Understanding modifier 57.
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Tag Archives: Understanding
Update Your Understanding of EEG Coding
2020 code changes for electroencephalograph (EEG) recording.
The post Update Your Understanding of EEG Coding appeared first on AAPC Knowledge Center.
Fortify Your Understanding of Medical Necessity
The quality of evaluation and management documentation is paramount for clinician reimbursement. Evaluation and management (E/M) services are the most vulnerable to billing errors because it is complicated to select the proper code for the level of service captured in the documentation. A firm grasp of the differences between medical decision making (MDM) and medical […]
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Update Your Understanding of Shoulder Arthroscopy Codes
Anatomy is important when applying bundling rules to procedures. The shoulder is a complex joint, and proper coding for shoulder procedures requires a strong foundation of knowledge in anatomy and physiology. Shoulder arthroscopy codes particularly can be confusing as the guidelines for arthroscopic shoulder surgeries have changed considerably in the last decade. Here are some […]
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Refresh Your Understanding of Date of Service Requirements
CMS’ latest guidance reiteration will, hopefully, make coding these sometimes-confusing services easier. Determining the date of service (DOS) when reporting a medical claim seems straightforward, but the Centers for Medicare & Medicaid Services (CMS) recently-released “Guidance on Coding and Billing Date of Service on Professional Claims,” is a good indication this topic is more complex […]
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Understanding The Valuation Changes In The Final Medicare Fee Schedule For 2019
Our review of the proposed 2019 Medicare Physician Fee Schedule (MPFS) showed that 201 Professional Component (PC) codes and 213 Global codes were to be decreased by at least 1% in the Diagnostic Radiology 70000-series of CPT codes. In the final MPFS, only 46 PC codes were reduced by 1% or more, but 280 global codes were reduced by at least 1%. The number of codes expected to increase in payment did not change as dramatically, but in both PC and Global billing fewer codes were increased than we expected. Here are the details:
Ask the expert: Understanding nuances of patient status and therapeutic services
Ask the expert
Understanding nuances of patient status and therapeutic services
Learning objective
At the completion of this educational activity, the learner will be able to:
- Identify strategies to comply with condition code 44 and the Medicare Outpatient Observation Notice (MOON), and understand rules related to some aspects of therapeutic services.
Assigning the correct patient status is a constant challenge for hospitals and the case managers who are charged with ensuring these decisions are accurate. CMM often gets questions from readers on related topics and we forward them to our experts to get the answers. This month’s questions were answered by Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago.
Q: If a Medicare patient is downgraded from inpatient to observation is it expected that the patient will be issued the MOON and condition code 44 will be used on the claim?
A: First, it must be noted that all patients who are downgraded using the condition code 44 process are being downgraded from inpatient status to outpatient status. If the patient then needs continuing hospital care (i.e., is not ready to be discharged), then observation can also be ordered. If observation is needed and is ordered, the MOON will be required only if the patient receives observation for 24 or more hours from the time of this order for observation services.
Q: I have a question about how to interpret the CMS Standard Operating Procedures. If a requisition/order for physical therapy treatment is received at a hospital facility and is not authenticated (e.g., signed, timed, dated) by a community physician who is not credentialed at the hospital, is it true that facility can begin treatment but the order must be authenticated when it will be filed in the record?
A: Therapy services (e.g., physical, occupational, speech-language pathology) are unique in that an actual order from a physician or non-physician practitioner is not required (see the Medicare Benefit Policy Manual, Chapter 15, Section 220.1, at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf). The following is required:
- The patient must be under the care of a physician
- The therapy must be provided under a plan of care
- The physician must certify that plan of care by way of signature and date
In this case, the therapy provider may develop a plan of care and forward it to the physician for certification. Treatment may begin while awaiting the return of the signed plan of care. But the organization staff should do their best to get the signed certification returned within 30 days of start of therapy services.
Because the physician is not on the medical staff, the therapy provider may want to confirm that the physician is enrolled with Medicare and therefore eligible to order and certify services on Medicare recipients.
Got a question on any case management topic that you’d like to ask our experts? Email it to Kelly Bilodeau at [email protected].
Bonus question
Q: What do you do with a patient who does not have a safe discharge plan, but does not meet inpatient criteria and has been in observation status for 48 hours?
A: The original instruction from CMS that still stands is that we give the patient an advance beneficiary notice that says his or her care in the hospital setting is no longer medically necessary and is not being billed to Medicare and that he or she will be financially responsible.
Sample form: Boost documentation improvement efforts as a team
Case management and clinical documentation improvement (CDI) specialists share a common goal: improving documentation, which is critical to quality care.
But all too often the two groups are working separately to achieve it. "Everyone is operating in a silo," says Glenn Krauss Glenn Krauss, BBA, RHIA, CCS, CCS-P, PCS, FCS, CPUR, C-CDI, CCDS, director of enterprise solutions at ZirMed in Chicago. To help the two groups work together more effectively, Krauss decided to develop a quick and easy reference guide that can be used to help foster collaboration.
"I put this form together based on my experience with denials and from reviewing denials for medical necessity," he says. "My goal was to create a document that educates CDI and case management so they can work together, collaboratively."
Working together as a team, CDI and case management can ensure that the patient moves along the continuum of care smoothly and is treated in the right setting at the right time for the right reasons. They can also ensure the proper terminology is in the report to ensure accurate payment.
The form below describes some of the most common documentation lapses, so CDI and case management can work together to address them.
"If you don’t have good processes in place to work together you may have the best value-based care in the hospital, but there is no real value if you don’t get paid," says Krauss.
Understanding Coding of Hypertension in Pregnancy
Understanding Coding of Hypertension in Pregnancy
Saturday, June 23, 2018
Hypertension in pregnancy still remains as one of the most misunderstood complications of pregnancy, in addition to the incorrect usage of the ICD-10 diagnosis codes that go with it. ICD-10cm has a specific block of codes allocated to Pregnancy and hypertension, that should be used with all pregnancy coding. These codes denote a pre-existing hypertention and then the gestational or pregnancy-induced hypertension.
ICD-10cm Code block Group
· O10 Pre-existing hypertension complicating pregnancy, childbirth and the puerperium
· O11 Pre-existing hypertension with pre-eclampsia
· O12 Gestational [pregnancy-induced] edema and proteinuria without hypertension
· O13 Gestational [pregnancy-induced] hypertension without significant proteinuria
· O14 Pre-eclampsia
· O15 Eclampsia
· O16 Unspecified maternal hypertension
As you can see from the list above, there are numerous codes to choose from. As coders, we rely on our physicians to give us good clinical documentation within the pregnancy record, so we can code and bill appropriately for their services. As in the case of a pregnancy that the OB is supervising, the added diagnosis of Hypertension in pregnancy brings added risk factors to that pregnancy oversight. We also need to add ICD-10cm code for a high risk pregnancy due to hypertension. The pregnancy supervision code for high risk pregnancy will be coded as the primary code based upon the ICD-10cm guidelines. ICD-10cm coding guidelines for high-risk pregnancy changed in 2017. The current rule from the 2018 ICD-10-CM Official Guidelines for Coding and Reporting (effective Oct 1, 2017 – Sept 30, 2018) is below:
Supervision of High-Risk Pregnancy (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 58 of 117) Codes from category O09, Supervision of high-risk pregnancy, are intended for use only during the prenatal period. For complications during the labor or delivery episode as a result of a high-risk pregnancy, assign the applicable complication codes from Chapter 15. If there are no complications during the labor or delivery episode, assign code O80, Encounter for full-term uncomplicated delivery.
For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category O09, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis..
The high risk supervision codes noted below, do not have a category specifically for oversight of hypertension in pregnancy, however this is something that we need to have coded for our diagnoses. If we are going to add a high risk pregnancy diagnosis to our record, the code choice of O09.89 would the best choice, as the hypertension in pregnancy is in the “other high risk” category and our provided has specified it as such.
O09 Supervision of high risk pregnancy
· O09.0 Supervision of pregnancy with history of infertility
· O09.1 Supervision of pregnancy with history of ectopic pregnancy
· O09.A Supervision of pregnancy with history of molar pregnancy
· O09.2 Supervision of pregnancy with other poor reproductive or obstetric history
o O09.21 Supervision of pregnancy with history of pre-term labor
· O09.3 Supervision of pregnancy with insufficient antenatal care
· O09.4 Supervision of pregnancy with grand multiparity
· O09.5 Supervision of elderly primigravida and multigravida
o O09.51 Supervision of elderly primigravida
o O09.52 Supervision of elderly multigravida
· O09.6 Supervision of young primigravida and multigravida
o O09.61 Supervision of young primigravida
o O09.62 Supervision of young multigravida
· O09.7 Supervision of high risk pregnancy due to social problems
· O09.8 Supervision of other high risk pregnancies
o O09.81 Supervision of pregnancy resulting from assisted reproductive technology
o O09.82 Supervision of pregnancy with history of in utero procedure during previous pregnancy
o O09.89 Supervision of other high risk pregnancies
· O09.9 Supervision of high risk pregnancy, unspecified
In some cases, the high blood pressure diagnosis is present prior to the pregnancy, however, the patient can develop high blood pressure during pregnancy, which would then be noted as gestational hypertension.
Ø Chronic hypertension is high blood pressure that was present before pregnancy or that occurs before 20 weeks of pregnancy. But because high blood pressure usually doesn’t have symptoms, the provider may be reluctant to state this as a chronic condition, as this may or may not have been noted as a diagnosis for the patient by a previous provider or prior to the pregnancy.
Ø Chronic hypertension with superimposed preeclampsia is condition that can also occur in women with chronic hypertension before pregnancy who develop worsening high blood pressure and protein in the urine or other blood pressure related complications during pregnancy.
Ø Gestational hypertension is the patient noted in the record to have high blood pressure that develops after 20 weeks of pregnancy. Normally there is no excess protein noted in the urine or other signs of organ damage however, some women with gestational hypertension may develop preeclampsia.
Ø Preeclampsia occurs when hypertension develops after 20 weeks of pregnancy, and is associated with signs of damage to other organ systems, including the kidneys, liver, blood and/or brain. Untreated preeclampsia can lead to serious complications for mother and baby, including development of seizures which then the diagnosis becomes eclampsia.
o Previously, preeclampsia was clinically diagnosed only if a pregnant woman had high blood pressure and protein in her urine. However, it has been noted that it’s possible for the patient to have preeclampsia without having protein in the urine.
Ø Eclampsia is the onset of seizures (convulsions) in a woman with pre-eclampsia. The onset may be before, during, or after delivery, but it can be diagnosed and treated during the second trimester in the pregnancy.
o The seizures are usually the tonic–clonic type and typically last between 30 and 60 seconds. Complications of eclampsia include aspiration pneumonia, cerebral hemorrhage, kidney failure, and cardiac arrest
Ø HELLP Syndrome is another variant of pre-eclampsia and/or eclampsia as a known pregnancy complication. HELLP syndrome is characterized as hemolysis, elevated liver enzymes, and low platelet count. HELLP syndrome can be fatal to both the mother and the fetus.
The clinical documentation of consistent pregnancy blood pressure is an important part of the patients’ prenatal care. The list below designates the levels at which the blood pressures should be noted. As a coder, if you are not seeing these designations, you will want to query the provider and ensure if the patient has a true “hypertension” or simply an elevated blood pressure. This will make a difference in your code choice. This will also determine if the ob visit should be considered part of the prenatal care/OB package, or if it should be billed as a separately identifiable visit outside of the prenatal care/OB package.
o Elevated blood pressure: Elevated blood pressure is a systolic pressure ranging from 120 to 129 millimeters of mercury (mm Hg) and a diastolic pressure below 80 mm Hg. Elevated blood pressure tends to get worse over time unless steps are taken to control blood pressure.
o Stage 1 hypertension: Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.
o Stage 2 hypertension: More severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.
NOTE: After 20 weeks of pregnancy, blood pressures that exceeds 140/90 mm HG — documented on two or more occasions within the prenatal record, that are at least four hours apart, without any other organ damage — is considered to be gestational hypertension.
As we look to the ICD-10cm coding guidelines, the pre-existing condition (such as hypertension) should be considered carefully.
Pre-existing conditions versus conditions due to the pregnancy (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 59 of 117)
Certain categories in Chapter 15 distinguish between conditions of the mother that existed prior to pregnancy (pre-existing) and those that are a direct result of pregnancy. When assigning codes from Chapter 15, it is important to assess if a condition was pre-existing prior to pregnancy or developed during or due to the pregnancy in order to assign the correct code.
Categories that do not distinguish between pre-existing and pregnancy-related conditions may be used for either. It is acceptable to use codes specifically for the puerperium with codes complicating pregnancy and childbirth if a condition arises postpartum during the delivery encounter.
The ICD-10cm guidelines also go on to say that the “O” codes that have been set forth for hypertension in pregnancy also include the codes for hypertensive chronic kidney disease. If this is the case we are then to assign not only the appropriate O10 code, but also add an additional code from the appropriate hypertension category from ICD_10cm Chapter 9: Diseases of the Circulatory System (I00-I99) and specify the type of heart failure or CKD.
Pre-existing hypertension in pregnancy (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 60 of 117)
Category O10, Pre-existing hypertension complicating pregnancy, childbirth and the puerperium, includes codes for hypertensive heart and hypertensive chronic kidney disease. When assigning one of the O10 codes that includes hypertensive heart disease or hypertensive chronic kidney disease, it is necessary to add a secondary code from the appropriate hypertension category to specify the type of heart failure or chronic kidney disease. See Section I.C.9. Hypertension
Office Coding Scenario – Admission to L&D:
Patient is a 32 year old who has come in at the request of our Triage RN status post patient call 1 hr ago. Pt is G2 and P1 at 35 and 3/7 weeks with gestational hypertension stable on labeletol. Pt arrived 20 minutes ago and is now complaining of a severe headache, leg swelling, blurred vision, abdominal pains, and a BP of 170/102. She notes baby is moving well, but is having contractions. Her husband is present with her and is very supportive, but concerned. Sarah has a history of mild pre-eclampsia with her first child who delivered vaginally 2 years ago. She is allergic to PCN with a bad rash noted 4 years ago. Her Blood pressure in the clinic 2 days ago was 140/85.. She was not started on any new medications, nor any changes to her current Labeletal dose, but was put on bedrest. She continues to complain of a severe headache. She is oriented x3, but somewhat sleepy. She has pitting edema bilaterally at a 3+ She has also complained of some mild nausea with no vomiting at this point. No complaints of shortness of breath. Lungs are still clear. She continues to complain of upper abdominal pain. Her urine dip indicated some mild 2+ proteinuria. Her most recent vital signs are BP158/98, P98 R14, T98.6 . She has current symptoms of severe pre-eclampsia, with pre-term labor and trending toward eclampsia. At this time, I will send orders for direct admission to L&D Observation for continued surveillance of severe pre-eclampsia. Patient directed to L&D. I will follow with patient at evening rounds.
Coding Considerations:
ICD-10 cm Diagnosis:
O09.89 Supervision of other high risk pregnancies
O14.13 Severe pre-eclampsia third trimester
O60.03 Preterm labor without delivery
Z3A.37 37 weeks gestation of pregnancy
O60.03 Preterm labor without delivery
Z3A.37 37 weeks gestation of pregnancy
According to the CPT Maternity Care and Delivery guidelines that are noted at the beginning of the maternity care section within the CPT book it clearly states
“Medical complications of pregnancy; (eg cardiac problems, neurological problems, diabetes, hypertension, toxemia, hyperemesis, preterm labor, premature rupture of membranes,trauma) and medical problems complicating labor and delivery management may require additional resources and may be reported separately.”
Billing/Reimbursement Issues
Some 3rdparty payers may consider the above scenario of care as part of the OB package of care, and not reimburse for the admission to observation as a separately identifiable service outside of the OB package. If that is the case, CPT does allow for this and you should code, bill and subsequently appeal for your appropriate payment of such.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at [email protected] or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.
Refresh Your Understanding of Basic Health Insurances
Better equip yourself to answer patient questions and secure patient cost-sharing. Nothing stays the same for long in this industry, so even if you are a seasoned healthcare business professional, you may not know all types of insurances and plans available, and how they work. A quick review will assist you in correctly coding, billing, […]
AAPC Knowledge Center
ED coders – need help understanding IVs
Hi – I’m a CPC but currently my job isn’t in ED coding. I’m just making sure nurses/doctors are documenting all supplies used and they are hitting the billing system. We have a charge for an IV Cath, but I’m not really understanding when those are used or when to charge for them. I don’t think it’s something that’s necessarily documented in a chart. Are they used any time medications or fluids are pushed? Infusions as well? Just trying to get somewhat of a rundown of components of IVs – and what equipment is used when. any help is appreciated!