Decipher why you should include a seconding diagnosis.

Question: A 38-year-old patient presents to the emergency room with complaints of wheezing, coughing, and trouble catching her breath. After the nonphysician practitioner (NPP) performs a problem-focused history, the physician performs a detailed history and exam and discovers focal ronchi. The physician orders a two-view chest x-ray to check for upper respiratory infection (URI) The chest x-ray results reveal acute URI, and the ronchi clears up upon reevaluation. The patient is treated with antibiotics. How should I code this scenario?

Answer:You’ll submit two of each for this claim: CPT codes, modifiers,and ICD-9...

Remember frequency rules differ for average, high risk.

Getting Medicare to pony up for colorectal cancer screenings is not difficult provided you follow its frequency guidelines and eligibility requirements to the letter. A coding slip up on one of these items will knock you out of the saddle, and Medicare won’t accept the claim at all.

Rope in all the coding info you’ll need via this Medicare colorectal cancer screening FAQ.

Who’s Eligible for Average-Risk Test?

If the Medicare patient is 50-plus years old, he is eligible for a covered Medicare screening, confirms Dena Rumisek, CPC, biller at Michigan’s Grand River Gastroenterology PC.

However: These patients are considered average risk, and can have a colorectal cancer screening only once every 10 years, says Cheryl Ray, CCS, CPMA, of Atlantic Gastroenterology in Greenville, N.C. Ignore Medicare’s frequency guidelines at your peril, experts warn.

“Medicare is very stringent on the date … it has to be 10 years or longer — it can’t be 9 years and 360 days,” between covered screening colonoscopies, assures Rumisek.

Example: A 68-year-old established Medicare patient reports for a screening colonoscopy on Dec. 5, 2009. The patient’s records indicate that he last had a covered screening on Sept. 15, 1998. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

What ICD-9 Codes Are In Play for G0121?

Just one, provided there is no need for any therapeutic intervention during the colonoscopy. Medicare requires V76.51 (Special screening for malignant neoplasms; colon) on all G0121 claims. You might list other identified conditions secondarily, including diverticulosis (562.10) or hemorrhoids (455.0).

Always list the V code first for an average-risk screening, however.

What if the Patient Had a Recent Flexible Sig?

The frequency rules differ depending on whether other related...

Sometimes CCI compliance requires looking beyond the edit pairs.

Correct Coding Initiative (CCI) edits don’t bundle SPECT (78803) and planar (78070) parathyroid imaging codes, but coding experts often tell you not to code the two together for SPECT and planar parathyroid imaging on the same date.

Add some method to this madness by looking at the information offered by two coding resources, the Society of Nuclear Medicine (SNM) and the NCCI Policy Manual for Medicare Services (CCI Manual).

1. SNM Singles Out 78803

SNM’s online Practice Management Coding Corner features a Q&A that recommends reporting 78070 (Parathyroid imaging) for planar imaging alone, but 78803 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; tomographic) for parathyroid SPECT imaging with or without planar, says Jackie Miller, RHIA, CCS-P, CPC, vice president of product development for Coding Metrix Inc. in Powder Springs, Ga.

Support: “Choose the single code that describes the protocol and procedure performed,” states the Q&A, located at http://interactive.snm.org/index.cfm?PageID=2442&RPID=1995. SNM “would NOT recommend coding both CPT codes,” the article notes.

2. CCI Makes the Case for SPECT Code

Although there is notyou won’t find any a specific edit bundling 78070 and 78803, CCI does address the SPECT/planar issue in the CCI Manual, says Miller.

CCI Manual, Chapter 9, Section E.2, explains that you may not report a SPECT study and planar study of the same limited area because “Single photon emission computed tomography (SPECT) studies represent an enhanced methodology over standard planar nuclear imaging. When a limited anatomic area is studied, there is no additional information procured by obtaining both planar and SPECT studies.”

Bonus tip: The manual indicates you may report both planar and SPECT codes only when the size of the scanned area makes both sets necessary, such as with whole body bone scans with...

Tip: You need to know the hook-up date and disconnect day.

Question: Which date(s) of service should I report for 30-day cardiac event monitoring?

Washington Subscriber

Answer: For Noridian Medicare, your Part B administrator for Washington, you’ll need to know both (1) the date the staff hooked up the patient and (2) the day they disconnected the patient. But knowing which dates to report is only half the battle — you also need to know where to report them.

When you’re reporting 30-day cardiac event monitoring, Noridian requires providers to report the hook-up date as the “from” date and the disconnect date as the “through” date in Item 19 of the CMS-1500 (or its electronic equivalent).

Watch out: You should report only the “from” date (that is, the hook-up date) in Item 24A (or its electronic equivalent), Noridian instructs. You should not report the “through” (disconnect) date in 24A because if you have dates spanning two months and only a single unit, “the system inappropriately suspends the claim and asks the provider for clarification,” Noridian states.

The codes for 30-day monitoring include 93268-93272 (Wearable patient activated electrocardiographic rhythm derived event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time …) and 93012-93014 (Telephonic transmission of post-symptom electrocardiogram rhythm strip[s], 24-hour attended monitoring, per 30 day period of time).

Or if the “monitoring service meets the definition of the new 30-day cardiovascular telemetry service,” look to 93228-93229 (Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage [retrievable with query] with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days …), Noridian states.

Learn more: You can read more from...

Don’t look for a raise just yet, in most cases.

CMS may talk, but MACs don’t always listen — at least not quickly.

As we told you in last week’s Insider, CMS recently corrected several “technical errors” published in the 2010 Fee Schedule, and thanks to these corrections, Medicare will increase payment for several cardiology-related testing codes, including codes 75571-75574 (Heart CT) and 78451-78454 (Heart muscle SPECT imaging).

Although many practices are eager to see the payment boosts in their next Medicare payments, that may be an overly ambitious goal at this point.

“I inquired with a few MAC carriers such as Trailblazer, Noridian, and Palmetto, and was told different things by different Medicare payers,” says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CCC, CEMS, CMS, CEO of Terry Fletcher Consulting Inc.

“One did not even know there was a change,” she says. “Next, Noridian said that they will be making the adjustments when they get the directive from CMS. And Palmetto said they would need the provider to contact them and then batch retroactive to January the myocardial perfusion imaging claims and send a letter to request the increase,” she says.

Bottom line: Until CMS provides a clear answer to the MACs regarding when they must implement the changes, you may not see your pay increases, but keep an eye on your carrier’s Web site for information on when it intends to reprocess claims using the new rates.

@ Part B Insider. Editor: Torrey Kim, CPC

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