audiologists, and speech language pathologists. 

Below outlines some of the criteria necessary to bill correctly for the CNM.

Documentation Criteria:  CNM must personally document, date and signs all entries (e.g., chief complaint or reason for visit, history, exam, services rendered, care plan). Diagnoses are required for all rendered/ordered services.  In some states, the supervising MD must countersign non-MD entries, or have a supervisory protocol/clause/standard of practice in place regarding the oversight of care provided by the CNM. . 

Evaluation and Management:    CNM’s may utilize codes 99201-99205, and  codes 99211-99215 for services performed in the physician office, and the CNM has their own UPIN/NPI number to bill under.  However, if the services are provided as “incident to”, then billing of a claim for payment must be made under the supervising physician’s UPIN/NPI and billed at full fee schedule. 

Consultations:  The CNM can request a consultation from an outside provider.  However, if the CNM is providing a “consultation” then they are recognized as a “general practitioner” providing expertise, not as a “specialty provider” {i.e. OB/GYN specialty)  providing expertise.  So you will need to have clear documentation when billing a consultation codes for a CNM. Consultation codes 99241-99245 can be billed if documented clearly in the medical record. (providing all criteria is met, however, CPT still includes consultation codes in the CPT manual, however, CMS no longer recognizes or pays on the consultation codes, and many private or 3rd party payers will not recognize them or pay if billed with them. 

Diagnostic Testing and Procedures:   CNM’s can request and perform diagnostic testing, and procedures however, these are subject to the individual scope of practice for the state in which the CNM is practicing in.  The scope of practice can vary widely from state to state.  Most CNM’s perform the full scope of pre-natal, vaginal delivery, and post-partum care for OB services and do the same for private payors.  However, CNM’s do not provide cesarean delivery services. 

Designation HCPCS Modifier SB:  Some payors or insurance carriers may require the addition of the modifier “SB” appended to the base code to designate that the service was provided by a CNM.  However, this is becoming less and less common, as the NPI number should designate to the intermediary or clearing house that the service was rendered by a CNM.  Some smaller payors however, still require hard copy claims, in which the SB modifier may be needed on the claim before they will process your request for payment.

OB Prenantal/Delivery/Postpartum Packages:  Most CNM’s are employees of a private practice, and are paid a flat, hourly salary.   However, some CNM providers are paid on a case-by-case global billing code, based upon the RBRVS payment for physicians.   In some OB/GYN practices,  if the CNM provides the Antenatal, vaginal delivery, and post-partum care they can bill the OB/GYN “global package” (i.e. code 59400) .  However, if they do the antenatal, and post-partum care but the MD/DO does the cesarean section, you will only bill for the services rendered. 

In some practices, CNM’s are used as a “physician extender”  where the CNM see’s and evaluates the patient prior to the patient ever meeting the MD/DO.  In other practices,  CNM’s may only provide the antenatal and post-partum care, then MD/DO OB/GYN will perform the delivery. (regardless of what type of delivery it may be)  In other practice scenario’s, the CNM  has the MD/DO meet with the patient, in case a cesarean is required. CNM's can also be an assist at surgery for a OB surgeon.  If they are working as the assist at surgery, be sure to append modfier AS, not modfier 80/81.  Modifier AS was created by HCPCS to  specify an non-MD/DO provider.  

The best way to code and bill for the CNM is to follow the coding convention guidelines carefully.   Global pregnancy package guidelines and state payors may have different criteria, so you should always pre-authorize CNM services by the insurance payor to make sure that you’ll get paid. 

HAPPY CODING... As always, if you have questions, please feel free to contact me.