5/24/2010. The 10 Ways to Improve Coding

Transcription

1 10 WAYS TO IMPROVE an ASCs ORTHO & SPINE CODING Orthopedic, Spine & PM ASC Conference asc Communications/the ASC Assoc. Conference Speaker: Stephanie Ellis, R.N., CPC Ellis Medical Consulting, Inc. (615) The 10 Ways to Improve Coding Understanding the coding & billing issues that can get you into trouble Learn core basics for assuring the coding & billing performed at your facility are correct Be sure your facility is billing for incidentals that cost you money like Implants 2 The 10 Ways to Improve Coding Diagnosis coding is key to being paid correctly for these procedure be sure your understand the basics for correct diagnosis coding of Ortho/Spine/PM procedures Revenue Code and Modifier issues that are important to know 3 1

2 The 10 Ways to Improve Coding Documentation Do s & Don ts to keep you out of trouble Tips on Common Ortho. procedures that are frequently miscoded Understand when Injections for Post-Op Pain Control are billable and when they aren t 4 The 10 Ways to Improve Coding Putting your best foot forward to code foot procedures more accurately Tips to code Spine/Pain Management procedures correctly 5 Coding & Billing Issues Billing non-covered services as covered services Billing new procedures (No CPT Code) Billing Medicare for Cataracts when ASC does NOT purchase the IOL for the case Upcoding Unbundling Failure to Refund Credit Balances timely Medical necessity issues 6 2

3 Coding & Billing Issues Anesthesia Services Scope of Practice violations Billing improperly for cancelled cases Transforaminal Injection Med. Necessity issues Place of Service issues Inappropriately billing Medicare patients Changing DOS to correspond with coverage dates 7 General Billing Basics/Tips Read the ENTIRE OP Report before coding Avoid Canned OP reports Check for proper documentation for Service billed Review EOBs/RAs for denial reasons Check CCI Unbundling Material for multiple procedures Correctly Sequence CPT codes on claim forms OP Report must identify ASC facility as Place of Service Read Medicare Bulletins monthly Be Aware of Medicare LCDs Use Post-Operative Diagnosis for coding Are Implants billable to payor? Are X-rays and Fluoroscopic guidance billable to payor? 8 Implants Correctly billing for Implants 9 3

4 Implants Common Implant Codes: C1713 Anchor/Screw L8630 Metacarpophalangeal Joint Implant L8631 Metacarpophalangeal Joint Replacement Implant L8641 Metatarsal Joint Implant L8642 Hallux Implant L8699 or Misc. Implants 10 Implants Common Implant Codes (Cont.): C2614 Probe for Percutaneous Lumbar Discectomy C Prosthesis, Penile, noninflatable C1778 Neurostimulator Lead C1767 Neurostimulator Generator (nonrechargeable) C1820 Neurostimulator Generator (rechargeable) L8680 L8688 Misc. Implantable Neurostimulator Components Q4107 Graft Jacket C9361 Synthetic Conduit for Nerve Repair * In Most Cases, Do Not Use C-Codes on Medicare Claims. 11 Diagnosis Coding Ortho. Diagnosis codes provide payors with the what and why the service(s) was necessary. Diagnosis codes provide the tools to report the Medical Necessity of the service(s) provided. Over 85% of Medical Necessity claim denials are related to Diagnosis coding! 12 4

5 Diagnosis Coding Ortho. Avoid Upcoding of Injury Diagnoses Removal of Hardware Arthropathies Arthropathy Associated with Infections Traumatic Arthropathy Internal Derangement of the Knee Chondromalacia Degenerative Spine Disorders Pathological Fractures Malunion/Nonunion Valgus vs. Varus 13 Diagnosis Coding Ortho. Muscle Tears Rotator Cuff Injuries Impingement Syndrome Tear/Rupture Tendinitis and Shoulder Bursitis Adhesive Capsulitis Little League Shoulder SLAP Lesions Dislocations of Shoulder Joints Open Injury Closed Injury 14 Diagnosis Coding Ortho. Tennis Elbow Other Orthopedic Diagnoses de Quervain s Syndrome Trigger finger Dupuytren s contracture Synovitis Tenosynovitis 15 5

6 Diagnosis Coding Ortho. Bunions Bursitis Ganglions Paget s Disease Osteochondropathies Flat Foot 16 Diagnosis Coding Ortho. Other Foot Diagnoses Hallux Valgus Hallux Varus Hallux Rigidus Hallux Malleus Hammertoes Claw Toe 17 Diagnosis Coding Spine/Pain Mgmt. Spinal Stenosis Radiculitis Spondylosis Enthesopathies Postlaminectomy Syndrome Herniated Discs DDD Sacral Disorders 18 6

7 Tips for Appropriate Diagnosis Code Assignment: List Diagnosis Chiefly responsible for surgery first Avoid Unspecified codes Do not code from the Alphabetic Index Acute and Chronic conditions Link the what and why Keep library of Coding books up-to-date 19 Tips for Appropriate Diagnosis Code Assignment: V-Codes V-Codes: Use for encounters for reason other than injury or illness ICD-9-CM definition: Personal History codes used for a patient with disease in the past but condition no longer exists (not active) and patient is not receiving any treatment, however, the disease has the potential for recurrence and may require continued monitoring. 20 V-Codes Use V-codes for: Patient history Family history Diagnostic tests Attention to devices Some symptoms 21 7

8 E-Codes E-Codes: Commonly used on Worker s Comp. Claims Used for how an accident happened Do not use for Medicare claims Classify external causes Not for primary diagnosis Identify trauma or condition Late effects of accidental injury 22 Revenue Codes Code 250 for Pharmacy Services Code 270 for Medical/Surgical Supplies Code 271 for Non-sterile Supplies Code 272 for Sterile Supplies Code 274 for Prosthetic/Orthotic Devices Code 276 for IOL Implants (Cataracts) Code 279 for Supplies Code 278 for Other Implants 23 Revenue Codes Code 320 for X-rays (Fluoroscopy) Code 360 for Surgical Procedures performed in a Surgical Hospital Code 370 for General Anesthesia Code 379 for Other Anesthesia Code 490 ASC Surgical Procedure CPT codes Code 710 for Recovery Room Services (PACU) 24 8

9 Using Modifiers on CPT codes correctly to help avoid billing problems and to not leave money on the table 25 Bilateral Procedure Modifiers Using the correct Modifiers to bill payors for Bilateral Procedures according to payor requirements is very important. The five usual methods for the billing of Bilateral procedures include: o o o o o Bill the same code as two line items, using the RT Modifier on one code and the LT Modifier on the other (same) code. (***Medicare) Bill the bilateral procedures as two line items with no Modifier on the 1st code and a 50 Modifier on the 2nd line item (same code). Bill the procedure as a single line item on the claim form with a 50 Modifier on the procedure code. Be sure if you use this method to double the facility fee. Bill the same code as two line items with no Modifiers. (***Medicare) Bill the procedure as a single line item on the claim form with no Modifier on the procedure code and put a 2 in the Units column on the claim. Be sure if you use this method to double the facility fee. (***Medicare) *** Do NOT use the -50 Modifier on Medicare claims. 26 Modifier Issues Do NOT use the -51 Multiple Procedure Modifier on ASC claims, unless the payor specifically requires its use it is for use on physician claims only. Add-on Codes Don t list alone List code for the Primary procedure before add-on code 27 9

10 Correct use of the -59 Modifier on CPT Codes which are Unbundled or designated as Separate Procedures in the CPT book may be billable with the use of the 59 modifier, to indicate that the procedure is not considered a component of another procedure, but a distinct, independent procedure, such as a: o Different site or organ system; o Separate incision/excision; o Separate compartment; o Separate lesion. o In many cases for Medicare patients, if the code is Unbundled, it is not separately billable. 28 Medical Record Documentation Issues The medical record must support the Medical Necessity of the CPT and Diagnosis codes billed. All entries in the medical record must be dated with a full date (Month/Day/Year) and should be signed by all physicians and nurses recording in the record. Patient s name and/or Medical Record Number should be on every page in the medical record. The medical record should be complete and legible with entries made in black ink. Notify the surgeon if a scheduled procedure is not on the Medicare s list of covered procedures for Medicare patients, and try to divert the case to another setting. 29 Medical Record Documentation Issues Incomplete OP Reports and Op Report Addendums o Read the entire OP Report. o Code only from the OP Report Never code from the schedule or superbill/chargeticket documents without an OP Report in hand. o Code in a compliant manner Medicare directs that only those procedures documented in the body of the OP Report can be billed. o OP Report Addendums Addendums should be dated with the date the Addendum is done. o State it is an Addendum. o Addendums can be done on the original OP Report or on a separate piece of paper. o If done on a separate piece of paper, document the date of the original procedure and the procedure performed. o Do not re-type OP Reports as a new original document. o Addendums can be handwritten by the surgeon or typed. o Addendums must be signed by the surgeon

11 Medical Record Documentation Issues Canned OP Reports Issues with Canned OP Reports: Canned OP Reports may not contain all of the information necessary for proper documentation of the procedure performed. Reports may have no Pre- or Post-operative diagnosis tailored to the patient. The report may contain no language tailored to the patient s surgery. Report may not list the procedure performed and/or indicate upon which side (Left or Right) the procedure was performed. Medicare frowns on the use of Canned OP Reports ( Cloned Records ). 31 Medical Record Documentation Issues OP Report Requirements: OP Reports must be tailored enough to each individual surgery and circumstances for use, and not appear to be canned. Any deviations from normal during surgery, (complication, or a change in something for just that patient s procedure, etc.) must appear and be correct in the OP report. 32 Medical Record Documentation Issues OP Report Requirements (cont.): If the report is not accurate, detailed and individualized, it can be a compliance issue. Consequences: Can cause the ASC to have to refund money. Can cause an issue with the facility s state survey. Can be a potential malpractice issue for both the surgeon and the facility

12 Medical Record Documentation Issues Radiology Documentation When x-rays are taken or fluoroscopy is used in procedures, the physician s report/interpretation of the findings must be documented. The interpretation can be documented in the OP Report itself or on a separate piece of paper. If no report of the x-ray is documented, do not bill the service. 34 Medical Record Documentation Issues Place of Service Issues with OP Reports It can cause problems when Physicians dictate OP Reports off-site from the ASC facility. Off-site reports can make it appear that the procedure was performed at the hospital or at the physician s office, with the ASC not listed as the place of service anywhere on the report. It is insufficient for the ASC facility to only be listed as cc:xyz Surgery Center at the bottom of the OP Report. The ASC could be charged with filing a false and Fraudulent claim, due to it not being clear the procedure was performed at the ASC facility. It MUST be very clear on the OP Report that the procedure was performed at your surgery center. 35 Medical Record Documentation Issues Doctor s Codes on OP Reports If physicians list diagnosis and/or CPT codes on OP Reports, it does not relieve the ASC s coder from the obligation of checking through the entire OP Report to be sure the codes given are correct. Use of Signature Stamps Medicare and other payors say physicians are not to use signature stamps to sign their OP Reports, H&Ps, etc. If you have physicians using signature stamps, it is wise to discontinue this practice at your ASC

13 Correct Coding of Cases If you are doing ALL or Most of the coding for the ASC using superbill documents where the physicians code, if no one at your facility is checking the OP Report with the surgeon s coding, you are probably leaving money on the table. 37 Orthopedic Procedures Frequently Miscoded Hardware Removals Code Deep Implant Removals only code once per fracture site Code Superficial Pin Removals Tendon Grafts with Scope ACL Repairs Not billable unless harvested from either ankle or opposite knee (code 20924) 38 Orthopedic Procedures Frequently Miscoded Lipoma Removals Use codes from section (Skin codes) if removed from just under the surface of the skin based on size Deeper lipoma removal procedures should be coded from the section with Excision of Tumor codes based on size and depth of procedure performed 39 13

14 Ortho. Procedures Frequently Miscoded Knee Chondroplasty procedures o Chondroplasty = Debridement o For Arthroscopic Debridement of ACL, use code not code o Use Chondroplasty code only once per Knee o CCI edits for code mean per Compartment not that it is not billable o Use code G0289-GY for Medicare cases with Chondroplasty in separate compartment not covered for ASC o Use code for other payors for Chondroplasty in separate compartment o Bill Medicare when the only procedure performed on knee 40 Ortho. Procedures Frequently Miscoded Synovectomy vs. Debridement Procedures Debridement codes used when articular cartilage is debrided and Chondroplasty procedures are performed Synovectomy codes used when only soft tissue is removed, synovium is excised, or plica is excised Joint Manipulations - perform as an Add-on Procedure only 41 Ortho. Procedures Frequently Miscoded Subacromial Decompressions separately billable with Rotator Cuff Repairs with -59 Modifier if Unbundled Treatment of SLAP Tears Scope and Open codes Clavicle Procedures Scope and Open codes Surgeon should document removed 1 cm. of bone 42 14

15 Injections for Post-Op Pain DON T bill to Medicare Must be performed by a different doc Must have an OP Report separate from Anesthesia Record and surgery OP Report Not all payors will reimburse for them Use codes or for Shoulders Use codes or for Knees 43 Ortho. Procedures Frequently Miscoded Abrasion Arthroplasty procedures Code Also called Pick Arthroplasties Surgeon should document procedure was performed down to bleeding bone Don t code Chrondroplasty separately with these procedures Can code more than once per knee if performed in a separate compartment 44 Ortho. Procedures Frequently Miscoded ACL Procedures Arthroscopic ACL Reconstruction code There is no code for an ACL Debridement use Unlisted code Use code for an ACL Re-do procedure 45 15

16 Ortho. Procedures Frequently Miscoded Epicondylitis procedures Percutaneous procedure standard Epicondylectomy Epicondylectomy with Tendon work Manipulation of Elbow Ortho. Procedures Frequently Miscoded CMC Joint Arthroplasty (Thumb Arthritis) procedure codes and for tendon transplant in wrist or for tendon transplant in CMC area Dupuytren s Contractures percutaneous vs. more extensive open procedures 47 Ortho. Procedures Frequently Miscoded Foot Procedures Bunionectomy procedures Hammertoe Corrections Code Unbundled from Bunion procedure but separately billable with Toe Modifiers when performed on a different toe Use code if MTP Joint Capsulotomy also performed with Hammertoe procedure 48 16

17 Spine/PM Procedures Frequently Miscoded ESI procedures Transforaminal ESI procedures Bundling issues with ESIs 49 Spine/PM Procedures Frequently Miscoded Facet Joint Injections CPT Code Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), cervical or thoracic; single level reimburses $ by Medicare. CPT Code Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) reimburses $ by Medicare. 50 Spine/PM Procedures Frequently Miscoded Facet Injections, cont. CPT Code Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) reimburses $ by Medicare. CPT Code Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), lumbar or sacral; single level reimburses $ by Medicare

18 Spine/PM Procedures Frequently Miscoded Facet Injections, cont. CPT Code Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) reimburses $ by Medicare. 95. CPT Code Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoro. or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) reimburses $ by Medicare. 52 Spine/PM Procedures Frequently Miscoded SI Joint Injections o 3 Codes Use depends on circumstances G Imaging used in procedure Surgeon and ASC facility s codes will NOT match 53 Spine/PM Procedures Frequently Miscoded Discogram Procedures Bill 64490/64491 codes once per level Bill TC or TC Imaging codes once per level Cages used in spine fusion procedures bill per level not per cage used 54 18

19 QUESTIONS? 55 19