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How to Avoid Common Coding Errors
Presented by: Raemarie Jimenez, CPC, CPB,
CPMA, CPPM, CPC-I
How to Avoid Top Coding Errors
CPT® Disclaimer
CPT copyright 2012 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not
assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The
AMA does not directly or indirectly practice medicine or dispense medical services. The AMA
assumes no liability for data contained or not contained herein.
CPT is a registered trademark of the American Medical Association.
How to Avoid Top Coding Errors
Objectives
• Review steps to avoid coding mistakes
• Discuss common coding errors that result in a denial for
medical necessity
• Discuss common coding errors for preventive services
• Discuss common coding errors with modifiers
• Discuss common coding errors for E/M services
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1
Our Goals as Coders
• Maintain coding and billing compliance
• Capture appropriate revenue
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Steps to Avoid Coding Errors
• Know the payer rules. Same codes but the rules for
payment are different.
– LCD/NCD for CMS
– Medicare Claims Processing Manual
– Private payer payment polices
• Do NOT apply CMS rules across the board for all
payers.
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Steps to Avoid Coding Errors
• Review denials
– Analysis denials by payer and denial code
– Make sure all denials are posted with zero payment
and reason for denial for easy report generation
– Identify errors
• Internal
• Payer
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2
Steps to Avoid Coding Errors
• Review audit findings
– Comprehensive Error Rate Testing (CERT)
– Recovery Audit Contractor (RAC)
– Office of Inspector General (OIG)
• Work plan
• Audit findings
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2012 CERT Report
• E/M services 14.0 improper payment rate,
approximately $4.2 billion
– Incorrect coding
– Insufficient documentation
– Lacked records for E/M performed outside of the office
(eg, hospital visits)
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2012 CERT Report
• Split/Shared E/M
– Documentation submitted contained provider
signature on the NPP clinical note, no other
documentation supported physician involvement
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3
Mosh Micrographic Surgery (MMS) (L32627)
Documentation Requirements
All documentation must be maintained in the patient’s medical record and available to the
contractor upon request.
•
Every page of the record must be legible and include appropriate patient identification
information (e.g., complete name, dates of service(s)). The documentation must
include the legible signature of the physician or non-physician practitioner responsible
for and providing the care to the patient.
•
The submitted medical record must support the use of the selected ICD-9-CM
code(s). The submitted CPT/HCPCS code must describe the service performed.
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Mosh Micrographic Surgery (MMS) (L32627)
•
The medical record documentation must support the medical necessity of the services
as directed in this policy.
•
The physician must document in the patient’s medical record that the diagnosis is
appropriate for MMS and that MMS is the most appropriate choice as the treatment of
the particular lesion.
•
The surgeon’s documentation in the patient’s medical record should be legible and
support the medical necessity of this procedure. Operative notes and pathology
documentation in the patient’s medical record should clearly show MMS was
performed using accepted MMS technique, in which the physician acts in two
integrated and distinct capacities: surgeon and pathologist (e.g., should show that
true MMS was performed).
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Mosh Micrographic Surgery (MMS) (L32627)
•
If the 59 modifier is used with a skin biopsy/pathology code on the same day the MMS
was performed, physician documentation should clearly indicate:
– The biopsy was performed on a lesion other than the lesion on which the MMS
was performed.
– If the biopsy is of the same lesion on which the MMS was performed, a biopsy of
that lesion had not been done within the previous 60 days.
Or,
– If a recent (within 60 days) biopsy of the same lesion on which MMS was
performed had been done, the results of that biopsy were unobtainable by the
MMS surgeon using reasonable effort.
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4
MLN Matters® Number: SE1318
Guidance To Reduce Mohs Surgery Reimbursement Issues The
Identified Coding Problems
During an audit of the CPT® codes associated with MMS across several
states in a region, Medicare Recovery Auditors found instances in which
the preparation and/or interpretation of the slides of tissue removed during
the procedures was performed by someone other than the surgeon (or his/
her employee).
This is often referred to as modified Mohs which should not be reported
with codes 17311-17315.
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2013 HHS OIG Work Plan
• Hospitals—Hospital-Owned Physician Practices Using
Provider-Based Status (New)
• Physicians—Error Rate for Incident-To Services Performed
by Nonphysicians
• Physicians—Place-of-Service Coding Errors
• Evaluation and Management Services—Potentially
Inappropriate Payments in 2010
• Evaluation and Management Services—Use of Modifiers
During the Global Surgery Period
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OIG Audit Findings
06-21-2013 Meritus Medical Center Refunded
Overpayments for Physician Claims With Place-of-Service
Coding Errors For 2009 Through 2012
Meritus Medical Center (the Hospital) (operating in Maryland) submitted
17,000 claims with overpayments of $568,000 for physician services for
calendar years 2009 through 2012. The Hospital, billing on behalf of its
wound care facility physicians, incorrectly coded these claims by using
nonfacility place-of-service codes for services that were actually
performed in the Hospital's wound care center. The Hospital refunded the
overpayments.
http://oig.hhs.gov/reports-and-publications/oas/cms.asp
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5
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Injections
(Rev. 968. Issued: 05-26-06; Effective/Implementation Dates: 06-26-06)
If a significant separately identifiable evaluation and management service
is performed, the appropriate E/M code should be reported utilizing
modifier 25 in addition to the chemotherapy administration or
nonchemotherapy injection and infusion service. For an evaluation and
management service provided on the same day, a different diagnosis is
not required.
MCM 100.04 Ch. 12 30.5
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Cosmetic Procedures
• Diagnosis determines medical necessity
– Review payer policies
– Review LCDs/NCDs
– Proper use of ABN for Medicare patients
• Modifiers for claim submission
– GA Waiver of liability statement issued as required by payer policy,
individual case
– GX Notice of liability issued, voluntary under payment policy
– GY Item or service statutorily excluded, does not meet the definition of any
Medicare benefit or, for non-Medicare insurers, is not a contract benefit
– GZ Item or service expected to be denied as not reasonable and necessary
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6
LCD: Removal of Benign Skin Lesions
078.0
078.11
MOLLUSCUM CONTAGIOSUM
CONDYLOMA ACUMINATUM
235.1
NEOPLASM OF UNCERTAIN BEHAVIOR OF LIP ORAL CAVITY AND PHARYNX
236.3
NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED
FEMALE GENITAL ORGANS
236.6
NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED MALE
GENITAL ORGANS
238.2
NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN
239.2
NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN
374.84
686.1
702.0
702.11
CYSTS OF EYELIDS
PYOGENIC GRANULOMA OF SKIN AND SUBCUTANEOUS TISSUE
ACTINIC KERATOSIS
INFLAMED SEBORRHEIC KERATOSIS
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Skin Tag Removal -Medicare
• 701.9 Unspecified hypertrophic and atrophic
conditions of skin
– Requires a secondary diagnosis to support medical
necessity
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Secondary Diagnosis for Skin Tag Removal
682.0
CELLULITIS AND ABSCESS OF FACE
682.1
CELLULITIS AND ABSCESS OF NECK
682.2
CELLULITIS AND ABSCESS OF TRUNK
682.3
682.5
CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM
CELLULITIS AND ABSCESS OF HAND EXCEPT FINGERS AND
THUMB
CELLULITIS AND ABSCESS OF BUTTOCK
682.6
CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT
682.7
CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES
682.8
CELLULITIS AND ABSCESS OF OTHER SPECIFIED SITES
682.9
CELLULITIS AND ABSCESS OF UNSPECIFIED SITES
682.4
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7
Secondary Diagnosis for Skin Tag Removal
686.8
OTHER SPECIFIED LOCAL INFECTIONS OF SKIN AND SUBCUTANEOUS
TISSUE
686.9
UNSPECIFIED LOCAL INFECTION OF SKIN AND SUBCUTANEOUS TISSUE
692.9
CONTACT DERMATITIS AND OTHER ECZEMA UNSPECIFIED CAUSE
695.89
695.9
698.9
708.9
729.5
782.0
OTHER SPECIFIED ERYTHEMATOUS CONDITIONS
UNSPECIFIED ERYTHEMATOUS CONDITION
UNSPECIFIED PRURITIC DISORDER
UNSPECIFIED URTICARIA
PAIN IN LIMB
DISTURBANCE OF SKIN SENSATION
782.9
OTHER SYMPTOMS INVOLVING SKIN AND INTEGUMENTARY TISSUES
OTHER AND UNSPECIFIED INJURY TO OTHER SPECIFIED SITES
INCLUDING MULTIPLE
V10.82 PERSONAL HISTORY OF MALIGNANT MELANOMA OF SKIN
V10.83 PERSONAL HISTORY OF OTHER MALIGNANT NEOPLASM OF SKIN
959.8
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Aetna Policy
Aetna considers medically necessary removal of seborrheic keratoses (also known as basal cell
papillomas, senile warts or brown warts), sebaceous cysts (pilar and epidermoid cysts), acquired or
small (less than 1.5 cm) congenital nevi (moles), dermatofibromas (skin tags), and pilomatrixomata
(slow-growing, hard mass underneath the skin that arises from hair follicle matrix cells), or other
benign skin lesions if any of the following criteria is met:
• Biopsy or clinical appearance suggests or is indicative of pre-malignancy (e.g., dysplasia) or
malignancy; or
• Due to its anatomic location, the lesion has been subject to recurrent trauma; or
• Lesion appears to be pre-malignant (e.g., actinic keratoses (see CPB 0567 - Actinic Keratoses
Treatment), Bowen's disease, dysplastic lesions, lentigo maligna, or leukoplakia) or malignant
(due to coloration, change in appearance or size, etc., especially in a person with dysplastic
nevus syndrome, family history of melanoma, or history of melanoma); or
• Skin lesions are causing symptoms (e.g., bleeding, burning, itching, or irritation); or
• The lesion has evidence of inflammation (e.g., edema, erythema, or purulence); or
• The lesion is infectious (e.g., warts [verruca vulgaris]); or
• The lesion restricts vision or obstructs a body orifice.
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Aetna Policy
ICD-9-CM Code
078.10 - 078.19
214.0 - 214.9
216.0 - 216.9
232.0 - 232.9
528.6
702.0
702.11 - 702.19
706.2
Description
Viral warts [* note - report 17110-17111 per AMA CPT
guidelines]
Lipoma [lipomata]
Benign neoplasm of skin [nevi, moles] [dermatofibromas]
[pilomatrixoma]
Carcinoma in situ of skin [Bowen's disease, lentigo
maligna]
Leukoplakia of oral mucosa, including tongue
Actinic keratosis
Seborrheic keratosis
Sebaceous cyst
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8
Aetna Policy
ICD-9-CM Code
686.9
695.9
698.9
701.9
702.8
757.39
782.0
782.2
Description
Unspecified local infection of skin and subcutaneous
tissue [inflammation]
Unspecified erythematous condition
Unspecified pruritic disorders [itching]
Unspecified hypertrophic and atrophic conditions of skin
[skin tags]
Other specified dermatoses [leukoplakia]
Other congenital anomalies of the integument [accessory
skin tags]
Disturbance of skin sensation [burning]
Localized superficial swelling, mass, or lump
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Aetna Policy
ICD-9-CM Code
782.3
V10.82
V10.83
Description
Edema
Personal history of malignant melanoma of skin
Personal history of other malignant neoplasm of skin
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Anesthesia Denials
• Transeshophageal Echocardiography (TEE)
– Diagnostic 93312-93317
– Monitoring 93318
– Can not be billed separately when performed for
monitoring
• Labor epidurals and the reporting of time
– Face to face time
– Flat rate
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9
EKG Denials
Diagnosis does not meet medical necessity
• Evaluation of a patient with known Coronary Artery Disease (CAD)
and/or heart muscle disease that presents with symptoms such as
increasing shortness of breath (SOB), palpitations, angina, etc.
• Pre-operative Evaluation of the patient when:
– undergoing cardiac surgery such as CABGs, automatic implantable cardiac
defibrillator, or pacemaker, or
– the patient has a medical condition associated with a significant risk of
serious cardiac arrhythmia and/or myocardial ischemia such as Diabetes,
history of MI, angina pectoris, aneurysm of heart wall, chronic ischemic heart
disease, pericarditis, valvular disease or cardiomyopathy to name a few.
•
Include the ordering/rendering provider and NPI
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Preventive Services
• Know the payer policy for appropriate codes
– G0101 Cervical or vaginal cancer screening; pelvic
and clinical breast examination
• Not just for Medicare
– Lab denials
• Providers must indicate when labs are screening
• V72.62 Laboratory examination ordered as part of a
routine general medical examination
How to Avoid Top Coding Errors
Service
29
Cardiovascular Screening Blood Tests
HCPCS/CPT codes 80061–Lipid panel
82465–Cholesterol
83718–Lipoprotein
84478–Triglycerides
ICD-9-CM codes
Report one or more of the following codes:
V81.0, V81.1, V81.2
Who is covered
All Medicare beneficiaries without apparent signs or
symptoms of cardiovascular disease
Frequency
Every 5 years
Beneficiary Pays
Copayment/coinsurance waived
Deductible waived
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10
Service
Diabetes Screening Tests
HCPCS/CPT codes
82947– Glucose; quantitative, blood (except reagent strip)
82950– Glucose; post-glucose dose (includes glucose)
82951– Glucose; tolerance test
(GTT), 3 specimens (includes glucose)
ICD-9-CM codes
V77.1
Who is covered
Medicare beneficiaries with certain risk factors for diabetes or
diagnosed with pre-diabetes
Beneficiaries previously diagnosed with diabetes are not eligible
for this benefit
Frequency
Two screening tests per year for beneficiaries diagnosed with
pre-diabetes
One screening per year if previously tested, but not diagnosed
with pre-diabetes, or if never tested
Beneficiary Pays
Copayment/coinsurance waived
Deductible waived
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Preventive Services-United Healthcare
Service
Codes
Limits
Cervical Cancer Screening,
Pap Smear
Procedure Code(s):
Code Group 1 (payable regardless of diagnosis
code):
G0101, G0123, G0124, G0141, G0143 – G0145,
G0147, G0148, Q0091, P3000, P3001
Code Group 2 (requires a diagnosis code from list
below):
88141 – 88143, 88147, 88148, 88150, 88152 –
88155, 88164 – 88167, 88174, 88175
Diagnosis Code(s) Code Group 2: V70.0, V72.31,
V72.32, V76.2
Females,
no age
limits.
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Preventive Services-United Healthcare
Service:
Codes:
Limits:
Cholesterol
Screening
(Lipid
Disorders
Screening)
Procedure Code(s): 80061, 82465, 83718, 83719, 83721, 84478,
36415, 36416
Diagnosis Code(s) (Required for all): V70.0 or V77.91
Additional Diagnosis Codes Required (for Men 20-34, and all Women
20 and up): V15.82, V17.3, V17.49, 278.00, 278.01, V85.41 – V85.45,
401.0, 401.1, 401.9, 405.01, 405.09, 405.11, 405.19, 405.91, 405.99,
642.01, 642.03, 642.04, 642.11, 642.13, 642.14, 642.21, 642.23, 642.24,
642.30, 642.31, 642.33, 642.34, 642.91, 642.93, 642.94, 249.00, 249.01,
249.10, 249.11, 249.20, 249.21, 249.30, 249.31, 249.40, 249.41, 249.50,
249.51, 249.60, 249.61, 249.70, 249.71, 249.80, 249.81, 249.90, 249.91,
250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20,
250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41,
250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62,
250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83,
250.90, 250.91, 250.92, 250.93, 440.0, 440.1, 440.20, 440.21, 440.22,
440.23, 440.24, 440.29, 440.30, 440.31, 440.32, 440.8, 440.9, 414.00,
414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07
All males age 35
and up.
Males age 20-34 if
at increased risk for
coronary heart
disease.
Females age 20 and
up if at increased
risk for coronary
heart disease.
NOTE: These will
only pay as
preventive if there is
no prior history of a
lipid disorder.
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11
Medicare Example
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Bilateral Procedures
• MUE change went into effect 4/1/2013
• For Medicare, report bilateral procedures with
modifier 50 and 1 unit
• Letter to AMA can be found at:
http://www.acr.org/~/media/ACR/Documents/PDF/Economics/Coding%20Source/2013%2
0Jan%20Feb/CMS%20MUE%20Letter%20to%20AMA.pdf
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Modifier 25
Significant, separately identifiable evaluation and management
service by the same physician or other qualified health care
professional on the same day of the procedure or other service
• Appended to the E/M code
• Used to indicate a minor procedure or additional E/M is
performed on the same date of service
• E/M must be separately identifiable
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12
Documentation Example
SUBJECTIVE:
Mrs. X is a 43-year-old Caucasian female in for followup. She presents with knee pain and swelling. She is
here for arthrocentesis of the left knee.
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Documentation Example Continued
OBJECTIVE:
Procedures: Joint pain, lower leg
Procedure Note: Arthrocentesis/Injection
Arthrocentesis of left knee joint is performed. Written informed consent
was obtained. The site is prepped with betadine and sterile drape is
placed. The site is anesthetized with 4 cc of 2% lidocaine. The needle is
carefully introduced into the joint space. Aspiration of 20 cc of amber fluid
is obtained. No complications. Estimated blood loss: 2 cc. The specimen is
sent for routine path plus special studies ( acid fast bacilli, cell count and
differential, bacterial culture, and fungal culture).
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Documentation Example
S. Continues to have achiness in her knees. Her current meds include
ALEVE only as needed a few days out of the week as before. She is on
LEXAPRO at night, XANAX, and CLONAZEPAM as needed. She is on a
B12 injection once a month. We had given her a prescription for VICODIN
but she lost the prescription.
O: Weight is 188 pounds. Blood pressure is 112/74. Pulse is 60. There is
some crepitus at the knees without tenderness elicited. There is no active
synovitis noted at this time. There is no alopecia noted on exam.
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13
Documentation Example Continued
Review of lab work from April 29, 2013 revealed a
negative ANA. Urinalysis had no blood or protein.
Normal liver and renal function tests. Uric acid was
normal with normal CRP, rheumatoid factor, anti-CCP,
and TSH. Hemoglobin was 10.8 with MCV of 79.6 and
normal white count and platelets.
A: Osteoarthritis of knees, Anemia
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Documentation Example Continued
P: Patient was prescribed an IRON supplement, which she
plans to start tomorrow. I did ask her to check with Dr. R about
actual use of ALEVE given her anemia.
Will start HYALGAN injections today. After informed consent,
the left knee was sterilely prepped. Used 1 cc LIDOCAINE for
anesthesia. Injected the first of five HYALGAN injections, 2 cc,
into the left knee without complications, followed by ice and
rest. Follow up weekly for HYALGAN.
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E/M Exam Component
• How many bullets are assigned for the following
documented exam findings:
–
–
–
–
Cardiovascular-no murmurs, rubs or gallops
Respiratory- lungs clear to auscultation, normal effort
ENT- ear canals clear
Eyes- EOMI
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14
1997 CMS Documentation Guidelines
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1997 CMS Documentation Guidelines
How to Avoid Top Coding Errors
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1997 CMS Documentation Guidelines
How to Avoid Top Coding Errors
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15
1997 CMS Documentation Guidelines
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Modifier 59
Distinct Procedural Service
• Procedures not normally reported together
• Different session or patient encounter
• Different procedure or surgery
• Different site or organ system
• Separate incision/excision
• Separate lesion
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National Correct Coding Initiative (NCCI)
• Implemented by CMS
• Promotes correct coding methodologies
• Controls the improper assignment of codes that results in
inappropriate reimbursement
Medicare publishes NCCI:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/
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16
Documentation Example
Preoperative Diagnosis: Actinic keratosis x 3 of the left medial cheek.
Procedure #1: Cryotherapy of 3 lesions.
Procedure Note: The patient’s face was examined. He was found to have
3 areas of actinic keratosis of the left cheek.
They were treated with 20 seconds of liquid nitrogen. The patient tolerated
the procedure well.
Procedure #2: Wide local excision of squamous cell carcinoma of the left
face. Total excision 3 cm (lesion 2.0 cm and margins .5 cm) with a 3.5 cm
intermediate layer of closure.
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Documentation Example
Procedure Note: The patient’s left face was examined. The site of the lesion was noted.
The site of intended excision was marked out in elliptical fashion surrounding the lesion.
This site was prepped with Betadine then injected with 1% Lidocaine with 1:100,000
epinephrine. The patient was prepped in the usual fashion. A #15 blade scalpel was used
to make the incision at the previously marked site. The incision was carried down to the
subcuticular tissue; it was tagged and handed off the field for pathologic examination.
Frozen sections were taken. They returned with clear margins. At this point the wound
edges were widely undermined using an iris scissors. The wound was then closed using
3-0 Vicryl for the deep layer, followed by 5-0 Prolene for the skin. The patient tolerated
these procedures well and he should follow up with me in approximately 5 to 7 days time
for suture removal.
How to Avoid Top Coding Errors
* = In
Deletion
existenc
Date
e prior to Effective *=no
Column 1 Column 2 1996
Date
data
17000
11640
19980401 *
17000
11641
19980401 *
17000
11642
19980401 *
17000
11643
19980401 *
17000
11644
19980401 *
17000
11719
19990401 *
17000
11900
19980401 *
17000
11901
19980401 *
17000
12001
20121001 *
17000
12002
20121001 *
Modifier
0=not allowed
1=allowed
9=not applicable
1
1
1
1
1
1
1
1
1
1
50
Code Nonfacility
RVU
12052 8.83
11640 6.06
17000 2.45
17003 0.20
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17
Coding Error?
P
O
S
Proc
22 92941
Mod
Units From
LC
26
1
Thru
Billed
Paid Detail
EOBS
05/02/13 05/02/13 1711.00 0.00 4257
4257 Invalid Procedure Code Modifier
How to Avoid Top Coding Errors
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Modifier PT versus 33
• Proper codes and sequence for a cold biospy polyp
removal and snare polyp removal performed during
a screening colonoscopy. The diagnoses include
polyps, diverticulosis and internal hemorrhoids
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Sources
•
Medicare Preventive Services Quick Reference Information
http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf
•
The Guide to Medicare Preventive Services
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/mps_guide_web-061305.pdf
•
Aetna Policy for Benign Skin Lesion Removal
http://www.aetna.com/cpb/medical/data/600_699/0633.html
•
Medicare Coverage Database (LCD and NCD search)
http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
•
United Healthcare Summary of Preventive Services
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/enUS/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocol
s/Medical%20Policies/Medical%20Policies/preventive_care_services_coding_guideline_summary.pdf
How to Avoid Top Coding Errors
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18
Thank You!
Time for Questions
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19