Knowledge Base Category -

Q:

For the hospital inpatient setting, which guideline applies when  a physician documents  comparative/contrasting diagnoses for secondary diagnoses?

A:

Apply the following guideline for Uncertain Diagnosis, Section II.H:

If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established.  The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

Resources:

ICD-10-CM Official Guidelines for Coding and Reporting

Coding Clinic, Second Quarter 2016:  Page 9 

Q:

I have heard there are a lot of changes for CPT codes for fine needle aspiration (FNA) for 2019. What are those changes?

A:

Currently there are only two CPT codes for fine needle aspiration (FNA):

• 10021 – FNA without imaging guidance
• 10022 – FNA with imaging guidance

In 2019, there will be a total of 10 codes for FNA, based on the specific type of imaging guidance used (i.e., ultrasound, fluoroscopy, CT, MRI), and differentiated by initial lesion and each additional lesion.

The descriptions have also been revised to include the word “biopsy”, for a biopsy performed with fine needle technique.

Since the new codes include imaging guidance, a separate CPT code for imaging guidance cannot be reported. This has major implications for Radiology if they have been entering a charge for the procedure plus a separate charge for the guidance – in 2019, the radiology / imaging component is “bundled” into the main procedure.  Ultrasound guidance (76942) is the most common type of guidance used.

In most cases, only one lesion is aspirated. However, when a needle core biopsy is performed in addition to an FNA biopsy, CPT guidelines describe how these should be reported, even breaking it down to specific information about:

• same lesion,
• separate lesion(s),
• same imaging modality,
• different modality(ies)
• and instructions on when to use modifier 59.

For Coding / HIM staff who code these procedures:

Keep in mind that in order to report a CPT code that includes imaging guidance, permanently recorded images should be obtained. As you know….whether permanently recorded images are obtained is rarely documented in the procedure note. To confirm this, check with the radiology department to find out if this is their standard procedure.

Example: If an FNA was performed using ultrasound guidance, but permanent images were not recorded, in 2019 you will report revised CPT code 10021 = FNA “without imaging guidance” first lesion. 

Q:

Do you code Pneumonia, nos (J18.9) when a physician documents “Right Upper Lobe Pneumonia” and no causal organism is identified?

A:

No.  Effective with discharges September 24, 2018, Right Upper Lobe Pneumonia is coded to Lobar Pneumonia, unspecified organism (J18.1).  If the physician documents that Pneumonia is specified in one  or more lobes, code to Lobar Pneumonia or Multi-lobar Pneumonia, depending on how many lobes are affected.  Remember, the right-side has three lobes and the left-side has two lobes. By coding Lobar Pneumonia, we are coding the specific site of the Pneumonia instead of the type of Pneumonia.  Of course, if an organism is identified as causing the Pneumonia, code to the type of Pneumonia instead.  Please refer to the Coding Clinic listed below for the full update.  

Resource:  Coding Clinic for ICD-10-CM/PCS, Third Quarter 2018:  Page 24 

Q:

With so many different Contractors requesting medical records for review, how can I keep current with who is reviewing what?

A:

You are correct, there are several Contractors requesting records and staying abreast of all of the issues can be a challenge. Here are some of the key players auditing Medicare records.

Office of Inspector General (OIG):

In June of 2017 OIG began updating their once Annual Work Plan on a monthly basis as the Work Planning Process is “dynamic and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available. You can access the Work Plan on the OIG website at: https://oig.hhs.gov/reports-and-publications/workplan/index.asp

Medicare Administrative Contractors (MACs):

In October 2017 CMS implemented a Target Probe and Educate (TPE) Review Process for the MACs. With this type of approach, MACs are focused on providers/suppliers who have the highest claim error rates or billing practices that vary significantly from their peers. In general, MACs will post a current Active Medical Log to their website. Depending on the MAC, this can sometimes be a challenge to find.

CMS has a MAC Website List page where you can select your state to go to your specific MACs website (https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/MAC-Website-List.html#Alabama).

Recovery Audit Program (RACs)

The RAC’s review claims on a post-payment basis. CMS maintains a RAC webpage that provides links to the different RACs across the country, Proposed and Approved RAC Topics. A few of their current Approved Topics includes cardiac pacemakers, cataract surgery and implantable automatic defibrillators – ICDs. You can access the CMS RAC webpage at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Index.html.

Supplemental Medical Review Contractor (SMRC)

Prior to February 13, 2018 Strategic Health Solutions was the SMRC. The SMRC performs reviews at the direction of CMS with the aim of lowering the improper payment rates. On February 13, 2018 CMS announced that Noridian Healthcare Solutions, LLC was awarded the new $227 million contract. CMS does have a SMRC webpage (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/SMRC.html). However, at the time of this article neither CMS nor Noridian have posted any issues under review.

The Comprehensive Error Rate Testing (CERT) Program

CMS implemented this program to measure improper payments in the Medicare Fee-for-Service program. Annually, the CERT selects a stratified random sample of approximately 40,000 claims submitted to Part A/B MACs and Durable Medical Equipment MACs (DMACs) for review. It is important to keep in mind that they report a measurement of payments not meeting Medicare requirements meaning their improper payment is not a “fraud rate.”  They post an Annual Report and Appendices to the CERT CMS webpage. Reviewing these reports can help you identify high find error prone cases types. For example, in the 2017 National Annual Report, the CERT reported Major Joint Replacement or Reattachment of Lower Extremity, Heart Failure and Shock, and Chronic Obstructive Pulmonary Disease as three of the top 20 service types with the highest improper payment in the acute inpatient setting. The CERT webpage can be accessed at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.html.

Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs)

In 2015, CMS made the decision to move Short Stay reviews from the MACs to the BFCC-QIOs. These reviews are for a hospital length of stay less than two midnights and focus on ensuring doctors and hospitals are following the Part A payment policy for inpatient admission. If a hospital is identified as having a consistent trends of high denial rates, the process if for the BFCC-QIO to refer that hospital to the RACs who will conduct patient status reviews. You can locate your QIO at this website: https://qioprogram.org/contact.

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

The PEPPER is an electronic data report containing a single hospital’s claims data statistics for MS-DRGs and discharges at risk for improper payment due to billing, coding and/or admission necessity issues. Each report compares a hospital to their state, MAC Jurisdiction and the nation. “The Office of Inspector General encourages hospitals to develop and implement a compliance program to protect their operations from fraud and abuse. As part of a compliance program, a hospital should conduct regular audits to ensure charges for Medicare services are correctly documented and billed. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide the hospital’s auditing and monitoring activities.” In general, a hospital’s Quality Department can provide the report to key departments (i.e. Case Management and HIM).

MMP, Inc. Compliance Assessment Tool (CAT)

In January of 2017, the OIG, in collaboration with a group of compliance professionals, released a Resource Guide to measure the effectiveness of compliance programs.  Items 5.27-5.36 emphasize a Risk Assessment is key to developing an effective Compliance audit/work plan.  As you can see from the list of Contractors above, the number of Medicare risk areas to consider can be overwhelming and the financial risk is great. Medical Management Plus, Inc. (MMP) can help.  We can provide a Compliance Assessment Tool that summarizes the Medicare risk areas from Medicare review entities with your facility’s volumes, charges, and payments for each issue.  The report also includes information on coverage policies that define the medical necessity requirements for these issues.  And MMP is always available to help with audits or education.  If you are interested in learning more about our Compliance Assessment Tool or our audit and education services, please contact us using the form at the bottom of this page or call 205-941-1105.

Q:

We have a new physician that wants to use isoproterenol injections for ablation procedures.  Is there a HCPCS code for this drug as an injectable?  If there is not a specific code for it, would this drug qualify for the C9399 code? Is there any reimbursement for this drug? It is high cost and we want to evaluate the financial impact of using it.

A:

Isoproterenol has been around for years, so C9399 would not be applicable unless there is a formulation one of the drug newly released from the FDA.

There are HCPCS codes available for the inhalation form of isoproterenol, but I am not aware of a HCPCS code for the injectable form.  Without a HCPCS code, you will have to report the drug without a HCPCS code and revenue code 250, thus, no separate reimbursement for that line item drug.

Q:

We are doing hydration infusions pre- and post-IV contrast studies (e.g., CT, IVP, etc.) for patients with elevated creatinine levels.  The question was asked whether we should be charging for it.  Can we report hydration infusions in this scenario (CPT codes 96360, 96361)?

A:

The definitive documentation you need is in Coding Clinic for HCPCS, 3Q 2007, pages 6-9.

In that discussion, they say hydration ‘cannot’ be reported in that scenario, with the specific example of a patient with an elevated creatinine receiving IV hydration to prevent damage to the kidneys.

Hydration is incidental to the CT scan, and not separately reportable.

There is a similar Coding Clinic article (4Q 2007, page 6) asking about patients with mitral valve prolapse coming in for an endoscopy, who are given a prophylactic antibiotic. Again, administration of the antibiotic is part of the pre-procedure preparation and should not be reported separately.

Q:

Should decompression/release of a spinal nerve root be assigned along with the spinal fusion code(s) if the decompression is performed at the site of the fusion?

A:

Yes, if there is a distinct intent, then both release and the fusion can be coded at the same level.  This issue will be addressed in an upcoming Coding Clinic.

Resource: Maria Ward, MEd, RHIT, CCS, CCS-P, Director, HIM Practice Excellence, Coding Services at AHIMA

Q:

We have documentation that a PICC line nurse inserted a “PIV” in the patient’s right lower arm with a 20-gauge needle / angiocath. If the nurse had also documented the vein as the cephalic, basilic, or dorsalic, could we report this as a PICC line insertion, CPT code 36569?

A:

This sounds like a regular IV start that happened to be done by the PICC nurse.

Usually, if the PICC nurse puts in a true PICC line, they will specifically call it a PICC line. In your question, the PICC nurse calls it a PIV = peripheral IV, and they used a 20-gauge needle.

In order to report a PICC line, you would also need documentation of the final position of the catheter tip in a central vessel or right atrium – per CPT guidelines.

We usually see this documented by a chest x-ray or with a tip confirmation system like Sherlock.

Based on the details stated in the question, and assuming the PIV will be used for medications and/or IV fluids, there is not a CPT code to report.

It’s just an IV start - - even if it was difficult and required the skills of a PICC nurse.

Q:

Is there any information available yet concerning the 2019 CPT codes for Radiology services?

A:

Yes. The American College of Radiology (ACR) has released information about the 2019 CPT code changes expected for Radiology. Just like years past, we will see more procedures with bundling of the Radiology component into the surgical procedure; in other words, no separate reporting of the imaging guidance 7xxxx CPT code.  

If your facility performs any of the procedures listed below, you may want to take a closer look. Click here to see ACR’s summary.  

• Fine needle aspirations inclusive of imaging guidance
• Breast MRI with CAD
• Knee arthrography
• Ultrasound elastography
• Contrast enhanced ultrasound
• Deletion of fluoroscopy CPT code 76001
• PICC line insertion inclusive of imaging guidance
• Gastrostomy tube replacement – simple and complex
• Bone density ultrasound
• PET absolute quantitation myocardial blood flow

Q:

What are the Medicare rules for reporting modifier GG?

A:

Modifier GG is defined as the performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day.

In MMP’s experience, extra mammogram views to further investigate a potential problem seen on a screening mammogram are typically performed on a subsequent day. This allows the radiologist ample time to review the patient’s previous mammograms for comparison. But, additional diagnostic views are sometimes performed on the same day as the screening mammogram, and this creates the scenario for reporting modifier GG.

One of the best CMS references for using modifier GG is in the Correct Coding Initiative (CCI) Policy Manual for Medicare Services, chapter IX, page IX-8, paraphrased here:

Screening and diagnostic mammography are normally not performed on the same date of service. However, when the two procedures are performed on the same date of service, Medicare requires that the diagnostic mammography CPT code be reported with modifier GG and the screening mammography CPT code be reported with modifier 59.

The Medicare Claims Processing Manual, chapter 18, section 20.6 provides some additional information.

• A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam. 
• When a radiologist’s interpretation results in additional films, Medicare will pay for both the screening and diagnostic mammogram.
• Providers submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier “GG” to the diagnostic mammography. 
• A modifier “-GG” is appended to the claim for the diagnostic mammogram for tracking and data collection purposes.