Thursday, December 27, 2012

A Free Webinar - 2013 Coding Changes

It's not to late to get a quick 30 minute update on the CPT coding changes.  I will be doing this webinar at Noon (Eastern time)    This is a great quick way to get the updated info, without having to spend a lot of time or money to get the info you need.

I'll be doing this webinar update with the company.....   It's not too late, sign up!  I'd love to have you join me   L  : )

Wednesday, December 5, 2012

Fetal NST Testing...Documentation

The information today revolves around the Fetal Non Stress Test (FNST or NST).   The FNST test is denoted by CPT code 59025.  The NST is a basic standard of care in an OB/GYN practice or in an OB/GYN hospitalist (emergency practice).  The ultimate goal of antepartum fetal surveillance is preventing fetal death. The definition of this test is:The monitoring of the fetal heart rate in response to fetal movement. 

The FNST is within the scope of the OB/GYN physician or provider of care, and  is regarded as a very routine part of the practice.  Many providers as their standard of care  “always” run a FNST or at least do dopplers on the fetus to ensure that fetal activity is normal and not compromised by maternal complications.  However, this standard of practice does not mean that the FNST’s importance to the care of the patient be minimized.  In fact, this is probably one of the single most non-invasive tests we can perform to ensure maternal and fetal well being, when care is given in an emergent or acute care setting.

The code 59025 is considered a “global” code when performed in the office setting, as normally the office owns the equipment and the provider does an interpretation of the test findings.  If you are performing this test in an office setting there must be very "definitive" medical necessity for this to be billed as a separately identifiable test - outside of the globall antepartum package.   It is not medically necessary to run this test simply because the patient comes in for their regularly scheduled OB/antepartum visit.   It would be appropriate to run the test if there is a documented "reason" such as decreased fetal movement, maternal diabetes, maternal hypertension,  or symptoms such as pain, pressure, bleeding, spotting etc.

 When this testing is performed in the hospital facility, the hospital will be billing the test (59025-TC) as the  technical component only.  You, as the OB/GYN hospitalist, need to bill the interpretation of this test as denoted by code 59025-26.  This test will be billed separate to your Evaluation and Management of the patient.  (eg  codes 99201-99215 etc)

As we have discussed before, medical necessity is the driver for all testing.  Documentation is the key to supporting the medical necessity of any testing provided.  Good documentation will “seal the deal” for insurers (3rd party payers) to pay for FNST testing.  Your documentation for this testing should include a good solid diagnosis which can be a definitive dx such as IUGR, or signs and/or symptoms such as spotting, bleeding, abdominal pain/pressure etc.

Your role, as the provider/physician is the interpretation of the test results.  Most often, the nursing/assistive staff will probably be the ones to set up and run the test over the course of the patient’s stay in the office or facility.  If you have a patient that is pregnant with a multiple gestation, You can code and bill for each fetus.   

If you are performing a multiple FNST, you can only for one (1) technical component, (or global)  but you can bill for a separately interpretation each baby/fetus’s reading on the printouts 

If you are in an office setting to bill for a multiple it should look like this: 
59025 (Global) for Baby A 
59025-26-51-59  (Interp only) for Baby B 

If you are billing for a facility only  (regardless of how many babies are on board)

If you are billing for the Professional interpretation only 
59025-26 for Baby A
59025-26-51-59  Baby B

When interpreting these results best practices include the following for documentation of the FNST.   The interpretation of the fetal heart rate tracing should follow a systematic approach.  Third Party Payers require documentation/interpretation of all FNST’s to be noted and signed by the provider.
The bullets below denote what needs to be included for an interpretation of the FNST:

         Clinical Indication: (i.e. Decreased Fetal Movement, IUGR, etc..)
  • Interpretation:  Fetal Heart Tones (FHT) show a baseline of 130 with 10x10 accelerations and moderate viariability  Reactive with no decelerations
  • Time noted: (Best practices):  patient was monitored for “x” minutes, over the course of the stay. 
  • Signed/Authenticated by: Jose Hero, MD

Note: If the NST service is a ‘global service”  the bill date will be the same as the date performed.  If the interpretation of the test is performed on a different date than the NST test itself, then interpretation only should be billed on the date the ‘interpretation was performed’

Beware of “bundled” services with the code 59025:  CPT includes the FNST as part of the code set  definition for Ultrasound codes 76815, 76818, 76819.  If the ultrasound is performed and also the FNST, do not report them separately.

Text based Documentation:
Ms. L is a 35-year-old gravida 5, para 3, white female patient of Dr. Hero at 36-4/7 weeks' gestation who presents complaining of uterine contractions.  They are anywhere from 4-10 minutes apart and are mild to moderate.  She denies any leaking fluid or ruptured membranes or bleeding.  She has had no problems with this pregnancy except that her blood pressure has been running somewhat high throughout her pregnancy with systolics in the 140s on numerous occasions.

VITAL SIGNS:  Afebrile, vital signs stable.
GENERAL:  The patient is a well-developed, well-nourished, female in no acute distress.
ABDOMEN:  Soft.  Uterine contractions are present about every 4-6 minutes.  
Fetal heart tones show moderate variability, 15 x 15 accelerations and no decelerations with a baseline of 145 Testing was based over 45 minutes on the fetal monitor. .
PELVIC:  Cervix is very posterior, -2 station, 50% and tight 2 cm, unchanged after walking for an hour.

ASSESSMENT: False labor in a multiparous patient at 36-4/7 weeks' gestation. Fetal status reassuring

PLAN:  Patient was given labor instructions.  She will be calling Dr. Hero's office later in the day to get a refill on her Norco and Fioricet.  She does not want anything else from us now.

Last but not least -  If it wasn’t documented, it wasn’t done! Clear and concise documentation works well.  You don’t have to dictate volumes and pages to support your coding and billing.

Thursday, November 29, 2012

The Complexities of Place of Service (POS) Codes – Getting it correct up front!

Welcome back to my blog...  The post for today revolves around Place of Service (POS)  Codes.  POS codes are one of the "first" things to check when claims are being denied.  Below I've outlined what POS codes are, and how their usage can define success or failure when billing physician based, outpatient and inpatient claims.   Enjoy!.......... 

The Complexities of Place of Service (POS) Codes – Getting it correct up front!  
Physicians and providers practice in many different areas within a hospital setting.  The trick to accurate physician and provider coding/reimbursement requires knowledge and understanding of the Place of Service Codes also known as POS codes. Coders should be diligent in determining the correct POS code up front.  The place of service will be the determining factor for physician/care provider E&M services to be coded or billed.  The POS is also a factor for facility codes to be coded and billed.  In some circumstances, the hospital and the provider may submit conflicting information if the claim is not coded with the correct POS up fron.  The ramification of an incorrectly coded claim is the possibility of an inappropriate or incorrect reimbursement to the provider or facility. In reviewing documentation prior to coding, the coder should consider: .  :

a) The correct “place of service” where the evaluation of the patient took place,(such as in the Labor and Delivery, Radiology, or the Emergency room)

b) The hospital/facility licensure of the area within the facility that services were rendered (i.e. an area such as an outpatient office –type that provides physician/provider based services within a hospital setting.)
c) the type of service provided by the physician or care provider. (i.e. evaluation/management, surgery, critical care, infusion, rehabilitation)….

The Centers for Medicare/Medicaid services (also known as CMS) and the American Medical Association (also known as the AMA) have developed a specific set of POS codes dedicated to the designation of where medical services have been provided for a patient.  These codes are standardized and have specific licensure for facilities associated with them.  These codes are known as “Place of Service Codes”.  The most common areas where a physician or care provider may be providing services are:

§    Inpatient Hospital Care Area
o       Place of service code = 21
§         Definition:  A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

§    Emergency Department Care Area
o       Place of service code = 23
§         Definition:  A portion of a hospital where emergency diagnosis and Hospital treatment of illness or injury is provided

§    Outpatient Hospital Care Area ( or Observation – short stay)
o       Place of Service code = 22
§         Definition:  A portion of a hospital which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

§    Provider Office (to include provider based services that occur within a hospital setting)
o       Place of service code = 11  
§         Definition:  Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

§    Urgent Care facility
o       Place of service code = 20
§         Definition:  A location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

Each of the areas denoted above, are designated a specific “Place of Service” code by CMS and the American Medical Association. .This complete listing can be found in the CPT4 manual.  The hospital or facility also must have specific state and federal licensure established within these areas for physicians and care providers to render treatment.  Although these areas are all under the same “roof” of the hospital/facility, these service areas are considered “separately identifiable” and the billing of the provider’s services must correspond and be reported correctly when billing the medical claim.

Below are examples of different case scenarios that commonly occur in an OB/GYN hospitalists’ job scope and function.  The brief case examples below give a glimpse of how the importance of the POS code and its relationship to documentation and reimbursement.

Case Scenario #1:  Patti is a 23 week gravida 1 para 0 presenting to L&D with diarrhea and malaise. Patient is evaluated over the course of 30 minutes and discharged back to home with a diagnosis of viral gastroenteritis in addition to the pregnancy.  This service would be coded with a “place of service” code of 22 -  Outpatient hospital services – Evaluation and management codes 99201-99215

Case Scenario #2 Patti is a 23 week gravida 1 para 0 presenting to L&D with diarrhea and malaise. Patient is evaluated over the course of 7 hours and 30 minutes.  During the course of care, patient received IV hydration and discharged back to home with a diagnosis of viral gastroenteritis in addition to the pregnancy.  The facility and the physician determined the patient needed full observation status services and was admitted to L&D as observation care.  This service would be coded with a “place of service” code of 22 -  Outpatient hospital services,  E&M services for the physician/provider would be In/out same day hospital service codes of 99234 – 99236.  The Facility would be able to bill for the room, and any associated ancillary services such as the IV hydration and any medications that were included in the hydration. 

Case Scenario #3:  Patti is a 23 week gravida 1 para 0, presenting to L&D with decreased fetal movement and abnormal bleeding from the vaginal area.  Patient is evaluated over the course of 60 minutes, and determined that the patient has a possible placental abruption.  The orders are then sent that the patient will be “admitted” as an inpatient.  Dr. Stamps then documents an H&P/admission and a bed is secured for the patient in the inpatient area of L&D.  This service would be coded with a “place of service” code of 21.  The E&M services billable by Dr. Stamps would be the Inpatient Admission codes of 99221 – 99223. 

Case Scenario #4:  Dr. Stamps is called to the Emergency room to see patient Patti, a 23 week gravida 1 para 0, who was a passenger in a motor vehicle accident and currently being evaluated by the Emergency department for neck pain.  Dr. Stamps was called down to the ED to evaluate the patient, as she is 23 weeks pregnant.  Dr. Stamps does a full evaluation of the patient in the ED area and denotes that Patti has a mild abdominal contusion from the seat belt restraint, but no other major concerning “pregnancy related” issues.  This service would be coded with a “place of service” code of 23. The E&M services billable by Dr. Stamps would be the Emergency Department codes of 99281 – 99285

In 2012, CMS and the OIG work plan have targeted place-of-service errors for audit.  In addition, many hospitals and hospital based physician practices are finding POS problems on their own through careful screening and the usage of software connected to scrubbing of claim edits to match the place of service with specific CPT codes.  Unfortunately, POS errors can cause areas of overpayment, and incorrect reimbursement for the services provided.  The software should also be tested to confirm that the claim edits and scrubs are set up appropriately.
In addition, the 2012 OIG work plan, has targeted three POS codes as potential areas of audit, with the “risk factor” of inappropriate reimbursement to either the physician/provider office, or the facility where the services took place.
·         POS code 11 (offices),
·         POS code 21 (hospital inpatient departments), and
·         POS code 22 (hospital outpatient departments, such as provider-based entities).
Compliance for POS errors is difficult, as the provider may submit codes for physician based services well ahead of the facility.  If the facility has “changed” the POS code and not notified the provider office, the two claims submitted (the provider claim and the facility claim) will not “match”, and thus a red-flag may go up that these claims need to be reviewed by the 3rd party payers or insurance carriers. 
For coders, there seems to be an “under-education” and misunderstanding of POS codes.  Not only do coders not have a good grasp of the importance of POS codes, but physicians and providers also do not understand them. 

In the nuts and bolts world of the coder, the POS code(s) should be one of the first areas looked at before determining the E&M billable services, or ancillary services to be coded and billed.  Coders need to be better educated in understanding the importance of the POS codes, and the direct relationship and impact on the reimbursement for providers and the facilities they work in.

For a full listing and definition of place of service codes, and their appropriate usage, the listing and definitions of POS codes found in the current CPT4 manual.  Coders and also find more specific Medicare/Medicaid requirements for correct POS assignment and documentation at and

Thursday, November 1, 2012

ICD-9 to ICD-10 PCS -- Robotic Assisted Procedures - Where do we go from here??

The conversion date for ICD-10CM and PCS has now been confirmed by CMS to be October 1,
2014. The challenge for coders is to continue their education and proficiency in the new ICD-10 pcs system. The onus to become proficient in this new coding code-set system begins in earnest. Not only do coders need to understand the new ICD-10 pcs system and its guidelines, but they need a very clear understanding of the devices, anatomy and physiology too.

Robotic Assist at surgery has traditionally been coded in ICD-9 volume 3, with the following category:

17.4 Robotic-Assisted Procedures
17.41 Open robotic assisted procedure
17.42 Laparoscopic-assisted robotic procedure
17.43 Percutaneous robotic assisted procedure
17.44 Endoscopic robotic assisted procedure
17.45 Thoracoscopic robotic procedure
17.49 Other and unspecified robotic assisted procedure

Usage of a robotic assistance or computer assisted surgical system, laparoscopic surgeons gain a skilled technical advantage that includes enhanced vision of the operative field from the scope, and improved manual dexterity for fine motor procedures such as lysis of adhesions, within the abdominal cavity. In addition, the surgical robotic assist device allows a physician increased ability for surgical precision of incision, excision, reattachment and opening/closing of the surgical operative field. However, the usage of the robotic assistive device, does not mean the primary surgical procedure itself has changed. The basic concept of the surgery is still defined as a laparoscopic procedure.

According to CMS and the usage of HIPPA defined code-sets, facilities are required to report the primary surgical procedure with the appropriate ICD-9-CM Volume 3 procedure, plus the appropriate procedure code for the robotic assistance. (e.g. 68.41 and 17.42). The HCPCS procedure code-set gives us only the code “S2900”, (surgical techniques requiring use of robotic surgical system),which may be used with the CPT4 procedure coding for physician based service claims.

An area of concern for coding of the utilization of surgical robotic assist devices for third party payers/Insurance carriers is those payers are not governed under federal CMS guideline. (payers such as Blue Cross, Blue Shield, Aetna, etc…) These private payers may provide their own policy coverage and guidelines for specific procedures that utilize a robotic assist device. When submitting claims to private or 3rd party payers, you will want to know up front if they want the S2900 HCPCS code appended to the claim in addition to the ICD-10PCS code. Currently, there is no clear information regarding how these 3rd party payers will respond in regard to ICD-10pcs and claim submission. As we get closer to the go-live date for ICD-10PCS on October 1, 2014, the claim submission issues will be a hot-topic that will need clarification from these 3rd party privare insurance payers.

As the coding industry progresses toward transition of ICD-10PCS, this new procedural coding
system enables us to give a more accurate picture of what was actually performed with the robotic assist devices. What would have previously been coded in ICD-9 volume 3, as a laparoscopic total abdominal hysterectomy (LAH) as code 68.41, can now be coded as 0UB94ZZ, or as 0UT94ZZ as per the ICD-10PCS tables (found at

The correct choice of code in ICD-10PCS will depend on what is documented and noted in the
operative report. In the illustrations below, the ICD-10PCS tables outline two different ICD-10 PCS procedure code scenarios that could be considered with usage of the laparoscopic robotic device.

Lets review and consider code 0UB94ZZ from the ICD-10 code-set:
0UB94ZZ Or code: 0UT94ZZ

The difference between these two codes 0UB94ZZ, and 0UT94ZZ is that code OUT94ZZ is a
Resection: Cutting out or off, without replacement, all of a body part whereas code OUB94ZZ is a Excision: Cutting out or off, without replacement, a portion of a body part

It is these verbiage differences (eg,“resection vs/excision”) where ICD-10PCS differentiates between the procedures in the code-set. These differences need to be documented clearly within the operative record by the physician or provider. This becomes a critical informational area for the coders to know and understand what the physician has documented in the operative report. In addition, the application of an incorrect procedure could impact the DRG weight for those specific services to the revenue for the hospital or facility either up or down. In addition, the coder must truly understand the ICD-10PCS guidelines and terminology as to what procedure was performed, and how the procedure was performed to correctly code the ”operation”, “body part”, and “approach” in ICD-10pcs guidelines. The fact that the procedure was performed with a robotic assist also becomes very important at this point.

However, it is interesting to note, that ICD-10PCS does not specifically state a “robotic” assist at all, nor does it address a “laparoscopic” assist with the new ICD-10 PCS codes. ICD-10 PCS simply gives us the choices of “Open”, “Percutaneous”, “Percutaneous Endoscopic” “Via Natural or Artificial Opening” or “Via Natural or Artificial Opening Endoscopic” as the surgical/procedure approach choices. CMS addresses the definition of “percutaneous endoscopic” as: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure…

In using the above guideline and definition from CMS, the best definition for a hysterectomy utilizing a laparoscopic robotic device would be the percutaneous endoscopic definition.

Below is an operative record excerpt for a Robotic-Assisted Laparoscopic Hysterectomy (RALH)

OPERATIVE REPORT: Total laparoscopic hysterectomy using the daVinci robotic equipment.

The abdomen and vagina were prepped and draped in the normal sterile fashion. A Foley catheter was inserted. A long weighted speculum was placed into the vagina and an anterior wall retractor was placed into the vagina. The cervix was grasped with a single-tooth tenaculum and the uterus was sounded to 7.5 cm and was anterior.

The balloon manipulator was then properly placed. The balloon was filled to approximately 3 cc of saline. The cervical cup was placed around the cervix. A sterile glove filled with a lap pad was then placed inside the vagina to help with pneumoperitoneum. An 11 mm port was placed in the left upper quadrant just under the inferior costal margin. Adequate pneumoperitoneum was obtained. A 12 mm port was placed supraumbilically and the 12 mm trocar was placed through that port. The daVinci camera was then placed supraumbilically. 3 more ports were then placed. The 11 mm port was then placed in the left upper quadrant and there were two 8 mm ports that were placed 10 cm laterally to the umbilicus and 2 cm inferiorly. The daVinci robot was then docked in the normal fashion. The patient was placed in steep Trendelenburg positioning.

Inspection of the pelvis showed a normal uterus, ovaries and tubes. The right fallopian tube was cauterized using the PK bipolar cautery and was ligated using the hot shears. The utero-ovarian ligament was also coagulated and cut. The round ligament was coagulated and cut. A bladder flap was created with the hot shears and the bladder was dissected down from the cervix.

This entire procedure was then repeated on the left side. The blue balloon cuff was then identified and an incision was made in the cervicovaginal junction on top of the vaginal cuff. This was also repeated posteriorly. The incision was extended laterally, freeing the uterus from the surrounding vagina and including the excision of the cervix itself.

The uterus was then morcellated and delivered posteriorly through the endocatch bag using the robotic assistant. The vaginal cuff was closed with four figure-of-eight sutures of 0 Vicryl. The ureters were identified bilaterally. The entire pelvis was hemostatic. The supraumbilical site was closed with a suture of 0 Vicryl. The skin was closed with 4- 0 Monocryl using subcuticular stitches. Steri-Strips were placed. The final needle, sponge and instrument count
was correct. The patient tolerated the procedure well. Patient to the recovery room in good condition.

If we code this operative record excerpt, per our ICD-10pcs coding guidelines, the procedure above would be coded as the ICD-10PCS code 0UB94ZZ. The rationale for this code choice, is the operative note states the uterus was removed, but not the fallopian tubes or ovaries. If you review the anatomy and physiology of the uterus, fallopian tubes and ovary(ies), those body parts are all connected as one major “organ” with accessory structures. As per the definition of a percutaneous endoscopic procedure, this approach would be chosen, (as the surgeon utilized a laparoscopic surgical assist device , aka daVinci robot, for the approach). There was no other device or qualifier noted in the record.

In conclusion, the surgical robotic assist device, will become inclusive into the entire ICD-10pcs
process(es) as part of the approach, rather than a separately identifiable assistive device, as is the case with ICD-9 procedural coding.

Again...  the full ICD-10 cm and ICD-10 pcs codes in addition to all draft coding guidelines for ICD-10 can be found at

Happy Coding! 

Thursday, September 20, 2012

Capture Revenue and Stay Safe with Surgical Chart Audits

This is a great article from the AAPC regarding surgical chart audits... Happy to share... To help ensure accurate surgical coding and provide peace of mind if an outside audit occurs, you should regularly perform internal reviews of surgical code selection. The goal of an internal audit is to strengthen documentation weaknesses and mend holes in claims management to help you capture all revenue. Know What to Look For According to Charla Prillaman, CPC, CPMC, CPC-I, CCC, CEMC, CPCO, an essential part of audit efforts in a surgical practice should include: * Checking the accuracy of evaluation and management (E/M) levels and reviewing surgical services charts. * Looking for erroneously selected CPT® codes, missing charges, and missing or inaccurate modifier selections. *Reviewing inaccurate ICD-9-CM diagnosis code selections. * Apply Complex Coding Principles and Payer Policies * Surgical services auditing has unique coding guidelines and rules to follow. When auditing, Prillaman says to pay close attention to: * Surgical global package concept * Correct modifier application * Payer policy * Screening vs. diagnostic vs. therapeutic procedures * Place of service (POS) reporting * National Correct Coding Initiative (NCCI) edits * E/M services provided during the global period * Complex rules surrounding services furnished by mid-level providers Dissect the Op Report When reviewing op reports, be sure to catch overlooked surgery details such as headings that inadequately or incompletely describe rendered services. An example of an incomplete heading, according to Prillaman, is "colonoscopy with polypectomy." She said, "Selecting a code from just the heading might lead to a claim submission of 45384 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. The detailed description in the body of the operative report, however, may reveal the surgeon removed two polyps using hot biopsy forceps, and removal of a separate polyp by snare." Prillaman continued, "A qualified auditor will recognize that an additional procedure (45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) should be reported, with modifier 59 Distinct procedural service appended because the National Correct Coding Initiative (NCCI) indicates this code pair usually is ‘mutually exclusive.' As a result, reimbursement may increase nearly $500 per case where this type of error has occurred." Take Coding Issues Seriously When an audit reveals miscoding, formulate steps to improve coding and weaknesses. Don't be afraid to call in the expertise of a surgical specialty auditor to help you with the audits and come up with a plan of attack. Proper audits will reduce claim denials and lost revenue and boost your billing confidence and your practice's bottom line.

Friday, August 24, 2012

CMS: ICD-10 2014 Date Official

CMS: ICD-10 2014 Date Official

Friday, August 24, 2012

The final rule setting the ICD-10-CM implementation date as October 1, 2014 was released by the Centers for Medicare & Medicaid Services (CMS) this morning.

The rule, which will be published in the Federal Register Sept. 5, ends months of speculation spawned when public comment was solicited by CMS in April. The rule, which also sets dates for health plan and provider identifiers, emphasizes providers and payers must adopt the code set by the 2014 date, which is a one-year delay from the previous implementation date.

The rule explains the one-year postponement allows providers and payers additional time to implement the new code set.

View the final rule

Review the fact sheet

Thursday, August 23, 2012

Training our Residents, Teaching Physician, Interns and Residents - Coding it correctly

I put this article out for HCPRO - and wanted to also share some of my Insight of this topic with you too...   Teaching physicians bear a huge responsibility in getting our residents, medical students, and interns trained "on the job".  It's one thing to do it in a classroom setting, but quite another to be "on the job".   The coding for these services is very tricky.  CMS has put out a great guideline resource, but I've tried to dissect this out to make it easier for you (as the coder/biller/manager) to figure out what needs to happen to get reimbursed for the services provided...  ENJOY!!  and HAPPY CODING!

Clearing up the confusion:  Coding Tips for Teaching Physicians, Interns, Residents and Students

There are many challenges to coding for Teaching physicians, interns, residents and students.  Medicare (CMS = Centers of Medicare and Medicaid Services) has very specific rules and regulations as to what they will and will not pay for when services are provided by an intern, resident or a student.   Coding is only one piece of the reimbursement puzzle when it comes to these issues.  The first area that we need to outline is the definition of “who” is the provider of care, and “who” is the oversight /proctoring/mentoring provider for the intern, resident and/or student. 

The guidelines provided by CMS may or may not be followed by independent 3rd party insurance payers.  It is wise to contact those payers if unsure if they will recognize any billing or payment for services provided by an intern, resident and/or student for their subscribers

Definitions we need to know: (As per CMS)

Teaching Physician: A physician, other than an intern or resident, who involves residents in the care of his or her patients. Generally, the teaching physician must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire service in order for the service to be payable under the Medical Physician Fee Schedule.

Intern or Resident: An individual who participates in an approved Graduate Medical Education (GME) Program or a physician who is authorized to practice only in a hospital setting (e.g., has a temporary or restricted license or is an unlicensed graduate of a foreign medical school).    Also included in this definition are interns, residents, and fellows in GME Programs recognized as approved for purposes of direct GME and Indirect Medical Education (IME) payments made by Fiscal Intermediaries or A/B Medicare Administrative Contractors, receiving a staff or faculty appointment, participating in a fellowship, or whether a hospital includes the physician in its full-time equivalency count of residents does not by itself alter the status of “resident.”.

Student:  An individual who participates in an accredited educational program (e.g., medical school) that is not an approved Graduate Medical Education Program and is not considered an intern or resident. Medicare does not pay for any services furnished by a student. Medical students are not licensed physicians; they are students. 

Now that we have ascertained what the roles are in a teaching physician setting, the next thing we have to do, is determine the service that is being provided, and if that service can be reimbursed by a 3rd party payer.

According to CMS (Medicare services)  Medicare will pay for medical or surgical services if the service was provided by a licensed physician (face to face) and that provider of the service is not a resident.  In some of Medicare’s information the term “physically present” will be noted.  This simply means the teaching physician and the resident physician are together with the patient in the same room or exam area. 

CMS (Medicare Services) will pay for services provided by a resident if a “teaching physician is present during critical or key portions of the service or procedure.   The issue here is CMS (Medicare) does not elaboarate with their guidelines of what they consider “critical or key portions” of the service being provided by the resident.  Documentation by both the resident and the teaching physician is critical, in the absence of guidelines as to what CMS considers “creitical or key” in regard to the service being provided.

CMS (Medicare) requires strict adherence to their guidelines, so payment can be made to the provider of the service.  For 3rd party payers, most will default to what CMS has outlined.  However, some 3rd party insurers have their own guidelines, and may or may not pay when a resident has seen the patient and provided services. 

Documentation Criteria and guidance for the teaching physician:

If your provider is operating in the capacity of a ‘teaching physician” or “oversight physician, these are the nuts and bolts of what needs to be documented.

§    As the Teaching Physician your participation in the review of the history/chief complaint of the patient as taken by the Intern/Resident and/or student and verified by you.

§    As the Teaching Physician Your participation in the management of the patient to include the examination and medical decision making.

§    As the Teaching Physician, you were physically present during the “critical or key” portions of the service/procedure provided by the Intern/Resident and/or student.

§    The combined entries from BOTH you and the Intern/Resident and/or student will be needed to support the medical necessity of the care of the patient, and to be billed to Medicare or another 3rd party payer.

§    Documentation of a service or procedure provided by the resident only – with a notation stating the Teaching Physician’s presence and participation IS NOT sufficient to bill CMS(Medicare) for  that service. 

§    It must be clearly documented and identifiable by BOTH the Teaching Physician and the Intern/Resident and/or student as to what portions of the services were performed by each provider of care.

Unacceptable documentation examples by a Teaching Physician include those such as below, that are followed with a countersignature.   A Countersignature by itself is insufficient for documentation purposes.

§    “I saw and evaluated the patient,
§    “I reviewed the residents note and agree with the plan”
§    “agree with the above……” 
§    “patient seen and evaluated…….”
§    “discussed with Resident and agree with plan……….”

Minimally acceptable documentation (provided below from CMS) outlines what needs to be included when billing for services provided by the Intern/Resident with a Teaching Physician
Examples of minimally acceptable documentation include:
§    "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care."
"I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note."
"I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs

Both the Resident/Intern and the Teaching Physician must have separately identifiable documentation, and clarity regarding their physical attendance (face to face) with the patient.

If the service that was provided is a time-based code such as code 99238 or 99239, the teaching physician must be present for the entire period of time specified by the code.  For code 99238 it states the discharge is 30 minutes or less, code 99239 states 30 minutes or more.  With code 99239, 30 minutes or more does not specifically note “face to face” time, by CPT,  so as long as the documentation by the teaching physician details that the time took more than 30 minutes it would be sufficient.

In the case of critical care time, where code 99291 states it can be used for the first 30-74 minutes, this time must be face to face time with the patient, and the teaching physician must be present for the entire period of time for which you are billing for.  The same holds true for E&M codes.  If the provider wants to bill for a time-based E&M code, then 50% of the total time spent must be face to face with the patient, documenting that the 50% was spent in counseling and coordination of care with the patient.

When coding and billing for teaching physicians, CMS requires the use of modifier “GC”, or the use of modifier “GE”  When the CMS 1500 form is filled out these two modifiers are required by Medicare to provide information in respect of teaching physician service,  The use of the modifier, does not increase or decrease the payment to the teaching physician.  If you are billing for a 3rd party payer, they may or may not want either of these modifiers included.

Definition:  Modifier GC,   This service has been performed in part by a resident under the direction of a teaching physician.
Definition:  GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception

Originally posted to on August 22, 2012 
Informational references from 

Wednesday, July 11, 2012

ICD-10 & the IDHC news

Just wanted to let you know that  I was recently picked up for an article on the ICD-10 collaborative -  Here's the link where it is if you'd like to see it...

Thanks!  L  : )

Thursday, June 21, 2012

CMS posts new update for ICD-10 PCS for 2013 files

I just got notification from AHIMA that CMS just posted new information on the update for the ICD-10 PCS format files.  So all of you that are actively training and working with ICD-10 PCS this is a GREAT resource. 

CMS has a PDF file out there that walks you through the entire PCS Processes... and best of all it's free!!!    Here's the CMS link.  On the CMS site, it also has the 2012 information for ICD-10 cm.  I'm hoping the CM informational update for 2013 will be out soon too!   Happy Coding!  L : )

Thursday, June 14, 2012

G0101 & Q0091 - What constitutes "high risk"

This week I had the opportunity to utilize CMS's educational resources in regard to all the preventive and/or screening services that Medicare pays for.  This web site is a searchable PDF file.  It has ALL the info you'll need to know.  

I  needed to find out the criteria for "high risk" in regard to the guideline for Medicare's Pap/Pelvic screening code for G0101 and the Q0091.  Medicare will normally only pay for the G0101 screening code once every two years, unless the patient is in a 'high risk" category.  The screening Pap test benefit is covered by Medicare as a stand-alone billable service separate from the IPPE screening benenfit and does not have to be obtained within a certain time frame following a eneficiary's Medicare part "B" enrollment.  Medicare has disclosed the criteria of what 'high risk"  for cervical and vaginal cancer includes.  I've outlined below in the bulleted list
  • Early onset of sexual activity (aged 16 and younger)
  • Multiple sexual partner (5 or more in a lifetime)
  • History of sexually transmitted disease (including human papilliomavirus (HPV) and/or Human Immunodeficiency Virus (HIV) infection
  • Fewer than three negative Pap tests or no Pap test within the previous seven year 
  • DES (Diethylstilbestrol) exposed daughters of women who took DES during pregnancy 
Additional high risk factors for cervical and vaginal cancer include:
  • smoking 
  • Using birth control pills for an extended period of time (five or more years) 
If the patient does qualify as a "high risk" patient, the above information needs to be clearly documented within the patient's chart.  In addition to the G0101 and Q0091 code, the diagnosis of V15.89

For women that are not "high risk" - there are a number of diagnoses that are payable once every 2 years.  Those diagnoses are 

V72.31 Routine Gynecological Examination ( NOTE: This diagnosis should only be used when the provider performs a full gynecological examination.)
V76.2 Special screening for malignant neoplasms, cervix
V76.47 Special screening for malignant neoplasms, vagina
V76.49 Special screening for malignant neoplasms, other sites (NOTE: Providers use this diagnosis for women without a cervix.)

The big take-away from this all, is that the physician MUST DOCUMENT if the patient is considered high-risk,  If the patient does not have any of the high risk-factors for cervical or vaginal cancer, yet the patient or physician determines that the patient needs a Pap test yearly, be sure to get an ABN signed, and inform the patient they may be responsible for the cost of the test..    Here's the link for the full PDF document for Medicare preventive services....

Monday, June 4, 2012

Urodynamic testing - Handy cheat sheet info (CMG, Uroflow)

Giving Credit, where Credit is due....  This is a GREAT cheat sheet for keeping the urodynamics coding
information clear, when coding for Cystometrogram and Uroflow procedures. --  Thanks are extended to Dr. Michael Ferragamo... 

When your urologist says he performed urodynamics tests, you need to dig deeper into his documentation for clues about which code to report. Tack this overview up by your computer to help you quickly choose the right code every time.

• In a simple CMG (51725, Simple cystometrogram [e.g., spinal manometer]), the urologist places a small catheter in the bladder, fills the bladder by gravity, and measures capacity and storage pressures using a spinal manometer.

• A complex CMG (51726, Complex cystometrogram [e.g., calibrated electronic equipment]) involves filling the bladder through a catheter and measuring the pressures with calibrated electronic equipment. If your urologist also performs a urethral pressure profile (UPP), report 51727 (Complex cystometrogram [i.e., calibrated electronic equipment]; with urethral pressure profile studies [i.e., urethral closure pressure profile], any technique). For a complex CMG with voiding pressure study, report 51728 (… with voiding pressure studies [i.e., bladder voiding pressure], any technique).

For a complex CMG with voiding pressure study and UPP, use 51729 (… with voiding pressure studies [i.e., bladder voiding pressure] and urethral pressure profile studies [ie, urethral closure pressure profile], any technique).

• During a simple UFR (51736, Simple uroflowmetry [e.g., stopwatch flow rate, mechanical uroflowmeter]), the urologist visually observes the urine flow, sometimes using a stopwatch to gauge and measure the flow.

• A complex UFR (51741, Complex uroflowmetry [e.g., calibrated electronic equipment]) makes use of special electronic equipment to measure the urine flow.

• EMG studies (51784, Electromyography studies of anal or urethral sphincter, other than needle, any technique), in which the urologist places skin patch electrodes on the perineum to measure electrical and muscular activity of the perineal muscles and urinary sphincter.

• A needle EMG (51785, Needle electromyography studies of anal or urethral sphincter, any technique) involves placing needles into the pelvic floor to measure muscle activity during bladder filling and at rest. Few urologists use needle electromyography these days.

• Stimulus evoked response (51792, Stimulus evoked response [e.g., measurement of bulbocavernosus reflex latency time]) involves stimulating the sacral arch via the glans or clitoris and measuring motor activity in the pelvic floor or urethral sphincter. Urologists rarely perform this test.

• VP studies (+51797, Voiding pressure studies, intra-abdominal [i.e., rectal, gastric, intraperitoneal] [List separately in addition to code for primary procedure]) measure specific pressures during oiding. This is an add-on code that cannot be independently billed. You can bill is with 51728 or 51729.

• Valsalva (abdominal) leak point pressure: The urologist asks the patient to bear down forcefully (Valsalva maneuver) while he observes the abdominal pressure at which leakage occurs from the bladder at the urethral meatus (around the urethral catheter) when the bladder has been filled with a minimum of 150 cc of fluid. The bladder pressure at leakage is called the leak point pressure. This is now included in 51727 and 51729

Sunday, May 27, 2012

5010 deadline -

Version 5010 Enforcement Discretion Period Ends on June 30, 2012.

The deadline for all HIPAA-covered entities to upgrade to Version 5010 electronic standards was January 1, 2012. However, the Centers for Medicare and Medicaid Services (CMS) initiated an enforcement discretion period until June 30, 2012 to give the industry additional time to complete testing. CMS made this decision based on industry feedback that many organizations and their trading partners were not yet ready to finalize system upgrades for this transition.

If you have not yet finalized your Version 5010 upgrade, you should be working to complete this step as soon as possible!

Version 5010 Resources
CMS is committed to helping you successfully upgrade to Version 5010 and ICD-10 by providing resources on the CMS ICD-10 website to help you understand and manage your upgrade.

CMS regularly updates the CMS ICD-10 website, including a web page dedicated to Version 5010 information and resources.

CMS has also posted a fact sheet, which discusses steps providers should be taking now to be compliant with the upgrade to Version 5010 by June 30, 2012.

If you are looking to find good ICD-10 information, or training, check out what I have to offer, as I am an AHIMA certified ICD-10 cm/pcs trainer.  In addition, please check out the educational information available with some of my great clients and resources at AHIMA, AAPC, and  Check out the link and access my free 30 minute webinar related to ICD-10 training strategies...  Free is good!!!!

L  : )

Saturday, May 19, 2012

Rho(D) aka (Rhogam) coding quandry: Two ways to code, both are correct!

It's hard to believe, but in pregnancy Rhogam administration, there are actually two correct methods to code the administration of the Rho(D) globulin serum.  As a coder, it is up to you to determine how best to accomplish this for your OB/GYN practice.  I've outlined below what you need to know to correctly code, bill and get reimbursement for this service. 

History of Rho(D)

RHo(D) Immune globulin is the serum globulin extracted from human blood, or can also be a recombinant immune globulin product that has been created through genetic manipulation of human and/or animal protein.  RH plays an important role in the pregnant patient and the developing fetus. 

Rh blood types were discovered back in 1940, and over the last 70 years researchers have learned a lot about the genetic complexities of Rh and blood typing in relationship to fetal and maternal well being.  The Rh system was initially named after rhesus monkey, since they were the initial research subjects. (and also since the rhesus monkey blood bears similar human qualities).  What was determined in these studies is that when creating the antiserum – if the antiserum agglutinates the red cells you are considered and Rh+(positive) and if it does not you are considered an Rh-(negative). 

From a clinical standpoint, the Rh factor of positive and negative can lead to problems between a mother and the developing fetus.  It is referred to as mother-fetus incompatibility, and occurs when the mother is Rh-(negative) and the fetus is Rh+(positive).  Amazingly enough, these antibodies can cross the placenta and destroy fetal red blood cells.  The risk for this happening increases with each pregnancy.

To help prevent these complications during pregnancy,  physicians routinely order the pregnant patient to undergo testing to determine the Rh and ABO blood typing.  Once this has been completed, the physician will then determine if having the patient receive the Rho(D) immune globulin. 

According to the American College of Obstetricians and Gynecologists (ACOG) they have developed a standard guideline of re administration of the Rho(D) immune globulin product
These standards are:

  • The first dose of Rho(D) immune globulin is to be given at 28 weeks’ gestation (earlier if there’s been an invasive event),
  • Followed by a postpartum dose given within 72 hours of delivery.
The Two Coding Scenario's 

As a coder, you need to understand the documentation requirements for the administration of a Rho(D) immune globulin, and then how to bill and code for it appropriately.  This is where the coding of the product becomes somewhat complex. 

CPT identifies the Rho(D) immune globulin serum with these three codes

  • 90384 Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use
  • 90385 Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use
  • 90386 Rho(D) immune globulin (RhIgIV), human, for intravenous use

To code and bill the serum itself, CPT also directs us to report the administration of the serum with codes 96365-96368, 96372, 96374 or 96375 as appropriate.  CPT also instructs us that modifier 51 should not be appended when performed with another procedure.

However, CMS (Center for Medicare & Medicaid Services) the part B physician fee schedule does not recognize the coding or payment for the codes 90384, 90385 and 90386.  CMS does however recognize the HCPCS codes for Rho(D) as shown below.

  • J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg (250 i.u.)
  • J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg (1500 i.u.)
  •  J2791 Injection, Rho D immune globulin (human), (Rhophylac), intramuscular or intravenous,100 IU
  • J2792 Injection, Rho D immune globulin, intravenous, human, solvent detergent, 100 IU

If you choose to bill the HCPCS codes J2788—J2792, again you will need to code and bill for the injection of the serum with either the CPT code(s) 96365-96368, 96372, 96374 or 96375 as appropriate, or with the ICD-9 Volume 3 procedure code of 99.11

This creates the issue where both methods of coding are correct.  The issue then falls upon the coder to determine how to code the service based upon how the 3rd party payer will reimburse for the service. 

The next issue with the coding of Rho(D) in pregnancy is determining the correct diagnosis to be appended with the service rendered.  The most common diagnoses for a pregnant patient with the need for a Rho(D) are:  

V07.2          Need for prophylactic immunotherapy
V22.1          Supervision of other normal pregnancy
656.10                  Rhesus isoimmunization unspecified as to episode of care in pregnancy
656.11                   Rhesus isoimmunization affecting management of mother, delivered
656.13         Rhesus isoimmunization affecting management of mother, antepartum condition

However, there are many other pregnancy diagnoses that would denote the need for a Rho(D) injection.  The diagnosis needs to be clearly documented by the provider for the coder to accurately code and bill for the procedure.

As with any and all services, it is recommended that you pre-authorize the Rho(D) injection first with the insurance carrier/3rd party payer.  When pre-authorizing, inquire with the carrier how they would like to see the service coded.  This will help you code and bill for this correctly up-front, and avoid payment and coding denials on the backside. 

Office/outpatient Practice
CPT Code
Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use.
(e.g. serum itself)

V07.2   Need for prophylactic immunotherapy
V22.1   Supervision of other normal pregnancy
656.13 Rh Iso afft mgmt of mother antepartum
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
(e.g. injection of the serum)

V07.2   Need for prophylactic immunotherapy
V22.1   Supervision of other normal pregnancy
656.13 Rh Iso afft mgmt of mother antepartum

Office/outpatient Practice
Rho D immune globulin, human, full dose, 300 mcg (1500 i.u
(e.g. serum itself)

V07.2   Need for prophylactic immunotherapy
V22.1   Supervision of other normal pregnancy
656.13 Rh Iso afft mgmt of mother antepartum

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
(e.g. injection of the serum)

V07.2   Need for prophylactic immunotherapy
V22.1   Supervision of other normal pregnancy
656.13 Rh Iso afft mgmt of mother antepartum

Inpatient/Outpatient Facility
HCPCS/ICD-9 vol 3 procedure code
Rho D immune globulin, human, full dose, 300 mcg (1500 i.u
(eg. serum itself)

V07.2   Need for prophylactic immunotherapy
V22.1   Supervision of other normal pregnancy
656.13 Rh Iso afft mgmt of mother antepartum

Therapeutic, prophylactic, or diagnostic injection of Rh Immune Globulin

V07.2   Need for prophylactic immunotherapy
656.13 Rh Iso afft mgmt of mother antepartum

This creates the issue where both methods of coding are correct.  The issue then falls upon the coder to determine how to code the service based upon how the 3rd party payer will reimburse for the service.