Coding Tips Feb 5th 2016

7/24/2019 Coding Tips Feb 5th 2016

1/5

CODING TIPSFeb 5th 2016

Sam [email protected]

THE FIRST STEP FROM WHERE YOU ARE TO WHERE YOU WANT TO BE

2016 The Coding Institute LLC. All Rights Reserved.
mailto:[email protected]:[email protected]


2/5

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,[email protected]

When You See FAST Exams, Check for This Code Pair Quickly

Heres why an exam that lacks an ECG isnt a FAST exam.

If youre looking at a claim for a focused assessment with sonography for trauma (FAST) exam, coding

quickly gets tricky if you dont know thebasics.

The skinny: Physicians often emergency department (ED) physicians perform FAST exams to check

for internal bleeding. This exam typically involves a check for either bleeding in the peritoneal cavity or

bleeding in the pericardial sack surrounding the heart. Youll often see patients present for FAST exams

after traumatic events involving internal bleeding; blunt force trauma, motor vehicle accidents,

significant falls, etc.

Youll also need some modifier smarts to make most FAST exam claims sail through. Follow these rulesto foster FAST exam coding success.

Look for Evidence of ECG, Ab Study Before Coding FAST Exam

The first part of any FAST exam is a limited transthoracic echocardiography (ECG) to check for pericardial

fluid, which you should code with 93308 (Echocardiography, transthoracic, real-time with image

documentation [2D], includes M-mode recording, when performed, follow-up or limited study).

After the ECG, the physician concludes the FAST exam with a limited abdominal study to check for free

fluid in the abdomen. You should code this service with 76705 (Ultrasound, abdominal, real time with

image documentation; limited [e.g., single organ, quadrant, follow-up]).

Make Modifier 26 Part of Most Fast Exam Claims

Most FAST exam claims also require that you apply modifier 26 (Professional component) to 93308 and

76705 to show that youre only coding for the physicians service, not the equipment he used.

Best bet: Before reporting any FAST exam claims without modifier 26, consult your physician for

guidance.

By Chris Boucher


3/5


If Disaster Hits, You Might Need Modifier CR

Catastrophes that occur nearby can affect your coding.

When a disaster strikes and you have to treat patients affected by the event, be sure youre coding

properly.

Explanation: Depending on the extent and circumstances surrounding the disaster, it could affect your

coding, and modifier usage, when reporting services for affected patients. To make claims processing forpatients in disaster areas go more smoothly, the Centers for Medicare & Medicaid Services (CMS)

created modifier CR (Catastrophe/disaster related).

Remember, however, that the event has to meet some very specific parameters in order to be

considered a disaster. Check out this info on what has to happen before you can start using modifier

CR.

Look for HHS, Presidential Declarations Before Using CR

According to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pa.,the feds must clearly define the catastrophe/disaster before you can use modifier CR.

In disaster/catastrophe situations, Section 1135 of the Social Security Act authorizes the Secretary of the

Department of Health and Human Services (HHS) to waive or modify certain Part B Medicare, Medicaid,

Childrens Medicaid (CHIP), and Health Insurance Portability and Accountability Act (HIPAA)

requirements.

Why? HHS allows these waivers in order to better monitor how payers process claims amid the chaos of

a disaster, explains Dawn Rogers, coding specialist at Caduceus Inc. in Jersey City, N.J.

Before HHS can invoke the 1135 waiver, and you can use modifier CR, two events must occur:

The president must declare an emergency or disaster under the Stafford Act or the National

Emergencies Act.

The HHS Secretary must declare a Public Health Emergency (PHE) under the Public Health Service Act.

Read also: Coding for Reduced Services? Make Sure Your Documentation Is In Order

Experts: Any Event Could Trigger CR Coding

According to Rogers, some of the most recent declarations to meet the above parameters are:

Floods in North Dakota (2011);

Storms and tornadoes in Missouri (2011); Tropical Storm Lee in New York (2011); and

Hurricane Sandy in New York and New Jersey (2012).

All of the above scenarios involve weather, although you might use modifier CR modifier for mass

shootings, bombings, explosions; anything that would meet the criteria for a Section 1135 waiver,

explains Rogers. Once the President and Secretary make the Section 1135 waiver official, you should

report modifier CR along with any services for patients affected by these catastrophes, she adds.

By Chris Boucher


4/5


Responding to Patient Records Requests?

Be as accommodating as you can with patients who want to access their info.

Patients requesting access to their medical records should be a top priority for any practice that wants

to stay compliant and trustworthy.

The basics: A patient has every legal right to her medical records, and if you dont provide access ASAP,not only could you run afoul of the law you could erode patient trust in the process.

Maria V. Ciletti, RN, works as a medical administrator in Niles, Ohio, and is also a member of the

American Medical Writers Association. We checked in with her to see how to best respond to patient

requests for medical records.

Reply to Requests with Trio of Options

When a patient requests to review her medical records, these are the best choices for the practice,

according to Ciletti:

Send medical records to the patient through an online patient portal, if your practice offers this option.

Copy the patients record, and let her come into the office and review it when staff are available to

answer questions, or

Copy the requested records and hand-deliver or mail them to the patient.

Best bet: Try to be flexible; offer the patient all three options to access her medical records, if you have

the capabilities to do so.

Make Time for Patients Who Dispute Record

When a patient accesses her medical record, there is always the chance that she will challenge thecontents of it. Should a

patient challenge your records, you have to be ready to respond with a practice representative that

knows the patients record and is qualified to speak on the practices behalf.

Patients with concerns about their medical records should feel welcome to discuss the issue with the

practice, Ciletti says. We will sit down with them and go over their concerns, she says. Often, these

meetings result in greater patient understanding, according to Ciletti.

Sometimes [the misunderstanding] is language the patient doesnt understand. Sometimes [the record]

was dictated wrong, she says.

If the practice committed the error, however, a meeting with the patient can also help restore patient

confidence. If the practice has made the mistake in the patient record, a face-to-face meeting with the

patient is the best way to handle the situation. This will show the patient that you are aware of, and

concerned about, the situation. A face-to-face meeting about the misstep will help the patient feel that

you will resolve the situation quickly, which you should most certainly do.

By Chris Boucher


5/5


The Coding InstituteAVOID AUDITS . IMROVE REIMBURSEMENT . REDUCE DENIALS . INCREASE REVENUE

The Coding Institute is dedicated to offering quality products and services that delivers Coding &

Compliance Intelligence and improve financial performance of healthcare organizations for more than

60 years, with roots going back to 1947. Whether it's clarifications on modifier use, specific

instructions for navigating tricky scenarios, HIPAA guidance or updates on how the latest

changes will affect your organization we cover it all at lower costs.

We can work with you to help you achieve your 2016 strategic objective -

Boost productivity, improve coding accuracy and pre-empt claim rejections by online

time saving tools that are inspired by coders, powered by coding expert SuperCodero BoneCoder10 works with your EHR, practice management software, or encoder to cut ICD-10

coding time down to the barest of minimums.

Keep your coding, billing, compliance, and healthcare-management know-how up-to-

date with training solutions made simple - AudioEducator.

Get accuracy-boosting guidance you need to perfect your coding choices, maximize

revenue and steer clear of audit time-bombs through most extensive collection of up-

to-date medical coding, billing, compliance and reimbursement booksTCIs Books

Reduce denials, protect your payments from audits, and cut hours from your dailycoding routine by bringing your team timely, relevant and accurate coding, billing,

compliance and reimbursement guidance TCIs medical coding and compliancenewsletters

Improve Coding Accuracy, Ensure Compliance, and maximize your revenue through-

TCIsChart Auditing Services

Improve your financial health by eliminating cost of reworks, low self-pay collections,

and underpayments TCIs Outsourced billing, coding and collection services.

CONTACT US

SAM NAIR

Associate Director Enterprise Practice

Direct: 704 303 8150

Desk: 866 228 9252, Ext: 4813

[email protected]

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713
mailto:[email protected]://player.vimeo.com/video/124605624https://player.vimeo.com/video/124605624https://player.vimeo.com/video/124605624https://player.vimeo.com/video/124605624https://www.youtube.com/watch?v=Ywyf6wj-PY4mailto:[email protected]:[email protected]://www.youtube.com/watch?v=Ywyf6wj-PY4https://player.vimeo.com/video/124605624https://player.vimeo.com/video/124605624mailto:[email protected]

Documents

Coding Tips Feb 5th 2016