Align ‘medical necessity’ with ICD-9 instruction.

Ordering a human papillomavirus (HPV) screen with a Pap test isn’t the same as ordering a reflex HPV screen following an abnormal Pap. Although ICD-9 instruction and coverage rules might appear to be at loggerheads, our experts can show you the way out.

Question: Should the physician order a screening and/or reflex HPV Pap test (such as 87621, Infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, amplified probe technique) with V73.81 (Special screening examination for human papillomavirus [HPV])?

What you stand to gain: “Many ‘V’ codes are paid as part of a screening benefit for patients who have those specific benefits,” says Tina Burkhalter, billing manager with SouthEastern Pathology in Rome, Ga. On the other hand, “tests ordered with diagnostic codes tend to go to the deductible,” she says. “We hear from patients complaining that they must pay for the HPV test because their insurer tells them we used the ‘wrong’ code.”

Medical Necessity Points to 795.0x

Although no national coverage policy exists for screening HPV testing to evaluate cervical cancer risk, many payers follow the consensus guidelines recommended by the American Society for Colposcopy and Cervical Pathology (ASCCP).

A core ASCCP recommendation is to screen for high-risk HPV DNA in patients over the age of 20 years with a Pap cytologic result of 795.01 (Papanicolaou smear of cervix with atypical squamous cells of undetermined significance [ASC-US]). The guidelines also address the role of HPV with other Pap outcomes in special populations, such as recommending reflex HPV testing for postmenopausal women with cytologic findings of 795.03 (Papanicolaou smear of cervix with low grade squamous intraepithelial lesion [LGSIL]).

Key: If your payers have adopted any or all of these guidelines, you’ll need to report the Pap findings, such as 795.01, to...

From head to toe, the new diagnosis codes hold something for everyone.

Whether your patients present with cardiologic, orthopedic, or gynecologic complaints, the next round of ICD-9 codes could hold important changes for you. Here’s the rundown on the new codes most relevant to radiologists — including a new option for retained magnetic metal fragments.

Remember: ICD-9 2011 will go into effect Oct. 1, 2010. The official version will be released in the fall, so the codes below are not yet final.

1. Look Forward to More Specific Ectasia Codes

The proposed changes to ICD-9 2011 add four codes specific to aortic ectasia. These codes are among the most significant changes for radiology coders because you may see that term in your radiologist’s findings, says Helen L. Avery, CPC, CHC, CPC-I, manager of revenue cycle services for Los Angeles-based Sinaiko Healthcare Consulting Inc. “Ectasia” means dilation or enlargement, and aortic ectasia typically refers to enlargement that is milder than an aneurysm. But ICD-9 2010 does not distinguish ectasia from aneurysm, indexing aortic ectasia to 441.9 (Aortic aneurysm of unspecified site without mention of rupture) and 441.5 (Aortic aneurysm of unspecified site, ruptured).

The proposed 2011 codes are specific to aortic ectasia and differ based on anatomic site:

• 447.70 — Aortic ectasia, unspecified site
• 447.71 — Thoracic aortic ectasia
• 447.72 — Abdominal aortic ectasia
• 447.73 — Thoracoabdominal aortic ectasia.

2. Watch for ‘Claudication’ in Stenosis Report

Another one of the important changes is the proposed addition of 724.03 (Spinal stenosis, lumbar region, with neurogenic claudication), says Avery. The code refers to lumbar spinal stenosis, which is a narrowing of the spinal canal, according to the Sept. 16-17, 2009, ICD-9-CM Coordination and Maintenance Committee meeting proposal (available here). Neurogenic claudication “is a commonly used term for a...

The reason your patient is visiting is key.

Question: We have a patient who came in for a routine eye exam, but reported retinal damage from a BB-gun incident six years ago. What would be the best way to code this? This is a new patient, and I do not have any old records.

Answer: Unless the BB-gun injury six years ago has something to do with why the patient is there, it may not have any bearing on your coding. The diagnosis code always depends on the reason for the visit. If the patient decided to see an optometrist because of eye pain, eye pain (379.91, Pain in or around eye) — or whatever the optometrist found that was causing the pain — would be the diagnosis. If the eye pain is indeed the late effect of the BB-gun injury, you could report 906.0 (Late effect of open wound of head, neck and trunk) as a secondary diagnosis.

“When reporting late effects of an acute injury,” instruct the ICD-9 guidelines, “code the residual problem/condition as the primary diagnosis and record the appropriate late effects code as a secondary diagnosis.” In the above example, 379.91 would be the primary diagnosis, and 906.0 would be the secondary diagnosis.

However: If this was truly a routine exam, and the patient denies any current complaints, you would have to use V72.0 (Examination of eyes and vision) as the diagnosis. Unless the patient has vision insurance that covers routine exams, most carriers won’t reimburse you for this visit.

@ Ophthalmology Coding Alert (Editor: Jerry Salley, CPC).

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Maximize 11040-11044 pay with modifier 51.

In most cases, your practice won’t report debridement separate from wound repair codes. But when exceptions arise, follow these three tips to choose the appropriate wound repair code.

If you’re considering reporting debridement separate from a wound closure, make sure your physician’s notes clearly document that the wound was contaminated and required saline or other substances or instrumentation to cleanse and debride the wound.

Don’t miss: If you report a debridement code with your wound closure codes, append modifier 59 (Distinct procedural service) to the debridement code. This informs the payer that you recognize that debridement is generally bundled into wound repair, but that clinical circumstances required the physician to perform debridement as a separate service.

1. Look for Wound Repair With the Debridement

CPT specifies that you may also report debridement codes independently of repair codes when the physician removes large amounts of devitalized or contaminated tissue or when the physician performs debridement without immediate primary repair of a wound, notes Pamela Biffle, CPC, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas.

The physician may clean debris from the wound without repairing the wound because it was either not deep enough to require repair or the physician delayed the repair due to an extenuating circumstance.

In the case in which the dermatologist excises a lesion, debridement is included in the procedure. However, when the dermatologist only performs debridement or performs the debridement in addition to the wound repair, such as the case when a wound is excessively dirty or contaminated with debris, you would also code the debridement code with the wound repair/excision code, appending modifier 51 (Multiple procedures) for the multiple procedure.

Example: A patient returns to the dermatologist several days after a chemical...

If patient’s critical care and visit satisfies time regs, 99291 is the better bet.

When scouring the notes for evidence of an emergency department caveat scenario, coders can easily forget to ask themselves one simple question: Can I report a critical care code for this scenario?

The answer’s yes more often than you might think, says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La.

“Many patients who qualify for the caveat may also be candidates for critical care. If the condition is severe enough that the patient’s ability to provide this information is impaired, then the condition may be critical,” she explains.

Critical Care Omits Specific History Component

Considering critical care and the caveat simultaneously can make your head spin, as the ED caveat does not even apply to 99291 (Critical care, evaluation and management of the critical ill or critically injured patient; first 30-74 minutes) or +99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

Why? “There are not the same bullet-counting requirements for documentation of history, physical examination, or MDM [medical decision making] for critical care,” explains Edelberg. The descriptors for critical care concern only E/M of the critically ill or injured patient.

So when your physician invokes the emergency department caveat for a patient, check to see if the patient was critically ill or injured; if she was, and the physician documents at least 30 minutes of critical care, consider 99291.

Payout: The only level of service you can invoke the emergency department caveat on is 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a...