Acromioclavicular Joint Billing

Transcription

1 Acromioclavicular Joint Billing October 27, 2016 When our physician performs an injection into the acromioclavicular (AC) joint of a patient in the office, can we bill for a large joint arthrocentesis? I say yes because it is in the shoulder, which is listed as an example large joint in the code descriptor. No. The correct code to bill in this case would be for an intermediate joint. Although the AC joint is between the shoulder and the clavicle, it is considered an intermediate joint. If you look at the example intermediate joints in the descriptor for they include: temporomandibular, acromioclavicular, wrist, elbow or ankle, or olecranon bursa. The example large joints listed for code include: shoulder, hip, knee, subacromial bursa. If the physician performs the AC injection utilizing ultrasound guidance with permanent recording and reporting, then you should report code instead of And don t forget to bill the HCPCS II code for the medication itself. of 10/27/16.

2 Surgical Modifiers: How Do They Impact Reimbursement? October 13, 2016 What reimbursement should we expect when using the global period modifiers 58, 79 and 78? Surgical modifiers are used to indicate that a subsequent procedure was performed during the global period of a prior surgery. Modifiers tell the payer the rationale for allowing payment for this subsequent procedure. The modifiers and reimbursement impact of each is shown below: Modifier 58: to indicate a second procedure was performed as a staged procedure. Reimbursement should be 100% of the allowable fee. Modifier 79: To indicate an unrelated procedure was performed during the global period of the original procedure. Reimbursement should be 100% of the allowable fee. Modifiers 78: To indicate that a complication of an original procedure was treated by a return to the operating room, catheterization or endoscopy suite. Reimbursement should be at 70-80% of the allowable fee. This reduction reimburses for the intra- operative portion of the procedure only, since the patients pre and post-operative services are paid under the original surgery s flat fee. of 10/13/16.

3 Reimbursement: Assistant Surgeon September 29, 2016 What is the reimbursement for an assistant surgeon using modifier 80? Is the payment different for the primary and the assistant? What about a PA or nurse practitioner who assists at surgery? An assistant surgeon is described as one surgeon, of the same or a different specialty, providing assistance during a surgical procedure or CPT code. Modifier 80 (modifier 82 for an assistant surgeon in an academic setting when a qualified resident is not available) is appended to any CPT code the assistant participates in. Medicare reimburses 16% of the allowable for the assistant surgeon (modifier 80 or 82) and multiple procedure/bilateral procedure reductions also apply. The primary surgeon s reimbursement is not affected. In an assistant surgeon scenario, the assistant need not and should not dictate a separate note. However, it is critical that the primary surgeon document in his/her note, specifically what the assistant did. Stating an assistant was needed because the case was complex is not sufficient. The primary surgeon must state what the assistant did, for example, assisting with positioning and retraction, surgical closure, etc. When a

4 physician assistant or nurse practitioner assists in surgery, Medicare reduces their reimbursement by 15% of what a physician would be paid for assisting, and Medicare directs us to designate a PA or NP service using modifier AS (instead of modifier 80). Keep in mind, Medicare does not allow payment for assistant support for all surgical CPT codes. For private payers, coding guidelines and payment rates may vary. of 09/29/16. Medicare X Modifiers: Use or not Use? September 15, 2016 What s new with the X modifiers established by Medicare? Should we be using them now? As of July 7, 2016, Medicare has yet to finalize a formal policy for the use of the X modifiers as a replacement to the 59 modifier. The X modifiers are shown below. XE: Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

5 XS: Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure XP: Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner XU: Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service At this point, Medicare has given practices the option to use the X modifier or the 59 modifier. Some of our clients tell us that they are using the X modifiers without any payment issues. Be assured that eventually the X modifier will become standard Medicare policy since the intent of these modifiers is to force providers to be more specific regarding the rationale for unbundling two bundled CPT codes. Medicare developed these modifiers to reduce misuse and abuse of the 59 modifier. of 09/15/16. New Patients and PAs September 1, 2016 Our office-based PA usually sees established patients with established problems, and the supervising physician is onsite. What should we do if the PA sees a new patient or a returning

6 patient has a new problem? The practice has two options. First, the PA could simply bill that visit using the direct method (under the PA s name). Alternately, a physician could see the new patient to set the plan of care, with the visit reported by the physician. Remember, for a new patient or new problem seen in the office setting, the physician cannot use the documentation elements already captured by the PA; code assignment would be based only on the work the physician performs and documents. of 09/01/16. Orthopedic Spine Coding August 18, 2016 We have a billing company for which we bill for many different specialties. We have an orthopedic spine doctor who insists we bill the cage code for each inter-space. However, the CPT book lists as cage(s) therefore our thinking is that no matter how many are placed this code is only allowed one time per surgery. His note states C3-C4, C4-C5, C5-C6 anterior cervical interbody fusion using PEEK titanium interbody spacers. Your client is correct. CPT code is reported per

7 interspace to describe intervertebral biomechanical devices, including PEEK cages. The term is both, single or plural, cage(s), because sometimes there are two devices placed at a single spinal level. If you do an internet search on PEEK cages, you ll find a variety of designs. As long as the supporting documentation in the body of the note is appropriate, the statement above supports 3 units of Remember that this CPT code is not subject to multiple procedure discounts. of 08/18/16. Signing NPP Notes August 4, 2016 Do I have to sign each of my NP s notes that are reported incident to? The guidelines for reviewing and signing NPP documentation are set by each state in its scope of practice regulations. Each practice must research those requirements individually. But as an employer, you are responsible for the care provided by the NP, and reviewing and signing off on the notes may be an efficient method for keeping tabs on patient treatment. of 08/04/16.

8 Reimbursement: Co-surgery July 21, 2016 What is the reimbursement for co-surgery using modifier 62? Is it different for the primary and co-surgeon? For Medicare, co-surgery requires two surgeons performing separate parts of a single CPT code. For both surgeons, modifier 62 is appended to the appropriate CPT code(s). Medicare multiplies the allowable by 125% and splits the reimbursement exactly in half, resulting in a payment of 62.5% to each surgeon. So to answer your question, the payment is the same for both surgeons. Both surgeons dictate an operative note describing their work and both have post-operative responsibilities. For private payers, coding guidelines and payment may vary. of 07/21/16.

9 Split / Shared Visit July 7, 2016 In our office, the physicians use our PA as they would residents. The PA sees the patient first, performs an examination, and then discusses the case with the physician. The physician also sees the patient, but doesn t repeat everything the PA has done. Can this be reported in the physician s name? It depends. This scenario is termed a split/shared visit, because neither the PA nor physician did everything; they each performed a portion of the work and combined it. In the office setting, incident to rules must be considered before applying split/shared rules, which do not allow an NPP and a physician to combine their work when it is performed and individually documented on the same day. If the patient has an established problem, with a plan of care that was set previously by a physician, then the combined work can be reported in the physician s name, and it will be allowed at 100 percent of the physician rate. However, a new patient or a new problem cannot be reported as split/shared for the combined work. One option is to report the visit in the PA s name and accept 85 percent of the allowable; alternatively, the visit can be reported in the physician s name, but only for the work that the physician performed. Keep in mind, Medicare and other payers use place of service code 11 to designate services performed in a physician office. In academic- and hospital-based settings, a physician may instead use place of service code 19 or code 22, which are handled differently.

10 of 07/07/16. Joint Injections June 9, 2016 When my PA performs joint injections, can we report those services under the incident-to billing rules? If the PA scope of practice regulations in your state allow PAs to perform joint injections, the determining factor is whether the incident-to billing rules are met. If you previously set the plan of care for joint injections, they could be reported as incident-to. If the PA made the decision to perform the injection independently, it should be reported as a direct service. of 06/09/16.