final regular icd-9-cm code update continues trend of ... · update continues trend of increased...

Final regular ICD-9-CM code update continues trend of increased specificity

Beginning October 1, coders will have 17 additional

V codes to report personal history of various conditions,

as well as 40 new diagnosis codes for skin malignancies.

The new ICD-9-CM codes are part of the final regular

update to ICD-9-CM before the switch to ICD-10-CM

on October 1, 2013. The Centers for Disease Control and

Prevention (CDC) will make limited updates to both the

ICD-9-CM and ICD-10-CM codes in 2012, and will only

update the ICD-10-CM codes beginning in 2013.

In addition, the CDC revised the code descriptions for

41 ICD-9-CM diagnosis codes and deleted 31 ICD-9-CM

codes altogether.

“The most noticeable trend with these changes has to

be the specificity of the code descriptors,” says Shelly

Cronin, CPC, CPMA, CANPC, CGSC, CGIC, CEU

vendor department manager for the AAPC in Salt Lake

City. “The revised codes as well as the newly created

codes include a specificity level that has not been seen

in previous incarnations of the ICD-9-CM manual.”

Codes add specificity

The increased specificity for a number of codes and

code categories could be the biggest challenge for coders.

“As coders, we tend to fall into habitual coding pat-

terns; we become used to using the same code repeat-

edly,” says Cronin. “These changes will require us

to change our

thinking and to

be vigilant of the

documentation

specificity in rela-

tion to the codes

they choose—

again, a great

precursor to the

ICD-10 changes that is right around the corner.”

The CDC added six new codes for thalassemia that

include additional specificity:

➤ 282.40, Thalassemia, unspecified

➤ 282.43, Alpha thalassemia

➤ 282.44, Beta thalassemia

➤ 282.45, Delta-beta thalassemia

➤ 282.46, Thalassemia minor

➤ 282.47, Hemoglobin E-beta thalassemia

In the past, coders could only report sickle-cell thalas-

semia without crisis (282.41), sickle-cell thalassemia with

crisis (282.42), and other thalassemia (282.49).

In addition to the thalassemia codes, new codes in

the 999.- series indicate the reason for an anaphylactic

or other reaction:

➤ 999.41, Anaphylactic reaction due to administration

of blood and blood products

“ The revised codes as well

as the newly created codes

include a specificity level

that has not been seen in

previous incarnations of

the ICD-9-CM manual.”

—Shelly Cronin, CPC, CPMA,

CANPC, CGSC, CGIC

October 2011 Vol. 12, No. 10

IN THIS ISSUE

p. 4 APC Panel debates codes for packaged servicesShould CMS require facilities to report HCPCS codes for packaged services?

p. 6 Proposed IPPS-based payment cap raises concernsAPC Panel meeting attendees are concerned about CMS’ plan to cross payment systems to set maximum reimbursement.

p. 8 ICD-10-CM anatomy refresher: SpineCheck out the first in our occasional series of anatomy and physiology refreshers.

p. 10 This month’s Q&AOur experts answer your coding questions about charging for triage-only ED visits, the timing of status and written discharge orders, assigning modifier -59 for multiple tests, billing compression wrap and debridement together, and reporting admit and discharge codes on the same day.

Briefings on APCs October 2011

© 2011 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

➤ 999.42, Anaphylactic reaction due to vaccination

➤ 999.49, Anaphylactic reaction due to other serum

➤ 999.51, Other serum reaction due to administration

of blood and blood products

➤ 999.52, Other serum reaction due to vaccination

➤ 999.59, Other serum reaction

Skin malignancies

The CDC significantly expanded code series 173.x

(other malignant neoplasms of the skin) by adding a

fifth digit to each code in the series. For example, coders

currently report a malignant neoplasm of the lip with

code 173.0. After October 1, coders will need to know

the type of malignancy in order to choose between the

following codes:

➤ 173.00, Unspecified malignant neoplasm of skin of lip

➤ 173.01, Basal cell carcinoma of skin of lip

➤ 173.02, Squamous cell carcinoma of skin of lip

➤ 173.09, Other specified malignant neoplasm of skin

of lip

The series still includes one code for unspecified

malignant neoplasm, but coders should start asking

physicians for additional information so they can select

a more specific code.

“In previous years, the coding has been limited

because the codes were not specific to a particular type

of malignancy despite the specific documentation pro-

vided by physicians,” says Cronin. “Having the ability to

report a code that specifically states that the patient has

a squamous cell carcinoma will bring us closer to the

specificity required for ICD-10 coding.”

New V codes

The CDC added new personal history V codes for

gestational diabetes (V12.21); other endocrine, metabolic,

and immunity disorders (V12.29); pulmonary embolism

(V12.55); anaphylaxis (V13.81); and other specified dis-

eases (V13.89).

Coders can also report two new family history V codes:

family history of glaucoma (V19.11) and family history

of other specified eye disorder (V19.19).

Other new V codes include the following:

➤ V23.42, Pregnancy with history of ectopic pregnancy

➤ V23.87, Pregnancy with inconclusive fetal viability

➤ V54.82, Aftercare following explantation of joint

prosthesis

➤ V88.21, Acquired absence of hip joint

➤ V88.22, Acquired absence of knee joint

➤ V88.29, Acquired absence of other joint

New E. coli codes

E. coli (code 041.4) is currently covered by a single

code. However, beginning October 1, coders will need to

select the appropriate E. coli code from the following list:

➤ 041.41, Shiga toxin-producing Escherichia coli

[E. coli] (STEC) O157

➤ 041.42, Other specified Shiga toxin-producing

Escherichia coli [E. coli] (STEC)

Editorial Advisory Board Briefings on APCs

Dave Fee, MBAProduct Marketing Manager, Outpatient Products3M Health Information Systems Murray, UT

Frank J. Freeze, LPN, CCS, CPC-HPrincipalThe Wellington Group Valley View, OH

Carole L. Gammarino, RHIT, CPURRecruiting Management, HIM ServicesPrecyse Solutions King of Prussia, PA

Susan E. Garrison, CHCA, PCS, FCS, CPC, CPC-H, CCS-P, CHC, CPARExecutive Vice President of Healthcare Consulting Services Magnus Confidential Atlanta, GA

Kimberly Anderwood Hoy, JD, CPCDirector of Medicare and ComplianceHCPro, Inc.Danvers, MA

Diane R. Jepsky, RN, MHA, LNCCEO & PresidentJepsky Healthcare Associates Sammamish, WA

Lolita M. Jones, RHIA, CCSLolita M. Jones Consulting Services Fort Washington, MD

Jugna Shah, MPHPresidentNimitt Consulting Washington, DC

Briefings on APCs (ISSN: 1530-6607 [print]; 1937-7649 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $249/year. Copyright © 2011 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. For editorial comments or questions, call 781/639-1872 or fax 781/639-7857. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. Visit our website at www.hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be on this list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of BAPCs. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Current Procedural Terminology (CPT) is copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of American Medical Association; no fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

Editorial Director: Lauren McLeod

Associate Editorial Director: Ilene MacDonald, CPC

Senior Managing Editor: Michelle Leppert, CPC-A, [email protected]

October 2011 Briefings on APCs


➤ 041.43, Shiga toxin-producing Escherichia coli

[E. coli] (STEC), unspecified

➤ 041.49, Other and unspecified Escherichia coli

[E. coli]

Stages of glaucoma

The CDC added codes to specify the stage of glaucoma

in a patient. These five codes, listed below, are completely

new and require a fifth digit:

➤ 365.70, Glaucoma stage, unspecified

➤ 365.71, Mild stage glaucoma

➤ 365.72, Moderate stage glaucoma

➤ 365.73, Severe stage glaucoma

➤ 365.74, Indeterminate stage glaucoma

Additions to influenza

The CDC expanded subcategory 488.8 ( influenza

due to certain identified influenza viruses) to include a

fifth digit identifying pneumonia and other manifestations

that occur as a result of the viral infection. The fifth digit

specifies with pneumonia (488.81), with other respira-

tory manifestations (488.82), and with other manifesta-

tions (488.89).

Pulmonary codes

The CDC added 15 new codes in the 516.- series for

diagnosis of lung diseases. Thirteen of the new codes

require a fifth digit for added specificity:

➤ 516.30, Idiopathic interstitial pneumonia, not

otherwise specified

➤ 516.31, Idiopathic pulmonary fibrosis

➤ 516.32, Idiopathic non-specific interstitial

pneumonitis

➤ 516.33, Acute interstitial pneumonitis

➤ 516.34, Respiratory bronchiolitis interstitial lung

disease

➤ 516.35, Idiopathic lymphoid interstitial pneumonia

➤ 516.36, Cryptogenic organizing pneumonia

➤ 516.37, Desquamative interstitial pneumonia

➤ 516.4, Lymphangioleiomyomatosis

➤ 516.5, Adult pulmonary Langerhans cell histiocytosis

➤ 516.61, Neuroendocrine cell hyperplasia of infancy

➤ 516.62, Pulmonary interstitial glycogenosis

➤ 516.63, Surfactant mutations of the lung

➤ 516.64, Alveolar capillary dysplasia with vein

misalignment

➤ 516.69, Other interstitial lung diseases of childhood

Pneumonitis refers to inflammation of lung tissue.

Although pneumonia is a type of pneumonitis because

the infection causes inflammation, physicians use pneu-

monitis to refer to other causes of lung inflammation.

Revised code descriptions

In the 317–319 series of codes, the words “ intellectual

disabilities” replaced “mental retardation.” Intellectual

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Should CMS require hospitals to report HCPCS codes

for all packaged services that have HCPCS codes? That

topic generated plenty of discussion during the August

12 APC Advisory Panel on Ambulatory Payment Clas-

sification Groups meeting.

The requirement would benefit CMS by allowing it

to set more accurate rates and pay more accurately for

packaged services, especially drugs. But many are con-

cerned the burden would outweigh that benefit.

Currently, facilities generally do not need to report

HCPCS codes for packaged services, including drugs,

even when a HCPCS code exists. The exception is for

devices and radiopharmaceuticals, for which CMS

has instituted edits to ensure that packaged codes are

reported.

Attendees intensely debated whether the panel

should recommend CMS require providers report

HCPCS codes for all services that have codes, regard-

less of whether they are separately paid, according to

Kimberly Anderwood Hoy, JD, CPC, director of

Medicare and compliance for HCPro, Inc., in Danvers,

MA.

“It was really hotly debated,” says Hoy, adding that

she made her only comment during the discussion.

“Some people had really strong opinions.”

Although CMS does not currently require hospitals

to report HCPCS codes for packaged services, including

drugs, it strongly encourages providers to do so because

this data influences the APC rate-setting process, says

Jugna Shah, MPH, president of Nimitt Consulting in

Washington, DC.

HCPCS codes for packaged services

One of the attendees at the meeting suggested that

instead of worrying about reporting HCPCS codes for

packaged services, hospitals should focus on clini-

cal software to help clinicians do their job. After the

clinical piece is in place, the commenter argued, then

hospitals can worry about integrating the reporting of

HCPCS codes for packaged services.

Hoy responded with a comment based on her expe-

rience with hospital software contracts. “If you make

something required, the software vendors will add it to

the software,” Hoy says. “Until you make it required,

you’ll never have that integration where the clinical

piece will be integrated.”

Other attendees expressed concern that reporting

HCPCS codes would represent a burden to hospitals,

Hoy says. Hospitals don’t receive additional reimburse-

ment for packaged services even when they report

HCPCS codes for them.

“Interestingly, everyone from the provider side who

was there and commented said it wouldn’t be a heavy

burden on hospitals, but that hospitals probably would

not do it unless required,” Hoy says.

Kathy Dorale, RHIA, CCS, CCS-P, vice president of

HIM at Avera Health System in South Dakota, noted

during the meeting that hospitals end up coding the

National Drug Code anyway on many drugs.

Although providers said reporting HCPCS codes

wouldn’t be a burden for them, several members of the

panel disagreed, Hoy says. Other panel members rec-

ognized the burden but said that without accurate and

APC Panel debates requiring codes for packaged services

disabilities can be mild, moderate, severe, profound,

or unspecified. The same change was made in V codes

V18.4 (family history of intellectual disabilities) and

V79.2 (special screening for intellectual disabilities).

Three influenza codes, 488.11, 488.12, and 488.19,

now specify “2009 H1N1 influenza” within their code

descriptions instead of using the phrase “identified

novel.”

The codes in series 995.5x now denote “anaphylactic

reaction” instead of anaphylactic shock. Coders still

need to select the appropriate fifth digit to denote the

substance that caused the reaction. n



complete data, rate setting will continue to be compro-

mised. In the end, the panel did not approve any recom-

mendation to CMS on the issue because they weren’t

sure how or whether CMS would enforce it, Hoy says.

Reporting HCPCS codes for all packaged services

could lead to better reimbursement down the line, Hoy

says.

“If hospitals report these packaged services, it will

give CMS better data about the costs of services and

ensure their costs are incorporated into separately paid

items,” she says. “We’ve got the codes and we can dif-

ferentiate things, so we should provide the data to CMS,

which should lead to better payments.”

Once a hospital adds the HCPCS codes to the charge-

master, it will only have to update the codes each year.

“They are mostly chargemaster-driven items, so it’s

really a one-time thing,” Hoy says. “It’s not an ongoing

burden. Once you get the codes in your chargemas-

ter, when the item is billed the code is automatically

reported.”

Many individuals at the meeting acknowledged that

it would be best to report HCPCS codes for all packaged

services that have them. However, because reporting is

seen as a “nicety” rather than a requirement that must

be implemented, making it a priority for hospitals will

be difficult, says Shah.

Audience members agreed with this sentiment,

repeatedly commenting that if CMS does not require

reporting of HCPCS codes, it will fall by the wayside for

most hospitals because other, bigger projects will take

center stage, Hoy says.

Drug payments

The first day of the APC Panel meeting featured a

discussion of how to pay more appropriately for sepa-

rately payable drugs. Alpha-Banu Huq, a member of

CMS’ division of outpatient care, discussed the proposed

payment for drugs. A pharmacy stakeholder group pre-

sented ways in which CMS’ methodology for reimburs-

ing hospitals for separately payable drugs is woefully

inadequate.

CMS must allocate additional dollars from packaged

drugs (those reported with HCPCS codes as well as those

reported without HCPCS codes; called coded and uncod-

ed packaged drugs respectively in the proposed rule) to

separately payable drugs. This would allow the agency

to appropriately reimburse hospitals for drug acquisition

costs as well as the drug handling/overhead costs associ-

ated with preparation, storage, mixing, quality checks,

and safe disposal of drugs. “These costs are not insig-

nificant, yet CMS has continued to provide inadequate

reimbursement for them,” says Shah.

By reallocating a greater proportion of packaged drug

costs to separately payable drugs, CMS would be able

to increase the current proposed payment rate of the

average sales price (ASP)+4% to ASP+6%, which would

provide more adequate compensation to hospitals for

their drugs.

One reason CMS is hesitating on this reallocation is

because hospitals do not report the drug HCPCS codes

on claims, which means CMS doesn’t really know what

packaged drugs hospitals are using or whether the drug

has more overhead costs associated with it than appro-

priate, say Hoy and Shah.

In addition, some facilities may not be reporting all

of the drugs that are eligible for separate payment based

on the packaging threshold. As a result, some packaged

drugs may actually qualify for separate payment because

they exceed the packaging threshold, but CMS is unable

to make that determination due to lack of data. n

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Proposed IPPS-based payment cap raises concernsCMS’ plan to cap payment for cardiac resynchroniza-

tion therapy (CRT) based on Medicare severity diagnosis-

related group (MS-DRG) 227 payment drew plenty of

discussion at the August 12 APC Advisory Panel on Am-

bulatory Payment Classification Groups meeting.

As part of the 2012 OPPS proposed rule, CMS an-

nounced plans to create a new composite APC for CRT

defibrillator (CRT-D) and CRT pacemaker (CRT-P) proce-

dures. CMS proposes capping payment for those services

at the lesser of the newly established APC median cost or

the inpatient standardized payment for MS-DRG 227.

The issue was not whether CMS should create a

composite, says Kimberly Anderwood Hoy, JD, CPC,

director of Medicare and compliance for HCPro, Inc.,

in Danvers, MA. Everyone who spoke seemed to agree

that CRT was perfect for an APC composite. Instead, the

debate focused on CMS’ plan to cap the payment based

on MS-DRG 227. Many commenters opined that CMS’

proposal to cap an outpatient payment based on an in-

patient rate is a radical and inappropriate departure from

the usual rate-setting process, Hoy says.

Jugna Shah, MPH, president of Nimitt Consulting in

Washington, DC, commented that CMS has never before

been willing to look across payment systems—even

when asked to do so, as in the case of drug payment

parity with the physician office setting.

Historically, CMS has been unwilling to compare one

payment system to another because IPPS, OPPS, and the

physician payment system are very different. Rather,

CMS has relied on Congress to cross payment systems—

for example, with mammograms—and has shied away

from doing so itself.

Crossing payment systems

Shah asked the APC Panel to think about CMS’

proposal in two ways. First, she posed a philosophi-

cal question of whether the agency should look across

payment systems. If CMS decides to do so for its CRT-D

proposal, then it must consider doing it for all services,

including drugs and biologicals. ”If CMS wants to walk

through the door of comparing payment systems, then

it must do so for other services as well, such as drugs,”

says Shah.

If CMS’ proposal is finalized, she said the panel

should recommend that CMS also finalize the repeated

requests to eliminate the drug packaging threshold and

provide separate payment for all drugs as it does in the

physician office setting.

Second, Shah cautioned the panel about assuming that

CMS’ cost calculations for one care setting are more or less

accurate given that the rate-setting processes for inpatient

and outpatient charges are completely different. “You sim-

ply cannot compare apples and eggplants and ask every-

one to believe the comparison is valid,” Shah says.

Valerie Rinkle, MPA, revenue cycle director for

Asante Health System in Medford, OR, reminded the

panel that CMS stated it always makes payment deci-

sions based on data from hospitals. In the past, when

CMS made decisions that negatively affected hospital re-

imbursement, its reasoning was always that the hospital

data reflected those revised costs or APC assignment.

With this proposal, however, CMS would not be

relying on hospital claims data to set reimbursement.

Instead, it would be crossing over to the inpatient pay-

ment system, which may be completely inapplicable to

the outpatient side or not as accurate as the outpatient

data, Rinkle says.

One factor that makes the outpatient data potentially

more accurate are edits that CMS implemented to ensure

that the costs of devices are reported on outpatient claims

even though they are not paid separately. No such edits

are in place in the inpatient billing system, and claims

could be submitted without reporting the cost of devices,

a significant portion of the cost of these procedures.

APC Panel recommendation

The panel voted almost unanimously to recommend

that CMS’ base payment for new proposed composite



APC 8009 and APC 0108 (insertion/replacement/repair

of cardioverter-defibrillator leads) be set on the outpa-

tient claims data only.

The concern among providers is not just about new

composite APC, Hoy says. CMS seems willing to cross

payment systems for its own advantage, but chose not to

do so in the past when it would have raised rates for pro-

viders. Providers worry that this opens the door for CMS

to adopt this method in other places, lowering reimburse-

ment if a lower rate exists in another payment system,

without regard to the cost providers report. “It’s definitely

a slippery slope that no one wants CMS to start down.”

The thing that many in the provider community are

questioning is why CMS is beginning to make compari-

sons across sites of service. “Is it only because limiting

payment in this instance benefits the agency?” asks

Shah. Where else will CMS limit the payment based on

the inpatient rate or limit inpatient payment based on

the outpatient rate? Will the agency ever increase pay-

ments? The answers to these questions are still unclear.

New APCs

The APC Groups and Status Assignments Committee

recommended creation of new APCs. The panel adopted

the committee’s recommendation to support the cre-

ation of two new APCs (0331 and 0334) for the HCPCS

codes for reporting combined abdominal and pelvic CT

scans (74176–74178). When these codes were intro-

duced, CMS assigned them to existing APCs for indi-

vidual CT scans.

Providers argued that these codes represented the

combination of predecessor codes and that assigning

them to the same APC as single exams did not sufficient-

ly compensate providers for what are effectively multiple

exams. The new APCs would raise the payment for these

codes from a range of $193–$334 in calendar year (CY)

2011 to $402–$571 in CY 2012.

The panel also adopted the committee’s recommenda-

tion to support CMS’ proposal to create a new APC for

upper gastrointestinal (GI) procedures. This new APC

would result in three levels of upper GI procedures.

However, the subcommittee recommended that two

codes—43227 (endoscopic esophageal repair) and 43830

(placement of gastronomy tube)—be assigned to the Lev-

el III APC rather than Level II because their median costs

are closer to the median costs of Level III procedures.

Magnetoencephalography payment

CMS currently uses claims data from electroencephalo-

grams (EEG) to set the cost-to-charge ratio for magneto-

encephalography (MEG), which is incorrect according to

one presenter. The presenter argued that MEG costs more,

but did not provide data showing that hospitals charged a

proportionally different amount for this service, Hoy says.

MEG currently falls under revenue code 086x, but

many facilities don’t report it there because CMS does not

require them to, Hoy says. Instead, they report it under

the regular EEG revenue center. Even if hospitals use the

separate revenue code, MEG does not have a cost center

where CMS and hospitals can compare cost data.

The APC Panel recommended that CMS require

facilities to report MEG under revenue code 086x with

appropriate edits to make sure facilities report it there. Al-

though the presenter argued that MEG is more expensive

than it looks on paper, CMS’ average cost data showed

that the procedure had been priced too high. As a result,

the panel recommended CMS move MEG from APC 67

to APC 66, which is a lower payment, Hoy says.

Inpatient-only procedures

Panel members also stated they would need addi-

tional clinical information before determining whether

to recommend removing 43279 (Laparoscopic esoph-

agomyotomy [Heller type], with fundoplasty) from the

inpatient-only list and deciding which APC it should be

grouped to as an outpatient procedure.

Rinkle suggested that the panel consider Medicare Ad-

vantage Plan data to determine how often a procedure is

performed on an outpatient basis when deciding whether

to remove it from the list. A CMS representative con-

firmed that CMS currently reviews OPPS data only and

does not consider Medicare Advantage Plan data. n



ICD-10-CM anatomy refresher: SpineEditor’s note: With the increased specificity required for

ICD-10-CM coding, coders need a solid foundation in anatomy

and physiology. To help coders prepare for the coming switch,

we will provide a series of occasional anatomy and physiology

refreshers for different parts of the body. This month we start

with the spine.

The spine is only one part of the musculoskeletal

system, but its interwoven bones, nerves, and muscles

make it a very complicated section. To make matters

even more confusing, a single vertebra is more than just

a bone; it is a complex segment of anatomical structures.

“It’s important for a coder to understand all of these

individual segments of the vertebrae because these de-

tails are necessary for accurate coding in both diagnoses

and procedures,” says Shelley C. Safian, PhD, MAOM/

HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved

ICD-10-CM/PCS trainer of Safian Communications Ser-

vices in Orlando, FL.

That complexity can make it difficult to accurately

assign ICD-9-CM diagnosis codes for the wide range of

spinal conditions—coding these conditions in ICD-10-

CM could be challenging as well.

Spinal column

A knowledge of spinal anatomy provides the founda-

tion necessary to assign codes both before and after the

switch to ICD-10-CM.

The spine is essentially a stack of bones (known as

vertebrae) that run down the posterior of the torso from

the brainstem to the tailbone. The spinal column is broken

into five separate areas, based on location from the top of

the spine to the bottom:

Figure 1

Figure 2



➤ Cervical, known as C1–C7

➤ Thoracic, known as T1–T12

➤ Lumbar, known as L1–L5

➤ Sacral, known as S1–S5

➤ Coccyx, known as CX

The first cervical vertebra, usually known as C1, is

also called the atlas. C2, the second cervical vertebra,

is also known as the axis. “The good news is these are

the only two vertebrae that have alternate names,” says

Safian.

The sacral vertebrae, or sacrum, start out as five

separate bones at birth. By the time an individual

reaches his or her mid-20s, the bones fuse into one

bony section. After the bones fuse, the S1–S5 desig-

nation refers to the location on the single bone, says

Safian.

Similar to the sacrum, the coccyx also fuses into one

bone as a person ages; it starts out as three to five indi-

vidual bones at birth.

Vertebral body

Each vertebra includes a vertebral body that sur-

rounds the spinal cord to protect it in the front. The

spinous process and the pedicle protect the spinal cord

in the back.

The pedicles are short stout processes that attach to

the superior part of the vertebral body on each side.

These extend posteriorly to meet the laminae, which are

broad flat plates of bone. The pedicles also overlap the

laminae of the vertebrae below.

The articular processes arise from the junctions of the

pedicles and laminae. These bony projections have a

small smooth surface known as a facet. Each vertebra in-

cludes four articular processes, two upper and two lower,

that comprise the facet joints.

Coders also need to understand the difference be-

tween an interspace and a segment, says Kim Pollock,

RN, MBA, CPC, consultant with KarenZupko & Associ-

ates, Inc., in Chicago. A vertebral segment represents a

single complete vertebral bone with its associated articu-

lar processes and laminae.

Although the bones of the vertebral column are stacked

on top of each other, they don’t actually rest on each

other. The vertebral interspace is the non-bony compart-

ment between two adjacent vertebral bodies that contains

the intervertebral disc and includes the nucleus pulposus,

annulus fibrosus, and two cartilagenous endplates.

“Think of the segment as two bones and the space

between,” says Pollock. n

Figure 3

Figure 4



Charging for triage-only ED visits

Q A patient presents to the ED and is triaged and

assessed by a nurse, but leaves before being seen

by the ED physician. Is there a CPT code we can use for

the nursing assessment, and can we charge the patient

for the nursing assessment?

A These visits are often referred to as triage-only

or nurse-only visits. Medicare contractors vary in

their policies for reimbursing such visits. CMS published

an FAQ on this issue in 2008, ID 8810, but it does not

clearly answer the question of a patient leaving the ED

before he or she sees the physician:

FAQ Q: Is it appropriate for a hospital to bill a visit code

under the Outpatient Prospective Payment System (OPPS)

for care provided to a registered outpatient if the patient was

not seen by a physician?

FAQ A: Under the OPPS, unless indicated otherwise, we

do not specify the type of hospital staff (for example, nurses,

pharmacists, etc.) who may provide services in hospitals

because the OPPS only makes payments for services provided

incident to physicians’ services. Hospitals providing services

incident to physicians’ services may choose a variety of staff-

ing configurations to provide those services, taking into ac-

count other relevant factors such as State and local laws and

hospital policies.

Billing a visit code in addition to another service mere-

ly because the patient interacted with hospital staff or

spent time in a room for that service is inappropriate. A

hospital may bill a visit code based on the hospital’s own

coding guidelines, which must reasonably relate the inten-

sity of hospital resources to the different levels of HCPCS

codes. Services furnished must be medically necessary and

documented.

If a hospital provides a distinct, separately identifiable

service in addition to the test, the hospital is responsible

for billing the code that most closely describes the service

provided.

Querying CMS’ MACs provided these responses:

➤ In order for incident-to requirements to be in

effect, there first must be an established physician-

patient relationship. In order to provide services

incident to the physician, the physician must have

seen the patient and established some type of plan

for the patient’s care.

➤ In the rare instance when a medically necessary ser-

vice is well documented and meets the definition of

an emergency service, a facility charge may be ap-

propriate. However, one CMS FI/MAC has provided

guidance to bill a low-level clinic visit 99211, which

is the only E/M service that does not require the

presence of a physician. Additional guidance states

that a visit level should not be assigned when only

administrative services are provided.

➤ If the services are not otherwise separately pay-

able, the hospital may charge the lowest-level

emergency room visit charge.

Noridian has stated that a low-level visit may be re-

ported in this “triage-only” scenario. Highmark has stated

that it will not pay for an ED service when the patient

has not been seen by the physician. TrailBlazer, the MAC

for Colorado, New Mexico, Oklahoma, and Texas, has

published an FAQ on its website (see below) stating that it

will pay for a triage-only visit:

Question: Is it appropriate for a hospital paid under

OPPS to bill a low-level visit code for care provided to a regis-

tered outpatient if the patient was not seen by a physician?

Answer: Under the OPPS, unless indicated otherwise,

CMS does not specify the hospital staff who may provide ser-

vices in hospitals because the OPPS only makes payment for

services provided “incident to” physicians’ services. Hospi-

tals providing services incident to physician’s services may

choose a variety of staffing configurations to provide those

services, taking into account other relevant factors such as

state and local laws and hospital policies.



➤ Facilities should code a level of service based on facility

resource consumption, not physician resource consump-

tion. This includes situations where patients may see a

physician only briefly or not at all.

➤ If a visit and another service are also billed, the visit must

be separately identifiable from the other service since the

resources used to provide non-visit services including staff

time, equipment, supplies, etc., are captured in the line

item for that service.

➤ Billing a visit in addition to another service merely be-

cause the patient interacted with hospital staff or spent

time in a room for that service is inappropriate.

➤ All services furnished must be medically necessary and

documented.

See www.trailblazerhealth.com/Publications/ Questions%20

and%20Answers/OPPSQandA.pdf?DomainID=1 for more

information.

Chapter 4 of the Medicare Claims Processing Manual pro-

vides the following guidance:

CMS has acknowledged from the beginning of the OPPS

that CMS believes that CPT Evaluation and Management

(E/M) codes were designed to reflect the activities of physi-

cians and do not describe well the range and mix of services

provided by hospitals during visits of clinic and emergency

department patients. While awaiting the development of a

national set of facility-specific codes and guidelines, provid-

ers should continue to apply their current internal guide-

lines to the existing CPT codes. Each hospital’s internal

guidelines should follow the intent of the CPT code descrip-

tors, in that the guidelines should be designed to reasonably

relate the intensity of hospital resources.

Each hospital must clearly document its internal

guidelines and apply them consistently following its

MAC’s payment policies. Since the responses vary by

contractor, each hospital must understand the payment

policy that applies in its area. Working with the local FI

or MAC and your internal compliance team, consider the

following questions when deciding whether to bill for a

“triage-only” ED visit:

➤ Was the visit medically necessary?

➤ Did the visit meet the definition of an ED service?

➤ Was the visit a distinct and separately identifiable ser-

vice from a test or procedure provided and billed?

➤ Were the resources expended entirely administrative?

Timing of status and written discharge orders

Q Is a status order valid if the physician writes it after

the discharge order while the patient is still in the

bed? Where can I find this Medicare guideline?

A The order must be written to change the status

from inpatient to outpatient while the patient is still

in the facility, as required by condition code 44 criteria.

Medicare does not permit retroactive orders as noted in

the Medicare Claims Processing Manual, Chapter 1, section

50.3.2. If the patient has been discharged and the status

Contributors

We would like to thank the following contributors for

answering the questions that appear on pp. 10–12:

Andrea Clark, RHIA, CCS, CPC-H

President

Health Revenue Assurance Associates, Inc.

Plantation, FL

Shelley C. Safian, PhD, MAOM/HSM, CCS-P,

CPC-H, CPC-I CHA

Safian Communications Services

Orlando, FL

Candace E. Shaeffer, RHIA, RN, MBA

Chief Compliance Officer

LYNX Medical Systems, Inc.

Bellevue, WA

Denise Williams, RN, CPC-H

Director of Revenue Integrity Services

Health Revenue Assurance Associates, Inc.

Plantation, FL



was still inpatient, there are certain services that can be

billed on an inpatient Part B–only claim. The information

concerning such a claim is also found in section 50.3.2 of

the Claims Processing Manual:

When Condition Code 44 is appropriately used, the hos-

pital reports on the outpatient bill the services that were

ordered and provided to the patient for the entire patient

encounter. However, in accordance with the general Medi-

care requirements for services furnished to beneficiaries and

billed to Medicare, even in Condition Code 44 situations,

hospitals may not report observation services using HCPCS

code G0378 (Hospital observation service, per hour) for ob-

servation services furnished during a hospital encounter

prior to a physician’s order for observation services. Medi-

care does not permit retroactive orders or the inference of

physician orders. Like all hospital outpatient services, ob-

servation services must be ordered by a physician. The clock

time begins at the time that observation services are initiat-

ed in accordance with a physician’s order.

Assigning modifier -59 for multiple tests

Q When could we use modifier -59 (distinct proce-

dural service) if all the following procedures are

performed in one session:

➤ 92541, Spontaneous nystagmus test

➤ 92542, Positional nystagmus test

➤ 92544, Optokinetic nystagmus test

➤ 92545, Oscillating tracking test

A All of these codes bundle to 92540. However, per

the CPT Manual and Medicare CCI edits, combi-

nations of three or fewer of codes 92541, 92542, 92544,

and 92545 are allowable on the same date of service and

modifiable as appropriate. If a physician orders all four of

the above procedures (92541, 92542, 92544, and 92545)

and the tests are performed on the same date, report

comprehensive code 92540 (basic vestibular evaluation)

instead of the individual codes.

The American Speech-Language-Hearing Association

website provides a helpful table explaining this at www.

asha.org/practice/reimbursement/ medicare/Aud_coding_rules.htm.

Billing compression wrap and debridement

Q Are you allowed to bill a compression wrap along

with a debridement (any level) on the same day?

Also, must a culture specimen be performed with every

debridement at any level (e.g., 97597, 97598)?

A The compression wrap CPT code (29581) billed

with the debridement code will hit an NCCI edit.

They should not be assigned together unless the wrap

was applied to a different site not involving the debride-

ment. Under the Medicare NCCI edits this is incorrect

separate reporting of codes if the codes are billed for ser-

vices provided to the same beneficiary by the same physi-

cian on the same day.

Reporting admit, discharge codes on same day

Q A patient is in a swing bed in the hospital and

is seen by the physician. The physician admits

the patient as an inpatient. The physician writes a dis-

charge summary note and an interval progress note.

Can we bill a nursing facility discharge day manage-

ment code 99315 from the swing bed and admit to

inpatient code 99222?

A The CPT guidelines located directly above code

99221 state the following:

When the patient is admitted to the hospital as an

inpatient in the course of an encounter in another site of

service (e.g., hospital emergency department, observation

status in a hospital, physician’s office, nursing facility),

all evaluation and management services provided by

that physician in conjunction with that admission are

considered part of the initial hospital care when performed

on the same date as the admission.

Within the same facility on the same date of service,

the discharge and admission become part of the initial

hospital (admission) management. Therefore, you may re-

port only 99222. You should query the physician and ask

him or her complete the appropriate documentation. n

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