CODING & DOCUMENTATION
Fam Pract Manag. 2020 Mar-Apr;27(2):31.
Author disclosure: no relevant financial affiliations disclosed.
- NEW CODE FOR VAPING-RELATED ILLNESS
- ULTRASOUND SERVICES IN THE OFFICE
- AUTISM SCREENING
- DOES YOUR DOCUMENTATION NEED CODES OR MODIFIERS?
NEW CODE FOR VAPING-RELATED ILLNESS
I've heard that there will soon be a code for reporting vaping-related illness. Is that true?
Yes. A new chapter is being added to ICD-10-CM (the U.S. version of ICD-10) effective April 1, 2020, to match the World Health Organization's addition of a new ICD-10 U-code for vaping-related disorder. The code, U07.0, should be reported for vaping-related disorder with additional codes reported for specific manifestations such as lipoid pneumonia, drug-induced interstitial lung disorder, or acute respiratory distress syndrome. Symptoms such as abdominal pain or diarrhea may also be reported with additional codes. The new code is found in a new chapter of the tabular list of ICD-10-CM: Chapter 22, Codes for Special Purposes. More information is available at https://www.cdc.gov/nchs/icd/icd10cm.htm (see ICD-10 FY2020 April addenda). Current medical record and billing systems may require updates to accommodate the reporting of U07.0.
ULTRASOUND SERVICES IN THE OFFICE
When I provide point-of-care ultrasound services in the office, what codes should I report?
To report codes for ultrasound services, the following requirements must be met:
Conduct a thorough evaluation of the organ(s) or anatomic region specified in the code,
Retain permanent image documentation (film or digital) with measurements (when measurements are clinically indicated),
Report the indications for testing, description of findings for each organ and structure examined, and interpretation of the test in the medical record,
Meet the criteria specified in the code.
CPT includes ultrasound codes for many areas of the body. Here are two examples:
76881, “Ultrasound, complete joint (i.e., joint space and peri-articular soft-tissue structures), real-time with image documentation.”
76882, “Ultrasound, limited, joint or other nonvascular extremity structure(s) (e.g., joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation.”
If you use an ultrasound device that does not create permanent images, the service is considered part of a related E/M service and is not separately billable.
What code should I report for autism screening?
Report CPT code 96110, “Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument,” and ICD-10 code Z13.41, “Encounter for autism screening,” for autism screening using a standardized screening instrument, which is a previously validated test that is administered and scored in a standard manner. Code 96110 may be reported per instrument. For example, if a developmental screening instrument and an autism screening instrument are administered to an 18-month-old patient at a well-child visit, 96110 may be reported twice with diagnoses of Z13.41 and Z13.42, “Encounter for screening for global developmental delays (milestones).”
DOES YOUR DOCUMENTATION NEED CODES OR MODIFIERS?
Our new centralized coding office requires that physicians amend their documentation when the coders add a modifier to the codes that were documented in the medical record. Is this necessary?
No. In fact, there is not even a requirement for the codes to be listed in the documentation of an encounter or service, only for your documentation to support the codes and modifiers submitted on claims. Auditors look at the codes and modifiers used on claims in comparison to the physician's documentation to determine if the codes and modifiers were accurately submitted to the payer. Prior to electronic health records, it was not typical for codes to be included in the patient's medical record. However, the physician is ultimately responsible for the accuracy of codes and modifiers on each claim and may wish to be notified when changes are made to the codes or modifiers assigned.
WE WANT TO HEAR FROM YOU
Send questions and comments to firstname.lastname@example.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.
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