CODING, INSURANCE, AND THIRD-PARTY PAYERS

It is a fact of life that the oral and maxillofacial surgeon must perform complicated surgical procedures, including surgical orthognathic, temporomandibular joint surgeries, cosmetic procedures, and trauma procedures, in addition to extractions, third molar surgery, implants, and other surgical procedures, which make up a practicing scope of oral and maxillofacial surgery. Each and every surgeon would like to perform what they are able to do on any given day and not have to be bothered with the everyday business decisions of practice.

However, there is a business side of practice, which every surgeon needs to become very familiar with to practice efficiently and ethically and to be reimbursed properly for the procedures that they perform. In this chapter, the topics that will be discussed will focus on the parts of practice that will lead to a successful career within the specialty.

CODING

HISTORY OF CODING

It appears that the listing of causes of death in the London Bills of Mortality in the late seventeenth century was the first attempt to determine what different diseases were responsible for death in live births who died by the age of 6. From this early study of deaths, there developed statistical study of all diseases that were linked to the death of a patient. As diagnosis and types of diseases matured over time, with the advances in medicine and science, there was a need to include diseases that, although not fatal, were causes of disability and sickness. This was called the International Lists of the Causes of Death . Since this first listing, there were five revisions of the established list. In 1948, the first World Health Organization (WHO) updated a sixth revision of the list and published it as The International Classification of Diseases (ICD) . Two additional revisions occurred in the 1950s and 1960s. In 1977, ICD-9-CM was published with wide acceptance by the international medical community.

DIAGNOSTIC CODING

A major revision of the ICD Code usually occurs in 10-year cycles and becomes the accepted official code set. However, revisions within the official code set can occur on a yearly basis.

The Centers of Medicare and Medicaid Services (CMS) previous to 2005 allowed a 90-day grace period for practitioners to use revised, deleted, and new codes in the submission of codes for reimbursement for services performed. Now CMS does not allow a grace period, and practitioners are required to use the current codes, which become effective on October 1 of each year.

ICD-9-CM is a numeric code set, which is composed of three to five numerals. The three-digit codes indicate a category of a disease. For example, 524 is that category of dentofacial abnormalities, including malocclusion. The fourth digit is preceded by a decimal point and indicates a subcategory of the section. The code for temporomandibular joint disorders is 524.6. The fifth number is specific for the diagnosed disorder (e.g., 524.63 is articular disk disorder [reducing or nonreducing]).

To find appropriate codes to describe clinical situations, you must use both the alphabetic index and the tabular list found in category 1 of ICD-9-CM. To find the proper diagnostic code, look up the main term of the diagnosis (e.g., a patient who has a right preauricular swelling with a history that the swelling has been present for 5 days and is painful while eating). The clinical diagnosis is parotitis of the parotid gland. The alphabetic index indicates a code of 527 (diseases of the salivary glands). In a tabular list, subcategories of this section indicate specific salivary gland diseases. For sialoadenitis (parotitis), the proper code is 527.2.

Cross-references are listed under the main code, in addition to any exclusion terms that appear with the main code describing the condition.

Any code selected must be supported by proper documentation within the clinical chart.

There has been an initiative carried out by third-party payers to add a significant number of dental ICD-9-CM codes in the past several years. These new diagnostic codes, which impact dentists, are mainly in the 520 to 529 ranges. This is an attempt to be prepared for the possible mandate that all dental claims submitted will require diagnostic codes for submission on the dental claim form. This will also be a mechanism by which the third-party payer may judge that the procedure code submitted is compatible with the diagnostic code for the treatment to be considered for reimbursement.

INTERNATIONAL CLASSIFICATION OF DISEASES—ICD-10

The next revision of the code is ICD-10, which was endorsed by the WHO in 1990 and has been used in some countries since 1994. The United States began studying the Code in 1999 to develop ICD-10-CM. During 2000, there were 23 countries using ICD-10. The U. S. Department of Health and Human Services (HHS) has approved the use of ICD-10 by 2010, unless another date is determined. The date of use will occur when the date is filed in the Federal Register 2 years before implementation.

Other diagnostic code systems, which have been listed as possibilities for the future, are the Systemized Nomenclature of Dentistry (SNODENT) and Systemized Nomenclature of Medicine (SNOMED). SNODENT and SNOMED were both developed by the College of American Pathology as a descriptive code set, which would be used in an electronic chart environment. SNODENT contains 6000+ terms and 4000 codes, which are highly specific as to physical findings that, in many instances, are not related to specific disease processes. For a diagnosis of caries, the dental record would be supplemented with codes defining diabetes, hypertension, or obesity. At the present time, there has been no field testing on use in a clinical situation. The use of the codes is cumbersome and, at the present time, requires a professional individual to input the codes for a complete chart and cannot be easily delegated to a staff individual for input into the chart.

CURRENT PROCEDURAL TERMINOLOGY (CPT)

CPT codes that are used to record specific medical, surgical, and diagnostic procedures are maintained by the American Medical Association under a CPT editorial board. The revisions occur yearly and become effective January 1 of each year.

A CPT code contains five numerals, which are specific for a medical or surgical procedure and are mandated by law to be used in the submission of Medicare and Medicaid medical claims. They are required by most commercial carriers to adjudicate claims that fall under health policies. These codes provide a definition of the specific procedure.

CPT codes are divided into eight sections, including:

Evaluation and management 99201 to 99499
Anesthesiology 00100 to 01999, 99100 to 99140
Surgery 10021 to 69990
Radiology 70010 to 79999
Pathology and laboratory 80048 to 89356
Medicine 90281 to 99199, 99500 to 99602
Category II performance management 001F to 4018F
Category III emerging technology 03T to 0140T

CPT codes are not specialty specific and may be used by any provider. Where indicated the specific code may have a modifier attached to add additional information.

Modifiers for surgical procedures performed by oral and maxillofacial surgeons may include:

  • -22 Unusual procedural services —Use where procedures are greater than usually required to perform the surgery. Usually used when there are complications associated with the procedure. Use of -22 should be carefully considered because the procedures should be significantly unusual and more extensive than normally performed.

  • -23 Unusual anesthesia —Use when a procedure usually performed with local anesthesia must be done under general anesthesia.

  • -47 Anesthesia by surgeon —Use when regional or general anesthesia is provided by the operating surgeon.

  • -50 Bilateral procedures —Use when the same procedure is provided bilaterally. It is not used when “unilateral or bilateral” is stated in the definition of the code. If a code depicts that it is bilateral and is performed only on one side, use the HCPC level II modifier -LT for the left side and -RT for the right side.

  • -51 Multiple procedures —Use when multiple procedures are carried out by the same provider on the same day at the same session. Use to identify surgical procedures performed in combination. The primary procedure is reported, and all subsequent procedures have the -51 modifier appended.

  • -53 Discontinued procedure —Use when a procedure is terminated for various reasons. The modifier is used when the procedure is stopped before the desired result is obtained. It is not used when the procedure is stopped before anesthesia induction.

  • -62 Two surgeons —Use to report two surgeons operating as primary surgeons on the same patient at the same session. It should not be used if one surgeon is operating as an assistant surgeon.

  • -80, -81, or -82 Assistant surgeons —May be used for an assistant surgeon, a minimal assistant surgeon, or when a qualified resident is not available.

Other modifiers are indicated as explanations of specific codes.

For example, an 18-year-old male has been evaluated for a surgical orthognathic defect and was diagnosed as having a vertical maxillary hyperplasia and a skeletal retrognathia. His surgical plan was to include a Le Fort I maxillary osteotomy with intrusion and separated into three parts and a bilateral saggital osteotomy. This was accomplished by surgeon A and an assistant surgeon, surgeon B. The ICD-9-CM codes are 524.01 and 524.04. The surgical reconstruction is coded as 21143 and 21195. Surgeon A submits these codes for reimbursement. Surgeon B submits 21143-80 and 21195-80 as the assistant. The reason the bilateral sagittal osteotomy is not reported with the modifier -50 is because the definition of 21195 contains the word rami, meaning two.

EVALUATION AND MANAGEMENT CODES (E/M)

These codes are probably the most misunderstood of all the codes in CPT and require the documentation of multiple levels of evaluation to be used.

There is a need to establish if the patient is a new patient or an established one. The definition of a new patient is a patient who has not been seen by the physician servicing the patient or by any other physicians within the same practice and in the same specialty for 3 years. An established patient is one who has received services from the physician who is providing services or received services from another physician in the same practice and the same specialty within 3 years.

There is no difference if the patient is seen in the emergency department. E/M services in the emergency department are treated in the same manner, whether a new or established patient.

Levels of Service

There are three to five levels of E/M within each code. The most important levels are medical history, physical examination, and medical decision-making process and are considered the key elements of all the E/M codes. All of the E/M codes carry the requirement to have a chief complaint noted in the documentation of an encounter.

History

The medical history can be classed as problem focused, expanded focused, detailed history, and comprehensive history. Each category has specific subcategories, which have increasing values.

History of Present Illness (HPI)

The HPI includes the location of the signs or symptoms, such as what are the signs of pain or swellings; how significant are the signs; how long have the symptoms been present; what caused the symptoms; what makes it better or worse; and are there any other signs that go along with the presenting signs.

A brief HPI would include from one to three of the above signs. An expanded HPI would include at least four or more signs or symptoms.

A detailed history includes the chief complaint (CC), expanded HPI, a problem-focused system review (a review of the system that contains the CC, such as the head and neck), and pertinent past and family history that applies to the patient’s complaints.

A comprehensive history includes the CC, expanded HPI, pertinent past and family history that applies to the patient’s complaints, and a comprehensive review of systems.

Examination

Examination can be classified as a problem-focused, expanded-focused, detailed, or comprehensive examination.

Examinations can be classified into two types. The first is a single organ system, which is specifically related to the patient’s symptoms and the judgment of the examiner as to the scope of the examination.

The second type of examination is a general multiple system examination, which examines multiple organ or body systems.

CPT classifies the organ systems as:

  • 1.

    Eyes

  • 2.

    Ears, nose, mouth, and throat

  • 3.

    Cardiovascular

  • 4.

    Respiratory

  • 5.

    Gastrointestinal

  • 6.

    Genitourinary

  • 7.

    Musculoskeletal

  • 8.

    Skin

  • 9.

    Neurologic

  • 10.

    Psychiatric

  • 11.

    Hematologic, lymphatic, immunologic

A problem-focused examination includes the area of the chief complaints.

Expanded problem-focused examinations include an examination of the affected area and any other organ systems that may be symptomatic.

A detailed examination includes an extended examination of the symptomatic area and other symptomatic systems.

A comprehensive examination is a complete examination of multiple organ systems.

Medical Decision Making

Decision making deals with three major decision points, which have to be considered to determine the complexity of the decisions. The first is the number of potential diagnoses that could apply, the second deals with the amount and complexity of data necessary for the review, and the third is the risk of complications, morbidity, or mortality.

Each of these classifications can be subclassified into straightforward, low complexity, moderate complexity, and high complexity. Each of these subclassifications can be identified as minimal, limited multiple, or extensive.

There is a difference in the code description between the new or established patients in the requirements for satisfying the conditions of correct coding.

Time

CPT in establishing the E/M codes has included time frames, which should be considered in choosing the correct code. The times include work done before the consult, during the consult, and after the consult. The time frames vary for new patients from 10, 20, 30, or 45 to 60 minutes for codes 99201 to 99205. For established patients, the time frames vary from 5, 10, 15, 25, or 40 minutes for codes 99211 to 99215.

Counseling during Consultations

When consultations or coordination of care are mainly a discussion with the patient or family and occur for a 25-minute time frame, the code used should be 99214. The amount of time should be recorded in the chart, with start and finish times listed in the chart, and 50% of the time documented should be face-to-face counseling.

Emergency Department Evaluations

Only one provider can report an emergency department service on any given encounter. If the emergency room physician reports the emergency encounter using CPT codes 99281 to 99285, the requested oral and maxillofacial consultation should be one of the office or other outpatient visits, new or established patient, codes 99201 to 99205 or 99211 to 99215.

If the oral and maxillofacial surgeon requests a patient to go to a specific emergency department for after-hours evaluation, it should be reported as a new or established patient encounter, office or other outpatient visit, codes 99201 to 99205 or 99211 to 99215.

INPATIENT CONSULTATIONS

Hospital consults have to satisfy certain requirements. The request for the consultation must be documented in the patient’s chart and state the requested consultant and the reason for the consultation. To write in the chart “Refer to Doctor X for evaluation” is not appropriate.

There can be only one consultation per hospital admission. If there is subsequent care, they should be documented using subsequent hospital care (99231 to 99233).

The consultant must report the CC, an HPI, previous medical history as it applies to the CC, and the examination. Also incorporated is any laboratory or radiographic tests that are indicated and the proposed treatment plan with follow-up. There is no distinction made between new or established patients in these cases. In coding for these procedures, the same levels of complexity of the parameters of the codes apply in the same way that they do for other E/M codes.

RADIOGRAPHIC CODING

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Jun 3, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on CODING, INSURANCE, AND THIRD-PARTY PAYERS
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