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Reader Questions: Avoid 'Rule-Out' Diagnoses for Outpatients

Rule Out 'Rule-Out' Diagnoses

Question: We had an ED physician transfer a patient to observation with chest pain. While the patient was under observation, our cardiologist determined he had gastroesophageal reflux disease (GERD). I understand that Medicare will  pay for observation under the chest pain diagnosis, but not for GERD. How should I code this appropriately?


North Dakota Subscriber

 
Answer: Since you should code to the highest degree of certainty and it is inappropriate to code "rule-out" diagnoses in the outpatient setting, you should code this as GERD. While it is often necessary to code the symptoms rather than the final diagnosis in order to justify the tests the ED physician performs, you
should only code chest pain as a secondary diagnosis, even though you will not get reimbursed for the observation.

Question: Can a provider choose whether to provide certain nonemergency treatment to a patient based on the amount of reimbursement for the procedure or treatment? For example, if payer A reimburses the procedure above cost and payer B below cost, can the provider choose to treat only those patients who are insured by payer A, and refer payer B patients to other providers?


Louisiana Subscriber

Answer: Probably not - many insurance plans contain provisions that require you to offer their beneficiaries all services that you offer to anyone else. The purpose behind this provision: so providers can't trade a favorable (to the payer) rate for one service with one favorable to themselves, and then not provide the former to their beneficiaries.

The same is true of services that a payer covers with a per diem or some other arrangement. For example, suppose you find that with a new technology, the cost of a certain procedure is far more than it was when you negotiated the agreement for reimbursement with the payer. In such a case, you can't deny that service to the beneficiaries of just that payer. However, for managed-care contract payers, you might bring the reimbursement disparity to their attention and be able to negotiate a better rate.

Most likely, if you ask the payer to allow you to deny that service to its beneficiaries, the insurer will not only say no but also insist more strongly that you provide the service, because you are providing it to the beneficiaries of other payers.

Report Cast for Definitive Care

Question: A patient with a fracture presented in the ED, and the ED physician applied a cast without giving the patient a full course of treatment. Instead, she casted the bone to stabilize it and referred the patient to an orthopedic clinic for a full evaluation. How should I report this?


Arizona Subscriber

Answer: If the physician applies the cast without recommending a full course of treatment, you should report the appropriate code from the 29000-29590 series, because the care qualifies as definitive and therefore isn't included in the fracture treatment code. But if she applies a cast as the restorative treatment (rather than just for temporary protection), the application is rolled into the CPT code for treatment and you shouldn't report it separately.

Experts disagree about exactly what constitutes "restorative" or "definitive" care, so when in doubt, ask yourself whether the emergency department doctor performed all the services a specialist would perform.

Two giveaways from the ED physician that the treatment was definitive:

She scheduled the patient's follow-up care with a nonspecialist, such as a family practitioner (FP) or internist.

She scheduled the patient's follow-up for three to five days after the initial treatment. If the patient can wait that long for care, the initial treatment was most likely definitive.
 
For example, suppose a patient with a broken toe (826.0) presents in the ED, so the care provided is buddy taping. The patient should follow up with his FP in two weeks, so you should report 28510 (Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each).
 
On the other hand, let's say a patient shows up with a severe ankle sprain (845.01) and the physician can't tell whether the bone is broken. The doctor splints the ankle and instructs the patient to see an orthopedist as soon as possible. In this case, you should only report the splinting (29515 or 29590).

Avoid -73 With Sedated Patient

Question: A patient scheduled for an outpatient endoscopic procedure was in the outpatient surgery suite under sedation. But before the doctor took the patient into the endoscopy room, she changed her mind about the procedure, and the physician discharged her. Would it be appropriate to code this cancelled procedure with modifier -73?


Nevada Subscriber


Answer: No, modifier -73 (Discontinued outpatient hospital/ambulatory surgery center [ASC] procedure prior to the administration of anesthesia) wouldn't be appropriate in this case. According to CPT, modifier  -73 requires the physician's decision to cancel the procedure "due to extenuating circumstances or those that may threaten the well-being of the patient." In this situation, the patient herself made the choice to stop the procedure, so you shouldn't report the intended procedure code at all.

And appending modifier -73 to a procedure code indicates that the procedure took place in an outpatient or ambulatory surgery center prior to anesthesia (which CPT defines as general anesthesia), but  this patient was sedated.
 
Tip: Don't be tempted to use modifier -52 (Reduced services) either, because this code also requires physician discretion in the decision.

Best bet: Report an evaluation and management code based on the documentation provided, and add the injections given for the sedation.

Calculate Fully for Lesion Code

Question: How should I determine the total excised diameter when choosing a lesion excision code?


Wyoming Subscriber

Answer: To determine the total excised diameter, calculate the lesion diameter at its widest point, then calculate the width of the margin at its narrowest point. Add these measurements together, and you have the total excised diameter.

For example, suppose the physician excises an irregularly shaped, malignant lesion from a patient's left shoulder. The lesion measures 1.5 cm at its widest. To ensure removal of all malignancy, the physician allows a margin of at least 1.5 cm on all sides. In this case, add the size of the lesion (1.5 cm) and the width of the narrowest margin (1.5 cm top, 1.5 cm bottom) for a total of 4.5 cm. Therefore, the appropriate code is 11606 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm).

Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.