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Coding & Billing
Leaving Money on the Table?
Lolita Jones
Publish Date: October 10, 2007   |  Tags:   Financial Management

Lolita M. Jones, RHIA, CCS As I perform ASC coding audits across the country, I'm amazed at how much money surgery centers are leaving on the table simply because they fail to properly code their cases. As we review some common examples, keep in mind two rules: The higher the payment group, the higher the Medicare ASC payment. And the higher the relative value unit (RVU), the higher the Medicare fee-schedule payment.

Lolita M. Jones, RHIA, CCS\ Blepharoplasty

  • Documentation impact. Clear documentation that the patient had "excessive skin weighting down the upper eyelid" will justify the coding and billing of higher-paying code 15823. Your Medicare carrier will likely request visual-defect documentation before paying 15822 or 15823.
  • Coding tips. See code 15823 for an upper-eyelid blepharoplasty, which is performed for the removal of excess, redundant skin from the upper eyelid. This fold of skin may mechanically weight the lid, causing it to droop and obscuring the superior portion of the visual field. Often removal of this fold skin will lead to resolution of any eyelid drooping. The two skin edges are then sutured together. A blepharoplasty procedure often includes the removal of orbital fat as well as the excess skin.

Blepharoptosis repair requires repair on the levator muscle of the upper eyelid due to ptosis (drooping) - see codes 67903, 67904, 67908. Unlike the blepharoplasty, blepharoptosis repair doesn't involve surgery on the skin of the eyelid. Most blepharoptosis repair involves either a resection of a portion of the levator muscle or an advancement of the levator muscle from an abnormally recessed position to the normal anatomic position on the tarsus of the upper eyelid. Both of these techniques accomplish the same goal - effectively strengthening the muscle and elevating the eyelid. (Source: CPT Assistant newsletter, Sept. 2000, page 7).

Blepharoplasty

CPT Code and Description

2004 ASC Payment Group Rate

2004 Fee Schedule Relative Value Unit*

15822 Blepharoplasty, upper eyelid;

3 ($510)

9.07

15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid

5 ($717)

13.67

* When service is rendered in an ASC

Nasal/sinus endoscopy

  • Documentation impact. Documentation of an endoscopic anterior and posterior ethmoidectomy will justify the higher paying code 31255.
  • Coding tips. Codes 31233-31294 are used to report unilateral nasal/sinus endoscopy procedures. If performed bilaterally, you should append these codes with bilateral procedure modifier ?50 or report them twice or with two units of service (depending on the payer's billing requirements). Most payers would reimburse one of the bilateral endoscopic procedures at 100 percent and the other at a discounted rate (such as 50 percent) depending on their payment structure.

Nasal/Sinus Endoscopy

CPT Code and Description

2004 ASC Payment Group Rate

2004 Fee Schedule Relative Value Unit*

31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)

3 ($510)

7.92

31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)

5 ($717)

11.69

* When service is rendered in an ASC

Bunionectomy

  • Documentation impact. Clear documentation of a double osteotomy - such as an Austin-Akin osteotomy - will justify the coding and billing of 28299. You'd code an Austin bunion correction procedure as 28296, an Akin bunion correction as 28292 and an Austin-Akin bunionectomy as the higher-paying 28299.
  • Coding tips. Code 28299 represents a combination of codes 28296 and 28310-28315. As bunion surgery has evolved, it is now common practice to perform a double osteotomy. Two operative procedures are required to correct hallux valgus deformities with double osteotomy. The first is an osteotomy (chevron, for example) of the distal first metatarsal with correction of the hallux valgus, followed by an osteotomy of the proximal phalanx to correct additional angular deformity. You may also use 28299 to report two osteotomies of the first metatarsal. Source: CPT Changes 2002: An Insider's View, American Medical Association; Chicago, 2001.

Bunionectomy

CPT Code and Description

2004 ASC Payment Group Rate

2004 Fee Schedule Relative Value Unit*

28296 Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (Mitchell, chevron or concentric procedures, for example)

3 ($510)

16.51

28298 Correction, hallux valgus (bunion), with or without sesamoidectomy; by phalanx osteotomy

3 ($510)

14.68

28299 Correction, hallux valgus (bunion), with or without sesa-moidectomy; by double osteotomy

5 ($717)

18.47

* When service is rendered in an ASC

Cystourethroscopy

  • Documentation impact. Clear documentation of the size/dimension of each bladder tumor can result in higher reimbursement, particularly if the tumor is 2.0cm or larger. Reimbursement is greater when you remove multiple tumors.
  • Coding tips. When you fulgurate or resect multiple bladder tumors using a cystourethroscope, don't add the tumor sizes together for a cumulative total size. Rather, measure each tumor individually to determine the appropriate category (small, medium or large). Report Code 52234 [Cystoscopy for treatment of small/0.5cm to 2.0cm bladder tumor(s)] once for single or multiple tumors that individually measure 0.5cm to 2.0cm. Report Code 52235 once for medium (single or multiple) tumors that individually measure 2.0cm to 5.0cm. Tumors larger than 5.0cm are considered large tumors; report them using code 52240 once. Source: Oct. 2002 CPT Assistant newsletter, AMA.

For example, if you cystoscopically remove a 3.5cm bladder tumor and a 6.0cm bladder tumor during the same session, report code 52235 for the 3.5cm tumor and 52240 for the 6.0cm bladder tumor. Most payers would reimburse one of the cystoscopic procedures at 100 percent and the other at a discounted rate (such as 50 percent) depending on their payment structure.

Cystourethroscopy

CPT Code and Description

2004 ASC Payment Group Rate

2004 Fee Schedule Relative Value Unit*

52234 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 to 2.0 cm)

2 ($446)

6.58

52235 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)

3 ($510)

7.73

52240 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s)

3 ($510)

13.71

* When service is rendered in an ASC

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