Coding for new technology.

New procedures and new technology often outpace the development of medical codes to report these services to the insurance payors. Although unlisted procedure codes are not the first choice for reimbursement, it is essential that services be reported with only the code that accurately describes the procedure. For new equipment and techniques, this may result in an increased need for preauthorizing, reporting an unlisted procedure code, and ensuring that complete documentation accompany the claim. Practices should educate the insurance community where necessary to ensure that everyone is working toward the same goal: the best patient care possible.

Using codes for patient tracking.

Although diagnosis and procedure codes are primarily assigned to ensure correct reimbursement, a number of codes can be used for patient tracking purposes. These codes are generally located in the "Supplementary Classification of Factors Influencing Health Status and Contact With Health Services" section of the ICD-9-CM manual, also known as the "V Codes." By using these codes to track certain segments of patient population, a practice can be prepared to forecast patient mix and anticipate specific collection or self-pay issues.

The reason for the cardiovascular test.

When diagnosis codes are reported and sequenced on an insurance claim, official guidelines are available to provide instructions for the correct assignment of ICD-9-CM codes. These instructions are intended to ensure that the correct reason for the diagnostic service is reported and that procedures are reimbursed when they are medically necessary.

The 2005 coding update.

Keep in mind that this is not the end of the 2005 coding changes; there are also new HCPCS level II codes to contend with the advent of the Medicare Final Rules for physician and outpatient hospital-fee schedules. For now, we can prepare for the CPT changes by verifying charge master updates, ensure that fee tickets were corrected, and review any other documents or electronic systems where procedures are captured for billing purposes.

Echocardiography "add-on" codes.

Doppler pulsed wave or continuous wave and color-flow velocity services are reported with add-on codes in addition to the basic echocardiography study. To be reimbursed, payor medical necessity guidelines must be met, and documentation in the echography report must clearly support all services performed.

Planning for a dedicated coder.

Although there are a number of complaints about the complexity of coding rules and regulations, physicians and facilities are still responsible for knowing the guide- lines-or employing someone who does. Also, the practice needs to establish processes to monitor compliance with payor guidelines. The good news is that physicians have an opportunity to improve their income through appropriate coding. According to MD Compliance Alert, April 15, 2002: "In fact, improper coding is the number one most visible and correctable problem in any given practice. Corrected, it can have the simplest, biggest, and quickest impact on most doctors' income".

Cardiac telemetry coding.

In summary, documentation of the procedure performed and individual insurance payor guidelines will determine the procedure code billed for telemetry services. Because codes accepted for these services and reimbursement guidelines may vary, it may be necessary to obtain specific guidance before claim submission.

A consultation, by any other name.

The decision to report a consultation code is based on a number of factors, including: the existence of a request from a physician or other authorized source for opinion or advice, documentation of the face-to-face patient encounter, and a written report of the findings, opinions or advice to the attending physician. Depending upon practice location, relationship with the referring physician population, number of self-referred patients, and other factors, some practices will report primarily consultation codes, whereas others may assign more codes for new patient visits.

And still more new codes.

Before reporting the new Category III CPT codes, contact payors to determine both acceptance of these temporary codes and reimbursement allowances. Documentation must clearly support all services performed, and the requirements for an online medical evaluation should be followed, with the encounter recorded in the individual patient medical record. Hospitals should also review the quarterly changes to OPPS codes and descriptors and ensure that Charge Description Masters are updated as new codes become effective.

IMRT bundling myths.

Payment for IMRT planning bundles, or includes, many services represented by other procedure codes when performed on the same date. As a result, radiation therapy providers must maintain an awareness of bundling edits and coding guidelines to ensure complete and accurate reimbursement for this advanced technology.

Cardiac nuclear medicine.

Documentation of the specific nuclear medicine procedure performed should include whether the test represents the following: Perfusion or blood pool study. Planar or SPECT images. First pass or gated equilibrium (multiple-gated acquisition). Single or multiple studies. Criteria for the performance of add-on procedure codes. This will ensure that the correct procedure codes are reported and result in appropriate reimbursement.

Here we go again!

New CPT procedure codes are added annually (quarterly for Category II and Category III codes), definitions of existing codes are changed, and codes we have memorized are often deleted and replaced. In addition, guidelines for code assignment are constantly revised and may be altered based upon individual insurance payer interpretation. Remember, a code must accurately represent the service performed, and a code that is "close" to the procedure performed cannot be assigned. If the service performed is not defined by an existing procedure code (CPT Category I, II, III or HCPCS Level II), then an unlisted procedure code must be used. The forms and guidelines to request new codes or changes to procedure code descriptors are currently located on the American Medical Association website in the "CPT Process" section (www.ama-assn.org/ama/ pub/category/3112.html).

Coding consultations versus referrals.

Providers can expedite reimbursement and avoid nomenclature errors by properly differentiating between consultations and referrals. Since consultations allow higher levels of reimbursement, providers will also avoid possible fraud and abuse charges because of such mislabeling.

Coding for clinical trials.

Although CMS reimburses for routine care associated with clinical trials, it is essential that the correct diagnosis code, modifier, and, where necessary, HCPCS Level II procedure code be assigned to accurately report these qualifying trial services. Remember that not all insurance payors will provide reimbursement for services rendered as part of a clinical trial, and individual payor policies should be obtained and followed for these services.

To code, or not to code?

In summary, it is also important to remember the hidden rules: 1) Just because there is a code in the manual, it doesn't mean it can be billed to insurance, or that once billed, it will be reimbursed. 2) Just because a code was paid once, doesn't mean it will ever be paid again--or that you get to keep the money! 3) The healthcare provider is responsible for knowing all the rules, but then it is impossible to know all the rules! And not knowing all the rules can lead to fines, penalties or worse! New codes are added annually (quarterly for OPPS), definitions of existing codes are changed, and it is the responsibility of healthcare providers to keep abreast of all coding updates and changes. In addition, the federal regulations are constantly updated and changed, making compliant billing a moving target. All healthcare entities should focus on complete documentation, the adherence to authoritative coding guidance and the provision of detailed explanations and specialty education to the payor, as necessary.