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Advanced Care Planning Gets Paid Separately When billed with Wellness Visit

Advanced Care Planning Gets Paid Separately When billed with Wellness Visit.

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Radiology procedures should contain a written report

Radiology procedures should contain a written report

Radiology procedures should contain a written report, signed, as a component along with comprehensive documentation supporting the findings.  Instructions added to Radiology code section in the CPT® 2016 manual confirm, “A written report  handwritten or electronic signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation.” Radiology report templates should be structured to facilitate clear, concise, and complete documentation necessary for accurate billing.

Recommended documentation should include, at a minimum (and when applicable):

  • Facility or location where the study was conducted
  • Name of patient and medical records number
  • Name of referring physician
  • Type of examination/service
  • Date of examination/service
  • Time of examination/service
  • Injection of dye
  • Number of views
  • Date of dictation
  • Date and time of transcription
  • Patient age or DOB
  • Patient gender
  • Clinical information and diagnosis code (if available)
  • Procedures/materials
  • Findings
  • Potential limitations
  • Clinical issues
  • Comparison studies and reports
  • Impressions

Imaging studies such as magnetic resonance imaging (MRI), computed tomography (CT), ultrasound, nuclear medicine or X-ray exams play an increasingly important role in the diagnosis and treatment of disease. After completing an imaging study, the radiologist will analyze the images and prepare a report summarizing the findings and impressions.

Electronic Health Records

Many patients today can access their health records — including radiology reports — electronically online. Electronic access to health records allows patients to make more informed healthcare decisions in partnership with their physicians. Plus, patients are empowered to electronically share radiology reports with other medical providers. This potentially increases the safety, quality and efficiency of patient care.

The radiology report is primarily a written communication between the radiologist interpreting the imaging study and the physician who requested the examination. Typically, this radiology report is sent to the physician who originally requested the imaging study and who then conveys the results to the patient. Many patients can also directly access their radiology reports and, in some cases, their medical images using online patient portals and electronic health records.

These records and reports often contain complex anatomical and medical terms.

CPT® is a trademark of the American Medical Association

Cholesteatoma coding in ICD-10-CM

Cholesteatoma coding in ICD-10-CM

Proper cholesteatoma coding  should include the specific site as well as the side of the body.

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NCCI Edits For 2016

Update for NCCI Edits 2016

A reminder to providers and payers alike of the changing nature to the federal bundling rules, Version 22.1 of the National Correct Coding Initiative (NCCI) will be ready for upload after the first of the year. A test file will be available approximately January 31, 2016. The final file will be posted on or about Feb. 14.

Version 22.1 includes all previous versions and update since January 1996 and it will be released in the customer Column 1/Column 2 format with both National Correct Coding Edits and Mutually Exclusive Code edits.

The Centers for Medicare & Medicaid Services (CMS) developed the National Correct
Coding Initiative (NCCI) to promote national correct coding methodologies and to control
improper coding that leads to inappropriate payment in Part B claims. The coding policies
developed are based on coding conventions defined in the American Medical Association’s
Current Procedural Terminology manual, national and local policies and edits, coding
guidelines developed by national societies, analysis of standard medical and surgical
practice, and review of current coding practice.
The latest package of CCI edits, Version 22.0, effective January 1, 2016, will be available
via the CMS Data Center (CDC). A test file will be available on or about November 2,
2015, and a final file will be available on or about November 17, 2015.
Version 22.0 will include all previous versions and updates from January 1, 1996, to the
present. In the past, CCI was organized in two tables: Column 1/Column 2 Correct Coding
Edits and Mutually Exclusive Code (MEC) Edits. In order to simplify the use of NCCI edit
files (two tables), on April 1, 2012, CMS consolidated these two edit files into the Column
One/Column Two Correct Coding edit file. Separate consolidations have occurred for the
two practitioner NCCI edit files and the two NCCI edit files used for OCE. It will only be
necessary to search the Column One/Column Two Correct Coding edit file for active or
previously deleted edits. CMS no longer publishes a Mutually Exclusive edit file on its
website for either practitioner or outpatient hospital services, since all active and deleted
edits will appear in the single Column One/Column Two Correct Coding edit file on each
website. The edits previously contained in the Mutually Exclusive edit file are NOT
being deleted but are being moved to the Column One/Column Two Correct Coding
edit file. Refer to the CMS NCCI webpage for additional information

Operating Microscope Coding

Coding Operating Microscopes

An operating or surgical microscope is a specific type of surgical instrument which is different from magnifying loupes, corrected vision devices, or other simple magnification devices. An operating microscope is also not the same as a robotic surgical device.

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Tracheostomy coding

Understanding coding Tracheostomy

A tracheostomy is a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube.

A tracheostomy is usually done for one of several reasons:

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Warts coding utilizing ICD-10

Correct warts coding in ICD-10

Warts are benign (not cancerous) skin growths that appear when a virus infects the top layer of the skin. Viruses that cause warts are called human papillomavirus (HPV). You are more likely to get one of these viruses if you cut or damage your skin in some way. Wart viruses are contagious. Warts can spread by contact with the wart or something that touched the wart.
Warts are often skin-colored and feel rough, but they can be dark (brown or gray-black), flat, and smooth.

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Coding Vertebroplasty

Vertebroplasty Coding

Vertebroplasty or Percutaneous vertebroplasty is a procedure that involves injecting a cement kind material into the vertebral body to provide support for the structure using imaging guidance. The segment of the spine and the type of guidance helps in determining the coding. Vertebral augmentation is the process of cavity creation followed by the injection of the material or cement under imaging guidance. For 0200T and 0201T, sacral augmentation (sacroplasty) refers to the creation of a cavity within a sacral vertebral body followed by injection of a material to fill that cavity.

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Incomplete Colonoscopies, New Guidelines for 2016

New Guidelines for Coding Incomplete Colonoscopies


New values for incomplete colonoscopies (diagnostic and screening) that are performed on or after January 1, 2016 have been established by the Center for Medicare & Medicaid Services (CMS).

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Outpatient Hospital New Place of Service Codes (POS) 

New and Revised Place of Service Codes (POS) for Outpatient hospital

The Centers for Medicare and Medicaid Services (CMS) is requiring the use of place of service (POS) code 19 Outpatient Hospital-Off campus to describe, “A portion of an off-campus hospital provider-based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization effective Jan. 1, 2016.”

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