Take the challenge. Answers: B: No—Only the treating physician can take the HPI. The medical assistant is allowed to take the review of systems. If the documentation indicates the treating physician did not take the HPI, the insurance can deny the claim as not medically necessary. B: No—If the high-risk medication is not assessed and…
MACRA: More Points, Smarter Future
As the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is implemented in January with new models for quality-based reimbursement payments, rheumatologists must seize control of how they will be paid now—and in the future. This message was stressed by speakers during Holy MACRA! How to Survive and Thrive in the Era of MACRA,…
3 Ways the ACR Helps Practices Thrive
The ACR can be the first line of defense for rheumatologists when it comes to compliance efforts, quality control and oversight of physician billing and coding practices, says ACR Director of Practice Management Antanya Chung, CPC, CPC-I, CRHC, CCP. The ACR is focused on providing the support its members want and need. “We want to…
Rheumatology Coding Corner Answer: Joint Injection with Ultrasound Guidance, No Office Visit
Take the challenge. CPT: 20611-RT, J1040, 89060 ICD-10: M17.11 Coding Rationale Keep in mind, no evaluation and management services are billed because there wasn’t a separate and/or significant reason, other than the knee injection, addressed during the visit. Note: Although the injection was performed via ultrasound guidance, CPT code 76942 should not be billed with…
Rheumatology Coding Corner Question: Joint Injection with Ultrasound Guidance, No Office Visit
A 66-year-old male patient presents to the office with right knee pain. He was in the office two weeks prior for a follow-up visit of his primary osteoarthritis. He received an injection of hyaluronate sodium in his right knee four months before and states that his knee felt like new. He states that everything was…
Deadline to Seek Review for Potential Payment Penalties
Wondering if you will be subject to 2017 payment penalties associated with the PQRS and the Value Modifier? Practices have until Nov. 30 to file for an informal data review.
Rheumatology Coding Corner Answer: Gout Visit for Established Patient
CPT: 99213, 89060 ICD-10: M10.072 Coding Rationale This is an established outpatient visit. The encounter is coded as 99213 because it included: History—Expanded problem-focused history. The history of present illness was brief, the review of systems was extended and the past medical and social history was documented. Examination—Detailed. There were seven organ systems examined. This…
Rheumatology Coding Corner Question: Gout Visit for Established Patient
A 55-year-old female patient returns to the office with complaints of gout pain. She is complaining of swelling and a burning pain in her left toe. She has been taking an over-the-counter NSAID to treat the pain, but this has done little to alleviate it. This is her second flare this year. The patient denies…
ICD-10 2.0: An Evolving Data Set
One year after the official go-live of the International Classification of Diseases, 10th revision (ICD-10), the coding language is scheduled to undergo an evolution, with nearly 1,975 additions, more than 300 deletions and 425 revisions. This brings the total set of diagnosis codes to more than 71,480. The new and revised clinical modification codes (ICD-10-CM)…
How to Document E/M Services
Documenting evaluation and management (E/M) services involves many factors, and it’s important to code to the most appropriate level of service to avoid compliance risks. To assist providers with documentation, the Centers for Medicare & Medicaid Services (CMS) provides its 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. For billing purposes, either version…
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