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Alert – 2016 ICD-10-CM Code Changes

2016 ICD-10-CM Code Changes

Cardiologists, Nephrologists and Neurologists specialties will be the hardest hit with the 2016 ICD-10-CM Code Changes that will go into effect October 1, 2015. ICD-10 increases in specificity and more complexity in most of the cases and not in just the greater number of codes, which means some specialties could experience a more difficult transition compared to others. Drastic changes to some of the most common codes would be seen in cardiology, nephrology and neurology.

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Importance of Anatomy in ICD-10

Anatomy and Physiology skills required for successful transition to ICD-10

The transition from ICD-9-CM to ICD-10-CM/PCS will require a strong foundation in Anatomy and Physiology for professionals involved in medical coding to receive their ICD-10-CM/PCS certification by October 1, 2015. ICD-9 diagnosis codes are not as anatomically specific when it comes to where on the body the procedure is taking place, due to lack of specificity in the information conveyed through the current ICD-9 codes. Refreshing anatomy and physiology information will be especially important for coders working in specialty clinics who spend their time focused on one or two body systems. ICD-10-CM certification will require knowledge of the anatomy and physiology, disease processes and procedures for different body systems. This will not only help the coding professionals in refining their knowledge of anatomy and physiology, but will also help in improving clinical documentation practices. The greater level of detail in ICD-10 demands that coders have an in-depth knowledge of anatomy, physiology and pathophysiology, and that the documentation helps in selection of the most appropriate code(s).

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Importance of NCCI and CCI Edits

CCI edits are pairs of  CPT or HCPCS codes not payable separately for a individual patient billed by a provider on a single same day of service without a justifiable overriding causation.

The National Correct Coding Initiative (NCCI) was implemented in 1996. Bundling CCI Edits are among the top reason claims are denied for new providers. Errors can be avoided by following the National Correct Coding Initiative (NCCI) guidelines.

Correct Coding Initiative (CCI) edits are pairs of Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Level II codes that are not separately payable except under certain circumstances. The edits are applied to services billed by the same provider for the same beneficiary on the same date of service. The purpose of the National Correct Coding Manual is to promote correct coding nationwide and to assist physicians in coding services correctly for reimbursement. The policies included in the manual are based on coding conventions as defined by the American Medical Association (AMA) CPT manual.

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Myelography Radiology Billing

Myelography Radiology Billing

New coding, compliance, and reimbursement changes and challenges are the ones that are seen in 2015 for Radiology billing and coding. There were some changes made to the CPT code book sections for radiology as well:


Two myelogram injection codes have been revised and four new comprehensive codes have been introduced for myelogram contrast injection and imaging.

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Reporting Post-operative Care

Global Period, Post-operative Period and Global Surgical Package

All necessary services provided by a surgeon before, during, and after a procedure within the global period are included in the global surgical package. Payment for the global surgical package is split among the surgeon and physician, when post-op care is transferred from the surgeon to another physician. The Medicare payment will be limited to the same total amount as would have been paid if one physician provided all of the care.

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What is a National Drug Code (NDC)?

What is the significance of  National Drug Code, NDC’s in medical coding?

The NDC, or National Drug Code, is a unique 10-digit, 3-segment number. It is a universal product identifier for human drugs in the United States. NDC is a universal number that identifies a drug. The code is present on all nonprescription (Over The Counter) and prescription medication packages and inserts in the US. It should be noted that the NDC are displayed in a 10- digit format. Proper billing of NDC number consists of 11 digits in a 5-4-2 format. The 10-digit NDC is converted to 11-digit NDC by proper placement of zero. Hyphens are not used when the actual data is entered in the claim.

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What Is An ABN?

ABN = Advance Beneficiary Notice

An Advance Beneficiary Notice or more commonly known as ABN is a Medicare waiver of liability that providers are required to give a Medicare patient for services provided that may not be covered or considered medically necessary.

  • An Advance Beneficiary Notice is used when the service(s) provided may not be reimbursed by Medicare.
  • If the healthcare provider believes that Medicare will not pay for some or all of the items or services, an ABN should be given to the patient.
  • Examples of services that require an ABN include:
  • A visual field exam for an ophthalmologist
  • A pelvic exam for a primary care provider
  • An echocardiogram.

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Self Auditing Medical Claims Is It Worthwhile?

Self Auditing Medical Claims

Using human logic during your review to identify medical claims with the highest likelihood for improper payments can be a challenge. There is an old adjuster’s motto, “If it isn’t in the file, it didn’t happen.” Be aware that the number one area of problematic claim coding found by Claim Risk Adjusters is located under the Evaluation and Management documentation.

Identify and name your Auditing goals like:

  • Identification of payment errors and opportunities for future cost savings
  • Prevention of human misinterpretation of plan language
  • Fulfillment of due diligence and responsibility
  • Optimize claim paying performance by uncovering root causes of errors


An Audit Process includes:

• Investigating five charts per provider, and rotating each provider every week.
• Involving a comprehensive review of medical records, documents, hospital records, provider contracts, billing histories, fee schedules, and medical claims, to thoroughly investigate coding and billing procedures.
• A result letter including a claims report documenting all findings.
• Taking proactive action to correct and prevent coding, billing, other compliance shortfalls and conducting a baseline audit of your practice does require a considerable effort.
• Verification of the guidelines in the provider’s documentation and reporting the appropriate level of service for services provided are part of audits. There will be less risk for error and concern when a provider understands Evaluation and Management documentation guidelines and practices compliant documentation. Audits look for a medical record to be complete and compliant for patient care.

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Incision and drainage services

Incision and drainage services

Incision and drainage (I&D) is a common procedure for an abscess or cyst that may contain pus.
This procedure is performed by :
• Locally anesthetizing the area surrounding the abscess.
• A scalpel or needle is then inserted into the skin and the purulence is drained.
Incision and drainage is a minor surgical procedure that usually can be performed in the office setting by a physician, nurse practitioner or physician assistant

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Modifier 59 and sub-modifiers

Modifier 59, sub-modifiers XE, XP, XS, and XU

Modifier 59 Distinct Procedural Service: According to the CPT Guidelines, under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services that are normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system separate incision/excision, separate lesion or separate injury not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be rather than modifier 59.Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances.

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