-59 Modifier
CPT has some very specific rules for the use of modifier -59. This modifier is considered the modifier of last resort. You will typically use this modifier when no other modifier seems to fit.
Medicare and CPT have the same definition for this modifier. It is used for services that are not normally reported together but are appropriate under the circumstances. These circumstances may represent:
- different sessions or patient encounters
- different procedure or surgery
- different site or organ system
- separate incision or excision
- separate lesion
- separate injury
- services not normally encountered or performed on the same date by the same physician
-59 is an important modifier associated with the National Correct Coding Initiative (NCCI). This modifier is often used incorrectly with the NCCI edits. For NCCI, its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It is also appropriate to use this modifier when two procedure codes may not be reported at the same time except under special circumstances. It is inappropriate to use the -59 modifier to bypass the NCCI edits unless the special circumstance exists. The documented note should justify that the special circumstance exists and the criteria for this use of this modifier is met.
ICD-10: Where is it? When is it?
ICD-10 is out there. Did you know that we are the only country on the planet that has not converted to the ICD-10 system? ICD-10 has been trying to make its debut in our country for more than ten years now. Currently, the implementation date is set for October 1, 2009.
ICD-10 has over 200,000 diagnosis and procedure codes, ICD-9 has a little over 16,000. ICD-10 codes are all alpha-numeric codes while ICD-9 codes are numerical codes with the exception of V-codes and E-codes. ICD-10 will allow us to code to a much higher specificity and after all, that is the name of the game when it comes to coding our patient’s diagnoses for their insurance claims.
Providers and payers will need to completely redesign their business processes and systems to be able to handle this massive coding system. Although other countries have switched to ICD-10, no other country uses a version as complex as the US version.
There is a coalition of physicians, labs, and other providers and insurers that are urging Congress to push back the date. This group is urging for an implementation date of 2012 and here is why:
- Providers and payers will have to overhaul their business processes and systems. They will have to get their staffs educated and trained concerning the new ICD-10 system and their new software system to support it. This will be a costly venture. It is estimated that it could cost close to 14 billion dollars across the country.
- Physicians will not be able to rely on clearinghouses to translate their claims to a HIPAA compliant format before forwarding them on to the payers. ICD-9 codes cannot be translated to ICD-10 codes. There is no crosswalk as this is a completely different system.
- The current version of HIPAA transactions (4010) will not work with ICD-10. The industry will have to move to the newest version (5010). This is a major re-write and includes more than 850 individual changes. The ‘Workgroup on Electronic Data Interchange’ (WEDI) is concerned that upgrading to 5010 is too significant to be done in conjunction with ICD-10 implementation.
- Medicare is undergoing the largest contracting change in its history. They are transitioning more that 50 intermediary and carrier contracts to 15 Part A and B Medicare Administrative Contractors over the new few years. This requires transferring workloads from multiple contractors to a single entity, while at the same time integrating Part A and B claims processing systems and modernizing CMS information and accounting systems. This massive consolidation has the potential to cause major service problems for Medicare. Switching to ICD-10 so soon could further overwhelm Medicare and cause major backlog in claims processing and delayed payments to beneficiaries and providers, and increased opportunity for fraud. Medicare’s improper payments could soar.
The industry is hoping to begin the implementation date in 2009 after providers and payers have implemented version 5010 and Medicare contracting changes are finished. The providers and payers would then need 3 years to implement ICD-10 making the full implementation date 2012. It will be interesting to see what happens!
PET Scan Coverage is Expanding
Codes recognized by Medicare are:
G0296 (new code): “PET imaging, full and partial ring PET scanner only, for restaging of previously treated thyroid cancer of follicular cell origin following negative I-131 whole body scan.” This one is covered for recurrent or residual thyroid cancer can’t be localized using the Iodine-131 whole body scan.
Q4078 (new code): “Supply of radiopharmaceutical diagnostic imaging agent, Ammonia N-13, per dose.” This one is used for the Ammonia N-13 when it is used as a tracer for PET scan for perfusion of the heart.
CMS already covers PET scans for diagnosing and for determining the status of the previously diagnosed patients with colorectal cancer, non small cell lung cancer, esophageal, lymphoma, melanoma, and head and neck cancer. Medicare also covers scans for solitary pulmonary nodules and refractory seizures.
CMS is considering PET coverage for other diagnosis such as detecting brain tumors, pancreatic cancer, cervical cancer, ovarian cancer, testicular cancer, and small cell lung cancer.
Do You Have Difficult Patients?
All of us, at one time or another, have to deal with difficult patients. Have you ever stopped to think about why your patients are difficult?
Some patients have the idea that they have to be ugly and rude in order to get what they need from our office. Some are afraid of what the physician will find wrong with them. Others have the “white coat syndrome”. Some patients are grouchy because they just don’t feel good.
How do you deal with difficult patients? Put yourself in your patient’s shoes. Most of your patients are sick, they don’t feel good and they are not at their best. You have to be at your best each and every day. Treat them they way you would want to be treated and speak to them the way you would want to be spoken to.
Sometimes you can make your patients difficult. How does your patient perceive your office? Do all staff members possess the “I care attitude” or do you make them feel like they are just another number? Patients want to feel important. Treat them like they are the only one that matters at this very moment. Compassion, sincerity, cheerfulness, helpfulness and courtesy are traits that all staff members should have. Be a good listener. Keep them informed. Make them feel special.
When speaking to a patient, you should be aware of the words you use, tone and volume of your voice, and body language. Give them your complete attention. Look them in the eye, this lets them know they are important to you. Try to stay away from emotional trigger words and phrases like “No”, “Policy”, “I won’t”, “I can’t”, and “The computer”. These types of phrases put the patient on edge from the beginning.
Bottom line is “Kill ‘em with kindness”! Sometimes this takes more than one try. Don’t give up, keep trying. Practice the Golden Rule with every patient and remember to use those great manners that you learned as a child.
The patients are the reason we open our doors each day. Without them we would not have a practice. Every single patient is important to the practice. How you deal with them could make or break a good relationship.
Is Your Practice Ready for the New Year?
The New Year is upon us. Is your practice prepared? There is a lot to do.
When was the last time you took a look at the super bill? Here are a few things to consider:
- Are your most common procedures and services listed?
- Are there blank spaces to write in procedures and services performed but not listed?
- Are all procedure codes current? Be sure to check Appendix B & C of the 2002 CPT Manual for a list of all new and revised codes.
- Is every level of E/M per category listed? The OIG has cited practices that give their physicians only the highest levels to choose form.
- Do your physicians provide ICD-9’s or diagnosis verbiage on the superbill? If they are writing out the diagnosis, do you have enough information to code to the highest specificity?
- Do your physicians sequence the diagnoses per CPT code for you? In other words, what is the primary diagnosis, secondary dx, etc. per procedure or service?
- Is the patient’s name and birth date printed on the superbill? Account numbers are also helpful.
- Are your superbills numbered? It is easier to keep up with them if they are numbered.
- Are lost charges a problem in your practice? Are you billing for every service provided and billable?
- Who is responsible for noting charges, the physician, nurse, etc.? Failure to note a charge constitutes lost revenue. This is the chief cause of lost dollars in practices today.
- ‘Missing’ superbills are also lost charges. Run a report at the end of each day to show all patients seen and be sure there are charges entered for each of them.
- Be sure the charges entered into your computer equal the charges noted on the superbills. You don’t want any mistakes here.
- What services does your physicians provide outside the office, i.e. hospital, nursing home visits, etc.? Use a customized pre-printed form to capture all out-of-office charges. Be sure the form has a space for listing the place of service.
Take a look at your fees. Are your in line with other physicians of your specialty in your zip code? A fee analyzer specific to your zip code and specialty is a necessity.