SuperCoder Blog

When I first entered the coding world, printed coding manuals were the home of medical codes. Fast forward to today, and there are a lot of options if you prefer to find a code online instead. Here are some ideas on what to look for when choosing an online code search (don’t miss #6).

1. Does It Have the Code Sets You Need?

Let’s start with the obvious. Useful medical coding software (sometimes called encoder software for medical coding) will combine all the code sets you need.

For instance (shameless plug alert!) SuperCoder Code Search lets you search CPT®, HCPCS, ICD-10-CM, and ICD-9-CM. But if you want access to code sets used exclusively by outpatient or inpatient facilities, one of SuperCoder’s facility coding solutions would be a better fit for you.

2. Can You Search Terms That Makes Sense to You?

To get to the right code fast, a robust search engine is a must. Will the search box get you where you want to go if you enter a code, code range, keyword, string of keywords, or abbreviations?

3. Can You Narrow and Sort the Search Results?

A long list of results can slow you down. Check for the options your medical encoder offers for narrowing search results. For example, you may be able to limit the source of your results to index entries, index tables, specific code sets, or the online code search provider’s own search database.

When you’re searching a term that has a lot of results, being able to sort the results is also helpful. Ask if you can sort by code order and by relevance to the search terms.

4. Does It Provide Extras to Improve Accuracy?

Bare bones code search tools have their place, but they don’t do a lot to help ensure you’ve got the right code. Make sure your online code search is up to whatever job you need it to do.

For instance, having official code descriptors is essential, but you won’t be able to understand proper use of the codes if you don’t have the official guidelines, too. Sometimes even that isn’t enough, so look at whether the resource provides lay terms to help you match what you see in provider documentation to the correct code. Illustrations are another feature that can help you get a better understanding of the procedure the code describes.

5. Can You Create Personal and Group Notes?

Confirm that you can save a personal note with a code. If you’ll have more than one user, ask if you can share notes so it’s easier for the team to follow tips and internal rules consistently.

6. Can You Trust the Accuracy of the Results?

Details matter in coding. Every digit must be correct. And don’t get me started on the trouble the addition of “(s)” to a code descriptor can cause. Get your online code search from a company you can rely on to have all the particulars in place. Ask how and when updates occur. And choose a company that you know will be responsive to feedback, including suggestions for improvements.

7. What Else Should I Know About This Code Search?

Can you get CEUs with your subscription? Can you see both code details and range pages, and select the type of page you want to see as default? Ask what makes the online code search tool you’re considering unique.

What About You?

How would you describe your ideal medical billing and coding software?

Let’s mix things up today with a little test. An article in Oncology & Hematology Coding Alert about intracavitary chemotherapy made me think about the importance of knowing anatomy when you need to pick an appropriate code. We often think about anatomy with ICD-10-CM codes, but it’s important for CPT® codes, too.

That’s the inspiration behind this pop quiz. See if you can match the anatomic description to the correct chemotherapy administration CPT® code.

Here Are Your Code Options

A. 51720 (Bladder instillation of anticarcinogenic agent …)

B. 96440 (Chemotherapy administration into pleural cavity …)

C. 96446 (Chemotherapy administration into the peritoneal cavity …)

D. 96450 (Chemotherapy administration, into CNS (e.g., intrathecal) …)

E. 96401 (Chemotherapy administration, subcutaneous …)

F. 96413 (Chemotherapy administration, intravenous …)

Match the Codes Above to the Relevant Anatomy Defined Below

__ 1. The central nervous system, including the area inside the membrane covering the spinal canal

__ 2. A closed space between the two layers of the lung

__ 3. Related to a vein, a tube that carries blood toward the heart

__ 4. An empty space in the layer of connective tissue lining the abdominal cavity

__ 5. A hollow muscular organ that stores urine prior to urination

__ 6. The area under the skin

Check Your Answers (No Peeking!)

1. D. Intrathecal chemotherapy administration described by 96450 requires spinal puncture, which involves inserting a needle into the spinal canal to reach the cerebral spinal fluid.
2. B. Chemotherapy administration represented by 96440 involves using thoracentesis (inserting a chest tube) to get the chemotherapy drug into the area between the lung and the lung lining. This procedure can help control cancerous fluid accumulations called malignant pleural effusions.
3. F. Chemotherapy administration into a vein (IV) reported with 96413 is well known to coders who work with oncologists who provide chemo infusions. IV admin gets the medication into the bloodstream, which moves the meds through the body.
4. C. Code 96446 represents administration into the cavity surrounding the organs in the abdomen. The provider may have the patient change positions during treatment to help the medication move within the cavity.
5. A. Administration into the urinary bladder falls under 51720. Terms you may see for the agents involved include Bacille Calmette-Guerin (BCG) and Mutamycin.
6. E. A subcutaneous injection (sub-q) uses a short needle that reaches between the skin and muscle. The abbreviated code descriptor shown for 96401 above leaves out that the official descriptor also includes intramuscular administration. Intramuscular administration goes through the skin and into the muscle layer. Chemotherapy chemicals are often too harsh to be delivered directly into muscle.

What About You?

How did you do? How did you learn the anatomy important to your specialty?

Curious how your use of subsequent hospital visit codes compares to reporting by other practices? Palmetto was curious, too. The Part B MAC took part in developing a Comparative Billing Report (CBR) looking at 99231-99233 billing and payment patterns in 2015 for internal medicine providers. Motivation? Those codes see about a billion dollars in improper Medicare payments each year. Keep your hospital visit reporting on the up and up by getting to know the codes and common problem areas.

Did the Case Really Earn 99233?

One of the areas the CBR looked at is the percentage of total services reported as high-level code 99233. Nationally, the rate was 32 percent, but percentages varied state to state. For instance, Wyoming averaged 20 percent, but Arizona averaged 53 percent!

We can’t know from these numbers whether anyone is coding inappropriately. It’s possible the patient population in one area consistently requires higher level services than the patient population in another area. What you can do is look at your own usage patterns to see if you vary widely from your state. And, of course, make sure you’re coding each case based on the documentation available, with special attention to whether the medical necessity of the case supports the code level assigned.

Here are the elements in each code:

• Elements applicable to all three codes
  • Subsequent hospital E/M
  • Reported per day
• 99231
  • 2 of these 3 key components:
    • Problem focused interval history
    • Problem focused exam
    • Straightforward or low complexity medical decision making (MDM)
  • Patient is stable, recovering, or improving
  • 15 minutes at bedside and on floor/unit typical
• 99232
  • 2 of these 3 key components:
    • Expanded problem focused interval history
    • Expanded problem focused exam
    • Moderate complexity MDM
  • Patient is not responding adequately or has a minor complication
  • 25 minutes at bedside and on floor/unit typical
• 99233
  • 2 of these 3 key components:
    • Detailed interval history
    • Detailed exam
    • High complexity MDM
  • Patient is not stable, has a significant complication, or has a significant new problem
  • 35 minutes at bedside and on floor/unit typical

Keep the Documentation Focus on Quality Not Quantity

Based on problems commonly seen, Palmetto staff offered some areas to watch to ensure your 99231-99233 documentation is up to snuff:

• Easier to spot: Incomplete/illegible notes, lack of documentation, unclear dates of service, problems with provider signature
• Tougher to spot: Lack of medical necessity — base code choice on complexity supported by the documentation, not just the amount of documentation.

Bonus: When to Report Subsequent Code for Initial Visit

Let’s take your hospital visit know-how up another notch by going over an interesting oddity of Medicare reporting. When Medicare stopped accepting consultation E/M codes, it created some problems for reporting initial hospital services that didn’t meet the requirements for reporting an initial hospital visit code. Medicare’s solution is to allow you to report a subsequent hospital care code that describes the work and medical necessity requirements even when it’s the provider’s first inpatient service during the stay. You’ll find the rule in Medicare Claims Processing Manual, Chapter 12, Section 30.6.10.

What About You?

Do you have tips for choosing between the different code levels and getting the documentation you need?

Move over, unlisted vascular surgery code 37799! That’s what mechanochemical ablation (MOCA) codes 36473 and +36474 said when they became reportable CPT® codes on Jan. 1, 2017. Give your use of these new endovenous ablation codes a check-up with the four pointers below.

1. Read the Descriptors All the Way Through

Reading the descriptor is a pretty obvious first tip, but there’s a reason for that. Here are the descriptors:

• 36473 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated)
• +36474 (… subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)).

Just look at some of the fun facts you can learn:

• The codes apply to percutaneous services in an extremity
• Code 36473 is for the first vein, and +36474 is for one or more subsequent veins treated in that extremity
• The codes include all imaging guidance and monitoring.

2. Use the Code Only for the Intended Tech

What it is: These codes apply to “concomitant use of an intraluminal device that mechanically disrupts/abrades the venous intima and infusion of a physician-specified medication in the target vein(s),” according to CPT® guidelines.

That’s a mouthful. A device brand name you’ll see tied to MOCA is ClariVein®IC. In the procedure, the provider administers local anesthesia and inserts an infusion catheter with a special wire tip into the incompetent (varicose) vein. Remember that any imaging guidance used is covered under the surgical code. She attaches the catheter to a motor drive unit. The wire tip rotates quickly inside the vein and delivers the medicine the provider chooses.

What it is NOT: “Sclerosant injection by either needle or catheter followed by a compression technique is not mechanochemical vein ablation,” the CPT® guidelines state. Use 37799 (Unlisted procedure, vascular surgery) for catheter injection of a sclerosant without the accompanying mechanical disruption of the vein intima, which is the inner layer.

3. Be Sure You Get the POS Right

The fees vary considerably for these surgery codes depending on whether you’re reporting physician work in a facility or nonfacility setting. As the CPT® guidelines explain, supplies and equipment required are included in payment when performed in the office setting.

For 36473, the Medicare Physician Fee Schedule (MPFS)  in Q2 of 2017 shows these national rates (meaning they’re unadjusted for geography):

• Facility rate $179.80
• Nonfacility rate $1,522.40.

That’s a whopping $1,342.60 difference that you don’t want to lose or have to repay because of a simple place of service (POS) mistake.

The fee difference for +36474 isn’t quite as exciting, but getting POS wrong would add up fast:

• Facility rate $90.08
• Nonfacility rate $278.86.

4. Think Twice Before Reporting E/M

Code 36473 has a global period of 000. Here’s the official definition for that indicator from Medicare, which makes it clear that an E/M on the same date usually isn’t payable: Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.

As an add-on code, +36474 has a global period of ZZZ, which means: The code is related to another service and is always included in the global period of the other service.

How About You?

Code 36473 has an MUE of 1 in Q2 2017. Has that caused issues for you?

On Friday, SuperCoder blog covered molecular pathology CPT® code updates effective July 1. Today, let’s look at what’s coming our way in July for vaccines. Because why should January 1 have all the update fun?

Schedule: The codes we’re discussing here were published on the AMA website on Jan. 1, 2017. They’re effective July 1, 2017, and will be in the printed CPT® 2018 manual.

Adopt 90587 for Dengue

July 1 brings one new code: 90587 (Dengue vaccine, quadrivalent, live, 3 dose schedule, for subcutaneous use).

Dengue is a mosquito-borne illness typically associated with tropical and subtropical areas. Patients suffer from high fever, rash, and muscle and joint pain that has earned the disease the descriptive nickname “breakbone fever.” Treatment is often limited to hydration and pain medication.

Tip: You’ll find a lightning bolt symbol next to new code 90587. The CPT® Editorial Panel allows publication of new vaccine product codes before FDA approval. A lightning bolt symbol by the code lets you know FDA approval is pending.

Make Changes to 2 Meningococcal Vax Codes

There will be a minor change to use the term MenB-4C in a revised descriptor for 90620. The revised descriptor looks like this: Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB-4C), 2 dose schedule, for intramuscular use.

MenB-4C is the complete scientific abbreviation assigned by the Advisory Committee on Immunization Practices (ACIP). The CPT® Editorial Panel approved using these abbreviations in vaccine code descriptors in the May 2014 meeting.

You’ll see a similar ACIP abbreviation update in a revised descriptor for 90621: Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB-FHbp), 2 or 3 dose schedule, for intramuscular use. Also note the reference to the “2 or 3 dose schedule,” which differs from the reference to only a three-dose schedule in the 90621 descriptor published in the 2017 printed manual.

Meningococcal diseases can affect the brain and spinal cord, and cause bloodstream infections. Antibiotics can treat infected patients.

Update Dose Schedule for HPV Code 90651

On July 1, a new dose schedule enters the descriptor for 90651. Here is the revised descriptor: Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use.

Instead of referencing only a three-dose schedule, the descriptor effective July 1 includes the newly approved two-dose schedule.

HPV vaccines protect against certain types of HPV, helping with prevention of genital warts and some cancers, like cervical and anal cancers.

How About You?

Were you aware that to streamline reporting of immunizations, Category I vaccine codes have July 1 and January 1 early release dates? In urgent situations, a code may even be published outside of that schedule.

All of you who have never read the descriptor for a tier 2 molecular pathology procedure code, go check out 81400-81408. Then tip your hat to MoPath coders because those code descriptors are lo-o-o-o-ng.

To add to the fun, CPT® releases descriptor changes for these codes more than once a year. The descriptor changes effective July 1, 2017, take four pages to list, so in this post we’ll look only at additions. You can find the complete list under Downloads on AMA’s CPT® Molecular Pathology Tier 2 Codes site.

These changes were posted to the AMA site Jan. 1, 2017; are effective July 1, 2017; and will be published in the CPT® 2018 manual.

Look for New Tests Listed Under 81405

Before starting its long list of tests, the descriptor for 81405 begins with “Molecular pathology procedure, Level 6 (e.g., analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis).”

(Would be nice if 81405 was for level 5 and not level 6, right? But you can’t have everything.)

Effective July 1, insert these additions to the descriptor for 81405:

• CPOX (coproporphyrinogen oxidase) (e.g., hereditary coproporphyria), full gene sequence
• CTRC (chymotrypsin C) (e.g., hereditary pancreatitis), full gene sequence
• PKLR (pyruvate kinase, liver and RBC) (e.g., pyruvate kinase deficiency), full gene sequence.

Code 81406 Adds 2, Too

The descriptor for level 7 code 81406 begins this way: “Molecular pathology procedure, Level 7 (e.g., analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia).”

• HMBS (hydroxymethylbilane synthase) (e.g., acute intermittent porphyria), full gene sequence
• PPOX (protoporphyrinogen oxidase) (e.g., variegate porphyria), full gene sequence.

How About You?

Do you report MoPath tests? What tips would you offer someone just starting out in the specialty?

With all the hippity hoppity talk this time of year, I have coding for hips on the brain. Might as well go with it and look into some hip coding tips!

1. Watch for Mod 22 Opportunities With Congenital Cases

If your surgeon performs hip replacement surgery for a developmental or congenital hip dislocation, there’s a decent chance the procedure required enough extra time and work to merit the use of modifier 22 (Increased procedural services).

Don’t assume: The diagnosis alone doesn’t support use of this pay-enhancing modifier. Details of the work and time required beyond the normal range is key to convincing the payer.

In clinical documentation improvement training, inform surgeons about the reimbursement benefits of including a separate paragraph in the op note describing any extra work required for an individual case. Documentation that gives the reviewer clear information will go a long way. For instance, if an underdeveloped acetabulum requires advanced techniques and complex implants during the surgery, the op note should spell that out, identifying how the current case differs from a typical one.

2. Know Your Payer’s Edits and Expectations

You may find that different payers have different rules about which codes may be reported together. Keeping tabs on individual payer edits can be worth the effort if you discover you’ve been ignoring a reportable code.

Example 1: Suppose a patient previously underwent open reduction with internal fixation for a femoral neck fracture. Now, due to nonunion, the patient requires hip hemiarthroplasty with adductor tenotomy and hardware removal. The relevant codes are:

• 27125 (Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty))
• 27001 (Tenotomy, adductor of hip, open)
• 20680 (Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate)).

Medicare Correct Coding Initiative (CCI) edits prevent payment for 20680 when reported with 27125. But other payers may not apply that edit. You don’t want to miss legitimate opportunities to receive payment for both codes.

Example 2: For a patient who had a subtrochanteric osteotomy in the past and has another as part of total hip arthroplasty, you should report 27132 (Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft). Should you also report osteotomy code 27165 (Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast)? CCI doesn’t bundle the two codes, but some payers may not pay for both on the same claim. Knowing payer rules will help your practice know what to expect as reimbursement.

Bonus tip: When you do report more than one code, know your payer’s rule for modifier 51 (Multiple procedures). Medicare asks you not to use modifier 51, but other payers may require you to use the modifier on codes for additional procedures when you report more than one procedure for a patient on the same date.

How About You?

Have any hip coding success stories to share?

The weather is getting warm enough for bare feet, knees, and elbows, and that leaves them more vulnerable to lacerations. Check out these three scenarios to help you choose correct codes for those cuts, powering up your laceration coding skills for spring.

Case 1: Don’t Overcode for Bandaging Skinned Knee

Suppose an established patient presents to the pediatrician with a skinned right knee. The provider examines the knee, cleans it with warm soapy water, and applies gauze and sterilized bandages.

Should you report a simple repair, an E/M code, or both?

In this case, you should use an E/M code to cover the complete service. Generally, if the provider uses adhesive strips or bandaging, then the E/M code will be sufficient to cover what the provider did.

Case 2: Know Payer Preference for Tissue Adhesive Repair

Now imagine a Medicare patient presenting to a family practice for a 2 cm scalp laceration. The provider uses a tissue adhesive for the repair.

Should you report 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less)?

That code is a good choice except for one thing. Medicare accepts G0168 (Wound closure utilizing tissue adhesive(s) only). For other payers, 12001 may be appropriate.

Tip: In your manual or in your coding software, add a note with the CPT® laceration repair codes to remind yourself about G0168.

Case 3: Factor in Foreign Body Removal

In our final example, consider the coding for a patient who presents to the emergency department after stepping on a pile of branches and getting a puncture wound. The ED physician administers anesthesia, uses a blade to make an incision, explores the wound, and finds a foreign body extending into the deep tissues, including the fascia. The physician removes the foreign body and closes the wound.

Should you report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple)?

While 10120 does describe foreign body removal requiring incision. There’s a better option for this case: 28192 (Removal of foreign body, foot; deep).

If you caught the correct code, your wallet will be happy. Code 10120 pays about $105 in the facility setting, while the Medicare Physician Fee Schedule shows a national rate of $323 for 28192.

How About You?

What’s your best tip for how to ensure correct laceration repair coding? We didn’t go into ICD-10 codes here, but do you find diagnosis coding requirements for lacerations tough to take?

You get a fairly clear picture of what this rule is about from its name: Medicare Reporting and Returning of Self-Identified Overpayments. If you discover Medicare gave you too much money, you have to give it back.

But there are some layers here, so let’s dig in for a refresher on some of the more important details. (It’s worth it when you consider the potential consequences of not complying include False Claims Act liability, monetary penalties, and exclusion from federal health care programs.)

60 Days Is All You Have to Give Medicare Money Back

Under the rule, providers and suppliers who get Medicare funds have to report and return overpayments by the later of these two:

• 60 days after the date you identified the overpayment
• The date a corresponding cost report is due (if applicable).

6 Years Is How Long Your Responsibilities Extend

The clock stops on this rule after six years, which isn’t so bad when you recall that the original plan was for a 10-year lookback period.

Experts warn that the lookback period extends back six years even if that time is before the rule became effective March 14, 2016.

Not Doing Audits Is a Bad Idea — Here’s Why

During the comment process, some worried this rule would create a chilling effect on audits if people sought to avoid finding overpayments. The final rule got around that by stretching the definition of “identification” to include the time when you actually discovered the issue or when you should have discovered it:

“A person has identified an overpayment when the person has or should have, through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment.”

In other words, plan regular audits and take action to ensure compliance because Medicare is going to hold you to that standard.

What Should You Watch for to Find Overpayments?

The final rule provides some examples to help give an idea of what it means to “identify” an overpayment under this rule. For instance, if you discover any of these, you need to get moving to ensure your claims and compensation comply with the rule:

• Incorrect coding that yielded increased reimbursement
• A patient death prior to the date of service on your claim
• Services performed by an unlicensed or excluded provider
• Internal audit results that indicate overpayment.

And remember that you’re responsible for overpayments you should have discovered, too, as in these examples:

• A government agency performs an audit and alerts you to a potential overpayment that you need to investigate
• You see a significant increase in Medicare revenue with no obvious cause.

How About You?

Have you had to look into the finer details of this rule? What tips would you give others?

Consultations didn’t go the way of the dodo when Medicare decided to stop reimbursing the codes specific to those services. Some private payers still reimburse office and outpatient consult codes 99241-99245 and inpatient consult codes 99251-99255, as long as you follow the rules.

Recharge your consult coding batteries with these documentation reminders along with a special update for 2017.

Check Off Every R for the Medical Record

When talking about coding consultations, you’ll generally see reference to three Rs: request, render, and report. Many times you’ll also see a fourth R, reason, worked in with the request requirement. Let’s flesh that out a bit more.

Request: CPT® guidelines state that there must be documentation of a request by a physician or other appropriate source for the consultation in the patient’s medical record.

Reason: Including the reason for the request helps support the medical necessity for the encounter.

Render: You’ve got to supply the consult before you ask the payer to reimburse you for it, of course.

Report: The consulting provider must have her own record of the visit but also must share her opinion and information in a written report to the requestor on any services ordered or performed.

What Rs Do You Want to Avoid?

Responsibility for managing the patient’s condition is one R you have to watch out for. If the consultant takes on responsibility for managing the patient’s condition (all or part) before completing the consultation, then you shouldn’t use a consult code. Use another appropriate E/M code instead.

Another R to beware of is referral. Documenting the term referral or referring physician may lead to the interpretation that transfer of care, not a consult, was the intended plan all along.

Shine a Light on What’s New This Year

In a nod to these changing times, 99241-99245 and 99251-99255 sport stars in the 2017 CPT® manual, identifying them as codes that may apply to synchronous, real-time telemedicine services.

When reporting these services as telemedicine consults, be sure to follow your payer’s rules on which place of service to use (such as 02 for telehealth) and which modifier to append (such as GT, Via interactive audio and video telecommunication systems, or 95, Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system).

What About You?

Do you still use consult codes? Have you coded for any telemedicine E/M services?