The UK Department of Health is planning to authorize the use of goat’s milk protein in the manufacture of infant formula and follow-on formula. The current rules recommend only cow’s milk in formula feeds for the youngest children. According to the Draft Instrument – Infant Formula and Follow-on Formula Regulations 2014 released by the Department of Health, an EU directive was published in 2013 which requires the member states to implement the relevant changes to national law regarding the protein requirements for infant formula and follow-on formula by 28th February, 2014. The consultation period for this regulation ended on 6 December 2013. The premier health authority in UK has taken this step based on advice from European Food Safety experts. A study conducted by European Food Safety Authority (EFSA) in 2012 found that protein from goat milk is a suitable source of protein for infant and follow-on formula.

In the U.S., a young mother was investigated last August by the Department of Health and Human Services (DHHS) for feeding her young baby a goat milk based formula. She was unable to breastfeed him and he had problems with every store-bought cow’s milk based formula. Alorah Gellerson found that goat’s milk worked for him where all other formulas failed.

Allergy Issues

The most frequent allergy seen in the first years of life is allergy to cow’s milk. With the implementation of the new regulation, most parents may expect goat’s milk to be a suitable substitute for infants allergic to cow’s milk. However, experts warn that goat’s milk-based formula is not suitable for infants being allergic to cow’s milk. Several experts raised concerns about the use of goat’s milk as alternative as they believe that there is no convincing evidence that the allergic reactions to goats’ milk are lower than those to the cow’s milk-based formula. Since the proteins in cow and goat milk are similar, an infant allergic to one type of milk would almost certainly be allergic to the other.

According to Maureen Jenkins, director of clinical services at Allergy UK (a British medical charity dedicated to help humans having allergies and food intolerance), goat’s milk-based formula should not be used for babies with cows’ milk protein allergy. She adds that goats’ milk is perfectly safe and nutritious for babies that have no cows’ milk protein allergy.

Manufacturers will be prohibited from marketing goat’s milk-based formula as suitable for infants allergic to a cow’s milk-based formula.

Allergic Reactions to Milk in Infants

Milk allergy symptoms may appear from a few minutes to a few hours after your baby consumes the milk, though the most severe symptoms normally occur within half an hour. The common symptoms include rashes, gastrointestinal/stomach upset and vomiting and/or diarrhea. If the milk allergy affects the respiratory system of babies, they may also have chronic nasal stuffiness, cough, a runny nose, wheezing, or difficulty in breathing. Due to the contact with milk, hives, swelling, eczema, itching or a rash may occur around the mouth and on the chin. Take your baby to the doctor’s office or emergency immediately if you see the following severe allergic reactions to milk:

• Difficulty in breathing
• Extremely pale or weak
• Generalized hives
• Swelling in the head and neck region
• Turns blue
• Bloody diarrhea

Medical Coding – Diagnosis Codes for Milk Allergy

ICD-9

• 995.67: Anaphylactic reaction due to milk products

IC9-10

• T78.07: Anaphylactic reaction due to milk and dairy products
• T78.07XA: Anaphylactic reaction due to milk and dairy products, initial encounter
• T78.07XD: Anaphylactic reaction due to milk and dairy products, subsequent encounter
• T78.07XS: Anaphylactic reaction due to milk and dairy products, sequela

Treatment for Milk Allergy

Pediatricians use several medications to treat milk allergy which include antihistamines and anti-asthma medication (if there is wheezing). Antihistamines are widely used for the treatment of various allergic diseases which can be taken in oral, nasal spray, eye drop or injected form. However, oral antihistamines are usually recommended for toddlers.

Allergies and allergic asthma have been on the rise among children. To ensure proper and timely reimbursement, family practitioners and pediatricians can rely on professional medical billing services.

Though CMS is encouraging Medicare ‘meaningful use’ of EHRs by paying over $22.5 billion as incentives, a recent report released by the Office of the Inspector General for the Health and Human Services Department (HSS) says that CMS and its contractors have failed to ensure that the technology is not being used for inflating costs and overbilling. The report says Medicare has provided ‘limited guidance’ to its contractors on addressing potential fraud and misuse of the drive to digitize patient records. HSS officials have issued severe warnings against health care professionals using Web based medical billing systems to overbill.

There are two ways in which EHR contribute to fraud practices according to the HHS report:

• Copy-pasting – This technique, also known as cloning, allows doctors and nurses to copy-paste information from one document to another and reduce the time spent to enter patient data. However, this also allows users to indicate more expensive services (physical exams or treatment) than were actually provided. It could also happen that they are copy-pasting wrong information in their attempt to speed up digitization of patient records to meet the electronic health record (EHR) mandate deadline of January 1, 2015. It is pointed out that doctors and hospitals are overcharging Medicare for the treatment they provide and that the fraud could run into millions of dollars.

• Overdocumentation – The templates of some EHR systems populate fields automatically while others generate extensive documentation based in a single click on a checkbox. If these mistakes are not properly edited, false or irrelevant documentation would be entered, and the services documented would be inflated compared to what the practitioner actually rendered.

It is very difficult to assess whether healthcare providers make such errors because they fail to double-check the accuracy of information or whether they deliberately enter wrong information to inflating costs. A formal policy regarding the use of cloning technique is therefore very important. HSS authorities found that three-quarters of surveyed hospitals had no such formal policy.

The lack of guidance for Medicare contractors on how to handle payments and recognize the fraudulent practices in EHRs is a major issue. Though CMS appoints administrative and program integrity contractors including Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs) and Recovery Audit Contractors (RACs) to investigate fraud, these are based on traditional medical records. They need to adjust their techniques to identify improper payments with EHRs.

It is imperative to find solutions for the safe and legitimate use of EHRs. HHS recommends two solutions:

• CMS should provide proper guidance to its contractors on detecting fraudulent practices associated with EHR use. They should work with their contractors to find out the best practices and develop guidance and tools.

• CMS should provide proper directions to its contractors on the use of audit logs. As audit log data distinguishes EHRs from paper records, it could be valuable for contractors when they review medical records.

The report says CMS completely agreed with the first recommendation and partially agreed with the second one.

Health care institutions need to coordinate with their EHR vendors and implement a stringent policy for maintaining the accuracy of documentation. Many hospitals that invested in EHRs are finding their systems are complicated to use and taking up a lot of physicians’ valuable time. The New York Times mentions a study which found that emergency-room physicians in a community hospital spent 43% of their time on using EHRs and only 28% on caring for patients directly.

A professional medical billing and coding company can help health care providers avoid billing errors and adhere to industry guidelines while implementing EHR.

The American Congress of Obstetricians and Gynecologists (ACOG) reports that some Medicare contractors are refusing to provide payment for routine pelvic and breast examinations when they are reported using HCPCS Level II code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). To be very specific, the payment is denied when the medical documentation prepared for medical billing contains the notation of surgically absent organs as part of the seven of eleven necessary exam components.

As per the Centers for Medicare and Medicaid Services, G0101 is payable under Medicare physician fee schedule only if at least seven elements from the following are included in the exam.

• Adnexa/parametria (for example, masses, tenderness, organomegaly or nodularity)
• Anus and perineum
• Bladder (for example, fullness, masses, or tenderness)
• Cervix (for example, general appearance, lesions or discharge)
• Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses
• External genitalia (for example, general appearance, hair distribution, or lesions)
• Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge
• Urethra (for example, masses, tenderness, or scarring)
• Urethral meatus (for example, size, location, lesions, or prolapse)
• Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support)
• Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele)

Once the ACOG Health Economics and Coding Committee reviewed the issue of claim denial, they determined G0101 should be covered even if the documentation reports the absence of the breast(s), cervix, uterus, fallopian tube(s), and/or ovary(s).

Major Reasons for G0101 Claim Denials

According to the AAPC, there are mainly three reasons for G0101 claim denials such as

• Timing – Medicare Part B covers screening pelvic examination every 24 months (at least 23 months since the most recent screening pelvic exam) or every 12 months (at least 11 months since the most recent screening pelvic exam) for asymptomatic female beneficiaries if they are at high risk for developing cervical/vaginal cancer, or of childbearing age and have had a pelvic exam in the last three years which indicated the occurrence of cervical/vaginal cancer or other abnormality.

• Medical Necessity – If the timing is correct, the problem may be with the diagnosis that indicates medical necessity. You may have assigned the wrong diagnosis code for the relevant procedure. A few ICD-9-CM diagnosis codes are there that indicate a screening pelvic exam for a low-risk patient (for example, V72.31 routine gynecological examination). But if the documentation states the patient is without a cervix, the correct code to indicate that is V76.49 Special screening for malignant neoplasms, other sites.

• Place of Service – If your claim is not denied due to the above two reasons, check whether you have assigned the appropriate place of service code. This code should be included on the medical claim to specify the place where the service was provided.

You can find the entire Place of Service code set on the official website of the Centers for Medicare and Medicaid Services. Some of them are given below.

• 21 – Inpatient Hospital (A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions)

• 22 – Outpatient Hospital (A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization)

• 23 – Emergency Room – Hospital (A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided)

• 24 – Ambulatory Surgical Center (A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis)

By partnering with a professional medical billing and coding company, you can reduce costly coding mistakes and documentation errors to a great extent. Such a company will provide the service of experienced AAPC certified coders and conduct frequent audits to identify coding errors.

The United States Department of Health and Human Services (HHS) had changed the ICD-10 compliance date from October 1, 2013 to October 1, 2014 to provide more time for covered healthcare providers and other entities to prepare and fully test their medical coding system for a smooth and coordinated transition. However the October 2013 ICD-10 Readiness Survey by the Workgroup for Electronic Data Interchange (WEDI), a leading authority on the use of Health IT to improve healthcare information exchange, shows that the health care industry is farther behind the key ICD-10 compliance milestones specified for providers, payers and vendors in the WEDI/NCHICA timeline, compared to information given by a similar survey in February 2013. This indicates that most health care providers are still unprepared for the adoption of new medical coding system that includes about 141,000 codes for new procedures and diagnoses which is expected to improve the nature of information available for quality improvement and payment purposes.

Around 353 respondents participated in The WEDI survey including 196 providers, 59 vendors and 98 health plans. The major findings of this survey are as follows:

• While one-quarter of vendors said their system are complete, around one-fifth of the vendors indicated that they are halfway or less than halfway complete with product development to incorporate new codes. Around three-fifth of vendors said that they are already doing customer review and beta testing or plan to do the same by the end of 2013.

• Around three-fifths of health plans have finished their impact assessment while one-fifth of them are nearing finish. About two-thirds of health plans have started internal testing or expect to start by the end of 2013. If around one-third of plans have already started external testing or expect to begin by the end of 2013, three-fifths of them are expected to start external testing in the first half of 2014.

• Around one-half of the providers indicated that they have completed their impact assessment. About one-tenth of providers expect to start external testing in 2013 whereas one-half expect to begin the testing in the first half of 2014.

According to Jim Daley, WEDI Chairman, it is quite clear from the survey results that the industry continues to make slow process, but the extent of progress is not enough for a smooth transition. He suggests the main factors for slow progress are the change in compliance date, competing internal priorities and other regulatory mandates. However, it is very crucial to monitor industry progress and early testing results closely to predict what might happen on the compliance date.

Delaying ICD-10 implementation will be a great cost burden for providers, vendors and payers. Many facilities have already invested time and resources in their systems for ICD-10 preparedness and have contracted with vendors and consultants. If the deadline keeps getting extended, additional training and testing will be needed beyond the original date. Also, the HITECH (Health Information Technology) Act has already invested millions of dollars in educational grants to get the workforce prepared for ICD-10 transition. This training would of no use if ICD-10 is delayed too long as people would not remember what they learned if they do not use the knowledge.

So it is very important for health care entities to streamline their ICD-10 transition process, perform end-to-end testing and train their coders before 2014 deadline. You can save the cost for ICD-10 training in your practice by partnering with a professional medical billing and coding company that offers the services of experienced AAPC certified coders that are ICD-10 prepared. The right company can help you overcome ICD-10 end-to-end testing challenges and streamline the entire transition process.

Imagine you are hospitalized for a minor accident and the hospital charges you a huge amount, much higher than you expected your treatment to cost. This situation could be the result of medical billing errors or due to deliberate overbilling by the provider. If you think that you have been overbilled or billed wrongly for medical care you received, you should know how to handle the situation. Here’s what experts say:

Be Aware of Your Rights – You have the legal right to ask for an itemized bill. Certain hospitals may give inexplicable reasons for not providing an itemized bill that shows each and every detail of how your stay was charged. The truth is that most states have laws that say patients are entitled to an itemized bill. A few states have laws limiting how much hospitals can charge patients who pay for the services on their own. California passed a law in 2006 which prevents hospitals from charging uninsured patients more than what Medicare or other public insurance programs would pay for the same service. In California, if a patient contacts the hospital and proves evidence of their financial situation, state law requires the hospital to provide a discount based on Medicare rates. So, contact the billing department of your medical facility, request an itemized bill and let them know that you are aware of your legal rights to have one.

• Ask Explanations in Writing and Take the Issue to Top Level – Whatever communications you have with your health care provider should be in writing. Write to the billing department and insist that your account be placed on hold till the issue get resolved to avoid sending the bill for collection. If you do not get the response that you need, stop calling the customer service and address a certified letter to chief executive or chief financial officer of the medical facility that you have tried to resolve billing dispute but couldn’t find a better solution. Pat Palmer, the founder of Medical Billing Advocates of America (national advocacy firm of professionals dedicated to protecting and servicing consumers and businesses) says CFOs and CEOs would take this matter very seriously.

• Get Relevant Information from Your Insurer – Contact your insurer and make sure that the medical facility from which you have taken care is included in the network of providers specified in the plan. Also, ensure that the facility is charging you at the price negotiated by the insurer. Susan Pisano, spokeswoman for the trade group America’s Health Insurance Plans, says it is a good idea to stay in network as the insurers would always have the responsibility to seek what happens between the patient and contracted health care provider. Most insurers pass insurance claims without processing them at the reduced rate. Ask your insurer to process your claim again if the reduction wasn’t applied.

• Seek Expert Help and File Complaints If Necessary – If you have a large bill to settle and are having a hard time fighting it out by yourself, don’t hesitate to seek help from experts. You can consult medical billing advocates who can help you fight charges or lower your bill. If the health care provider does not respond to your issues in proper the manner and your insurer hasn’t helped, you can file a complaint with your state’s department of insurance. In case the provider is not included in the contracted providers’ network specified in your plan, the state’s attorney general’s office can help you.

You should also know that your billing problem could have been the result of inadvertent coding or documentation errors. Medical facilities that partner with a professional medical billing and coding company can avoid such catastrophic errors as they would have a professional team of certified coders handling the task.

The U.S. Department of Health and Human Services (HHS) has set October 1, 2014 as the deadline for all HIPAA-covered healthcare providers to convert to ICD-10 codes. Compared to 13,000 diagnostic codes in ICD-9-CM, the ICD-10-CM revision has more than 68,000. Moreover, ICD-10-CM introduces alphanumeric category classifications for the first time and has many more categories than ICD-9-CM. With less than a year to go, most physician practices are apprehensive about the changes that transition to ICD-10 will bring about such as the need for more specificity in documentation and medical coding and billing variations.

So it’s important to make sure that your practice is well prepared for the ICD-10 transition by adding ICD-10 to your compliance plans for 2014 and beyond. Your compliance plan should include ICD-10 risk assessments, auditing and monitoring, training, communication and incident management, advises an industry expert in an article published on the AAPC site.

• Risk Assessments – Perform an initial practice workflow or ICD 10 impact assessment to get a thorough knowledge about the crucial vulnerabilities to your practice and find out how they will affect work flow and revenue. This will help to avoid potential frauds and other allegations and minimize their effects. It is very important consider all the areas that the transition would affect such as management, documentation, clinical areas, lab orders, system, front-office jobs, coding and billing.

• Conduct Audits – By conducting a baseline audit on your documentation, you can determine the level of training that will be needed for ICD-10 compliance. It has been estimated that, on average, ten records per provider are all that is needed for such an audit. This can help address revenue integrity and false claim issues. Incorrect coding issues can be identified by auditing claim submissions before and after payments. Educate your staff about the importance of clinical record documentation and the need for record compliance with ICD-10.

• Training – Physicians should enroll in training sessions on new documentation requirements. In-house coders and billers, they would need to be trained on the new code sets. Practice staff should be made aware of their new responsibilities when ICD-10 is implemented.

• Encourage Communication – Practice management and staff should share their opinions and be well-informed about the necessary changes. This can help mitigate potential issues. If concerns are reported immediately, corrective action can be taken quickly. Routine staffs meetings help keep the lines of communication open.

• Incident Management – If a potential non-compliance issue is found or reported, document the incident and further investigations. This will help to take corrective measures quickly.

Outsourcing your billing tasks to a professional medical billing company can help to avoid non-compliance issues related to ICD-10. Professional service providers have a team of trained, AAPC-certified coders and billers who are ICD-10 ready.

Neuraxial Labor Analgesia/Anesthesia is provided to ease a woman’s pain during labor and delivery and is administered by an anesthesiologist and/or CRNA. Anesthesiology medical coding for obstetrical procedures involves the base units, time units and modifying units. Let’s see how to report this service using CPT codes.

When the neuraxial labor analgesia/anesthesia is administered by an anesthesiologist or CRNA, the anesthesia code 01967 should be reported along with an appropriate modifier from the following list.

Modifiers Used by Anesthesiologists

• AA: Anesthesia services performed personally by anesthesiologist
• AD: Medical supervision by a physician (anesthesiologist); more than four concurrent anesthesia procedures
• QK: Medical direction (supervision) of two, three or four concurrent anesthesia procedures
• QY: Anesthesiologist medically directs one CRNA

Modifiers Used By CRNAs

• QX: CRNA service with medical direction (supervision) by a physician
• QZ: CRNA service without medical direction (supervision) by a physician

Anesthesia time should also be reported along with this code, and the time units are calculated in 30-minute increments.

For a cesarean delivery or cesarean hysterectomy following neuraxial labor analgesia, report codes 01968 or 01969 appropriately. Anesthesia time and modifiers are required in this case.

Use code 01996 for daily management of epidural or subarachnoid drug administration; anesthesia time and modifiers are not required for this code.

Here are the CPT codes that can be used to report neuraxial labor analgesia/anesthesia along with the code description, basic values and guidelines.

Sometimes, the neuraxial labor analgesia/anesthesia is provided by one practitioner and the administration of anesthesia during cesarean delivery or cesarean hysterectomy is by another practitioner. In such cases, the correct code should be reported along with the appropriate modifier. The anesthesiologists can receive reimbursement for medical direction.

• Suppose the neuraxial labor analgesia/anesthesia is personally performed by the anesthesiologist and the anesthesia for the cesarean delivery is provided by a CRNA while the anesthesiologist supervises (medically directs two CRNAs). The CRNA is employed by the practice same as that of the anesthesiologist. The following should be the codes.

  01967-AA
  01968-QK
  01968-QX

• When the CRNA is not employed by the same practice as the anesthesiologist, the coding will be different. Take the case of neuraxial labor analgesia/anesthesia being personally performed by the anesthesiologist, and the anesthesia for cesarean delivery is provided by the CRNA while the anesthesiologist supervises (medically directs one CRNA). The coding would be:

  01967-AA
  01968-QY

In this case, the CRNA would file a separate claim, reporting the anesthesia administered for cesarean delivery only. Some insurers allow the CRNA in a case such as the above to report the “add-on” code 01968-QX as a standalone code on a separate claim without the code 01967. This policy change is applicable also to the “add-on” code 01969, which can be reported as a standalone code on a separate claim if applicable.

CRNAs cannot use the code 01961-QX to report the administration of anesthesia during the cesarean delivery in the above mentioned instance.

• In a case where the neuraxial labor analgesia/anesthesia is performed by a CRNA and the anesthesia for the cesarean delivery is performed by the supervising anesthesiologist (the CRNA is employed by the same practice as the anesthesiologist), medical direction is for one CRNA and the coding is as follows:

  01967-QX
  01967-QY
  01968-AA

Include only the anesthesia time for the labor on the line item for the neuraxial analgesia/anesthesia (01967). For the cesarean delivery (01968), include only the anesthesia time for the delivery on the line item.

As each insurance carrier would have individual guidelines for anesthesia billing and payment, it is prudent to seek help from an expert in anesthesia coding to report anesthesia services delivered for obstetrical procedures. Partnering with a professional medical billing and coding company having expertise in anesthesiology medical billing is a good option.

American Skier Lindsey Vonn is not participating in the Sochi Olympic Winter Games due to severe knee injury. Vonn is the most recognized name in Alpine skiing as a four-time overall World Cup champion. She is also the first American woman to win an Olympic gold in the downhill.

At the world championships last February, Vonn tore two ligaments in her right knee during a high-speed crash which sidelined her for around 10 months. In a training crash in November, she re-tore her surgically repaired ACL, which is the key setback. She did make a huge comeback by finishing 40th, 11th and fifth in a set of World Cup races at Lake Louise in early December. But she lost her balance during a race at Val D’Isere, France during the last week of December, which sent her left ski into the air, forcing all her weight onto her right knee.  As per her representative, Lewis Kay, an MRI taken after this accident showed an MCL sprain, which, coupled with the torn ACL made it impossible to stabilize her knee and safely ski again next month.

However, USA Today reported on a statement issued by Lewis Kay on January 15, 2014 which said that Lindsey Vonn successfully underwent ACL reconstruction surgery and is expected to make a full recovery for the 2015 World Championships in Vail, Colorado.

ACL Tear and MCL Sprains

The anterior cruciate ligament (ACL) inside the knee (which prevents the shinbone from sliding forward relative to the thigh bone) is the important stabilizer in the knee and it can be injured while landing awkwardly in pivot-heavy sports such as soccer, basketball and skiing. ACL injuries are classified according to the extent of damage to the ligament which are Grade I Sprain (some stretching and micro-tearing of the ligament), Grade II Sprain (Partial Disruption) and Grade III Sprain (Complete Disruption). ACL tear is a second or third degree sprain of the ACL.

ICD-9 codes for ACL tear

• 717.83: Old disruption of anterior cruciate ligament
• 844.2: Sprain of cruciate ligament of knee

ICD-10 codes for ACL tear (from October 1, 2014)

• M23.50:  Chronic instability of knee, unspecified knee
• S83.51: Sprain of anterior cruciate ligament of knee
• S83.511: Sprain of anterior cruciate ligament of right knee
• S83.511A: Sprain of anterior cruciate ligament of right knee, initial encounter
• S83.511D: Sprain of anterior cruciate ligament of right knee, subsequent encounter
• S83.511S: Sprain of anterior cruciate ligament of right knee, sequela
• S83.512: Sprain of anterior cruciate ligament of left knee
• S83.512A: Sprain of anterior cruciate ligament of left knee, initial encounter
• S83.512D: Sprain of anterior cruciate ligament of left knee, subsequent encounter
• S83.512S: Sprain of anterior cruciate ligament of left knee, sequela
• S83.519: Sprain of anterior cruciate ligament of unspecified knee
• S83.519A: Sprain of anterior cruciate ligament of unspecified knee, initial encounter
• S83.519D: Sprain of anterior cruciate ligament of unspecified knee, subsequent encounter
• S83.519S: Sprain of anterior cruciate ligament of unspecified knee, sequela

Medial Collateral Ligament (MCL) is a band of tissue inside the knee which connects the thighbone to the bone of the lower leg and keeps the knee from bending inward. MCL sprain may occur due to activities that involve bending, twisting or a quick change of direction. There are Grade I (Mild), Grade II (Moderate) and Grade III (Severe) MCL sprains.

ICD-9 code for MCL sprain

• 844.1: Sprain of medial collateral ligament of knee

ICD-10 codes for MCL sprain

• S83.41: Sprain of medial collateral ligament of knee
• S83.411: Sprain of medial collateral ligament of right knee
• S83.411A: Sprain of medial collateral ligament of right knee, initial encounter
• S83.411D: Sprain of medial collateral ligament of right knee, subsequent encounter
• S83.411S: Sprain of medial collateral ligament of right knee, sequela
• S83.412: Sprain of medial collateral ligament of left knee
• S83.412A: Sprain of medial collateral ligament of left knee, initial encounter
• S83.412D: Sprain of medial collateral ligament of left knee, subsequent encounter
• S83.412S: Sprain of medial collateral ligament of left knee, sequela
• S83.419: Sprain of medial collateral ligament of unspecified knee
• S83.419A: Sprain of medial collateral ligament of unspecified knee, initial encounter
• S83.419D: Sprain of medial collateral ligament of unspecified knee, subsequent encounter
• S83.419S: Sprain of medial collateral ligament of unspecified knee, sequela

Arthroscopic Surgery

The treatment for ACL injuries depends upon the patient’s age, level of activity, associated injuries and the importance of returning to athletic activities. Even so, surgery is the only definitive treatment of complete ACL injuries. MCL sprain may require surgery only if it is coupled with severe injuries on other parts of your knee such as the ACL or meniscus. Surgery is not necessary for older individuals who do not complain of knee instability with recreational activities or work.

Majority of orthopedic surgeons opt for arthroscopic surgery rather than open surgery for ACL injuries as it is easy to view and work on knee structures, uses smaller incisions and may have fewer risks. Knee arthroscopy allows the surgeon to see the joint space of the knee with an endoscope (a long tube with a lens at each end) inserted through a small incision and perform surgery using surgical instruments inserted through other small incisions.

Common Knee Arthroscopic Procedures and their CPT codes

• 29850: Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy)
• 29851: Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; with internal or external fixation (includes arthroscopy)
• 29855: Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed (includes arthroscopy)
• 29856: Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, includes internal fixation, when performed (includes arthroscopy)
• 29866: Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft[s])
• 29867: Arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty)
• 29868: Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral
• 29870: Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)
• 29873: Arthroscopy, knee, surgical; with lateral release
• 29874: Arthroscopy, knee, surgical; for removal of loose body or foreign body (e.g., osteochondritis dissecans fragmentation, chondral fragmentation)
• 29875: Arthroscopy, knee, surgical; synovectomy, limited (e.g., plica or shelf resection) (separate procedure)
• 29876: Arthroscopy, knee, surgical; synovectomy, major, two or more compartments (e.g., medial or lateral)
• 29877: Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)
• 29879: Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture
• 29880: Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving)
• 29881: Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving)
• 29882: Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)
• 29883: Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)
• 29884: Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)
• 29888: Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction
• 29889: Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction

If an arthroscopic procedure is done at one site and an open procedure is performed at a different site, it is very important to use the appropriate modifier (-59 (used with the second procedure), RT (right knee), LT (left knee)) to indicate this to the insurer so that the physicians can receive the correct reimbursement. Physicians can partner with a professional medical billing and coding company having a dedicated team of AAPC certified coders to assign appropriate diagnostic codes for ACL and MCL injuries and procedure codes for arthroscopic surgeries.

HEDIS is an important yardstick by which health plans can measure their performance and worth. In fact, this yardstick is being employed by over 90% of health plans in the US. Results that come with HEDIS data collection act as the measure for quality improvement as well as preventive care. These results transform to HEDIS rates that can evaluate how health plans have managed to show forth their ability to improve in quality measures and preventive care, ultimately benefiting health plan users. HEDIS contains 75 measures dealing with 8 vital care domains.

Care Domains Covered by HEDIS

These care domains include care effectiveness, care access or availability, patient satisfaction of the provided care, stability of the health plan, use of service, care cost, relevant and educated healthcare choices, and clarity and descriptive nature of health plan information.

HEDIS data is reported to the NCQA in the month of June in the reporting year. The data reflects events that have occurred in the measurement calendar year, which is January to December of the previous year.

How a Medical Coding Company Could Help

A reliable medical coding company can offer comprehensive measurement of HEDIS. HEDIS coding services can enable insurers to meet NCQA quality goals. It can also help healthcare practices maximize their HEDIS reimbursement, which will make their plans more attractive to users and prospective customers.

An efficient and experienced medical billing and coding company can offer its comprehensive services for health plans, Medicare Advantage Organizations (MAOs) and physician practices for improving HEDIS scores. HEDIS measurement services could tackle health issues such as the following:

• Asthma medication use
• Beta blocker treatment following heart attack
• Adult BMI Assessment
• Immunization status
• Childhood immunizations
• High blood pressure control
• Quit smoking advices
• Antidepressant medication management
• Older adults care
• Breast cancer screening
• Cervical cancer screening
• Fall risk management
• Comprehensive diabetes care

With HEDIS you have a great way to improve your health plan performance. For employers, this measure helps to select the right plan for their employees.

A recent CNN report has highlighted the 24.4% cut Medicare doctors are going to face in their reimbursements from January 1, 2014. This is much higher than the 2% reduction in 2013. This scheduled cut is determined by targets set under the Sustainable Growth Rate (SGR) formula. The SGR legislation was passed in 1997 to reduce Medicare spending and control cost growth.

SGR formula calculates an amount for a year based on four factors – the estimated percentage change in fees for physicians’ services, the estimated percentage change in the average number of Medicare fee-for-service beneficiaries, the estimated 10-year average annual percentage change in real gross domestic product (GDP) per capita and the estimated percentage change in expenditures due to changes in law or regulations. If Medicare spending increases more than this pre-determined amount, physicians’ Medicare reimbursements would be cut accordingly by next year to make up for the overspending.

However, Congress passes the legislation known as ‘Doc Fix’ regularly to avoid doctors taking the financial burden, and keep the reimbursement levels around the same. Even though it will defer the cuts, it does not give doctors an incentive for providing better value and coordinated care that is critical for preventing long-term growth in healthcare spending. This cut can’t be cancelled once and for all as it would add to deficits and the lawmakers would find it difficult to devise ways to pay for the difference by introducing other cuts or raising taxes. The Congressional Budget Office estimates that it will require around $139 billion over 10 years to permanently override the scheduled reimbursements.

The leaders of the Senate Finance and House Ways and Means committees released a draft proposal in October to repeal the SGR formula, freeze payment rates through 2023 and then introduce set increases with the option for bonuses. The bipartisan proposal would also reform fee-for-service reimbursement system of Medicare in accord with the system that rewards value over volume so that healthcare providers can receive incentives for delivering high-quality and efficient healthcare services.

Physicians May Refuse to Take Medicare Patients

The 24% pay cut will be too hard for physicians as they will have to cut corners due to this and refuse taking Medicare patients. They will lose a considerable number of their patients in this way as both Medicare and Medicaid cover more than 100 million Americans. The paperwork associated with medical billing tasks for Medicare and other insurers is proving quite arduous for many doctors. It also forces them to spend less time with their patients. Doctors who refuse to take Medicare and other health plans do see a fall in the volume of their patients, but they think that there will be others to take their place. Providers in this group list reduced in-house workload and cutting down on the number of staff as their major advantages.

In this scenario, there are other providers that find medical outsourcing a practical option. Among this group are physicians who feel that they can’t just refuse to treat senior citizens on Medicare plans. More and more physicians might drift towards billing companies outside to save money. There are reliable medical billing and coding companies in the United States with reliable offshore and onshore facilities to provide services in keeping with diverse payer requirements. With the right partnering firm, providers can save the time spent on medical billing, and devote more time to their patients as well as increase their patient base.