pqri measure coding and reporting principles - Indiana Academy of ...

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Add-on code 69990, microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure), should not be reported if the operating microscope is used for cerumen removal. In this latter instance, however, code 92504 binocular microscopy (separate diagnostic procedure), may be reported. Therefore, based on this information, Scenarios 1 and 2 above would not be reported with code 69210. These scenarios would be captured by the appropriate E/M code. Scenario 3, however, should be reported with code 69210 because both criteria were met; the patient had cerumen impaction and the removal required physician work using at least an otoscope and instrumentation rather than simple lavage. BURNS, LOCAL TREATMENT The following codes are used to report local treatment of burned surface only. CPT CODE STATUS OF PROBLEMS 16000 Initial treatment, first degree burn, when not more than local treatment is required 16020 Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) 16025 16030 Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (e.g., whole face or whole extremity, or 5% to 10% total body surface area) Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (e.g., more than one extremity, or greater than 10% total body surface area SPRAINED FINGER(S) The following information was presented during the 2003 CPT Coding Symposium, November 14, 2002. Question: What is the correct code for buddy taping fingers, taping one finger to another for immobilizing a sprained finger Answer: Taping one finger to another for immobilizing a sprained finger is not reported separately, as it is considered a part of an Evaluation and Management (E/M) code. FRACTURE CARE If a physician treats a fracture and is responsible for the total fracture care, the appropriate fracture code would be reported based on the treatment provided. The fracture/dislocation treatment codes are generally reported by the physician responsible for the initial casting/strapping/splinting and follow-up care until the fracture/dislocation is healed. This is considered surgical treatment. When the physician provides a non-surgical treatment of the fracture/dislocation without the application of a brace, splint, or cast or without any follow-up care, the physician should only report the appropriate E/M codes based on the type of history, exam, and medical decision making required by the patient. 5-22 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
HEMORRHOIDECTOMY BY SIMPLE LIGATURE Billing Excessive Units of Service for CPT 46221 Recent data analysis and Medical Review findings for CPT 46221 (Hemorrhoidectomy, by simple ligature (e.g., rubber band)) indicated a high error rate in the utilization of this code. Reviews revealed providers were billing CPT 46221 more than once per session for the same beneficiary. When billing CPT 46221, only one unit of service is reported regardless of the number of hemorrhoids ligated during the session. The October 1997 CPT Assistant article states "Each session of rubber band ligation, regardless of the number of hemorrhoids, is coded once." Please review your billing of CPT 46221 to determine any potential overpayments made to your practice. If you identify any overpayments, it is your responsibility to perform a voluntary refund to the Medicare Program. URETHRAL CATHETERIZATION Code 5170 describes catheterization of a patient for residual urine. Code 51702 describes insertion of Foley catheter for patients with chronic problems, such as neurogenic bladder and insertion of catheters in patients in acute retention in the hospital setting. Code 51703 describes a complicated insertion (e.g., altered anatomy, fractured catheter/balloon). Newby Note: Physicians should continue to use HCPCS code P9612, catheterization for collection of specimen, single patient, all places of service, when the patient is catheterized for a sterile urine specimen. GROUP PRACTICE DEFINED Medicare General Information, Eligibility, and Entitlement Chapter 5 §90.4 (Rev. 1, 09-11-02) A group practice is a group of two or more physicians and non-physician practitioners legally organized in a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association: • In which each physician who is a member of the group provides substantially the full range of services which the physician routinely provides (including medical care, consultation, diagnosis, or treatment) through the joint use of shared office space, facilities, equipment, and personnel • For which substantially all of the services of the physicians who are members of the group are provided through the group and are billed in the name of the group and amounts so received are treated as receipts of the group • In which the overhead expenses of and the income from the practice are distributed in accordance with methods previously determined by members of the group • Which meets such other standards as the Secretary may impose by regulation to implement §1877(h)(4) of the Social Security Act. The group practice definition also applies to health care practitioners. Physicians in Group Practice Medicare Claims Processing Manual Chapter 12 §30.6.5 (Rev. 1, 10-01-03) Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the 5-23 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
Page 1 and 2: PQRI MEASURE CODING AND REPORTING P
Page 3 and 4: ! The line item charge should be $0
Page 5 and 6: ICD-9: 250.00-250.93, 648.00-648.04
Page 7 and 8: _____ _____ _____ _____ _____ Beta-
Page 9 and 10: Definition: Pharmacologic Therapy:
Page 11 and 12: Definition: Characterization includ
Page 13 and 14: eport the proper CPT II Category II
Page 15 and 16: • Physicians and qualified nonphy
Page 17 and 18: preoperative medical evaluation (if
Page 19 and 20: The excision of malignant lesion co
Page 21: complex repairs (CPT codes 13100-13
Page 25 and 26: Medicare “Incident to Clarificati
Page 27 and 28: service or other face-to-face servi
Page 29 and 30: HOSPITAL OBSERVATION SERVICES - CPT
Page 31 and 32: If the physicians are each responsi
Page 33 and 34: documented. If the time is not docu
Page 35 and 36: Follow-Up Consultation Service Effe
Page 37 and 38: A physician (primary care or specia
Page 39 and 40: typical severity of the problem(s)
Page 41 and 42: Medicare Part B payment policy does
Page 43 and 44: HOME SERVICES - CPT CODES 99341-993
Page 45 and 46: the medical records must clearly do

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