Be prepared to supply supporting clinical reasons as part of your appeal to the payer.
For our bacillus Calmette-GuÃ©rin patients, our doctors will sometimes give a patient one-third dosage and treat three patients from one vial. We have been searching for proper coding, since 90586 and J9031 just say “each use,” and it is typically a one-dose vial. I have not found anything that looks appropriate for the drug. We don't want to be fraudulent so we’re seeking advice. Should we be using modifier –52 on code J9031?
You have asked a question with no good answer. During past BCG shortages, offices struggled with similar issues. For our clients, we began reporting partial doses of BCG with code J3490 (Unclassified Drugs) and used box 19 to include the drug name and National Drug Code with dosage used. The claims were often denied but were paid upon appeal based on the medical necessity to extend the drug to more patients. To date, we have not found a more accurate way to report doses split among patients.
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It is our understanding that some trials of partial doses were being studied, but we are not certain that these trials have resulted in supporting documentation that would allow for medical necessity support if partial dosing is provided by choice. As the reporting of partial dosing often requires appeal, make sure that you have supporting clinical or population health reasons for providing a partial dose.
Next: Am I required to list a patient’s chronic conditions?
Am I required to list a patient’s chronic conditions? I understand if the condition has a bearing on the decisions being made by the urologist, it should be listed as an active problem. But if chronic conditions are only historical, should they at least be listed in the History of Present Illness?
You have asked an important question, which may affect different parts of the payment equation.
As you know, updating three chronic health conditions will count the same as four comments in the History of Present Illness (HPI). To count this toward the HPI, the documentation must also support that something is provided to the patient in regard to the conditions, even if the support is continued monitoring of the problem.
If in fact you are managing a chronic condition or managing around a chronic condition, the condition(s) may also increase either the number of problems being managed or increase the risk level under Medical Decision Making.
If you are not treating the conditions as you suggest, they do not have to be listed in the HPI and in fact may be more appropriately listed in the Review of Systems (ROS) or Past Medical History. Here, they may help in qualifying for a Comprehensive History, and any changes, negative or positive, should be listed in the ROS update.
In addition to evaluation/management coding, the current focus on value-based medicine in the payment system makes recording the chronic condition(s) and further, the reporting of these diagnoses-even if they are non-urologic or not treated by you-important, as they relate to your Merit-based Incentive Payment System comparison, which may affect your payment 2 years from now.
We always encourage thorough and accurate documentation. If the patient makes you aware of a condition-chronic or otherwise-regardless of whether you are treating or going to treat the problem, we would recommend documenting the information accurately and documenting your instructions to the patient.
It is also important to remember priorities in reporting Dx codes as they relate to CPT codes when you are billing. Remember to tie the correct Dx code(s) to the CPT code as the reason for providing the service. Most systems will allow reporting of 12 Dx codes for each claim. If the chronic conditions are not affecting the services provided for that date, you can list the Dx code on the claim without tying the Dx to a CPT code.
Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at UT@advanstar.com. Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.