Coding Carpal Tunnel Syndrome.
Carpal Tunnel Syndrome.
Carpal tunnel syndrome is diagnosed when there is pressure on the median nerve in the wrist. Some symptoms include pain, numbness, tingling, and weakness in the hand. The physician may order physical therapy, or prescribe a wrist brace or nonsteroidal anti-inflammatory drugs (NSAID). To achieve coverage and payment, the provider should document the conservative treatment provided, along with the patient’s response to these methods.
Following more conservative treatments, an injection performed in the wrist with corticosteroids and/or anesthetics can provide temporary relief of the symptoms. The injection is reported with 20526 Injection, therapeutic (Eg: Local anesthetic corticosteroid), carpal tunnel. If one performs this service in an office setting and purchase the medication, the corticosteroid using the appropriate HCPCS Level II code (In a hospital or outpatient setting, the facility codes for the drug) should be coded.
A more productive intervention is for the physician to perform a release of the ligament, through either an endoscopic or open approach.
The endoscope is placed into the wrist through a small incision in the wrist joint. The scope is used to identify the carpal ligament, which is divided to relieve pressure on the median nerve and tendons. An endoscopic carpal tunnel release is reported with CPT® code 29848 Endoscopy, wrist, surgical, with release of transverse carpal ligament.
The National Correct Coding Initiative Policy Manual for Medicare Services, updated Jan. 1, states:
CPT code 29848 describes endoscopic release of the transverse carpal ligament of the wrist. CPT code 64721 describes a neuroplasty and/or transposition of the median nerve at the carpal tunnel and includes open release of the transverse carpal ligament. The procedure coded as CPT code 64721 includes the procedure coded as CPT code 29848 when performed on the same wrist at the same patient encounter. If an endoscopic procedure is converted to an open procedure, only the open procedure may be reported.
In an open approach, an incision is made over the carpal tunnel. The ligament is divided to release pressure on the median nerve, or the nerve may be relocated to relieve the pressure. An endoscope is not used in this procedure. The CPT® code to report this procedure is 64721 Neuroplasty and/or transposition; median nerve at carpal tunnel.
Both endoscopic and open carpal tunnel release surgeries are unilateral codes. To report bilateral injections, either append modifier 50 to the single code or bill the code on two lines and append modifiers RT and LT, depending on the insurance carrier’s preference.
Whether the patient is having an injection or surgery, consent is needed. Consent may be verbal for an injection given in a physician office, but must be in writing for surgery in a hospital or other outpatient setting. Most hospitals require consent forms to be filled out by the provider and signed by both the provider and the patient. For verbal consent, the provider must document that consent was obtained by the patient or the patient’s guardian.
Additionally, the physician should document the prep, the location, the needle, aspiration (if performed), drug, dosage, and how the patient tolerated the procedure.
ICD-10-CM breaks down carpal tunnel syndrome based on laterality. The codes are in Chapter 6, Diseases of the Nervous System:
- 00Carpal tunnel syndrome, unspecified upper limb
- 01Carpal tunnel syndrome, right upper limb
- 02Carpal tunnel syndrome, left upper limb
- 03Carpal tunnel syndrome, bilateral upper limb
Carpal tunnel surgery has a 90-day global period. Global periods can be found in the Physician Fee Schedule. Any evaluation and management (E/M) visits to the surgeon or the surgeon’s associates related to the carpal tunnel surgery are inclusive in the reimbursement for the surgery and cannot be separately reported.
If the physician performs internal neurolysis (such as a pain block) using an operating microscope during a carpal tunnel release using an open approach, report add-on code 64727 Internal neurolysis, requiring use of operating microscope (List separately in addition to for neuroplasty) (Neuroplasty includes external neurolysis) in addition to 64721. A parenthetical note states, “Do not report code 69990 in addition to code 64727.”
It is better to check with the insurance if they require modifier 51 Multiple procedures when billing bilateral procedures on two lines using the anatomic modifiers RT/LT
It should be noted that Novitas Solutions has a local coverage policy for CPT® 20526. Under the utilization guidelines it states, “More than 3 injections per anatomic site in a six month period will be denied. More than two anatomic sites injected at any one session will be denied.” It’s important to check these guidelines with the different payers.
Reporting G Codes for Mammogram.
The American Medical Association (AMA) deleted CPT® 77051, 77052, 77055, 77056, and 77057, and introduced three replacement codes to report mammography for 2017.
- 77065Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral
- 77066 bilateral
- 77067Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
The reason for the change is that the industry standard for mammograms now bundles computer-assisted detection (CAD) with mammograms.
The descriptors for these new codes mirror, exactly, the HCPCS Level II codes for reporting mammography services:
- G0202Screening mammography bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
- G0204Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral
Codes G0202-G0206 are required when reporting mammography to Medicare payers. Codes 77065-77067 have not replaced G0202-G0206 for Medicare billing.
On Jan. 4, the Centers for Medicare & Medicaid Services (CMS) published an update to Change Request (CR) 9861 (originally released on Nov. 16, 2016) and its accompanying spreadsheets for the National Coverage Determinations (NCD) affected by the CR. Unexpectedly, CMS added a note in the Revision History for NCD 220.4 Mammograms, stating that it would not recognize the 2017 CPT® codes for mammograms. CMS explained, “This is the result of being unable to properly process claims using CPT codes 77065, 77066, and 77067 for 2017.” CMS said that it intends to recognize the 2017 CPT® codes for mammograms in 2018.
For Professional Mammography Services:
For 2017 professional (practitioner’s) claims, report mammography services using the G-codes (G0202, G0204, G0206, G0279) or 77063. Be sure the service ordered and performed matches the description of the code. It is easy to confuse screening versus diagnostic and the accompanying tomosynthesis codes.
The CMS spreadsheet updated and released on Jan. 4 for CR9861 is confusing; it still contains the expired CPT® codes, but you may not use them for dates of service past Dec. 31, 2016.
A screening mammogram without tomosynthesis is coded G0202. If the patient also has screening tomosynthesis add 77063. Be sure to check the NCD for the covered diagnoses and allowable frequency.
A diagnostic mammogram is coded as either G0204 (diagnostic bilateral) or G0206 (diagnostic unilateral). If tomosynthesis is ordered, also report G0279 to either G0204 or G0206, as appropriate.
For Commercial Payers:
Payers other than Medicare will likely use the new CPT® codes, but check with them to be sure. If a payer is using the CPT® codes, a screening mammogram is coded as 77067. If tomosynthesis is ordered, also report 77063.
For commercial diagnostic mammograms, code either 77065 or 77066, depending on the order. If tomosynthesis is provided, also report G0279.
Codes 77065-77067 have not replaced G0202-G0206 for Medicare billing
Coding Sclerotherapy of Fluid Collection
Code 49185 Sclerotherapy of fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed describes sclerotherapy of a fluid collection, such as a lymphocele, cyst, or seroma, and includes related contrast injection, diagnostic study, imaging guidance, and radiological suction and irrigation.
There are other sclerotherapy codes in CPT®, such as those reported for esophageal and gastric varices; hemorrhoids; and veins. But, 49185 solely reports using the technique for fluid collections.
One should report one unit of 49185 per lesion treated. Append modifier 59 Distinct procedural service to the second and subsequent units. Report a single unit of 49185 for connected lesions.
Do not confuse sclerotherapy with collection or drainage. Code 49185 doesn’t include drainage of fluid prior to sclerotherapy.
According to AMA’s 2016 CPT Changes: An Insider’s View, drainage represents separate work and should be reported with the drainage procedure code for that particular anatomical site. One may separately report collection/drainage if performed on the same lesion (Eg: If an injection is made for collection or a drainage tube was inserted, that’s a separate service).
Billing Professional Courtesy
Billing Professional Courtesy: Physicians may provide “Professional Courtesy” discounts to other physicians, as well as to those with whom they work or have a personal relationship (e.g., office staff, hospital employees, and family members).
Medicare stipulates that a physician cannot bill for services or ordered services for his/her immediate family member, as shown below. Per the Medicare Carriers Manual [14-3-2332]:
Do not pay under Part A or Part B of Medicare for expenses, which constitute charges by immediate relatives of the beneficiary or by members of his/her household. The intent of this exclusion is to bar Medicare payment for items and services furnished by physicians or suppliers, which would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge. This exclusion applies to items and services rendered by a related physician or supplier, even if the bill or claim is submitted by an unrelated individual or by a partnership or a professional corporation. It applies to items and services furnished incident to a physician’s professional services (Eg: by the physician’s nurse or technician) only if the physician who ordered or supervised the services has an excluded relationship to the beneficiary. The only exception is items furnished by an incorporated non-physician supplier.
The following degrees of relationship are included within the definition of immediate relative:
- Husband and wife;
- Natural or adoptive parent, child, and sibling;
- Stepparent, stepchild, stepbrother, and stepsister;
- Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
- Grandparent and grandchild; and
- Spouse of grandparent and grandchild.
A father-in-law or mother-in-law relationship does not exist between a physician and his/her spouse’s stepfather or stepmother.
A step-relationship and an in-law relationship continue to exist even if the marriage upon which the relationship is based terminates through divorce or through the death of one of the parties. If a physician treats his step-father after the death of his natural mother or after the step-father and natural mother are divorced, or if he treats his father-in-law or mother-in-law after the death of his wife, the services are considered to have been furnished to an immediate relative and are excluded from coverage.
These are persons sharing a common abode with the patient as a part of a single family unit, including those related by blood, marriage, or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.
It should be noted that a brother-in-law or sister-in-law relationship does not exist between a physician (or supplier) and the spouse of his wife’s (her husband’s) brother or sister.
Identify POA indicators with correct documentation.
To assign an appropriate diagnosis related group (DRG), one must correctly identify present on admission (POA) indicators on all inpatient claims for services rendered in general acute care hospitals.
POA is defined as conditions present at the time the order for an inpatient admission is executed. This includes conditions developing during an outpatient encounter, including in the emergency department (ED), observation, or ambulatory surgery.
Each coded diagnosis requires a POA indicator. The ICD-10-CM Official Guidelines for Coding and Reporting advises, “A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnosis and procedures.”
There are four reporting options (with some conditions exempt from reporting):
- Y (Yes: Present at the time of the inpatient admission)
- N (No: Not present at the time of the inpatient admission)
- U (Unknown: The documentation is insufficient to determine if the condition is POA)
- W (Clinically undetermined: The provider is unable to determine whether the condition was POA)
The Centers for Medicare & Medicaid Services (CMS) tells us not to assign U routinely but to use it in limited circumstances.
- Cases of when to assign Y (POA):
- Any condition the provider unquestionably documents as POA
- Conditions diagnosed prior to the admission (e.g., chronic conditions)
- Conditions diagnosed during the admission that were clearly POA, but diagnosed post admission (e.g., admitted with melena, nausea/vomiting, and intractable abdominal pain, final diagnosis is stomach cancer)
- A condition that develops during an outpatient encounter prior to a written order for inpatient admission
- A newborn condition present at birth, developing in utero, or occurring during delivery (e.g., meconium aspiration)
- A condition documented as possible, probable, suspected, or rule-out at the time of discharge, which was suspected upon admission
- Scenarios where a single code identifies the chronic condition only and not the acute exacerbation (e.g., acute exacerbation of chronic leukemia)
- Examples of when to assign N (not POA):
- A condition the provider unquestionably documents as not being POA
- The final diagnosis contains possible, probable, suspected, or rule-out at the time of discharge, but was not suspected on admission
- The final diagnosis contains an impending/threatened diagnosis but was not suspected on admission
- Scenarios where a combination code is assigned and any part of the code was not POA (e.g., acute exacerbation of COPD, in which the exacerbation occurring post admission)
- A pregnancy/obstetrical complication not POA (e.g., laceration during delivery)
Coding Spinal Injections and Fluoroscopy.
Spinal Injections and Fluoroscopy.
Spinal Injections and Fluoroscopy: CPT® retains the instruction from previous years for coding spinal injections and fluoroscopy, “Fluoroscopic guidance and localization is reported with 77003 unless a formal contrast study (myelography, epidurography, or arthrography) is performed, in which case the use of fluoroscopy is included in the supervision and interpretation codes or the myelography via lumbar injection code.” But with the 2017 code changes, the codebook also now states, “Fluoroscopy or CT and any injection of contrast are inclusive components of 62321, 62323, 62325, 62327.” Parenthetical instructions following each of these codes explain, “Do not report [code] in conjunction with 77003, 77012, or 76942.”
You may report 62320-62327 only once, per session. Code choice is based on the region where the needle enters the body. CPT® instructions also explain that if a catheter is used only for a single day, report the services as if it were a single injection, using 62320-62323. If the catheter is left in place, report 62324-62327 for the initial placement of the indwelling catheter, or for the continuous infusion. Subsequent dates are reported with CPT® 01996 Daily hospital management of epidural or subarachnoid continuous drug administration.
One must ensure documentation supports the following five elements when reporting these codes:
- An injection(s) of diagnostic or therapeutic substance(s)– All codes
- Interlaminar epidural or subarachnoid space– All codes
- Location of the spine(cervical, thoracic, lumbar, sacral, or caudal)
- Cervical or thoracic codes: 62320, 62321, 62324, 62325
- Lumbar or sacral (caudal) codes: 62322, 62323, 62326, 62327
- With or without imaging guidance:
- Without imaging guidance codes:
- Cervical or thoracic: 62320, 62324
- Lumbar or sacral (caudal): 62322, 62326
- With imaging guidance codes:
- Cervical or thoracic: 62321, 62325
- Lumbar or sacral (caudal): 62323, 62327
- Single injection/single day infusion or continuous infusion/indwelling catheter
- Single injection/single day infusion codes:
- Cervical or thoracic without imaging guidance: 62320
- Cervical or thoracic with imaging guidance: 62321
- Lumbar or sacral (caudal) without imaging guidance: 62322
- Lumbar or sacral (caudal) with imaging guidance: 62323
- Continuous infusion/indwelling catheter codes:
- Cervical or thoracic without imaging guidance: 62324
- Cervical or thoracic with imaging guidance: 62325
- Lumbar or sacral (caudal) without imaging guidance: 62326
- Lumbar or sacral (caudal) with imaging guidance: 62327
When one has identified documentation for all five points, the service can be reported properly.
The injection code changes required fluoroscopy codes changes. The CPT® codebook now classifies all fluoroscopy codes (77001-77003) as add-on services. Also updated are the lists of codes that may be reported with CPT® +77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) and +77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or para spinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure). If the procedure code is not listed under the appropriate fluoroscopy add-on code, the fluoroscopy service is not separately reported.
In 2015, the CPT® codebook separated joint injections and aspirations into services “with” and “without” image guidance. This year, CPT® has taken a similar approach with spinal injection services. As of Jan. 1, 62310-63219 are deleted, and replaced with:
- 62320Injection(s), of diagnostic or therapeutic substance(s) (eg, anaesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
- 62321with imaging guidance (ie, fluoroscopy or CT)
- 62322Injection(s), of diagnostic or therapeutic substance(s) (eg, anaesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
- 62323with imaging guidance (ie, fluoroscopy or CT)
- 62324Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anaesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
- 62325with imaging guidance (ie, fluoroscopy or CT)
- 62326Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anaesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
- 62327with imaging guidance (ie, fluoroscopy or CT)
For easier understanding, all even numbered codes are without imaging guidance, and all odd numbered codes are with imaging guidance.
CMS revises Travel Allowance Rate
The Centers for Medicare & Medicaid Services has revised the 2017 travel allowance flat rate for laboratory technicians in accordance with the Internal Revenue Service.
Medicare Part B will pay a travel allowance for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient, provided the specimen collection fee is also payable. Payment for these services is made based on the Clinical Laboratory Fee Schedule.
Travel codes allow for payment either on a per – mileage basis (P9603) or on a flat rate per trip basis (P9604), depending on the Medicare administrative contractor’s (MAC) preference.
- P9603Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home or nursing home bound patient; prorated miles actually traveled – The allowance remains $0.535 per mile, plus an additional $0.45 per mile to cover the technician’s time and travel costs. MACs have the option of establishing a higher per mile rate if local conditions warrant it.
- P9604Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home or nursing home bound patient; prorated trip charge – The updated flat rate per trip basis travel allowance is $9.85.
The per mile travel allowance is appropriate for use where the average trip to the patients’ homes is longer than 20 miles, round trip. Payment is prorated based on the number of specimens collected per trip, and on the number of specimens drawn from non-Medicare patients in the same trip.
According to CMS, audits have shown the abuse of the per mile method, so many MACs have established local policy to pay based on a flat rate per trip basis only.
These payment rates are effective Jan. 1, 2017. MACs have until May 12, 2017, to implement these rates.
Prolonged service for Medicare
The Centers for Medicare & Medicaid Services (CMS) typically does not allow separate payment for physician services that do not require face-to-face time with a patient. As of Jan. 1, 2017, CMS has made an exception and will now cover prolonged services for Medicare. CMS will allow coverage for non- face-to-face prolonged service codes 99358 Prolonged evaluation and management service before and/or after direct patient care; first hour and +99359 …each additional 30 minutes (List separately in addition to code for prolonged service), in compliance with CPT® guidelines.
CPT® Evaluation and Management/Prolonged Services instructions dictate:
Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service and is beyond the usual physician or other qualified health care professional service time.
Report Prolonged Services with E/M Codes
Codes 99358 and 99359 are to be reported in addition to other E/M service codes, to which they relate. “For example,” CPT® explains, “extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records.”
In keeping with CPT® requirements, CMS stresses, “codes 99358 and 99359 cannot be reported during the same service period as complex chronic care management (CCM) services or transitional care management services. They are not reported for time spent in non-face-to-face care described by more specific codes having no upper time limit in the CPT code set.” CMS further stipulates, “99358 and 99359 can only be used to report extended qualifying time of the billing physician or other practitioners (not clinical staff).”
Codes 99358 and 99359 are time-based and include “the total duration of non-face-to-face time spent by a physician or other qualified health care profession on a given date providing prolonged services, even if the time… is not continuous,” according to CPT®. The codes are applied as follows:
Total duration of services Coding
< 30 minutes Not reported separately
30-74 minutes 99358
75-104 minutes 99358, 99359
105-134 minutes 99358, 99359 x 2
Documentation should summarize the necessity and specific content of the prolonged services. See the CPT® codebook for additional guidelines to report prolonged services.
Virtual Group Reporting in Quality Payment Program
When the Centers for Medicare & Medicaid Services (CMS) proposed the Quality Payment Program, there was talk of virtual groups individual clinicians and small group practices joined together to report on Merit-based Incentive Payment System (MIPS) requirements as a collective entity. CMS said in the Jan. 27, webinar “Virtual Group Reporting in the Quality Payment Program” that virtual groups will be a participation option starting in 2018.
Here are the rules for participation, to date:
• As with clinician groups, virtual groups will be scored on combined performance for quality and cost.
• Eligible clinicians and clinician groups must elect to participate in a virtual group prior to the performance year and may not change their status during the performance period.
• All group practice members must be included in the virtual group. A group practice can only be in one virtual group.
• A virtual group must be comprised of a combination of Tax Identification Numbers (TINs).
CMS is still in the rulemaking phase for virtual group reporting and is interested in learning what factors individual eligible clinicians and small practices would take into consideration when forming/joining a virtual group. In particular, CMS is looking for feedback such as:
• What potential barriers and challenges would you need to address to form/join a virtual group?
• How much time would groups need to form a virtual group and be ready for reporting?
• What elements would be critical to include in a virtual group agreement?
Billing Nail Procedures
To file accurate claims when coding and billing nail procedures, be familiar with the nuances of nail anatomy, common conditions, treatments, services, and procedures. Here are some tips to point you towards better nail reporting.