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Coding Corner

This quarter we are bringing handful of different coding topics that are informative and will help you going forward.

Co-management of ophthalmic postoperative care

Purpose

The purpose of this policy and procedure is to document and communicate Quartz coding and reimbursement policy for co-management of postoperative ophthalmic care. As illustrated by AMA CPT-4 coding instructions, when one physician or other qualified health care professional performs a surgical procedure, and another provides preoperative and/or postoperative management, the surgical service may be identified by adding modifier 54 to the CPT-4 code.

Policy

Quartz is committed to servicing its members in a compliant and cost-effective manner, with the primary objective of providing uniformity and consistency in the interpretation of compliant and accurate coding applications. Quartz follows Medicare and Medicaid policies as the authoritative source for correct coding applications, AMA coding directives, and industry standards. Quartz policy is subject to federal and state law to the extent applicable and the terms and limitations of the member’s benefits. Policies and Procedures that contain reimbursement policies are constantly evolving, and Quartz reserves the right to review and update these policies periodically.

  • Quartz will identify and comply with established provider contractual obligations. Any policy changes impacting claims submission guidelines, claims processing, and reimbursement will be communicated in advance to the provider community via direct communication (newsletter and/or letter), contract amendments, and/or provider manual updates.

Coding interpretation and applications

Occasionally, a physician must transfer the patient’s care during the global care period. In these instances, a modifier will be necessary to distinguish who is providing care for the patient.

Reasons for splitting care:

  • The operating surgeon is unavailable after surgery, and another physician must manage the patient’s postoperative care.
  • The patient is unable to travel the distance to the surgeon’s office for postoperative care visits.
  • The care is provided in a health professional shortage area (HPSA), and the patient is unable to travel to the surgeon’s office.
  • The surgeon practices in a site remote from where the patient recuperates, e.g., the surgery is performed in a remote area, and the surgeon does not return to the area frequently enough to provide preoperative or postoperative care.
  • The patient voluntarily wishes to be followed postoperatively by another physician.
  • The surgery is performed by an itinerant surgeon in a remote area of the country.

Transfer of postoperative care is not covered if:

  • The operating surgeon is available, and he/she can manage other patients postoperatively, unless the patient voluntarily wishes to be followed postoperatively by another provider.
  • The surgeon does follow the patient postoperatively but splits the fee with another provider.
  • Two or more physicians co-manage patients indiscriminately as a matter of policy and not on a case-by-case basis.
  • A physician demands to manage the postoperative care and indicates that he/she will withhold making referrals to surgeons who would not agree to split global surgery payments.
  • A surgeon opts to transfer postoperative care.
  • The transfer is not made in writing.
  • The transfer of care is used as an incentive for obtaining referrals from providers to receive postoperative care reimbursement.
  • The patient has not consented to the transfer of care even after being apprised of the medical and/or logistic advisability or the risks and benefits of transfer care.

Documentation requirements are as follows:

  • The surgeon should write the usual operative note, and the postoperative care physician should document appropriate follow-up care notes.
  • Transfer of care must be in writing and dated. The record must indicate the exact date the co-managing physician assumes postoperative care.
  • The medical record must indicate that the patient was appropriately informed of the medical and/or logistic advisability of transfer of care, along with any risks or benefits of this arrangement, and that the patient consented to this arrangement before its inception.
  • All documentation, including the documentation that the patient was properly informed, must be available upon request.

The transfer of postoperative care is not covered if:

  • The operating surgeon is available, and he/she is able to manage other patients postoperatively unless the patient voluntarily wishes to be followed postoperatively by another provider.
  • The surgeon does follow the patient postoperatively but splits the fee with another provider.
  • Two or more physicians co-manage patients indiscriminately as a matter of policy and not on a case-by-case basis.
  • A physician demands to manage the postoperative care and indicates he/she will withhold making referrals to surgeons who would not agree to split global surgery payments.
  • A surgeon opts to transfer postoperative management but follows the patient postoperatively as he/she would have done without transferring postoperative care.
  • The transfer is not made in writing.
  • The transfer of care is used as an incentive for obtaining referrals from providers to receive postoperative care reimbursement.
  • The patient has not consented to the transfer of care even after being apprised of the medical and/or logistic advisability or the risks and benefits of the transfer of care.
  • The care provided in the pre and postoperative period is not provided by a physician or advanced practice provider.

Quality assurance

In conjunction with Audit and Quality, the Coding Integrity Unit will periodically review claim payment trends to confirm adherence to best coding practices and modify established guidelines when necessary. We will communicate any deficiencies identified and/or recommendations for change in policy through updated policies published on the Quartz website.

Enforcement

Enforcement of coding policies will be conducted through periodic claim checks. These periodic reviews will ensure that Quartz is accurately and properly processing claims according to the coding policies and that providers are accurately submitting claims. This policy may occasionally require providers to submit supporting documentation of the services reported to substantiate care and billing.

We will include this policy in the next Provider Manual update. You can find all other policies in the Provider Manual.

Statin medication

Statin medication, specifically for diabetes or other heart diseases, has been proven to help prevent cardiovascular events. However, it might not be clinically appropriate for every patient due to an intolerance or contraindication.

Statin therapy does get measured via claims data and the diagnosis code for quality purposes to determine which members should be included or excluded from such quality measures. If a patient is not a candidate for statin therapy, it is important to include the appropriate ICD-10 code(s) on claims, so the patient is not included in quality measures. The ICD-10 code should be submitted on at least one claim every year. For more details on how we measure, please refer to the CMS Technical Specifications, specifically the Statin Use in Persons with Diabetes (SUPD) section.

Below are some conditions that prevent statin medication use and help us identify ineligible members.

ConditionAppropriate code
PregnancyG9778
Hospice careG9473-G9479
CirrhosisK70.30, K70.31, K71.7, K74.3, K74.4, K74.5, K74.60, K74.69
Dialysis procedureG0257
End stage renal diseaseN18.6
IVF procedureS4015, S4016, S4018, S4020, S4021
MyalgiaM79.1-M79.18
MyositisM60.80-M60.819, M60.821-M60.829, M60.831-M60.839, M60.841-M60.849, M60.851-M60.859, M60.861-M60.869, M60.871-M60.879, M60.88-M60.9
MyopathyG72.0, G72.2, G72.9
RhabdomyolysisM62.82

Timed dental codes

While Quartz is a medical health insurance provider, you may submit limited dental procedure codes to Quartz for reimbursement. Such dental procedure codes represent both medical services and medical diagnoses. Quartz relies on established coding guidelines published by the American Medical Association and CMS.

According to the CMS Claims Processing Manual, chapter 5, section 20.2, to bill one unit of a timed CPT code, a provider must perform that associated service for at least 8 minutes. When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single-timed CPT code in the same day measured in 15-minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes through and including 37 minutes, then two units should be billed. This includes CPT D9222 (deep sedation/general anesthesia, initial 15 minutes) and CPT D9223 (deep sedation/general anesthesia, subsequent 15 minutes).

Time intervals for 1 through 8 units are as follows:

UnitsNumber of minutes
1≥ 8 minutes through 22 minutes
2≥ 23 minutes through 37 minutes
3≥ 38 minutes through 52 minutes
4≥ 53 minutes through 67 minutes
5≥ 68 minutes through 82 minutes
6≥ 83 minutes through 97 minutes
7≥ 98 minutes through 112 minutes
8≥ 113 minutes through 127 minutes

The pattern remains the same for treatment times over 2 hours. If a service represented by a 15-minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit. If the service is performed for at least 30 minutes, that service shall be billed for at least two units, etc. Counting all minutes of treatment in a day toward the units for one code is inappropriate if other services were performed for more than 15 minutes.

Acute stroke coding tips

The Quartz Risk Adjustment Compliance team is finding many instances where acute stroke is coded incorrectly and should have been coded as a history of stroke. 

Tips to remember:

  • A cerebrovascular accident (CVA) or stroke should be documented and coded as acute only during the initial episode of care. This is rarely done in an outpatient office setting and is most likely to take place in the emergency department or hospital.
  • Post-discharge, providers should document and code history of CVA, with or without residual or late effects.
  • Providers should document any CVA late effects to the highest specificity, including:
    • The cause-and-effect relationship of CVA and related deficits.
    • Specific deficits, such as hemiplegia/hemiparesis, cognitive deficits, facial weakness, etc.
    • Laterality and whether the side affected is dominant or non-dominant.

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