Q&A

Q: What is the difference between a skin substitute that is invoiced and one that is not?

A: There are a lot of skin substitutes to choose from on the market.  It's important to understand the difference between those that have been priced by CMS (ASP) and those that require invoice information on the claim.  Did you know that when reporting the invoice price in box 19 of your claim, it is the net amount? What does this mean? According to Noridian, this means the "amount a provider pays for the item, taking into account ALL discounts, rebates, refunds, or other adjustments".  This is important because Medicare will reimburse only the actual cost of the item.  If the vendor tells you the skin sub will cost you $500 upfront and then they will refund/rebate/discount you (or % bill) $200, your cost is $300, not $500 and that is what is to be billed to Medicare.  Be careful to not get caught in the trap of charging Medicare a higher price than what you actually paid.

https://med.noridianmedicare.com/.../skin-substitute-codes

Q: Can I code 97760 for dispensing orthotics? 

A: CPT defines this code as "Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes".

This code is designed for the assessment and management of a patient using an orthotic, either prefab or custom. 

Can this code be billed for orthotic dispensing?  There is nothing in the CPT description that prevents you from billing this before scheduling the patient for orthotic casting as your assessment for orthotic management services nor at the time of dispense.

What about along with an E/M?  To answer that question, look at the definition,  it uses the term "assessment and management" which is very similar to an E/M.  Thus, an E/M would be appropriate only if there is another condition being evaluated and managed on that same visit.

One major problem with cpt 97760 is that Medicare and Medicare Advantage plans do not cover L3000-30 orthotics, which makes the 97760 also non-covered.  If an audit occurs, those payments would come back to Medicare.

In addition, some commercial payers have reimbursement policies for custom orthotics that include fitting, adjustment, and training in the payment of the devices.

Q: When reporting my office E/M visits, can I include the time I spent reviewing and confirming my notes when I select the code for the visit?

A: You can only count the time you spend completing documentation on the date of the visit. If you review and sign off on your documentation at a later date, you cannot include that time to determine the level of service. For code selection, total time is the time on the date of the encounter that a physician or other qualified health care professional personally spends in activities related to the care of a single patient. This also applies to review of test results on a later date. Although it’s part of the work of the visit, the time spent reviewing test results is not included in the total time on the date of the encounter. Also remember that if you bill based on medical decision-making instead of time, the review of test results would be considered part of the order and not counted separately.

Because we are discussing the time spent on the date of visit, you also cannot include the time spent preparing for the visit (e.g., reviewing the patient’s previous visits, labs or other tests, consultant reports, etc.) on the day(s) prior to the visit.  Only time spent ON THE DAY OF VISIT counts towards "time".

www.physicianspractice.com/view/answering-your-coding-questions 

Q: What are the most common coding problems?

Not coding to the highest level

When it comes to ICD-10 coding, a coder’s job is to code to the highest level of specificity. This means detailing and abstracting the most information out of the medical reports from the provider and taking accurate notes. It also means knowing the medical terminology for both procedures and diagnoses. Be sure to check your ICD-10 book to ensure that each code assigned has the required number of digits, or it can lead to a rejected or denied claim.

Bad or missing documentation

Of course, not coding to the highest level isn’t always the coder’s fault. In certain cases, the provider hasn’t documented enough specific information for a diagnosis or procedure. Providers may leave important details in their note that are needed to correctly choose a diagnosis, service or procedure. This problem is exacerbated by the next trouble spot on the list.

Not having access to the provider

Ideally, every coder would be in constant contact with the provider they’re coding for. Unfortunately, that’s not always the case. Providers aren’t always available to consult on difficult-to-understand claims, and it might take some time to clarify the coding issues. If you aren’t able to query the provider, less-specific or unspecified codes might need to be billed, which could lead to denials.

Failing to Use Current or Updated Code Sets

The organizations that maintain the three principal medical coding code sets (the World Health Organization (WHO) for ICD, the American Medical Association (AMA) for CPT, and the Centers for Medicare and Medicaid Services (CMS) for HCPCS) update these manuals yearly. The ICD book is updated October 1, and the CPT and HCPCS books are updated January 1 each year. It’s up to coders to learn any new, revised or deleted as they come out and use them correctly. This is partly why professional organizations like the AAPC and AHIMA require every member to complete a certain amount of educational credits every two years. Keeping your skills sharp is imperative.

Under- and overcoding

Undercoding occurs when codes fail to capture all work performed. This is often due to oversight, but some practices intentionally undercode to avoid an audit. This is not recommended because it results in substantial lost revenue and creates skewed claims data that ultimately lower reimbursement rates.

Overcoding occurs when reporting CPT or HCPCS codes that result in a higher payment than warranted for services provided. Whether intentional or unintentional, overcoding is inappropriate or even fraud and can trigger an audit.

Unbundling

Unbundling means separately coding procedures that would normally be included in one umbrella code. This can be due to either a misunderstanding or an effort to increase payment. Unbundling is closely related to upcoding, in that it involves false reporting designed to earn the provider a higher payout from a payor. Be sure to check the Correct Coding Initiative to see if two CPT codes can be billed together and read the description of each CPT code thoroughly to avoid unbundling.

www.physicianspractice.com/view/medical-coding-common-problems