Diagnosis Coding is Becoming Increasingly Important Diagnosis coding is becoming more and more important. The shift from volume to value, requires HCC coding for patient acuity not just diagnosis coding for medical necessity. During the “Good Old Days” (think pre-Meaningful Use) as well as during the Meaningful Use Era, diagnoses were primarily required…
The Medicare “Grace Period” for ICD-10 coding flexibility ends on October 1, 2016 CMS established the grace period for contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code. For the past eleven months, you could expect your claim to be paid as long as you…
For years under the fee-for-service model, physicians have been paid based on volume. Physicians were paid for CPT codes given that their diagnosis codes supported the CPT code for medical necessity. Diagnosis coding was an afterthought. As long as the CPT code was paid by the payer, everything else was fine. However, there are two…
Following the transition to ICD-10, many practices attribute their success to the “12 month grace period from CMS” regarding unspecified codes. It is true that CMS will not deny claims before October 1, 2016 and most of the commercial payers have followed suit. However, I often remind clients that there are short term and long…
February was a busy month in Washington DC for parties interested in ICD-10. The big question on everyone’s mind is will it get delayed again? ICD-10 has already been delayed three times, twice by CMS and most recently last March by Congress. The repeated delays make it difficult for anyone to say with certainty what…
Today, CMS made final a one-year proposed delay (from Oct. 1, 2013, to Oct. 1, 2014) in the revised ICD-10 implementation date. The CMS final rule report ends months of speculation about the timing of ICD-10. Practices and providers will need to make preparations well in advance of the conversion date to prevent revenue losses.
In addition, an extended timeline for early adopters of Meaningful Use has been adopted. The Stage 2 rule gives providers more time to meet Stage 2 criteria. A provider that attested to Stage 1 of meaningful use in 2011 would attest to Stage 2 in 2014, instead of in 2013. Therefore, providers are not required to meet Stage 2 meaningful use before 2014. For more information, please click here.
Did you know White Plume products can review claims for diagnosis sequencing and supporting diagnosis code errors? The April newsletter from the Medicare Learning Network (CMS) stated the following problems in recent audits:
1. Incorrect principal diagnosis for Kidney and Urinary Tract Disorders
2. Incorrect secondary diagnosis for Cholecystectomy
3. Improper diagnosis sequencing for spinal infusions
You can avoid unnecessary claims rejections by catching these coding errors on the front end of the billing cycle, and thereby avoiding extra costs associated with refiling. What can White Plume do for you? Contact us to find out.
When physicians perform multiple surgical procedures on a patient during the same session, certain rules must be applied in order to code the claim correctly. Claims must be reviewed to make sure the codes are reported in compliance with bundling rules, National Correct Coding Initiative (NCCI) edits, and relative value units (RVUs).
Code Order Matters
Surgeons are paid at 100% of the fee schedule for the primary surgical procedure, and at 50% for all subsequent surgical procedures performed during the same surgical session. As such, the procedure with the highest RVU should always be listed first. The Medicare Physician Fee Scheduled Database (MPFSDB) lists the RVU value for each surgical CPT® or HCPCS code. The MPFSDB is updated annually, and the current version is located on The Centers for Medicare & Medicaid Services (CMS) website.
If a surgical code with a lower RVU value is listed as the primary surgical procedure on the claim, insurance companies will pay the claim at the lower RVU rate—leading to a lower reimbursement rate.
Current Clients: White Plume’s AccelaSMART product offers Procedure Sequencing at the click of a button, relieving pressure on the billing staff to remember the RVU of all procedures.
Watch out for Unbundling
CMS developed the National Correct Coding Initiative (NCCI) to prevent invalid code combinations from being paid. NCCI edits are classified into two major categories:
- Column 1/Column 2 Edits (Status 0) – Code pairs that are not normally reported together because one of the procedures is already considered a component of the other procedure
- Mutually Exclusive Edits (Status 1) – Code pairs that are not reasonably performed together in the same operative session for anatomic reasons
Code pairs with a status indicator of 0 cannot use modifiers to override the NCCI edits. However, code pairs with status indicator of 1 can use certain modifiers to bypass an NCCI edit, when used appropriately. These modifiers include the following:
- Anatomic modifiers: E1-E4, FA-F9, TA-T9, LT, RT
- Coronary artery modifiers: LC, LD, RC
- Global surgery modifiers: 58, 78, 79
- Other modifiers: 59
Click here to access a list of NCCI edits.
Current Clients: The AccelaSMART validation product contains the NCCI edits including “Status 0” verses “Status 1” information. If a code pairing violates bundling edits, our messages will tell you if the pair accepts a modifier for correction or not. The message even suggests the appropriate modifier. The user does not have to research the pair!
Modifier 59 is often used to report subsequent procedures that are separate and distinct from the primary procedure. The criterion for “separate and distinct” means that the procedure was performed:
- During a different operative session
- On a different organ
- On a different incision or excision
- For a different injury or lesion
Current Clients: The AccelaSMART validation engine alerts users when a Modifier 50 is acceptable and suggest review of documentation to ensure it is a valid submission for the encounter.
When physicians perform multiple surgical procedures on a patient during the same session, certain rules must be applied in order to code the claim correctly. Claims must be reviewed to make sure the codes are reported in compliance with bundling rules, National Correct Coding Initiative (NCCI) edits, and relative value units (RVUs). Code Order Matters…