Medica Provider Forums

1
Medica Provider Forums

• May 2003
• Physician Coding Session

MEDICA
2
Coding Consultants

• Kathy Baker, CPC
• Radiology, ER, Laboratory, Pathology,
  Physician
• Carolyn Larson, CPC
• DME, IV Therapy, Medicare Policy
• Noreen Nowak, CPC
• Ancillary Networks, Public Health
• Pam Tienter, CPC
• Anesthesiology, Physician
• Ann Tomasetti, RHIT, CCS
• Hospital, Home Health, Nursing Home

MEDICA
3
Overview

• Units
• Child and Teen Checkups
• Lab Bundling
• Unbundling Review
• QA

• Coding Resources
• Assistant Surgeon
• Obstetrical Services
• Diagnostic Ultrasound
• H and S Codes
• Ear Lavage

MEDICA
4
Questions

• Provider Service Center (PSC) first point of
  contact [phone] or [phone]
• When to contact the coding department
• 067 (incorrect procedure code)
• 106 (units greater than normal)
• 478 (diagnosis inappropriate for service)
• 807 (unbundled service)
• E1399 claim denials
• questions on how to code a procedure
• regarding expired codes
• modifier issues

MEDICA
5
Questions (cont.)

• If you are initially appealing an 807 or 106
  denial, the adjustment request process should be
  followed. If a second denial is received after
  requesting an adjustment for the claim, then
  contact the Coding Questions Mailbox for further
  assistance.
• All other issues (i.e. reimbursement, other
  ineligible explanation codes, etc.) should be
  directed to Medica's Provider Service Center.

MEDICA
6
Coding Questions

• Coding Mailbox
• coding.questions_at_medica.com
• HIPAA
• Fax
• [phone]

MEDICA
7
Coding Questions(cont.)

• Turn around time 5 working days
• Answer or acknowledgement
• If no response within this time, contact Paige
  Hinz, Coding Department manager. e-mail
  paige.hinz_at_medica.com
• or [phone].
• Questions are logged, tracked, and data is
  trended.
• Used for education

MEDICA
8
Medica.com

• Resource
• Connections Bulletins
• Coding Questions Fax Form
• Coding Section
• Lists
• Assistant Surgeon Eligible Code List
• Co-Surgeon Surgeon Eligible Code List
• Team Surgeon Eligible Code List
• Procedure Codes That Require Notes
• Future Plans

MEDICA
9
Assistant Surgeon

• Changes effective 1/01/03, date of service
• Eligible codes consistent with CMS with minor
  changes
• NP and PA can submit using their own provider
  number
• Clinical nurse specialist can submit under
  primary surgeons number

MEDICA
10
Assistant Surgeon (cont.)

• Modifier Definitions
• -80 Assistant Surgeon (Physician)
• -81 Minimum Assistant Surgeon (Physician)
• -82 Assistant Surgeon (when qualified resident
  surgeon not available)
• -AS Physician assistant, nurse practitioner, or
  clinical nurse specialist services for assistant
  at surgery

MEDICA
11
Assistant Surgeon (cont.)

• Incorrect claim submissions noted with claims
  with -81 modifier. Claims with
• -81 for NP/PA are denied.
• If physician, provider must resubmit with own
  number.
• If non-physician, claim must be resubmitted with
  AS modifier.

MEDICA
12
Coding for Obstetrical Services

• Global vs. Component code submission
• 3 or less visits EM
• 81002 or 81003 (Urinalysis) included in global
  codes
• Unusual services -22 modifier appended to
  component

MEDICA
13
Diagnostic Ultrasound

• Five new obstetrical ultrasound codes in 2003
• 76801 Ultrasound, pregnant uterus, real time
  with image documentation, fetal and maternal
  evaluation, first trimester (lt14 weeks 0 days),
  transabdominal approach single or first
  gestation
• 76802 each additional gestation (List
  separately in addition to code for primary
  procedure)

MEDICA
14
Diagnostic Ultrasound (cont.)

• 76811 Ultrasound, pregnant uterus, real time
  with image documentation, fetal and maternal
  evaluation plus detailed fetal anatomic
  examination, transabdominal approach single or
  first gestation
• 76812 each additional gestation
• 76817 Ultrasound, pregnant uterus, real time
  with image documentation, transvaginal

MEDICA
15
Diagnostic Ultrasound (cont.)

• Units assignment for codes 76801, 76805 and 76811
  is one.
• Each additional gestation is reported with code
  76802, 76810 or 76812.
• Code 76815 Ultrasound, pregnant uterus, real time
  with image documentation, limited, one or more
  fetuses is reported once per exam and not per
  element.

MEDICA
16
Diagnostic Ultrasound (cont.)

• System error found on new codes for gt1 fetus-
• 76802
• 76812
• No need to resubmit charges.
• A report was run and claims will be reprocessed.

MEDICA
17
Prenatal Care H1000-H1005
MEDICA
18
Pregnancy Classes S Codes
MEDICA
19
CPT 69210

• Done under direct visualization using
  suction, a cerumen spoon or delicate forceps and
  irrigated if necessary, per Federal Register.
• Cerumen removal is normally considered part
  of an office visit and not separately billable on
  the same day as an EM.
• 69210 should only be submitted if medically
  necessary and requires a significant amount of
  time and effort.
• Must be documented as such to be billed
  separately. Appropriate diagnoses must be linked
  to each service.

MEDICA
20
Units

• Each code is assigned a units number
  appropriate for the specific code.
• If units greater than assigned, code is paid up
  to and including the number of units assigned.
• Reason Code 106 Incorrect Number of Units for
  Procedure

MEDICA
21
Units (cont.)

• If electronic submission and quantity is greater
  than 99 units, drop claim to paper.
• For consideration of payment for additional
  units, adjustment request form must be submitted
  with documentation.
• Beneficial for provider to highlight each unit in
  report for easy identification.

MEDICA
22
Single Line Claim Submission vs. Units Billing

• Frequently asked question-Medicare billing
  requirement for single lines.
• Current Submit code on single line with units
  designation.
• Single line exact code submission denial as
  duplicate.
• Medica researching single line code submission at
  this time.

MEDICA
23
-91 Modifier

• Definition Repeat Clinical Diagnostic
  Laboratory Test
• Used to report subsequent laboratory test on same
  date.
• Allows reimbursement for one additional line/code
  only.
• Exact code and modifier resubmission denies as
  duplicate.

MEDICA
24
-91 Modifier (cont.)

• Example
• 84132
• 84132-91
• Both lines will pay according to fee schedule.

MEDICA
25
Child and Teen Checkups (CTC)

• HCPCS code S0302 Completed early periodic
  screening diagnosis and treatment (EPSDT) service
  (list in addition to code for appropriate
  evaluation and management service)
• Required for provider to receive an additional
  40.00 for performing a child and teen check.

MEDICA
26
CTC (cont.)

• Complete CTC Use alpha codes
• ECTC Screening Procedure-
• No Referral
• R A referral, of any type, for detected
  abnormalities
• Informs state and county staff of needed
  follow-up care for patients and provides that
  follow-up care is received (for children ages
  0-10)
• Allows for enhanced reimbursement.

MEDICA
27
Lab Bundling

• To reflect current hematology laboratory
  practices, complete blood count (CBC) codes
  85021, 85022, 85023, and 85024 were deleted.
  References should be made to the following
  revised codes
• 85007 Blood count blood smear, microscopic
  examination with manual differential WBC count
• 85025 Blood count Complete (CBC), automated
  (Hgb, Hct, RBC, WBC and platelet count) and
  automated differential WBC count
• 85027 Blood count complete (CBC), automated
  (Hgb, Hct, RBC, WBC and platelet count)

MEDICA
28
Lab Bundling (cont.)

• Deleted hemogram codes-effective 4-1-03
• Processing irregularity if bundled with deleted
  code
• 300 Denial Reason-Submit active procedure code
• Corrected 4/26/03-Adjustment report requested

MEDICA
29
Unbundling Review

• Custom software based on CCI edits with additions
• Based on CMS, CCI, CPT and specialty society
  organizations
• Edits developed by specialty focused clinicians
• Follow-up review performed for accuracy and
  quality
• Medical director review of complex issues
• Updated quarterly

MEDICA
30
QA

• CPT vs. HCPCS codes Which does Medica want to
  see as a general rule?
• Prefer CPT

MEDICA
31
QA
MEDICA