Regenerative Medicine Injection (C1762)

Question:

There is a product called CTM Boost that is being marketed as a regenerative medicine injection covered by insurance under this code, C1762. Have you seen this and are any amniotic or regenerative products covered by Medicare or private payors? Is this an acceptable code for office use?

Answer:

Thank you for your inquiry. Unfortunately, these injections are considered experimental under Medicare and most all commercial insurance carriers. Therefore, it would not be a covered service at this time.

Using a Scribe

Question:

I would like to know if it is compliant for the doctor to make corrections or additional comments on the note written by the scribe? For example, the note is written by the scribe, but at the end of the day the doctor reviews the note and makes correction if he sees a mistake or should he write a separate paragraph at the bottom of the note, summarizing or adding information onto the same note?

Answer:

Thank you for your inquiry. In answer to your question, yes, the provider must update any notes documented by a scribe. CMS states “The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided”. In the EHR, corrections must be made according to the Medical Records Standards of Documentation; addendums must be noted as an addendum. Any corrections/addendums must be noted as such according to the documentation standards.
Since the provider is ultimately responsible for the contents of the documentation, the provider’s note should include:

1. Affirmation of the provider’s presence during the time the encounter was recorded
2. Verification that the provider reviewed the information
3. Verification of the accuracy of the information
4. Any additional information needed
5. Authentication, including date and time

It is recommended that you check your payor policies regarding the use of scribes. As a reminder, a scribe may only document the spoken word of the provider and must be present during the entire encounter. A scribe also may not enter the electronic signature, date, and time for the physician or practitioner in the note and cannot perform any clinical duties for the patient while acting as a scribe.

Internal Brace for ACL Reconstruction

Question:

We have a surgeon who is planning to perform an ACL procedure using the InternalBrace TM Technique. The surgeon is asking if she would still report CPT code 29888, use a modifier 52, or an unlisted code. Are you able to advise? I do not have an operative note to send.

Answer:

Thank you for your inquiry and recognizing we are not able to provide definitive coding advice without an operative note.  This is a good question.

In this case, based on your inquiry, let your surgeon know she will report CPT code 29888 without any modifiers.   The CPT code statesrepair/augmentation or reconstruction.   Please share with your surgeon KZA appreciates her due diligence in her planning process.

Radiology Reports

Question:

Earlier this year, I attended an education session (not provided by KZA) where radiology reports were discussed. We have been going to KZA courses for many years and have the workbook pages with the history of the requirement and definition change for reports. We were confident we knew the documentation requirements but thought maybe something has changed; we are coming back to KZA for clarification.

In the session, the presenter addressed the need for separate reports; but then said it would be okay if the interpretation was within the office note and not a separate report.

Is a separate report required or not when we report the global radiology codes or the radiology codes with a modifier 26? I just want to make sure nothing has changed.

Answer:

Thank you for your continued support of KZA. Yes, a separate stand-alone report with the professional interpretation (not just review of the X-Rays) is still required. Perhaps the presenter was talking about the documentation requirements when the professional interpretation of external diagnostic studies is documented as part of the E&M note; this interpretation is not separately reportable with a modifier 26; as such a separate stand-alone report is not required. All other interpretation requirements must still be met.

A separate stand-alone report is required if you are billing the global radiology codes or the radiology codes with a modifier 26.

Syndesmosis Repair

Question:

I coded a case for one of our surgeons where he did an ORIF of a distal tibia/fibula fracture (Pilon) and syndesmosis repair and documented a separate diagnosis to support each procedure. I recommended CPT code 27828 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of both tibia and fibula) and CPT code 27829 (Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed). My surgeon stated he was recently advised that the 2 codes were not reportable together and would not let me submit.

The patient is not Medicare and payor does not follow NCCI edits.

Answer:

Thank you for the thoroughness of your question.
You were correct! Repair of the syndesmosis is not inclusive to the Pilon fracture (27828). Perhaps you can do a corrected claim if it is not too late.
The repair is performed for different medical necessity than the ORIF of the fractures; not all Pilon fractures will have syndesmotic instability.

POS for Hospital Services

Question:

We are wondering if you can help address a discussion in our office related to the coding rule changes for hospital services. CPT instructs to report 99221-99223 (inpatient hospital/observation) and 99231-99223 (subsequent hospital/observation) for both inpatient and observation services. Our hospital does not have a dedicated outpatient observation area; all patients are cared for on the inpatient division. We believe we understand this does not matter for code selection. Here is our question. What is the place of service for the observation patient on the inpatient division now that we are using the same code series?

Answer:

Yes, you understand the guidelines correctly related to the inpatient/observation codes and physical location- it is about admit status in this situation.  You will continue to report the appropriate code from the 99221-99223 and 99231-99233 based on the type of service and the location status of the patient.

If the patient has been admitted as an inpatient, regardless of where there bed is located, you will report the appropriate initial or subsequent hospital inpatient code and the place of service is 21 (Inpatient Hospital).

If the patient is in outpatient observation status (‘admitted’ to observation) you will report the appropriate initial or subsequent observation code and the place of service is 22 (On Campus-Outpatient Hospital (e.g. observation).

POS 19 would not be correct for the patient in observation status as this place of service isOff Campus-Outpatient Hospital.