DRG Coding Advisor: Look for nuances in these coding problem areas
Note the new CPT changes
Chargemasters need to be maintained on a quarterly basis, and coders should be given educational updates at least that often to keep up with the CPT coding changes and the development of new codes by the Centers for Medicare & Medicaid Services (CMS), experts advise.
"Last year we had over 400 program memorandums issued by Medicare that dealt with all aspects of health care reporting, and if you are in a large facility, you need to read every one of them to know and discern and decide if it’s applicable to your facility," says Glenda Schuler, RHIT, senior consultant with Ingenix/St. Anthony Consulting in Salt Lake City.
"It’s a challenge for everyone, and one important thing I want to say is that nobody is doing everything right because it’s impossible to do it all correctly," Schuler adds.
Another challenge is making certain that as much attention is paid to outpatient coding as has traditionally been paid to the inpatient side, says Jill Giddens, RHIA, CCS, technical editor for Ingenix Publishing in Salt Lake City.
"What APCs have done is level coders for outpatient to the same as inpatient," Giddens notes. "Now they’re just as important today as the inpatient coders."
In 2003 there are new CPT coding changes for respiratory services. Several codes have been deleted, and these are listed below:
— HCPCS 94650: Intermittent positive pressure breathing (IPPB) treatment, air or oxygen, with or without nebulized medication; initial demonstration and/or evaluation.
— HCPCS 94651: Intermittent positive pressure breathing (IPPB) treatment, air or oxygen, with or without nebulized medication; subsequent.
— HCPCS 94652: Intermittent positive pressure breathing (IPPB) treatment, air or oxygen, with or without nebulized medication, newborn infants.
— HCPCS 94665: Aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; subsequent.
For service dates after March 31, 2003, hospitals that use the above codes will cause their claims to be rejected, and there will be no reimbursement, Schuler says.
The description for two respiratory therapy procedures has changed, affecting the method of reporting these CPT codes:
— HCPCS 94640: The new description is: Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing [IPPB] device).
— HCPCS 94664: The new description is: Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device.
One area often overlooked concerns arterial blood gas (ABG) analysis, which should be billed along with an arterial puncture, Schuler says.
The ABG is CPT 82803, and then the arterial puncture, which is CPT 36600, is reported in the same quantity as the ABG.
"Medicare doesn’t pay for arterial puncture, but it should still be reported as a procedure performed," Schuler says. "Medicare has status indicators on all CPT codes that provide a method of payment for the APC payment system, and CPT 36600 reimbursement is packaged with the ABG procedure."
Interventional radiology also requires reporting of correlating codes. For instance, if a shoulder arthrogram (CPT 73040) is reported, then there should be an injection CPT code to go with it, such as CPT 23350, Schuler says.
"When you look at the charges generated from a hospital, if they generated 15 shoulder arthrograms, you should see 15 CPT 23350 codes, as well," Schuler says.
"Hospitals are losing out because they’re not reporting the surgical component consistently," she says. "CPT 23350 is a packaged component, but you still want to report the revenue, and they’re not reporting the charge for the injection."
Another tricky coding area involves venography. The code for a bilateral selective is CPT 75833.
"The parenthetical statement beneath the definition states, See 3600 to 3612,’ so there are multiple codes between these," Schuler says. "And a technician or coder must decide what procedure was done to warrant one of these code selections."
One challenge is how to deal with modifier -25, which is for determining whether an evaluation and management code should be billed in addition to a procedure, Giddens says.
For example, suppose a patient comes into the emergency room with a cut on the arm that was the result of a kitchen knife wound inflicted during dishwashing. Emergency department (ED) doctors say they had to suture that wound, and an evaluation and management decision was made to conduct a physical exam, Giddens says.
In this case, whether the medical decision-making was a separately identifiable service warranting the -25 modifier is controversial, and documentation would have to support the definition of the modifier, Giddens says.
Just because the service is provided in an emergency setting doesn’t mean the modifier always applies. The definition still needs to be met in the documentation, Giddens explains.
Take a second example: A patient is a diabetic and has lost a lot of blood from a knife wound. ED doctors suture the wound and also do a diabetes work-up on the patient. In this case, the coder would report the level of service code in addition to the modifier -25 for the evaluation and management, Giddens explains.
"So the challenge for coders is they have to rely on physician documentation to make the decision of whether they can bill separately for the level of service or not," Giddens says. "If the doctors didn’t document the diabetes very well, or if they didn’t document what they had assessed for, then they couldn’t bill for the CPT modifier -25 for evaluation and management. It’s all reliant on physician documentation, and that’s subjective from one person to the next, so it’s a struggle on the coders’ part," Giddens says.
Another tricky issue involves casting and strapping, including applying a splint or strapping for fractures, dislocations, and casts used because of broken bones, Giddens says.
There is a series of CPT codes, from 29000 to 29799, that apply to casting and strapping.
CMS committee will address bundling issues
"The issue is whether they bundle these or not," Giddens says. "It’s a point of confusion for a lot of coders, and Medicare is confused about it also."
In fact, CMS has appointed a committee to look into the confusion and to try to figure out when codes will be bundled and when they won’t be, Giddens says.
An example of this is when a patient presents to the emergency department with a nondisplaced fracture of the ulna, distal left. The physician applies a splint. This results in a CPT 29125-LT, which is application of short arm splint on the left arm, Giddens says.
"The application of the short arm splint would be reported in addition to the evaluation and management [E/M] code, meaning the doctors evaluated the patient and provided an additional service," Giddens says.
For Medicare billing, the modifier -25 is suggested because code 29125 is an "S" status indicator. According to Medicare billing instructions, a procedure with an "S" or "T" status indicator, when performed on the same day as an E/M visit, should have a -25 modifier to avoid OCE edit 21, Giddens explains.
Another coding example would involve this scenario: A patient who came in with elbow pain was X-rayed and physicians noted muscle strain. So they applied a sling and gave instructions to the patient. The E/M code is the only thing recorded, Giddens says.
"So the sling bundles into the ER department because it’s not above and beyond and doesn’t require a lot of work," Giddens says.
The coding reported is 99281 to 99285. However, this is not considered a procedure, and because supplies are bundled into the E/M codes and thus cannot be billed separately, the splint cannot be billed separately. However, cast/splint supply items should be reported on the UB92 with a revenue code 27X, Giddens explains.
Chargemasters need to be maintained on a quarterly basis, and coders should be given educational updates at least that often to keep up with the CPT coding changes and the development of new codes by the Centers for Medicare & Medicaid Services (CMS), experts advise.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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