Thursday, October 16, 2014

Quick ICD-10 blast from CMS has issued a fule finzalizing Oct 1, 2015 as the go-live for ICD-10. They are offering a transitioning webinar that is free on 11/5/2014... See below for full information Transitioning to ICD-10 — Register Now Wednesday, November 5; 1:30-3pm ET To Register: Visit MLN Connects Upcoming Calls. Space may be limited, register early. HHS has issued a rule finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. During this MLN Connects™ National Provider Call, CMS subject matter experts will discuss ICD-10 implementation issues, opportunities for testing, and resources. A question and answer session will follow the presentations. Agenda: •Final rule and national implementation •Medicare Fee-For-Service testing •Medicare Severity Diagnosis Related Grouper (MS-DRG) Conversion Project •Partial code freeze and annual code updates •Plans for National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) •Home health conversions •Claims that span the implementation date 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. Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.

Thursday, August 14, 2014

RAC Monitor - A survival checklist of their top 10 Audit findings

RAC Monitor Article - GOOD STUFF This is GREAT info that I found... Very very helpful. Top 10 Federal Audit Findings in E/M Services: A Survival Guide Physicians, practice managers and compliance personnel have their work cut out for them: they must continually conduct and monitor internal coding audits and medical record (MR) documentation reviews for evaluation and management (E/M) services, a predominant but mundane service performed literally millions of times across all physician specialty practices. Why? In the face of Medicare's 2010 deletion of consultation reimbursement from its physician fee schedule, these fairly omnipresent service codes have become a ripe target for federal auditing initiatives. For Medicare beneficiaries the former consultations must now be reported using CPT codes for office/outpatient visits (99201 - 99215) as well as hospital inpatient services (99221 - 99233). This change drastically increases the traditional E/M services' value, enhances the codes' impact on provider revenue and, in a paradoxical twist, it makes these services more of a federal and state target following the Centers for Medicare & Medicaid Services (CMS) move to plump up reimbursements for these services (to account for the loss of consultation fees). Since billions of dollars are paid out to providers each year for E/M services, in particular 99213 and 99214 (the two most frequently reported E/M services), federal and state auditors are watching closer than ever to ensure fewer incidences of improper payments. Other robust federal audit programs assail providers through a variety of initiatives. The major audit schema includes, among others, efforts by CMS via jurisdictional Medicare Administrative Carriers (MACs), the Comprehensive Error Rate Testing (CERT) program, the Annual Work Plan by the Office of the Inspector General (OIG) and the aggressive audit program of the Recovery Audit Contractors (RACs). The following is a "Top 10" accounting of recent federal audit findings within the typical E/M service code ranges for office and inpatient hospital services. For each Top 10 audit result, "survival tips" are also provided: 1. Illegible, unauthenticated and/or indeterminate authorship of Medical Records (MRs): Illegible physician and NPP signatures, unauthenticated MR notes (i.e., unsigned either by hand or by e-signature), and/or the federal reviewer's inability to differentiate ancillary staff notes from treating provider's notes accounts for the preponderance of audit findings. Survival Tips: Legible signatures are required to certify services; illegible signatures submitted without evidence of proof-of-signature are adjudged by Reviewers as "indeterminate" and equated to unsigned MR documentation. Likewise, mixing ancillary staff/scribe notes in the body of the clinical note without signature clarification is tantamount to unauthenticated records. These various documentation errors are denied because "services were unable to be verified as being rendered by the billing provider." Ensure the providers and ancillary staff sign/date all clinical note contributions so authorship of MR documentation is clear. Excluding certain hospice documentation, facsimile stamped signatures are no longer valid for federal purposes. 2. Non-response to ADRs: Ignoring or not responding in a timely manner to official MR documentation requests, termed Additional Documentation Requests (ADRs) when issued by MACs/Part B Carriers, is another prevalent audit finding. ADRs are simple MR documentation inquiries to assess and verify services billed. The request encompasses all documentation germane to the date-of-service (DOS) under investigation; all relevant documentation must be copied and sent to the requesting entity. Survival Tips: Compliance staff should ensure the logging of each ADR, the processing of which must be tracked and monitored, and final fulfillment confirmed by certified mail. For larger group practices or multi-location practices, setting up an internal "ADR Response Team" is often an effective way to handle these third party requests for MR documentation. Follow up and/or remedial steps must be performed once feedback from the requesting entity is received, e.g., analysis of audit results, fiscal impact of repayment demands, provider education in documentation, additional coder training, etc. 3. Review of Systems (ROS) is missing or poorly documented: Recording the patient's history is, by audit, the weakest area of provider documentation for office and hospital visits. Easily the most overlooked element of the history portion of the note is the ROS which, when missing or poorly documented, severely limits the level of the E/M service that can be legitimately reported. This is paradoxical as the ROS can be expertly obtained by ancillary staff. Examples of poorly documented ROS include those with blanket statements like "all systems unremarkable" which many MACs/Part B Carriers do not recognize as legitimate. Survival Tips: There are few reasons why the ROS cannot be thoroughly obtained, unless it is not medically necessary. If the ROS is obtained on a separate form or questionnaire, the form should be signed/dated by the provider to certify the ROS document is germane to the current visit. All such segregated data should be bridged to the date-of-service in question, and 4. E/M code 99211 reported without sufficient documentation: CPT code 99211 is designed for minimal problems requiring quick visits carried out by ancillary staff and supervised by the reporting provider. Adequately substantiated in the MR documentation 99211 can be reported for myriad services. Errors in reporting 99211 range from inadequate or no MR documentation to the automatic billing of 99211 with other minor staff services, e.g., Bp checks, PPD readings, specimen collection, etc., without cognitive services being performed. Survival Tips: CPT code 99211 represents a true E/M service; as such, the MR documentation must convey features of both evaluation and management services, i.e., (a) essential clinical information is provided or exchanged based on the patient's condition or problem and (b) therapy, management or a treatment plan is rendered/provided. Both actions must be documented. Since this E/M service is typically furnished by ancillary staff under the provider's direct supervision, it is reported as "incident to." All criteria for incident-to services must be satisfied. 5. Time used as key component for E/M services but is inadequately documented: Providers can report non-time based E/M services using ‘time' as the key factor instead of the 3-key components of history, physical exam (PE) and medical decision making (MDM) when counseling and/or coordination of care (CoC) constitute 50% or greater of the total face-to-face time. Federal auditors find numerous instances of missing or poorly documented time(s) when the provider clearly intended to use time as the singular key component for the E/M service reported. Survival Tips: Document two strata of ‘time' when relying on time as the leveraging factor: (1) total face-to-face time for the entire encounter and (2) total time spent in counseling and/or CoC. The second stratum demonstrates the >50% rule; the first stratum creates the frame of reference for stratum #2. For office services non face-to-face time (i.e., time expended in pre-/post-visit work) cannot be included in the total time calculated; inpatient services, however, can include non face-to-face unit/floor time spent in the care of the patient. Content of counseling/CoC must be fully documented. 6. Misapplication of modifier -25: Modifier -25 is reported with an E/M code when significant, separately identifiable E/M services are rendered by the same physician on the same day of a procedure or other service. Federal auditors have found three frequently occurring errors after reviewing the MR documentation: (1) modifier -25 was incorrectly reported on a non-E/M service, e.g., 93000-25 for EKG; (2) modifier -25 was reported with an E/M code when the patient presented solely for a minor procedure, e.g., joint injection, however, the E/M service was not documented or was not medically necessary; and, (3) modifier -25 was not reported but was needed when an E/M service and a minor procedure (with a global surgery indicator of "000") were provided. Survival Tips: Modifier -25 is designed to allow certain E/M services to bypass system edits. It should only be appended to an E/M service to make clear that particular service is "significant, separately identifiable" and therefore separately payable. MR documentation must substantiate these separately payable circumstances. The triple-zero global surgery indicator ("000") signifies that only the day of the procedure is included in the global surgery period. If the E/M service is not reported with modifier -25 in these circumstances the service is denied. 7. The "4x4 Rule" and the conundrum of expanded problem focused (EPF) vs. detailed physical exams:Confusion surrounds these two specific exam levels because the 1995 and 1997 E/M Documentation Guidelines (DGs) are ambiguous for both EPF and detailed exams by stating both must contain "2-7 elements," specifying the EPF level requires a "limited" exam and detailed requires an "extended" exam. Both must address "the affected areas/systems and any other symptomatic or related areas/systems, up to 7." The similar definitions for "limited" and "extended" have caused provider misinterpretation and allowed for a predominant auditor finding of "insufficient PE documentation for a detailed level exam" such as for E/M codes 99203, 99214, 99221 and 99233. Survival Tips:Know the "4x4 rule;" it comprises four elements or items examined within four body areas or organ systems. For providers, the "4x4 rule" is a quick and uncomplicated method to avoid misinterpretation of these similar MR documentation levels. Compliance personnel should check with the Part B Carrier to ascertain applicability. Of note, federal auditors are tasked with referencing both sets of E/M DGs - 1995 and 1997 - adjudging each case being reviewed so the final assessment best benefits the provider. 8. Rules for reporting CPT code 99499 Unlisted E/M Service: CMS addresses billing of CPT code 99499 (MCPM 100-04, Chapter 12, §30), stating "the Carrier has the discretion to value the service." In effect, the Part B Carrier is in control and many maintain that 99499 should be reported only in rare instances. "Rare" is the operative term and used repeatedly in official literature. Adjudicators must review associated documentation and apply individual consideration (IC) protocols for appropriate pricing of each service reported under 99499. Survival Tips:Report 99499 in rare circumstances and only per Carrier instructions. A "rare" example provided by a local MAC follows: "If documentation criteria for initial inpatient hospital services 99221-99223 cannot be met and if ... even a 99221 cannot be met, but the documentation does meet the criteria for subsequent inpatient hospital services 99231-99233, then code appropriately even though it is chronologically an admission. If the documentation does not even meet the criteria for a 99231, then code 99499." 9. Modifier -24 and the global surgical period: When reporting E/M services after a major procedure but during a global surgical period (within 90 days) of a major procedure or after a minor procedure but also during the procedure's global surgical period (up to 10 days), the appropriate documentation must support the service and the E/M code must be appended with modifier -24 to circumvent system edits. Documentation must detail why an E/M service should be paid within the global surgical period. According to the MCPM 100-04, Chapter 12, §40.2.A.7, "services submitted with modifier -24 must be sufficiently documented to establish that the visit was unrelated to the surgery. An ICD-9-CM code that clearly indicates the reason for the encounter was unrelated to the surgery is acceptable documentation." Survival Tips: This is one of the few E/M services included in the 2010-2012 OIG Annual Work Plans. Implement steps to prevent inadvertent reporting of post-op E/M services as separately payable when the patient is in a post-surgical status, and bill these services correctly when appropriate. 10. Missing or poorly documented key components of the E/M service: This "Top 10" mention is the last-listed but in aggregate it is the most prevalent of all audit findings. For most E/M services 3-key components govern code selection: (1) History, (2) PE and (3) MDM. For new office visits and initial hospital inpatient services these key components must be included in the documentation. When only 2-key components are required to be documented, i.e., for subsequent office or hospital visits, at least two of the three components must meet the service's lowest threshold requirements. "Survival Tips" are interspersed with federal audit findings as follows: (a) History: Missing or lack of recorded critical elements including chief complaint (CC), past medical, family/social history (PFSH), and history of present illness (HPI). [ROS problems were previously addressed] Contradictory data between elements is a common error, e.g., the CC states one reason for the visit but the HPI details a different problem. Some Carriers require the CC and HPI to be documented only by the treating provider. Terms like "noncontributory" under the PFSH or ROS may be invalid; internal compliance staff must know Part B Carrier jurisdictional preferences. (b) PE: Missing or insufficient documented information. A common provider PE statement is "no change from prior visit." When 3-key components are required for the E/M service, this brief statement is inadequate and will be discounted by federal Reviewers. "Negative" and "WNL" notations are acceptable forms of documentation for unaffected areas/organ systems but are unacceptable under E/M leveling criteria for affected areas/organ systems that relate to the CC and/or HPI within the History. (c) MDM: Truncated or disorganized data. MDM information conveys the complexity and risk of the service, and must be fully documented. Additionally, disorganized MDM data can cause mistakes in copying and assembling audit packages for Reviewers. This is easily remedied when the provider creates a data bridge between the body of the visit text and other related supporting documents so that all elements of each date-of-service is connected. The data bridge is especially critical when the provider has reviewed old MRs, ordered tests/studies, carried forward or revised diagnoses and medications, etc. This also relates to History elements, e.g., the ROS, when recorded and maintained on separate forms. Educate staff tasked with processing MR and ADR requests on the proper assembling of complete audit packages for federal Reviewers. Meticulous MR documentation has always been one of the keystones of quality patient care. It is certainly the much-touted foundation for a successful transition from ICD-9-CM to ICD-10-CM/PCS code system implementation (still at this writing, by Oct. 1, 2013). It also has the capacity to protect providers in myriad scenarios including federal audits. The disparate audit findings included in this article are not all-inclusive but are among the predominant audit findings that have surfaced during federal review processes. Adhering to the survival tips can help physician practices avoid federal recompense demands by preventing E/M services from being downcoded or denied. About the Author Michael Calahan, PA, MBA, CCS, CCS-P, CPC, CPC-H, AHIMA Certified ICD-10-CM/PCS Trainer, is the Director of Physician Services at KForce Healthcare, Inc., working in compliance, coding and revenue cycle management in the physician and facility arenas. Contact the Author or To comment on this article please go to Sources: 1. Medicare Claims Processing Manual/Internet-Only Manuals 100-04, Chapter 12 Physicians/Nonphysician Practitioners, Sections 30 and 40 (various citations as disclosed): Consultations, CPT Code 99499, Modifiers -24 and -25 et al 2. Medicare Program Integrity Manual/Internet-Only Manuals 100-08, Chapter 3 Verifying Potential Errors and Taking Corrective Actions, Section Facsimile Signature Requirements 3. CMS Transmittal 327/Change Request 6698 June 16, 2010 (Revised), Signature Guidelines for Medical Review Purposes 4. Evaluation and Management Documentation Guidelines, 1995 and 1997, as published by two oversight entities: CMS and AMA 5. CERT errors (2009 - 2012) specific to E/M services; E/M audit FAQs; compounded information best viewed at three Medicare Carrier web sites: (a) Wisconsin Physician Services (WPS) Medicare, (b) Trailblazers Medicare, and (c) Cahaba Medicare (MAC A/B J10) 6. CMS Transmittal 1875/Change Request 6740, December 14, 2009, Revisions to Consultation Services Payment Policy 7. Trailblazer Health Interprises, LLC, Evaluation and Management Services (training manual), September 2011 8. Highmark Medicare Services, E/M FAQs "13. What is the 4x4method for determining if an examination is scored as an expanded problem focused or detailed?" Posted 10-5-2009; revised 8-29-2011 9. U.S. Department of Health & Human Services, Office of the Inspector General (OIG), Office of Evaluation & Inspections Reports, Review of Incident To Services, Report 09-06-00430, August 2009 U.S. Department of Health & Human Services, OIG Reports, 2012 Annual Work Plan, accessed October 2011

Tuesday, June 10, 2014

Technical Component/Professional Component; What Place of Service???

Had to share this with you.  I had a query this week, and one of our colleagues was wondering what place of service code to use when the physician sent the patient to the hospital outpatient setting to have the test performed, but the interpretation was done the following day in the office.   This below gives great advice, in what to do. 

The other caveat I would add, is on the "notes" line of your claims... you may want to note that the technical component performed on xx/xx/xxxx  and the interpretation was performed on xx/xx/xxxx 

Happy Coding! 

Place of Service and Date of Service Instructions for the Interpretation (Professional Component) and Technical Component of Diagnostic Tests

(RESTON, VA) -- Transmittal 1823, that was issued to provide instructions on Place of Service (POS) and Date of Service (DOS) is rescinded and replaced by Transmittal 1873, which announced the delay of the implementation date for DOS requirement to July 1, 2010. While CMS previously issued the POS guidelines to submit the ZIP code for the location of the service, the DOS guideline to use the date of interpretation is new. Note: the place of service requirement in this manual remains effective on Jan. 4, 2010.In transmittal 1823, the Centers for Medicare and Medicaid Services (CMS) instructed that the POS code for the interpretation should reflect the actual place where the service was provided, and that the DOS for the interpretation of diagnostic images should designate the date of interpretation.
The ACR, RBMA, HBMA, AHRA, and MGMA requested CMS to delay the implementation of the initial transmittal (Transmittal 1823) by six months due to concerns with the lack of operational preparedness of the industry to implement this new guideline and to get enough time to allow the specialty societies to provide input to address the concerns they have with the guideline.

CMS contractors will provide education to providers about the use of the actual date the interpretation was performed as date of service (DOS) for the interpretation.

Thursday, April 17, 2014

ICD-10 Education Webinar - Wolters Kluwer = 1 free AAPC CEU!

If you're needing CEU's for the AAPC -  our friends at Wolters Kluwer are having a webinar worth 1 CEU and it's free...  ICD-10 and post acute care.      check it out - take advantage of free education & CEU's.

A list of modifiers

I was searching for a good listing of HCPCS level I and level II modifiers.  I found this and wanted to share with you.  I can't take credit for putting it together, but it is really a helpful Listing.    Enjoy!
"CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association."

Modifier - as the name implies these are the two digit codes that modifies a service / procedure or an item under certain circumstances. Modifiers may add information or change the description according to the physician documentation to give more specificity for the service or procedure rendered. Appending of an appropriate modifier will effectively respond to reimbursement.

Modifiers are categorized into two levels

1. Level  I Modifiers: Normally known as CPT Modifiers and consists of two numeric digits and are updated annually by AMA - American Medical Association.

2. Level  II Modifiers: Normally known as HCPCS Modifiers and consists of two digits (Alpha / Alphanumeric characters) in the sequence AA through VP. These modifiers are annually updated by CMS - Centres for Medicare and Medicaid Services.

Both the above levels of Modifiers are recognized nationally.

List of Level I Modifiers:

Modifier -21 Prolonged Evaluation and Management Services (Deleted, please use CPT 99354- 99359)

Modifier -22 Unusual Procedural Services

Modifier -23 Unusual Anesthesia

Modifier -24 Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period

Modifier -25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

Modifier -26 Professional Component

Modifier -27 Multiple Outpatient Hospital E/M Encounters on the Same Date.

Modifier -29 Global procedures, those procedures where one provider is responsible for both the professional and technical component. This modifier has been deleted. If a provider is billing for a global service, no modifier is necessary.

Modifier -32 Mandated Services

Modifier -33 Preventive Service

Modifier -47 Anesthesia by Surgeon

Modifier -50 Bilateral Procedure

Modifier -51 Multiple Procedures

Modifier -52 Reduced Services

Modifier -53 Discontinued Procedure

Modifier -54 Surgical Care Only

Modifier -55 Postoperative Management Only

Modifier -56 Preoperative Management Only

Modifier -57 Decision for Surgery

Modifier -58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Modifier -59 Distinct Procedural Service

Modifier -62 Two Surgeons

Modifier -63 Procedure Performed on Infants less than 4kg

Modifier -66 Surgical Team

Modifier -73 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure prior to the Administration of Anesthesia

Modifier -74 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure after Administration of Anesthesia

Modifier -76 Repeat Procedure by Same Physician

Modifier -77 Repeat Procedure by Another Physician

Modifier -78 Return to the Operating Room for a Related Procedure During the Postoperative Period

Modifier -79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period

Modifier -80 Assistant Surgeon

Modifier -81 Minimum Assistant Surgeon

Modifier -82 Assistant Surgeon (when qualified resident surgeon not available)

Modifier -90 Reference (Outside) Laboratory

Modifier -91 Repeat Clinical Diagnostic Laboratory Test

Modifier -92 Alternative Laboratory Platform Testing

Modifier -99 Multiple Modifiers

List of Level II Modifiers:

AA Anesthesia services personally performed by anesthesiologist.

AD Medical supervision by a physician: More than 4 concurrent anesthesia procedures.

AE Registered Dietician

AF Specialty Physician

AG Primary Physician

AH Clinical Psychologist

AI Principal Physician of Record

AJ Clinical Social Worker

AK Non Participating Physician

AM Physician, team member service

AP Determination of refractive state was not performed in the course of diagnostic ophthalmological examination.

AQ Service performed in a Health Professional Shortage Area

AR Physician providing services in a physician scarcity area

AS Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery, non-team member.

AT Acute treatment (chiropractic claims) - This modifier should be used when reporting CPT codes 98940, 98941, 98942 or 98943 for acute treatment.

AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply

AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic

AW Item furnished in conjunction with a surgical dressing

AX Item furnished in conjunction with dialysis services

AY Item or service furnished to an ESRD patient that is not for the treatment of ERSD

AZ Physician providing a service in a dental Health Professional Shortage Area for the purpose of an Electronic Health Record Incentive Payment

A1 Dressing for one wound

A2 Dressing for two wounds

A3 Dressing for three wounds

A4 Dressing for four wounds

A5 Dressing for five wounds

A6 Dressing for six wounds

A7 Dressing for seven wounds

A8 Dressing for eight wounds

A9 Dressing for nine or more wounds

BA Item furnished in conjunction with parenteral enteral nutrition (PEN) services

BL Special Acquisition of blood and blood products

CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission.

CB Services ordered by a dialysis facility physician as part of the ESRD beneficiary's dialysis benefit.

CC Procedure code change- CARRIER USE ONLY - Used by carrier to indicate that the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed.

Automated Multi-Channel Chemistry (AMCC) Tests Modifiers - Effective date: Claims processed on or after April 5, 2010

CD – AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is not separately billable.

CE – AMCC tests has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity.

CF – AMCC tests has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable.


Modifiers Used to Report the Severity of Functional Limitations (Effective for the year 2013)

CH 0 percent impaired, limited or restricted

CI At least 1 percent but less than 20 percent impaired, limited or restricted

CJ At least 20 percent but less than 40 percent impaired, limited or restricted

CK At least 40 percent but less than 60 percent impaired, limited or restricted 

CL At least 60 percent but less than 80 percent impaired, limited or restricted 

CM At least 80 percent but less than 100 percent impaired, limited or restricted

CN 100 percent impaired, limited or restricted 


CR Catastrophe/Disaster Related

CS Item or service related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico, including but not limited to subsequent clean-up activities.

DA Oral health assessment by a licensed Health Professional other than a dentist

EA Erythropetic stimulating agent (ESA) administered to treat anemia due to anti-cancer chemotherapy.

EB Erythropetic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy.

EC Erythropetic stimulating agent (ESA) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy.

ED Hematocrit level has exceeded 39% (or Hemoglobin level has exceeded 13.0 G/DL) for 3 or more consecutive billing cycles immediately prior to and including the current cycle

EE Hematocrit level has not exceeded 39% (or Hemoglobin level has not exceeded 13.0 G/DL) for 3 or more consecutive billing cycles immediately prior to and including the current cycle.

E1 Upper left, eyelid

E2 Lower left, eyelid

E3 Upper right, eyelid

E4 Lower right, eyelid

EJ Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab.

EM Emergency reserve supply (for ESRD benefit only)

ET Emergency treatment - Use to designate a dental procedure performed in an emergency situation.

FA Left hand, thumb

F1 Left hand, second digit

F2 Left hand, third digit

F3 Left hand, fourth digit

F4 Left hand, fifth digit

F5 Right hand, thumb

F6 Right hand, second digit

F7 Right hand, third digit

F8 Right hand, fourth digit

F9 Right hand, fifth digit

FB Item provided without cost to provider, supplier or practitioner, or credit received for replaced device (examples, but not limited to covered under warranty, replaced due to defect, free samples)

FC Partial credit received for replaced device

G2 - Most recent URR of 60% to 64.9%

G3 - Most recent URR of 65% to 69.9%

G4 - Most recent URR of 70% to 74.9%

G5 - Most recent URR of 75% or greater

G6 - ESRD patient for whom less than seven dialysis sessions have been provided in a month.

G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening

GA Waiver of liability statement on file - Use to indicate that the physician's office has a signed advance notice retained in the patient's medical record.The notice is for services that may be denied by Medicare.

GC This service has been performed in part by a resident under the direction of a teaching physician.

GD Units of service exceeds medically unlikely edit value and represents reasonable and necessary services.

GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception.

GF Physician services provided by a nonphysician in a critical access hospital; nonphysician: NP, Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse (CRN), CNS or PA

GG Diagnostic Mammography - Use to indicated performance and payment of a screening mammography and diagnostic mammography on same patient, on the same day.

GH Diagnostic mammogram converted from screening mammogram on same day

GJ Opted Out physician or practitioner - Use to indicate services performed in an emergency or urgent service.

GM Multiple patients on one ambulance trip

GN Services delivered under an outpatient speech language pathology plan of care.

GO Services delivered under an outpatient occupational therapy plan of care.

GP Services delivered under an outpatient physical therapy plan of care.

GQ Telehealth services via asynchronous telecommunications system

GR This service was performed in whole or in part by a resident in a department of Veterans Affairs Medical Center or clinic supervised in accordance with VA policy.

GS Dosage of EPO or Darbepoietin Alfa has been reduced and maintained in response to hematocrit or hemoglobin level.

GT Telehealth services via interactive audio and video telecommunication systems

GU Waiver of liability statement issued as required by a payer policy, routine notice

GV Attending physician not employed or paid under agreement by the patient's hospice provider.

GW Service not related to the hospice patient's terminal condition.

GY Use to indicate when an item or service statutorily excluded or does not meet the definition of any Medicare benefit.

GZ Use to indicate when an item or service expected to be denied as not reasonable and necessary.Used when no Advanced Beneficiary Notice (ABN) signed by the beneficiary.

HM Less than Bachelor’s degree level

HN Bachelor’s degree level

HO Master’s degree level

HP Doctoral level

HQ Group setting (for behavioral health use)

HT Multidisciplinary team (for behavioral health use)

J1 Competitive Acquisition Program, no-pay submission for a prescription number

J2 Competitive Acquisition Program, restocking of emergency drugs after emergency administration

J3 Competitive Acquisition Program, (CAP) drug not available through CAP as written, reimburse under ASP Methodology

JA Administered intravenously

JB Administered subcutaneoulsly

JC Skin substitute used as a graft

JD Skin substitute NOT used as a graft

JW Drug or biological amount discarded/not administered to any patient

KB Beneficiary requested upgrade for ABN, more than 4 modifiers identified on claim

KC Replacement of special power wheelchair interface

KD Drug or Biological infused through implanted DME

KE Bid under round one of the DMEPOS competitive bidding program for use with non-competitive bid base equipment

KF Item designated by FDA as Class III device

KL DMEPOS Item Delivered via Mail

KM Replacement of facial prosthesis - including new impression/moulage

KN Replacement of facial prosthesis - Using previous master model

KR Rental item, durable medical equipment – billing for partial month

KX Specific required documentation on file (used for DMERC providers)

KZ New Coverage not implemented by managed care

LC Left circumflex coronary artery

LD Left anterior descending coronary artery

LM Left main coronary artery (Effective for the year 2013)

LR Laboratory Round Trip.

LT Left Side - Used to identify procedures performed on the left side of the body.

M2 Medicare Secondary Payer

NB Nebulizer system, any type, FDA-Cleared fo ruse with specific drug

NU New equipment (DME)

P1 A normal healthy patient

P2 A patient with mild systemic disease

P3 A patient with severe systemic disease

P4 A patient with severe systemic disease that is a constant threat to life

P5 A moribund patient who is not expected to survive without the operation

P6 A declared brain-dead patient whose organs are being removed for donor purposes

PA Surgery Wrong Body Part

PB Surgery Wrong Patient

PC Wrong Surgery on Patient

Please refer for proper usage of PA, PB and PC Modifiers

PD - Diagnostic or related non-diagnostic item or service provided in a wholly owned or wholly operated entity to a patient who is admitted as an inpatient within 3 days, or 1 day. (New modifier for the year 2012, Check for Usage and reimbursement)

PI PET Tumor init tx strategy

PS PET Tumor subsq tx strategy

PT Colorectal cancer screening test; converted to diagnostic test or other procedure

Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study.

Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study.

Q3 Liver Kidney Donor Surgery and Related Services.

Q4 Service for ordering/referring physician qualifies as a service exemption -

Q5 Service furnished by a substitute physician under a reciprocal billing arrangement

Q6 Service furnished by a locum tenens physician

Q7 One CLASS A finding

Q8 Two CLASS B findings

Q9 One CLASS B and two CLASS C findings

QA FDA Investigational device exemption (IDE) - The IDE project number must be included on the claim when modifier QA is billed.

QB Physician service in a rural HPSA.

QC Single channel monitoring.

QD Recording and storage in solid state memory by a digital recorder.

QJ Services/items provided to a prisoner or patient instate or local custody.

QK Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals.

QL Patient pronounced dead after ambulance called

QM Ambulance service provided under arrangement by a provider of services

QN Ambulance service furnished directly by a provider of services

QP Panel test - Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized panel other than automated profile codes.

QS Monitored anesthesia care

QT Recording and storage on tape by an analog tape recorder.

QU Physician service in an urban HPSA.

QV Item or service provided as routine care in a medical qualifying clinical trial

QW CLIA Waived Test - Effective October 1, 1996, all new waived tests are being assigned a CPT code (in lieu of a temporary five-digit G- or Q-code).

QX CRNA service with medical direction by physician.

QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist.

QZ CRNA service without medical direction by a physician.

RA Replacement of a DME item, Orthotic or Prosthetic Item

RB Replacement of a Part of DME, Orthotic or Prosthetic Item furnished as Part of a Repair

RC Right coronary artery

RD Drug provided to beneficiary, but not, administrated incident-to

RE Furnished in full compliance with FDA-Mandated Risk Evaluation and Mitigation Strategy (REMS)

RI Ramus intermedius (Effective for the year 2013)

RP Replacement and repair

RT Right Side - Used to identify procedures performed on the right side of the body.

RR Rental (use the RR modifier when DME is a rental)

SB NP (for use by midwives only)

SC Medically necessary service or supply (w.e.f Jan 1, 2012)

SF Second opinion ordered by a Professional Review Organization (PRO) per section 9401, P.L. 99-272 (100 % reimbursement – no Medicare deductible or coinsurance)

SG Ambulatory Surgical Center (ASC) modifier
SH Second concurrently administered infusion therapy

SJ Third or more concurrently administered infusion therapy

SK Member of high risk population (Use only with codes for immunization)

SS Home infusion services provided in the infusion suite of the IV therapy provider

SW Services provided by a certified diabetes educator

TA Left foot, great toe

T1 Left foot, second digit

T2 Left foot, third digit

T3 Left foot, fourth digit

T4 Left foot, fifth digit

T5 Right foot, great toe

T6 Right foot, second digit

T7 Right foot, third digit

T8 Right foot, fourth digit

T9 Right foot, fifth digit

TC Technical component only - Use to indicate the technical part of a diagnostic procedure performed.

TD Registered Nurse (RN) (for behavioral health use)

TE Licensed Practical Nurse (LPN) (for behavioral health use)

TJ  Child/Adolescent Program GP:  To be used for enhancement payment for foster care children screening exams. 

TK Extra member or passenger, nonambulance transportation

TS Follow-up service

UE Used durable medical equipment
UN Portable X-ray Modifiers; two patients

UP Portable X-ray Modifiers; three patients

UQ Portable X-ray Modifiers; four patients

UR Portable X-ray Modifiers; five patients

US Portable X-ray Modifiers; six patients

V1 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to a "minimal" level.

V2 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "self limited or minor" level.

V3 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "low to moderate" level.

V4 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "moderate to high severity" level and of at least 25 minutes duration.

V5 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "moderate to high severity" level and of at least 45 minutes duration.

VR Review report - This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 to indicate that the service was the treating doctor's review of report(s) only.

Modifier ZA (Anesthesia modifier especially used for Medi-cal insurance of California) denotes prone position or surgical field avoidance. To be used only for procedures that have a base value of three (3) units. These techniques are included in the anesthesia base value of surgical procedures with a base value of more than three.

Modifier ZE (Anesthesia modifier especially used for Medi-cal insurance of California) To be billed with the appropriate five-digit CPT-4 anesthesia code to identify a normal, uncomplicated anesthesia provided by a Certified Registered Nurse Anesthetist (CRNA).

Saturday, April 12, 2014

ICD-10 cm/pcs documentation: Adding “wordsmith” to your Coders’ job function!

ICD-10 cm/pcs documentation:  Adding “wordsmith” to your Coders’ job function!

As the countdown to the ICD10 implementation draws ever closer, one of the new challenge is to overcome and understand many of the new “words” that are in the code books, and knowing what they mean, and to discover if the documentation holds up to that new coding definition.

According to the Merriam-Webster dictionary a “wordsmith” is one who is an expert in the use of words; a person who works with words, or an especially skillful writer.  As a coder,  think about this.  Most coders fall into this category of expertise.  Coders are constantly challenged by the documentation noted from providers, to applying that which is written into a numeric format; such as ICD-9cm.  However, when ICD-10cm is implemented, coders will need an excellent understanding of, not only, medical terminology, but anatomy, physiology, disease process, the numeric codes, and a little bit of “wordsmithing” to correctly apply the diagnoses per the documentation in the new ICD-10cm format.

Many new terms have been put forth to coders, and certain codes will now require documentation to be more precise and complete to give us the best “picture” of the care the patient received via a numeric format.  Our challenge as good coders, is to communicate these new criteria to our providers, so we can all share the same understanding of the words needed to document important patient information.  Providers don’t normally have the inside track to what criteria or “words” need documented in ICD-9, and now we are challenged even more by the specificity needed in ICD-10.  A coder, or clinical documentation specialist is going to be looked up to as the expert to help educate and inform providers how to document more clearly, to get to the desired goal of clear, concise, correct documentation, which can be interpreted correctly, and most closely to ICD-10cm definitions.  If we succeed in this endeavor, everyone benefits.

Let’s start with some unusual words, found throughout ICD-9 and ICD-10.  Coders will need specificity in documentation.  Physicians and providers are accustomed to documenting descriptive and narrative processes in the patients’ medical record documentation (eg H&P, Operative Note, Discharge Summary etc) .  The impending go-live of ICD-10 will challenge us to “come together” with our physicians and providers to utilize specific, descriptive narratives to enable coders to append the correct ICD-10 diagnosis once the go-live date has come into effect.  In the example below, note the word “iatrogenic”

Outlined below is a challenging documentation excerpt.  The provider needs to more clearly document not only the procedure, but the diagnosis of the particular case.  In order to get this criteria “up to standard”  we, as coders will need to clearly understand what the procedure is, and why it’s being performed, then accurately code the current ICD-9 diagnosis.  Once that is done, we should cross-code/dual-code for to determine if the documentation can hold up to an appropriate and specific ICD-10cm code, prior to go-live on October 1, 2014.

Coding excerpt:  “………. the intention was on placing the Port-A-Cath in the left neck, given that this is the side of the patient's pathologic lung (eg lung cancer) , and we did not want to risk him having a pneumothorax in his right lung.  At this point, we considered that there was a very low likelihood of the patient having an iatrogenic pneumothorax.  The patient has a pleurodesis on the left, and likely has a trapped left lung already. Our concern is to avoid a pneumothorax in both lobes.”

As we focus on the words “iatrogenic”, “pneumothorax” and “pleurodesis”  We should verify what those definitions are in the medical dictionary.  There are many types and definitions of pneumothorax, and pleurodesis.  
primary pneumothorax:  is one that occurs without an apparent cause and in the absence of significant lung disease
secondary pneumothorax occurs in the presence of existing lung pathology
closed pneumothorax: air leaks from a discontinuity in the lung into the pleural cavity.
false pneumothorax: artifactual increased radiolucency of the thorax resembling free air in the pleural cavity.
iatrogenic pneumothorax: may occur following intrathoracic surgery or in association with procedures which involve entry into the pleural cavity, such as thoracentesis or placement of a chest drain.
open pneumothorax: caused by an open wound in the chest wall.
spontaneous pneumothorax: due to an unknown cause.
tension pneumothorax: a particularly dangerous form of pneumothorax that occurs when air escapes into the pleural cavity from a bronchus but cannot regain entry into the bronchus. As a result, continuously increasing air pressure in the pleural cavity causes progressive collapse of the lung tissue. If not relieved, it can lead to lung collapse and mediastinal shift.

Of course, the main diagnosis for the placement of the port-a-cath, is the lung neoplasm, (which in itself, neoplasms can be a coding challenge)  but a complication from this specific port-a-cath procedure, could result in a pnumothorax coupled with the fact the patient already has a pleurodesis.

Upon review of this small documentation example, it brings to light many documentation issues that arise in our quest for good documentation for coders to follow.  To get optimal coding specificity for each medical specialty, it is, and will continue to be, critical that coders communicate with the physicians and providers in a way that both get what they need, to achieve good, positive outcomes. (revenue, and quality patient care).  The coder is charged with translating the medical care documentation into a code-set, to be used  for payment and data analaysis; the provider needs to document the care of the patient for quality and medical necessity of care, combined with medical ethics and thus,  accuracy, for what was truly provided during the patients’ length of stay.

The coding query process can help.  The query process is a very useful tool, but real 1-1, face to face communication, combined with good ICD-10cm  training for the coder,  providers and physicians will be a critical point for ICD-10cm and pcs coding success.  Currently none of us are “good” or “expert” at ICD-10, so we all are struggling to become proficient at what we need.

The need for good documentation brings us back to the term “wordsmith”.  Again, both the coder and the physician/provider will need to add this to their job proficiencies.  A good way to get the conversation started with your physicians/providers’, is to conduct a review of the current physician/provider documentation by the coder.  The coder can develop, or may have a feel, as to how best to ascertain the top 5 or top 10 commonly mis-coded or difficult to code diagnoses in the practice.  If the coders’ are currently struggling with appending these “difficult” diagnoses now, utilizing ICD-9, this challenge now is amplified by dual coding/cross coding with ICD-10cm codes.  Document and analyze what is found.  This quick analysis will help define where better documentation is needed for both the coder and provider.   Below outlines this quick process to help enhance communication processes for both the coder and the physician/provider of care.

1. Ask the coder(s)  and provider(s) for the top 5 mis-coded or difficult to code diagnoses
2. Pull the operative/procedure notes that were associated with these diagnoses
3. Cross-code the documentation with both ICD-9 and ICD-10 codes
4. Identify areas that need to be clarified for the coder with the physician or provider
5. Schedule a meeting (face to face)  with the coder and the provider and include
a. The actual provider notes
b. The ICD-9 codes (using the code -book)
c. The ICD-10 codes (using the code-book)
Then, once this is all in place, you then have a terrific “learning opportunity” to share and commit to learning from each other how best to document or “wordsmith” so all get what they need.

Amazingly, the communication process is not only an informative session, but the opportunity to get to know and understand what each area needs for a successful transition and implementation to ICD-10