The experts share their favorite coding pearls.
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The experts share their favorite coding pearls.
Regardless of carrier or patient circumstances, to ensure correct coding and optimal reimbursement, you should always follow certain rules. At a recent conference sponsored by The Coding Institute, experts offered the following pointers for successfully coding patient services:
1. Document height, weight, and blood pressure. In doing so, you document the review of systems portion of the history, according to Philip N. Eskew Jr., medical director of infant and women's services at St. Vincent Hospital in Indianapolis.
Recording the patient's height represents a review of the musculoskeletal system, blood pressure indicates a review of the cardiovascular system, and weight a review of the constitutional system, Eskew says. The nurse can take these vital signs and record them in the chart for the physician to review. The physician can then pinpoint possible problems and discuss any unusual weight gain or loss, changes in blood pressure, or loss of height (associated with osteoporosis) with the patient during the face-to-face encounter. Correction
2. Choose the E&M and ICD-9-CM codes yourself. Coders shouldn't have to figure out your intent or guess what care you rendered and what diagnoses determined the need for the service, according to Eskew. A coder or other staff member might easily downcode or upcode E&M visits, resulting in lost revenue or skewed statistics of higher-level visits.
3. Don't confuse consultations with referrals. "Referral" implies that a transfer of care has taken place, and the referring physician is essentially handing the patient's problem to the new physician for further treatment. So don't use the "R" word when a patient is seen on a consultative basis, advises Harry L. Stuber, a gynecologist in Cookeville, TN. In other words, the chart note should not read, "Patient A was referred by Dr. B for evaluation and management of . . . ," Stuber explains. Instead, say "Dr. B has sent patient A for consultation regarding the evaluation and management of . . . ."
For a true referral, Stuber says, the patient's initial visit would be coded as a new-patient E&M service (e.g., 99203, evaluation and management of a new patient . . . ), assuming neither you nor another doctor in your practice had seen the patient within the past three years.
Payers reimburse consultations at a higher rate than new patient visits, Stuber adds. So if the criteria for a consultation are met, the appropriate consultation code should be billed (e.g., 99243, office consultation for a new or established patient . . .) even if a transfer of care takes place following the consultation.
4. Don't confuse modifiers 52 (reduced services) and 53 (discontinued procedure). You should use modifier 52 if a procedure you performed didn't involve all of the components defined by the code reported, or the work you did was less than would be normally expected for the code, Stuber says. The modifier is used because no CPT code accurately describes the work done; instead, an existing code is modified to show that less work was performed.
Use modifier 53 if you started the procedure but didn't finish it because circumstances discovered at the time of surgery made it impossible to complete.
5. Obtain an advance beneficiary notice (ABN) from Medicare patients. "With services Medicare deems 'not medically necessary,' obtaining an ABN can mean the difference between collecting and not collecting," says Wanda Brown, president of ProActive Coding Service in Jacksonville, FL. A typical ABN would include items that Medicare may or may not pay for, Brown says. By signing it, the patient guarantees that she'll pay the bill if Medicare denies the claim.
An ABN needn't include items that Medicare never pays foronly those covered under certain circumstances or subject to carrier discretion, Brown explains. The GA modifier (waiver of liability statement on file) lets Medicare know that you have reason to believe the service might not be covered but that the patient has agreed to pay for it in that case. It allows you to balance bill the patient for the Medicare allowable (or the limiting charge).
What if you expect Medicare to deem a service medically unnecessary and deny payment, but the patient can'tor won'tsign an ABN? CMS says you can then append GZ (item or service expected to be denied as not reasonable and necessary), a new modifier that Medicare added in 2002, essentially to signify that an ABN isn't on file. But this doesn't necessarily mean you'll be able to collect from the patient, CMS cautions. If there's no ABN on file, the carrier may instruct the patient not to pay you unless you provide extenuating documentation.
6. Use "Incident to" coding only with Medicare. This elementary rule can make a big difference in how practices use their nonphysician practitioners, says Melanie Witt, a coding educator from Fredericksburg, VA. Medicare's "incident to" rule requires that a physician be present in the office suite when a nonphysician practitioner is treating patients. The rule also stipulates that the supervising physician must initiate the treatment, so the NP or PA cannot see new patients.
However, private payers have their own rules, Witt cautions. Many allow nonphysician practitioners to treat new patients, and some even allow them to be the supervising provider in the office. Knowing each carrier's rules for nonphysician practitioner billing can prevent having to repay claims after an audit if the rules aren't followed, she notes.
This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Rd. South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.
Coding Consult: Six top coding tips. Medical Economics 2002;21:18.