Read Microsoft PowerPoint - 2009 Surgical Coding, Etc - Napa PI text version

2009 Surgical Coding, Etc.

Presented by Harry Goldsmith, DPM

WHAT'S NEW IN 2009?

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Victory!

CIGNA Reverses its Policy on 1st Metatarsal-Phalangeal Implant Arthroplasty

Victory!

DME Accreditation ­ Physicians Exempt

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Victory!

Surety Bond ­ Physicians Exempt

What's New?

· 1.1% raise for 2009 · ...but for 2010, as of now, there is a 20+% Medicare decrease in fees across the board

New 2009 CPT Codes

CPT 64455 ­ Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (e.g., Morton's neuroma) CPT 64632 ­ Destruction by neurolytic agent; plantar common digital nerve

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New 2009 ICD-9 Codes

· 038.12* · 041.12* · 078.12 · 249.00 · 249.01 Methicillin resistant Staphylococcus aureus septicemia Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site Plantar wart Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified Secondary diabetes mellitus without mention of complication, uncontrolled

New 2009 ICD-9 Codes

· 249.10 Secondary diabetes mellitus with ketoacidosis, not stated as uncontrolled, or unspecified Secondary diabetes mellitus with ketoacidosis, uncontrolled Secondary diabetes mellitus with hyperosmolarity, not stated as uncontrolled, or unspecified Secondary diabetes mellitus with hyperosmolarity, uncontrolled

· 249.11 · 249.20

· 249.21

New 2009 ICD-9 Codes

· 249.30 · 249.31 · 249.31 · 249.40 · 249.41 Secondary diabetes mellitus with other coma, not stated as uncontrolled, or unspecified Secondary diabetes mellitus with other coma, uncontrolled Secondary diabetes mellitus with other coma, uncontrolled Secondary diabetes mellitus with renal manifestations, not stated as uncontrolled, or unspecified Secondary diabetes mellitus with renal manifestations, uncontrolled

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New 2009 ICD-9 Codes

· 249.50 · 249.51 · 249.60 · 249.61 · 249.70 Secondary diabetes mellitus with ophthalmic manifestations, not stated as uncontrolled, or unspecified Secondary diabetes mellitus with ophthalmic manifestations, uncontrolled Secondary diabetes mellitus with neurological manifestations, not stated as uncontrolled, or unspecified Secondary diabetes mellitus with neurological manifestations, uncontrolled Secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled, or unspecified

New 2009 ICD-9 Codes

· 249.71 · 249.80 · 249.81 · 249.90 Secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled Secondary diabetes mellitus with other specified manifestations, not stated as uncontrolled, or unspecified Secondary diabetes mellitus with other specified manifestations, uncontrolled Secondary diabetes mellitus with unspecified complication, not stated as uncontrolled, or unspecified Secondary diabetes mellitus with unspecified complication, uncontrolled

· 249.91

New 2009 ICD-9 Codes

· · · · · · · 707.20 707.21 707.22 707.23 707.24 707.25* 729.90 Pressure ulcer, unspecified stage Pressure ulcer, stage I Pressure ulcer, stage II Pressure ulcer, stage III Pressure ulcer, stage IV Pressure ulcer, unstageable Disorders of soft tissue, unspecified

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New 2009 ICD-9 Codes

· 729.92 · 729.99 · V02.53* · V02.54* · V12.04* Nontraumatic hematoma of soft tissue Other disorders of soft tissue Carrier or suspected carrier of Methicillin susceptible Staphylococcus aureus Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus Personal history of Methicillin resistant Staphylococcus aureus

New 2009 ICD-9 Codes

· V13.51 · V13.52 · V13.59 · V15.51 · V15.59 · V46.3 Personal history of pathologic fracture Personal history of stress fracture Personal history of other musculoskeletal disorders Personal history of traumatic fracture Personal history of other injury Wheelchair dependence

New 2009 HCPCS Codes

· Apligraf Q4101 · Oasis Q4102 · Oasis Burn Q4103 · Integra Wound Q4104 · Integra DRT Q4105 · Dermagraft Q4106 · GraftJacket Q4107 · Integra Q4108 · Tissuemend Q4109 · Primatrix Q4110 · Gammagraft Q4111

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What About ICD-10 Codes?

October 1, 2013 ­ 4+ years to get ready

ICD-10-CM Codes

· Codes are 3-5 digits in length, up to 13,000 · ICD-10-CM codes are 3-7 characters in length, total up to 68,000

ICD-10-CM Codes

This transition will require · significant planning, training, software/system upgrades/replacements · investments for health care payers, clearinghouses, software vendors, physicians and other health care professionals.

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New ABN

· ABN ­ advance beneficiary notice ­ applies to the Medicare fee-for-service program · Revised ABN title is actually, "Advance Beneficiary Notice of Noncoverage" (CMS-R131) · While it went into effect March 3, 2008, it wasn't until March 1, 2009 that it became mandatory · Available at www.cms.hhs.gov/bni

New ABN

· Available in English and Spanish · Has a mandatory field for cost estimates of the items/services at issue · IMPORTANT: Includes a new beneficiary option, under which an individual may choose to receive an item/service, and pay for it out ­of-pocket, rather than have a claim submitted to Medicare

New ABN

· If you submit a claim to Medicare, you still need to append a "GA" modifier · May also be used for voluntary notifications

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Old

New

New ABN

New ABN

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New ABN

Webinars

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Webinars ­ APMA Members

Go to the APMA site, log on · Click on Practice Management tab · Click on Practice Resources tab · Choose a webinar to listen to or watch

http://members.apma.org/Members/PracticeManagement/PracticeReso urces/Webinars.aspx

Coding Clinic, Controversies, Etc.

Statement of Fact

Just because you got paid... ...doesn't mean you billed it right ...or that the payer won't eventually wake up

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Statement of Fact

Just because a CPT or HCPCS code exists on Earth, it doesn't mean you should use it or expect to be paid for using it

Diagnosis

Inflammation of the Blue Cross

YOU BE THE JUDGE

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Surgery:

Matrixectomy with subungual exostectomy, right hallux

Procedures:

­ CPT 11730 (nail avulsion) ­ CPT 28124 (exostectomy dist phal) ­ HCPCS A4550 (sterile tray)

Services:

­ CPT 99218 (initial observation) ­ CPT 93790 (BP monitoring) ­ CPT 95955 (EEG) ­ CPT 90788 (IM injection antibiotic) ­ CPT 64450 (peripheral nerve block) ­ CPT 64450 (periph nerve block #2) ­ CPT 20500 (inject sinus tract)

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Procedures:

­ CPT 28126 (condylectomy dist phal) ­ CPT 11762 (reconstruc. nail bed/graft ­ CPT 11765 (wedge resection skin) ­ CPT 11755 (biopsy nail unit) ­ CPT 11755 (biopsy nail unit #2) ­ CPT 11740 (evacuation hematoma) ­ CPT 11760 (repair nail bed)

Procedures:

­ CPT 14000 (adjac tissue transf, trunk) ­ CPT 15740 (flap, island pedicle) ­ CPT G0168 (wound closure adhesive)

Services:

­ CPT 99373 (telephone call, complex) ­ CPT 88300-26 (path, gross prof) ­ CPT 88300-TC (path, gross TC)

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SO, WHAT WAS THE TOTAL BILLED FOR THE SURGERY?

$1,452.00? - nope -

$6,112.00? - nope -

$13,480.00

Other Billings:

­ CPT 99204 ­ CPT 99275 (confirmatory consult. compr) ­ CPT 99218 (initial observation) ­ CPT 99214 ­ CPT 99373 x 3 post op ­ HCPCS G0168 (adhesive closure) x3 ­ CPT 15852 (dressing change anesth.) ­ CPT 13160 (secondary closure,

dehiscence, extensive)

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Disclaimer

Not everything I say is true...for all payers...in all cases...

"Mrs. Jones, you're going to love your new shoes, I guarantee it."

Documentation

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WOUND: DOCUMENTATION

WOUND: DOCUMENTATION

WOUND: DOCUMENTATION

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Electronic Medical Records

FORMS

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PODIATRY INSTITUTE

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Consultations

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So, What the Hell is a Consultation?

· First and foremost, it is a request for an opinion from a physician (or other appropriate source) · It involves written communication from specialist to referral doc · Treatment may follow completion of the consultation

Consultation

What's Wrong with this Consultation Picture?

· Speaking to your patient about an upcoming surgery or procedure or problem is not a consultation if it involves you and the patient/family only · Patients cannot initiate a consultation

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What's Wrong with this Consultation Picture?

· It isn't a consultation if the referring doctor could care less about your opinion · It isn't a consultation if the referring doctor tells you what to do ("trim the nails")

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New Patient?

I was asked to see a patient new to me in the hospital and perform a consultation. When the patient comes to my office for the first time, can I bill a "new patient" E/M since this is the first time I am seeing the patient in my office?

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Next...

E/M + PROCEDURE

· If it's a "significant, separately identified E/M service, it should be allowed · The diagnosis does not have to be different · Circumstances can dictate reasonableness: new patient, new problem, failed treatment with new workup, or change of treatment determination

Chief Complaint - HPI

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Past Med History ­ Fam History

Inflammation Specific ROS

Review of Systems Intake

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General ROS

Physical Exam - General

Ingrown Nail Specific Exam

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Imaging Studies Performed

Assessment

Treatment A

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Treatment M

Additional Therapy

Biomechanical Examination

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Gait Evaluation

Gait Evaluation

Surgical Coding

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Global Concepts

How many global days are assigned to CPT 28285 (hammertoe correction)?

Global Surgical Guidelines

Global Surgical Guidelines

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Global Surgical Guidelines

Global Surgical Guidelines

Next...

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Unlisted Codes

CPT 17999 - Unlisted procedure, skin, mucous membrane and subcutaneous tissue CPT 27899 - Unlisted procedure, leg or ankle CPT 28899 - Unlisted procedure, foot or toes

Unlisted Codes

CPT 64999 - Unlisted procedure, nervous system CPT 95999 - Unlisted neurological or neuromuscular diagnostic procedure CPT 97139 - Unlisted therapeutic procedure (specify)

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Myth: I&D of Paronychia

If I resect a portion of nail to treat a paronychia, can I bill CPT 10060? Well... To bill CPT 10060, you've got to have an abscess (collection of pus)

Controversy: CPT 10061

"Exactly how do you define a `complicated' toe abscess?"

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Excision of Benign & Malignant Lesions

CPT 11420 ­ 11426 (benign) CPT 11620 ­ 11626 (malignant)

0.2 cm each

2 cm

2 cm + 0.2 cm + 0.2 cm = 2.4 cm

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Excision of Benign & Malignant Lesions

"....Attention was directed to the plantar aspect of the right foot. A solitary lesion measuring 0.75 cm in diameter was identified..." "...Two semielliptical incisions were made on either side of the lesion, including not only the lesion in toto, but also 3 mm of skin margin on either side..."

Next...

Skin Substitutes

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New

Product

Misc. Apligraf Oasis Wound Oasis Burn Integra Wound Integra DRT DERMAGRAFT Graft Jacket Integra Tissuemend Primatrix Gammagraft Cymetra Allograft Graft Jacket Express Integra Flowable Wound Matrix

Codes

2008 Code

For 2009 For Advanced Engineered Products

Descriptor

2009 Code

Q4100 Q4101 Q4102 Q4103 Q4104 Q4105 Q4106 Q4107 Q4108 Q4109 Q4110 Q4111 Q4112 Q4113

n/a J 7340 J 7341 J 7341 J 7347 n/a J 7342 J 7344 J 7347 J 7348 J 7349 J 3590 N/A J7346

SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED SKIN SUBSTITUTE, APLIGRAF, PER SQ CM SKIN SUBSTITUTE, OASIS WOUND MATRIX, PER SQ CM SKIN SUBSTITUTE, OASIS BURN MATRIX, PER SQUARE CENTIMETER SKIN SUBSTITUTE, INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER SQ CM SKIN SUBSTITUTE, INTEGRA DERMAL REGENERATION TEMPLATE (DRT), PER SQ CM SKIN SUBSTITUTE, DERMAGRAFT, PER SQ CM SKIN SUBSTITUTE, GRAFTJACKET, PER SQ CM SKIN SUBSTITUTE, INTEGRA MATRIX, PER SQ CM SKIN SUBSTITUTE, TISSUEMEND, PER SQ CM SKIN SUBSTITUTE, GRAFTJACKET, PER SQ CM SKIN SUBSTITUTE, GammaGraft, PER SQ CM ALLOGRAFT, CYMETRA, INJECTABLE, 1CC ALLOGRAFT, GRAFTJACKET EXPRESS, INJECTABLE, 1CC

Q4114

N/A

ALLOGRAFT, INTEGRA FLOWABLE WOUND MATRIX, INJECTABLE, 1CC

New Modifiers For Skin Substitutes

"JC" - Skin substitute used as a graft "JD" - Skin substitute not used as a graft "JW" - Unused portion of single dose drug or biological

Next...

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Wound Care

· Describe size, depth, drainage, base, undermining, bone exposed, cellulitis,etc · Document what tissue is debrided not just the depth of the wound · Debridement vs E/M­ hyperkeratotic rim care only? ­ decreasing complexity? Reflected in E/M level

Wound Care

· If condition worsening: E/M level reflects this · Can also bill other procedures such as debridement · Coordination of care with other specialists, lab tests, medications, etc

Wound Care

· Nationwide: limitations in frequency · DME supplies · Cam walker and post-op shoes not allowed for ulcer care, use ABN for cam walker, none required for post-op shoe

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Next...

Abscess Post Wart Destruction

A patient came in for debridement and chemical treatment of a wart. I billed CPT 17110 (destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions). The patient returned within the 10 day global period with an abscess in the same area of the treated wart. Can I bill incision and drainage of abscess - CPT 10060 with a modifier, or is this considered global and related to original treatment?

Next...

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Two-for-One Sale

CPT 20550 - Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia") CPT 20612 - Aspiration and/or injection of ganglion cyst(s) any location

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Achilles Insertional Calcific Tendinosis

I had a patient with a bony prominence at the posterior superior aspect of the calcaneus as well as an intraAchilles tendon calcification at its insertion. I resected the bony prominence, as well as split the Achilles to remove the bone within it. I repaired the Achilles and anchored it back down. How do I bill this?

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Achilles Insertional Calcific Tendinosis

...and you may want to add a "-22" modifier...

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Dislocation

I have a patient with a hammertoe which she says has been present for years. Can I bill the MTPJ release as an open treatment of dislocation?

No

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Hammertoe Coding

CPT 28285

Hammertoe Global Components

· · · · · Exostectomy, partial Digital tenotomies IPJ capsulotomies Tendon transfer (digit) IPJ implant

Next...

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Floatin' Toe Diagnosis Code

I recently saw a patient who had hammertoe deformities on the second and third toes bilaterally "corrected." The result left the digits unstable and "floating." I plan on surgically repairing the instability (as best I can), and was wondering what the diagnosis code would be for the condition presented by the patient?

Floatin' Toe Diagnosis Code

ICD-9 718.87 (instability of joint, foot) ICD-9 735.9 (toe deformity, unspecified) ICD-9 998.9 (post-operative complication, unspecified, not elsewhere class

Next...

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Scarf Bunionectomy

How do you code a scarf-type bunionectomy?

CPT 28296

Bunion Coding

How do you bill a McBride-type bunionectomy with a closing base-wedge osteotomy? CPT 28292 CPT 28306-59

Bunion Coding

How do you bill a McBride-type bunionectomy with a opening base-wedge osteotomy with an autograft? CPT 28292 CPT 28307-59

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Bunion Coding

How do you bill a McBride-type bunionectomy with a opening base-wedge osteotomy with an allograft? CPT 28292 CPT 28306-59

Bunion Coding

How do you bill an Austin-type bunionectomy with fusion of the first metatarsal-medial cuneiform joint? CPT 28740 CPT 28296-59 or CPT 28297 CPT 28306-59

(23.65 RVUs)

(21.97 RVUs)

Bunion Coding

How do you bill a Lapidus-type bunionectomy with an osteotomy of the proximal hallux phalanx? CPT 28740 CPT 28298-59 or CPT 28297 CPT 28310-59

(23.32 RVUs)

(21.02 RVUs)

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Next...

Coding Scenario

How would you recommend coding the following scenario (left foot): 1. modified McBride bunionectomy 2. Aiken osteotomy 3. plantar condylectomy 2nd metatarsal head 4. plantar condylectomy 5th metatarsal head 5. ostectomy to the hallux interphalangeal joint 6. arthroplasty 2nd digit

Next...

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Coding with Implants

· · · · CPT 28293 for 1st MPJ implant CPT 28899 (unlisted) for lesser MPJ implant CPT 28285 for inter-digital implant CPT 28899 for subtalar arthroereisis implant

Next...

Pearl: CPT 28313

Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes) · No bone of contention 5th digit correction · Hallux varus · Abducted or adducted digit at MTPJ

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Pearl: CPT 28313

Oh, by the way...

Next...

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Fracture Coding

When treating fractures, what are the rules governing the use of the fracture management codes? Can I just bill E/M codes, and bill for x-rays, cast application, supplies, etc.?

Fracture Coding

CPT states that if a code exists that accurately reflects the procedure or service performed, you must bill that code

Fracture Coding

Ms. Jones has a non-displaced closed fracture of the base of the 5th metatarsal

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Fracture Coding - Initial

Global Fracture Code Use

· · · · · Initial fracture E/M X-rays Global Fracture Code Cast supplies Cast shoe

"A La Carte" E/M+ Coding

· · · · · Initial fracture E/M X-rays Application of initial cast Cast supplies Cast shoe

Fracture Coding ­ Next Visit

Global Fracture Code Use

· Application of subsequent cast · Cast supplies

"A La Care" E/M+ Coding

· Application of subsequent cast · Cast supplies

Fracture Coding ­ Injured?

Global Fracture Code Use

· X-rays · Application of subsequent cast · Cast supplies

"A La Carte" E/M+ Coding

· E/M · X-rays · Application of subsequent cast · Cast supplies

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Fracture Coding

The correct way to code fracture treatment is with the use of the appropriate global fracture code* * Not only that, but it generally pays better

Next...

Multiple Fracture Coding

How would I code the closed reduction of 2 adjacent metatarsal fractures?

CPT 28470, CPT 28470-59

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Next...

ESWT

CPT 28890

Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia

Next...

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Cast Application

· Initial cast applied at time of surgery is included in the allowance for the surgery · Supplies are not included in the surgical global allowance (including the initial cast application) · Subsequent casts applications are payable, but use "-58" modifier due to global period · DME is not subject to the global allowance

Next...

Radiofrequency to Nerve

How do I bill for a radiofrequency procedure designed to destroy a Morton's neuroma?

CPT 64640

(destruction by neurolytic agent; other peripheral nerve)

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Next...

Nerve Decompressions

If I make a scab incision and incise the intermetatarsal ligament to treat a neuroma, can I bill that as a nerve decompression?

No

CPT 28899 (unlisted foot/toe procedure)

Nerve Decompressions

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Nerve Decompressions

"External neurolysis includes division of perineural adhesions and/or excision of perineural scar tissue."

Next...

Surgery Coding Questions?

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Next...

Billing X-Rays

How do you bill an... ankle AP ankle lateral foot AP?

Billing X-Rays

ankle AP ankle lateral foot AP CPT 73600 CPT 73620-52

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Next...

Psst...Looking for an AFO?

Miscellaneous Stuff

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Next...

AFO CODING

Fracture AFO

Do not bill unless you are treating a tibial or femoral fracture, and dispensing a fracture AFO

Next...

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Modifiers

Modifiers: Defining Point

A modifier provides the means by which a physician can indicate to a payer that a service or procedure provided to a patient has been 1) Altered by some special circumstance, or 2) More clearly defined beyond the coded service or procedure itself

Modifiers Should be Used...When?

· An adjunctive service is being performed · A procedure is performed in more than one location · A service or procedure is performed more than once · A procedure is being increased or decreased

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Modifiers Should be Used...When?

· A bilateral procedure is performed · Only part of a procedure is performed · A service or procedure is globally defined, but only the professional or technical portion was performed · More than one doctor performs the service or procedures

Modifier: Important

While a modifier may provide the means by which a physician can indicate to a payer that a service or procedure provided to a patient has been altered by some special circumstance, the basic code description itself cannot change

CPT Modifiers

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CPT Modifiers

"-24" "-25" "-26" "-57" "-58" "-59" "-76" "-78" "-79" "-80" "-22" "-52" "-TA thru T9" "LT" "RT"

"22" Modifier

Increased Procedural Services · Applied to a surgical code that the surgeon feels inadequately described all that was performed ("greater than usually required for the listed procedure") · Be ready for delays in processing the claim ...and disappointment

"24" Modifier

Unrelated E/M Service by the Same Physician During a Postoperative Period Applied only to an E/M code

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"25" Modifier

Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service

"26" Modifier

Professional Component Used only when a global fee code (e.g., CPT 73630) is split between one party performing the technical component and another party performing the professional component of the service

"52" Modifier

Reduced Services · Applied to a procedure or service in which the surgeon reduced or eliminated a component part of the procedure, but did still performed the core procedure · Be ready for delays in processing the claim ...and your wish for reduced allowance coming true

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Subtalar Arthroereisis Coding

Can I bill CPT 28725 (subtalar arthrodesis) with a "-52" modifier when performing a subtalar arthroereisis procedure?

No

It is coded as CPT 28899

"57" Modifier

Decision for Surgery

· CMS allows its use on E/M codes when a decision for surgery involves a "major" procedure only · CPT only says when the "...initial decision to perform the surgery..." resulted from the E/M service

"57" Modifier

Decision for Surgery

· The surgery must be performed within 24 hours of the decision for surgery (i.e., trauma, infection, vascular compromise, etc. cases) · Applied only to an E/M code

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"58" Modifier

Staged or Related Procedure or Service by the Same Physician During the Postoperative Period · Applied to the staged (subsequent) procedure or service code; not on the initial procedure code

"58" Modifier

· Does not require a return to the operating room · The post op global period shifts to the staged procedure; beginning from that point

"59" Modifier

Distinct Procedural Service · Modifier of last resort (i.e., use more specific modifiers if you can) · Identifies the procedure(s) as being distinct and separate from other procedures performed the same date

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"59" Modifier

· This modifier unbundles CCI or other global bundling edits · The documentation must clearly evidence that the procedure or service was comprehensive, and not a component of another billed procedure

"76" Modifier

Repeat Procedure by Same Physician · Applied to repeat procedure code (e.g., post reduction fracture x-ray done at the same session as the taking of the initial x-ray) · CPT code must be exactly the same

"78" Modifier

Unplanned Return to the Operating Room for a Related Procedure During the Postoperative Period · Generally considered a "complication" situation requiring a returned to the operating room

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"78" Modifier

· CMS requires that the operating room be equivalent to the original surgery (e.g., original: ASC with the return: hospital outpatient OR) · The global period continues from the original procedure's global period

"79" Modifier

Unrelated Procedure or Service by the Same Physician During the Postoperative Period · Applied to the subsequent surgery code(s) · The global period begins for the "79" modified procedure(s)

Next...

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Billing for Buttress Pads, Pads

I regularly apply pads to my patients feet. Sometimes they are buttress pads, sometimes accommodative corn pads, and sometimes pads incorporated in strapping. How do I bill for these?

Billing for Buttress Pads, Pads

CPT CASH

What's Wrong with Cash?

Cash is good

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The Cash Practice

· Practices that deal in high volume, "low" dollar services are considered "cash `n carry" · Practitioners have come to rely on insurers to pay their fees · Practitioners have lost sight of the value of their services

Benefits of Cash

· You don't have to bill insurers · You don't have to wait for payments · You don't have the same level of payer "hoops" to jump through · The patient becomes a consumer · You hardly ever get audited

Next...

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Coding Questions?

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Information

Microsoft PowerPoint - 2009 Surgical Coding, Etc - Napa PI

72 pages

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