[Music] Welcome to the Codecast podcast. Realworld insights for your daily medical coding and billing processes. And now here's your host, Terry Fletcher. Hello everyone and welcome to the Codecast podcast. Today my name is Terry Fletcher. So, it is the last Tuesday of July and we are going to actually do a top 10 Tuesday, which are basically my top 10 coding questions that I received for the month. And I am all over the place with some of the different specialties, the questions, and there's some pretty good ones in there, too. So, hopefully you uh will find something that uh may apply to your practices or to you personally. Um, but they are some interesting questions. So, I do want to thank my membership clients for sending them over. I'm also starting to put these as a blog on my website. So, you'll not only get to hear my responses and some of the innuendos, but I'll also have it up on my blog within probably a week of of listening to this podcast. But first, the Codecast podcast is also brought to you today by Inopro Whitening Strips. Natural whitening ingredients, peroxidefree, 30 minutes to whiter teeth. You can find this on Amazon or in your local drugstore. Okay, so let's get started. Yes, I know I have sponsors coming out of the woodwork from everywhere, which I appreciate. Thank you very much. Keeps us in business. So, let's look at some of the um questions that I've received. And it's interesting because they go from ICD10 to CPT to compliance and different departments, some in the hospital, some you know, different specialties. So, I really got a flood of questions that I thought were interesting. So, let's see um how you know we we start this off. So, the first one says, "What Terry? What is your understanding on coding for conditions where rheumatic is not documented, but the ICD10 guidelines lead you to code a romatic diagnosis?" And so, we're really talking about mitro valve regurgitation and romatic versus non-romatic. And so one of the things that's tough is that we do have sometimes direction in CPT. Just think of COVID where I'm sorry, not in CBT, in ICD10, sorry, in the general guidelines that tell you to do something that really goes against some of your coding convention training. You know, when we were told um in 2020 when they first came out with some of the new codes for the CO 19, they told us if the doctor says they have it, even if it wasn't confirmed with a test, just go ahead and code it. Of course, they retracted that in 2021 and said, "No, you have to have a confirmation lab test, but here's some of the things when it comes to romatic versus non-romatic diagnosis codes." So, there was some advice on the APC website. I didn't always agree with that. And then there's also some advice from the um AHA, which is the American Hospital Clinic. And the it's it's interesting because the AHA, American Hospital Association guidelines, they really and they also um help with HEA guidelines, they really kind of set the stage when it comes to how you're supposed to apply the codes. So, one of the questions that came up, and this was published um in 2018 off of the AAPC website, and then somebody just said, "Here, I'm having the same problem." So if a patient has mitro um regurgitation without mention of it being non-romatic in the report, would you use a romatic diagnosis code? So we're told the correct way to code is with the rationale that if the documentation does not specify romatic or non-romatic, you would assign an unspecified code which is also the romatic code. But unfortunately that doesn't even make sense and it seems you know wrong to give a patient a romatic condition especially by default when there's no mention of them having romatic fever past or present and no uh definite finding in the documentation anywhere that says there's a romatic condition. So that kind of seems backwards. It seems like you would default to non-romatic. So how how do you kind of uh report this when it seems a little bit backwards and you know the presumption would be correct for the large majority of the population and so you you have to kind of figure out what to do and I know a lot of a lot of coders are like I'm just using non-romatic I don't want to be responsible for giving somebody you know a romatic valve disease um when there isn't any evidence of it in the documentation. So there's a lot of frustration here and you have to look at the ICD10 official guidelines because I agree with coding non-romatic unless stated otherwise. But here is something that um and I don't I don't agree or recommend always coding non-romatic regardless of ICD10 coding guidelines. So we have to follow the guidelines as well as the teaching and guidance of the American Hospital Association Association. So, AHA coding clinics and CMS guidance. So, here is some of the uh rules that they tell us to follow for roheatic heart disease. Now, you have to look for them, but this is how they they really talk about this. A singular uh cardiac valve disorder stated as unspecific or non-romatic is of course coded with non-romatic. A singular cardiac valve disorder stated as romatic is coded with a romatic code. So, that seems easy enough. But multiple cardiac valve disorders involving multiple valves stated as unspecified or roheatic are presumed roheatic and coded with a combination romatic code. Some multiple cardiac valve disorders of singular cardiac valve. So for example, mitro valve stenosis and mitro valve insufficiency are presumed roheatic and coded with a combination romatic code even though multiple cardiac valve disorders involving multiple valves are not documented. I hate it. You probably hate it. I don't like coding for things that I can't document or see with my eyes. It's kind of like it's it's in, you know, it's not they're trying to say it's not in blind sight and it's weird, but you have to follow the rules and I would always back up anything you have with the rules. So, make sure you always follow those rules. So, I know that was a long uh first question. Number two, it says, "Terry, I have a question regarding classification of hypertension as a chronic condition as well as diabetes." So during a follow-up visit, a follow-up patient visit, the provider documented hypertension which was diagnosed in May, the date of service for the encounter was June. Would we consider essential hypertension as a chronic condition and what about if a patient sees or if provider sees a new patient and has listed hypertension, diabetes in the assessment but hasn't documented the onset date or chronicity? Can we assume these conditions are chronic? So AHA Coney Clinic suggests they don't mandate they suggest that hypertension as a chronic condition if documented as benign that's it is hypertension but here's these are really tough because chronic conditions according to AHA also says that and the general guidelines for ICD10 says that patient has to have this condition that's going to be ongoing but for a minimum of three months and so the provider really has to document the chronicity and it would be helpful if they put the onset of the condition, but we know they don't really do that. So, here's what I would recommend. If they are on medication, you can usually find out how long they've been on the medication, which is a lot of times patients are, um, by talking to their pharmacy, looking at their, you know, pill bottles to find out how long they've been taking it to make a chronic determination. And so, that's the first thing I would do. But I'm also seeing a lot of documentation that isn't complete where you're just not doing enough research, not from the coding st coder standpoint, but from the physician standpoint to just slap on a diagnosis for a patient when there's really no lab test, no um litmus test, anything to show that this patient actually has it. They just have maybe high blood pressure today. So um with diabetes, you also need to figure out did they have a lab test? Was their A1C over 6.1? You know, what what are their blood sugars high? Where are you getting this from versus was this just an episodic situation? So, you know, and the other thing is that it seems like finally ICD10 is catching up with diagnosis codes that patients may no longer have. And one of the problems with HCC codes, hierarchy codes, which physicians, as you know, under the quality measures get some bonuses on this is they're not going to like this, but when patients do what they're told, they adhere to medical advice, they've changed their diet, they've lost weight, they take their meds, and now their A1C is under six, they are not thought to be diabetic anymore, clearly from the ICD10 guidelines and from the CDC rules. So starting October 1st, remember we're going to get a new code for type 2 diabetes that says in remission E11.8 and that's to report clinical status of regression after medication and lifestyle changes along the diabetes continuum in alignment with the correct clinical guidelines. Well, now providers may hate this because it won't be on the HCC list, but I hope this is more of a celebration of the patients improving. you know, they're able to get rid of medications for chronic conditions when not needed any longer, but I have a feeling this could be about money. So, I mean, it it's unfortunate, but you have to be able to say the patient's getting better and not always tie it to to money. Number three says, Terry, I have sort of a unique question I wanted to to present to you because it came to me by my provider today. We often see patients at a medical center emergency room uh who will be admitted as an inpatient to the hospital. These are adjacent facilities, but they do have separate tax ID numbers. The provider was questioning that if he saw the patient in the ER today and the patient is admitted tomorrow to inpatient status, will he be able to bill a new initial or initial uh hospital code 99221 to 223 um for tomorrow's visit? he wasn't quite sure what's appropriate. So, I get this question a lot. So, first of all, if you're a specialty provider and not an ER doctor, ER is considered by I all payers from my understanding, I haven't seen this ever denied as an outpatient service. And so, you can bill the 992 to 99205 codes. You don't have to bill an ER code. The ER doctor is going to and many payers are like, "Yeah, we're not paying we're not paying two doctors for that." But also when we got the new 2021 ENM rules and then the clarification in 2023 on page 22 of the CPT book, the initial paragraph under the uh new and the initial hospital codes says basically and I'm just paraphrasing if a provider has done a consult in anticipation of or related to an admission and then that same consultant performs an encounter once the patient is admitted by that provider. It says now you have to use a subsequent hospital code. So an answer to that original question, no, you won't be able to bill an initial visit for that second day. You'll be billing the codes either 99231 to 233. So know that when you see them initially, you can't get another initial. Okay. Number four. Now this was a good one. If a resident performs a teleaalth service without the teaching physician seeing the patient, can that still be build with a GE modifier under the primary care exception? The resident teaching physician are both in the clinic. The resident will discuss the visit with the teaching physician after the telealth visit has ended. So the short answer is yes, but there are some rules here I want to make sure you're you're clear on. So they can be furnished under the primary care exception rule. This allows residents to provide these service to beneficiaries where the physician or prov teaching physician supervising physician doesn't have to be present in the room during the encounter, but they still have to be under the direct supervision. But the super the uh exceptions to these rules, first of all, you can't use time to level the visit. Remember that. That's not part of the primary care exception. So only the face toface by the supervising physician could be used as time. Only medical decision-making can be a leveling factor. So, here's where it gets interesting, and this is a big one because, as most of you know, I've mentioned it several times, I'm not just a practice and provider auditor. I'm a payer auditor, you know. So, I audit for commercial plans and for Medicare plans. And what if the visit is actually a level four and the teaching physician, supervising physician is not present? Would you be able to downcode that to level two or three just to get something? The answer is no. Okay, that is incorrect coding and it could get you in trouble for a false claim. This is something payers are actually catching on to. The IG is all over this because we've seen it. So, make sure that if the visit is performed via teleaalth that the resident knows going into it that it's probably going to be a straightforward or low-level visit because under the primary care exception rule without the per the supervising physician or teaching physician present, they can only build a level two or three. Lastly, audio only visits are not covered under the primary care exception rule since 2024. So during CO they allowed it, but that ended last year. And the rest of what I just mentioned is okay through September 30th, 2025. And then we'll see if they're going to change that under this new administration. Question five. Oh my gosh, I get this all the time. So we have a hospitalist that is required by the hospital to see all patients no matter who saw them that same day. But we're noticing that the hospitalist is seeing patients in the posttop period and their documentation is all about the postsurgical discussion, the wound care, the surgical incision site, etc. Is this still considered a posttop or are they independent of that? So it's con still still considered posttop especially when it's under your you know tax ID and you know remind hospitalists if they are following them for something above and beyond the surgical posttop because the the posttop provider sees them as well or their staff does you know they're they're uh saying that they can now resume medications they were taken prior to the surgery or you know they um they're following them for something other some other medical condition that is unrelated to the surgery but needs to addressed post-operatively then that is a an appropriate visit but just again another posttop discussion no you can't code for that in addition and be careful with that number six Terry I know you've been talking recently more about the G2211 unfortunately people yes I have because it's never going away it seems like but our providers are using this statement to try and get this for every single visit okay I'm face planning here quote I serve as the continuing focal point for this patient's health service health care services. Now, they are the patient's primary care doctor and the statement may be true, but they're not taking into the account the big beginning of the description that says visit complexity. So, you know, here's here's what I my response to this is, and this is an ongoing pain point for all of us. I know those of you listening are going, "Yes, what do we do here?" Well, first of all, it it doesn't help that many medical associations are telling providers to automatically report this with every ENM. And it also it doesn't help because United Healthcare and Etna said, "Yeah, no, when they stop paying for it in 2024 when they hear those things." And I'm and I'm told that CMS was is going to be putting some guardrails on this for 2026. But this would be up to the provider regarding the complexity of the visit and today's medical decisionmaking. And if a patient comes in as a follow-up and conditions are stable, they refill meds and they don't say much about the complexity in that visit and their their medical decisionmaking based on their relationship with that patient is really not necessary for that day, you know, that's really not something that is appropriate to add on. But if the provider, let's say, puts in a a a referral to a specialist for a chronic condition that they don't cover, or if uh and they're specific about that, or let's say they they start a new medication because they know the patient's chronic history and what other medications they're on, or they give a recommendation where because they're on certain uh beta blockers, they can't take steroids, things like that. That's what they're talking about. So, you know, that's when you gauge, you know, the inherent complexity. I realize it's not for coders to question and you know a lot of times they're like just use the code but it is for coders, auditors, billers and your documentation staff to question what they have documented to support the code. Not just medical necessity but the complexity of the patient today. So just keep that in mind when you're having meetings or discussions with providers that there's, you know, there's no free lunch out there. You've got to make sure that you are documenting why you're billing something because the patient has a co-pay with this. Number seven says, Terry, our structural physician, I had to ask what that meant. I'm like, what's a structural physician? Is telling me he can build a level four consult and due to entering time spent with the patient, it can get paid a five rate. Oh my goodness. He claims other structural physicians are doing this due to the discussion process taking a lot of time during the consult, but he doesn't hit a 10-point review system to get the five code. Okay. So, first of all, you don't have to do the review system, the HPI in the exam anymore. It has to be problem appropriate and medically necessary. So, it still has to exist, but we don't count points uh in the HPI or in the uh exam for leveling service. But and I found out they they call their structural physician physicians who are interventionalists. So I go okay that's one way to put it. But my response was if his documentation supports 60 minutes or more and not just saying that and if he he has to give exact times and activities that took it to that level then that would be a level five new patient visit. 40 minutes would be or more would be a level five established. But you need to be careful here because as a payer auditor we also have this rule. It's under 30.6 6.7 in the Medicare manual and it was revised in 29 2023 um and implemented in May of 2023 and I'm quoting so 3 30.6.7g 6.7G Medical Review when practitioners use time to select a visit. Quote, "Our reviewers will use the medical record documentation to objectively determine the medical necessity of a visit and accuracy of the documentation of the time spent whether documented via a start stop time or documentation of total time if time is relied upon to support the ENM visit. So to me, that's saying, "Hey, we're watching you." If you really think that you're spending an hour with a patient face to face, you not your staff, not anything outside that, just you, the provider who's billing, then you will give it to you. But you, it also has to make sense. So when the provider is saying it's a level four medical decision-making, but I can manipulate the record to add time for a level five, you better watch out. That doesn't always work. As auditors, you know, we can downcode based on that published guidance and regulatory rule if it's thought that it's not a believable time. Also, an hour for a new patient or 40 minutes for, you know, patient again based on time, that's not very profitable. And so, I would be questioning it if there's a pattern that you see. So, make sure that you are just heads up and you check on that because if you have a provider that has 20 to 25 patients scheduled for a half day in the clinic, but everything's a level five based on time. Yeah. Ouch. Don't do that. Number eight, Terry, can you please tell me if this is the correct way to code a TAVR? So, that's a trans catheter aortic valve replacement or implantation. Some people call it a TAVI, TAV, I it's an acronym, but most call it a TAVR. uh with the replacement instead of imple implementation. But what this is basically is they're going in and you know putting in a replacement valve in an area where they they need it. It's it's artificial. So there's one code. It's still under clinical trials and it's 33 361 and again this is the trans catheter aortic valve. There's different ones. There's mitro valve but this is for the TAVAR specifically. you would need a Q0 with a 62 and then the clinical trial number on the notation line comments field on the the um uh hickopform and you can also code now since April 1st the 76937 with the 2659 modifier that's the ultrasound guidance if you did it uh you haven't been able to because now it's been bundled since 2019 but they finally opened that back up but I saw on their coding list oh my gosh they try to bill for um access. They try to bill for an angoplasty of the targeted area. They try to bill for a left heart cath and then also a left heart cath without they duplicated the left heart cath code. Left heart cow without coronaries, try to bill for a temporary pacemaker, try to bill for all kinds of things, you know, the the um root injection. So you really have to read your clinical guidelines for what's included in CPT codes and for specifically here CPT page 20 261 said anything that's related to the target area of this uh replacement implantation code 33361 is part of it. So you can build a 33361 with a Q062 and you have to make sure that you have a co-surgent on this um because they said all this came back denied except they made your code. Well, of course it did because it's not supposed to be build. Also remember the rules on the national coding correct uh coding initiative the NCCI on the temporary pacemaker. So the policy manual for Medicare services chapter 5 section D says the following uh number five it says CPT code 33210 and 33211 which are the temporary pacer makers. Um these codes should not be reported with open or perccutaneous cardiac procedures performed at the same encounter as they are inclusive. So they're bundled. So it's always important to not only read the code descriptor, it's just like reading a map. You have to read the directions to get there. I know we don't have navigation in our CPT book. We actually have to read it. Um, but you you want to make sure that you're not over coding because it'll come back to to bite you for sure. Number nine, Terry. Any resources that show it's okay to code only pertinent diagnoses for an encounter? We have providers listing every single diagnosis the patient has ever had since birth, specifically in the ER. Okay. So patients should list diagnoses that accurately reflect the patients current health status including chronic conditions, acute illnesses, and any relevant past medical history. It can be comprehensive and individualized and reflecting the patients concerns and goals. But AMA also states that the key is relevance and clarity, including, you know, any minor issue that may be um contributo to what you're doing now. But if anything's been resolved or irrelevant to the current situation or future care, um, you know, that can clutter the medical record and potentially make it difficult to quickly identify the most pertinent information and will lead will lead I'm not even going to say can lead will lead to payer audits and upcoding. So, what's pertinent today? And then number 10, the last one. I have an orthopedic physician trying to bill, oh my goodness, a 9941 in addition to his ENM on just about every encounter. Your thoughts on this? So what is a 9941? Preventative medicine counseling and a risk factor reduction interventions provided to an individual separate procedure parenthesis approximately 15 minutes. So this is what the doctor is stating. The patient was counseledled on the benefits of regular exercise and weight loss for overall joint health and recovery and encouraged to adopt these preventive strategies. Full stop. So first of all, there wasn't time. Secondly, separate procedure designation means that's the only thing you did that day. It's not something that can build be with anything else. And third, no, a public service announce announcement on being healthy. That's not counseling, especially if it's in every note. And you you have to be careful. Primary care providers bill for preventative, not specialty providers who get a referral to treat the patient. This is lifestyle medicine. That's that's a cash price cash practice trying you know to to to give them lifestyle changes that is not considered appropriate to bill extra. Are do you want to tell them that? Yeah, of course. Everyone should, you know, could benefit from regular exercise and weight loss. But, you know, I said, you know, send me 10 of those records. I just want to see. and they are a membership client so they get a discount for that and I review them and one patient which you'll find interesting was in a wheelchair and they said you know counted on the benefits of regular exercise and weight loss really so you have to be careful with these smart you know phrases and these macros that you're putting in for every single patient and trying to get paid for it extra stop doing that so be careful when you are told by somebody I always hear the practices say well we were told by whom? And they are like, "We don't know." Or, "We heard that." By who told you that? Where'd you hear it? I don't know. Okay. Well, you might want to find out because it can get you into trouble if you start a pattern of something that is inappropriate and I I just don't want to see that happen. So, make sure that if you are billing for services, it's appropriate, it's medically necessary, and you're not going outside the scope of what's the expectation for your specialty or it will come back to to get you. So, I know I was a little long-winded today. Usually, I'm between 16 minutes and 30 minutes and or 20 minutes. And today, we actually went almost the whole 30 minutes. So, thank you for staying with me today. Hopefully, you found the top 10 Tuesday helpful. And until next time, but hopefully everyone had a good July. Uh, shout out to my husband Tom. We just celebrated our 26th wedding anniversary, so that was really kind of fun. And again, we'll be in Hawaii in the fall to uh celebrate that again. And yes, my daughter did get onto that trip. Can you believe it? It's crazy. She's a teacher and she gets a fall week off and she talks her husband into getting that time off. And so, yeah, we bring the kids along. I know. 30 years old and I still call her my kid. They're always our kids, aren't they? Luckily, we like them. We like spending time with them. So, that'll be fun. All right, everyone. Make it a great rest of your day. Make it a good week. And thank you for listening to the CodeCast podcast. For more information on medical coding, billing, auditing, and compliance, including how to hire Terry, follow Terry on Twitter at terrycoder1 or visit her website at www.terry flec.net. Podcast producer Joe Kousma, music producer, Dassin Music. [Music]