5010 deadline -

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

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

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

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

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

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

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

L  : )

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

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

History of Rho(D)

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

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

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

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

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

These standards are:

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

The Two Coding Scenario's 

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

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

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

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

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

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

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

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

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

V07.2          Need for prophylactic immunotherapy

V22.1          Supervision of other normal pregnancy

656.10                  Rhesus isoimmunization unspecified as to episode of care in pregnancy

656.11                   Rhesus isoimmunization affecting management of mother, delivered

656.13         Rhesus isoimmunization affecting management of mother, antepartum condition

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

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

Office/outpatient Practice

CPT Code	Description	Diagnosis
90384	Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use. (e.g. serum itself)	V07.2   Need for prophylactic immunotherapy V22.1   Supervision of other normal pregnancy 656.13 Rh Iso afft mgmt of mother antepartum
96372	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (e.g. injection of the serum)	V07.2   Need for prophylactic immunotherapy V22.1   Supervision of other normal pregnancy 656.13 Rh Iso afft mgmt of mother antepartum

Office/outpatient Practice

HCPCS/CPT Code	Description	Diagnosis
J2790	Rho D immune globulin, human, full dose, 300 mcg (1500 i.u (e.g. serum itself)	V07.2   Need for prophylactic immunotherapy V22.1   Supervision of other normal pregnancy 656.13 Rh Iso afft mgmt of mother antepartum
96372	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (e.g. injection of the serum)	V07.2   Need for prophylactic immunotherapy V22.1   Supervision of other normal pregnancy 656.13 Rh Iso afft mgmt of mother antepartum

 

Inpatient/Outpatient Facility

HCPCS/ICD-9 vol 3 procedure code	Description	Diagnosis
J2790	Rho D immune globulin, human, full dose, 300 mcg (1500 i.u (eg. serum itself)	V07.2   Need for prophylactic immunotherapy V22.1   Supervision of other normal pregnancy 656.13 Rh Iso afft mgmt of mother antepartum
99.11	Therapeutic, prophylactic, or diagnostic injection of Rh Immune Globulin	V07.2   Need for prophylactic immunotherapy 656.13 Rh Iso afft mgmt of mother antepartum This creates the issue where both methods of coding are correct.  The issue then falls upon the coder to determine how to code the service based upon how the 3rd party payer will reimburse for the service.

Pessary coding - Info from ACOG

ACOG recently put this out, and I felt it worthy to share... 

Coding and Billing for Pessaries


Two codes should be submitted on the 1500 claims form – one for the actual fitting and insertion of the pessary, and a second code for the pessary itself.

To report the initial fitting and insertion of the pessary or other intravaginal device, report CPT-4 code 57160. The supply of the new pessary may be reported separately with either HCPCS code A4561 (Pessary, rubber, any type) or A4562 (Pessary, non rubber, any type). In most cases, physicians are using non-rubber (silicone) pessaries and code A4562 should be reported. Please check with the vendor and/or package description if there is any question as to whether the pessary is rubber or non-rubber (silicone). Note: Non-Medicare carries may accept CPT code 99070 (Supplies and materials, provided by the physician over and above those usually included with the office visit or other services rendered) for the supply of the pessary instead of the HCPCS codes. Check with the payer before reporting.

According to CMS, pessaries can be provided to Medicare beneficiaries by properly enrolled Medicare Suppliers on the receipt of a valid prescription order from a physician. However, the beneficiary cannot "order" a Medicare-covered Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item and then submit a claim to Medicare and expect reimbursement. The Medicare program pays the DMEPOS Supplier directly upon submission by the Supplier of a valid claim.

According to a CMS representative, “If the pharmacy that you are purchasing the pessary from participates with Medicare they should submit a claim for the patient to Medicare (local carriers) for the item. If the patient is going to a pharmacy that is not enrolled with Medicare the patient will not have a method of being reimbursed so it is best to make sure they are going to a pharmacy that is enrolled with Medicare”.

Coding for pessary removal:

If a patient comes into the office to have her pessary removed, cleansed, and reinserted, an appropriate evaluation and management code (99211-99215) should be reported, based on the key components performed (history, examination, and medical decision making), as this is considered part of the E/M service.

If a patient presents to your office for the removal of an impacted pessary, it is appropriate to report CPT-4 code 57415 (Removal of impacted vaginal foreign body under anesthesia). However, if this is performed without anesthesia, report an E/M code at the appropriate level instead. Report ICD-9 diagnosis code 996.39 (Mechanical complication of genitourinary, other) in addition to the patients other conditions such as 616.10 [Vaginitis], or 618.2-618.4 [Cystocele with uterine prolaspe].
You can also access this article from the ACOG website at http://www.acog.org/About_ACOG/ACOG_Departments/Coding_and_Nomenclature/Coding_and_Billing_for_Pessaries