Coding Articles

Best Guide to E-Visit Documentation, Coding, and Billing August 3, 2022

The American Academy of Family Physicians (AAFP) encourages safe, secure online interactions between physicians and patients, such as electronic visits or “virtual e-visits.” In non-emergency situations, e-visits can substitute for office visits with primary care providers. It is a fast and easy online procedure for patients to receive a diagnosis and treatment plan.

This article will give you the best guide to e-visit documentation, coding, and billing.

What Should Providers Know About E-visits? 

An encounter must meet the following criteria to be considered an e-visit:

• The practice must have a well-established relationship with its patients.
• E-visits require patient consent and a communication request.
• The patient must initiate non-face-to-face electronic communication. For example, patient portal systems.
• Patients must not have seen an office visit to a physician or therapist for the same clinical concern in the past seven days.
• It is only possible to report e-visits every seven days.
• An e-visit is not the same as typical therapy sessions.

For e-visits, the following documentation requirements are needed:

• The main complaint with all evaluation and management services (E/M).
• The specifics of treatments, assessment of diagnoses or symptoms, evaluation, and conversation.
• An official patient consent record is backed up by a signature and captured in the clinical note. Moreover, e-visit software platforms accept scanned copies of signed consents. Some systems allow electronic signatures.
• The total time recorded over the seven days supporting the billable service.

List of Current Procedural Terminology (CPT) Codes That Require Providers to Follow Policies Set by Payers

The codes for online digital evaluation services (e-visits) used by doctors are complex. Below are the codes used:

Medicare uses the following HCPCS codes and descriptors for qualified non-physician professionals for its online digital evaluation service (e-visit):

Private payers and workers’ compensation are using the following online digital evaluation service (e-visit) CPT codes and descriptors:

Do’s and Don’ts in Billing E-Visits

When the following conditions are met, you can bill an e-visit:

• The provider establishes a relationship with the patient.
• Response time by the provider is longer than five minutes.
• A provider responds through the patient portal to a message initiated by the patient.
• A visit meets the 2021 E/M guidelines. 
• It has been seven days since the clinician last saw the patient.
• There is no global period for the same or similar condition for the patient.
• In this case, the provider is making a clinical decision that would normally be performed in the office (e.g., medication dose adjustment, ordering a test, or prescribing a new medication).
• A patient has consented to the e-visit and understands that he may be billed.
• For online digital E/M services, the service period includes all related work done within seven days by the reporting individual and other registered healthcare providers (RHPs) in the same group practice.
• The 7-day period begins when the reporting provider reviews the patient’s inquiry personally for the first time.
• A new/unrelated problem from the patient arises within seven days of the previous E/M visit for a different issue.

Do not bill an E-visit in the following situations:

• During the 7-day period, the provider may bill for other separately reported services (such as care management, INR monitoring, remote monitoring, etc.)
• The same or similar condition was billed to the patient for an e-visit within the past 7 days. 
• The patient inquires about a surgical procedure that happens during the surgery’s postoperative period (global).
• Providers are simply disseminating results, processing medication requests, or scheduling appointments (for billing, E/M services must be performed).
• A separate face-to-face E/M service (either in person or via telehealth) happens (included in the E/M) during the 7-day period of the e-visit.
• Besides clinical staff time, only provider time can be included.

The AAFP published an algorithm in response to the growing number of virtual visits. It was developed by James Dom Dera, MD, FAAFP, to determine which code should be used for virtual services.

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2022 Coding and Billing Updates for COVID-19 Services and Testing June 29, 2022

Many things have changed in the healthcare industry since the emergence of COVID-19 (2019-Novel Coronavirus). Besides straining medical supplies and personnel, it also sped up the process of producing and publishing coding guidelines. 

This blog article provides a guide to 2022 coding and billing updates for COVID-19 services and testing.

When to use the cs modifier for COVID-19? 

We use modifier CS on visits related to testing for COVID-19. The latest COVID-19 billing guidelines also state that physicians can apply it to two contexts relating to coding and billing.

• The visit could be virtual or in-person for suspected or probable exposure to COVID-19.
• Tests for diagnosing COVID-19 without including a COVID-19 test

Let’s examine each case individually.

Suspected or Probable Exposure to COVID-19 

When billing for virtual/in-person for suspected COVID-19 exposure, you typically use the following E/M codes:

• ICD-10 codes Z03.818, Z20.822, and Z20.828
• Modifier CS
• If the patient is receiving virtual care, append the modifier GQ, GT, or 95

Modifier CS can also apply for these services:

• If the result of the service involves the order for or the administration of a COVID-19 test
• If the service relates to delivering or administering tests
• If the purpose of the service is to evaluate and determine if the patient needs COVID-19 testing

The cost-share will be waived through April 20th, 2021. Thus, providers need to understand that the cost-share will be waived only when they bill the correct ICD-10 code and modifier CS.

What is Modifier CR? 

It indicates whether Medicare payment for a service is subject to the Centers for Medicare & Medicaid Services (CMS) approval. As a reminder, the CMS has informed us that the CR modifier does not apply to claims recently added to the CMS list of services that may be provided by telehealth.

It is also possible to bill modifier CR or condition code DR in place of modifier CS. Also, a customer cost-share will apply to services unrelated to COVID-19.

Tests for Diagnosing COVID-19

These are the common codes used for tests relating to COVID-19:

• ICD-10 codes Z03.818, Z20.822, or Z20.828
• Modifier CS

These codes are used for laboratory tests in cases where COVID-19 may be suspected. These tests must be reasonable practices to rule out the presence of COVID-19.

Only the code for the panel test will be reimbursed if the COVID-19-related test is part of the laboratory panel code.

If the test is not part of a laboratory panel but rather part of a series of pathogen tests, the relevant unbundling edits may be applicable.

Source: Journal of Ahima, 2021

Monoclonal Antibody Treatment Administration for Commercial Health Plans 

• This billing guidance applies only to urgent care facilities with an all-inclusive rate per case, per diem, per visit, and per unit.
• We are following the place of service testing and case rate guidelines per the Centers for Medicare & Medicaid Services (CMS).
• An in-network urgent care center must bill with the place of service 20 on a CMS-1500 form
• Accordingly, we will pay 100% of the CMS allowable rate for the codes below.

Service: COVID-19 Testing at Urgent Care Facilities

Newly Added Vaccine and Administration CPT Codes 2022

New Guidelines for Outpatient Services Under COVID-19 Cost Share Waiver

Use the CS modifier on appropriate outpatient claim lines for services provided through the end of the Public Health Emergency (PHE). This illustrates that the service is eligible for a cost-share waiver for COVID-19 testing-related services contracted for and related to the provision or administration of a COVID-19 test. 

Providers will receive a waiver of cost-share when they: 

• Submitting a claim line with CS modifier (professional, facility, telehealth) with a specific outpatient E&M or HCPCS code and when billed of probable or suspected exposure to COVID-19: ICD Z20.822 as the primary diagnosis, as needed.

• Submits a COVID-19 CPT/HCPCS claim line testing for preoperative procedures. 

• Z01.810 – preprocedural cardiovascular examination 
• Z01.811 – preprocedural respiratory examination 
• Z01.812 – preprocedural laboratory examination 
• Z01.818 – other preprocedural examination

• For each additional lab test other than the COVID-19 diagnostic test, a CS modifier must be added to each claim line. If the lab test was ordered specifically to determine a diagnosis of COVID-19 and if billed with probable or suspected exposure to COVID-19, a primary diagnosis of Z20.822 should be put forth.

We hope that this guide to COVID-19 updates in coding and billing for 2022 has been useful to you. Visit the American Medical Association (AMA) for more information on COVID-19 codes, services, and vaccine updates.

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What to Expect from New Pain Management Coding Updates and Guidelines 2022 May 3, 2022

The ability to understand medical terminology has always been an essential requirement for medical coders. To better understand the language of the new codes, they should review anatomy and physiology terms.

Troubleshooting is another important recommendation for ICD-10-compatible software and computer formats. This knowledge will assist healthcare providers in resolving any technical problems in time. Thus, healthcare providers must be aware of the potential impact of coding system changes on existing and new insurance programs.

In this article, we’ll find out what to expect from new pain management coding updates and guidelines 2022.

Pain Management Coding Updates 2022

As of 2022, two CPT codes have been deleted and replaced with new ones that provide more detail about procedures.

Moreover, the new codes 01937-01942 identify the type of surgical procedure performed under anesthesia and whether it’s done on the cervical, thoracic or lumbar spines.

New CPT codes for 2022

In the table below, you can refer to the  new CPT code changes for 2022 applicable to anesthesia and pain medicine:

Likewise, we’ll discuss some other commonly used pain management CPT codes. These include acupuncture, dry needling,  and radiofrequency ablation.

Acupuncture

In accordance with NCD 30.3.3, Medicare now covers all types of acupuncture as a treatment for lower back pain. Patients with chronic lower back pain can receive acupuncture treatment for up to 12 sessions within a 90-day period through Medicare.

The purpose of acupuncture is to relieve pain and restore energy flow by inserting tiny needles through the skin. According to the National Center for Complementary and Integrative Health Trusted Source, acupuncture effectively treats back pain, osteoarthritis, and knee pain. Furthermore, it stimulates the body’s natural healing processes and promotes health and happiness.

Acupuncture CPT Codes

Acupuncture data is reported based on 15-minute increments of personal contact (face-to-face) with the patient, not on the intensity or duration of the acupuncture treatment.

• When electrical stimulation is not used during a 15-minute increment, report CPT codes 97810 or 97811.
• Electrical stimulation of any needle during a 15-minute increment are reported by using CPT codes 97813 or 97814.
• For each 15-minute increment, you should report only one code
• Use CPT code 97810 or 97813 for the initial 15-minute increment
• Each day you should only report one initial code

Dry Needling

The following CPT codes are used for dry needling, which is also known as trigger point acupuncture.

The Current Procedural Terminology specifies that CPT codes 20552 or 20553 (trigger point injections) must not be reported with CPT codes 20560 or 20561 for the same muscle group.

Radiofrequency Ablation

The radiofrequency ablation (RFA) procedure involves delivering an electric current to a small nerve tissue area to prevent pain signals from being transmitted through that area. It can relieve chronic pain, specifically in the lower back, neck, and arthritic joints. 

These are the RFA CPT codes 2022:

• If radiofrequency ablation is used with traditional or cooled radiofrequency (80 degrees Celsius), report it with CPT code 64625.
• Report pulsed radiofrequency ablation by using CPT code 64999.

CPT Code Changes for Important Diagnoses

• C56.3 Malignant neoplasm of bilateral ovaries (previously only left, right, unspecified existed)
• C79.63 Secondary malignant neoplasm of bilateral ovaries (previously only left, right, unspecified existed)
• G44.86 Cervicogenic headache
• K22.81 Esophageal polyp
• K22.82 Esophagogastric junction polyp
• K22.89 Other specified diseases of esophagus (previously codes as K22.8, 5^th character added)

• K31.A—Gastric intestinal metaplasia (code to appropriate 6^th character)
• L24.A- Irritant contact dermatitis due to friction or contact with body fluids (code to appropriate 5^th character)
• L24.B- Irritant contact dermatitis related to stoma or fistula (code to appropriate 5^th character)
• M54.A- Non-radiographic axial spondyloarthritis (code to appropriate 5^th character)
• M54.50 Low back pain, unspecified
• M54.51 Vertebrogenic low back pain
• M54.59 Other low back pain

Any ambulatory surgical centers performing pain management procedures need to be aware of these low back pain diagnosis changes. In order to avoid an unspecified diagnosis, surgeons must understand how the revisions affect their documentation. They must be as specific as possible about the type of low back pain treated.

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Medical coders might face some new challenges in light of the new pain management billing codes and guidelines. As a result, healthcare providers should evaluate how medical coding changes will affect their programs and take steps to ensure a smooth transition.

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

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Podiatry CPT Coding Updates for 2022 April 27, 2022

Every year, the American Medical Association releases a new Current Procedural Terminology set that takes effect on January 1.

Most of this year’s changes come from new guidance language rather than code additions, deletions, or edits for podiatry practices. Let’s first define podiatry care in detail before moving on to the CPT updates.

The Role of Podiatry in Healthcare

The field of podiatry deals with the diagnosis and treatment of diseases, injuries, and deformities of the foot. It involves the diagnosis, medical, and surgical treatment of the foot, ankle, and lower extremity problems. In addition to medical and surgical treatments, mechanical and physical therapies are also available. Like other disciplines, podiatry requires regular collections to survive.

On the other hand, coding is complex in podiatry due to multiple procedures performed on the same structure or organ, requiring various codes.

The Current Procedural Terminology adds the following clarification for 2022: “All services that appear in the Musculoskeletal System section include the application and removal of the first cast, splint, or traction device when performed. Supplies may be reported separately.” 

Several third-party payers, such as Medicare, have long followed this guidance, which applies everywhere CPT codes are used, regardless of the payer.

This guidance does not change based on where you receive your services. If the triple arthrodesis is performed in the operating room, the CPT code representing the cast application should not be submitted.

Similarly, suppose any fracture care code is submitted in an office setting, such as closed fracture treatment without manipulation. In that case, the CPT code corresponding to the cast application should not be submitted.

Podiatrists managing fractures often have to decide whether to perform closed treatment with manipulation or closed treatment without manipulation CPT codes.

The new language in the 2022 CPT code set clarifies what “manipulation” actually means when used in code descriptors in CPT. Manipulation is defined as: “reduction by the application of manually applied forces or traction to achieve satisfactory alignment of the fracture or dislocation.” Usually, this is referred to as closed reduction.

The CPT clarified the following codes for external fixation this year:

“Codes for external fixation are reported separately only when external fixation is not listed in the code descriptor as inherent to the procedure.”

Therefore, providers can only submit external fixation CPT codes. CPT does not include the application of external fixation in its code descriptor for the primary procedure.

Below is the CPT code corresponding to a first metatarsophalangeal joint arthrodesis:

CPT 28750—Arthrodesis, great toe; metatarsophalangeal joint

Code descriptor doesn’t include external fixation in the list. Hence, the CPT code for the first metatarsophalangeal joint arthrodesis and the CPT code for the external fixation can both be submitted if external fixation is used. 

In the case of an open reduction and internal fixation (ORIF) of a metatarsal fracture that is fixed with external fixation, the CPT code for the external fixation would be:  

CPT 28485—Open treatment of metatarsal fracture, with or without internal or external fixation, each

This is listed in the code descriptor. Thus, if external fixation is used with this procedure, only the ORIF CPT code can be submitted; the external fixation CPT code cannot be submitted as well.  

Foreign Body vs Implant 

If a joint prosthesis becomes loose or isn’t functioning, is it considered a foreign body removal? The CPT clearly answers this question that has been asked for a while now. 

According to the new language on page 525 of the CPT book for 2022, it states that:  

 “An object intentionally placed by a physician or other qualified health care professional for any purpose (eg, diagnostic or therapeutic) is considered an implant.”

“An object that is unintentionally placed (eg, trauma or ingestion) is considered a foreign body.”

“If an implant (or part thereof) has moved from its original position or is structurally broken and no longer serves its intended purpose or presents a hazard to the patient, it qualifies as a foreign body for coding purposes, unless CPT coding instructions direct otherwise or a specific CPT code exists to describe the removal of that broken/moved implant.”

Wound Repair

This year, a new language adds that only one CPT code is required to represent the closure of one wound when multiple products and/or multiple techniques are used to close it. 

Further information on wound repair is provided in the 2022 CPT book, on page 106, where it is stated that wounds treated with chemical cauterization, electrocauterization, or adhesive strips cannot be coded with wound repair CPT codes.

Clarification of simple wound repair is on the list this year:

“Simple repair is used when the wound is superficial (eg, involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures) and requires simple one-layer closure.”

Moreover, anesthesia and hemostasis should not be reported separately when combined to treat simple wounds.

Key Takeaway

These are just a few changes relevant to podiatrist practices in 2022’s CPT codes. The podiatry providers who submit CPT codes should know the entire CPT code set or use experts who are familiar with it. From January 1, 2022, they should utilize the most current CPT code set.  

The CPT is a trademark of and copyright (2021) of the American Medical Association, with all rights reserved. 

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Prepare Your Practice for the New ICD-10 2022 Guidelines January 7, 2022

As fall approaches, not only do the leaves change but healthcare practices should also be prepared for ICD-10 changes, which take effect every October 1. The Big Question: Is Your Practice Already Prepared for the New ICD-10 2022 Guidelines? Worry no more! With this article, you can adhere to the New ICD-10 Coding Guidelines FY 2022.

So, what are ICD-10 Guidelines? 

In every healthcare setting, ICD-10-CM guidelines are used to classify diagnoses, morbidities, and reasons for patient visits. Healthcare providers and coders must use these guidelines and reporting requirements as companion documents to the official version of the ICD-10-CM.  ICD-10-CM and the ICD-10 code set under the new guidelines, including new, revised, and retired codes, are updated.  Also, the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) implement the newly updated International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), and the ICD-10 code set. A total of 72,748 codes are available this year including 159 new codes, 32 deleted codes, and 20 revised codes. 

New Codes for COVID-19 Infection

New codes are available for FY 2022 to report conditions secondary to COVID-19 infection (sequelae):

• J12.82: Pneumonia due to Coronavirus disease 2019 (MCC)
• M35.81: Multisystem inflammatory syndrome (CC)
• M35.89: Other specified system involvement of connective tissue (CC)
• Z11.52: Encounter for screening for COVID-19
• Z20.822: Contact with and (suspected) exposure to COVID-19
• Z86.16: Personal history of COVID-19

Below is the latest code in a series of six codes added on January 1, 2021:

• U09.9: Post COVID-19 condition, unspecified

New codes for conditions affecting the nervous system

The ICD-10 now includes 10 new codes in this category, with many of them classified as MCC or CC codes (please see above). Some of these new codes include:

• G04.82: Acute flaccid myelitis (MCC)
• G44.86: Cervicogenic headache
• G92.00: Immune effector cell-associated neurotoxicity syndrome, grade unspecified
• G92.01: Immune effector cell-associated neurotoxicity syndrome, grade 1
• G92.02: Immune effector cell-associated neurotoxicity syndrome, grade 2
• G92.03: Immune effector cell-associated neurotoxicity syndrome, grade 3 (CC)
• G92.04: Immune effector cell-associated neurotoxicity syndrome, grade 4 (CC)
• G92.05: Immune effector cell-associated neurotoxicity syndrome, grade 5 (CC)
• G92.8: Other toxic encephalopathy (MCC)
• G92.9: Unspecified toxic encephalopathy (MCC)

ICD-10 2022: New and Deleted Codes

ICD-10-CM coding guideline changes for 2022 include a number of corrections to spelling errors, as well as significant changes to diseases and conditions. Code additions and deletions are also major areas of change. The table below is a high-level breakdown of additions and deletions to the ICD-10-CM coding guidelines for 2022.

The deleted codes:

Implementing Diagnosis Code Changes

To ensure your claims are paid, healthcare practices should integrate the 2022 ICD-10-CM coding guideline changes into their system.

Billing/medical records software systems are a huge risk for your practice (if you use them). It can be disastrous if you blindly rely on your software system to implement ICD-10-CM updates in a timely manner. If there is a problem with your system, the software company is not responsible. The responsibility lies with you. Thus, you should compare the current year’s diagnosis code changes with those added to your software system to identify errors as soon as possible.

Lastly, you must teach your staff and providers about the key changes to the 2022 ICD-10-CM coding guidelines – based on your specialty. By doing so, you will be improving efficiency and accuracy when choosing diagnosis codes – either electronically or on paper.

Key Takeaway

To enhance the quality of reported data, the continuity of care, and patient outcomes, we endeavor to improve ICD-10 codes and clinical documentation throughout the process.

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The New AMA CPT Release Codes for 2022 January 7, 2022

The American Medical Association (AMA) has released the latest version of the Current Procedure Terminology (CPT) code set for 2022.  AMA made 405 changes to the current procedure code set in 2022, including 249 new codes, 63 deletions, and 93 revisions. These changes will take effect on January 1. 

What is a CPT® code?

Current Procedural Terminology (CPT®) codes provide doctors and healthcare professionals a uniform language to code medical services and procedures to simplify reporting, improve accuracy, and increase efficiency. CPT codes are also used to manage administrative tasks like claims processing and medical care reviews. Electronic medical billing utilizes CPT codes as well as ICD-9-CM or ICD-10-CM numerical diagnostic coding. Throughout the country, CPT terminology is used to report medical, surgical, radiology, laboratory, anesthesia, genomic sequencing, evaluation, and management (EM) services under public and private health insurance programs.

The following AMA CPT codes were announced for new vaccine-specific immunizations against the novel coronavirus. 

With the help of the Centers for Disease Control and Prevention (CDC), the AMA’s CPT editorial panel approved unique immunization codes for two coronavirus vaccines — as well as administration codes unique to each vaccine. In a press release, the AMA stated that the new CPT codes differentiate each coronavirus vaccine for better tracking, reporting, and analysis for data-driven planning and allocation.

The new Category I CPT codes and long descriptors for the vaccine products are:

Here are the new Category I CPT codes and long descriptors for vaccines:

To comply with new CPT codes for vaccine-specific products, the CPT editorial panel collaborated with the Centers for Medicare & Medicaid Services. Their purpose is to develop vaccine administration codes that are distinct for each Coronavirus vaccine and the specific dose used in the schedule.

According to AMA, the level of specificity is a first for vaccine CPT codes. However, it allows tracking all vaccine doses, even when the vaccine product is not reported, like when a vaccine may be given free to the patient. Moreover, these CPT codes report the actual act of administering the vaccine and all counseling needed to the patient or caregiver. They also update the electronic records. 

The AMA site provides a number of resources regarding the new vaccine administration CPT codes and long descriptors. As soon as each newly developed Coronavirus vaccine receives Emergency Use Authorization or FDA approval, all the new vaccine-specific CPT codes will be available for use.

AMA’s website offers short and medium descriptors for these new vaccine-specific CPT codes. They also provide recent changes to the set of CPT codes that have streamlined the public health response to SAR-CoV-2 and COVID-19 disease.

In addition to releasing the standard code descriptor PDF of SARS-CoV-2-related CPT codes, we are also providing an easy-to-use Excel file of SARS-CoV-2-related CPT codes. It contains all the SARS-CoV-2 CPT codes, some may not be included in the 2022 CPT data file, and it includes:

• CPT code descriptors (long, medium, and short)
• Published date
• Effective date
• Type of change. 

AMA will update these files as new CPT codes are approved by the CPT Editorial Panel:

Category I vaccine descriptors

• Coronavirus (SARS-CoV-2) vaccine: Long descriptors 
• Medium descriptors 
• Short descriptors 

Therapeutic Remote Monitoring New CPT Codes

CPT code set for 2022 includes five new codes (98975, 98976, 98977, 98980, 98981) for reporting therapeutic remote monitoring. These codes reflect the rise of digital care during the pandemic. In a news release, the AMA referred to codes 99453, 99454, 99457, and 99458 as “codes that expand upon the remote physiologic monitoring codes created in 2020.”

According to the AMA, the new code set includes a taxonomy that supports “increased awareness and understanding of approaches to patient care through diverse digital medicine services available for reporting.”

As noted by the AMA, technology continues to influence CPT code changes. In fact, 43% of the latest changes come from Category III codes or the Proprietary Laboratory Section section.

Updates to the Care Management Procedures

As of 2020, new CPT codes also apply to the principal care management program. Patients with a single chronic condition can receive reimbursement under that policy. Whereas before, only patients with multiple chronic conditions were eligible.

The AMA wrote that the new codes – 99424, 99425, 99426, 99427 – and changes to existing codes, “better align with Medicare guidelines.” Thus, a data file can be used to download the codes and descriptors into a provider’s software solution.

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Billing and Coding Guidelines for General Surgery December 1, 2021

Billing and coding for general surgery include a wide range of procedures, from gastrointestinal (GI) tract surgery, kidney, pancreas, liver, and thoracic and abdominal surgery to breast surgery and elective surgery. The coding and billing of general surgery can be challenging due to numerous guidelines. Moreover, the general surgeons in 2019 faced 135 changes to ICD-10 codes and more than 69 changes to CPT codes. 

The Health Common Procedure Coding (HCPCS) describes medical devices, supplies, products, and services and aids Medicare and other insurance companies in processing health claims. Physician billing companies should be up to date with all the latest changes in CPT, ICD, and HCPCS codes to submit accurate claims to payers. 

In this article, we’ll discuss billing and coding guidelines for general surgery.

CPT Codes 20000-29999: Top Surgical Procedures

Coding updates for Surgery Section 2021:

Integumentary System-Breast Repair and Reconstruction

In the breast repair and reconstruction subsection (19316-19499) of the Integumentary System, 15 codes were updated, and two were deleted (19324 and 19366) in 2021. Moreover, this subsection includes new instructions for each code and new fundamental guidelines for coders. 

Breast Reconstructions

The following code descriptions were updated:

Codes 19364-19369 cover breast reconstruction using different types of flaps, such as fTRAM, DIEP, SIEA, bi=pedicled TRAM, TRAM with and without separate microvascular anastomosis or “supercharging.” The supercharging procedure increases blood flow in TRAM flaps with marginal circulation to ensure flap survival. All of these procedures are the same as in 2020. The only difference is that they now all mention: “including the closure of donor sites.”  Of course, this is just part of the code. Notes before each code explain what each type of flap entails.

Revisions for Breast Procedures

In the past, coders found it difficult to distinguish between breast reconstruction and revision. The descriptions of the three codes were revised:

Indeed, the documentation of all breast procedures codes is crucial. It may be good to discuss with surgeons to review the changes above so the documentation needed for coders will be included in operative reports.

Thus, we encourage coders to use the Breast Reconstruction in CPT Action Plan and to look at photos of the various breast reconstruction techniques online. Visualizing these can sometimes make it easier to understand what should be done.

On the other hand, the guidelines clarify which reconstruction method should be used for each breast. Codes have been updated: mammary is now known as breast, and language has been added that indicates whether a breast implant was inserted simultaneously or after a significant mastectomy.

Respiratory System: The Nose

Respiratory System: The Lungs and Pleura

Male Genital System: Prostate

Before 2021, coders were following an unrecorded code to communicate that method.

Female Genital System: The Cervix Uteri

Auditory System—Other Procedures: 

There are new codes designed to practice the nasopharyngoscopy technique for the dilation of the eustachian tube. Eustachian tube balloon dilation (ETBD) is the name of this procedure. In the past, coders reported this procedure using unlisted code 69799 because no specific code was available. 

Notice: CPT codes, descriptions, and materials are the property of the American Medical Association (AMA). The Centers for Medicare and Medicaid Services (CMS) owns the copyright to HCPCS codes, descriptions, and materials.

Therefore, the following surgery coding guidelines 2021 have been updated recently. For more accurate billing and coding for general surgery, refer to this website.

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Medical Billing and Coding Guide for Substance Abuse: All You Need to Know December 1, 2021

In simple terms, substance abuse refers to the pattern of harmful use of any substance to change one’s mood.  Furthermore, the term “substances” can encompass not only alcohol and drugs ( legal or illegal) but also substances that do not technically qualify as drugs. On the other hand, “abuse” involves using a substance in a way that is not intended or recommended or when you consume too much of it. 

The substance abuse medical billing process is only one element of revenue cycle management, which begins with gathering accurate patient information. In this guide, we’ll guide you all you need to know about the Medical Billing and Coding Guide for Substance Abuse.

This table shows Outpatient SUD Services:

This table shows Residential SUD Services:

For more assistance on the billing guide, refer to this site.

Substance Abuse Diagnosis

Psychiatrists, psychologists, and licensed drug counselors are often involved in the evaluation process for diagnosing alcoholism, drug addiction, or other substance use disorders. Testing blood, urine, or other tests can assess drug use but not a diagnostic test for addiction. These tests can help monitor recovery as well as treatment.

Mental health professionals diagnose substance abuse using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

How to identify correct substance abuse ICD-10-CM codes?

ICD-10-CM uses the format F1x.xxx for substance use codes. In ICD-10-CM, the letter F indicates that the code belongs to Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders. Furthermore, the number 1 represents a mental or behavioral disorder due to the use of psychoactive substances. The first x, the next digit, indicates the problematic substance (see table below in Step 1). After the decimal point, all numbers indicate the severity and nature of the problem (see Table in Step 2 below). For example,  F10.121 refers to alcohol abuse with intoxication delirium. Not all specifiers are used for every substance (primarily perceptual disturbance), so users should refer to the complete ICD-10-CM code set.

For more information, you can visit the Centers for Disease Control and Prevention.

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How to Code Common Cardiac Conditions October 28, 2021

The term cardiovascular disease (CVD) refers to conditions that affect the heart or blood vessels. Also, the World Health Organization (WHO) estimates 17.9 million people died from cardiovascular diseases in 2019, representing 32% of all global deaths. A majority of these deaths resulted from heart attacks and strokes. Overall, CVD is the most severe disorder afflicting the majority of Americans. 

Before discussing CVD in further detail, let’s examine documentation and diagnosis coding for cardiac conditions to ensure accurate and compliant practices. 

The table below shows the ICD-10 diagnosis codes for common cardiac conditions.

Through this guide, ordering physicians can ensure accurate ICD-10 diagnostic codes for cardiac conditions.

Coronary Artery Disease (CAD)

The other term for coronary artery disease (CAD) is sometimes called ischemic heart disease. CAD is the narrowing and hardening of the coronary arteries (the blood vessels that supply oxygen and blood to the heart). According to the Centers for Disease Control and Prevention (CDC), coronary artery disease (CAD) is the most common form of heart disease in the United States.

The table below shows ICD-10 codes for CAD:

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For professionals in the healthcare industry, knowledge of ICD-10 codes is essential in reporting common cardiovascular diseases. Our team can ensure accurate medical billing and coding for optimal reimbursement, as well!

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality cardiology billing services. Entrust your practice with our professionals in cardiology outsourced billing.

Differentiating Between Inpatient and Outpatient Coding October 28, 2021

Medical coding is essential in medical practice. In this area, accuracy is crucial, as it will impact patient care, clinic operations, and revenue for your practice. The American Academy of Professional Coders (AAPC) describes healthcare coding as translating diagnoses, treatments, and even equipment into universal alphanumeric codes. In simple terms, it is the process of translating crucial medical information into codes to maintain accurate medical records and billing. The coding process assigns numerical or alphanumeric codes to every healthcare data element—outpatient and inpatient. It is essential to identify whether a patient is an outpatient or an inpatient as part of the hospital coding and billing process.

Let’s first understand the definition of Outpatient and Inpatient Coding:

What is Inpatient Coding?

Inpatient coding refers to the formal admission of a patient to a medical facility for a prolonged stay. It specifies the diagnosis of the patient and the services provided to them during their extended stay.

Inpatient coding allows accounting departments to determine the correct billing and reimbursement from insurers by providing a detailed overview of patients’ treatments during their extended stay. It has two standard coding guidelines: ICD-9/ICD-10-CM and ICD-10-PCS. But inpatient coders prefer to utilize ICD-10-PCS as the basis for procedural Coding. Furthermore, inpatient coding requires an admission status indicator (POA), distinguishing between a patient’s health status upon admission and new symptoms that develop throughout their stay.

What is Outpatient Coding?

In contrast, outpatient Coding is for patients who receive treatment but do not remain in a facility for an extended period. Outpatient Coding refers to a patient’s stay lasting less than 24 hours. Patients can still be classified as outpatients even after staying for 24 hours.

The outpatient coding system uses ICD-9/10-CM diagnostic codes but utilizes CPT or HCPCS for procedural Coding. Outpatient services and supplies fall under the latter category. CPT and HCPCS codes for services rely on documentation as well.

Outpatient settings do not allow the use of words such as “likely” or “probable” to describe a patient’s diagnosis. Instead, they must code conditions with certainty for signs, symptoms, or abnormal test results. In a single outpatient visit, the physician has limited time to observe the patient. A physician’s job is not to search for a comprehensive explanation of a patient’s health condition; instead, it is to form an educated conclusion based on the medical evidence at hand.

The Difference Between Inpatient and Outpatient Coding

• Outpatient Coding differs from inpatient Coding by the length of the patient’s stay. The outpatient Coding is done for patients who do not stay for long and can leave within 24 hours of admission, while under the doctor’s prescription, the inpatient coders handle patients admitted for several days with a thorough diagnostic report.
• The Medicare Part B program covers outpatient services, while Medicare Severity-Diagnosis Related Groups (MS-DRGs) cover inpatient services. Both types of services are eligible for Medicare reimbursement, but they use different plans.
• The Outpatient Prospective Payment System (OPPS) manages reimbursements for outpatients. For inpatients, the Inpatient Prospective Payment System (IPPS) seeks reimbursement. 
• The inpatient coding process stays longer and has greater complexity of care. For instance, patients who remain in the hospital for several days may receive medical care from an ER physician, nurses, a surgeon, an anesthesiologist, and others, which should be recorded in their medical records.
• Outpatient Coding requires the coders to know codes and guidelines of ICD-10-CM and HCPCS Level II, whereas an inpatient coder should be proficient in ICD-10-PCS and ICD-10-CM.
• The coders should have enough knowledge of the outpatient coding guidelines, including ICD-10-CM and HCPCS Level II. On the other hand, the inpatient coders should be an expert in ICD-10-PCS and ICD-10-CM.

The inpatient and outpatient coding guidelines for treatment also differ in numerous ways. Both settings use different codes and guidelines for reporting services. Refer to the table below:

According to the American Academy of Professional Coders (AAPC), the American Medical Association maintains the Current Procedural Terminology (CPT) code range for Office or Other Outpatient Services 99202-99215. These can also be the guide for outpatient hospital CPT codes. In contrast, the initial hospital care codes (99221-99223) report “the first inpatient visit by the admitting physician with the patient.” 

By understanding the differences between inpatient and outpatient coding, health care providers can reduce overhead costs. These medical codes are both essential for billing and for outpatient billing services. Coders must therefore have an in-depth understanding of medical coding to perform their duties efficiently. 

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It may take some time for your medical practice to adjust. So, you can also hire a medical coding company with mastery of the official coding guidelines!

At 5 Star Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

Schedule a call with our experts today!