Top 10 Errors in ENT Coding and Documentation. Candice Fenildo, CPC, CPMA, CPB, CPC-I, CRHC, CENTC, AAPC Fellow

Transcription

1 Top 10 Errors in ENT Coding and Documentation Candice Fenildo, CPC, CPMA, CPB, CPC-I, CRHC, CENTC, AAPC Fellow

2 Agenda Surgical Guidelines Nasal Fractures When to add on those grafts When is an E/M code justified with procedures Multiple Scopes in the same session Frenu WHAT? Incident too

3 A Coders Role Medical coders hold a key role in the success of many types of health care companies. Physicians need to understand coding - to appreciate the details that must be documented in their dictation to support coding of the procedure performed We need to have the ability to discuss discrepancies. ( if it wasn t documented, it wasn t done ) We can t assume Example: If a provider submits for total ethmoidectomy (31255) The documentation must include details of surgery on the posterior ethmoid cells. Not just the anterior cells.

4 Surgical Guidelines In defining the specific services "included" in a given CPT surgical code, the following services related to the surgery when furnished by the physician or other qualified health care professional who performs the surgery are included. Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical) Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals Writing orders Evaluating the patient in the post anesthesia recovery area Typical postoperative follow-up care

5 Botox BOTOX is used to treat a variety of problems with the voice box, including spasmodic dysphonia, laryngospasm, and granulomas BOTOX is also used for some facial nerve disorders such as Melkersson's syndrome These are a just a couple reimbursable, medically necessary uses for Botox injections in the ENT setting. Appropriate documentation and coding for the administration of Botox is key Lets look at a couple of examples

6 Botox Examples Dr. A preps the patient for Botox injection of vocal cords. After consent and prep. Patients vocal cords are visualized. Using flexible laryngoscope 80 units of Botox are injected into both the right and left vocal cords. There were 20 units left in the vial J0585 Units 80 J0585 JW Units 20

7 Botox Examples Dr. B preps the patient for Botox injection into the facial nerve for Bells Palsy. After consent and prep, The region above the overactive muscle is cleansed with alcohol and 155 units of Botox are injected J Units J0585 JW 45 Units

8 Closed Treatment Nasal Fracture = Closed Treatment Nasal Fracture WITHOUT Stabilization The physician treats a displaced nasal fracture by manipulating the fractured bones. The physician places nasal elevators or forceps into the nose and realigns the nasal bones. After the bones are realigned, they are stable and require no additional stabilization with splints.

9 Closed Treatment Nasal Fracture = Closed Treatment Nasal Fracture WITH Stabilization The physician treats a displaced nasal fracture by manipulating the nasal bones. The physician places nasal elevators or forceps into the nose and realigns the nasal bones. After the bones are realigned, they remain slightly mobile and require additional stabilization with splints. External splinting may consist of a cast taped to the reduced nose. Internal splinting consists of supporting the nasal septum by splints or packing with gauze strips.

10 Open Treatment Nasal Fracture = Open Treatment Nasal Fracture ( uncomplicated) The physician treats a displaced nasal fracture. After unsatisfactory results with closed manipulation of the fractured bones, the physician performs open treatment. Incisions are made inside the nose to expose the nasal septum and portions of the nasal bones. The physician realigns the fractured bones using nasal elevators and forceps. Intranasal incisions are closed in a single layer. Any lacerated skin areas are closed in layers. After the bones are realigned, they remain slightly mobile and require additional stabilization with splints.

11 Open treatment of Nasal Septal Fracture = Open Treatment of Nasal Septal Fracture The physician makes an incision to repair a nasal septal fracture. Open treatment is necessary after unsatisfactory results with closed manipulation of the fractured septum. Incisions are made inside the nose. The nasal septum is exposed and portions of the fractured cartilaginous and bony septum are removed. Trans septal sutures are placed to prevent formation of a septal hematoma. Intranasal incisions are closed in single layers. Stabilization such as internal splinting may be used to support the septum during healing. Internal splinting consists of supporting the nasal septum by splints or packing with gauze strips.

12 Nasal Fractures Open vs. Closed? Using a butter knife and manual manipulation, fractured bone of the nose was easily moved. The outer part of the nose appeared to be straight. At this point a left hemitransfixion incision was made along the right mucoperiosteal tunnel. His cartilage of the septum was fairly shattered in multiple pieces. Visibly, these were realigned and it was elected not to remove any of the tissue as they did realign quite well. These septal mucosal flaps are approximated using 4-0 suture in a running through and through mattress type fashion. Incision closed using interrupted chromic suture. Silastic sheeting placed on either side of septum to splint this in and hold in position and secured in the usual fashion. The right side nose which was concave was packed with Surgicel to help support nasal bone out into its anatomic position. External nose then taped.

13 Cerumen Removal Cerumen impairs the exam of clinically significant portions of the external auditory canal Extremely hard, dry, pain, itching, hearing loss Cerumen could be associated with foul odor, infection and/or dermatitis How to code for patients impacted every two months? code does not have physician work relative value units (RVUs) CPT code vs 69209

14 Cerumen Removal Effective 4/1/2017 CMS reduced the number of MUEs for cerumen removal code (Removal impacted cerumen using irrigation/lavage, unilateral) from two to one.

15 Cerumen Mo went to the physicians office with complaints of crickets in his ears. Dr. Happy inspected the patients ear with an otoscope and found that the patient had hard impacted cerumen bilaterally. Dr. Happy then uses alligator forceps and suction to remove the impacted cerumen. The patient immediately felt relief of his symptoms. Instrumentation + Provider Requirement + Impacted Cerumen = Sally went to the doctor due to itchy ears. Nurse Rose looked in the patients ear and determined that she was going to lavage the ears for relief No Instrumentation + Nurse Visit + Non Impacted Cerumen = 69209

16 Tube Insertion/ Removals Appropriate CPT code for Ventilating Ear Tube Removals in the office 9920X 9921X Appropriate CPT code for Ventilating Ear Tube Removal in the operating room Appropriate CPT code for Ventilating Ear Tube Insertions in the office ( Don t forget your modifier ) -50 Increased RVU for practice expense

17 Diagnostic Endoscopies nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) laryngoscopy, flexible; diagnostic nasopharyngoscopy with endoscope (separate procedure) nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannul diagnostication of ostium

18 Epistaxis 30901: control nasal hemorrhage, anterior, simple(limited cautery &/or packing) any method 30903: control nasal hemorrhage, anterior, complex (extensive cautery &/or packing) any method 30905: control nasal hemorrhage, posterior, with packs &/or cauterization, any method; initial 30906: control nasal hemorrhage, posterior, with packs &/or cauterization, any method; subsequent Documentation critical to distinguish correct service

19 Where is the bleed? Was it controlled with endoscopic visualization? What sources were used for control? Electrocautery Silver Nitrate

20 Example How do you code the services? Initial visit for patient with 3 weeks of intermittent nasal bleeding, mild but occasionally moderate. Perform & document level 3 initial visit care Identify left anterior bleeding site and control with silver nitrate cautery and Surgicel topical pack Physician documents use of nasal endoscope during evaluation.

21 Answer

22 Turbinates Common error is coding and billing for cautery of the turbinate's

23 Turbinates AAO-HNS Clinical Indicators state that indications for inferior turbinate surgery must include: Chronic nasal obstruction due in part to inferior turbinate hypertrophy. Failure of directed medical management with continued nasal symptoms (medications, allergy treatment, and duration of therapy) Failure of medical treatment of rhinitis medicamentosa. Symptoms of obstructive sleep apnea The failure of directed medical management might be considered (particularly if YOU are the patient) to include: Continued obstruction following straightening nasal septum Continued obstruction following endoscopic sinus surgery

24 Turbinates 30801: cautery and/or ablation, mucosa of inferior turbinates, unilat or bilat, any method; superficial 30802: intramural (this includes radiofrequency procedures) 30930: fracture inferior turbinates, therapeutic 30130: excision inferior turbinate, partial or complete 30140: submucous resection of inferior turbinate, partial or complete, any method 30801, 30802, & are components of & Middle turbinate Rx (nonendoscopic), including concha bullosa, now coded as unlisted procedure 31240: endoscopic resection concha bullosa; NOT bundled into & per CCI

25 Turbinates Example Dr. Johns documented that he used a blade to submucosally excise tissue with microdebrider and suction through a tube. Is CPT Correct?

26 Turbinates Answer Code (Submucous resection inferior turbinate, partial or complete, any method) specifies excision of bone. There must be documentation that your surgeon cut the mucosa to get to the bone and remove it, preserving the mucosa. If the surgeon removed the mucosa and bone together, the correct code would be (Excision inferior turbinate, partial or complete, any method).

27 Septal Cartilage Graft and Septoplasty Physician performed a septoplasty, CPT 30520, removed cartilage and fashioned it for a graft that he used in the surgical repair of vestibular stenosis, CPT Do you code for the fashioning of the graft or just and 30465? Only one code, or 20912, may be reported if the procedures were performed through the same incision. What was the reason for the incision to straighten the septum (30520) or to obtain the graft (20912)? Use whichever code is supported by the documentation but do not use both codes..

28 Nasal Valve Repair Common mistakes and Use of -59 to correct denials CPT guidelines state to use modifier 52 (reduced services) on if only one side is corrected. Therefore, implies both sides were surgically corrected and it would be inappropriate to append modifier 50 (bilateral procedure)

29 Debridement An otolaryngologist may perform postoperative Debridements (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) for sinusitis after Functional Endoscopic Sinus Surgery, which may also include Septopplasty and/or Turbinectomy, or Submucous resection inferior turbinate. The Medicare Physician Fee Schedule assigns different global periods to 30520, and FESS codes. Codes and have 90-day global periods. FESS codes contain zero global days.

30 Debridement Example: After a septoplasty for a deviated septum, a turbinectomy for hypertrophy, a total ethmoidectomy for ethmoidal sinusitis and a maxillectomy for maxillary sinusitis an otolaryngologist performs debridement. Documentation indicates the debridement was to remove the crusting that occurs following sinus surgery, to prevent infection and to keep the airway patent. Because the Otolatyngologist performed the debridement for a reason that is unrelated to the reason for the septoplasty and/or turbinectomy, you should report the debridement.

31 Debridement Opinion: From an audit perspective, appropriateness of is not a coding issue; it typically is either: Documentation issue Documentation fails to meet AAO-HNS policy statement conditions to be considered a debridement (rather than just suctioning)

32 Drug Eluding Implant ( Propel) The Propel sinus implant is a steroid-releasing sinus implant that is inserted into the ethmoid sinus Indicated for patients 18 years or older Inserted under endoscopic visualization Once in place medication ( mometasome furoate) is released over a 30 day period. Documentation is key for proper reimbursement

33 Drug Eluding Implant ( Propel) Example Code: 0406T Procedure: Nasal endoscopy of ethmoid sinus with placement of drug-eluting implant Procedure in detail: The right nasal cavity was endoscopically examined with a rigid scope. The Propel implant inserter was placed into the nasal cavity and used to open and place the implant into the ethmoid cavity. Good placement was achieved within the cavity to provide maximal contact with the cavity surfaces and provide continuous medication to reduce inflammation and scarring and improve healing.

34 UPPP & Tonsillectomy Coding Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) Tonsillectomy, primary or secondary; younger than age Tonsillectomy, primary or secondary; age 12 or over Code 42145(column 1) has a CCI conflict with code 42826(column 2). A modifier is not allowed to override this relationship. According to CCI data, there are not any CCI conflicts for and 42145

35 Vestibular Testing An ENG is used to detect disorders of the peripheral vestibular system (the parts of the inner ear that interpret balance and spatial orientation) or the nerves that connect the vestibular system to the brain and the muscles of the eye. Your provider might order an ENG if the patient is experiencing unexplained dizziness, vertigo, or hearing loss. Additional conditions that might warrant an ENG include acoustic neuroma, labyrinthitis, Usher syndrome, and Meniere s disease. During the test, electrodes are placed at locations above and below the eye to record electrical activity. By measuring the changes in the electrical field within the eye, ENG can detect nystagmus (involuntary rapid eye movement) in response to various stimuli. If nystagmus does not occur on stimulation, a problem may exist within the ear, nerves that supply the ear, or certain parts of the brain. This test may also be used to distinguish between lesions in various parts of the brain and nervous system.

36 Vestibular Testing 92541, Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording 92542, Positional nystagmus test, minimum of 4 positions, with recording 92544, Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording 92545, Oscillating tracking test, with recording , Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and once cool irrigation in each ear for a total of 4 irrigations , Monothermal (i.e., one irrigation in each ear for a total of two irrigations) Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording

37 Vestibular Testing In 2016 CPT introduced two new Caloric codes (Caloric vestibular test with recording, bilateral; bithermal [i.e., one warm and one cool irrigation in each ear for a total of four irrigations]) and ( monothermal [i.e., one irrigation in each ear for a total of two irrigations]), are considered the Column 1 code when performed with several specific procedures, a couple of them are and G0268

38 Frenulum Incision/Excision CPT code CPT code CPT code 41010

39 Global Period Modifiers How Do They Impact Reimbursement? Modifier 58: Indicates that a subsequent procedure was performed as a (1) planned or anticipated (staged); (2) more extensive than the original procedure; or (3) for therapy following a surgical procedure. Reimbursement should be 100% of the allowable and the global period is extended to that of the subsequent procedure. Modifier 79: Is appended to CPT code to show that an unrelated procedure was performed during the global period of a prior procedure. Reimbursement should be at 100% of the allowable and you re now in a separate global period that is related to the subsequent procedure. Modifiers 78: Indicates that an unplanned, related procedure was performed in the operating room, catheterization or endoscopy suite. Typically this is treatment of a complication such as wound dehiscence, infection, etc. Reimbursement is typically at 70-80% of the allowable. The reduction accounts for overlapping pre- and post-op care which was paid under the original procedure.

40 E/M with Procedure Every procedure with a defined global period (including 90 day, 10 day, and 0 day) includes an E/M component This E/M component is described by CMS as the usual pre- and postoperative work of a procedure with a global fee period Each procedure code with a global period includes RVUs assigned for the usual E/M services associated with that code A physician should not submit codes for an E/M service that is within the description of usual work associated with a procedure

41 Exam Issues Counting headers, not the content of the Exam. Counting Body Areas for a comprehensive Exam 1995 Guidelines 1997 ENT Comprehensive Exam frequently missing bullets: Assessment of hearing with tuning forks and clinical speech reception thresholds (e.g., whispered voice, finger rub); Examination by mirror of larynx including the condition of the epiglottis, false vocal cords, true vocal cords and mobility of larynx (Use of mirror not required in children); Examination by mirror of nasopharynx including appearance of the mucosa, adenoids, posterior choanae and eustachian tubes (Use of mirror not required in children).

42 Diagnosis Coding When a cancer has been removed and there is no evidence of recurrence, and there is no active treatment, it would not be proper coding to continue to use the malignancy ICD-10 codes personal history of section should be used In the absence of any signs or symptoms to suspect a recurrence, a surveillance scope is not covered by Medicare Provide an ABN (Advanced Beneficiary Notice)

43 Recent Release For Medicare purposes, for an ABN to be considered valid, the provider must use the most recent version of the CMS-R-131 The Office of Management and Budget (OMB) periodically reviews the ABN (Form CMS-R-131) and in March of this year (2017) approved it for renewal Update all forms around office

44 Incident too "Incident to" services are defined as services or supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. Reimbursement is based on 100% of the physician fee schedule amount. Note: Services with their own benefit categories include: clinical lab services, flu shots, diagnostic services. These services do not fall under incident to.

45 Incident too Applies to the following settings: Physician s Office Patient s home NOT inpatient services

46 OIG Report OIG found that Medicare allowed physicians billings for more than 24 hours of services in a day: 50% of the services were not performed by a physician. And of these, 21% of the services were performed by unqualified non-physicians Incident-to services are a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record. They may also be vulnerable to overutilization and expose beneficiaries to care that does not meet professional standards of quality.

47 What s the issue? Depending on who actually performed the service, erroneous reporting could result in either a 15% or 100% overpayment. Auxiliary person is unlicensed 100% Auxiliary person is licensed (NP/PA) but is not credentialed in the group 100% Auxiliary person is licensed (NP/PA) and is credentialed in the group 15%

48 The 5e Rule What are the circumstances that must be met for the physician to be able to bill using his/her NPI for services provided by a member of his/her staff (PA/ARNP)? Employed NPP Enrolled NPP Established patient to physician Established problem to physician Established plan of care by physician + Physician s direct supervision

49 NPPs and Incident to Never bill incident-to: New patients or consultations Established patient with a new problem In any inpatient setting Can bill incident-to: Established patient, without a new problem, and with direct physician supervision Never assume a 3 rd party payer recognizes NPP s services as incident-to Verify whether the payer includes NPPs as covered providers.

50 Example 1 Two weeks ago, Dr. B diagnosed Mr. Smith with Dysphagia, and today Mr. Smith is in the office with Dr. B s PA who s determining whether the medication Dr. B prescribed is working, no changes were made in the course of treatment. Meanwhile, Dr. B is walking a golf course; however, his colleague Dr. Jones is in the office suite available if the PA needs him. Can you bill Mr. Smith s visit with the PA as incidentto? 50

51 Answer 1 Yes. This service can be billed Incident to. However, under Dr. Jones NPI as he is the one who provided direct supervision. 51

52 Global Surgery Reporting Effective for services 7/1/2017 and after Includes 10 and 90 day global services Report for each postoperative visit ENT has MANY codes to report within

53 What is a post op visit per CMS Follow-up services performed during the post-operative period for reasons related to the original procedure Visits that are covered by the global period are to be reported Visits can occur in all sites of care including, but not limited to, ICU, outpatient clinic, or skilled nursing facility. Relevant telehealth visits should also be reported if the patient is located at an eligible originating site

54 What Services to Report Post-operative visits following selected procedures Procedures were selected based on 2014 data o Furnished by more than 100 practitioners o Performed 10,000 times or have allowed charges exceeding $10 million Changes in CPT coding have been accounted for Procedure codes subject to reporting will be updated yearly and published prior to beginning of reporting year NOTE: Reporting is not required for pre-operative visits within the global period or for services not related to a patient visit

55 Who Reports Billing practitioners (physicians and non-physician practitioners) are required to report post-operative visits if they: o Practice in one of nine states randomly selected by CMS And o Practice in a group of ten or more practitioners And o Are part of a practice that provides global services under one of the required procedure codes Practitioners who are not required to report are still encouraged to report post-operative visits. If you are voluntarily reporting, report all visits for all selected procedures

56 Selected States to Report Florida North Dakota Ohio Kentucky Oregon Louisiana Rhode Island Nevada New Jersey

57 Mandatory reporting codes

58 Mandatory reporting codes

59 References 2017 AMA CPT Professional Addition Optum s Encoder Pro Chapter 12 Section of the Medicare Claims Processing Manual

60 Questions

61 CEU#

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