F R O M T H E F I E L D
Identical Minor Surgical Procedures-Modifier 59 or Units?
By Luann Jenkins, CPC, CPMA, CEMC, CFPC
It is often hard to know if identical minor surgical services should be billed on one line with units, or on multiple lines with modifier 59. The CPT® manual provides some guidance within the code descriptors with terms such as "each additional" or "per," and Medicare Medically Unlikely Edits (MUE) provide guidance on how many units are allowed per day.
But these resources do not completely answer the question of quantity; therefore, some Medicare Administrative Contractors (MAC) also provide additional quantity lists to assist providers. For example, WPS Medicare developed Quantity Bill Lists to indicate the number of services acceptable per line. Commercial payers may also provide quantity indicators by CPT® code to assist in accurate billing. For instance, 11305 Shaving epidermal or dermal lesion, single lesion, scalp, neck, hands; lesion 0.5 cm or less may be billed on one line with quantity to most payers when removing multiple lesions of the same size and category during the same session. There may be exceptions, so be sure to know your individual payers' rules.
G O O D T I P S
Billing Minor Surgery? Watch that POS
Many offices use place of service (POS) code 11 Office incorrectly for minor surgeries at an ambulatory surgical center (ASC) or in the outpatient department of a hospital. You should apply POS 11 only for those services provided in the physician office.
Recently, the Office of the Inspector General (OIG) reviewed a sample of outpatient surgery claims filed in 2009 and found that 83 percent of those billed with POS 11 were performed in an ASC or hospital, and subsequently were overpaid. The OIG recommends that Medicare educate providers on proper use of POS codes, but also advises that Medicare audit all POS 11 services reported in 2009. The OIG estimates that approximately $9.5 million can be reclaimed from providers.
F E A T U R E D S T O R Y
Prepare for Dual Billing in ICD-10
Our code sets are mandated by HIPAA; however, there are entities not mandated under HIPAA, such as workers' compensation. Wise billers should understand the panels on which they're participating and if those panels will be making the transition to ICD-10-CM, or if they will still require the use of ICD-9-CM codes. The entities not mandated to make the switch could cause administrative nightmares for all of us.
Consider this scenario:
A patient was traveling for work. She fell on ice in the parking lot of the hotel where she was staying, breaking her ankle and wrist. Under this scenario, there are three plausible billing alternatives as to who might be held liable: the hotel, workers' compensation, or her personal health plan. Either way, it takes weeks for determinations and initially the personal health plan is billed. Six weeks later it is determined that workers' compensation will cover the accident. In the meantime, many bills have been submitted for surgeries, medications, DME, and therapy.
In our ICD-9-CM environment, we would just need to switch the carrier name on the claim, add a few details and submit with our notes. However, after October 1, 2013 this could all change. If you participate with a panel that does not make the switch, not only will you have to change the carrier, but the claim will require recoding as well, which could mean backing out your claim, messing up your A/R and your financial data, not to mention the time and effort spent recoding.
Billers will need a good solid education of both code sets and nuances like this in ICD-10. Working with panels early to determine where they stand on making the transition to ICD-10 will help you make informed decisions on which panels you want to remain. Dual billing in both systems ongoing will pose administrative nightmares for practices and careful preparation every step of the way will assist you in successful ICD-10 implementation.
FROM THE FIELD is thoughts and experiences from you the reader. If you have any tips, ideas, case studies, or just anecdotes please submit them to us for future editions.
In This Issue
Minor Surgical Procedures
Watch the POS
Dual Billing in ICD-10
Don't underestimate the importance of policies and procedures in the billing world.
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