Physicians Practice - March 2008 - (Page 61)

CODING YOUR TOP CODING CONCERNS SOLVED GETTING CLEARANCE FOR PRE-OP SERVICES; 2008 MODIFIER CHANGES B Y B I L L D A C E Y, C P C Generally speaking, it’s OK to use consultation codes when a primary-care physician provides preoperative clearance services. A surgeon is asking the opinion of the primary-care provider regarding his patient’s ability to undergo a speciﬁc procedure. Still, it’s not a perfect ﬁt. If you use the consult codes, document correctly to support them. Many chart reviews of these pre-ops ﬁnd deﬁciencies because there is no history of present illness (HPI). Many practices have a pre-op form that lists the name of the surgeon, the procedure to be performed, and the date or other details related to the proposed surgery. Often the primary-care physician will write something like “severe DJD of the knee — total knee” and then move directly onto a list of medical problems, usually expressed as past medical history or a review of systems. The note then typically reviews speciﬁc risk factors. Rarely do we see the HPI-type detail we’d ﬁnd in an ofﬁce visit or consult. To correct this, reference the patient’s past medical history (most often a list of chronic problems) in terms of the current status of those problems, e.g., “HTN well-controlled, pressures in the 115 range.” You need an HPI. If the patient doesn’t have any real chronic problems, you’ll need to get a bit poetic about the problem for which the surgery is being performed. For example, “ﬁve-year history of worsening DJD of left knee, signiﬁcant functional impairment, failing conservative tx and injections.” Although the surgeon knows all this, you still need an HPI. And don’t forget to include a decision-making area. Just because WWW.PHYSICIANSPRACTICE.COM the codes are being used a bit differently doesn’t mean the documentation requirements have changed. 2008 MODIFIER CHANGES Historically, CPT modiﬁer descriptions are long on technically precise jargon, short on common-sense instructions, and miss the boat in terms of explaining correct usage. This year’s addition to the 25 modiﬁer description is a case in point: “This modiﬁer is not to be used to report an E&M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identiﬁable services, see modiﬁer 59.” The ﬁrst two sentences do tell us something, although not the whole story. In fact, the E&M could well result in a decision to perform a minor surgical procedure that same day. What’s being referred to is actually the CMS policy that states you can only use a 25 modiﬁer on the E&M code when the other service is a procedure with zero or 10 global days. Mentioning modiﬁer 57 changes the context from the usual use of 25 to an entirely different situation. Perhaps modiﬁer 57 should contain some language to indicate that it is intended for use when the procedural code that will be billed (not necessarily on the same day) has a 90-day global period. The real red herring here is the last comment about modiﬁer 59. Why is that mentioned at all? It is a procedural modiﬁer, usually for surgeries, and doesn’t have anything to do with E&M. The modiﬁer section could beneﬁt from subsection guidance, such as “Only ﬁve modiﬁers may be appended to E&M codes: 21, 24, 25, 32, and 57. Of these, 21, 24, 25, and 57 are appended only to E&M codes; modiﬁer 32 may also be appended to procedural services.” That would be helpful. In fact, some of the biggest misunderstandings about modiﬁers could be cleared up with simple instructions relative to their use with the different CPT sections. In the radiology section they might want to say, “Don’t use modiﬁers 50 and 51 in this section. Modiﬁer 59 may be used in exceptional cases as indicated in parenthetical notes.” People still don’t really know if they are supposed to append a 25 to an E&M code when the other service comes from the Medicine section of the CPT manual. Do you use it with EKGs, PFTs, and other nonsurgical procedures? Let’s get some real guidance here. YOUR CODING Q&As Q I read in one of your past columns a question regarding coding for unusable balance testing results. What about when a Pap smear result is reported as having inadequate cellularity or no endocervical cells? In many cases the patient must return to the office for another Pap test. The billing has usually already been submitted for the first Pap. How do we bill the second? A Simply bill the repeat Pap with a 76 modiﬁer and a more speciﬁc diagnosis code, if possible. • Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting ﬁrm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 18 years. He can be reached at billdacey@msn.com or via info@physicianspractice.com. MARCH 2008 | PHYSICIANS PRACTICE | 61 http://WWW.PHYSICIANSPRACTICE.COM

Table of Contents Feed for the Digital Edition of Physicians Practice - March 2008

Physicians Practice - March 2008 Contents The Bigger Picture: Try a Little Tenderness Second Opinion Letters Physicians Practice Pearls: The Value of First Impressions Noteworthy Cover Story: Your Complete Guide to Patient Service Billings & Collections: Rules to Code By The Administrators Desk: Selecting an EMR Technology: Learn to Love Your Nerd Ask The Experts Coding The Guide The Tech Doctor: All About Blogs The Great Practice Makeover: When Bad Things Happen to Good Practices Start It Up - NEW! The Law: Audits 101 In Practice: Do As I Say... Pretty Please? Healthonomics: Handling the Changes Wrought by Medicare D Classifieds Advertiser Index

Physicians Practice - March 2008

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