Academy Advantage Partner OptumInsight Essentials for Procedure Coding
There are many elements required to submit a clean claim. While it should be routine to verify the patient contact information and insurance coverage, the process of selecting and reporting procedure and diagnosis codes is more complex and requires skill and understanding of multiple coding systems. Current Procedural Terminology (CPT®) codes are updated yearly, effective January 1. The new CPT codes are published in November in the Federal Register and your Academy will alert you to the codes relating to otolaryngology—head and neck surgery prior to their effective date. In addition, there are interim updates to category III codes. Every provider’s office must review those changes and adjust its billing practices to reflect only the most current codes. One of the more difficult issues with coding is translating CPT language into easily understood descriptions. This is particularly challenging when the CPT code uses specialty-specific terms or eponyms that identify the service after the procedure innovator, e.g., Epley manuever. CPT codes are subject to specific guidelines regarding code combinations, order of reporting, and reduction of multiple procedures. Healthcare providers must submit claims in accordance with these guidelines. The guidelines include verifying that CPT code combinations do not result in a Correct Coding Initiative (CCI) edit, verification of appropriate modifiers, and reporting the highest valued procedure first. It is important to compare code pairs using the CCI edits that are in effect for a specific date of service. Additional guidelines include the appropriateness of an assistant at surgery, identification of procedures not subject to multiple procedure reduction or that are add-on codes, and code-specific instructions. See a related article, “NCCI and MUEs,” (page 44) to read more about how the Academy’s Physician Payment Policy (3P) workgroup reviews proposed edits. The Academy website also provides many resources available on edits and how you can check codes for edits, www.entnet.org/login.cfm. Just as procedure codes have complex rules, so do diagnosis (ICD-9-CM) codes. Incomplete codes that do not contain the appropriate fourth and fifth digits should not be reported. Some ICD-9-CM codes require that additional codes be reported, and often the order of the codes is set by coding guidelines. Diagnosis codes should relate to the procedure codes, and it is important to note that when multiple procedures are reported, the diagnosis codes for each procedure may be the same code or a unique code, for each procedure. ICD-9-CM codes are updated and effective on October 1 of each calendar year. Although the healthcare industry is planning for the adoption of ICD-10-CM in two years, there will still be changes to ICD-9-CM codes. For 2011, these changes were significant as they better align the ICD-9-CM codes with some of the coding conventions found in ICD-10-CM. The Academy published articles in the April and August issues of the Bulletin this year to prepare you for the transition and will continue to inform you of milestones in preparation for the switch. The article in this month’s Bulletin, “Preparing for ICD-10,” (page 42) by Kim Reid contains further information. The change to ICD-10 will affect the way all of medicine will report visits and procedures beginning in 2013. As a member benefit, the Academy will also publish a crosswalk of the top 200 diagnosis codes from the ICD-9 code to the new ICD-10 coding structure in an upcoming issue of the Bulletin as well as on the website. Please watch for this valuable resource. A helpful tool in bringing all of these coding elements together into a single source is the Ingenix 2012 Coding Companion for ENT/Allergy/Pulmonology. Focusing on the CPT codes most commonly encountered by otolaryngology and head and neck surgery practices, this tool includes lay descriptions of the surgical procedures and coding tips to help in code assignment. The most commonly associated ICD-9-CM diagnosis codes, ICD-9-CM volume 3 procedure codes, terms, Medicare Relative Value Units (RVUs), and modifiers related to specific CPT codes are included. Completing the coding essentials are the CCI edits with quarterly CCI updates available online. OptumInsight, previously Ingenix, specializes in technology services, information, analytics, business services and consulting. OptumInsight may be reached at (800) 464-3649, via email at kelly.armstrong@ingenix.com or online at www.shopingenix.com. The AAO-HNS contracts with Physician Reimbursement Systems, a group of experienced, competent, and courteous coding professionals who will respond to your coding requests within 24 hours. Dedicated hotline staff can help you in the following coding areas for Medicare and private payers: ICD-9-CM, CPT, and HCPCCS Level II Evaluation and Management services Appropriate modifier use Correct Coding Initiative (bundling) edits Deciphering complex operative reports Call 1-800-584-7773 now to take advantage of this excellent Academy member benefit. Please have your AAO-HNS membership number available when you call.
Current Procedural Terminology (CPT®) codes are updated yearly, effective January 1. The new CPT codes are published in November in the Federal Register and your Academy will alert you to the codes relating to otolaryngology—head and neck surgery prior to their effective date. In addition, there are interim updates to category III codes. Every provider’s office must review those changes and adjust its billing practices to reflect only the most current codes. One of the more difficult issues with coding is translating CPT language into easily understood descriptions. This is particularly challenging when the CPT code uses specialty-specific terms or eponyms that identify the service after the procedure innovator, e.g., Epley manuever.
CPT codes are subject to specific guidelines regarding code combinations, order of reporting, and reduction of multiple procedures. Healthcare providers must submit claims in accordance with these guidelines. The guidelines include verifying that CPT code combinations do not result in a Correct Coding Initiative (CCI) edit, verification of appropriate modifiers, and reporting the highest valued procedure first. It is important to compare code pairs using the CCI edits that are in effect for a specific date of service. Additional guidelines include the appropriateness of an assistant at surgery, identification of procedures not subject to multiple procedure reduction or that are add-on codes, and code-specific instructions. See a related article, “NCCI and MUEs,” (page 44) to read more about how the Academy’s Physician Payment Policy (3P) workgroup reviews proposed edits. The Academy website also provides many resources available on edits and how you can check codes for edits, www.entnet.org/login.cfm.
Just as procedure codes have complex rules, so do diagnosis (ICD-9-CM) codes. Incomplete codes that do not contain the appropriate fourth and fifth digits should not be reported. Some ICD-9-CM codes require that additional codes be reported, and often the order of the codes is set by coding guidelines. Diagnosis codes should relate to the procedure codes, and it is important to note that when multiple procedures are reported, the diagnosis codes for each procedure may be the same code or a unique code, for each procedure.
ICD-9-CM codes are updated and effective on October 1 of each calendar year. Although the healthcare industry is planning for the adoption of ICD-10-CM in two years, there will still be changes to ICD-9-CM codes. For 2011, these changes were significant as they better align the ICD-9-CM codes with some of the coding conventions found in ICD-10-CM.
The Academy published articles in the April and August issues of the Bulletin this year to prepare you for the transition and will continue to inform you of milestones in preparation for the switch. The article in this month’s Bulletin, “Preparing for ICD-10,” (page 42) by Kim Reid contains further information.
The change to ICD-10 will affect the way all of medicine will report visits and procedures beginning in 2013. As a member benefit, the Academy will also publish a crosswalk of the top 200 diagnosis codes from the ICD-9 code to the new ICD-10 coding structure in an upcoming issue of the Bulletin as well as on the website. Please watch for this valuable resource.
A helpful tool in bringing all of these coding elements together into a single source is the Ingenix 2012 Coding Companion for ENT/Allergy/Pulmonology. Focusing on the CPT codes most commonly encountered by otolaryngology and head and neck surgery practices, this tool includes lay descriptions of the surgical procedures and coding tips to help in code assignment. The most commonly associated ICD-9-CM diagnosis codes, ICD-9-CM volume 3 procedure codes, terms, Medicare Relative Value Units (RVUs), and modifiers related to specific CPT codes are included. Completing the coding essentials are the CCI edits with quarterly CCI updates available online.
OptumInsight, previously Ingenix, specializes in technology services, information, analytics, business services and consulting.
OptumInsight may be reached at (800) 464-3649, via email at kelly.armstrong@ingenix.com or online at www.shopingenix.com.
The AAO-HNS contracts with Physician Reimbursement Systems, a group of experienced, competent, and courteous coding professionals who will respond to your coding requests within 24 hours. Dedicated hotline staff can help you in the following coding areas for Medicare and private payers:
- ICD-9-CM, CPT, and HCPCCS Level II
- Evaluation and Management services
- Appropriate modifier use
- Correct Coding Initiative (bundling) edits
- Deciphering complex operative reports
Call 1-800-584-7773 now to take advantage of this excellent Academy member benefit. Please have your AAO-HNS membership number available when you call.