The new fifth-digit diagnosis codes for body mass index (BMI) can help you better document a patient’s condition, especially when the patient’s BMI might contribute to more complex risk factors for the anesthesiologist to handle. Having documentation of a high BMI doesn’t automatically lead to more pay, however. Watch two areas before assuming you can automatically append modifier 22 (Increased procedural services) because of BMI and potentially score a 20-30 percent higher pay for the procedure.

Not All Morbid Obesity Means Modifier 22

A patient is considered to be morbidly obese when his or her BMI is 40 or more. New BMI codes for 2011 include:

• V85.41 — Body Mass Index 40.0-44.9, adult
• V85.42 — Body Mass Index 45.0-49.9, adult
• V85.43 — Body Mass Index 50.0-59.9, adult
• V85.44 — Body Mass Index 60.0-69.9, adult
• V85.45 — Body Mass Index 70 and over, adult.

While morbid obesity can be an appropriate reason to report modifier 22, don’t assume you should always append the modifier just because the patient is morbidly obese.

Example 1: During surgical procedures that are performed because of morbid obesity (such as bariatric surgery), the patient must meet the morbidly obese criteria too support medical necessity for the procedure. In those type instances, simply having a patient who is morbidly obese doesn’t support using modifier 22. Remember, if you report a physical status modifier for a patient who is morbidly obese, it is not appropriate to also include modifier 22. Keep in mind that Medicare does not pay for physical status, qualifying circumstances, or extra work modifiers.

The anesthesia provider’s documentation should direct you to the correct BMI code as well as support when you can append modifier 22.

Example 2: The patient’s obesity might contribute to breathing problems that lead to lower oxygen and...

If your dermatologist is treating vitiligo or dychromia patients with phototherapy, read your physician’s documentation carefully to determine what type of light, wavelength, and materials he used. These two frequently asked questions will help you combat both E/M and multi equipment correct coding initiative (CCI) situations.

Evaluate These Phototherapy + E/M Tips

If you’re charging for an office visit on the same day as phototherapy, your reimbursement may depend on whether your physician’s documentation warrants a different diagnosis code. Payers may reimburse at times if the doctor sees the patient for a different problem, thus with a different diagnosis code, experts say.

Example: If your physician performs 99212 (Office or other outpatient visit for the evaluation and management of an established patient … Physicians typically spend 10 minutes face-to-face with the patient and/or family) with phototherapy, you will bill it with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the E/M service. You can only consider reporting modifier 25 when coding an E/M service, Janet Palazzo, CPC, a coder in Cherry Hill, N.J., says. Remember your E/M documentation has to show medical necessity for the additional work.

If you reported the nurse visit code 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician …), your payer would likely consider it bundled into the light treatment.

Ask 2 Questions to Choose Best Light Therapy Code

For patients with vitiligo (709.01), your dermatologist may use narrow band UVB phototherapy.

The dermatologist administers phototherapy two to three times per week for several months until the patient achieves repigmentation of the skin. For this procedure, you need to pinpoint what types the...

How many times has it happened with you that you submit a clean claim but still don’t get paid even three months later? Do you have any recourse? Yes, thanks to the prompt pay laws that each payer must follow when paying your medical claims.

Verify Which Laws Apply to Your Practice

Each state requires private insurers to pay all clean claims within a certain time frame. If the insurer does not pay the claim in a timely manner, then the payer is subject to paying interest on the charges owed to the practice (or directly to the beneficiary). Most time frames range from 15 to 45 working days, with 30 days about the average.

“If you are a little adventurous, you could search for your state law on the Internet,” says Joseph Lamm, office manager with Stark County Surgeons, Inc. in Massillon, Ohio. Lamm warns, however, that “reading through state laws and their multiple exceptions, references to other sections of state law, and ‘legalese’ can make this a very frustrating exercise.”

“Take advantage of your local or state medical society and the experts they employ to see if your state has a prompt pay law, and to which insurance companies it applies,” Lamm suggests. “The medical societies are on your side and will give you the correct information.”

State prompt pay laws do not apply to federal insurers, because the Federal Government dictates that clean claims must be paid in 30 days for Medicare Part B.

“If a state wants a prompt pay rule that’s longer or shorter, they certainly can do that with reference to other payer services,” says Connie A. Raffa, Esq., partner with Arent Fox, LLP in New York, NY. “But Medicare rules are federal and span across the country.”

If your private payer...

Correct Coding Initiative version 17.1 brings 11,831 new edit pairs, effective April 1 for physicians. That’s the word from a March 17 announcement by Frank Cohen, principal and senior analyst for the Frank Cohen Group. Here’s a look at the major pointers you need to keep in mind to comply with the new cardiology-related edits, including cardiac catheterization, radiological supervision and interpretation, cardiac rehabilitation, and more.

1. Prevent Denials by Remembering 93454-93461 Are Diagnostic

New edits will prevent you from reporting heart catheter/angiography codes 93454- 93461 (column 2) with the following cardiovascular therapeutic services and procedures (column 1):

• 92975 — Thrombolysis coronary; by intracoronary infusion, including selective coronary angiography
• 92980 — Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel
• 92982 — Percutaneous transluminal coronary balloon angioplasty; single vessel
• 92995 — Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; single vessel.

The 929xx codes in column 1 describe coronary therapies. The 934xx codes in column 2 are diagnostic procedures. You should never use the 934xx diagnostic codes in column 2 to report catheter placement and coronary angiography performed as an integral part of the therapeutic column 1 services.

Opportunity: The edits have a modifier indicator of 1, so you may override them with an appropriate modifier when the procedures are distinct. If you report both codes in the edit pair and don’t append a modifier to the column 2 code, Medicare (and payers applying Medicare rules) will reimburse you for only the column 1 code.

The AMA, via CPT Assistant (April 2005), indicates that you may report a true diagnostic catheterization in addition to the therapeutic procedures described by 92980 and 92982: “These two distinct procedures (diagnostic catheterization and therapeutic procedures), therefore, should...

If your physician administers trigeminal nerve blocks to patients for headache relief, brush up on the ins and outs of anatomy and potential diagnoses. Read on for two keys that will keep your coding for these procedures pain free.

Learn the Location

The trigeminal nerve provides sensory innervations to most of the face; providers might also refer to the trigeminal nerve as the “cranial nerve V” or the “fifth cranial nerve.” The name “trigeminal” stems from the fact that the cranial nerve has three major divisions, or branches:

• The ophthalmic nerve (V1 division) primarily innervates the forehead and eye area
• The maxillary nerve (V2 division) provides innervation to the upper jaw area from below the eye to the upper lip
• The mandibular nerve (V3 division) provides both sensory and motor innervation to the lower jaw area.

Providers can administer trigeminal injections at any of the three divisions or branches of the divisions, says Debbie Farmer, CPC, ACS-AN, with Auditing and Compliance Education in Leawood, Kan. You should report injections with 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch).

Patients who need trigeminal nerve injections can have conditions ranging from severe headache to postherpetic neuralgia to trigeminal neuralgia (also known as tic douloureux). Common diagnosis codes can include:

• 053.12 — Postherpetic trigeminal neuralgia
• 350.1 — Trigeminal neuralgia
• 350.2 — Atypical face pain.

Review Bilateral Rules

If your provider administers bilateral injections, include extra details with the claim that will help garner the appropriate reimbursement. Medicare and many other payers allow you to report trigeminal injections bilaterally by appending modifier 50 (Bilateral procedure).

Most Medicare contractors request that providers report bilateral services as one line item with modifier 50 appended and one unit of service noted (64400-50 x 1). Medicare will process the service at...