Warning: Just including EGD diagnosis with your claim doesn’t guarantee reimbursement — here’s help.

Question: Our anesthesiologist provided anesthesia during an esophagogastroduodenoscopy (EGD) procedure, at the request of the attending physician. We coded the anesthesia portion with 00810. A note in the documentation mentions the request was due to the patient’s symptoms, but no other details were provided. The claim we submitted was denied, but we followed all of the other guidelines provided by the payer, including proof that the anesthesiologist administered Propofol. What did we do wrong?

Answer: One key to the denial might be found in the lack of coding for the patient’s condition. Your diagnosis code should indicate the co-existing medical condition that justifies your anesthesiologist’s involvement in the case, not the gastrointestinal condition leading to the endoscopy.

You may want to consult with your anesthesiologist to verify that the patient had a condition such as:

• Parkinson’s disease (332.0)
• Heart conditions (such as 410.xx, Acute myocardial infarction or 427.41, Ventricular fibrillation)
• Mental retardation (318.x)
• Seizure disorders (such as 780.39, Other convulsions)
• Anxiety (such as 300.0x, Anxiety states)
• Pregnancy
• History of drug or alcohol abuse.

These are just some of the conditions that payers may require to justify the presence of an anesthesiologist at a colonoscopy. ICD-9 2010 also has two codes to describe failed sedation attempts: 995.24 (Failed moderate sedation during procedure) and V15.80 (Personal history of failed moderate sedation).

If your anesthesiologist’s documentation confirms one of these conditions, 995.24 or V15.80 would also justify an anesthesiologist’s involvement to most payers. The conditions listed above constitute the medical necessity of anesthesia with the procedure. If you used a screening diagnosis or treatment of commonly found conditions instead of the clinical condition requiring anesthesia, payers will not pay you for these services.

Also note the...

Overlooking these new Interstim and hemorrhoid destruction bundles could mean denial headaches.

Don’t let CCI version 16.1’s lack of ob-gyn mutually exclusive edits lull you into a false sense of security. Here’s what you need to know to prevent a denial from landing on your desk.

Payers like Noridian Part B will cover the female stress urinary incontinence treatment code 0193T, but before you submit a 0193T claim, you’ll have to check with the Correct Coding Iniative (CCI) version 16.1’s edits. For instance, as of April 1, the work represented by 0193T will include that of cystourethroscopy codes 52000-52001 and 52281.

1. Look For 0193T in Both the Column 1, Column 2 Position

In 2009, CPT added 0193T (Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence) to your possible stress urinary incontinence (SUI) treatment coding options. This code includes the Renessa transurethral collagen radiofrequency denaturation procedure. Ob-gyns typically perform this nonsurgical, minimally invasive alternative for women who have failed other nonsurgical treatments or who aren’t good candidates for surgery.

What happens: The ob-gyn uses controlled heat at low temperatures and targets tissue in the woman’s lower urinary tract. The heat changes the structure of the patient’s natural tissue collagen. This helps the firmness of tissue and improves her continence. Although the ob-gyn may use heat on multiple sites and document multiple cycles, you should report 0193T once to represent all the treatment cycles performed during an encounter.

As of April 1, 0193T will include the work represented by 52000-52001 (Cystourethroscopy …) and 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female).

Reaction: “These edits don’t surprise me at all because 0193T says ‘transurethral’ which implies the...

Practice size does not matter when dealing with compliance — even solo practitioners have to stay on the straight and narrow.

Even small dermatology practices have to stay compliant with government regulations — and although this sounds like a simple fact, it’s one that many Part B providers may overlook.

Ensuring physician practice compliance can be a complex path, and many practices think of it is something that large hospitals should focus on — after all, those are the entities that get all of the media exposure when they violate compliance rules. But every practice is responsible for compliance, no matter how big or small.

Doctors Take Note

In some cases, small practices think compliance rules don’t affect them — but also don’t realize they’re at risk of being noncompliant.

Example: “I met with a solo practitioner a few years ago who hired me as a consultant,” says Laura E. Hill, CPC, CPC-I, an Arizona- based compliance consultant.

“It was my sad duty to let him know that his office manager,who submitted all of his claims, was upcoding all of his office  visits as she entered them into the computer so that she could pay his quarterly malpractice-insurance premiums,” Hill says. “She had been working for him for 10 years and was a loyal and trustworthy employee.”

The fault was the physician’s, because he never took the time to review the monthly reports that the office manager gave to him, Hill says. He also never looked closely at his deposits into his corporate checking account, where there was an obvious trend toward increased deposits every third month.

Pay attention to your advisors: In the example above, the physician’s accountant had pointed the problem out to him, “but he accepted his office manager’s explanation that insurance...

Treatment plans are a must, experts say.

You’ve treated your chiropractic patient, you’ve selected the correct codes, and you’ve submitted your claim. All set, right? Not quite. Check out this common mistake that chiropractors make.

“Many chiropractors do not create written chiropractic treatment plans for every new patient,” says Marty Kotlar, DC, CHCC, CBCS, president of Target Coding, a chiropractic coding and billing consulting firm. Use this checklist to ensure you send Medicare the information CMS most wants to see included “with every new patient plan of care,” Kotlar says:

__ The history
__ Present illness
__ Family history
__ The past health history
__ The physical examination
__ The diagnosis
__ The plan — This should include:

• Therapeutic modalities to effect cure or relief (patient education and exercise training)
• The level of care that is recommended (the duration and frequency of visits)
• Specific goals that are to be achieved with treatment
• The objective measures that will be used to evaluate the effectiveness of treatment
• Date of initial treatment.

__ Signature/initials to authenticate the records.

@ Part B Insider (Editor: Torrey Kim, CPC).

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Don’t assume 90911 is the correct code choice.

Question: Is there a procedure code for billing for Kegel exercise teaching? Can we use code 90911 or possibly 97110?

Answer: There are no specific CPT or HCPCS codes for the performance of or teaching of Kegel exercises. To bill for teaching a patient how to properly perform these exercises, a nurse or medical technician must document a brief history and physical examination as well as the indications for and the expected goals of the Kegel exercises. Under these circumstances, you can then report 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician …) for this encounter.

About the service: Kegel exercises are voluntary contraction and relaxation of the perineal musculature including the urinary sphincter (pelvic diaphragm). These exercises are usually performed outside of the office without medical staff supervision, and are a non-invasive and non-surgical treatment for female and occasionally male stress urinary incontinence.

Pitfall: You should only use 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) for the teaching of biofeedback therapy with face-to-face supervision in office by a trained member of your medical staff.

Additionally, you should use 97110 (Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) only for pelvic floor muscle rehabilitation (PFMR) performed under one-on-one supervision with a physician, physiotherapist, or ancillary office staff member specifically trained in an accredited physiotherapy program.

@ Urology Coding Alert (Editor: Leesa A. Israel, CPC, CUC, CMBS).

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