CODING & COMPLIANCE

Common Coding Dilemmas

Recommendations for navigating Medicare’s Surgical Coding Rules

BY RIVA LEE ASBELL

Working with many physicians, even in a physician-owned ASC, presents a myriad of problems for those charged with the responsibility of coding for Medicare cases. To help, here are recommendations on how to troubleshoot three common dilemmas.

Dilemma #1: Coding new technology that may not have a specific code

This is a difficult one for both the ASC and the consultant. However, it is mandatory to follow the rules, which are clearly stated in the introduction of the Current Procedural Terminology (CPT): “Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. In surgery, it may be an operation; in medicine, a diagnostic procedure or therapeutic procedure; in radiology, a radiograph … It is equally important to recognize that as techniques in medicine and surgery have evolved, new types of services, including minimally invasive surgery, as well as endovascular, percutaneous, and endoscopic interventions have challenged the traditional distinction of Surgery vs. Medicine. Thus, the listing of a service or procedure in a specific section of this book should not be interpreted as strictly classifying the service or procedure as ‘surgery’ or ‘not surgery’ for insurance purposes. The placement of a given service in a specific section of the book may reflect historical or other considerations …”

Example: Multiple iStents

In my February 2015 column, I discussed the use of two iStents during the same session. The case included a cataract extraction with insertion of an intraocular lens, and two iStents for correction of mild to moderate open angle glaucoma. Two codes applied:

• 0191T: Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; initial insertion.

• +0376T: Each additional device insertion (List separately in addition to code for primary procedure).

(Note: The + sign indicates that the code is an add-on code and cannot be used alone.)

The FDA approval of the iStent is for initial insertion of a single stent during a given session. The use of an iStent as an additional stent during the same session (new code +0376T) is not FDA approved. The ASC payment is packaged with that of 0191T. It has an N1 Payment Indicator (PI) and, thus, no extra payment is made to an ASC for packaged items. The January 2015 national ASC payment amount for procedure code 0191T was $1,711.02.

The physician should follow proper protocol regarding off-label use when inserting multiple iStents. This includes obtaining the following: An addendum to the iStent informed consent form if you use the one OMIC (Ophthalmic Mutual Insurance Company) provides, or any other, regarding the use of multiple stents at the same session; a separate informed consent for using the second device as off label; and a written confirmation showing that the patient was informed of his financial responsibilities for the procedure/device and, in fact, signed an Advanced Beneficiary Notice (ABN). It is a good idea for the ASC to make sure all of the above items are in order before scheduling multiple stent procedures. Keep in mind that there is no way to charge the patient for the two stents.

Recommendation #1: If the surgical case being scheduled is known not to have a CPT code, you have two choices: Don’t accept the case or make the patient responsible for payment, just as you would for a cosmetic case.

Recommendation #2: Have the nurse manager or other qualified person review any unusual cases before accepting them for scheduling.

Recommendation #3: When dealing with codes that are “close,” sometimes an expert opinion is needed to help determine which code is most acceptable. Don’t hesitate to contact consultants, manufacturers, healthcare attorneys, OMIC, OOSS, or other specialists who have a vested interest in you getting it right.

A word of caution: Always question any code selection advice that starts with “try,” “take a look at,” or “maybe.”

Dilemma #2: Incomplete operative notes

Incomplete operative notes generally don’t describe procedures coded by the physician or listed under the “Surgery Performed” section at the beginning of the operative note. It is the surgeon’s responsibility to provide a complete and accurate operative note to the ASC. Steps are often omitted in oculoplastic surgical cases, making it very difficult for the ASC coder to determine which procedure(s) was performed.

Example: Retinal Detachment

Preoperative diagnosis: Rhegmatogenous retinal detachment, right eye.

Postoperative diagnosis: Same as preoperative diagnosis. Operative Procedure: Vitrectomy, repair of retinal detachment, laser, C3F8 gas fill, right eye.

Careful reading of the operative notes revealed that there was indeed a retinal detachment that was repaired using a pars plana vitrectomy, a horseshoe tear, as well as a round hole superonasally. Perfluoron gas was used, and the previously placed intraocular lens became displaced into the anterior chamber. A gas-air exchange was performed, and focal endolaser and cryopexy were also used. Then the dislocated intraocular lens was repositioned.

As you may have noticed, the repositioning of the intraocular lens was not listed in the Operative Procedure section. It could easily have been missed for coding.

Recommendation #1: It is better to return the operative note to the surgeon with a request to clarify it rather than using codes unsubstantiated in the operative note — thereby avoiding having a problem if the case is audited. In my experience, this type of poor documentation is common in cases involving repair of complex retinal detachment (CPT code 67113), complex cataract extraction (CPT code 66982), and various oculoplastic surgical procedures.

Recommendation #2: Develop a format for dictation of operative notes for all physicians who use your ASC. If you’re associated with a residency/fellowship training program, it would be worthwhile to develop some type of orientation program and include this template in the handout.

Recommendation #3: ASCs cannot use unlisted CPT codes (nonspecific codes that end in xxx99). Therefore, it is better not to accept cases that might include these procedures, among others. This also applies to Dilemmas 1 and 3.

Dilemma #3: Dividing up payment responsibilities for cosmetic and/or functional procedures performed by the same surgeon in one session

There are legal consequences when an ASC does not charge the patient his or her share of the costs attributable to cosmetic procedures. This applies to the surgeon fee, the anesthesiologist fee, as well as the facility fee for the ASC.

Example: Multiple Procedures

Upper and lower eyelid blepharoplasty surgery (cosmetic procedures) is performed and paid for by the patient. The patient is told, “Don’t worry about that little lesion on your forehead; we’ll just take care of it at the same time.” In this case, if the patient isn’t charged for the excision (by the physician, facility, and anesthesiologist, when appropriate) then an infringement of Medicare compliance has occurred.

Recommendation #1: It is wise that written notification be given to the patient by the ASC of the financial responsibilities. The surgeon and anesthesiologist should do this as well. When it comes to cosmetic procedures, payment in advance ensures that an empty slot won’t appear in your schedule at the last minute. Obtaining advance payment 2 weeks prior to the surgery date is good practice.

Recommendation #2: Make surgeons aware that there are Medicare compliance violations if a surgeon performs a “free” noncosmetic procedure. Allowing this to occur may lead to accusations of inducement for the ASC. It is best to consult with a healthcare attorney regarding this issue.

Recommendation #3: It is important that all physicians and staff know that if a cosmetic and noncosmetic surgery are performed during the same session, the fees for anesthesia time, facility fees, and the surgeon’s fee for the noncovered procedure should be billed to the patient. ■

All CPT codes © 2015, American Medical Association