As discussed in Part I of this article, coding for procedures in all specialties is often a complex process. In Part I we discussed common areas that are prone to erroneous coding in orthopedics, gastroenterology and ophthalmology. Part II of this two-part series focuses on podiatry and otolaryngology and provides universal coding tips applicable to most specialties.
There were major changes to podiatry codes in 2017. AMA added two new codes, deleted three bunionectomy codes and revised multiple codes. The following is a brief summary of the affected codes:
- 28291 – Hallux rigidus correction with implant
- 28295 – Bunionectomy with proximal metatarsal osteotomy
The following bunionectomy codes have been deleted in order to eliminate all proper names from code descriptions (Austin, McBride, etc.) and more accurately describe the services as they are currently performed:
- 28289 – Hallux rigidus repair without implant. Note: This previously read with or without implant but 28291 (see above) was added for the procedure with an implant.
- 28292 – Bunionectomy with sesamoidectomy with resection of proximal phalanx base
- 28296 – Bunionectomy with sesamoidectomy with distal metatarsal osteotomy (new code 28295 is now used for proximal metatarsal osteotomy – see above)
- 28297 – Bunionectomy), with sesamoidectomy with first metatarsal and medial cuneiform joint arthrodesis
- 28298 – Bunionectomy with sesamoidectomy with proximal phalanx osteotomy
- 28299 – Bunionectomy) with sesamoidectomy with double osteotomy
- +77002 – Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). Note: The previous description did not designate this code as an add-on code.
Multiple procedure codes may be listed for one operative note but some of them may be considered part of the more complex procedures being performed. Separate procedure codes may sometimes be billed with other codes, but be aware of what the payer’s requirements are for these codes. Careful review of all the codes in this range is recommended before choosing the final code for bunion correction.
ENT can often be difficult to code as it encompasses four parts of the respiratory system: 1) ears; 2) nose; 4) sinuses and 4) throat. In addition, there are eight sinuses, six turbinates and two separate nasal cavities to choose from and an extensive range of procedure codes spanning several different areas of CPT codes.
The following are a few areas where errors can occur:
- 31231-31297 – Functional endoscopic sinus surgery (FESS) done under direct visualization. Tip: These are for coding unilateral diagnostic and surgical endoscopic sinus procedures, except for 31231 which is unilateral or bilateral. Do not bill additional codes 31231 (diagnostic nasal endoscopy), 31233 (endoscopy procedure accessory sinuses) or 31235 (diagnostic endoscopy of nose and sphenoid sinus) as these procedures are included in a FESS procedure.
- +61782 – Stereotactic computer-assisted (navigational) procedure; cranial, extradural. Tip: These guidance systems allow navigation in areas adjacent to the sinuses, such as the optic nerve. This code should be listed, in addition to the primary endoscopic code, when computer-assisted FESS is performed. 61782 should never be used as a primary procedure code but rather only as an add-on code.
- 69436 – Tympanostomy with insertion of ventilating tube under general anesthesia. Tip: Do not bill for a myringotomy (64921) in addition to this code as a myringotomy is required in order to place the tube and is included in 69436. Also, don’t forget to add a -50 modifier if this is a bilateral procedure.
General coding tips
The following are suggestions that may be helpful in achieving accurate coding of procedures in all specialties:
- Assign the CPT code(s) that describes the procedures. If there is not a specific procedure code listed, do not use a code that is “close” to avoid use of an unlisted code.
- If a specific diagnosis code is not payable by the insurance carrier, don’t just pick another code from the same section that is payable. Codes are generally not interchangeable and it is not acceptable to use one that “means almost the same thing.” Search the history and physical for other diagnosis codes that may be payable.
- Don’t assume a diagnosis that is not specifically stated just because that is “probably” what it is.
- Don’t assign a congenital diagnosis code unless the provider has stated it is a congenital condition, even if the index points to congenital codes only. Query the physician before assigning a questionable diagnosis so as to avoid labeling the patient with something he/she doesn’t have as this may have far-reaching consequences for that patient.
- Become familiar with the ICD-10 coding guidelines and updates. Refer to them for direction on coding specifics.
- There are many reasons why coding errors occur, however, the most common are unqualified coders, inadequate documentation and outdated coding references (software or books).
Most modifiers used in ASC coding are two-digit numbers. Modifiers provide additional information to payers to make sure the provider is paid correctly for services rendered. If appropriate, more than one modifier may be used with a single procedure code; however, they are not applicable for every category of the CPT codes. Some modifiers can only be used with a particular category and some are not compatible with others.
Here are some tips to aid with appropriate modifier use:
- Modifier -59 – CPT manual defines modifier -59 as a distinct procedural service. This modifier is often misused in an attempt to avoid a bundling edit. The carrier may come back years later and require a return of payment made. Just because that -59 got the claim paid doesn’t mean it was used correctly.
Modifiers -73 and -74 – It is critical that you understand the difference.
- Modifier -73 – Guidelines state that the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed, but prior to the administration of anesthesia (local, regional block or general)). This is a result of extenuating circumstances or those that threatens the wellbeing of the patient. The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. When none of the planned procedures are completed, then the first planned procedure is reported with the modifier -73. The others are not reported. This modifier should be used to cover the expenses involved for the use of the facility.
- Modifier -74 – Guidelines state that the physician may cancel a surgical or diagnostic procedure after the administration of anesthesia or after the procedure is started. This is a result of extenuating circumstances or those that threatens the wellbeing of the patient. This procedure would be reported by the usual CPT code along with the modifier -74. If this modifier is not used and the patient has to return for the same procedure, then the subsequent procedure will be denied.
Other modifiers that may be appropriate in the ASC setting include the following:
- -50 Bilateral procedure
- -52 Partially reduced/eliminated services
- -76 Repeat procedure by same provider
- -77 Repeat procedure by another provider
- -78 Return to operating room for related surgery during post op period
Although there are many other surgical specialties that utilize the ASC arena, this two-part series showcased just a few of the more common coding errors and provided tips to help coders avoid the many pitfalls they may encounter. One of the most important components of correct coding is accurate and detailed procedure notes. Remember the adage: If it’s not documented, it didn’t happen.
Caryl Serbin, RN, BSN, LHRM , is president and founder of Serbin Medical Billing, an ASC revenue cycle management company. Serbin Medical Billing's primary objectives are to provide the best coding, billing and accounts receivable management services available to ambulatory surgery centers (hospital joint-venture, corporate-owned or independent) and anesthesia providers. Serbin has been a leader in the ASC industry for 30 years. She was the founder of the first ASC-specific billing company.