Reimbursement Methodologies – Week 4 Assignment 1

Billing Correctly

This week’s assignment involves the coding of 3 case studies followed by the completion of the bottom portion of the CMS 1500 claim form. This part of the claim form is for your practice in documenting the CPT codes and the ICD-10 codes that meet the requirement for medical necessity. We are going to pretend that the 3 fictitious case studies are being performed in an outpatient surgical facility. Download this fillable CMS 1500 claim form. It is important that you decide which of the CPT codes should be listed first and second. This information is covered for you in both the lecture and in the PowerPoint. While you might not look up the RVUs for every procedure when working as a billing specialist, this is a good foundation activity that will help to instill in you the ability to choose the CPT codes that are the most labor intensive.

Connect the CPT code on a claim form with the ICD-10 code that demonstrates medical necessity.

Please use the information from each case study to complete a separate form. You only need to fill in the following numbered boxes on the claim form.

17 – The physician’s name

21 – The ICD-10 codes (these are the codes that you will indicate by their letters A-L)

24 A - The DOS - Enter eight-digit date with spaces (MM DD YYYY).

24 D – The CPT code and up to four modifiers

24 E – the ICD-10 indicator, which will be the letter of the code in box 21 of the ICD-10 codes that shows medical necessity for each CPT code.

Case Study 1: Dr. Bones

DOS 02-17-2020

A Grade I, high velocity open right femur shaft fracture was incurred when a 15-year-old female pedestrian was hit by a car. She was taken to the operating room within four hours of her injury for thorough irrigation and debridement, including excision of devitalized bone. The patient was then reprepped, redraped, and repositioned. Intramedullary rodding was then carried out with proximal and distal locking screws.

Codes to use:

11012 Intramedullary rod, RVU = 6.87

27506, RVU = 19.65

Modifier -51 needs to be added to your second listed CPT code

ICD-10 = S72.309B

Case Study 2: Dr. Cystspur

DOS 02-15-2020

An elderly female presented with increasing pain in her left dorsal foot. The patient was brought to the operating room, at which time she was placed under general anesthesia. A curvilinear incision was centered over the lesion itself. Soft tissue dissection was carried down through to the ganglion. The ganglion was clearly identified as a gelatinous material. It was excised directly off the bone and sent to pathology. There was noted to be a large bony spur at the level of the 1st metatarsal. Using double action rongeurs, the spur itself was removed and sequestrectomy was performed. Following that, a rasp was utilized to smooth the bone surface. The eburnated bony surface was then covered, utilizing bone wax. The wound was irrigated and closed in layers.

Codes to use:

28122 – RVU = 6.76

28090 - RVU = 4.55

Modifier -51 needs to be added to your second listed CPT code

ICD-10 codes:

M77.32 bone spur

M67.472 ganglion left foot

Case Study 3: Dr. Nodes

DOS 02-16-2020

An operative report lists excisional bilateral biopsies of deep cervical nodes and biopsy of right deep axillary nodes as the procedures performed. The pathology report comes back confirming lymphadenitis.

Codes to Use:

38525-RT axillary – RVU = 6.43

38510 cervical – RVU = 6.74 x 2

Modifier -51 needs to be added to your second listed CPT code

Modifier -50 needs to be added to the bilateral procedure

ICD-10 codes:

L04.9 bilateral Cervical

L04.2 right axillary