Everything's up-to-date in Kansas City
Last week, I received a call from a doctor's office inquiring why her claim for a B-12 injection might have been denied by a particular payer. She indicated that they used Current Procedural Terminology (CPT) code 90772 to report the service.
A quick check of my 2009 CPT book identified the problem. Code 90772 has been deleted for 2009; the correct new code is 96372.
It never ceases to amaze and amuse me when a physician's practice is not using the current versions of a CPT, Healthcare Common Procedure Coding System (HCPCS), or International Classification of Diseases, 9th Revision - Clinical Modification (ICD-9-CM) manual. It does not take too many claims denied because of out-of-date codes to equal or exceed what it would have cost the practice to buy current copies of the necessary coding manuals. Indeed, the ICD-9-CM manual is available on CD-ROM from the U.S. Government Printing Office for only $19.00, and HCPCS can be accessed freely on the Centers for Medicare and Medicaid Services web site (although I still prefer to use the manual version).
So, take a moment right now, while you're thinking about it, and pull your CPT, HCPCS, and ICD-9-CM books off the shelf. If they are not the most current versions (i.e., 2009, as I write this), then it's time to order new ones. This ounce of prevention for denied and returned claims should more than equal the pound of cure found in resubmitting or appealing such claims.
Posted at 12:09PM May 28, 2009 by Kent Moore | Comments[1]
Another urban myth about coding
Recently, I received a call from a physician who had heard from a consultant that he should code his levels of evaluation and management (E/M) services based solely on the medical decision making involved. He asked me if this was true.
As I have done with other callers asking the same question, I assured him that this was incorrect information. Current Procedural Terminology (CPT) clearly states that all of the key components (i.e., history, examination, and medical decision making) play a role in selecting a level of E/M service (unless you’re coding on the basis of time because counseling and/or coordination of care dominated the encounter). For some codes (e.g., new patient office visits), all three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. For other codes (e.g., established patient office visits), two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. In no case does CPT state that medical decision making, by itself, determines the level of E/M service.
Medicare policy supports this interpretation. Section 30.6.1, “Selection of Level of Evaluation and Management Service,” of Chapter 12 of the Medicare Claims Processing Manual states, in part, “Instruct physicians to select the code for the service based upon the content of the service.” That content includes the history and examination.
This particular urban coding myth grows out of confusion between medical decision making and medical necessity. As the same section of the Medicare Claims Processing Manual says, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.” Using an extreme example, you can perform and document the history, examination and medical decision making necessary for a level-five office visit for a patient with a common cold, but there are not many people who would say that level of service was medically necessary in that circumstance. In any case, medical necessity is not the same as medical decision making, and medical necessity governs payment, while medical decision making plays but one part in selecting the level of E/M service.
So the next time someone tells you to code E/M services only on the basis of medical decision making, you might warn them about all the alligators living in the sewer system.
Posted at 04:47PM Apr 27, 2009 by Kent Moore | Comments[0]
