Wednesday, December 11, 2013

Another Free Webinar - HIPAA & the OCR Audit Program

For those of ou that are specialists with HIPAA Privace and Security Enforcement and the OCR audit program is on your Radar, our friends at Wolters Kluwer Law is prsenting another free Webinar. The best part is there is the opportunity for HCCA education units. Follow this link to register... or cut/paste into your browser: HIPAA Privacy & Security Enforcement: Expert advice for those preparing and responding to the OCR Audit Program DATE Wednesday, December 18, 2013 TIME 1:00-2:00 p.m. EDT 12:00-1:00 p.m. CDT 11:00-12:00 p.m. MDT 10:00-11:00 a.m. PDT CEUs This program has been approved by or is pending approval from the Health Care Compliance Association (HCCA). Space is limited! This popular topic is open to the first 1,000 approved registrants and is expected to fill up quickly. Don’t delay! Registration requires a complete Name, Title, Organization, and a valid business Email Address. SPEAKERS Chuck Burbank CHP, CHSS FairWarning, Inc. Ryan Redman Product Manager Wolters Kluwer Law & Business SUMMARY This webinar will use real-world examples to address the background, challenges, and best practices of the OCR Audit Process. Ryan will walk through how organizations prepare for an OCR audit while achieving the broader goal of mitigating breach risk by conducting a risk assessment. Chuck, a former Information Security Manager of both a large healthcare organization and a U.S. health plan targeted by an OCR audit, will share his experiences and lessons learned. Together they will address how organizations prepare for and what they can expect from this type of audit, as well as how organizations can address the broader challenges that can result in breaches. OBJECTIVES Learn about and increase self-awareness of the privacy and security challenges within today’s healthcare organizations Review industry best practices to overcome challenges providers face Hear detailed analysis of real world audit experiences in the form of a case studies REGISTRATION This live webinar requires nothing more than an Internet connection. Register today for this FREE webinar!

Tuesday, November 26, 2013

2014 CPT Changes Free Webinar

Wolters Kluwer Law is offering 2 sessions of a free 2014 CPT changes overview webinar. Again, this is FREE and also will be offering CEU's. We all can use this info, so please support them, and take adavantage of this educational opportunity. L : ) Here is the link... cut and paste to sign up SUMMARY Attendees will gain a better understanding of 2014 CPT changes, with an overview of changes, the rationale behind those changes, and a review of each change by section, including: Anesthesia Surgery Radiology Pathology/Laboratory Medicine and Category II & III codes ABOUT THE SPEAKER Georgeann Edford, RN, MBA, CCS-P, President and Founder of Coding Compliance Solutions, is an author and frequent presenter to hospitals and physician groups. Georgeann is a recognized leader in the coding and medical records fields. Georgeann has served as an expert witness on numerous occasions and is an Advisory Board Member for Dennis Barry’s Reimbursement Advisor as well as serving her fourth term as a CCH & MediRegs Coding Advisory Board Member. REGISTRATION Space is limited! This popular topic is open to the first 1,000 approved registrants and is expected to fill up quickly. Don’t delay! Registration requires a complete Name, Title, Organization, and a valid business Email Address. Choose from one of two dates: DATE Wednesday, Dec 4, 2013 TIME 1:00-2:30 p.m. EST 12:00-1:30 p.m. CST 11:00-12:30 p.m. MST 10:00-11:30 a.m. PST OR DATE Wednesday, Dec 11, 2013 TIME 1:00-2:30 p.m. EST 12:00-1:30 p.m. CST 11:00-12:30 p.m. MST 10:00-11:30 a.m. PST CEUs This program has been approved by or is pending approval from AAPC and AHIMA.

Thursday, November 7, 2013

Phase 2 Medicare Ordering & Referral Denial Edits

If you haven't heard, or not aware... Medicare put this out yesterday, These denial edits will affect both Part A and Part B -- L : ) MLN Connects - Provider eNews - Medicare Learning Network Wednesday, November 6, 2013 Ordering and Referring Denial Edits Will Be Implemented on January 6, 2014 CMS will instruct contractors to turn on Phase 2 denial edits on January 6, 2014. These edits will check the following claims for a valid individual National Provider Identifier (NPI) and deny the claim when this information is invalid: Claims from clinical laboratories for ordered tests; Claims from imaging centers for ordered imaging procedures; Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS; and Claims from Part A Home Health Agencies (HHAs). For more information: MLN Matters® Article #SE1305, “Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856)” For More information... click this link

Tuesday, November 5, 2013

CCI 19.3 Update - Free Webinar

Good Afternoon!!!! has put out a flyer for a free webinar in regard to the CCI update version 19.3 If you attend live it is good for 1.0 CEU from the AAPC. Good Stuff and FREE!!!! Take advantage if you can. L : )

Sunday, September 8, 2013

Is incomplete documentation affecting reimbursement for your practice?

Is incomplete documentation affecting reimbursement for your practice? As a physician or provider, your first priority is giving good patient care. However, you are still in control of how financial revenue is generated on a daily basis.

Since you are the integral piece of this financial venture, you should be aware of whether your charges are being paid, or denied. Many provider have a lack of understanding regarding why claims are denied. Unfortunately, the success of your practice or service may hinge on the success or failure of this revenue process.

According to the Texas Medical Associations’ Medicare contractor Trailblazer, the following E&M codes are the most problematic for getting claims paid correctly.
• New patient office or other outpatient visits - CPT codes 99201-99205
• Established patient office or other outpatient visits - CPT codes 99211-99215
• Initial hospital care for new or established patient - CPT codes 99221-99223
• Subsequent hospital care - CPT codes 99231-99233
• Emergency department services - CPT codes 99281-99285

The primary issue with the above listed codes, are these codes are the nuts and bolts of what we bill. The most common issue found with these codes is documentation by the providers. Incomplete or insufficient documentation leads to denials or take-backs of payment pending pre-payment or post-payment audits. Even if you feel you are documenting correctly, take the time to find out if your E&M codes are being denied.

The list below (also from the Texas Medical Association and Trailblazer) drill down to the most common ‘type’ of documentation errors they are discovering.
• Documentation does not support the level of service billed (i.e., up-coding or down-coding of services).
• Required components (as required by the CPT book) are not documented in the medical record.
o This includes the components of; history, exam, medical decision making and/or time.
o The history component is incomplete or absent.
o The medical decision-making documented is inappropriate or incomplete. Services were rendered by one physician and billed by another.
  • Documentation does not support a face-to-face encounter between physician and patient.
• The medical record contains conflicting information o the diagnosis on the claim is inconsistent with the diagnosis in the medical record o documentation in the patient's history conflicts with the examination o the date of service in the documentation is different from the date of service billed)
o The service is not performed on the date of service billed
o The service is/was not documented on the date of the visit.
• Medical documentation does not support medical necessity for the frequency of the visit

The big take-away from the above information, is as a provider, you are giving good patient care, but documentation of that care is a critical piece of our fiscal solvency puzzle. One of the ways to ensure that your documentation is up to scrutiny, is to ask and receive feedback from your coding and financial teams in regard to the denials that your practice is receiving. Analyze and educate yourself and your team for improvement. If you are struggling with the core concepts of coding, ask for help and/or education. The cost of the education is minimal, when compared to not receiving full reimbursement for the services you are providing. It costs far more to have claims denied, and appealed, than if they are correct the first time through.

In an OB/GYN hospitalist, or even a private OB/GYN practice, the “labor check” patients are thoroughly evaluated, and this should be substantiated by the diagnosis driver. If you are seeing the patient on the labor unit, or in the emergency department, this should not be considered a “normal” visit. It would be inappropriate to code these encounters with the V22.1 Supervision of other normal pregnancy code.

These visits should be documented with a clear diagnosis driver of an antepartum complication to the pregnancy. The use of code 646.83 Other specified complication, antepartum is a great code to use if there is not a code that fits the case your are working on. Use code 646.83 first, then specify what the reason for the visit is. You know what the reason is for seeing the patient, it just happens that you may have forgotten to get it documented, or documented clearly in the record.

The patients' presenting symptoms should be paramount in the first few lines of your documentation. One of the first things an auditor looks at is the chief complaint. The chief complaint should be very short, clear and concise. (eg. Patient thinks she may have leaking fluid, patient is having right sided pain and nausea; patient has had diarrhea and vomiting, etc..)

Ensure that the date the patient is seen, is correct in your documentation. The patient may have been admitted at 11:53 pm on 08/2/2013 to the labor deck, but if you did not see and evaluate the patient until 2:00 a.m on 08/03/2013, the date of service needs to be reflected as such. If the claim is denied, and has to be corrected – you may be required to amend the documentation, in addition to filing a formal appeal for re-submission.

Even if it only takes a few minutes for you to amend the documentation, the cost of doing business has just increased. These “quick” corrections still take your valuable time, that could have been better spent taking care of patients. In addition, this also costs the practice for the coder/biller’s time to gather your amended document, then re-send the claim for payment.

In some practices the physicians are coding their own claims, in other practices a coder oversee’s the charge entry process. In either circumstance, the provider or the coder should be reviewing the codes to the documentation on a regular basis. For clearer documentation and understanding of the claims processes, communicate with your coder, biller and practice manager on a regular basis to find out where your denials are, and if you can be an active part of reducing them. Happy Coding!

Wednesday, September 4, 2013

Free Webinar: External Cause coding ICD-10 Sept. 17 2013

As you know, I like to post free or low-cost webinars that you can take advantage of. Here's another one from Wolters Kluwer. It is on the change over from "E" codes in ICD-9 to the "Z" codes in ICD-10. Take advantage of it if you can. the link is below.

Saturday, August 31, 2013

OB Coding for a "missed" delivery - what is right? wrong? what do I do?

This seems to be at the forefront of a lot of OB offices. In Idaho (where I reside) these are the scenario's that we utilize the most. However, your facility or practice, may choose something different. There is nothing from ACOG stating what is "right". I have come up with this bulleted list, to view your options. Again, it would depend on your physician practice and/or facility (if MD's are salaried vs/private) Thanks L : ) There are a number of scenario's, but I have reviewed what has been most common that yy readers have inquired aboaut. The "most appropriate" way to do these I've compiled below. (eg that insurance carriers like to see) Scenario A A)If you are the attending(Global OB): Bill the global code (59400) with a mod -52 (for not actually "catching" the baby, or if the RN is the one who has actually "caught" the baby.) When you bill these, be sure to denote that the physician "missed" the delivery of the infant, but completed the balance of care. Also, be sure use the "precipitous delivery" diagnosis driver of 661.31 as our primary dx. Scenario B b) If your provider is the attending and has missed the delivery but the Nurse was in attendance: Bill the Antepartum care only (59425/26), a placenta only delivery(59414) and any vaginal repairs if needed, and post-partum care(59430) once your provider actually see the patient back in the clinic setting/office. Some carriers and 3rd party payers prefer this methodology. If you choose to bill with the above, you may also bill the placenta only delivery with diagnosis code 661.31 for preciptate labor. With ACOG's guidelines, you could then appropriately bill subsequent daily hospital visit codes(99231-99233) for the maternal hospital stay, and also a Discharge (99238-99239) If you truly only provided the "intra-partum" care, and not a full "delivery spectrum" of care. Once the patient arrives in your clinic for a 2/4/6 wk follow up, bill the 59430 post-partum care code. Scenario C c) If an outside physician or OB hospitalist (someone outside your practice or tax ID #)delivers the baby, the placenta & does any repairs, then the outside physician/hospitalist will usually bill the 59409 delivery only code. The PCP/Antepartum OB would only bill the Ante/Posts for that patient, and any other subsequent care during the delivery stay. Scenario D d) If the outside physician or OB hospitalist have a reciprocity agreement, or a Financial agreement of cross/coverage, you could then bill the global feel to the insurance carrier or 3rd party payer as OB/Gyn provider, office. You owuld then provide an outside reimbursement to the actual delivery physician or OB hospitalists service via in-house transfer/or private payment methodology. (eg. $500.00 lump sum to the OB hospitalists for the delivery only) If the hospitalists and the OB's have a reciprocity agreement in place, it would then be inappropriate to bill the OB's for a placenta only delivery and/or repairs. I am sure there are many, many more scenario's and different issues that come up in regard to "missed delivery" billing. If you are unsure, contact all proviers of care involved, and contact the insurance payers/3rd party payers to inquire as to what methodology they would like to see the claims submitted under. L : )

Monday, August 26, 2013

Wet Prep and Fern Testing in OB-GYN

Good Morning - I had a query last week regarding the criteria necessary for billing for these two tests in an OB/Gyn and OB Hospitalist office. Here's what you need to know: The FERN test: Provided the physician documents that THEY did the procurement (not a nurse or medical assistant) and personally reviewed the slide, and notated the medical record as such. The physician can then bill a HCPCS code Q0114 with dx's such as 658.13 (Premature Rupture of Membranes PROM), 646.83 (Oth antepartum complication) KOH Wet prep: Again the physician must document and be the one who procures the KOH Wetmount HCPCS Code Q0112 can be billed. This code will pass a CCI edit scrub with dx's such as 658.13 (PROM), 646.83 (Oth Antepartum complication) 623.5 Leukorrhea. It did not pass edit check for code 616.10 (Bacterial Vaginosis). Wet mounts, including preparations of vaginal, cervical or skin specimens HCPCS Code Q0111 can be billed and it passes the edits with the same dx's as above (see KOH Wet Prep) . Actual reimbursement for these would depend on the insurance carrier, or 3rd party payers, and their particular edit scrubs and/or contracts with providers. However, at this time these HCPCS codes are the valid way to code for these services provided by a physician. If these services are provided by the Laboratory, then the appropriate CPT codes from the 80000 code section would be billed. Have a GREAT day!

Sunday, August 4, 2013

The Top “10’s” What can your practice learn from this?

Welcome back to my blog -  This is a copy of an article that I wrote for the OB/GYN hospitalist website.  This article is geared toward the specialty of OB/GYN hospitalists.  However, this type of data mining can be of help to any practice. As I specialize in the OB/GYN field, this excercize was really informative for me, as I wrote the article. Enjoy! 


The Top “10’s”  What can your practice learn from this?  

In an OB Hospitalist practice, you are faced with so many different medical scenarios each and every day that to know what is your top 10 might be a difficult assignment.  Well, this is exactly what we decided to take on. 
We encounter patients who don’t have a regular health care provider, and those patients rely on OB hospitalists to respond to their emergencies and care for them around the clock. Because the hospitalist program is fairly new to the American hospital system, coding for this subspecialty poses a bigger challenge for the providers, as well as the hospital itself.  We have to maintain good patient care, in addition to being fiscally solvent. 

The OB-GYN hospitalist program has a positive impact on these at-risk OB patients’ health care because our programs enable these patients to have emergent care for any type of OB or GYN emergency when their own physician is unavailable.  Of course, we provide many other functions such as, supporting local obstetricians as back-up for deliveries and emergency C-sections; providing ancillary testing services for walk-in or emergent trauma situations, and also step in as an assistant surgeon for many operative procedures at a moment’s notice.  

The fiscal mainstay for the OB Hospitalist practice is the E/M services, which include all areas of inpatient hospital, outpatient hospital, emergency department, critical care and office codes.  The next area of importance is the CPT procedures, which can include surgery, interventional, diagnostic and therapeutic medicine, radiology/ultrasound services. 
In trying to ascertain the “top ten” E&M Services, this was difficult, because each OB hospitalist program functions under many different licenses within the hospital setting.  Some practices are embedded with the Emergency Room, some are an integral part of the Labor & Delivery floor, while others operate as a “emergent outpatient” area of the hospital similar to a “quick-care, urgent-care” walk in clinic.  

Each OB hospitalist practice should really take the time to figure out which “top ten” E&M services are in your practice, and evaluate how those particular E&M codes  impact your fiscal bottom line.  The next step is to look at the top ten procedures that your practice is billing for, then follow all of that up with a list of the top 10 diagnoses that are being treated within the practice.  Once you have this information it may surprise you as to what your “standard of care” really is. 

Below is a quick analysis of what I put together from an OB hospitalist practice in the Northwest.  The lists below are the analysis of the three separate areas of “top tens”
Evaluation and Management Services:
1.     99213 Office or other outpatient visit for the evaluation and management of an established patient.

2.     99201 Office or other outpatient visit for the evaluation and management of a new patient,.

3.     99214 Office or other outpatient visit for the evaluation and management of an established patient
4.     99232 Subsequent hospital care, per day, for the evaluation and management of a patient

5.     99221 Initial hospital care, per day, for the evaluation and management of a patient,

6.     99222 Initial hospital care, per day, for the evaluation and management of a patient,

7.     99234 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date,.

8.     99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components:.

9.     99217 Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status."

10. 99282 Emergency department visit for the evaluation and management of a patient,.
Our next “top ten” that we did analysis on was our procedures that we are performing. This is what we found.

Ob Hospitalist Procedures:

  1. 59514-80     Assist to a surgeon for cesarean delivery
  2. 59514          Cesarean delivery only;
  3. 59409          Vag Deli Only
  4. 59412          External cephalic version, with or without tocolysis
  5. 59612          V-back
  6. 59025-26     Fetal NST interpretation
  7. 59160          Curettage - Post Partum
  8. 59300          Episiotomy or vaginal repair, by other than attending physician
  9. 58611          Tubal Ligation (Add on w/c-section)
  10. 58605          Ligation or transection of fallopian tube(s),  during same hospitalization (separate procedure)

OB Hospitalist Top 10 Diagnosis for the practice:
1.       646.83  Other specified complication, antepartum
2.       644.03  Threatened premature labor, antepartum before 37 wks
3.       644.13  Threatened premature labor, antepartum after 37 weeks
4.       644.20  Early onset of delivery, unspecified as to episode of care
5.       655.73  Decreased fetal movements, antepartum condition or complication
6.       649.53  Spotting complicating pregnancy, antepartum condition or complication
7.       658.13  Premature rupture of membranes in pregnancy, antepartum
8.       646.63  Infections of genitourinary tract antepartum
9.       659.73  Abnormality in fetal heart rate or rhythm, antepartum condition or complication
10.     922.2   Contusion of abdominal wall

OB Hospitalist Top 10 +10 more  Diagnosis Cesarean Delivery

1.       644.21 Early onset of delivery, delivered, with or without mention of antepartum condition
2.       654.21 Previous cesarean delivery, delivered, with or without mention of antepartum condition
3.       659.71 Abnormality in fetal heart rate or rhythm, delivered,
4.       652.21 Breech presentation without mention of version, delivered
5.       661.11 Secondary uterine inertia, with delivery
6.       661.01 Primary uterine inertia, with delivery
7.       642.51 Severe pre-eclampsia, with delivery
8.       652.51 High fetal head at term, delivered
9.       651.01 Twin pregnancy, delivered
10.     656.31 Fetal distress affecting management of mother, delivered
11.     645.11 Post term pregnancy, delivered, with or without mention of antepartum condition
12.     648.01 Maternal diabetes mellitus with delivery
13.     658.11 Premature rupture of membranes in pregnancy, delivered
14.     656.61 Excessive fetal growth affecting management of mother, delivered
15.     658.01 Oligohydramnios, delivered
16.     658.41 Infection of amniotic cavity, delivered
17.     656.51 Poor fetal growth, affecting management of mother, delivered
18.     652.31 Transverse or oblique fetal presentation, delivered
19.     659.01 Failed mechanical induction of labor, delivered
20.     641.11 Hemorrhage from placenta previa, with delivery

As we have shared this information with you, please remember that each practice is different.  You will discover trends and opportunities that you weren’t aware of before, and your information analysis may or may not surprise you. 

Once you have this information, you can then audit and pull out areas and ideas that you may want to improve upon, such as documentation, staffing, or even how you market your practice to the community. 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:  

Thursday, July 18, 2013

ICD-10 Basics Webinar (Free) on 08/22/2013

For those who are interested, here's an upcoming CMS webinar on ICD-10 basics:

ICD-10 Basics MLN Connects™ National Provider Call

August 22, 2013
1:30-3 p.m. ET

Space may be limited, register early.
Target Audience: Medical coders, physicians, physician office staff, nurses and other non-physician practitioners, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories, and all Medicare providers

Are you ready to transition to ICD-10 on October 1, 2014? Join CMS for a keynote presentation on ICD-10 basics by Sue Bowman, MJ, RHIA, CCS, FAHIMA, Senior Director, Coding Policy and Compliance, along with an implementation update by CMS. A question and answer session will follow the presentation.

Monday, July 8, 2013

Modifiers 58, 78, 79 – OB Hospitalist coding help!

For those of you that follow my "coding life" ..  I had a very successful teaching and training session in Scottsdale, AZ for the AzHIMA.    

I did a educational session on Modifiers, Myths & Misconceptions, and another on the DaVinci robotic device, and many of the new and emerging surgical technology uses for the robotic assist device.   Over the next few weeks, I'll be including information from my presentation into the blog  but for today...

This is a copy of the column that I have written for Dr. Rob Olsen in conjunction with the site:   These three modifiers, 58, 79 and 79 can be very confusing for coders, and it is imperative that you understand the differences between them.  Since my background is primarily in OB, the coding scenarios are relevant to that specialty.  However, the information remains pertinent to all CPT guidelines and specialties.  Enjoy!   L  : )


Modifiers 58, 78, 79 – OB Hospitalist coding help!  

Modifiers 58, 78 and 79 are confusing for coders and providers alike.  Even experienced coders have a difficult time determining which of these modifiers should be appended.  The CPT modifiers -58, -78 and -79 are very similar in definition, yet are very different in scope and usage.  CMS and many 3rd party insurance carriers have specific guidelines and edits as to which CPT codes these modifiers can be used with.  In some OB hospitalist practices, you have the luxury to have a coder assigned to your practice to help with these difficult issues for coding your services.  If you do not have a coder on-staff, or easily accessible, this should help you out.   Feel free to share this with your coders, billers, or practice managers.

The definitions outlined within CPT for these three modifiers contain “critical verbiage” that you need to understand to help get your claims paid timely and correctly.  The key to getting claims paid with these modifiers is to ensure you’re using the correct modifier on the correct procedure within the specified guidelines for surgical procedure/services. 

All three of these modifiers have similar definitions, and also include the words ‘related procedure’ and ‘during the post-operative period” within their definitions.  Therefore, a good understanding of each of these will help you get the correct modifier appended, in the correct situation and speed your claim though the adjudication process to payment from the insurance carrier.

The other issue at hand for these 3 modifiers is that they “re-set or re-start” the global service days for the service or procedure (eg a new postoperative period begins when the next service or procedure in the series is billed).  The Medicare Fee Schedule Database (MFSDB)  global surgery indicator identifies CPT procedures as 000, 010, 090, YYY, or ZZZ global surgery days

Modifier 58:
§    Definition: Modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional  during the postoperative period
It may be necessary to indicate that the performance of a procedure or service during the postoperative period was
a) planned or anticipated (staged);
b) more extensive than the original procedure; or
c) for therapy following a surgical procedure.
This circumstance may be reported by adding modifier -58 to the staged or related procedure.  Note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier -78.

There are a number of critical verbiage areas within the definition for modifier 58.  The first is the notation of “staged” OR “related procedure or service”  A ‘staged’ procedure is one that is pre-planned to take more than one session in the operating room or procedure room.  Normally “staged” procedures are performed in two or more separate sessions with a designated time period between the operative/procedure sessions to facilitate healing, or to lower the medical risk to the patient.  (eg  (A tubal ligation scheduled 30 days post vaginal delivery)

Modifier 78
o       Definition:  Modifier 78 Unplanned return to the operating/procedure room by the same physician or Other Qualified Health Care Professional following initial procedure for a related procedure during the postoperative period
Note: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure).  When this procedure is related to the first, and require the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure.  (for repeat procedures, see modifier 76)

Modifier 78 also contains verbiage that was updated to reflect an unplanned return to the operating room/procedure room....  This change in the description of Modifier 78 allows for a provider to now provide ‘unplanned’ services in either an operating room or a procedure room.  A procedure room, can be one that is located in a physician office, ambulatory setting or a formal operating room setting. 

Another key clue to usage of this modifier is the word “unplanned’.  This is extremely important that the procedure or surgery was unplanned in relationship to the original procedure or service. 

Example:  Mary White has an uneventful vaginal delivery(59400) ,  Four days post discharge, Mary was returned to the procedure/operating room, for a post-operative hemorrhage. , Dr. Sam then performed a postpartum D&C for the uterine hemorrhage.  In this scenario, the modifier 78 would be appended to CPT code 59160 . 

As of 2013, the definition of modifier 78 now reflects updated verbiage to include both physicians, and qualified health care professionals.  This verbiage change has also been included in many of the 2013 CPT codes for evaluation and management services and procedural and surgical services.

Modifier 78, like modifier 58, also re-sets/re-starts the global service days in relationship to the Medicare Fee Schedule Database (MFSDB).  .  If the surgery or procedure does not have these specific indicators, it is inappropriate to use modifier 78 with those codes.
An example of an inappropriate CPT code to add a modifier 78 to,  is code 59409 Vaginal Delivery only.  The MFSDB denotes the global service days for code 59409 as MMM.  Many maternity services have an MMM designation.  If you are unsure about the MFSDB designation, or postoperative days associated with your surgical code, you can obtain this information from the CCI indicators on the Medicare website at

Another important issue for the usage of modifier 78 is that the unplanned surgery/procedure be performed by the same physician who performed the original procedure. 

Inappropriate usage of modifier 78, is appending this modifier to a procedure/surgery that is unrelated to the original procedure, or if a different physician performed a subsequent unplanned return to the operating room/procedure room. 

Modifier 79
o       Definition: Modifier 79: Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period.
Note:  The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.  This circumstance may be reported by using modifier -79.  (for repeat procedure on the same day, see modifier -76)

Usage of modifier 79 requires the service/procedure to be an “unrelated” procedure or service performed by the same physician within a post-operative time frame.  You will note that the critical verbiage between modifier 78 and modifier 79 is that modifier 78 is the modifier for a “related” procedure; modifier 79 is for an ‘unrelated” procedure.  We also have to tie this back to modifier 58, which denotes a “staged or related” procedure. 

The definition verbiage for modifier 79 does not have a requirement that the service/procedure be performed in an operating room or a procedure room (as is with modifier 78).  The definition of modifier 79 does require this to be appended if the same physician performs an unrelated procedure within a postoperative time frame.  An example of the appropriate use of a modifier 79 is:
Example:  Dr. Sam a cesarean section delivery code 59510  on patient Dana Mann.  One week later, Dr. Sam then performs a skin tag removal from Dana’s back in the hospital outpatient surgery center.  (CPT code 11200 with a 10 day global surgery indicator). When the claim is submitted modifier 79 should be appended to code 11200 to denote this is an unrelated procedure to the previous cesarean procedure, code 59510.

Modifier 79 rules:
·         Modifier 79 applies to surgical procedures performed on patients while they are in a postoperative period for a different, unrelated surgery.
o       eg, the new surgical procedure is performed to treat a new problem or injury.
·         The unrelated procedure starts a new global period.

·         Do not report modifier 79 with modifiers 58 or 78.  It is inappropriate if the procedure performed is staged or related to the original procedure, which are included in the definitions for mods -58 and 78.
·         Modifier 79 is an information only modifier, and does not affect reimbursement from insurance payers.

As confusing as these three modifiers are, CPT has very specific verbiage that outlines exactly the circumstances for when they should be used.  As a coder or biller, take the time to read carefully the operative scenario, and if in doubt regarding the procedures, be sure to query the physician or provider to clarify all necessary information. 

If you are receiving denials from the insurance carrier or 3rd party payer, in regard to an incorrect or inappropriate modifier on your claim, take the time to re-review the operative/procedure note and the modifier definitions.  Many times, it is a quick fix to correct the modifier and re-submit your claim for payment.  As a coder, understanding the ‘critical verbiage’ contained in the definitions of modifiers 58, 78 and 79 will enhance not only your coding expertise, but also expedite a clean claim and improved reimbursement back to the medical practice. 

Friday, June 21, 2013

AzHIMA - State Convention & Coding Symposium

Hi to all my blogger friends... It is fitting that I will be in Arizona today for the first day of Summer.   Tomorrow I'll be at the  AzHIMA convention and coding symposium.  I'll be doing a session on modifiers and on Robotic assist during surgery.  I'm hoping to inspire some new coders, bring education and a renewed and recharged look at coding for some of our more experienced coders.

I'll post more, when I return.   Happy Coding!

Wednesday, June 12, 2013

Another free CEU opportunity: Inside Criminal Minds

Hi my blogger friends...  Here is another free CEU opportunity.  Wolters Kluwer is presenting a 1 hr event regarding fraud and abuse.    GREAT STUFF!   This is a terrific time for you to take advantage of some good info and get your CEU's too.  L  : )


Allan P. DeKaye, MBA, FHFMA

President and CEO DEKAYE Consulting, Inc.

Lynne Rinehimer, JD
Sr. Manager Compliance Services
Wolters Kluwer


Fraud! Settlements! Restitution! Jail time! All headlines ripped from industry trade journals and newsletters. The unsettling fact is that these same headlines have appeared with regularity over the last 20 years, or at least since Health Care Fraud has become a target of investigation at the federal, state, and local levels.

Inside Criminal Minds is a presentation that will take a closer look at those who have committed fraud, and will examine the characteristics that may have led to this criminal behavior. It will also look to define varying degrees of greedy behavior, including organized greed, as well as behavioral traits common to the criminal mind.

Inside Criminal Minds also reexamines the way many compliance structures work to detect and prevent fraudulent activities, and evaluates if they provide sufficient safeguards. The presentation will look at more sophisticated data models used to guard against identify theft and record data breaches. Finally, we will look at the way organizations screen new hires and reevaluate existing staff to see if lapses or loopholes exist that threaten to exploit vulnerable areas.

Identify characteristics common to criminal behavior

Introduce the concept of the “Hierarchy of Greed”

Evaluate effectiveness of existing system safeguards

Learn about alternative data security measures

Consider changes to hiring and retention protocols


This live webinar requires nothing more than an Internet connection. Register today for this FREE webinar!


Wednesday, June 19, 2013


1:00-2:30 p.m. EDT

12:00-1:30 p.m. CDT

11:00-12:30 p.m. MDT

10:00-11:30 a.m. PDT


This program has been approved by, or is pending approval from, the Health Care Compliance Association (HCCA).

Space is limited!

This popular topic is open to the first 1,000 approved registrants and is expected to fill up quickly. Don’t delay! Registration requires a complete Name, Title, Organization, and a valid business Email Address.

Tuesday, June 11, 2013

Free Webinar with 1 CEU: Thursday 06/13/2013 2013’s Toughest Coding & Compliance Challenges Made Easy

** This is a free webinar that is being presented by SuperCoder, that is worth 1.0 CEU. I know we're all looking to get good education, and free is good! If you are interested be sure to sign up. L : )

Dear Colleagues:
2013 has already ushered in innumerable coding and reimbursement changes. Frequent changes in coding practice and policy, and complexity and uncertainty in day-to-day coding work can often leave you stressed, forcing you to give up your deserved reimbursement!
If you are still struggling with 2013 CPT changes, inappropriate modifier use, quarterly CCI Edits, LCD/NCD compliance issues, it’s time to set things right and take charge of your practice!

Join expert speaker Kristie Stokes, CPC for an action-packed webinar on June 13, at 12 PM EST. You’ll learn to simplify your work, code correctly, garner complete pay, and ensure compliance with a complete coding solution on SuperCoder – Physician Coder.
During this complimentary tip-packed session, Kristie will teach you how to:
Overcome Payment-Threatening 2013 Code, CCI, and Modifier Challenges

Navigate Intricacies of 2013 CPT® Updates

Overcome Your Toughest CPT Coding Scenarios with Physician Coder

Pick the Right Code to Ensure Substantial Ethical Reimbursement for Your Practice

Find Out If a Code Has Been Deleted on SuperCoder

Demystify Invalid Message on 95015 Billing

Research Any Questions Related to Your Modifier Confusions

Check Whether 69210-50 a Valid Entry

Reduce CPT-ICD-9 Code Mismatches in 2013

Adhere to Quarterly CCI Changes in 2013

Ensure LCD/NCD Compliance
And Much More!
Webinar attendees can earn 1.0 CEU from AAPC!
Register Now for this live webinar and learn everything you need to know to topple 2013’s toughest coding and compliance challenges!
Jen Godreau, CPC, CPMA, CPEDC
Director of Development and Operations ! The Coding Institute, LLC

Monday, June 10, 2013

Medicare clarifies signature requirements

As of May 17, 2013 -  Medicare has clarified and updated the usage of rubber stamps for signature on medical documentation, as noted a transmittal from CMS (see links below)  The big “take-away” from this is that legible signatures need to be in place prior to billing services to Medicare.  To ensure compliance with Medicare, I would encourage providers to sign all orders and documentation in a timely manner.  Reimbursement is a critical factor for many practices, and this is an "easy" area to work on in your practice.  Be sure to audit and review your documentation for compliance.  Happy Coding!  L  : )


The general signature requirements state that services that are provided to Medicare Beneficiaries need to be authenticated by the author, for medical review.  

If signatures are illegible or missing from medical documentation (other than orders), a signature log or attestation can be used to provide additional information to the reviewer.  However, orders without a signature will be disregarded during the claim review.

Signatures cannot be “captured” after the fact through signature logs or attestation.  Refer to the transmittal for detailed information on the signature log and attestation process. 

NOTE: The transmittal states: “If AC, MAC or CERT reviewers identify a pattern of missing/illegible signatures it shall be referred to the appropriate PSC/ZPIC for further development.”

NOTE: Stamp signatures are not acceptable  Per Transmittal 465, stamped signatures are acceptable only if the author has a physical disability and can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. The rubber stamp certifies that the provider has reviewed the document.  

NOTE: Any notation of “signature on file” also does not meet the signature requirements

Saturday, April 27, 2013

Clinical Documentation: Tips and Hints

I wrote the article below for Dr. Rob Olson with   This information is applicable for all specialties.   enjoy!   L : )

     We have all heard the adage “if it wasn’t documented, it wasn’t done”.  However, for physicians, the fast pace of the job can get in the way of the accuracy of documentation. The way to remain fiscally solvent, is by accurate coding and billing, and providing good patient care.  Clinical Documentation is a fundamental piece of the total job function. 

     The importance of clinical documentation cannot be underestimated.  Medical documentation is essential to ensure high quality medical care for your patient throughout the continuum of care.  Good clinical documentation both to and from all medical providers (physicians, nurses, PT/OT, etc) benefit not only the patient, but also your revenue stream.  If your coder/biller is able to quickly decipher and bill the claim it means the reimbursement will be back to your practice that much faster.  Good documentation supports medical necessity for payment and clarification of services provided to your patients, especially if they have an emergent visit, or unexpected clinical finding upon testing.

     The term ‘medical necessity’ has become commonplace verbiage with insurance carriers.  Your clinical documentation will be the first thing requested for audit or review, if there is a question regarding payment for your services.

     Outlined below are a few quick clinical documentation tips and hints to help clarify your clinical record documentation.  

A)  The medical record should be complete and legible
Documentation for each encounter should include:
§    Reason for the encounter and relevant history, physical exam findings and prior diagnostic test results;
§    Assessment, clinical impression or diagnosis
§    Plan of care
§    Time spent (eg face to face/counseling-coordination of care)
o        Documented time in
o        Documented time out
o        Documented total time spent (eg at bedside, on monitor(s), etc)
§    Date and Signature
§    The rationale for ordering diagnostic and other ancillary services
§    Past and present diagnoses (If pertinent to the encounter)
§    Appropriate health risk factors should be identified (if pertinent to the encounter)
§    Patient’s progress, response to and changes in treatment and/or revision of diagnosis

B)  Avoid Ambiguous Language
Eg.. “Non-contributory” : The term “non-contributory” is  good example of ambiguous documentation.  In some instances, a provider intends the term to mean the body system was not relevant, therefore was not reviewed... while another provider may intend that verbiage to mean that the body system was reviewed, but had no pertinent findings to be reported.   Be clear, concise and relevant by avoiding using the term “non-contributory”.

Another term that can be misconstrued is “abnormal”  be sure to clarify, qualify, or quantify  what is “abnormal”.

C)  Clarify your diagnosis
“For a presenting problem with an established diagnosis the documentation should reflect whether the problem is:
a)       improved, well controlled, resolving or resolved; 
b)        inadequately controlled, worsening, or failing to respond/or change as expected

“For a presenting problem without an established diagnosis, the assessment or clinical impression can be
a) as a “possible”, “probable”, or “rule out” (R/O) diagnosis,(such as rule out kidney stone) 
b) and should also denote any signs and/or associated symptoms in your findings (such as pelvic pain, sinus pressure etc)

D) Ordering of Tests and Procedures
Clinical documentation guidelines state that the rationale for tests/procedures should be ‘easily inferred’, but suggest clearly documenting the reason(s) for any testing or procedures

§    document ‘what’ test/procedure is being ordered.  (i.e. Fetal NST, fetal fibronectin)
§    document ‘why’ the test/procedure is being ordered (i.e. decreased fetal movement)

E)  Omitted Information
In the event information is inadvertently forgotten, delayed, or omitted from the medical record, it is acceptable to amend the record. “Late entries” are also acceptable however,  should be used infrequently.

Acceptable methods for recording “amendments”, “addendum” and “late entries” follow:
•Create a new entry for the additional information
•Do not annotate in the margins to add information
•Keep all entries chronological and in record sequence
•Title or head the entry or note as “Addendum”, “Amendment” or “Late Entry”
•Use the actual date of the addendum, amendment or late entry
•Reference the original entry or document by indicatingthe date of the service
•Always sign the additional entry or document

     Documentation will always be a “necessary evil” in the role of healthcare and reimbursement.  The conversion to ICD-10 cm will take place October 1, 2014, and providers will be tasked with providing better documentation with this new diagnostic/diagnosis system.  Your willingness to improve your clinical documentation now, will only make it easier for you to adapt and continue to provide excellent patient care in the future.