© Springer International Publishing Switzerland 2015David A. Schulsinger (ed.)Kidney Stone Disease10.1007/978-3-319-12105-5_32
32. Billing, Coding and Your Stone: What the Patient Should Know!
Department of Urology, Stony Brook Medicine, Stony Brook, NY, USA
When it comes to billing and coding, it’s all about YOU, the patient! The physician does the billing for your office visit, your procedure, and post-operative visits. However, there are important points for you, as the patient, to understand and facts that you should be aware of in the billing process.
There are several terms that you should be aware of in the billing and coding process:
ICD-9: Playing by the Numbers!
International Classifications of Diseases (ICD). ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and in some instances, cause of death attributed to human beings. Currently, the codes we see in the United States today are version 9, called ICD-9 codes. The paperwork we receive when we leave a doctor’s office will contain ICD-9 codes to describe why that service was provided.
For example, if you present to the ER with flank pain, you may undergo testing that also determines that you have a right kidney stone with hydronephrosis. When you leave the hospital, you will receive a summary sheet that will have diagnostic codes for renal colic (788.0), renal stone (592.0) and hydronephrosis (591).
New ICD-10 Coding System
ICD-10 is on the horizon to replace the current ICD-9-CM diagnosis code reporting. The numeric ICD-9-CM codes for renal or ureteral stones (592.0 or 592.1) with which you are currently familiar with be replaced by an alphanumeric system. Implementation for ICD-10 is underway and is in the testing stage in Australia at this time. The new diagnosis coding system will require more specific documentation from practitioners and further clinical knowledge for the coding/billing staff.
CPT: The Numbers Tell the Story!
Current Procedural Terminology or CPT® (registered trademark of the American Medical Association), is the listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. These codes are numbers that describe every task and service a medical practitioner may provide to a patient, including medical, surgical and diagnostic services that a patient receives. The information collected ensures uniformity of medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial and analytical purposes.
For example, a patient is undergoing a percutaneous nephrolithotomy procedure for a staghorn calculus. If the stone is smaller than 2 cm, you will label this as 50080, and if it is a larger stone (>2 cm), it will be categorized with CPT code 50081.
Global Period: The Numbers Are In!
All procedures on the Medicare Physician Fee Schedule are assigned a Global period. A “global fee period”, also known as a surgical aftercare period, is defined as the period during which office visits for the postoperative period following surgery are included in the fee for surgery and not separately billable.
There are three types of global periods based on the number of postoperative days:
0-Day postoperative period: 0 days for endoscopies and certain minor procedure for which the physician visits the patient on the same day as the procedure.
Example: Ureteroscopy has a 0 day global period.
10- Minor Surgery: 10 days for most minor surgeries.
Example: a circumcision has a 10 global period.
90-Major Surgery: 90 days for major surgeries. To determine the global period for major surgeries, count 1 day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery.
Example: PCNL or ESWL procedures have a 90 day global period.
Modifiers: It’s All About the Numbers!
A modifier provides a way to report that a service or procedure has been altered by some specific circumstance but not changed in its definition or code. Modifiers are used to indicate that services were performed bilaterally, professional or technical in nature or performed by more than one surgeon. Also, that a service or procedure was unusual, i.e. increased or reduced by specific circumstances.
Documentation is also important when appending Modifiers to CPT codes whether they are surgical or medical. The following are modifier examples:
Modifier 22- Unusual Procedural Service
This modifier should be used when the service(s) provided is greater than that usually required for the listed procedure.
With this modifier, the physician would need to document, for example, that extra work during a procedure was provided. For instance, Procedures that take an unusually long time to perform due to obesity, dense adhesions or anatomical anomalies would require modifier 22 for proper payment.
Modifier 24- unrelated evaluation and management service by the same physician during a postoperative period
A physician may need to indicate that an E & M service was performed during a postoperative period for a reason(s) unrelated to the original procedure.
For example, a patient in a global period for an ESWL comes into the office for a penile lesion. Modifier 24 would be appended to the E & M code and it would be linked with the diagnosis with the reason for the visit, penile lesion.
Modifier 25- Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
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