Advance Care Planning

CMS started paying for voluntary Advance Care Planning (ACP) from January 1, 2016.

ACP helps Medicare patients decide the plan of care that they would like to get when they are unable to take such decisions themselves.

Voluntary ACP is a face-to-face service between a physician (or other qualified health care  professional) and a patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document in which a patient appoints an agent and/or records the  wishes of a patient pertaining to their medical treatment at a future time if they cannot decide for themselves at that time.

There are no limits on the number of times you can report ACP for a given patient in a given time period. When billing the service multiple times for a given patient, document the change in the patient's health status and/or wishes regarding their end-of-life care.

There are no place-of-service limitations on ACP services. You can appropriately furnish ACP services in facility and non-facility settings. ACP services are not limited to a 
particular physician specialty.

CMS requires no specific diagnosis to bill the ACP codes.

CPT 99497                
Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first  30 minutes, face-to-face with the patient, family member(s), and/or surrogate

CPT 99498      
Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Retrieved from https://www.medicare.gov/coverage/advance-care-planning.html

For more information refer the following link :  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf

Abdomen X-ray coding in 2018

Abdomen X-ray codes have changed, the old Abdomen X-ray codes 74000, 74020 are being deleted and are being replaced by 74018, 74019 and 74021.

As the new Abdomen X-ray codes are coded based on the number of views, from a documentation compliance standpoint it is imperative for the practice to ensure that the number of views are appropriately documented.

The new Abdomen X-ray codes are,

• 74018 Radiologic examination, abdomen; single view
• 74019 Radiologic examination, abdomen; two views
• 74021 Radiologic examination, abdomen; three or more views

Chest X-ray coding in 2018

Chest X-ray coding has become simpler in 2018, the chest x-ray codes are some of the most frequently used imaging codes in healthcare.

Previously Chest X-ray codes used nine different codes, now these nine codes have been replaced with four codes that are simply determined by the number of views.

As  the new Chest X-ray codes are coded based on the number of views, from a documentation compliance standpoint it is imperative for the practice to ensure that the different types / number of views are appropriately documented.

The new Chest X-ray codes are,

• 71045 Radiologic examination, chest; single view
• 71046 Radiologic examination, chest; 2 views
• 71047 Radiologic examination, chest; 3 views
• 71048 Radiologic examination, chest; 4 or more views

New Patient or Established Patient ?

Who is a New Patient ? When do we bill a New Patient ? When does a Patient become an Established Patient ? These are some of the questions that confuse some practices when billing New/Established patients.

There are instances when a patient is seen by a Physician in the Hospital and in the Office and many Practices are not clear as to how to bill the patient visit. 

Determining whether a Patient visit is to be billed as a New Patient visit or an Established Patient visit has significant implications from a Clinical, Financial, Billing and Coding standpoint.

"A New Patient visit is an evaluation and management service provided to a patient who has not received any face-to-face service from any physician of the same specialty who belongs to the same group practice for at least three years".

Conversely an "Established Patient visit is an evaluation and management service provided to a patient who has already received any face-to-face service from any physician of the same specialty who belongs to the same group practice in the last three years".

An established patient is one who has received professional services from the physician/qualified health care professional or another physician/ qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years - See more at: http://www.aap.org/en-us/professional-resources/practice-support/Coding-at-the-AAP/Pages/New-Vs-Established-Patient.aspx#sthash.O0LGrQSh.dpuf

New Patient visits

1. Patient John Doe comes to see Dr A in his practice after a period of 4 years.

2. Patient John Doe was seen by another physician belonging to a different specialty in the same multispecialty practice, but Patient John comes to see Dr A for the first time.

Established Patient visits

1. Patient John Doe comes to see Dr A in his practice for the first time, Dr A has never seen Patient John before but Dr B another physician in Dr A's practice has seen patient John last year.

2. Patient John Doe was seen by Dr A in the hospital a month ago, he comes to see Dr A in his practice for the first time. Since Dr A has seen patient John within the last 3 years, the office visit becomes an Established visit.

E&M and other Procedures

In a Patient encounter we might perform procedures apart from the regular E&M procedure, in such instances payors would deny the E&M procedure but would pay the additional procedure alone.

Let us take an example of an encounter where a Trigger Point Injection (CPT 20553) is given and an E&M procedure (99213)  is also performed.

The procedure 20553 has an Evaluation component built into its reimbursement, this is the reason why payors may deny the payment for the E&M procedure. So the Payors are right in denying the E&M procedure if the E&M procedure is not distinct and not separately identifiable from the other procedure performed.
 
But We are definitely allowed to bill a Procedure (20553)  and a distinct E&M service (99213) on the same visit, as long as the E&M service is separate and distinct from the procedure, and the same is documented in the progress notes. A distinct E&M service refers to an evaluation where the service is significant and separately identifiable from the other procedure.

An example would be :  

20553        Trigger point Inj                                 
99213 - 25  E&M service for  HTN, DM, CAD   
 
Here the E&M service is separate and distinct from the Procedure 20553, the E&M service needs to be submitted with modifier 25 to indicate that it is separate from the other procedure performed. If the E&M service is submitted without the 25 modifier, it would be denied.

E&M Coding & Documentation Guidelines

It is essential that we code and document every patient encounter accurately so as to maximize revenues and avoid potential audits and recoupments later. It is imperative that we document all procedures that are performed. Any procedure that is not documented would be considered as not performed by the payors.

While coding the E&M codes, we need to be careful in choosing the right level of code. We should choose the right E&M code level based on the Complexity of MDM (Medical decision making that is involved in the evaluation of the patient), once we arrive at the level of code based on the level of medical decision making : MDM, we need to ensure that we have sufficiently  documented the progress note  to support the required level of History and Physical Exam.

For e.g if you see a Patient for f/u in hospital for whom the MDM is moderate then as per MDM which points to level 2, we should code only level 2 CPT 99232 and we need to document a EPF (Expanded problem focused) History and an EPF Exam, this would ensure that we comply with regard to Coding and Documentation
guidelines

Instead for the same patient if we have not adequately documented the progress note, let us assume that we have documented only a PF History and PF Exam and have billed CPT 99232, then we may get paid for CPT 99232, but in case of an audit later, CMS / other payors could recoup the payment for inadequate documentation

Another scenario for the same patient would be wherein,  we have documented more than what is needed, let us assume that we have documented  a Detailed History and a Detailed Exam and have billed  CPT 99233 instead of CPT 99232 as per MDM, then again CMS / other payors may recoup the payment for lack of medical necessity / upcoding.

Hope the above examples give you some idea as to Coding the levels and the documentation required. Please refer the below link for CMS manuals  on Coding and Documentation.   http://www.cms.gov/Outreach-and-Education/Outreach-and-Education.html

Prolonged Services codes CPT 99354 - 99357

Prolonged Services billing is allowed by Medicare in the Office, other Outpatient and Inpatient settings, the Prolonged Service codes are used as add-on codes to E&M codes to indicate the extra time that the Physician has spent face-to-face with the patient.

The Prolonged Service codes are billed based on the length of time spent with the patient beyond the usual time required for the E&M code billed, the time spent with the patient need not be continuous but it must be time spent in one calendar day and must be time spent face-to-face with the patient.

For Office/Outpatient settings :

CPT 99354 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code. Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99355.

For Inpatient settings :

CPT 99356 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code.
Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99357.

Prolonged service cannot be billed when the prolonged service duration is less than 30 minutes as then it would be considered as included in the E&M code billed.

Prolonged services of less than 15 minutes beyond first hour or less than 15 minutes beyond the final 30 minutes cannot be billed.

Total time of Prolonged services	Outpatient	Inpatient
(do not include visit code time)	Prolonged Services Code	Prolonged Services Code
Less than 30 minutes	Not reported	Not reported
30 – 74 minutes	99354	99356
75 – 104 minutes	99354 and 99355	99356 and 99357

As regards the documentation, the documentation needs to be explicit, documentation is required to be in the medical record about the duration and content of  the medically necessary evaluation and management service and prolonged  services that you bill. 

You must sufficiently document in the medical record that you  personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.   The progress note has to have the start and end times of the visit, along with the date of service.

Modifiers 52 & 53

The usage of Modifiers 52 & 53 is very clear and straightforward but still many claims have these modifiers applied incorrectly opening up the possibility of a recoupment later on.

52 Modifier - Reduced Services.

In many instances a procedure or service is reduced at the discretion of  a physician.

We need to apply the 52 modifier to that CPT code, when the physician is performing a reduced procedure rather than the entire procedure, as denoted by the CPT code and when that reduced procedure does not have a specific CPT code for billing. The 52 modifier should not be applied to a CPT code, when the procedure that was planned had to be discontinued / terminated for any reason whatsoever. In these instances we need to use modifier 53 to indicate that the procedure was discontinued.

If the reduced procedure is surgical, the claim needs to submitted with an Operative report and a separate report detailing how the reduced procedure differs from the normal procedure.

For procedures that are non-surgical, a report detailing how the reduced procedure differs from the normal procedure needs to be sent alongwith the claim.

Example :

The provider is planning on performing pure tone audiometry, air only, for a patient on only one ear. There is no CPT code for this test when performed on one ear, while we have CPT code 92552 pure tone audiometry (threshold), air only, for both ears ( bilateral procedure ). 

In this instance since the provider plans to perform the test for one ear only, this becomes a reduced procedure. Hence we need to append modifier 52 to CPT code 92552.

53 Modifier - Discontinued Procedure.

In many instances a surgical or diagnostic procedure may need to be terminated / discontinued due to various reasons.

A procedure that was initiated may need to be terminated / discontinued due to various reasons, in such cases we need to apply Modifier 53 to the CPT code. A procedure may be discontinued / terminated due to various reasons, such as the patient not being able to tolerate the procedure. The 53 modifier basically indicates that the procedure was initiated but not completed.

If the discontinued procedure is surgical then a Operative report needs to be sent alongwith the claim. 

For procedures that are non-surgical, a report detailing how the discontinued procedure differs from the normal procedure needs to be sent alongwith the claim.

The 53 modifier cannot be used, if a Procedure is discontinued by the Physician before administering anesthesia or surgical preparation in the operating room.

Example :

Colonoscopy was initiated on a patient. Polyps were removed by hot biopsy from the descending colon. The provider then attempted to move the colonoscope past the splenic flexure but due to a tortuous colon / blockage the colonoscope could not advance past the splenic flexure. The procedure was hence discontinued.

In this instance the physician had initiated a Colonoscopy by Hot biopsy CPT 45384, but the procedure was discontinued as the colonoscope could not move past the splenic flexure. Hence we need to append mofifier 53 to CPT code 45384.

Hemodialysis & E & M visits

In general when Hemodialysis is billed alongwith an E&M procedure, the Hemodialysis procedure alone is paid while the E&M procedure is denied.

This is because the Hemodialysis procedure has an E&M component built into it and hence the additional E&M procedure is denied. The Evaluation and Management services related to dialysis treatment for ESRD are included in the Dialysis codes and so are not separately reimbursable.

However an E&M can be billed if it is for a separate and distinct service.

For example if a Physician treats a separate and unrelated condition, than the E&M code can be billed with modifier 25, the important point to note is that the documentation should substantiate that the E&M is for a separate and identifiable service apart from the Dialysis procedure on the same day.

Services that are generally included into the Dialysis code are the Physician's evaluation, treatment plan, phone calls, counselling, physician laboratory visits and overall management of the patient.

Annual Wellness Visit

From January 1, 2011 Medicare has initiated the Annual Wellness Visits. Medicare uses the codes  G0438 and G0439 for these wellness visits.

G0438 Initial visit 

Annual wellness visit, consisting of  a personalized prevention plan of service (PPPS), first visit.

G0439 Subsequent visit

Annual Wellness visit, consisting of  a personalized prevention plan of service (PPPS), subsequent visit.

Annual Wellness Visits can be for both new or established patients. The initial AWV, G0438, is used for patients enrolled with Medicare for more than a year.

A patient becomes eligible for their subsequent AWV, G0439, a year after the initial visit. During the first year a patient has enrolled with Medicare the patient is eligible for the Welcome to Medicare visit or IPPE, Initial Preventive Physical Exam. This visit is billed using HCPCS code G0402. The Annual wellness code of G0438 should not be used in this scenario  and will be denied since the patient is eligible for the Welcome to Medicare visit G0402 during the first year.

Initial Annual wellness visit consists of,

– Medical and family history

– List of current  providers

– Height, weight, BMI, BP and other parameters

– Detection of cognitive impairment

– Review risk factors

– Review of functional ability

– Establish a written screening schedule for next 5-10 years

– Establish list of risk factors

– Provide advice and referrals to health education and preventive counseling services

– Other elements as determined by the Secretary of Health and Human Services

The above list is just a summary. Check out http://www.cms.gov/MLNMattersArticles/downloads/MM7079.pdf for additional information and links to other Medicare resources on services that must be provided at the AWV and subsequent AWV.

"Incident to" Services

“Incident to” services are defined as services commonly furnished in a physician’s office, which are “incident to” the professional services of a physician or a Non-Physician Practitioner (NPP) and provided by auxiliary personnel.

"Incident to" is a Medicare billing provision that allows services provided by PAs in an office or clinic setting to be reimbursed at 100 percent of the physician fee schedule by billing using the physician's NPI. The Medicare Benefit Policy Manual defines "incident to," in part, as "services furnished as an integral although incidental part of a physician's personal professional service." This is limited to situations in which there is direct physician/non-physician personal supervision. This applies to auxiliary personnel under the supervision of the physician/non-physician, which includes, but is not limited to, nurses, technicians, therapists, NPPs, etc.

Requirements for “incident to” are:

• The services are commonly furnished in a physician’s office.
• The physician must perform the initial patient visit and ongoing services of a frequency that demonstrate active involvement of the physician in the patient’s care, thereby creating a physician service to which the non physician provider's services relate.
• There is direct personal supervision by the physician of auxiliary personnel, regardless of whether the individual is an employee, leased employee or independent contractor of the physician.
• A physician must be on the premises, but not necessarily in the room, when incident-to services are performed.
• Incident-to services cannot be performed in the hospital.

Direct supervision in the office setting does not mean the physician must be present in the same room with his aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.

Colonoscopy Billing Guidelines

A Colonoscopy is an exam that allows a doctor to closely look at the inside of the entire colon. The doctor is looking for polyps or signs of cancer. Polyps are small growths that over time can become cancer. The doctor uses a thin (about the thickness of a finger), flexible, hollow, lighted tube that has a tiny video camera. This tube is called a colonoscope.

Colonoscopy Codes

CPT Code
Description
45378
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)
45379
Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body
45380
Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
45381
Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance
45382
Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45383
Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45384
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45385
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45378 – Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without collection colon decompression (separate procedure).  Because this code is diagnostic and a separate procedure, it should never be reported with any other colonoscopy code.  Per the CPT manual, when a diagnostic endoscopy is followed by a surgical endoscopy, the diagnostic endoscopy is considered part of the surgical endoscopy and is not to be separately reported.  Only when the provider performs a diagnostic colonoscopy with brushings, washings and/or decompression and nothing else (no biopsies, excisions, etc.) should this code be reported.

45380 – Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple. The physician performs colonoscopy and obtains tissue samples.  This code can only be reported once regardless of the number of biopsies.  According to CPT Assistant, July 2004, this code is also used to describe polypectomy with cold biopsy forceps.  A cold biopsy with forceps is not the same as hot biopsy forceps and it is not a snare technique, therefore codes 45384 and 45385 would not be appropriate.  If the physician does remove a polyp or other lesion with a different technique and then takes a biopsy on a separate lesion, this code may be reported in addition with modifier -59. 

45381 – Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injections(s), any substance. The physician injects a substance into the submucosa, directed at specific areas through the scope while viewing the colon. (E.g. saline, India Ink).  This code is not to be used for injections used to control bleeding.  45381 may be reported in addition to other procedures with modifier -51 or -59. 

45382 – Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g. injections, laser, stapling, plasma coagulator).  This code is used when a physician controls bleeding in the colon due to a condition such as diverticulosis.  This code is not used to report control of bleeding caused by a procedure performed during the same encounter.  For example, there may be small amount of bleeding after a polyp is excised.   This would not be reported because control of bleeding is integral to therapeutic or surgical procedures.  However, if the physician treated a bleeding condition and then removed a polyp at a different location, the services may be reported together with modifier -59. 

45383 – Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amendable to removal by hot biopsy forceps, bipolar cuatery or snare technique.  This code is used when a physician ablates tumors, polyps or other lesions by laser or other method (e.g. fulguration).   

45384 – Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cuatery.  Hot biopsy forceps (also called monopolar cautery forceps) have “jaws” that are between 1 and 2 mm in size and can open up to about 1 cm wide to encompass a small polyp or lesion. The physician then applies cautery to ablate the base of the polyp (or other lesion) so it can be retrieved and sent to pathology for analysis. 

45385 – Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.  Snaring involves “lassoing” a polyp or lesion with a wire loop and shaving it off the bowel wall.  The snare may or may not be heated.  Any snare technique including cold snare, hot snare, and bipolar snare would be reported with this code.  The snare technique is the most often used technique and is best when removing both sessile polyps (those attached by a large base) and pedunculated polyps (those attached by a stalk).

Coding Multiple Procedures

When more than one procedure is performed using the same technique, report only one code.  For example, if the physician removes multiple polyps throughout the colon with snare technique, 45385 can be reported only once. 

However, if multiple polyps or lesions are removed with different techniques, you may report each separately.  For example, a physician removes a polyp with snare technique in the rectum and then biopsies a lesion in the transverse colon, you may report 45385 and 45380-59. 

In the absence of a CCI edit, always list the procedure with the highest RVU first.

Sigmoidoscopy Billing Guidelines

During a Sigmoidoscopy, a doctor closely looks at the lower parts of the colon, called the sigmoid colon and the rectum, for signs of cancer or polyps. Polyps are small growths which can over time become cancer. The doctor uses a thin (about the thickness of a finger), flexible, hollow, lighted tube that has a tiny video camera. This tube is called a sigmoidoscope.

The colon comprises three main parts: the ascending colon, the transverse colon, and the sigmoid colon—sometimes called the descending colon. The sigmoid colon is the last one-third of the colon. Flexible sigmoidoscopy enables the doctor to see only the sigmoid colon, whereas colonoscopy allows the doctor to see the entire colon. 

CPT Code
Description
45330
Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
45331
Sigmoidoscopy, flexible; with biopsy, single or multiple
45332
Sigmoidoscopy, flexible; with removal of foreign body
45333
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45334
Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45335
Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
45337
Sigmoidoscopy, flexible; with decompression of volvulus, any method
45338
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45339
Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45340
Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures
45341
Sigmoidoscopy, flexible; with endoscopic ultrasound examination
45342
Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
45345
Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)

Debridement Coding 2011

 2011 Changes in Debridement Coding

• Surgical wound debridement codes 11040 and 11041 are deleted. Report 97597 and 97598 for debridement of epidermis or dermis
• Debridement is now coded based on depth and diameter
• The debridement codes were modified to provide a method of reporting for the more extensive debridement procedures required for MRSA and other complex wound infections  
• For multiple wounds of the same depth, report the combined sum of the surface area debrided
• For multiple wounds of different depths, report sums of “different depth” debridement procedures
• Use the 59 modifier for different depth wound debridements (11042, 11045 or 11044 at same surgical session)

2011 Debridement Codes

• 11042 – debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less
• 11045 – each additional 20 sq cm, or part thereof (add on code to be listed in addition to code for primary procedure)
• 11043 – debridement, muscle and fascia (includes epidermis and dermis, and subcutaneous tissues, if performed); first 20 sq cm or less
• 11046 – each additional 20 sq cm, or part thereof (add on code to be listed in addition to code for primary procedure)
• 11044 – debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
• 11047 – each additional 20 sq cm, or part thereof (add on code to be listed in addition to code for primary procedure)

Debridement Documentation

Documentation is the key to appropriate code selection. The depth of debridement, manner of debridement, presence of gross contamination and the tissues involved in the debridement or depth of debridement  drive the coding choice.


Debridement procedure notes should include documentaion of the :

• Type of debridement (excisional, non excisional)
• Depth of tissue debrided (skin and subcutaneous, soft tissue, muscle, bone)
• Instrument (s) used to perform the debridement
• Associated diagnosis; if ulcer, document type of ulcer (diabetic, pressure, etc.)
• The nature of the tissue removed ( slough, necrosis, devitalized tissue, non-viable tissue, etc.)
• The appearance and size of the wound