January 2014, Vol. 6, No. 1 (Pages 1-8)
Podiatry Coding & Billing Alert
Your practical adviser for ethically optimizing coding, reimbursement, and efficiency in podiatry practices Also Access Your Alert Online at www.SuperCoder.com
The Coding Institute
AVOID AUDITS.IMPROVE REIMBURSEMENT.REDUCE DENIALS.INCREASE REVENUE
In this issue
CPT® 201499446-99449: New E/M Codes
Capture Doc Discussions p3
Make sure to include a written report.
E/M
Navigate the New-Versus-Established-Patient Maze
With Expert Tips p3
Different locations, same physician? Use established patient codes.
EHR Mythbuster
3 EHR Myths That Could Cost
Your Practice Heavily p5
Warning: Blindly relying on your electronic system could mean payer audits.
You Be the Coder p5
Diabetes Patient, Post-Amputation
Reader Questions
Test Your ICD-10 Codingin March p6
Know How to Email Without
Violating HIPAA p6
Opt for First-Initial, Last-Name
Privacy Protocol p7
ICD-9 Coding
}
Avoid Tough Callus and Corn Coding
Keep the jargon straight for common foot conditions.
For podiatrists treating the skin of a patient’s foot, one of the most commonly coded diagnoses is corns (and calluses). The condition has a slew of confusing names that may be hard to find — or may not even be in your coding book — and could quickly derail your claims.
Deciphering all of the corn and callus terminology can be especially difficult if you work for several physicians and each one has his own way of naming the same thing, or if you’ve recently started working at another practice. But you no longer have to be in the dark over a callus-related term that comes your way.
Familiarize Yourself With the Jargon
You may recognize the word “clavus,” since the ICD-9 corn/callus code (700, Corns and
callosities; includes callus, clavus) names it up front. But here are a few more related words
that many providers use interchangeably in their notes that you should keep in mind: Clavi (the word for more than one “clavus”)
Keratosis Keratoma Hyperkeratosis
Intractable plantar keratosis (may be abbreviated as “IPK”) Heloma
Callosity Tyloma Tylosis
Durum (this term refers to “heloma durum,” which is considered a “hard corn”).
Watch out: “Tylosis” could lead you down the wrong coding path if you’re not careful.
The ICD-9 index in the front of the coding book leads you to several options, such as 757.39 (Other specified anomalies of skin; other; includes accessory skin tags, congenital;
congenital scar; epidermolysis bullosa; keratoderma [congenital]), and this is the
wrong path for a basic corn or callus. Your best bet when you encounter this term in the documentation is to ask the physician to clarify the condition.
ICD-10: Once ICD-9 converts to ICD-10 in October, 2014, code 700 will no longer be
valid. Instead, you would report ICD-10 code L84 (Corns and callosities). The deadline » » » » » » » » » »
Editorial advisory Board
Jean Acevedo, LHRM, CPC, CHC
Senior Consultant Acevedo Consulting, Inc. Delray Beach, Fla.
Arnold S. Beresh, DPM, CPC
Certified, ABPS Fellow, ACFAS Peninsula Foot & Ankle Hampton, Va.
Cathy Klein, LPN, CPC
Director of Regional Network Services Cardinal Health Initiatives LLC Muncie, Ind.
Janet McDiarmid, CMM, CPC, MPC
CEO, McDiarmid Consultants LLC Past President, AAPC National Advisory Board Sylacauga, Ala.
Richard Odom, DPM, CPC, AOPS
Practicing Podiatrist Gulf Coast VA Hospital System Mobile, Ala.
Daniel Waldman, DPM, FACFAS
Blue Ridge Foot Centers, Asheville, NC
President, Blue Ridge Podiatry Association, PA
Hoda M. Henein, CHBME, CP
President and CEO of Active Processing, Inc. Active Management College Point, NY
Podiatry Coding & Billing Alert (USPS# 023-041) (ISSN 1558-6405) is published monthly 12 times per year by
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for using ICD-10 is Oct. 1, 2014, with no grace period, stresses Pat Brooks, RHIA, senior technical advisor with the Centers for Medicare and Medicaid Services.
Master the Definitions
If you’re still unsure about your physician’s everyday description of these common conditions, learning the definitions of “corn” and “callus” will help.
A corn is a small, horny area of the skin caused by local pressure (e.g., a shoe or hosiery) irritating the tissue over a bony prominence.
Corns usually occur on a toe, where they form “hard corns.” “Between the toes, pressure can form a soft corn of macerated skin, which often yellows.
A callus is localized thickening and enlargement of the horny layer of the skin due to pressure or friction. Generally, calluses as well as corns can cause pain, and soft-tissue inflammation may occur around the base of the lesion.
Knowing these definitions is also helpful if you plan to ask the physician for clarification.
Example: You’re struggling with how to code a patient diagnosis that describes a
“keratosis” of the bottom of the great toe and the heel. You’ve learned the synonyms for corns/calluses and remember that this is another name for a callus, but you notice that another nearby code has the same word in its descriptor: 701.1 (Keratoderma,
acquired; Keratosis [blennorrhagica]).
You ask the physician for more details about the patient’s condition so you can code it properly, and he describes a basic thickening of the skin because of bad shoes. Referring back to the definitions, now you know that it’s just a callus and you can code it as 700.
However: Keep in mind that claims “using ICD 700 are rarely paid, especially by private insurance carriers,” warns Arnold Beresh, DPM, CPC, CSFAC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va.
If the condition were keratosis blennorrhagica, the physician would have described a scaly rash that is associated with Reiter’s syndrome, and this would tell you to code something other than 700, which is for a mere callus.
But if a diagnosis brings you to the 701.x series (Other hypertrophic and atrophic
conditions of skin), pay special attention to the definitions under each code.
The definitions can help you verify whether the doctor is using the corn/callus term as a synonym or for a more specific description of the condition.
»
CPT® 2014
}
99446-99449: New E/M Codes Capture Doc Discussions
Make sure to include a written report.
Who knows if Medicare will pay, but you should be able to bill some payers for your podiatrist’s interprofessional consultation services beginning Jan. 1, 2014.
That’s because CPT® 2014 introduces four new codes that
describe the work of two medical professionals who discuss a patient’s condition via phone or Internet, as follows:
99446 — Interprofessional telephone/Internet assessment
and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consul-tative discussion and review
99447 — … 11-20 minutes of medical consultative
discussion and review
99448 — … 21-30 minutes of medical consultative
discussion and review
99449 — … 31 minutes or more of medical consultative
discussion and review.
These codes make sense as more and more health plans allow for communication between physicians and patients via the internet. “Codes 99446-99449 appear to be in recognition of these situations. It affords the physician the ability to forward patient information (securely) to another physician for opinion and insight without having the patient come to all the different appointments,” says Suzan Berman, MPM, CPC, CEMC,
CEDC, manager of physician compliance auditing for West
Penn Allegheny Health Systems, Pittsburgh, Pa.
Check Who Reports and How
“These new codes are intended to be used only by the consultant physician,” notes Kent Moore, senior manager
»
» » »
for physician payment at the American Academy of Family
Physicians. “The patient’s treating physician, which is typically
the attending or primary care physician, who is seeking the consultant’s opinion or advice with respect to diagnosis and/or management of the patient will not be able to use these codes for his or her portion of the conversation,” Moore adds. “The physicians will want to know if the codes are something they might be able to utilize,” says Chandra L. Hines, practice supervisor of Wake Specialty Physicians in Raleigh, N.C. And it looks like the answer is “yes” when a primary care physician consults with a general surgeon in your practice, because the surgeon is the “consultant.”
Write report: These new codes are effectively “consultations,”
which means you must provide a written report to the requesting physician to qualify for the code. You’ll see that requirement right in the code definitions, which state “including a verbal and written report.”
Tick tock: Time distinguishes the four codes. “I am a bit
curious about why they are broken into time and how that time will be measured (reading, discussing, interpreting, further research, etc.). How will the time be documented?” Berman asks. For any time-based codes, it would be expected that documentation includes the time component.
Watch for Payment
Medicare stopped paying for consultations in 2010, and
much discussion followed about CPT® eventually eliminating
consultation codes. But here we are with four new consultation codes in 2014. Now the question becomes whether Medicare will recognize these codes. q
E/M
}
Navigate the New-Versus-Established-Patient Maze With Expert Tips
Different locations, same physician? Use established patient codes.
When reporting many common E/M services, you must askyourself two questions: First, is the patient new or established? And second, what are the documented levels of history,
physical exam, and medical decision-making (MDM)? We’ve got some quick tips on how to use this information to select the correct E/M level every time.
3 Year Rule Determines Patient Status
Generally, you should consider a patient to be established if any physician in your group (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months, says Marvel Hammer, RN, CPC, CCS-P, PCS,
ASC-PM, CHCO, owner of MJH Consulting in Denver, Co. For example: A patient complaining of skin rash comes to
your office. Although this is provider A’s first time meeting the patient, provider B, in the same group practice, saw the patient two years ago for a similar complaint. In this case, the patient is established.
Don’t let different locations lead you astray: If your practice
has multiple locations, and a physician in location A sees the patient in January but a physician in location B sees the patient the following December, the patient is still established. The need to create a new chart is inconsequential, Hammer says.
Non-face-to-face encounters don’t count: A primary-care
physician recommends that a 60-year-old female see the ophthalmologist regarding flashes and floaters. One of the physicians in your practice interpreted some test results for the same patient the previous year but provided no face-to-face service. In this case, you can still consider the patient to be new when selecting an initial E/M code because no physician within your practice provided the patient with a face-to-face service within the past three years.
According to section 30.6.7 of the Medicare Claims Processing Manual, “An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”
Exceptions Could Occur for Different Specialties
The new patient rule applies when physicians in the same practice are also of the same specialty.
In a nutshell: If your practice is big enough and covers enough
specialties, two physicians may see a patient for completely different reasons. This could allow you to report a new patient visit even though two physicians in the same practice saw the same patient within a three-year period if they are different specialties.
Consult Codes Don’t Differentiate
The consult codes do not differentiate between new and established patients. Therefore, regardless of the patient’s
status, you should make your outpatient consult code choice from the 99241-99245 range.
When reporting consults and new patient E/M services, you’ll need to meet the requirements of all three key components (history, exam and MDM) to report a given level of service.
Shortcut: In effect, this means that whichever key component
is the -lowest- will determine the E/M service level you choose, Hammer says.
The AMA added text to CPT® in 2006 to clarify that all of
the key components (history, exam and MDM) must meet or exceed the stated requirements to qualify for a particular level of service for office, new patient (99201-99205), hospital observation services (99218-99220), initial hospital care (99221-99223), office consultations (99241-99245), initial inpatient consultations (99251-99255) and others.
2 of 3 Will Do for Most Established E/M Visits
When reporting most established patient outpatient E/M services (except consults and initial observation care, which do not distinguish new from established patients), you can assign an E/M level based on just two of the key components, Hammer says.
Per CPT®, you must meet or exceed the stated requirements
for two of the three key components for established patient office visits (99212-99215), subsequent hospital care (99231-99233), subsequent nursing facility care (99307-99310) and others.
Watch for Overcoding
Generally, medical necessity should determine the MDM level and, ultimately, the appropriate E/M service level. Physicians should not, for instance, report a comprehensive history and exam at every visit and expect to report 99215, regardless of medical necessity or the documented level of MDM.
Simply stated: If the presenting problem won’t support a
high-level E/M service, you can’t get paid just because the physician documented a comprehensive history and exam.
A final note: Remember, you may report E/M services based
on time — rather than the key components of history, exam and MDM — if the physician spends more than 50 percent of the visit on counseling and/or coordination of care AND documents total time, percent (or time) spent for counseling/coordination of care and specific detail about the counseling/coordination of care. q
EHR Mythbuster
}
3 EHR Myths That Could Cost Your Practice Heavily
Warning: Blindly relying on your electronic system could mean payer audits.
If you are using an electronic health records (EHR) system orcontemplating adding it for your optometry practice, you also need to know the pitfalls of the system, such as inadequate documentation or unnecessary documentation, and how you can overcome them to get your hands on deserved reimbursement. Consider these three EHR myths to determine exactly where your EHR system could be leading you astray.
Myth 1: Exam Documentation Will Carry Over for Follow-Up Visits
If your EHR is producing documentation that is robust in one section (such as History) and thin in another (such as the Physical Examination), you may trust the device to do too much. A coder recently told the Coding Institute that an auditor downcoded most of her E/M claims due to an empty “Physical Exam” section in the documentation. However, the practice argued that the EHR vendor had told them that patientsbeing seen for established problems already have a physical examination documentation on file, and that the EHR will carry it over from one visit to the next.
Reality: This may be true for past medical, family, and social
history (PFSH), but not for a physical examination.
E/M guidelines state that if a patient’s PFSH has not changed since a prior visit, your provider does not need to document the information again, says Elizabeth Hollingshead, CPC, CUC,
CMC, CMSCS, corporate billing/coding manager of Northwest
Columbus Urology Inc. in Marysville, Ohio. He does, however, need to document that he reviewed the previous information to be sure it’s up to date and also note in the present encounter’s documentation the date of acquisition and location of the earlier PFSH. Some payers will give no PFSH credit if you overlook one of these two criteria.
Good documentation: For instance, you can say, “I reviewed
the past, family, social history with the patient taken from today’s patient questionnaire and our previous visit of June 1, 2013. She reports that nothing has changed since that date.”
Myth 2: EHR’s Calculation of Time Spent Qualifies You to Code
Based on Time
One of the perks of electronic health records is that they typically record the date and time that you input information. In fact, many EHRs record a summary of the time spent on the
You Be the Coder
Diabetes Patient, Post-Amputation
Question:
A patient visited our clinic for a checkup for some ulcers on her right ankle. She had the toes on her right foot amputated six months ago due to gangrene. She has type II diabetes, peripheral vascular disease (PVD), and malignant hypertension. How should I code her condition?
Delaware Subscriber
Answer: See page 7. q
(Continued on next page)
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Test Your ICD-10 Coding in March
Question:
I have heard that there will be a test period for using ICD-10 codes on claims before the October 1, 2014 implementation. When will that be?
Connecticut Subscriber
Answer:
You’ll get to test out your ICD-10 coding skills this spring with a dry run that CMS plans to offer practices who want to submit sample ICD-10 claims, CMS announced in MLN Matters article MM8465, published on Nov. 1.
During the week of March 3 through March 7, 2014, your MAC will allow you to send in your test claims that include ICD-10 codes. If you have difficulty processing the claims, you’ll be able to contact the help desk to figure out what went wrong. In addition, you will get electronic acknowledgement of
your test claims that will tell you whether they were accepted or rejected.
After the testing period ends, CMS will share information about the percentage of test claims that were accepted versus rejected, and will offer additional information about lessons learned during the testing period.
To read more about the ICD-10 test dates, visit www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM8465.pdf. q
Know How to Email Without Violating HIPAA
Question:
I sometimes e-mail patient records to consultants for help on how to bill. How can I make sure I’m not committing a HIPAA violation?
Connecticut Subscriber
Reader Questions
}
record at the bottom of each visit’s documentation and give a total, such as “Total time: 26 minutes, 15 seconds.”
Several coders have told the Coding Institute that they have used this time calculation to select an E/M code based on time alone. For example, if the EHR says that the time spent is 25 minutes, these practices are automatically reporting 99214 for the visits, using the rationale that CPT® and Medicare
guidelines allow you to code E/M services based on time alone.
Reality: The key to billing based on time is that counseling and/
or coordination of care must dominate the visit, says Barbara
J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting
firm in Tinton Falls, N.J. Therefore, you can only select an E/M code using time as the controlling factor if you meet the rules, and an EHR’s notation of time spent in the record will not meet those guidelines. Instead, to bill on time alone, your provider’s documentation must contain the following three elements:
Notation of the total time spent on the encounter, Notation of the total time spent on counseling and/or coordination of care or the percentage of the visit spent on counseling/care coordination, and
A description of the counseling/care coordination. In an EHR, you may not know where to put such a statement, but most of these systems will have a radio button somewhere in the software that you can press to create a comment box. As long as you enter your statement about time as indicated above anywhere in the record for the encounter, you can code based on time alone, but simply stating the total time you spent — or letting the EHR calculate it for you — is not adequate.
» » »
Myth 3: You Should Use the EHR’s Code Selection in Every Case
Your electronic health record will most likely offer an E/M code suggestion at the end of each visit — but that doesn’t mean you should use that to justify all high-level codes.Several practices have told the Coding Institute that their providers “thoroughly document” the History and Physical Exam elements for all conditions whether the nature of the presenting problem requires such detailed documentation. This leads to the ability to report high-level codes, even if the medical decision making (MDM) and medical necessity of the encounter do not support 99214 or 99215. They justify this by pointing out that established patient office visits only require two out of three key components (History, Exam, MDM). “However, keep in mind that the method of calculating MDM is not always consistent with medical necessity,” Cobuzzi warns.
Reality: CMS indicates in section 30.6.1 of chapter 12
of its Medicare Claims Processing Manual that “Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT® code.” In addition,
the 1995 and 1997 E/M Documentation Guidelines state, “The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.”
Therefore, you should use your EHR’s code selection only as a suggestion, but the final code choice should be up to the clinician, and should be based on medical necessity and the nature of the presenting problem as well as the other key components of the service.
— Answers to You Be the Coder and Reader Questions were reviewed by Arnold Beresh, DPM, CPC, CSFAC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va.
Answer:
A simple request for help can land you in plenty of trouble with HIPAA. The key is to remove all identifying information from the report before you send it.
Here’s how: Under HIPAA’s Privacy Rule, you have to make
sure you don’t send protected health information (PHI) by removing all individually identifiable health information, including health information that reasonably allows individual identification. In general, HIPAA is based on reasonableness.
Best bet: Only send the portions of the report that describe the
clinical procedure and findings, and include a confidentiality notice at the end of your e-mail. This guideline applies whether you send the e-mail from an office or from home.
Specifics: Before you send the report by e-mail, remove the
patient’s name and Social Security number. You should also remove geographic identifiers, dates, phone, fax, and e-mail
information, and medical record and device serial numbers. Then you read through the report before you send it to be sure you can reasonably assume the patient is no longer identifiable. Experts advise that for extra security, you send an encrypted email to keep information safe. q
Opt for First-Initial, Last-Name Privacy Protocol
Question:
What guidelines should our group follow to protect the privacy of patient information in public areas? For example, we keep our charts in a rack visible to visitors who enter our office. The charts show the patient’s name and physician’s name; no testing or code indicators are visible.
South Carolina Subscriber
Answer:
You’re definitely on the right track because you aren’t
disclosing code or testing information. But there are even more steps you can take to ensure your patients’ privacy.
Step 1: Explore the option of moving the chart rack to an area
that is not visible to all the visitors entering your office.
Step 2: Consider not including the physician’s name on charts
that could be visible to visitors.
Step 3: Instead of using a patient’s full name, use her first
initial and last name (or first initial and only the first few letters of the patient’s last name). This works on several levels. First, it doesn’t pose a patient identity risk because it’s rare that there would be two patients with the same first initial and last name in the same room. This process also meets The Joint Commission’s Standard IM.2.10 specifically, to maintain patient privacy. Although The Joint Commission doesn’t specifically address patient privacy, your state and federal regulations do. And The Joint Commission does require organizations to be compliant with state and federal laws and regulations.
Another benefit to noting the patient’s name this way is that the patient’s gender remains undisclosed, which provides even greater security as a passer-by would know even less about the patient.
Trap: If your organization used first name and last initial, there
would be a greater likelihood of having two people with the same first name and last initial in the same room. The same problem would occur if you used first initial and last initial. q
You Be the Coder
Diabetes Patient, Post-Amputation
(Question on page 5) Answer:
For your patient, code:
443.81 (Peripheral angiopathy in diseases classified
elsewhere)
250.70 (Diabetes with peripheral circulatory
disorders; type II or unspecified type, not stated as uncontrolled)
V49.73 (Lower limb amputation status; foot) 401.0 (Essential hypertension; malignant).
Use V49.73 to identify the specific amputation site. You should use the V49.6x and V49.7x codes only to report acquired amputation status due to trauma or surgical amputation due to disease.
For the hypertension, list 401.0 for this patient. Don’t list a code for gangrene because it’s no longer present. The PVD, however, is likely to continue to be a problem, so listing 443.81 is appropriate.
Note: ICD-9 assumes the gangrene is a consequence of a
diabetic peripheral vascular circulatory disorder. This is usually true when the gangrene is of the lower extremity. If there is no other stated cause, gangrene is considered a manifestation of diabetes. q
» » » »
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