01/26/16 – You Be the Coder: Know When and How to Use P Modifiers



Question: Why do we need to use P modifiers even when we don’t get paid extra for the designation?


Answer: There is always the risk of adverse reaction when a patient needs anesthesia. The P (physical status) modifiers indicate the patient’s physical status pre-anesthesia, which paints a better picture of the overall encounter. Your choices are as follows:

  • Modifiers P1 (A normal healthy patient) and P2 (A patient with mild systemic disease) indicate minimal to no risk to the patient during the surgery. Generally, most people under the age of 30 will fall into this category.


  • Modifiers P3 (A patient with severe systemic disease) and P4 (A patient with severe systemic disease that is a constant threat to life) indicate a moderate to constant threat to a patient’s life when undergoing surgery.


  • Modifier P5 (A moribund patient who is not expected to survive without the operation) is for patients who are pretty sickly. The surgery could lifesaving or life threatening, but without the surgery, the patient will surely die.


  • Modifier P6 (A declared brain-dead patient whose organs are being removed for donor purposes) indicates a patient who is brain dead but the body is still alive. You’ll typically use P6 for a patient who is receiving anesthesia to harvest organs before the provider removes life support.

Many payers — including traditional Medicare — will not reimburse for P modifiers. Payers might require the modifiers to prove medical necessity for other anesthesia services in certain situations. The patient’s physical status must be documented in the patient’s medical record, regardless of whether you’ll be reimbursed for it. If you are not sure whether the modifier is paid separately, you should include the appropriate P modifier on the claim.




6 compliance trends likely to affect your practice in 2016

Published by DecisionHealth, January 11, 2016, by Marla Durben Hirsch

Your practice faces several compliance challenges this year, with a greater likelihood that you’ll be slammed with enforcement actions on several fronts. Here’s a rundown of what our experts predict you can expect in 2016:


Prediction 1: “Big” data and data analytics will become more important. The government and private payers will rely more on data to judge you and your performance, especially since HHS plans to fast track much of its Medicare reimbursement to value- and quality-based payments by the end of 2016. “It’s [more so now than before] a higher risk if your numbers are out of skew and a downward reimbursement if you don’t comply [with the targets],” warns attorney Brian Flood with Husch Blackwell in Austin, Texas.


In addition, more people will view the data in the Open Payments program to see what payments physicians received from pharmaceutical and medical device manufacturers. “There are so many data points. It’s how the public, the government and the whistleblowers will see you,” adds Flood.


Prediction 2: Federal agencies besides the Office for Civil Rights (OCR) will get in on the privacy and security enforcement action. 2016 won’t see a slowdown of HIPAA enforcement, especially in light of the many breaches in 2015. However, regulators outside of health care — such as the Department of Homeland Security, the Securities and Exchange Commission and Federal Communications Commission — also will try to extend their foothold into the health care compliance realm, much in the way that the Federal Trade Commission (FTC) has, says attorney Michael Kline with Fox Rothschild in Princeton, N.J.


Prediction 3: False Claims Act, kickback and related compliance will remain a front-burner issue. Because the government has enjoyed great success and return on investment in enforcing these actions — about $8 recovered for every dollar spent on the recovery — practices should expect even more activity in this area, particularly with newer business models, warns Flood. “I can’t recall a time it’s been this adverse,” he notes.


While regulators will continue to focus on kickbacks and self-referrals, they also may move into areas such as documentation for medical necessity and national coverage determinations that are hard to comply with, says Mary Nell Cummings, adjunct professor and director, Health Care Compliance Online with the University of Pittsburgh School of Law. “As CMS and its contractors are continually improving their ability to access and evaluate data, this may be an area of low-hanging fruit,” she notes.


Prediction 4: The Department of Justice (DOJ) and OCR will focus more on individual liability. DOJ announced in September, via a document called the Yates memo, that it is shifting its strategy to hold individuals more accountable for an entity’s wrongdoing. It likely will move to make true on that promise. “Many will be indicted under the new Yates theory,” predicts Flood.


OCR also will focus more on individuals who violate HIPAA. “They’re trying to put the fear in smaller entities. A small breach is as important as a big one,” says attorney Elizabeth Litten with Fox Rothschild in Princeton, N.J.


Prediction 5: OCR will examine business associate relationships. OCR’s permanent HIPAA audit program, which was delayed but will be rolled out in 2016, for the first time will scrutinize several business associates. This will increase attention on all business associate relationships. “There will be more focus on how you selected and use a business associate and what due diligence you used,” says Kline. People also will be more careful about reviewing the content of business associate agreements and determining whether one between the parties is needed.


Prediction 6: States will increase enforcement activity. States will pick up their enforcement efforts against providers in the areas where they have authority. For instance, more state attorneys general, empowered to enforce HIPAA thanks to the HITECH Act in 2009, will move into this arena. States also will boost enforcement of consumer fraud laws.




ICD-10: More Specificity Helps You Report COPD

Published on Tue, Dec 12, 2015 by AAPC


You’ll still have 7 choices to consider.


Chronic obstructive pulmonary disease (COPD) is one condition that can complicate surgeries and lead to more intensive work for the anesthesiologist. The good news from a coding perspective is that ICD-10’s options for the condition are very similar to the codes you used under ICD-9.


The seven base COPD codes in ICD-9 were:


  • 490 — Bronchitis, not specified as acute or chronic
  • 491 — Chronic bronchitis
  • 492 — Emphysema
  • 493 — Asthma
  • 494 — Bronshiectasis
  • 495 — Extrinsic allergic alveolitis
  • 496 — Chronic airway obstruction, not elsewhere classified.


ICD-10 versions: Now you’ll turn to the following base codes:


  • J40 — Bronchitis, not specified as acute or chronic
  • J41 — Simple and mucopurulent chronic bronchitis
  • J42 — Unspecified chronic bronchitis
  • J43 — Emphysema
  • J44 — Other chronic obstructive pulmonary disease
  • J45 — Asthma
  • J47 — Bronchiectasis.


Note that while the ICD-9 codes expanded up to five digits, you’ll need to go out to a fifth or even a sixth character for more specificity in ICD-10.


Heads up: Some coding confusion may ensue when a code excludes a complication. If you have a patient that has COPD with a complication of acute bronchitis, you will use J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection), but you will also need J20. – (Acute bronchitis).


‘With all the specificity needed for ICD-10, looking at these respiratory issues shows that we had the specificity needed for ICD-10 in ICD-9,’ says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director of coding operations at Allegheny Health Network in Pittsburgh, Pa. ‘For a many physicians, the transition from one set to the other will be a smooth trans

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