One of the most common procedures in ophthalmology is A-scan ultrasound biometry, which is associated with some of the most uncommon coding problems.

According to CPT, A-scans — 76511, 76516, and 76519 — are the shortened names for amplitude modulation scans, “one-dimensional ultrasonic measurement procedures,” notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director, Best Practices-Network Operations at Mount Sinai Hospital in New York City.

Ophthalmologists use 76511 (Ophthalmic ultrasound, diagnostic; quantitative A-scan only) to diagnose eye-related complications such as eye tumors, hemorrhages, retinal detachment, etc.

Physicians use 76516 (Ophthalmic biometry by ultrasound echography, A-scan) to measure the axial length of the eye in preparation for cataract surgery.

And 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) allows ophthalmologists to determine the intraocular lens calculation prior to cataract surgery only.

Typically, most A-scans are performed bilaterally. However, circumstances may only require the physician to perform a unilateral scan.

Each A-scan code has separate requirements when billed bilaterally. For example, payers consider 76511 unilateral, requiring the use of modifiers LT/RT/50 (Left side/Right side/Bilateral procedure) or the units value of “2.”

But 76516 is inherently bilateral, so you shouldn’t append modifier 50 to it.

For CPT Code 76519, some payers (including Medicare) consider only the technical component bilateral whereas the professional component is unilateral.

Some non-Medicare payers, on the other hand, want you to bill globally and don’t typically divide the professional and technical components, so you must determine which insurance company you are coding for and what its policy is for billing A-scans.

Medicare carriers for Part B services have published articles specifying their preference to report a bilateral service with a single line item with modifier 50 and one unit of service, whereas [some] non-Medicare payers prefer reporting bilateral services with two line items...

Effective April 1, your practice’s bottom line is going to be hit, especially if your provider uses chemodenervation to treat patients. Reason: Medicare Physician Fee Schedule is all set to introduce a bunch of changes. So here’s the big news.

Bilateral Indicator Shifts to ‘2’

Neurologists and pain management specialists sometimes use chemodenervation to help relieve symptoms of spasmodic torticollis (333.83), cerebral palsy (such as 343.x), or other conditions. The codes you rely on for these procedures include:

• 64613 — Chemodenervation of muscle(s); neck muscle(s) (e.g., for spasmodic torticollis, spasmodic dysphonia)
• 64614 — … extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis).

Previous versions of the physician fee schedule listed a bilateral status indicator of “1” for 64613 and 64614. That meant you could append modifier 50 (Bilateral procedure) and receive additional payment if your provider injected botulinum toxin into bilateral anatomic sites, such as the right and left upper extremities.

Medicare is changing the bilateral status indicator for 64613 and 64614 to “2,” effective April 1, 2011. You’ll no longer be able to report the service bilaterally, even if your provider chooses that treatment option.

“Medicare now considers that the RVUs (relative value units) are already based on the procedure being performed as a bilateral procedure,” explains Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co.

Pay cut: Submitting a claim with modifier 50 means the payer will reimburse at 100 percent for the first procedure and at 50 percent for the second contralateral procedure. Based on the national conversion factor of $33.9764, Medicare pays $145.42 for code 64613 in a facility setting and $164.11 in a non-facility setting. Medicare pays $151.87 for code 64614 in a facility setting and $174.98 in a nonfacility setting. Once the...

The catch is you have to make the request for your rightful dollars.

Here’s a piece of good news for you. As per the Medicare’s April update, three Holter monitor codes will get a slight boost in pay.

The change has an implementation date of April 4, 2011, and an effective date of Jan. 1, 2011. That means contractors have to be ready to comply with the change by April 4, but the change in practice expense relative value units (PE RVUs) is retroactive to Jan. 1 dates of service.

Medicare isn’t requiring contractors to search their files to adjust claims they have already paid (which is good news for any physician who reports a code seeing a fee decrease). But contractors do have to adjust claims if you bring them to their attention. Take a look at how many 93224-93227 services you provided from January to March to see if making the claim for the small increase in RVUs is worth your time.

93224: The PE RVUs for 93224 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation) will change from 2.30 to 2.53. That’s a difference of .23 RVUs. Multiply that by the 2011 conversion factor (33.9764), and you can expect roughly an additional $7.81 for this code. (Remember that geographic region will affect your fee, as well).

93225: For 93225 (…recording [includes connection, recording, and disconnection]), the PE RVUs only increase by .09, changing from 0.82 to 0.91. So the additional reimbursement should be roughly $3.06.

93226: You may see an additional $4.76 for 93226 (… scanning analysis with report). Its PE RVUs change from 1.21 to 1.35.

Swan-Ganz: If you ever report 93503 (Insertion and placement of flow directed catheter [e.g.,...

Keeping track of all the different potential allergens that may be causing a patient’s skin rash is challenging enough. But when you add the complexity of the several different kinds of dermatitis tests that a dermatologist can perform, it’s enough to cause a coder to break out in a rash herself. The variety and complexity of allergy tests can certainly lead to coding mishaps — but understanding the codes and having clear documentation can help clear things up.

The tests that dermatologists commonly perform to learn the source of a patient’s allergic dermatitis include scratch tests and patch tests. Knowing what code to use means understanding what each test does, and how.

Count Each Allergen in Scratch Tests

Procedure: Percutaneous tests

AKA: Scratch tests, prick tests, puncture tests, Multi-Test

Codes: 95004 (Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests) and 95010 (Percutaneous tests [scratch, puncture, prick] sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, including test interpretation and report by a physician, specify number of tests).

In these tests, the dermatologist applies test solutions of possible allergens to scratches or shallow punctures of the skin. The code you report will depend on the type of solutions applied — allergenic extracts, such as dust, cat dander, and molds (95004), or antibiotics, biologicals, stinging insects, and local anesthetic agents (95010).

Dermatologists usually want to test several substances at once (often in blocks of eight), and each substance counts as a separate test, notes Pamela Biffle, CPC, CPC-P, CPC-I, CCSP, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas. Be sure to code for each allergen administered by putting the number in the “units” field of your claim form.

Hidden...

When reporting inhaler service, you should remember the type of device the provider is using, but shouldn’t stop with just that. Documentation requirements and qualifying modifiers are just as important when coding for inhaler services.

When you’re confused why some payers would deny reimbursement for certain inhaler claims, the following ideas could guide you to a better understanding of how inhaler service codes work out.

94664 Is Your Ticket to Diskus Demo Pay

The Advair Diskus is an “aerosol generator.” If the nurse/medical assistant taught someone to use an Advair Diskus — or any other diskus — you should report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

For example, a pulmonologist starts a patient with asthma (493.00, Extrinsic asthma; unspecified or 493.20, Chronic obstructive asthma; unspecified) on Advair. A nurse then teaches the patient how to use the Diskus. As per CPT guidelines, you should report 99201-99215 for the office visit and 94664 without a modifier, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

In addition, CMS transmittal R954CP also indicates that modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) applies only to E/M services performed with procedures that carry a global fee, which 94664 does not have.

Nonetheless, many payers will only pay for the service if you append modifier 25 to the visit code. It’s always best to check with your major insurers’ policy first.

Bundle Dose in Teaching Session

The patient may administer medication dose during the teaching session. Both services (treatment + teaching) are bundled into one CPT: 94640 (Pressurized or nonpressurized inhalation treatment for acute...

Stick to these 3 tips for your E/M and lesion removal procedures.

You can report both the E/M and lesion removal if the E/M service was a significant and separately identifiable service for an E/M service with actinic keratoses (AK) removal procedure.

Always verify with your carrier before appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

You can only consider reporting modifier 25 when coding an E/M service, says Janet Palazzo, CPC, coder for a practice in Cherry Hill, N.J. If the procedures you are reporting don’t fall under E/M services, it is possible the encounter qualifies for another modifier instead.

Have a look at the following three tips to help you report these services accurately so your practice won’t miss out on about $41 for 99201 and $80 for 17000 or more, according to national averages indicated in Medicare’s 2011 Physician Fee Schedule.

1. Know When You Should Charge an E/M

Each insurer has its own guidelines for office visits (99201- 99215, Office or other outpatient visit …) and lesion removals (17000-17111, Destruction, Benign or Premalignant Lesions). So, knowing whether to appeal an E/M denial is difficult unless you know that the service deserves payment.

You should report the office visit (99201-99215) in addition to the procedure when the dermatologist performs a significant, separately identifiable E/M service from the AK removal, especially if the patient is new to your practice.

Along with the appropriate E/M code, report any diagnoses that come with that examination, which may include more than just the AK.

For example, if a patient comes in for an initial AK visit, you should charge an E/M service, since the physician has to examine the area and discuss treatment options. But...