Counting Radiologic Views
When reporting Radiologic exams, the number of views claimed must meet the basic requirements of the CPT® code reported. It is the coder’s responsibility to count the number of views and select the correct corresponding CPT® code.
For example, knee exam may be reported using one of four CPT® codes; to report 73564 Radiologic examination, knee; four or more views documentation must substantiate at least four views. “AP, lateral, and both oblique views,” is also acceptable documentation.
If, however, the physician uses the phrase “multiple views of the knee” (which is imprecise), you must report the lowest-level corresponding CPT® code for the particular study. For example, knee exam stated as “multiple views,” you must report 73560 Radiologic examination, knee; one or two views.
The medical report must state the number of views, and referring physician orders must indicate the number of views or the name of the specific views desired. If the views/number of views is not listed in the order, the radiology office cannot impose their department standards. Instead, the radiology department or office should contact the referring physician and ask for a new order indicating the views he or she would like performed.
Some diagnostic studies require specific view names. For example, if the physician dictates the number of abdomen views instead of the precise names of the views, you must report lowest-level code (74000 Radiologic examination, abdomen; single anteroposterior view).
How to Recognize Critical Care
CPT® defines critical care (99291, +99292) by three components:
- A critical illness is an illness in which “one or more vital organ systems is impaired such that there is a high probability of imminent or life threatening deterioration in the patient’s condition”
- A critical intervention involves “high complexity decision making to assess, manipulate, and support vital organ system failure”
- Critical care time is “time spent in work that directly relates to the individual patient’s care,” whether that time is spent at the immediate bedside or elsewhere on the floor or unit.
These criteria assume the physician takes an ongoing and active role in managing the care of that patient. Evidence that the above criteria have been met must be present in the medical record, along with the physician’s attestation that critical care was provided.
Some examples of vital organ system failure include but are not limited to:
- Central nervous system failure
- Circulatory failure
- Renal, Hepatic, Metabolic, and/or Respiratory failure.
Critical care usually (but not always) is given in a critical care area such as a coronary care unit, intensive care unit, or the emergency department. Critical care may be provided in any location as long as the care provided meets the definition of critical care. Just because a patient is in the ICU, does not mean you can code critical care: If the patient is stable, he or she does not meet the criteria for critical care.
Skilled Nursing Facility (SNF) vs. Nursing Facility (NF)
What is the difference between a skilled nursing facility (SNF), place of (POS) code 31, and a nursing facility (NF), POS code 32.
Per CPT®, POS code is 31 describes a facility that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitation services, but does not provide the level of treatment available in a hospital. POS code 32 is similar, and describes a facility that provides nursing care and related services for the rehabilitation of injured, disabled, or sick persons above the level of custodial care to other than mentally disabled persons. Always make sure you are using the correct POS.
The care rendered in each location is different. Care provided in a SNF requires the involvement of skilled nursing and/or rehabilitative staff on a daily basis, which might include registered nurses, licensed practical and vocational nurses, physical and occupational therapists, speech-language pathologists, and audiologists. Care that can be given by non-professional staff isn’t considered skilled care, but rather custodial or personal care, and includes assistance with activities of daily living, such as: bathing, dressing eating, grooming, getting in and out of bed, or toileting.
Modifier 91: For Additional Tests, Not “Do-Overs”
Modifier 91 Repeat clinical diagnostic laboratory test is used to report the same lab test when performed on the same patient, on the same day, to obtain subsequent test results.
Modifier 91 causes a lot of confusion when differentiating its use from that of modifier 59 Distinct procedural service. When reporting lab procedures, modifier 59 is used when the same lab procedure is done, but different specimens are obtained, or the cultures are obtained from different sites.
The June 2002 CPT Assistant provides a great example of the correct use of modifier 91:
A 65-year-old male patient with diabetic ketoacidosis had multiple blood tests performed to check the potassium level following subsequent potassium replacement and low-dose insulin therapy. After the initial potassium value, three subsequent blood tests were ordered and performed on the same date following the administration of potassium to correct the patient’s hypokalemic state.
Coding for this scenario is:
84132 Potassium; serum, plasma or whole blood
Per CPT® guidelines, modifier 91 is not to be used to report lab tests that are repeated to confirm the initial results, due to malfunctions of either the testing equipment or the specimen, or when another appropriate one-time code is all that is needed to report the service. If the test is rerun to confirm the initial results or because of a malfunction of the equipment, the service cannot be coded and modifier 91 would not apply.
If multiple tests are run, but a single code describes the test, only one code should be reported and modifier 91 would not apply. For example, 82951 Glucose; tolerance test (GTT), 3 specimens (includes glucose) includes three specimens. Therefore, if three specimens were obtained during the encounter, only 82951 would be reported.
Applying Modifiers for Post-Op Reimbursement
Modifiers are the key to payment for surgical complications. The CPT® codebook and the Centers for Medicare & Medicaid Services (CMS) agree that a complication that requires a return to the operating room (OR) should be paid separately.
For complications requiring additional surgical procedures in the OR that are related to the original surgery, append modifier 78 Unplanned return to the operating room/procedure room by the same physician following initial procedure for a related procedure during the postoperative period to the appropriate procedure code. Under CMS policy for this purpose, an OR is defined as “a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).”
CPT Assistant Sept. 2010, provides the following coding example:
A partial colectomy was performed in the hospital on March 1. The postoperative period for this procedure (code 44140) is 90 days. On March 15, the patient was returned to the operating room for treatment of partial dehiscence of the incision with secondary suturing of the abdominal wall. The secondary suturing was related to the original surgery.
CPT code reported for the first procedure: 44140
CPT code and modifier reported for the second procedure: 49900-78
Because suturing of the abdominal wall was an unplanned procedure within the global period of the initial procedure to treat a complication, reporting modifier 78 indicates to the third-party payer that the procedure is related to the first procedure. The preoperative and postoperative care services, which are usually a part of the surgical package for a surgery, are not included when modifier 78 is used.
In some cases, modifier 58 Staged or related procedure or service by the same physician during the postoperative period, rather than modifier 78, may properly describe a return to the OR during the global period. The Medicare Claims Processing Manual Chapter 12, Section 40.1.B states, “If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.” In such circumstances, modifier 58 is appropriate.
For example, the physician performed a dilation and curettage (D&C) on April 1, followed by a hysterectomy on April 10. In this case, the D&C (e.g., 58120 Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)) is the initial procedure. The hysterectomy (e.g., 58260 Vaginal hysterectomy, for uterus 250 g or less) is a more extensive procedure during the global period of the initial, related procedure, to which you would append modifier 58.