ICD-10 Medical Coding For Heart Murmur In Neonates – An Overview

ICD-10 Medical Coding For Heart Murmur In Neonates – An Overview

Heart murmurs in new born babies are a cause of concern and require immediate attention of a pediatric cardiologist. It is diagnosed by health practitioners during physical examination of the infant. If the heart murmur is abnormal, the patient needs to undergo the following tests:

  • Echocardiogram: Used to detect the cause of a heart murmur with the help of detailed images of the heart and structures using ultrasound waves.
  • Chest X-Ray: Takes the image of the heart, lungs and blood vessels. It shows the size of the heart and the enlargement of the heart shows the cause for abnormal heart murmurs.
  • Electrocardiogram (ECG): Helps the pediatric cardiologist to determine the rhythm of the heart and its structure.
  • Cardiac Catheterization: The pressure of the heart chamber is measured by inserting a catheter into the vein or artery.

Cardiology medical billing and coding could be a hectic and complex process. The complexities can incur claim denials. Therefore, professional medical billing companies are essential to ensure accurate payment to physicians by maintaining correct documentation standards. A focused approach is required in this regard as cardiology billing is ever changing with additions, deletions and revisions of cardiology codes. Accurate coding involves correct compilation of CPT and diagnostic ICD-10 codes corresponding to specific procedures, treatments and diagnoses.

Cardiovascular CPT codes

  • 93224-93278: Cardiovascular Monitoring Services
    • 93224: In this procedure, the provider applies an electrocardiographic, or ECG recorder, to a patient for up to 48 hours to detect abnormal heart rates and rhythms. He analyzes, compiles, and interprets the electrocardiographic findings.
    • 93225: The physician or other healthcare professional applies an electrocardiograph, or ECG recorder, to a patient for up to 48 hours to help detect abnormal heart rates and rhythms. This service reports the recording only portion of the test.
    • 93226: The physician or other healthcare professional applies an electrocardiographic, or ECG recorder, to a patient for up to 48 hours to help detect abnormal heart rates and rhythms. This service reports the scanning analysis and report only portion of the test.
    • 93227: In this procedure, the provider reviews and interprets the data from an external electrocardiographic, or ECG recorder, worn by a patient for 48 hours to detect abnormal heart rates and rhythms. He reviews and interprets the electrocardiographic findings.
  • 93303-93356: Echocardiography Procedures
      • 93303: The provider performs a complete transthoracic echocardiography to obtain images of the heart structures through the chest wall in patients born with heart defects. This study includes visualization of heart chambers, valves, blood flow, and cardiac activity. This service has both a professional and technical component.

    <li93304: The provider performs a limited or follow-up transthoracic echocardiography to obtain images of the heart through the chest wall in patients born with heart defects. It is a limited examination of a focused clinical concern that does not attempt to evaluate or document all the heart structures included in a complete echo. This service has both a professional and a technical component.

  • 93306: The provider uses transducers to obtain two-dimensional (2D0 images of the heart structures through the chest wall. He evaluates the anatomy and function of all four heart chambers, valves, adjacent aorta, and wall of the heart. This service has both a professional and a technical component.
  • 71045-71555: Diagnostic Radiology ( Diagnostic Imaging) Procedures of the chest
    • 71045: In this diagnostic procedure, the provider performs a single radiological view of the chest. He performs this study for the assessment of conditions affecting the chest, its contents, and nearby structures.
  • 93593-93598: Cardiac Catheterization for Congenital Heart Defects
    • 93593: For a patient born with one or more heart defects and normal native connections, the provider navigates a catheter through the blood vessels to the heart and inserts the catheter into the right side. The provider takes samples to measure blood gases and may perform other measurements.

ICD 10 codes for heart murmur in neonates

  • R01 : Cardiac murmurs and other cardiac sounds
    • R01.0: Benign and innocent cardiac murmurs
    • R01.1 : Cardiac murmur, unspecified
    • R01.2 : Other cardiac sounds
  • P03.81 : Newborn affected by abnormality in fetal ( intrauterine) heart rate or rhythm
    • P03.810: Newborn affected by abnormality in fetal ( intrauterine) heart rate or rhythm before the onset of labor
    • P03.819: Newborn affected by abnormality in fetal (intrauterine) heart rate or rhythm, unspecified as to time of onset.
  • Q24: Other congenital malformations of heart
    • Q24.0: Dextrocardia
    • Q24.1: Levocardia
    • Q24.2: Cor triatriatum
    • Q24.3: Pulmonary infundibular stenosis
    • Q24.4: Congenital subaortic stenosis
    • Q24.5: Malformation of coronary vessels
    • Q24.6: Congenital heart block
  • Q24.8: Other specified congenital malformations of heart
    • Q24.9: Congenital malformation of heart, unspecified

Outsourcing medical billing and coding can ease the complexities associated with the rules related to diagnostic testing and evaluation procedures. The application of these codes is critical for cardiologists for timely reimbursement of the services provided without compromising patient care.

Has ICD-10 Made Medical Coding More Complicated? How Will It Change When ICD-11 Is Implemented?

Has ICD-10 Made Medical Coding More Complicated? How Will It Change When ICD-11 Is Implemented?

ICD-10 ushered in a new era of diagnostic coding. The transition to from ICD-9 codes to the ICD-10 codes took place on October 1, 2015. ICD-10 is the tenth edition of the International Classification of Diseases and allows for a greater level of specificity with detailed classifications of patients’ conditions, injuries, and diseases. ICD-10 codes allow medical billing and coding companies to report anatomic sites, etiologies, and comorbidities and complications. As ICD-10 codes are very granular, they improve the physician’s ability to demonstrate severity of illness.

The medical industry is now gearing up for a new official reporting system – ICD-11. Officially released on June 18, 2018, ICD-11 will replace ICD-10 beginning January 1, 2022. Implementation in the U.S. may take longer but it’s time to take a look at how ICD-10 changed medical coding, whether it made things more complicated, and what differences ICD-11 will bring.

There is no doubt that ICD-10 offers higher quality data for assessing service quality, outcomes, safety, and efficiency.

  • Higher level of granularity: With ICD-10, there was a four-fold increase in the number of available codes over the ICD-9 version. The number of ICD-10 codes stood at 72,616 in FY 2021. This indicates the scale of detail available to denote real-world clinical practice and medical technology advances.
  • Increased specificity: With increased specificity for screening encounters, ICD-10 supports enhanced study of utilization and health system effects. When physician documentation indicates the most specific clinical diagnosis, medical coding service providers can assign highly specific diagnosis codes that align with the documentation.
  • Laterality: One of the most distinct features of ICD-10 codes is laterality. There are specific codes that can be used to signify laterality and distinguish right, left, and bilateral. This is important for pain management billing and coding.
  • Extensions to identify encounter type: For injuries, ICD-10 offers an expanded category with a seventh character extension to identify the encounter type: “A” for the initial encounter, “D” for the subsequent encounter for fracture with routine healing, “G” for subsequent encounter for fracture with delayed healing, and “S” for sequela of fracture.
  • Other Specified and Unspecified: There may be an “other specified” or “other” code and an “unspecified” code within a category of codes. An “other” code denotes there are codes for some diagnoses, but there is no one specific for the patient’s condition. An “unspecified” code indicates that the condition is unknown at the time of coding. If more information is obtained about the patient’s condition at a later time, an “unspecified” diagnosis can be assigned a specific code.

ICD-10: Predictions that failed to Materialize

While it offers all of these features and benefits, it was predicted at the time of implementation that ICD-10 would make things more complicated. An AHIMA article noted that some healthcare industry stakeholders predicted the following:

  • Financial disruptions caused by claims denials and more
  • Administrative problems
  • Adverse impact on coding accuracy
  • Burdensome clinical documentation requirements
  • Complexity caused by an increased number of codes, such as
    • impossible to learn, and difficult to use
    • Complications caused by expanded specificity in ICD-10 external cause codes
    • Level of detail in ICD-10-CM not supported by the medical community
    • increase in the number of miscoded and rejected claims due to code complexity and number
    • Medically unnecessary tests would be need to assign ICD-10 codes
    • Widespread denials related to “unspecified” ICD-10 codes
  • Adverse impact on coding productivity and clinician productivity due to increased documentation requirements
  • ICD-10 transition would be expensive, especially for small practices
  • There would be major disruptions in operations of healthcare entities
  • Delays in ICD-10 transition
  • ICD-10 would not be implemented

The AHIMA article notes that most these dire predictions failed to materialize and that most of the healthcare industry transition to ICD-10 implementation smoothly:

  • ICD-10 included new concepts that provide a better understanding of severity, risk, comorbidities, causation, and other important parameters related to proper healthcare assessment and treatment.
  • Clinical documentation improvement efforts and EHR documentation tools eased documentation capture.
  • A 2016 study from the AHIMA Foundation reported only a 0.65% decline in coding accuracy following ICD-10 implementation. Training on ICD-10 actually improved coding accuracy to a higher level than before ICD-10.

As with any major transition, there were some problems but these have been minor or limited in nature, resolved quickly, and have not caused widespread disruption. Also, some reported issues were related to EHR design and functionality problems, and not ICD-10. Healthcare providers could overcome claims submission challenges by outsourcing medical billing and coding. Certified medical coders who are well-trained in their field communicate with providers to clarify clinical documentation to assign the most accurate ICD-10 and CPT codes on a claim. Now, it’s time for ICD-11 and medical billing and coding companies are well into the learning process.

ICD-11: Changes and Improvements

The International Classification of Disease, Eleventh Revision (ICD-11) comprises codes for documenting diagnoses, diseases, signs and symptoms and social circumstances. ICD-11 builds upon its predecessor and offers improvements that are intended to address gaps in the ICD-10.

Key changes include:

  • ICD-11 will be entirely electronic and easy to install. The coding system has been reconstructed to adapt ICD to digital use.
  • ICD-11 has around 55,000 unique codes for classifying diseases, disorders, injuries, and causes of death in greater detail as well as several new chapters.
  • It incorporates medical updates, discoveries, or changes in thinking
  • Revisions have been made to categorization and coding structure, international usage, and user-friendliness
  • Introduction of cluster coding supports more comprehensive alphanumeric coding of complex clinical situations
  • Updating of the chapter on mental disorders has been done to account for new information on mental disorders. Each mental, behavioral, and neuro developmental disorder listed includes a description with guidance on meaning that can be accessed on the site.
  • Added diagnosis include attention deficit disorder, complex PTSD, compulsive sexual behavior, gaming disorder and prolonged grief disorder.
  • The revised system offers a common coding language for use globally, including guidance for use with different cultures and translations into 43 languages.
  • The dimensional approach of the new system makes it better at capturing change over time.

When implemented, ICD-11 will involve significant changes over ICD-10. The number and specificity of the new code set will be a game changer for coding and patient care, according to experts (fortherecordmag,com). Healthcare organizations can make the transition to ICD-11 easier and less stressful by reaching out to experts. In medical billing and coding companies, teams have started efforts to get familiar with the underlying structure and organization of the ICD-11 code set, and understand the new concepts and how to classify diagnosis.

What Is The Significance Of Time In Physician Office E/M Coding?

What Is The Significance Of Time In Physician Office E/M Coding?

Starting January 1, 2021, new reporting guidelines were implemented for Office and Ambulatory Services Evaluation and Management (E&M) and changes made to code descriptors for office and outpatient E/M codes. As a medical coding outsourcing company serving all specialties, we keep track of industry guidelines and medical coding and billing trends to help physicians submit accurate claims, optimize revenue cycle management, and get reimbursed appropriately.

In the updated 2021 Office and Ambulatory Services Evaluation and Management (E&M) Guidelines, selection of codes for office/outpatient E/M services are based on:

  • Medically Appropriate History and/or Examination and Medical Decision Making

OR

  • Total Time on the Day of Encounter.

The selection of E&M levels of service (LOS) according to time is a key aspect of this E/M update. Let’s take a look at the significance of time in physician office E/M coding.

How “Time” was used Before 2021

Beginning CPT 1992, time was included as an explicit factor to assist in selecting the most appropriate level of E/M services.

In 2020, office and outpatient visit codes 99201-99215 used history, exam, MDM, or time for code selection. The 2020 CPT code set provided guidelines on how to use patient history, clinical examination, and medical decision making (MDM) to determine the correct level of E/M codes. It also included guidance on using time to select E/M codes when counseling, coordination of care, or both made up more than 50% of the intra service time. Best practice was for provider to meet and document these specifications and indicate what was discussed or addressed in the counseling or coordination of care.

In 2021, outpatient and prolonged services codes are based on amount of time.

2021 Time Reporting Changes for Office/Outpatient E/M codes

In 2021, except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes 99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215. The instructions for each category have to be studied as time requirements vary for different categories of services.

The 2021 definition of time, which applies when code selection is based on time and not medical decision making (MDM), is as follows:

  • The minimum time, not typical time spent, and</li
  • Represents total time spent by physician/qualified health care professional (QHP) on the date of service

The 2021 time ranges for physician office E/M Codes are as follows:

New Patient Visits

CPT code MDM 2021 Time Range
99202 Straight forward 15-29 min
99203 Low complexity 30-44 min
99204 Moderate complexity 45-59 min
99205 High complexity 60 min

Established Patient Visits

CPT code MDM 2021 Time Range
99212 Straight forward 10-19 min
99213 Low complexity 20-29 min
99214 Moderate complexity 30-39 min
99215 High complexity 40-54 min

Time in the 2021 code descriptors

  • Time is total time on the encounter date and includes both face-to-face and non-face-to-face time spent by the provider. The total time does not include time for activities the clinical staff normally performs.

  • Examples what time covers for the 2021 codes

    • Preparing to see the patient, such as reviewing tests done prior to the visit
    • The provider getting or reviewing a history that was separately obtained
    • Performing a medically appropriate physical examination;
    • Counseling and education of the patient, a family member, and/or a caregiver;
    • Ordering medications, tests, or procedures, including electronic order entry, and other related tasks;
    • Communicating with other healthcare professionals;
    • Documenting information in the health record
    • Independently interpreting results (not separately reported) and communicating results to the patient, family or caregiver
    • Care coordination (not separately reported)
  • Time may be used to select a code level in office or other outpatient services regardless of whether counseling and/or coordination of care dominates the service. For other E/M services coded based on time, the provider has to meet the threshold of counseling and/or coordination of care taking up more than 50% of the visit.
  • A shared or split visit is when a physician and one or more other qualified healthcare professionals perform the face-to-face and non-face-to-face work for the E/M visit. When coding shared visits based on time, the time spent by the physician and other qualified healthcare professionals should be added to get a total time.
  • Do not include the following when counting time:

    • Time spent on a calendar day other than day the patient was seen’
    • Services that are separately reportable (e.g., chronic care management and transitional care management)
    • Clinical staff time (activities performed by medical assistants, licensed practical nurses, registered nurses

Outsourcing medical billing and coding is a widely accepted strategy to avoid errors that can lead to audits, and payment delays and denials. For medical coding service providers to ensure accurate reporting of E/M services, providers should know the requirements of time-based billing and importantly, ensure documentation that correctly reflects the services provided, total time spent, and medical necessity.

New PCM Codes For Medical Billing & Coding Services In 2022

New PCM Codes For Medical Billing & Coding Services In 2022

The Principal Care Management (PCM) service was created by the Centers for Medicare and Medicaid Services (CMS) in 2020. The aim of the program was to allow for provision of additional care to patients with a single chronic condition. In 2022, there are four new codes to bill PCM services that replace two existing codes for these services. When introducing PCM services, CMS expected that specialists who are focused on managing patients with a single complex chronic condition requiring substantial care management will bill PCM services the most. Outsourcing medical billing is an ideal option to meet the requirements for billing PCM codes.

Principal Care Management Services: Key Points

CMS defines a typical patient (for PCM) as one that “may present to their primary care practitioner with an exacerbation of an existing chronic condition.” With the PCM codes, practices can bill for care management for services provided to patients with one serious chronic condition by a specialist or primary care physician. While Chronic Care Management Services (CCM) focus on the care of two or more chronic conditions, PCM describes care management services for a single, complex chronic condition. The key elements for the provision of PCM services are as follows:

  • A qualifying condition for PCM services may be expected to last between three months to one year or until the death of the patient.
  • The qualifying condition should be of such complexity that it cannot be managed effectively by primary care and requires management by another, more specialized practitioner.
  • Typically, a PCM service is initiated to address an exacerbation of the patient’s chronic condition or recent hospitalization.
  • While a specialist may manage services for the specific chronic condition, the patient’s primary care physician will continue to supervise the patient’s overall care.
  • A patient can receive PCM services from multiple specialists for multiple different conditions simultaneously, for e.g., a cardiologist for arrhythmia and a pulmonologist for chronic obstructive pulmonary disease (COPD).

New PCM Codes for 2022

In 2022, four new PCM codes replace the two previous PCM codes (HCPCS codes G2064 and G2065):

  • CPT code 99424: PCM services for a single high-risk disease first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month
  • CPT code 99425: PCM services for a single high-risk disease each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month
  • CPT code 99426: PCM, for a single high-risk disease first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month
  • CPT code 99427: PCM services, for a single high-risk disease each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

Requirements for Billing PCM Services

CMS has set forth several requirements that must be met for billing PCM codes for services provided to a patient. Important conditions include:

  • The billing practitioner must be a physician or a qualified health care practitioner.
  • PCM services should not be reported by the same practitioner simultaneously with other care management services.
  • According to the Final Rule, the expected outcome of the provision of PCM services is for the patient’s condition to be stabilized by the treating specialist so that overall care can be returned to the patient’s primary care practitioner.
  • The billing practitioner should document ongoing communication and care coordination between all practitioners providing care to the patient.
  • For new patients and patients not seen within a year prior to initiation of PCM, the billing practitioner must conduct an initiating visit with the patient to educate the patient on PCM and obtain the patient’s informed consent. This visit can be an annual wellness visit (AWV) or other separately billable visit.
  • Consent – The patient’s informed consent can be obtained verbally or in writing and should be documented in the patient’s medical record.

PCM services are aimed at improving patient health outcomes, but not reporting PCM services correctly can leave revenue on the table. Outsourced medical billing and coding services can help primary care physicians and specialists treating high-risk diseases or complex chronic conditions to get properly reimbursed for the services they provide.

Billing Guidelines For Biopsy Services

Billing Guidelines For Biopsy Services

Various types of biopsy procedures are used to make a cancer diagnosis such as bone marrow biopsy, endoscopic biopsy, needle biopsy, skin biopsy and surgical biopsy. Providers of biopsy services need to know how to properly bill and code for these procedures and outsourcing medical billing and coding is a practical solution to report them correctly.

CPT Codes For Biopsy Procedures

In 2019, a series of CPT codes for biopsy procedures were introduced which are specific to the method of removal – tangential, punch, and incisional:

11102 Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion

+11103 each separate/additional lesion (List separately in addition to code for primary procedure)

11104 Punch biopsy of skin [including simple closure, when performed]; single lesion

+11105 each separate/additional lesion (List separately in addition to code for primary procedure)

11106 Incisional biopsy of skin (e.g., wedge) (including simple closure, when performed); single lesion

+11107 each separate/additional lesion (List separately in addition to code for primary procedure)

Tangential biopsies (codes 11102–11103), are performed with a sharp blade and shave, scoop, saucerization, or curette techniques are used to remove a sample of epidermal tissue, with or without a portion of the underlying dermis.

Punch biopsies (codes 11104–11105) involve using a punch tool to remove a full-thickness cylindrical sample of the skin.

In incisional biopsies (codes 11106–11107), a sharp blade is used to make a vertical incision or wedge to remove a full-thickness sample of tissue, penetrating deep to the dermis and into the subcutaneous space.

Reasons For Denials

Reports indicate improper billing and denials have increased. Medicare Administrative Contractor First Coast Service Options (FCSO) identifies the reasons for biopsy procedure claim denials as:

  • When biopsy codes are billed with other surgery codes on the same date of service, modifier 59 (“a distinct procedural service”) is being appended to the other surgery code instead of the biopsy code.
  • Biopsy codes exceed the CMS Medically Unlikely Edits (MUEs). An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.
  • The wrong primary code is being billed or no primary code is billed at all.
  • Biopsy codes are billed with a screening diagnosis.

Prevent Denials For Biopsy Services – Follow These Guidelines

According to AAPC, CPT guidelines on coding biopsy services can throw light on why these codes are facing denials: use of the incisional, punch, and tangential biopsy codes indicates that the procedure was to obtain tissue for “diagnostic histopathologic examination” and that the procedure was “performed independently or was unrelated or distinct from other procedures/services provided at that time.”

To obtain proper payment for biopsy services, follow these steps:

  • Report CPT codes 11102-11107 only for diagnostic biopsies and do not bill these codes with a screening diagnosis code.
  • Apply the appropriate modifier to the appropriate code. Modifier 59 (distinct procedural service) should be appended to the biopsy code, if applicable. Check National Correct Coding Initiative (NCCI) edits. National Correct Coding Initiative Procedure-to-Procedure (NCCI PTP) edits generally allow a modifier when the biopsy is billed secondary to a major procedure, but most often do not allow a modifier when the biopsy is billed primary to a surgical procedure.
  • Report the appropriate primary code. Denials will occur if the wrong primary code is reported or if no primary code is billed.
  • Know the rules for reporting multiple biopsies. Biopsy codes can be “mixed and matched” to report biopsy of numerous lesions by various methods (e.g., incisional biopsy of an initial lesion, tangential biopsy of a second lesion). When performing multiple biopsies for the same patient on the same day, use only one primary code. Report the highest-valued code first, without a modifier:

    • If multiple biopsies are performed using the same technique, report the primary code with the highest RVU, and use the corresponding add-on code for the other biopsies.
    • If multiple biopsies are performed using different techniques, report the primary code with the highest RVU, and append the add-on code specific to the other biopsies done.
  • When billing for biopsy services, document the method, the number of units, and the location.
  • Ensure that the maximum units of service that can be reported for a single patient on a single date of service is not exceeded. The Centers for Medicare & Medicaid Services’ Medically Unlikely Edits (MUEs) provides the following instructions on this:

    • For 11102, 11104, and 11106, only one unit per line item can be billed
    • For 11103, 11105, and 11107, multiple units can be submitted on a single line item is allowed.

Primary care providers who perform biopsies can report their services correctly by relying on an experienced family practice medical billing company. Partnering with an expert can help them avoid denials and receive proper and timely payment from Medicare.