2021 ICD-10-CM and ICD-10-PCS CODING HANDBOOK
The handbook's format and style of presentation follows that of previous editions inspired by the Faye Brown approach to coding instruction. The handbook is authored by Nelly Leon-Chisen, RHIA, Director of Coding and Classification at the AHA.
- Fiscal year 2021 code updates, including new information on COVID-19, vaping-related disorder, history of diabetes mellitus or hypertension, immunodeficiency, cytokine release syndrome,cerebrospinal fluid leak, intracranial hypotension, neonatal cerebral infarction, and “chronic stroke”
- Up-to-date guidance on coding signs and symptoms, diseases, disorders, procedures, conditions, complications of care, long-term care, and more
- Reflects the Official Coding Guidelines
- Over 200 chapter-based and final review exercises
- Built-in workbook of case summary exercises
- More than 50 four-color illustrations of anatomy, common disorders, and procedures
"Allergy|Immunology" & "HCPCS Coding" Articles
Click on the title to see the article summary and a link to the full article.
April 12th, 2021
How to Combat COVID-Related Risk Adjustment Losses with the Medicare Annual Wellness Exam
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 12th, 2021
Identifying new ways to encourage Medicare beneficiaries to schedule and attend their Annual Wellness Exam (AWE) can be difficult, but the Open Enrollment period is a prime time for every payer to identify new beneficiaries and provide a reminder to both new and existing patients that this preventive service does ...
April 8th, 2021
58% of Improper Payments due to Medical Necessity for Ventilators
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 8th, 2021
Proper documentation not only protects the provider, the payer, and the patient, it protects the integrity of the entire healthcare system. When it comes to coverage and documentation for durable medical, the DMEPOS supplier and staff must be familiar with the National and Local Coverage Determinations (NCDs and LCDs) as these are ...
March 10th, 2021
COVID-19 Vaccines
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 10th, 2021
To accommodate the new COVID-19 immunizations the CPT editorial panel has approved 11 Category I codes. Watch for new and revised guidelines and parenthetical notes with these codes. For example; which administration codes should be used with the vaccine codes and the NCD codes applicable to the dose being administered. These ...
February 17th, 2021
Why CMS Created G2212 for Prolonged Services Instead of 99417
By Wyn Staheli, Director of Research | Published February 17th, 2021 - Last Review/Update February 22nd, 2021
This article discusses WHY CMS decided to create code G2212 to be used with prolonged office Evaluation and Management (E/M) services instead of code 99417 as of January 1, 2021. The proposed Medicare Physician Fee Schedule stated that code 99417 would be used so it is essential to understand why they made this change to avoid potential problems with billing these services.
February 11th, 2021
2021 Medicare Physician Fee Schedule Updates - Do You Really Need to Worry?
February 3rd, 2021
How To Properly Report Prolonged Services Using 99417 or G2212
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 3rd, 2021
Prolonged Evaluation & Management codes underwent big changes in 2021, including the creation of a new prolonged code (99417), reportable only with codes 99205 or 99215. While Medicare has agreed to accept the AMA's CPT E/M coding changes, they have formulated an opinion contrary to how CPT calculates time specific ...
January 11th, 2021
Good and Bad News Regarding the 2021 Medicare Physician Fee Schedule
By Wyn Staheli, Director of Research | Published January 11th, 2021
When the proposed Medicare Physician Fee Schedule came out last year, it really got everyone worried. In a time where we are all facing issues related to COVID, this seemed like a really big problem. Professional organizations lobbied and everyone tried to stop the proposed changes, and the 10.2% decrease didn’t happen, but other changes will still be taking place. So how bad is it really and how will it affect your organization?
January 11th, 2021
Instructions for Looking up IOM References in innoviHealth's HCPCS Publication
By Wyn Staheli, Director of Research | Published January 11th, 2021
These instructions help owners of innoviHealth's HCPCS Coding for 2021 book access the references to Medicare's Internet-only Manuals (IOMs) which are copies of official program instructions, policies, and procedures that are based on statutes, regulations, guidelines, models, and directives.
January 5th, 2021
CMS Final Rule Changes E/M Reporting Guidelines
By Wyn Staheli, Director of Research | Published January 5th, 2021
Just when we thought we had figured out Evaluation and Management (E/M) reporting for 2021, CMS released their final rule and now we will need to make some adjustments. While CMS stated that they were adopting the AMA guidelines for E/M office or other outpatient services, they did make a few changes.
December 31st, 2020
CMS Final Rule Changes E/M Reporting Guidelines
By Wyn Staheli, Director of Research | Published December 31st, 2020
Just when we thought we had figured out Evaluation and Management (E/M) reporting for 2021, CMS released their final rule and now we will need to make some adjustments. While CMS stated that they were adopting the AMA guidelines for E/M office or other outpatient services, they did make a few changes.
December 8th, 2020
Final Rule on Communications Technology and 2021 Physicians Fee Schedule
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020
To create a healthcare system that will benefit providers as well as Medicare beneficiaries there have been several new rules issued that begin on or after January 01, 2021. CMS released the final policy and payment provisions on December 01, 2020, which includes the physician fee schedule (PFS) for 2021. ...
October 1st, 2020
New Codes for Cytokine Release Syndrome (CRS)
By Wyn Staheli, Director of Research | Published October 1st, 2020 - Last Review/Update October 6th, 2020
New codes for Cytokine Release Syndrome (CRS) are effective October 1, 2020 based on the grade/severity of the symptoms. This article covers the new grading scales.
September 1st, 2020
Not Following the Rules Costs Chiropractor $5 Million
By Wyn Staheli, Director of Research | Published September 1st, 2020
Every healthcare office needs to know and understand the rules that apply to billing services and supplies. What lessons can we learn from the mistakes of others? What if we have made the same mistake?
August 10th, 2020
Coding Injections for Pain Management
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2020
Coding for pain management can get confusing. How many injections, the location, and when to use a modifier are all common questions. This article will cover some of the most common injections used in pain management.
Trigger Point Injections
Trigger point injections are reported by how many muscles are treated using an ...
June 29th, 2020
HCPCS Codes Were NOT all Created for the Same Purpose
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 29th, 2020
Have you ever wondered why you were unable to find a particular product/code with our DMEPOS search? When looking for HCPCS Level II codes, there are several kinds of codes and not all HCPCS codes were created for the same purpose. If you are searching for a certain HCPCS product ...
June 1st, 2020
Additional Practice Reopening Tips
By Wyn Staheli, Director of Research | Published June 1st, 2020
As practices begin reopening across the nation, there are several things that need to be considered. Policies and Procedures Manuals need to be updated, malpractice carriers need to be contacted and everyone needs to consider mental health screenings and support.
May 18th, 2020
Packaging and Units for Billing Drugs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 18th, 2020
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number.
Take a look at the following
J1071 - Injection, testosterone cypionate, 1mg
For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL
(100 mg/mL = 1 mL and there are ...
April 21st, 2020
Special COVID Laboratory Specimen Coding Information
By Wyn Staheli, Director of Research | Published April 21st, 2020
With all the new laboratory test codes that have been added due to the current public health emergency (PHE), there are a few additional guidelines CMS has released about collecting samples to perform the testing. Please keep in mind that these guidelines are by CMS and may or may not apply to other commercial payer policies.
April 20th, 2020
Emergency Room and Ancillary Services
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2020
Billing for an Emergency department is not the same as billing for a hospital or in the provider's office; there are several differences and requirements. For example. the hospital will report a stay with Diagnosis Related Groups (DRG's), which include hospital resources used during the patient's stay, while office visits ...
April 15th, 2020
Medicare Released the Amount they Will pay for COVID Testing Eff 4/14/2020
April 2nd, 2020
More Telehealth Changes Announced by CMS
By Wyn Staheli, Director of Research | Published April 2nd, 2020
On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). See this article for further information as well as references & links to CMS information
March 30th, 2020
Providing Telehealth Services During COVID-19 Crisis
By Wyn Staheli, Director of Research | Published March 30th, 2020
The rules for providing telehealth services during this pandemic have changed and some requirements have been waived. Please keep in mind that “waiving requirements” does not mean that anything goes. Another important consideration is that Medicare and private payers may likely have different rules so you need to make sure that you know individual payer requirements during this time.
March 26th, 2020
LATEST COVID-19 INFORMATION FOR BILLING NON-FACE-TO-FACE SERVICES
By Namas | Published March 26th, 2020
Healthcare providers and the population at large are concerned about safe access to care considering the COVID-19 pandemic. As a result, we have received many inquiries this week about how to bill for “telehealth” services.
Let’s first address that true telehealth services have some pretty stringent requirements from CMS, including that ...
March 21st, 2020
Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2020
The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...
March 20th, 2020
Implementing Telehealth Visits
By Namas | Published March 20th, 2020 - Last Review/Update March 23rd, 2020
The following is a step-by-step guide on how to convert office-based encounters to telehealth encounters during the current COVID-19 pandemic. These rules may change post-pandemic, as many changes relaxing existing rules were made on a temporary basis by CMS and commercial payers to facilitate patient access and minimize risk of infection.
Step ...
March 17th, 2020
Additional Coronavirus Testing Code Announced
By Wyn Staheli, Director of Research | Published March 17th, 2020
On March 13, 2020, a new CPT code was announced by the American Medical Association (AMA) who maintains the CPT code set. This early release of a CPT code is rare and is effective immediately.
February 20th, 2020
New HCPCS Code for Coronavirus Testing Announced
By Wyn Staheli, Director of Research | Published February 20th, 2020 - Last Review/Update February 26th, 2020
Currently, healthcare providers testing patients for Coronavirus must use an unspecified code. To provide better tracking, on February 13, 2020, CMS announced the creation of a new HCPCS code.
December 30th, 2019
Medicare Changes Bilateral Reporting Rules for Certain Supplies
By Wyn Staheli, Director of Research | Published December 30th, 2019 - Last Review/Update January 6th, 2020
DME suppliers must bill bilateral supplies with modifiers RT and LT on separate claim lines or they are being rejected.
December 19th, 2019
Reporting the Health Effects of Vaping Now and in April 2020
By Wyn Staheli, Director of Research | Published December 19th, 2019
To report vaping related conditions/disorders, use the official CDC guidelines to ensure proper documentation of vaping related health conditions. There is also a new code that will become effective April 1, 2020.
September 30th, 2019
Vaccine Administration - When The Right Vaccine Code is Not Enough
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 30th, 2019
Understanding how to apply immunization administration codes properly will support correct reimbursement for vaccinations. Reporting the right vaccine code alone is not enough to guarantee proper billing. The majority of the time, providers can charge for the vaccine/product as well as the administration of the vaccine; always consult your payer ...
August 16th, 2019
Medical ID Theft
By Namas | Published August 16th, 2019 - Last Review/Update August 20th, 2019
Medical ID Theft
"So, do you guys think you can do something with that?" John asked angrily at our first meeting with him in August 2017 as he slammed a stack of medical bills, EOBs and collection letters - three inches high - down in front of my partner and I. ...
August 13th, 2019
Healthcare Common Procedure Coding System (HCPCS)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 13th, 2019
There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...
August 13th, 2019
Q/A: I Billed 2 Units of L3020 and Claim was Denied. Why?
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published August 13th, 2019
Question:
We billed 2 units of L3020 but were denied for not using the right modifiers. What should we do?
Answer:
Rather than submitting two units of the L3020 to indicate that the patient one orthotic for each foot, you would need to use modifiers identifying left foot and right foot. Appropriate coding ...
August 9th, 2019
The OIG Work Plan: What Is It and Why Should I Care?
By Namas | Published August 9th, 2019 - Last Review/Update August 14th, 2019
The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...
August 6th, 2019
CMS Proposes to Reverse E/M Stance to Align with AMA Revisions
By Wyn Staheli, Director of Research | Published August 6th, 2019
On July 29, 2019, CMS released their proposed rule for the Medicare Physician Fee Schedule for 2020. Last year’s final rule “finalized the assignment of a single payment rate for levels 2 through 4 office/outpatient E/M visits beginning in CY 2021.” It also changed some of the documentation requirements (e.g., ...
July 15th, 2019
Denial Management is Key to Profitability
July 12th, 2019
5 Ways to Minimize HIPAA Liabilities
By BC Advantage | Published July 12th, 2019 - Last Review/Update July 30th, 2019
Last year was historic for HIPAA enforcement. The HHS Office of Civil Rights collected a record $23.5 million in settlements and judgments against providers guilty of HIPAA violations. To avoid becoming part of that unwanted statistic, it’s important to pay extra close attention to five key areas of HIPAA vulnerability.
Take ...
July 9th, 2019
When Can You Bill Orthosis Components Separately?
By Wyn Staheli, Director of Research | Published July 9th, 2019
Othoses often have extra components. When can you bill those components separately? For example, can you bill for a suspension sleeve (L2397) with a knee orthosis (e.g., L1810)?
July 8th, 2019
Will the New Low Level Laser Therapy Code Solve Your Billing Issues?
By Wyn Staheli, Director of Research | Published July 8th, 2019
Low level laser therapy (LLLT), also known as cold laser therapy, is a form of phototherapy which uses a device that produces laser beam wavelengths, typically between 600 and 1000 nm and watts from 5–500 milliwatts (mW). It is often used to treat the following:
Inflammatory conditions (e.g., Rheumatoid Arthritis, Carpal ...
July 1st, 2019
Q/A: Do I Really Need to Have an Interpreter?
By Wyn Staheli, Director of Research | Published July 1st, 2019
Question:
I heard that I need to have an interpreter if someone who only speaks Spanish comes into my office. Is this really true?
Answer:
Yes! There are both state and federal laws that need to be considered. The applicable federal laws are:
Title VI of the Civil Rights Act of 1964,
Americans with Disabilities ...
June 18th, 2019
How to Properly Report Monitoring Patients Taking Blood-thinning Medications
By Wyn Staheli, Director of Research | Published June 18th, 2019 - Last Review/Update June 19th, 2019
Codes 93792 and 93792, which were added effective January 1, 2019, have specific guidelines that need to be followed. This article provides some guidance and tips on properly reporting these services.
June 13th, 2019
Medicare Approves Reimbursement for Virtual Communication (G2012)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Medicare has taken a stand to recognize communication technology-based services by approving two newly defined physicians' services that will significantly help providers who deal with phone calls and patient triage. One of these services includes:
Virtual check-in (G2012), which allows the provider to be reimbursed for communicating with the patient via ...
June 13th, 2019
Medicare Now Reimburses for Remote Monitoring Services (G2010)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Medicare's 2019 Final Rule approved HCPCS code G2010 for reimbursement, which allows providers to be paid for remote evaluation of images or recorded video submitted to the provider (also known as "store and forward") to establish whether or not a visit is required. This allows providers to get paid for ...
May 13th, 2019
Electrical Stimulation and Electromagnetic Therapy Devices
By Raquel Shumway | Published May 13th, 2019 - Last Review/Update May 20th, 2019
Electrical Stimulation and Electromagnetic Therapy Devices can be used for pain, muscle atrophy, help spinal cord injuries, treat symptoms caused by other medical conditions and can be used in the treatment of wounds. This Regence BC/BS article lists codes and devices and gives guidance on coding from Medicare Advantage viewpoint.
May 8th, 2019
Facts on Procedure Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 8th, 2019
There are two levels of codes used for services and procedures:
Level I Codes are used for Services and Procedures provided by physicians.
5 digit numerical code, example, 99213 - Office or other outpatient visits
Level II Codes are used to bill Medical equipment supplies and transport services.
4 digit Alpha/Numerical code example, ...
April 24th, 2019
Biofeedback - Is it Medically Necessary?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 24th, 2019
Biofeedback is used for many reasons, and most commonly used for pain management. Each payer should be consulted with to verify coverage when treating with Biofeedback to verify if the treatment is considered experimental or investigational.
The majority of payers will list Biofeedback on an exclusions list. Others such as BC ...
April 1st, 2019
Spinal Cord Stimulator Used for Chronic Pain
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 1st, 2019
Chronic pain is a condition that can be diagnosed on its own or diagnosed as a part of another condition. When coding chronic pain, there is no time frame defining when pain becomes chronic pain; the provider’s documentation should be used to guide the use of these codes.
ICD-10-CM Diagnosis Codes ...
April 1st, 2019
Corrections and Updates
By Wyn Staheli, Director of Research | Published April 1st, 2019 - Last Review/Update April 2nd, 2019
One constant in our industry is change. Policies change, contracts change, and there are updates. Also, people aren’t perfect and mistakes can be made. So this article will cover a variety of topics.
Published Articles
We appreciate feedback from our valued customers. We have received feedback regarding two of our articles which ...
March 11th, 2019
Spotlight: Services Excluded from Global Surgery Payment
By Brittney Murdock, QCC, CMCS, CPC | Published March 11th, 2019
The following services are excluded from global surgery payment according to Noridian Medicare. These services may be paid for separately. The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial...
March 4th, 2019
Billing Guidelines for Repositioning
By Wyn Staheli, Director of Research | Published March 4th, 2019 - Last Review/Update March 6th, 2019
Code 95992 has some very limited payer payment guidelines which need to be understood for proper reimbursement. Many payer policies consider this service bundled with Evaluation and Management Services, therefore, it would not be separately payable if there was an E/M service performed on the same date. Some providers have reported having trouble ...
March 4th, 2019
UnitedHealthcare to Discontinue Coverage of Consultations
By Wyn Staheli, Director of Research | Published March 4th, 2019 - Last Review/Update March 7th, 2019
In United Healthcare's March provider bulletin, they announced that beginning on June 1, 2019, they will be phasing out coverage of consultation services (99241-99255).
February 12th, 2019
Coding Medicare Initial Preventive Physical Exams (IPPE)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 12th, 2019
The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward.
Purpose
An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...
February 1st, 2019
Physical Therapy Caps Q/A
By Wyn Staheli, Director of Research | Published February 1st, 2019 - Last Review/Update February 4th, 2019
Question: How do I code it so that PT services in a chiropractic office don’t count against their PT visit max? Is there a way to code claims so that they are considered chiropractic only? But still get compensated enough? We have been running into some issues as of late ...
January 24th, 2019
Q/A: Which Code Should I Use for a Lab Interpretation Fee?
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published January 24th, 2019 - Last Review/Update February 4th, 2019
Question
Which code should I use for a lab interpretation fee? Specifically, I have ordered a female hormone saliva test, and would like to charge a fee for time spent on the interpretation and consult.
Answer
This type of service generally does not involve a third party, so it may be acceptable to ...
January 23rd, 2019
Everything You need to Know about Drugs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 23rd, 2019
We have it all! Search our WK Drug Database for drugs and pharmaceuticals. When it comes to support and guidance the WK Drug Database offers a paramount search and is conveniently presented in one place.
Pricing
GPIs
NDCs
Billing Codes
Indications/Diseases
Packaging Information
Active and Inactive
and more...
Additionally, learn more about drugs and pharmaceuticals that can be used to detect, treat, or monitor ...
January 22nd, 2019
Home Oxygen Therapy
January 14th, 2019
What is Virtual Communication (G0071)?
By NAMAS | Published January 14th, 2019 - Last Review/Update January 16th, 2019
Beginning January 1st, 2019 all of our RHC and FQHC organizations have a new CPT code to
consider implementing for their Medicare populous (check per Advantage Plan Administration for coverage). In its current form, this code is not reportable by organizations not meeting the RHC/FQHC designation.
The code isG0071 and is termed ...
January 14th, 2019
Q/A: Is G8730 Still Required? Are G Codes Required at all?
By Wyn Staheli, Director of Research | Published January 14th, 2019 - Last Review/Update January 21st, 2019
G8730, when is it required. Many G codes are still active and are required for non-quality reporting.
January 4th, 2019
Nine New Codes for Fine Needle Aspirations (FNA) in 2019
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 4th, 2019
If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...
January 3rd, 2019
2019 Coding Changes for Chiropractic
By Wyn Staheli, Director of Research | Published January 3rd, 2019
The new year is upon us and so it’s time to double check and make sure we are ready. Those with Premium Membership can use the ChiroCode Online Library and search all the official code sets: ICD-10-CM, CPT, and HCPCS. It also includes the updated NCCI edits and RVUs for ...
November 29th, 2018
Billing Exercise Equipment
By Wyn Staheli, Director of Research | Published November 29th, 2018
While equipment for home strengthening is arguably good for the patient and the prognosis of their condition(s), payers have very strict guidelines as to what is considered medically necessary when it comes to Durable Medical Equipment (DME). While I have seen some workers compensation policies which do pay for DME ...
November 26th, 2018
Allergy Immunotherapy Coding Guidelines (CMS) Effective: 01/01/2006
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 26th, 2018
Immunotherapy (Allergy Shots) is a medical treatment to used to treat and prevent reactions or desensitize the immune system to specific allergens that trigger allergy symptoms. Payers have specific coverage guidance and rules for reporting injections, the specific type of antigen(s) provided and how they should be reported.
Below are the coding guidelines from ...
November 7th, 2018
Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
By Wyn Staheli, Director of Research | Published November 7th, 2018
The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...
November 7th, 2018
Medi-Cal Coverage Criteria for Hospital Beds and Accessories
By Raquel Shumway | Published November 7th, 2018
Medi-Cal coverage of child and adult hospital beds and accessaries. What is covered and what documentation is required.
October 30th, 2018
Documentation Requirements for Allergy Testing 10/29/2018
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 30th, 2018
Per CMS, First Coast Service Options LCD 33261:
Medical record documentation (e.g., history & physical, office/progress notes, procedure report, test results) must include the following information, and be available upon request:
A complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient.
The medical necessity for performing ...
October 30th, 2018
Common Allergy CPT Codes and MUEs
By Find-A-Code™ | Published October 30th, 2018
Below is a list of common CPT codes for Allergy and Immunology. Each code is listed with the following information:
Medicare Unlikely Edits (MUEs) for both a Non-Facility (NF) and Facility (F) setting.
Professional/Technical Component (PC/TC) Indicator.
Key Indicator or Procedure Code Status Indicator, which is a Medicare assigned "Indicator" to each code in ...
October 29th, 2018
Allergy Testing 10/29/2018
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 29th, 2018
Allergy testing may be performed due to exaggerated sensitivity or hypersensitivity. Using findings based on the patient’s complaint and face-to-face exam. Testing may be required to identify and determine a patient's immunologic sensitivity or reaction to certain allergens using certain CPT codes.
According to CMS, LCD 33261, allergy testing can be ...
October 17th, 2018
Wolters Kluwer Drug Pricing
By Find-A-Code | Published October 17th, 2018
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
October 16th, 2018
Pelvic Floor Dysfunction Treatment Coverage
By Wyn Staheli, Director of Research | Published October 16th, 2018
Pelvic floor dysfunction is often the underlying cause of conditions such as pelvic pain; urinary or bowel dysfunction; and/or sexual symptoms. Treatment generally begins with an evaluation and testing (e.g, EMG) followed by a variety of services (e.g., biofeedback, manipulation, pelvic floor electrical stimulation), depending on the findings.
Coverage by payers ...
August 30th, 2018
Keys to Successful Claims Filing
By Noridian Medicare | Published August 30th, 2018
There are many factors that can contribute to your success in filing claims and getting reimbursed. The information below is from the CMS website.
Completing Item 12, Patient's or Authorized Person's Signature, on the CMS-1500 form for a non-assigned claim
A signature on file (SOF) indicates the supplier has obtained the beneficiary's one-time authorization on ...
August 16th, 2018
Importance of Depression Screenings
By Wyn Staheli, Director of Research | Published August 16th, 2018
Why would a chiropractor be concerned about depression screenings when you aren’t trained to be a mental health provider? The answer lies in patient outcomes. Many quality care organizations recommend depression screenings for patients with a chronic condition. According to The National Institute of Mental Health, “People with other chronic ...
August 16th, 2018
Using Modifiers 96 and 97
By Wyn Staheli, Director of Research | Published August 16th, 2018
The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. ...
July 25th, 2018
Q/A: Can I Bill Spinal Decompression Table to Insurance?
By Wyn Staheli, Director of Research | Published July 25th, 2018 - Last Review/Update January 28th, 2019
Are visits when a Chiropractor just uses a spinal decompression table billable to insurance? If so, what code is recommended?
July 9th, 2018
Documentation: Face to Face for Home Health Certification
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2018
As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. The ...
June 14th, 2018
Home Oxygen Therapy -- CMN for Oxygen
By Raquel Shumway | Published June 14th, 2018
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.
June 11th, 2018
Inappropriate Use of Units Costs Practice Over $800,000
By Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | Published June 11th, 2018
A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut improperly submitted multiple units for drug screening urine tests. The proper billing of units has proven to be problematic for more than just lab tests. Is your billing of drugs & biologicals, injections and timed codes appropriate?
June 4th, 2018
How Many Modalities Are Too Many?
By Dr Evan Gwilliam, Clinical Director for PayDC chiropractic EHR software | Published June 4th, 2018 - Last Review/Update January 30th, 2019
Q: I have a payor who is denying modalities, claiming that they are “excessive”. At a single encounter I billed for:
98940- Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
97110- Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
G0283- Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
97010- Application of a modality to 1 or more areas; hot or cold packs
Is this excessive? How do I know how much is too much?
May 30th, 2018
EM Code Changes in CPT 2018
By Amy C. Pritchett, BSHA, CCS, CPC, CPMA, CPC-I, CEDO, CANPC, CASCC, CEDC, CRC, ICDCT-CM/PCS | Published May 30th, 2018 - Last Review/Update June 4th, 2018
It is that time of year again! The time to throw out the old and bring in the new. With the release of the CPT 2018 updates, we will see major changes in coding throughout the E/M section.
May 9th, 2018
Preventive Medicine: General Procedures
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update July 30th, 2018
Preventive Medicine Topics Page
General Procedures
Procedure Codes 36415: Collection of venous blood by venipuncture 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) 90472: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List ...
May 9th, 2018
Preventive Medicine: Alcohol Misuse Screening & Counseling
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update July 30th, 2018
Preventive Medicine Topics Page
// Alcohol Misuse Screening and Counseling
Procedure Codes G0442: Annual alcohol misuse screening, 15 minutes G0443: Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes 99408: Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to ...
May 9th, 2018
Preventive Medicine: Annual Wellness Visit
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Annual Wellness Visit
Procedure Codes G0438: Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit G0439: Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit 99385: Initial comprehensive preventive medicine evaluation and management of an individual including ...
May 9th, 2018
Preventive Medicine: Bone Mass Measurements
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Bone Mass Measurements
Procedure Codes G0130: Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) 76977: Ultrasound bone density measurement and interpretation, peripheral site(s), any method 77078: Computed tomography, bone mineral density study, 1 or more ...
May 9th, 2018
Preventive Medicine: Breastfeeding Supplies
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Breastfeeding Supplies
Procedure Codes A4286: Locking ring for breast pump, replacement E0602: Breast pump, manual, any type E0603: Breast pump, electric (ac and/or dc), any type E0604: Breast pump, hospital grade, electric (ac and / or dc), any type S9443: Lactation classes, non-physician provider, per session
ICD-10-CM ...
May 9th, 2018
Preventive Medicine: Colorectal Cancer Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Colorectal Cancer Screening
Procedure Codes G0104: Colorectal cancer screening; flexible sigmoidoscopy G0105: Colorectal cancer screening; colonoscopy on individual at high risk G0106: Colorectal cancer screening; screening sigmoidoscopy, barium enema G0121: Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0122: Colorectal cancer screening; barium ...
May 9th, 2018
Preventive Medicine: Contraceptive Methods
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Contraceptive Methods
Procedure Codes A4261: Cervical cap for contraceptive use A4266: Diaphragm for contraceptive use A4264: Permanent implantable contraceptive intratubal occlusion device(s) and delivery system J7300: Intrauterine copper contraceptive J7301: Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg J7303: Contraceptive supply, hormone containing vaginal ring, each J7304: ...
May 9th, 2018
Preventive Medicine: Counseling to Prevent Tobacco Use
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Counseling to Prevent Tobacco Use
Procedure Codes 99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
ICD-10-CM 99406-99407: No specific diagnoses
Frequency 99406-99407: 2 attempts a year, ...
May 9th, 2018
Preventive Medicine: Depression Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Depression Screening
Procedure Codes G0444: Annual depression screening, 15 minutes 96127: Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
ICD-10-CM G0444, 96127: No specific diagnoses
Frequency G0444:Once annually 96127: No specific frequency guidelines
Additional Information 96127
Only covered for ages ...
May 9th, 2018
Preventive Medicine: Diabetes Self-Management Training
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Diabetes Self-Management Training
Procedure Codes G0108: DSMT, individual, per 30 minutes G0109: GDSMT, group (2 or more), per 30 minutes
ICD-10-CM G0108-G0109: Contact payer for more specific guidelines
Frequency G0108-G0109
Initial year: Up to 10 hours of initial training within a continuous 12-month period
Subsequent years: Up to 2 ...
May 9th, 2018
Preventive Medicine: Glaucoma Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Glaucoma Screening
Procedure Codes G0117: Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist G0118: Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist
ICD-10-CM G0117-G0118: Z13.5
Frequency G0117-G0118: Once a year
Additional information G0117-G0118
Coverage as is indicated with ...
May 9th, 2018
Preventive Medicine: Hepatitis B Virus (HBV) Vaccine and Administration
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Hepatitis B Virus (HBV) Vaccine and Administration
Procedure Codes G0010: Administration of hepatitis b vaccine 90739: Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use 90740: Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use 90743: Hepatitis ...
May 9th, 2018
Preventive Medicine: Hepatitis C Virus (HCV) Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Hepatitis C Virus (HCV) Screening
Procedure Codes G0472: Hepatitis c antibody screening, for individual at high risk and other covered indication(s) 87522: Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed 86804: Hepatitis C antibody; confirmatory test (eg, ...
May 9th, 2018
Preventive Medicine: Human Immunodeficiency Virus (HIV) Screening
By Brandon Herman, QMC, QMCC, QMBHC, QMPM, QMPoC | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Human Immunodeficiency Virus (HIV) Screening
Procedure Codes G0432: Infectious agent antibody detection by enzyme immunoassay (eia) technique, hiv-1 and/or hiv-2, screening G0433: Infectious agent antibody detection by enzyme-linked immunosorbent assay (elisa) technique, hiv-1 and/or hiv-2, screening G0435: Infectious agent antibody detection by rapid antibody test, hiv-1 ...
May 9th, 2018
Preventive Medicine: Influenza Virus Vaccine and Administration
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Influenza Virus Vaccine and Administration
Procedure Codes Q2034: Influenza virus vaccine, split virus, for intramuscular use (agriflu) Q2035: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (afluria) Q2036: Influenza virus vaccine, split virus, when administered to individuals ...
May 9th, 2018
Preventive Medicine: Initial Preventive Physical Examination
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Initial Preventive Physical Examination (Medicare Only)
Procedure Codes G0402: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment G0403: Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation ...
May 9th, 2018
Preventive Medicine: Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity Prevention
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity Prevention
Procedure Codes G0270: Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, ...
May 9th, 2018
Preventive Medicine: Lung Cancer Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Lung Cancer Screening
Procedure Codes G0296: Counseling visit to discuss need for lung cancer screening (ldct) using low dose ct scan (service is for eligibility determination and shared decision making) G0297: Low dose ct scan (ldct) for lung cancer screening S8092: Electron beam computed tomography (also ...
May 9th, 2018
Preventive Medicine: Newborn Screenings/Tests
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Newborn Screenings/Tests
Procedure Codes 82775: Galactose-1-phosphate uridyl transferase; quantitative 83498: Hydroxyprogesterone, 17-d 82017: Acylcarnitines; quantitative, each specimen 82136: Amino acids, 2 to 5 amino acids, quantitative, each specimen 82261: Biotinidase, each specimen 83020: Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) 83021: Hemoglobin ...
May 9th, 2018
Preventive Medicine: Pneumococcal Vaccine and Administration
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Pneumococcal Vaccine and Administration
Procedure Codes G0009: Administration of pneumococcal vaccine 90670: Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use 90732: Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
ICD-10-CM G0009, ...
May 9th, 2018
Preventive Medicine: Prostate Cancer Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Prostate Cancer Screening
Procedure Codes G0102: Prostate cancer screening; digital rectal examination G0103: Prostate cancer screening; prostate specific antigen test (PSA)
ICD-10-CM G0102-G0103: Z12.5
Frequency G0102-G0103: Once annually
Additional Information G0102-G0103
Only for males aged 50 and older
G0102
Copayment and deductible may apply, consult your payer
Find-A-Code™ - Preventive Services - ...
May 9th, 2018
Preventive Medicine: Screening for STIs & HIBC to Prevent STIs
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Screening for STIs and High Intensity Behavioral Counseling (HIBC) to Prevent STIs
Procedure Codes 86592: Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) 86593: Syphilis test, non-treponemal antibody; quantitative 86631: Antibody; Chlamydia 86632: Antibody; Chlamydia, IgM 86780: Antibody; Treponema pallidum 87110: Culture, chlamydia, any source ...
May 9th, 2018
Preventive Medicine: Screening Pap Tests
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Screening Pap Tests
Procedure Codes G0123: Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision G0124: Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation ...
May 9th, 2018
Preventive Medicine: Screening Gynecological Examination
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Screening Gynecological Examination
Procedure Codes G0101: Cervical or vaginal cancer screening; pelvic and clinical breast examination S0610: Annual gynecological examination; clinical breast examination without pelvic evaluation S0612: Annual gynecological examination, established patient S0613: Annual gynecological examination, new patient
ICD-10-CM G0101:Low risk patients - Z01.411, Z01.419, Z12.4, Z12.72, ...
April 26th, 2018
Documenting DMEs
By Find-A-Code | Published April 26th, 2018
As per MLN MM8304,
This article is based on Change Request (CR) 8304, which instructs DME MACs to implement requirements, which are effective July 1, 2013, for detailed written orders for face-to-face encounters conducted by the physician, PA, NP or CNS for certain DME items as defined in 42 CFR 410.38(g).
Due to concerns ...
April 19th, 2018
Coverage Criteria for Nonwearable Automatic Defibrillators
By Find-A-Code | Published April 19th, 2018
According to Noridian and CGS Administrators LCD L33690, a nonwearable automatic defibrillator (E0617) is covered for beneficiaries in two circumstances. They meet either (1) both criteria A and B or (2) criteria C, described below:
The beneficiary has one of the following conditions (1-8):A documented episode of cardiac arrest due to ventricular fibrillation, not due to a ...
April 16th, 2018
Indications for Serotypes A and B Botulinum Toxins
By Find-A-Code | Published April 16th, 2018
According to Novitas LCD L27476, the following indications apply:
1. Blepharospasm and strabismus2. Spastic dystonia or focal dystonias to relieve pain, to assist posturing and walking, to increase range of motion, to assist in the outcome of physical therapy, and/or to reduce spasm thus allowing adequate perineal hygiene.3. Spasmodic dysphonia4. Achalasia and cardiospasm when ...
April 12th, 2018
Billing Nutrition Counseling in a Chiropractic Setting
By Wyn Staheli, Director of Research | Published April 12th, 2018
Billing nutrition counseling services may not be as straight-forward as you might think. Some providers mistakenly choose Medical Nutrition Therapy (MNT) codes (97802-97804, G0270, G0271) because it states nutrition therapy in the title. However, according to CPT guidelines, when MNT assessment and/or intervention is performed by a physician or qualified healthcare professional ...
April 12th, 2018
Billing Nutrition Counseling
By Wyn Staheli, Director of Research | Published April 12th, 2018
Billing nutrition counseling services may not be as straight-forward as you might think. Some providers mistakenly choose Medical Nutrition Therapy (MNT) codes (97802-97804, G0270, G0271) because it states nutrition therapy in the title. However, according to CPT guidelines, when MNT assessment and/or intervention is performed by a physician or qualified healthcare professional who may report evaluation and management ...
April 9th, 2018
Coverage Criteria for Peripheral Venous Examinations
By Find-A-Code | Published April 9th, 2018
According to National Government Services LCD L33627, indications for venous examinations are separated into three major categories: deep vein thrombosis (DVT), chronic venous insufficiency, and vein mapping. Studies are medically necessary only if the patient is a candidate for anticoagulation, thrombolysis or invasive therapeutic procedure(s).
Since the signs and symptoms of ...
March 29th, 2018
Medicare Telemedicine Changes for 2018
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 29th, 2018
Find-A-Code presented a webinar on “Coding and Auditing Telemedicine Services,” on March 29, 2018, which did not include the new and updated CMS information published in the MNL Matters Number: MM10393 on January 2, 2018. New and exciting changes were introduced in this article, which is addressed below.
Originating Site Fee
Each ...
March 27th, 2018
Home Oxygen Therapy -- A Face-to-Face Encounter
By Raquel Shumway | Published March 27th, 2018 - Last Review/Update June 14th, 2018
What is required for a Home Oxygen Therapy, Face-to-Face Encounter.
March 9th, 2018
Documentation for Negative Pressure Wound Therapy
By Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for negative pressure wound therapy.
March 9th, 2018
Documentation for Surgical Dressings
By Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for surgical dressings.
March 9th, 2018
Documentation for Urological Supplies
By Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for urological supplies.
March 9th, 2018
Documentation for Enteral Nutrition
By Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for enteral nutrition. ...
March 8th, 2018
Documentation for Home Blood Glucose Monitors (BGM)
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 14th, 2018
The Medicare Learning Network provides guidance on how to Prevent Denials for Home Blood Glucose Monitors (BGM)...
March 8th, 2018
Documentation for Therapeutic CGMs and Related Supplies
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 14th, 2018
The Medicare Learning Network, provides coverage guidance on therapeutic CGMs and Related Supplies
March 8th, 2018
Documentation for Manual Wheelchairs
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning network provides guidance on how to prevent denials for Manual Wheelchair Bases....
March 8th, 2018
Documentation for Lower Limb Prosthesis
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them:
For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation.
For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s ...
March 8th, 2018
Documentation for Power Tilt/Recline Seating Systems for Wheelchairs
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides coverage guidance for Power Tilt and/or Recline Seating Systems...
March 8th, 2018
Documentation for Ostomy Supplies
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides guidance on essential documentation elements required to prevent denials for ostomy supplies....
March 8th, 2018
Documentation and Orders for Respiratory Assistive Device
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for a respiratory assistive device and ordering guidelines.
February 28th, 2018
Telemedicine Billing and Reimbursement
By Jared Staheli | Published February 28th, 2018
The opportunities for providers who want to provide telemedicine continue to expand in all sectors of the healthcare market. Even the VA, long a symbol of a fossilized, bureaucratic healthcare entity, has begun to embrace this technology. Though most are familiar with what telemedicine is, many still have questions surrounding ...
February 26th, 2018
Medicare Changes Requirements for Implantable Cardioverter Defibrillators (ICDs)
By Wyn Staheli, Director of Research | Published February 26th, 2018
Whenever there is a high-cost item, CMS has historically evaluated usage to determine appropriateness of billing and this is another example. A Decision Memo was released on February 15, 2018 which included the following changes:
Changes to who qualifies for a device and the required waiting periods
Patient registry no longer required
Cardiac magnetic resonance ...
February 21st, 2018
No HCPCS Code Available? Now What?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 21st, 2018
HCPCS level II codes classify products into categories for the purpose of claims processing. HCPCS level II codes are alphanumeric with a descriptive terminology that identifies the item or service used primarily for billing purposes.
There are several types of HCPCS level II codes such as:
Permanent National Codes
Dental Codes
Miscellaneous Codes
Temporary National ...
February 13th, 2018
Payment Rates Increase for Behavioral Health Office Services
By Wyn Staheli, Director of Research | Published February 13th, 2018
Behavioral health providers may see some improvement in payment rates for office-based behavioral health services. This is due to the fact that the overhead expense evaluation portion of the RVU was increased. The following information is from the Federal Register (see References):
We agree with these stakeholders that the site of service ...
February 1st, 2018
Patients Undergoing a Bone Marrow Transplant (BMT)
By Find-A-Code | Published February 1st, 2018
Accoring to Wisconsin Physicians Service Insurance Corporation L34699, when using J2820 for patients undergoing a bone marrow transplant (BMT), 2 diagnosis codes are required:1) Z76.82 Awaiting organ transplant status2) Pick a code from one of these categories:
C81- Hodgkin Lymphoma
C82- Follicular Lymphoma
Non-follicular Lymphoma
C83.1- Mantle cell lymphoma
C83.3- Diffuse large B-cell lymphoma
C83.7- Burkitt lymphoma
C83.8- Other (Intravascular large B-cell lymphoma, Primary effusion B-cell lymphoma, or Lymphoid granulomatosis)
Mature T/NK-cell lymphomas
C84.4- Peripheral T-cell ...
February 1st, 2018
How to Code Screening and Diagnostic Colonoscopy
By Natalie Tornese, CPC | Published February 1st, 2018
The following information is from BC Advantage.
Colonoscopy is a common procedure performed byGastroenterologists. CPT defines a colonoscopy examination as "the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis" ...
February 1st, 2018
CMS Changes Definitions for Therapeutic Shoe Inserts
By Wyn Staheli, Director of Research | Published February 1st, 2018
CMS recently revised their definitions for custom fabricated and therapeutic inserts in order to meet current technology standards. Healthcare providers need to be sure to review the revisions in order to appropriately bill Medicare for inserts. For example, for custom fabricated, molded-to-patient, they have added the following:
iii. For inserts used with ...
February 1st, 2018
Strapping and Kinesio Taping Coding Differences
By Wyn Staheli, Director of Research | Published February 1st, 2018
There are differences between the purposes of strapping and taping and using the correct codes depends on the application - literally.
Strapping: This application is for the purpose of immobilizing an area. It is clinically indicated for the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures, or other deformities involving soft tissue.
Coding: ...
February 1st, 2018
Multiple Diagnostic Imaging Payment Reduction
By Wyn Staheli, Director of Research | Published February 1st, 2018
CMS and some other payers have adopted policies of reducing payments when certain multiple diagnostic imaging procedures (see Applicable Codes below) are performed in a single session by the same healthcare provider and/or group. They have done the same when there are multiple units for a procedure code. The rationale ...
January 31st, 2018
Influenza, Are You Billing Correctly?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 31st, 2018
With this year's Flu season being the most widespread on record, providers are seeing more patients and giving more immunizations for influenza than normal. Here are a few things to keep in mind during this flu season.
Know the rules with your payers to ensure proper reimbursement and correct billing. For example, did you ...
January 25th, 2018
Psychiatric Partial Hospitalization Programs
By Wyn Staheli, Director of Research | Published January 25th, 2018
Psychiatric Partial Hospitalization Programs (PHPs) are a more comprehensive level of care than Intensive Outpatient Programs (IOPs - click here to read more about IOPs). When the patient requires a minimum of 20 hours per week and hospitalization is not clinically indicated, a PHP can be the most effective type of ...
January 23rd, 2018
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
January 18th, 2018
Medicare's Integrated Behavioral Healthcare Services and Collaborative Care Program
By Wyn Staheli, Director of Research | Published January 18th, 2018
Over the last several years, primary care has begun to integrate behavioral health services to better address shortfalls in patient quality of care. Some of the first codes were the Health and Behavior Assessment/Intervention (96152-96155) codes, which were added in 2002. Since then, many different models have been experimented with and have ...
January 15th, 2018
Medicare Requiring Specific Modifiers on Therapy Services
By Wyn Staheli, Director of Research | Published January 15th, 2018
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:
Services furnished under the Outpatient ...
January 15th, 2018
Billing with a GP Modifier
By Wyn Staheli, Director of Research | Published January 15th, 2018 - Last Review/Update January 30th, 2019
Q: When patients have a true Medicare secondary insurance we've always billed other Medicare non-covered codes such as G0283 for electric stimulation with modifier GY because we are aware Medicare will not pay for that service but the secondary insurance does. We just were notified by our MAC that GY is not a valid modifier and I have to enter a GP or other therapy modifier. What is the new proper modifier to enter?
January 11th, 2018
Intensive Outpatient Treatment (IOP)
By Wyn Staheli, Director of Research | Published January 11th, 2018
Intensive Outpatient Programs (IOPs) are considered to be an intermediate level of care which is commonly considered after the patient has been discharged from inpatient care. For some patients and/or conditions they can also provide an effective level of care when hospitalization is not clinically indicated or preferred. The following ...
January 11th, 2018
Preventative Services: Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
By Find-A-Code | Published January 11th, 2018
The following information from the Medicare Learning Network provides guidance on Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
January 9th, 2018
Diagnosis billing with J0888
By Find-A-Code | Published January 9th, 2018
The following information is from LCD L36276.
The diagnosis codes listed below require the use of the EC modifier (ESA administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy) when submitting claims for J0888. In addition, these diagnosis codes are marked with an * indicating they require a dual diagnosis. The ...
January 9th, 2018
Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive
By Find-A-Code | Published January 9th, 2018
According to Palmetto GBA, Medicare will cover the cost of the injection and the injected hyaluronate polymer for patients who meet the following clinical criteria:
Knee pain associated with radiographic evidence of osteophytes in the knee joint, sclerosis in bone adjacent to the knee, or joint space narrowing.
Morning stiffness of less than 30 minutes in duration or crepitus on motion of the ...
January 9th, 2018
Billing Electrotherapy with AcuKnee
By Christine Woolstenhulme | Published January 9th, 2018
This code is commonly used to bill for AcuKnee products. Per AcuKnee, “NMES and electrotherapy may be covered by most insurance providers, provided the following criteria are met;”
Documentation of chronic pain or muscle atrophy 3 months or longer
Must document improvement
Must have physician document medical necessity/Prescription
Appropriate authorization from your insurance provider
Suggested codes when billing
64550 initial electrotherapy education and placement
E0720 Electrotherapy unit itself
E0731 Garment ...
January 9th, 2018
Outpatient Rehabilitation Modifiers
By Jared Staheli | Published January 9th, 2018
Modifiers are used for outpatient rehabilitation services to identify the type of service performed. This is necessary for payers to determine service coverage for beneficiaries.
For services delivered under an outpatient plan of care use modifier:
GN for speech-language pathology
GO for occupational therapy
GP for physical therapy
In addition to using the correct modifier, ...
January 5th, 2018
Medicare Reimburses for Discarded/Wasted Drugs
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 5th, 2018
Your organization may be leaking revenue without realizing the leak can be stopped. If your organization purchases single-use packets or single dose vials for individual patient use and ends up discarding some of the drug, Medicare has now authorized payment for the discarded or wasted portion. Stop leaking revenue today by reading this article and implementing the guidance provided here.
January 4th, 2018
Beware of Limitations When Using Electrical Stimulation - Ultrasound
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 4th, 2018
Ultrasound is often used to reduce inflammation, and improve the flexibility of connective tissue. This is done by applying sound waves to produce heat and/or vibration. Be aware of the many limitations when reporting this code. Be sure to consult your local carrier LCDs and carefully determine the correct code and the requirements for ...
January 4th, 2018
Proper Usage of Electrical Stimulation
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.
97032 is a constant attendance electrical stimulation modality ...
January 4th, 2018
General Physical Therapy Modality Guidelines
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention.
CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes ...
January 4th, 2018
Hydrotherapy Guidelines
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, hydrotherapy involves the patient’s immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.Qualified professional/auxiliary personnel one-on-one supervision of the patient is required. If the level of care does not require the skills of ...
January 4th, 2018
2017-2018 Influenza (Flu) Resources for Health Care Professionals
By Find-A-Code | Published January 4th, 2018
Per CMS: Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies. Annual Part B deductible and coinsurance amounts do not apply.
Payment allowance limits for personal flu and pneumococcal vaccines are 95 percent of the Average Wholesale Price (AWP), except where the vaccine is furnished ...
January 3rd, 2018
Abuse, Neglect, or Maltreatment
By Wyn Staheli | Published January 3rd, 2018
According to the official ICD-10-CM Guidelines, in situations of maltreatment (e.g., adult and child abuse, neglect, etc.), the sequence of coding is important. Regardless of whether it is suspected or confirmed, it is important to document the type of abuse. Use the following sequence:
An appropriate code from category T74- (confirmed) or T76- (suspected)
Any accompanying mental ...
December 28th, 2017
Sleep Testing
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 28th, 2017
Once a patient has been evaluated for symptoms associated with sleep apnea, testing is ordered to identify severity and determine treatment.
There are several types of sleep tests, but coverage is based on meeting the criteria for Type I (inpatient facility based) or Type II-IV and Other (home-based sleep tests). All ...
December 28th, 2017
Alcohol Misuse Screening and Counseling
By Wyn Staheli | Published December 28th, 2017
Codes G0442 (screening) and G0443 (15 min counseling) are typically a covered preventive service for most payers. As a preventive service, copayment/coinsurance and deductibles are typically waived. These are NOT considered treatment services or sessions for alcoholism or other substance abuse. If the screening results indicate that the patient is dependent and is open to the ...
December 20th, 2017
Lung Cancer Screening Counseling and Shared Decision Making Visit, and Annual Screening for Lung Cancer with LDCT
By Find-A-Code | Published December 20th, 2017
Effective February 5, 2015, a CMS National Coverage Determination (NCD) added lung cancer screening counseling and shared decision making visit, and for certain beneficiaries, annual screening for lung cancer with Low Dose Computed Tomography (LDCT), as an additional screening service benefit under the Medicare program if all eligibility criteria described ...
November 27th, 2017
Erythropoietin Stimulating Agents (ESA)
By Wyn Staheli, Director of Research | Published November 27th, 2017
Coverage
ESA is typically covered for the following condition(s):
Treatment of anemia associated with chronic renal failure (whether or not that patient is on dialysis)
Treatment of significant anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy
Treatment of anemia due to AZT and/or other Nucleoside Reverse Transcriptase Inhibitors (NRTI) used in treatment of HIV/AIDS
Treatment of selected ...
October 27th, 2017
Speech-Language Pathology Services Policy from UniCare
By Find-A-Code | Published October 27th, 2017
Medically Necessary:
Rehabilitative speech-language pathology (SLP) services are considered medically necessary when ALL of the following criteria are met:
The services are used in the treatment of communication impairment or swallowing disorders resulting from illness*, injury, surgery, or congenital abnormality; and
Based on a plan of care, the therapy sessions achieve a specific ...
October 18th, 2017
Physicians Reciprocal Billing Arrangements
October 5th, 2017
Q/A: Do we Need to Charge for Non-covered Services Performed Under a Maintenance Visit if we Use the S8990 Code When Billing Medicare?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published October 5th, 2017 - Last Review/Update February 5th, 2019
Do we need to charge for non-covered services performed under a maintenance visit if we use the S8990 code when billing Medicare?
September 30th, 2017
Annual Wellness Visit & Health Risk Assessment
By Find-A-Code | Published September 30th, 2017 - Last Review/Update October 1st, 2017
Coding tips regarding Annual Wellness Visit and Health Risk Assessments
September 8th, 2017
Global Surgical Package: When to Bill and When Not to Bill, that is the Question
By Stephanie Allard, CPC, CEMA, RHIT | Published September 8th, 2017 - Last Review/Update January 31st, 2018
The global surgical package is inclusive of the services that would normally be provided to the patient following surgery. Depending on the global period assigned to a CPT code, the pre-operative, intra-operative and post-operative services could be included in the global surgical package.....
September 1st, 2017
Preventive Services: Alcohol Misuse Screening and Counseling
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 5th, 2018
The following information from the Medicare Learning Network (MLN) provides guidance on Alcohol Misuse Screening and Counseling.......
September 1st, 2017
Preventive Services: Annual Wellness Visit (AWV)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update March 12th, 2018
The following information from the Medicare Learning Network provides guidance on Annual Wellness Visits (AWV)
September 1st, 2017
Preventive Services: Bone Mass Measurements
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Bone Mass Measurements
September 1st, 2017
Preventive Services: Colorectal Cancer Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Colorectal Cancer Screening.....
September 1st, 2017
Preventive Services: Counseling to Prevent Tobacco Use
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Counseling to Prevent Tobacco Use....
September 1st, 2017
Preventive Services: Depression Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Depression Screening....
September 1st, 2017
Preventive Services: Diabetes Self-Management Training (DSMT)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 4th, 2018
The following information from the Medicare Learning Network provides guidance on Diabetes Self-Management Training....
September 1st, 2017
Preventive Services: Glaucoma Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 9th, 2018
The following information from the Medicare Learning Network provides guidance on Glaucoma Screening....
September 1st, 2017
Preventive Services: Hepatitis B Virus (HBV) Vaccine and Administration
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 9th, 2018
The following information from the Medicare Learning Network provides guidance on Hepatitis B Virus (HBV) Vaccine and Administration....
September 1st, 2017
Preventive Services: Hepatitis C Virus (HCV) Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Hepatitis C Virus (HCV) Screening....
September 1st, 2017
Preventive Services: Human Immunodeficiency Virus (HIV) Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 4th, 2018
The following information from the Medicare Learning Network provides guidance on Human Immunodeficiency Virus (HIV) Screening....
September 1st, 2017
Preventive Services: Influenza Virus Vaccine and Administration
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 4th, 2018
The following information from the Medicare Learning Network provides guidance on Influenza Virus Vaccine and Administration....
September 1st, 2017
Preventive Services: Initial Preventive Physical Examination (IPPE)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Initial Preventive Physical Examination (IPPE)......
September 1st, 2017
Preventive Services: Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)....
September 1st, 2017
Preventive Services: Intensive Behavioral Therapy (IBT) for Obesity
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Intensive Behavioral Therapy (IBT) for Obesity....
September 1st, 2017
Preventive Services: Lung Cancer Counseling and Annual Screening for Lung Cancer With LDCT
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Lung Cancer Screening Counseling, and Annual Screening for Lung Cancer With Low Dose Computed Tomography (LDCT)....
September 1st, 2017
Preventive Services: Medical Nutrition Therapy (MNT)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Medical Nutrition Therapy (MNT)....
September 1st, 2017
Preventive Services: Pneumococcal Vaccine and Administration
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Pneumococcal Vaccine and Administration....
September 1st, 2017
Preventive Services: Prostate Cancer Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Prostate Cancer Screening....
September 1st, 2017
Preventive Services: Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests....
September 1st, 2017
Preventive Services: Screening for STIs and High Intensity Behavioral Counseling (HIBC) to Prevent STIs
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.....
September 1st, 2017
Preventive Services: Screening Mammography
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on a Screening Mammography....
September 1st, 2017
Preventive Services: Screening Pap Tests
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening Pap Tests....
September 1st, 2017
Preventive Services: Screening Pelvic Examinations
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening Pelvic Examinations (includes a clinical breast examination)....
August 29th, 2017
Quality Measures for Chiropractic - 2017
By Wyn Staheli, Director of Research | Published August 29th, 2017
Performance Measurement Codes for Chiropractic:
Although there are hundreds of Performance Measurement (PM) services and events, only two may be reported for chiropractors for the 2017 reporting year.
Pain Assessment and Follow-Up
131
ENCOUNTER: 90791, 90792, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 96116, 96118, 96150, 96151, 97161, 97162, 97163, 97164, 97165, 97166, 97167, ...
August 24th, 2017
Q/A: MIPS and G Codes
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 24th, 2017 - Last Review/Update February 5th, 2019
We have one doctor in our practice who qualifies under the MIPS guidelines so he is continuing to use the PQRS and G-codes. We are having the rest of our doctors do the same, just in case, and because it is good practice, but is that completely unnecessary and can it possibly do us more harm than good?
August 4th, 2017
List of Common Unclassified Injectable drugs (this list in not all-inclusive)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 4th, 2017
This is a list of some of the most common Injectable unclassified drugs used with J3490
Antilirium – 1 mg/ml
Ascorbic Acid – 500 mg/ml
Ascorbic Acid – 250 mg/ml
Bacitracin, Intramuscular – 50,000 unit vials
Bacitracin, Intramuscular – 10,000 unit vials
Brevital Sodium – 500 mg/5 ml
Caffeine and Sodium Benzoate – 250 mg/ml
Capastat Sulfate – 1 ...
August 4th, 2017
Proposed Telehealth Changes for 2018
By Wyn Staheli | Published August 4th, 2017 - Last Review/Update October 4th, 2017
Medicare has proposed making some changes to policies regarding telehealth services. They are adding some new codes to their covered list of telehealth services and propose eliminating the requirement to use the GT modifier. Since many payers adopt similar policies, watch for further announcements from other third-party payers.
Proposed Codes
HCPCS code G0296 ...
August 1st, 2017
Requirements for Physicians Orders for DME/HCPCS
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 1st, 2017
Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed may be denied ...
August 1st, 2017
Annual Wellness Visit (AWV)
By Wyn Staheli, Director of Research | Published August 1st, 2017
Annual Wellness Visits (AWVs) are a preventive medicine service. It is a comprehensive evaluation and management service which is covered by payers as part of the Affordable Care Act (ACA)'s covered services and there are typically no deductibles or co-pays.
July 26th, 2017
HCPCS Codes - ASP Reporting is done in Units not NDC
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 26th, 2017
HCPCS CODES FOR WHICH ASP REPORTING IS DONE IN UNITS OF MEASURE OTHER THAN AN NDC Updated November 14, 2016
A9587 GALLIUM GA-68, DOTATATE, DIAGNOSTIC, 0.1 MILLICURIE 0.1 millicurie
A9588FLUCICLOVINE F-18, DIAGNOSTIC, 1 MILLICURIE 1 millicurie
A9606 RADIUM RA-223 DICHLORIDE, THERAPEUTIC, PER MICROCURIE 1 microcurie
C9132 PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY 1 IU
C9140 INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (AFSTYLA), 1 I.U. 1 IU
J0256 INJECTION, ALPHA 1 PROTEINASE INHIBITOR ...
July 7th, 2017
Telemedicine: The Next Frontier in Care Delivery
By Valora Gurganious, MBA, CHBA | Published July 7th, 2017 - Last Review/Update January 25th, 2018
Technology is ubiquitous in modern society, and just when we thought that computers could not replace the "human touch" of a healthcare provider, technology is making specialized care accessible to patients anywhere there is an internet connection.
June 30th, 2017
Treating Diabetic Patients in Your Office?
By Shannon DeConda | Published June 30th, 2017
CMS will be rolling out an Expanded Diabetes Prevention Plan January 1, 2018 as well as new Durable Medical Equipment (DME) supply codes for Continuous Glucose Monitors (CGM) July 1, 2017. These services will offer your practice the opportunity to better assist your diabetic patient's needs.
Remember that prior to providing ...
June 29th, 2017
New payments for Psychiatric Collaborative Care Services (COCM) from Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 29th, 2017
Medicare has agreed to make separate payments to physicians and non-physicians for Behavioral Health Integration (BHI) services beginning Jan. 1st, 2017.
Any condition new or pre-existing behavioral health or substance use disorders are eligible. Beneficiaries may have comorbid, chronic, or other medical conditions they are being treated for as well.
Using the ...
June 27th, 2017
Modifier JW With Drug Codes
By Find-A-Code | Published June 27th, 2017
Modifier JW
In the past, some Medicare Administrative Contractors have required providers to report wasted drugs with modifier JW (Drug amount discarded/not administered to any patient). Use of the modifier was at the contractor’s discretion, and some contractors told providers not to report it. But effective January 1, 2017, all providers ...
June 20th, 2017
Changes with DME
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 20th, 2017
Due to the cost and refills that is required with portable oxygen systems separate payment classes were added in 2007 for oxygen generating portable equipment. Each year, Payment Classes for Oxygen Generating Portable Equipment, Stationary Oxygen Contents, and Portable Oxygen Contents, are adjusted to make additional payment classes for oxygen ...
May 12th, 2017
When Using Code 99050 (After Hours)
By | Published May 12th, 2017 - Last Review/Update February 8th, 2019
Question: When using code 99050 (after hours), do I just add a amount, example $25.00, to our normal total charges for that patients visit?
April 26th, 2017
Modifiers: Reporting Wound Dressings
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 26th, 2017 - Last Review/Update July 28th, 2017
When reporting dressings for wounds, it is important to indicate if the dressing is the primary or secondary dressing as well the number of wounds the dressing will be used for.
Primary Dressing: May be therapeutic or protective coverings applied to wounds either on the skin or caused by an opening ...
April 20th, 2017
Billing Dermal Filler Injections
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2017 - Last Review/Update July 28th, 2017
When billing dermal filler injections, separate payment may be made under the OPPS and ASC payment systems for HCPCS G0429- Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (lds) (e.g., as a result of highly active antiretroviral therapy).
Use in addition: Q2026- Injection, radiesse, 0.1 ml, and Q2028 - Injection, sculptra, 0.5 mg
With a diagnosis of B20 - ...
March 29th, 2017
Newly Revised "Common Procedure Codes" section in the 2016 ChiroCode DeskBook
By Evan M. Gwilliam, DC MBA BS CPC CCPC NCICS CPC-I CCCPC MCS-P CPMA | Published March 29th, 2017
The force used to create a degree of tension of soft tissues and/or to allow for separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration (time), and angle of pull (degrees) using mechanical means. Terms often used in describing pelvic/cervical traction ...
March 28th, 2017
Respiratory Assist Devices (RAD) E0470 and E0471 - Billing Reminders
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 28th, 2017 - Last Review/Update July 28th, 2017
Add the KX modifier to all claims for RADs and accessories for the first through third months if all thecoverage criteria have been met.
Add the KX modifier to all claims for the fourth month and thereafter if all the coverage criteria have been met and if the physician signed and dated a ...
March 27th, 2017
Devices Used for Treatment with TMJ
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 27th, 2017 - Last Review/Update July 28th, 2017
Dynamic splinting systems or devices are used to assist in restoring physical function and are commonly used for treating TMJ. Injury or joint stiffness are diagnoses that may qualify for medically necessity.
If physical therapy has proven ineffective to restore or improve range of motion, mechanical devices are often a next step.
This ...
March 3rd, 2017
Chiropractic Manipulation
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published March 3rd, 2017 - Last Review/Update February 8th, 2019
Q: If a patient is treated with chiropractic manipulation and it is clinically appropriate but doesn't qualify as medically necessary care, what is the proper way to communicate this when billing the insurance company for the service?
March 2nd, 2017
Requirements for Physicians Orders for DME/HCPCS
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed ...
March 1st, 2017
Care Plan Oversight Services
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 1st, 2017 - Last Review/Update January 16th, 2018
Care Plan oversight services is commonly done but rarely billed. The following codes can only be billed once every 30 days. The use of the following codes are determined by the complexity and approximate time spent by the physician or other health care professional within a 30-day period.
G0179
MD re-certification HHA PT
May be ...
February 27th, 2017
Documentation: Face to Face for Home Health Certification
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 27th, 2017 - Last Review/Update August 16th, 2017
As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. ...
February 23rd, 2017
Care Plan Oversight Services
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2017 - Last Review/Update August 2nd, 2017
Care Plan oversight services is commonly done but rarely billed. The following codes can only be billed once every 30 days. The use of the following codes are determined by the complexity and approximate time spent by the physician or other health care professional within a 30-day period.
G0179
MD re-certification HHA ...
February 21st, 2017
Telehealth Psychiatric Service
By Wyn Staheli, Director of Research | Published February 21st, 2017
Telehealth (also known as telemedicine) is playing an ever increasing roll in the reimbursement process. Internet services continue to expand and many insurance payers/providers are now covering (paying for) telehealth services. Telepsychiatry (providing behavioral health services in a telehealth environment) has been highly successful because video conferencing makes providing psych ...
February 10th, 2017
Beware of Limitations When Using Electrical Stimulation - Ultrasound
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 10th, 2017 - Last Review/Update August 2nd, 2017
Ultrasound is often used to reduce inflammation and improve the flexibility of connective tissue. This is done by applying sound waves to produce heat and/or vibration. Be aware of the many limitations when reporting this code. Be sure to consult your local carrier LCDs and carefully determine the correct code and the ...
February 10th, 2017
Q/A: What is the Proper Code for "Lumbar Decompression?
By ChiroCode | Published February 10th, 2017 - Last Review/Update February 8th, 2019
Q: What is the proper code for "Lumbar Decompression?
February 2nd, 2017
Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 2nd, 2017 - Last Review/Update August 2nd, 2017
Verify your local coverage determination and medical necessity requirements for the following codes:
Hyaluronate Polymers (L33432) - Noridian Medicare
J7320 - Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg
J7321 - Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose
J7322 - Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg
J7323 - Hyaluronan or ...
January 23rd, 2017
New and Deleted Drug Screen codes for 2017
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 23rd, 2017 - Last Review/Update March 8th, 2017
Deleted Codes for Drug Screening, the following codes are no longer valid for services performed on or after January 01, 2017.
Deleted Codes for 2017
80300
Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (eg, immunoassay) capable of being read by direct optical ...
January 12th, 2017
Sleep Studies: Billing with Reduced Hours
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 12th, 2017 - Last Review/Update August 2nd, 2017
When using codes 95800, 95801, 95806, 95807, 95810, and 95811, and fewer than six hours of recording is performed, you must report the reduced services using modifier 52.
Also, when using 95782 and 95783, and fewer than seven hours of recording is performed, modifier 52 would be appended to the appropriate code.
95805 would require modifier 52 if fewer than four hours of recording is performed.
Medicare recognizes the ...
January 2nd, 2017
G-Codes eff Jan 01,2017 for additional payment for Psych - Collaborative Care
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 2nd, 2017 - Last Review/Update July 26th, 2017
Medicare has agreed to make separate payments to physicians and non-physicians for Behavioral Health Integration (BHI) services beginning Jan. 01, 2017.
Any condition new or pre-existing behavioral health or substance use disorders are eligible. Beneficiaries may have comorbid, chronic, or other medical conditions they are being treated for as well.
Using the ...
December 30th, 2016
How APC Payment Rates Are Set
By Brittney Murdock, QCC, CMCS, CPC | Published December 30th, 2016
The payment rates for most separately payable medical and surgical services are determined by multiplying the prospectively established scaled relative weight for the service’s clinical APC by a conversion factor (CF) to arrive at a national unadjusted payment rate for the APC.
December 6th, 2016
Oral Maxillofacial Prosthesis (A53496)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 6th, 2016 - Last Review/Update August 1st, 2017
Implants, which could be considered dental but are being inserted to secure, attach, or support the maxillofacial prosthesis, will be covered when the prosthesis is to be used secondary to maxillofacial surgery or repair of traumatic injury. Use CPT code 21299 to bill the implants with an explanation of the intended use. ...
November 21st, 2016
Best Diagnosis Codes for E-stim
By ChiroCode | Published November 21st, 2016 - Last Review/Update March 5th, 2019
What are the best diagnosis codes for E-stim?
September 30th, 2016
Medicare Condition Code 44
By Jeanette Anderson, CPC, CPMA | Published September 30th, 2016 - Last Review/Update August 17th, 2017
Medicare Condition Code 44 is used when an inpatient admission needs to be changed to outpatient status. There are some instances where a Medicare patient was admitted to the hospital with an inpatient status, but upon review it is deemed more appropriate for the entire encounter to be an outpatient ...
August 23rd, 2016
Smoking and tobacco cessation counseling, covered indications and # of visits
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 23rd, 2016 - Last Review/Update August 2nd, 2017
Nationally Covered Indications:Effective for claims with dates of service on or after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries1. Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;2. Who are competent and alert at the time that ...
August 16th, 2016
Functional Limitation Reporting Codes and Modifiers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 16th, 2016
The following G-codes are used for reporting on claims for Medicare Part B and must be used with a severity/complexity modifier, the use of G-codes are enforced and required beginning Jan. 01, 2013, claims will be returned or rejected if they do not contain the required functional G-Code/modifier information.
There are ...
August 10th, 2016
Guidance for the Use of Codes in Physical Medicine - Pub-100
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2016 - Last Review/Update August 4th, 2017
The following provides guidance about the use of codes 96105, 97026, 97150, 97545, 97546, and G0128.
• CPT Codes 96105, 97545, and 97546.
Providers report code 96105, assessment of aphasia with interpretation and report in 1-hour units. This code represents formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination. If this formal assessment is performed during treatment, ...
July 29th, 2016
CODING ARTHROSCOPIC KNEE PROCEDURES
By Codapedia | Published July 29th, 2016
Knee Anatomy: The medical compartment includes: Medial Femoral condyle Medial tibial plateau Medial meniscus The lateral compartment includes: Lateral Femoral condyle Lateral tibial plateau Lateral meniscus The Patellofemoral compartment includes: Patella Patellofemoral joint Intercondylar notch of the femur Suprapatellar pouch Trochlea Arthroscopy: Knee arthroscopy allows the physician to visualize the...
July 28th, 2016
E-prescribing pay cuts loom for some in 2014, 2015
By Codapedia | Published July 28th, 2016
Some practices may find 2014 immediately off to the wrong foot when their Medicare payments are reduced by 2 percent for failing to participate successfully in Medicare’s E-prescribing Incentive Program. Unfortunately, at this point successfully claiming an exemption may be the only way to stave off the cut for non-reporters,...
June 28th, 2016
NAMAS - Study the Rules Before Auditing E&M Services by Teaching Physicians
By Find-A-Code | Published June 28th, 2016
If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ...
June 24th, 2016
Study the Rules Before Auditing E&M Services by Teaching Physicians
By Sara San Pedro, CPC, CEMC, CPMA | Published June 24th, 2016 - Last Review/Update August 17th, 2017
If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ...
June 9th, 2016
CMS Calculations for Average Sales Pricing ASP
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 9th, 2016 - Last Review/Update August 2nd, 2017
Because Drugs are not a part of the Medicare fees schedule, Drug pricing by Medicare is done according to Average Sales pricing (ASP) and is used to pay Part B claims. Average Wholesale pricing was used for part B Medicare payments until 2005, then ASP pricing/payment structure was implemented.
How ASP ...
June 9th, 2016
Pass-Through Payments, how they work and Device Category Codes List
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 9th, 2016 - Last Review/Update August 4th, 2017
If you want to know if a DRUG is a Pass through drug - Find-A-Code has that information on the code information page under FEES and APC Fee information
A pass through payment for a drug is Medicare reimbursement paid in addition to an ASC's facility fee, however, CMS limits the eligibility ...
June 6th, 2016
Billing, Documentation and Billable Units
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 6th, 2016 - Last Review/Update August 2nd, 2017
Most third-party payers (eg, commercial insurers, Medicare, Medicaid) cover REMICADE® (infliximab) for its approved U .S . Food and Drug Administration indications (see Indications on page 5 of this guide) . However, benefits may vary depending upon a patient’s insurer or specific insurance plan (or “product”) offered by a payer.
When third-party ...
May 27th, 2016
Documentation Criteria: Medicare Physicals
By Jeanette Anderson, CPC, CPMA | Published May 27th, 2016 - Last Review/Update August 16th, 2017
When billing annual Medicare physicals, it's very important to know the status of the patient, determining when they became eligible, and/or if they've seen another provider for any of these services as the initial visit codes are once in a lifetime codes and will be denied if they have already ...
May 9th, 2016
Billing Compound Drugs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 9th, 2016 - Last Review/Update August 4th, 2017
Unclassified HCPCS codes can only be used when there is not a specific HCPCS code available for the drug being billed.
Each NDC associated with an unclassified drug code should be submitted on a separate claim line following the instructions specified in the Manual for Physicians and Providers- Coding and Filing ...
May 9th, 2016
NOC Drug and Biological Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 9th, 2016 - Last Review/Update August 4th, 2017
The following are tips to help you when billing NOC drugs and biologicals, such as J3490, J3590, and J9999. Providers submit NOC codes in the 2400/SV101-2 data element in the 5010 professional claim transaction (837P).
When billing an NOC code, providers are required to provide a description in the 2400/SV101-7 data element. The 5010 ...
May 3rd, 2016
Using the SBIRT
By Wyn Staheli, Director of Research | Published May 3rd, 2016
Screening, Brief Intervention, and Referral to Treatment (SBIRT) services are an effective tool for healthcare providers to identify, reduce, and prevent problematic substance use disorders. Healthcare practices can help their patients and improve their integrated care standards with the proper use of the SBIRT.
April 29th, 2016
Adaptive Behavior Coding
By Wyn Staheli, Director of Research | Published April 29th, 2016 - Last Review/Update April 9th, 2018
Information about Adaptive Behavior Coding for Members.
April 4th, 2016
Coverage Criteria and Medical Necessity with Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 4th, 2016 - Last Review/Update August 3rd, 2017
Negative Pressure Wound Therapy (NPWT) is defined as the application of sub-atmospheric pressure to a wound to remove exudate and debris from wounds. NPWT is delivered through an integrated system of a suction pump, separate exudate collection chamber and dressing sets to a qualified wound. In these systems, exudate is ...
April 4th, 2016
Written Order Prior to Delivery (WOPD) is Required for Payment by Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 4th, 2016 - Last Review/Update August 3rd, 2017
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare ...
March 28th, 2016
Q&A: Is There a Better Supply Code to Use Than 99070?
By ChiroCode | Published March 28th, 2016 - Last Review/Update March 5th, 2019
Are there more specific codes for supplies rather than using 99070?
March 25th, 2016
Auditing Smoking Cessation Services
By John Burns, CPC, CPC-I, CEMC, CPMA | Published March 25th, 2016 - Last Review/Update August 16th, 2017
Most payers do indeed recognize smoking and tobacco cessation services as a covered health insurance benefit. We have found that some providers perform these services without fully understanding the reimbursement opportunities, while others claim such services without adequately documenting to support them. Medicare, for example, will pay for two (2) ...
March 7th, 2016
Discarded Drugs and Biologicals
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 7th, 2016 - Last Review/Update August 3rd, 2017
When a portion of a drug must be discarded, Medicare allows payment for amount administered as well as the discarded portion. Your Medicare carrier may require you to use modifier JW. The JW modifier is to be applied only to the portion discarded. Multi-use vials are not subject to payment for discarded amounts.
Take ...
March 4th, 2016
Medicare Improper Payment Report for Behavioral Health Services (2014)
By Wyn Staheli, Director of Research | Published March 4th, 2016
Medicare Improper Payment Report information regarding Behavioral Health Services
February 25th, 2016
Pricing is for a single shoe or individual inserts
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 25th, 2016
If you are contracted with a payer be sure you recognize that the pricing is for a single shoe or insert.
When billing orthotics it seems to be less confusing to bill two line items, one for the Left - LT and one for the Right Rt.
...
February 24th, 2016
Nebulizer Therapy Billing Reminders - Modifiers, Dispensing Fees, and Orders
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 24th, 2016 - Last Review/Update August 3rd, 2017
The ICD-10-CM code describing the condition necessitating nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs.
When ever a unit dose code is billed, it must have a KO, KP, or KQ modifier. (Exception: The KO, KP, and KQ modifiers should not be used with code J7620.)
When billing miscellaneous equipment or accessories (E1399), the claim must ...
February 23rd, 2016
PRESCRIPTION (ORDER) REQUIREMENTS (Confirm with your Local Payer)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 4th, 2017
All items billed to Medicare require a prescription. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items dispensed and/or billed that do not meet these prescription requirements and those below must be ...
February 23rd, 2016
Coverage Criteria and Medical Necessity for a Mobility Device
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 4th, 2017
General Coverage Criteria for a Mobility DeviceAccording to CMS, all of the following basic criteria (A-C) must be met for a power mobility device (K0800-K0898) or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below.
The beneficiary has a mobility limitation ...
February 23rd, 2016
Billing Reminders - (POV - Power Operated Vehicles) Modifiers, Verification, Delivery time...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 4th, 2017
According to CMS, delivery of the PMD must be within 120 days following completion of the F2F.
Exception: within 6 months from the date of an affirmed ADMC.
• The PMD will be denied if the underlying condition is reversible and length of need is < 3 months.
• The KX modifier ...
February 17th, 2016
Getting Paid When Reporting Unlisted Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 17th, 2016 - Last Review/Update August 4th, 2017
Using unlisted codes can be quite labor intensive, but if you are prepared and understand ahead of time about using unlisted codes you will have a higher success rate of reimbursement.
Verify the payers guidelines - Be sure your code selection it is a payable code; if it is not a payable code ...
February 17th, 2016
TeleMedicine Terms and Definitions and who can bill - Using Modifiers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 17th, 2016 - Last Review/Update August 4th, 2017
Medical practitioners who can bill for a covered Telehealth service vary by state law, but they may include:
physician,
nurse practitioner,
physician assistant,
nurse midwife,
clinical nurse specialist,
clinical psychologist,
clinical social worker, and
registered dietician or nutrition professional
Distant or Hub site: Site at which the physician or other licensed practitioner delivering the service is located at the time the ...
February 15th, 2016
Message to DME Suppliers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 15th, 2016
The Patient Access and Medicare Protection Act (PAMPA) was recently signed into law on December 28, 2015. Beginning January 1, 2016, the DME fee schedule rates are adjusted to reflect information from the DMEPOS competitive bidding program as required by section 1834(a)(1)(F)(ii) of the Social Security Act. These adjustments are ...
February 12th, 2016
Behavioral Heath Treatment/Services - Documentation Requirements
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 12th, 2016 - Last Review/Update August 4th, 2017
Reason for referral.
Tests administered, scoring/interpretation, and time involved.
Present evaluation.
Diagnosis (or suspected diagnosis that was the basis for the testing if no mental/neurocognitive illness was found).
Recommendations for interventions, if necessary.
Identity of person performing service.
...
February 1st, 2016
Documentation and Billing Practices
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 1st, 2016 - Last Review/Update August 7th, 2017
Prescribed to:
Reduce pain by restricting mobility of the trunk: OR
Facilitate healing following an injury to the spine or related tissue; OR
Otherwise support weak and/or deformed spinal muscles.
Documentation and billing practices be sure you are meeting all the requirements to bill a spinal orthoses.
Spinal Orthoses billed with HPCPCS L0450, L0454, L0621, L0625 and L0628 must be billed with ...
February 1st, 2016
Elastic Garments - Medicare Noncovered
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 1st, 2016 - Last Review/Update August 4th, 2017
According to Noridian, CMS has determined that elastic garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. Therefore, effective for claims with dates of service on or after April 1, 2009, these items will be denied as Medicare noncovered, no benefit category.
This ...
January 29th, 2016
Wound Care & Debridement- Provided by Physician, NPP or as Incident-to Services
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 29th, 2016
Providers must document the medical necessity for all services provided. If there is no documented evidence (e.g., objective measurements) of ongoing significant benefit, then the medical record documentation must provide other clear evidence of medical necessity for treatments. The medical record must also clearly indicate the complexity of skills required ...
January 29th, 2016
Certificate for Provider - Performed Microscopy Procedures
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 29th, 2016
Effective January 19, 1993, a laboratory that holds a certificate for provider-performed microscopy procedures may perform only those tests specified as provider-performed microscopy procedures and waived tests, as described below, and no others.
HCPCS Code Test
Q0111
Wet mounts, including preparations of vaginal, cervical or skin
specimens
Q0112
All potassium hydroxide (KOH)
preparations
Q0113
Pinworm examinations
Q0114
Fern test
Q0115
Post-coital direct, qualitative ...
January 6th, 2016
Preventive Medicine Services for Medicare Patients
By Codapedia | Published January 6th, 2016
The most widely known fact about Medicare and preventive medicine is that fee-for-service Medicare does not cover an annual physical exam. This is because in its beginning, Medicare was prohibited from paying for routine services. Over the years, Congress has mandated the payment of some screening...
January 6th, 2016
Reporting Administration Codes with Vaccines
By Codapedia | Published January 6th, 2016
When it comes to billing for vaccines, the rules for reporting administration codes can be tricky. Reporting the right vaccine code alone is not enough to guarantee proper billing. Most billing scenarios allow providers to charge for both the vaccine product and the administration of the vaccine itself. However, there...
December 21st, 2015
Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (code G0105) examination
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 4th, 2017
According to the Pub-100, screening barium enema examinations may be paid as an alternative to a screening colonoscopy (code G0105) examination. The same frequency parameters for screening colonoscopies (see those codes above) apply. In the case of an individual who is at high risk for colorectal cancer, payment may be made for ...
December 21st, 2015
Colorectal Cancer Screening; Barium Enema; as an Alternative to G0104, Screening Sigmoidoscopy
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 7th, 2017
G0106 - Colorectal Cancer Screening; Barium Enema; as an Alternative to G0104, Screening Sigmoidoscopy Screening barium enema examinations may be paid as an alternative to a screening sigmoidoscopy (code G0104). The same frequency parameters for screening sigmoidoscopies (see those codes above) apply.In the case of an individual aged 50 or over, payment may be ...
December 21st, 2015
Characteristics of High Risk and How Often Test can be Performed
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 7th, 2017
According to Medicares Pub-100, 60 - Colorectal Cancer Screening Ref: AB-03-114;
Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month ...
December 21st, 2015
Service is considered colorectal cancer screening services, age limit, every 48 months
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 7th, 2017
G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy
Screening flexible sigmoidoscopies (code G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below.For claims with dates of service on or after January 1, 2002, contractors or carriers pay for screening ...
December 11th, 2015
How to bill for Well Woman Exams (WWE)
By Codapedia | Published December 11th, 2015
Well Woman Exam CodingThere are options for billing pelvic exams and Pap smears for non-Medicare payers, albeit inconsistently by health plan. Some health plans will pay G0101, Q0091, S0610 and/or S0612. Some will pay one or another, some will pay a combination of two, others...
October 19th, 2015
The JW Modifier is Only Applied to the Amount of Drug or Biological that is Discarded
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 19th, 2015 - Last Review/Update August 4th, 2017
According to CMS, local contractors may require the use of the modifier JW to identify unused drug or biologicals from single use vials or single use packages that are appropriately discarded. This modifier, billed on a separate line, will provide payment for the amount of discarded drug or biological.
For example, ...
October 13th, 2015
Pricing Modifier
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 13th, 2015 - Last Review/Update August 7th, 2017
Place the modifiers listed below (except modifiers with an *) to the right of the procedure code in Item 24D on the CMS 1500 claim form or for ANSI X12 4010 electronic claims submission use segment 2-370-SV101-3.
Processing delays can occur for claims submitted without the pricing modifier in the first modifier position. ...
October 8th, 2015
Conditions or Exceptions that might justify coverage of foot care
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 8th, 2015 - Last Review/Update August 7th, 2017
When using G0127 keep in mind routine foot/nail care is generally excluded from coverage under Medicare, however there are some exceptions:
Click here to read the entire article
Although not intended as a comprehensive list, the following metabolic, neurologic,and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that might ...
September 25th, 2015
Bone Mass Measurements (BMMs)
By Find-A-Code | Published September 25th, 2015
Listed is a summary of the revisions and additions to Chapter 13 of the Medicare Claims Processing Manual and Chapter 15 of the Medicare Benefit Policy Manual.
CHAPTER 13
Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of ...
September 21st, 2015
Documentation and Reimbursement for Testing
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 21st, 2015 - Last Review/Update August 7th, 2017
The medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s).
TC - Technical component Modifier may be ...
August 10th, 2015
Adjunctive (Add-On) Codes
By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017
Stop losing hard-earned dollars. Too often, dollars are left on the table at billing time. Adjunctive codes for associated services should be added when they are appropriate. Here are a few examples of coding that are often overlooked.
97014 & 97032 Electrical Stimulation Supplies
According to the Relative Value Update Committee (RUC), ...
August 7th, 2015
TMJ Medical Necesity and Documentation- Aetna
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2015 - Last Review/Update August 7th, 2017
Notes: Most Aetna HMO plans exclude coverage for treatment of temporomandibular disorders (TMD) and temporomandibular joint (TMJ) dysfunction
For plans that cover treatment of TMD and TMJ dysfunction, requests for TMJ surgery require review by Aetna's Oral and Maxillofacial Surgery patient management unit. Reviews must include submission of a problem-specific history ...
August 7th, 2015
Reimbursed on a Daily Basis /Modifiers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2015 - Last Review/Update August 7th, 2017
HCPCS codes E0935 (Continuous passive motion exercise device for use on knee only), and E0936 (Continuous passive motion exercise device for use other than knee) are reimbursed on a daily basis consistent with CMS guidelines.
The following HCPCS codes are also reimbursed on a daily basis:
E0193 -Powered air flotation bed (low air loss therapy)
E0194 -Air fluidized bed
E0277 –Powered ...
August 3rd, 2015
Method for Computing Fee Schedule Amount (Rev. 1, 10-01-03)
By | Published August 3rd, 2015
B3-15006
The CMS continually updates, refines, and alters the methods used in computing the fee schedule amount. For example, input from the American Academy of Ophthalmology has led to alterations in the supplies and equipment used in the computation of the fee schedule for selected procedures. Likewise, new research has changed ...
July 20th, 2015
Hospice Pre - Election Evaluation and Counseling Services (Rev. 2258)
By Find-A-Code | Published July 20th, 2015
Effective January 1, 2005, Medicare allows payment to a hospice for specified hospice pre-election evaluation and counseling services when furnished by a physician who is either the medical director of or employee of the hospice.
Medicare covers a one-time only payment on behalf of a beneficiary who is terminally ill, (defined ...
July 17th, 2015
Mandatory Assignment on Carrier Claims (Rev. 2487, Issued: 06-08-12)
By Find-A-Code | Published July 17th, 2015
The following practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed amount as payment in full for their practitioner services. The beneficiary’s liability is limited to any applicable deductible plus ...
July 10th, 2015
Coding Requirements for Specimen Collection (Rev. 3056, 12-01-14)
By Jared Staheli | Published July 10th, 2015
The following HCPCS codes and terminology must be used:
• 36415 – Collection of venous blood by venipuncture.
• G0471 – Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency ...
July 10th, 2015
Certificate for Provider-Performed Microscopy Procedures (Rev. 865, 07-03-06)
By Jared Staheli | Published July 10th, 2015
Effective January 19, 1993, a laboratory that holds a certificate for provider-performed microscopy procedures may perform only those tests specified as provider-performed microscopy procedures and waived tests, as described below, and no others.
HCPCS Code
Test
Q0111
Wet mounts, including preparations of vaginal, cervical or skin specimens
Q0112
All potassium hydroxide (KOH) preparations
Q0113
Pinworm examinations
Q0114
Fern test
Q0115
Post-coital direct, ...
July 10th, 2015
Certificate of Waiver (Rev. 1652, 01-05-09) - CLIA
By Jared Staheli | Published July 10th, 2015
Effective September 1, 1992, all laboratory testing sites (except as provided in 42 CFR 493.3(b)) must have either a CLIA certificate of waiver, certificate for providerperformed microscopy procedures, certificate of registration, certificate of compliance, or certificate of accreditation to legally perform clinical laboratory testing on specimens from individuals in the ...
July 10th, 2015
HCPCS Subject To and Excluded From CLIA Edits (Rev. 865, 07-03-06)
By Jared Staheli | Published July 10th, 2015
At this time, all claims submitted for laboratory tests subject to CLIA are edited at the CLIA certificate level. However, the HCPCS codes that are considered a laboratory test under CLIA change each year. The CMS identifies the new HCPCS (non-waived, nonprovider-performed procedure) codes, including any modifiers that are subject ...
July 10th, 2015
National Minimum Payment Amounts for Cervical or Vaginal Smear Clinical Laboratory Tests (Rev. 1, 10-01-03)
By Jared Staheli | Published July 10th, 2015
For cervical or vaginal smear clinical laboratory tests, payment is the lesser of the local fee or the national limitation amount, but not less than the national minimum payment amount (NMPA). However, in no case may payment for these tests exceed actual charges. The Part B deductible and coinsurance do ...
July 9th, 2015
Hospital Outpatient Payment Under OPPS for New, Unclassified Drugs and Biologicals After FDA Approval But Before Assignment of a Product-Specific Drug or Biological HCPCS Code (Rev. 3085)
By Jared Staheli | Published July 9th, 2015
Section 621(a) of the MMA amends Section 1833(t) of the Social Security Act by adding paragraph (15), Payment for New Drugs and Biologicals Until HCPCS Code Assigned. Under this provision, payment for an outpatient drug or biological that is furnished as part of covered outpatient department services for which a ...
July 9th, 2015
Pharmacy Supplying Fee and Inhalation Drug Dispensing Fee (Rev. 754, 01-03-06)
By Jared Staheli | Published July 9th, 2015
Section 303(e) (2) of the MMA implements a supplying fee for immunosuppressive drugs, oral anti-cancer chemotherapeutic drugs, and oral anti-emetic drugs used as part of an anti-cancer chemotherapeutic regimen. Effective January 1, 2005, Medicare paid a separately billable supplying fee of $24.00 to a pharmacy, dialysis facility in the State ...
July 9th, 2015
Reporting of Hematocrit and/or Hemoglobin Levels (Rev. 1412, 04-07-08)
By Jared Staheli | Published July 9th, 2015
Effective January 1, 2008, the following claims must report the most recent hematocrit or hemoglobin reading:
1. All claims billing for the administration of an ESA (HCPCS J0881, J0882, J0885, J0886 and Q4081).
2. All claims for the administration of a Part B anti-anemia drug (other than ESAs) used in the treatment ...
July 9th, 2015
Required Modifiers for ESAs Administered to Non-ESRD Patients (Rev. 1412, 04-07-08)
By Jared Staheli | Published July 9th, 2015
Effective January 1, 2008, all non-ESRD claims billing HCPCS J0881 and J0885 must begin reporting one of the following modifiers:
EA: ESA, anemia, chemo-induced
EB: ESA, anemia, radio-induced
EC: ESA, anemia, non-chemo/radio
Institutional claims that do not report one of the above modifiers will be returned to the provider.
Professional claims that are billed without ...
July 9th, 2015
Hospitals Billing for Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) for Non-ESRD Patients (Rev. 1412, 04-07-08)
By Jared Staheli | Published July 9th, 2015
NOTE: For EPO and Aranesp billing instructions for beneficiaries with ESRD, see the Claims Processing Manual, Chapter 8, sections 60.4 and 60.7.
For patients with chronic renal failure who are not yet on a regular course of dialysis, EPO and Aranesp administered in a hospital and billed as an outpatient service ...
July 9th, 2015
Claims Processing Rules for ESAs Administered to Cancer Patients for Anti-Anemia Therapy (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
The national coverage determination (NCD) titled, “The Use of ESAs in Cancer and Other Neoplastic Conditions” lists coverage criteria for the use of ESAs in patients who have cancer and experience anemia as a result of chemotherapy or as a result of the cancer itself. The full NCD can be ...
July 9th, 2015
Claims Processing Rules for Hospital Outpatient Billing and Payment - Drugs, Biologicals, and Radiopharmaceuticals (Rev. 2903, 04-07-14)
By Jared Staheli | Published July 9th, 2015
A. General Billing and Coding for Hospital Outpatient Drugs, Biologicals, and Radiopharmaceuticals
Hospitals should report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used. It is also of great importance that hospitals billing ...
July 9th, 2015
Claims Processing Rules for Hospital Outpatient Billing and Payment - HCPCS Codes Replacements (Rev. 2903, 04-07-14)
By Jared Staheli | Published July 9th, 2015
The HCPCS code list of retired codes and new HCPCS codes reported under the hospital OPPS is published quarterly via Recurring Update Notification. The latest payment rates associated with each APC number may be found in the OPPS PRICER file available on the CMS Web site, as well as in ...
July 8th, 2015
DMEPOS - Repair Labor Billing and Payment Policy
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 8th, 2015
The following table contains repair units of service allowances for commonly repaired items billed under HCPCS code K0739 (Repair or Non-routine Service for Durable Medical Equipment Other than Oxygen Equipment Requiring the Skill of a Technician, Labor Component, Per 15 Minutes). This applies to non-rented and out-of-warranty items.
When billing for ...
July 8th, 2015
Single Drug Pricer (SDP) (Rev. 397, 01-03-05)
By Jared Staheli | Published July 8th, 2015
Effective January 1, 2003, contractors pay drug claims on the basis of the prices shown on the SDP files, if present.
On a quarterly basis, CMS furnishes three SDP files to all FIs, carriers, and ROs except regional home health intermediaries (RHHIs) and durable medical equipment regional carriers (DMERCs), as follows:
1. ...
July 8th, 2015
Assignment Required for Drugs and Biologicals (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
A. Local Carriers
Under §114 of the Benefits Improvement Act of 2000, effective for claims with dates of service on or after February 1, 2001, payment for any drug or biological covered under Part B of Medicare may be made only on an assignment-related basis. Therefore, no charge or bill may ...
July 8th, 2015
Claims Processing Requirements - General (Rev. 3085, Implementation: Upon Implementation of ICD- 10)
By Jared Staheli | Published July 8th, 2015
A/B MACs (B) are billed with the ASC X12 837 professional claim format or, if approved, with the paper form CMS-1500. A/B MACs (A) are billed with the ASC X12 837 institutional claim format or, if approved, with the paper Form CMS-1450.
See Chapters 24, 25 and 26 for detailed claims ...
July 8th, 2015
HCPCS Service Coding for Oral Cancer Drugs (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
The following codes may be used for drugs other than Prodrugs, when covered:
Generic/Chemical Name
How Supplied
HCPCS
Busulfan
2 mg/ORAL
J8510
Capecitabine
150mg/ORAL
J8520
Capecitabine
500mg/ORAL
J8521
Methotrexate
2.5 mg/ORAL
J8610
Cyclophosphamide *
25 mg/ORAL
J8530
Cyclophosphamide *
(Treat 50 mg. as 2 units
50 mg/ORAL
J8530
Etoposide
50 mg/ORAL
J8560
Melphalan
2 mg/ORAL
J8600
Prescription Drug chemotherapeutic NOC
ORAL
J8999
Each tablet or capsule is equal to one unit, except for 50 mg./ORAL of cyclophosphamide (J8530), which is shown as ...
July 8th, 2015
HCPCS and NDC Reporting for Prodrugs (Rev. 136, 04-09-04)
By Jared Staheli | Published July 8th, 2015
FI claims
For oral anti-cancer Prodrugs HCPCS code J8999 is reported with revenue code 0636.
DMERC claims
The supplier reports the NDC code on the claim. The DMERC converts the NDC code to a “WW” HCPCS code for CWF. As new “WW” codes are established for oral anticancer drugs they will be ...
July 8th, 2015
Oral Anti-Emetic Drugs Used as Full Replacement for Intravenous Anti-Emetic Drugs as Part of a Cancer Chemotherapeutic Regimen (Rev. 2931, 07-07-14)
By Jared Staheli | Published July 8th, 2015
See the Medicare Benefit Policy Manual, Chapter 15, and the National Coverage Determination (NCD) Manual, Section 110.18, for detailed coverage requirements.
Effective for dates of service on or after January 1, 1998, Medicare Part B (including (institutional claims processed by Part A Medicare Administrative Contractors (MACs) and physician/supplier claims processed by ...
July 8th, 2015
HCPCS Codes for Oral Anti-Emetic Drugs (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 8th, 2015
The physician/supplier bills for these drugs with the ASC X12 837 professional claim format, or if approved, with the paper form CMS-1500. The facility bills with the ASC X12 837 institutional claim format, or if approved, with the paper Form CMS-1450. The following HCPCS codes are assigned:
Code
Description
J8501
APREPITANT, oral, 5 mg ...
July 8th, 2015
Claims Processing Jurisdiction for Oral Anti-Emetic Drugs (Rev. 2931, 07-07-14)
By Jared Staheli | Published July 8th, 2015
The following chart shows which drugs are billed to the A/B MAC, or carrier and which drugs are billed to the DME MAC.
Per the Balanced Budget Act of 1997, effective for claims with dates of service on or after January 1, 1998, the claims processing jurisdiction rules in Chart 1 ...
July 8th, 2015
Requirements for Billing A/B MAC (A) for Immunosuppressive Drugs (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 8th, 2015
Hospitals not subject to OPPS bill on ASC X12 837 institutional format or paper Form CMS-1450 (if approved) with bill type 12x (hospital inpatient Part B) or l3x (hospital outpatient) as appropriate.
For claims with dates of service prior to April 1, 2000, providers report the following entries:
• Occurrence code 36 ...
July 7th, 2015
Policy for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11)
By Jared Staheli | Published July 7th, 2015
Claims with dates of service on and after October 14, 2011, the Centers for Medicare & Medicaid Services (CMS) will cover annual alcohol misuse screening (HCPCS code G0442) consisting of 1 screening session, and for those that screen positive, up to 4 brief, face-to-face behavioral counseling sessions (HCPCS code G0443) ...
July 7th, 2015
Institutional Billing Requirements for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11)
By Jared Staheli | Published July 7th, 2015
For claims with dates of service on and after October 14, 2011, Medicare will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and brief, face-to-face behavioral counseling for alcohol misuse, 15 minutes, G0443 for:
• Rural Health Clinics (RHCs) - type of bill (TOB) 71X only – based on ...
July 7th, 2015
Professional Billing Requirements for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11,
By Jared Staheli | Published July 7th, 2015 - Last Review/Update February 5th, 2018
For claims with dates of service on and after October 14, 2011, CMS will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and behavioral counseling for alcohol misuse, 15 minutes, G0443, only when services are submitted by the following provider specialties found on the provider’s enrollment record:
01 - ...
July 7th, 2015
Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for alcohol misuse screening and alcohol misuse behavioral counseling sessions:
• For RHC and FQHC claims that contain screening for alcohol misuse HCPCS code G0442 ...
July 7th, 2015
Professional Billing Requirements for Screening for Depression in Adults (Rev. 2431, 10-14-11)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the following claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare Summary Notice (MSN) messages when denying payment for G0444 when reported more than once in a 12- month period.
o CARC 119 – “Benefit maximum for this time period or occurrence has ...
July 7th, 2015
Institutional Billing Requirements for Screening for Depression in Adults (Rev. 2431, 10-14-11)
By Jared Staheli | Published July 7th, 2015
For claims with dates of service on and after October 14, 2011, Medicare will allow coverage for annual screening depression in adults, HCPCS G0444 for:
• Rural Health Clinics (RHCs) type of bill (TOB) 71X only – based on the all-inclusive payment rate.
• Federally Qualified Health Centers (FQHCs) TOB 77X only ...
July 7th, 2015
CARCs, RARCs, Group Codes, and MSN Messages for Screening for Depression in Adults (Rev. 2431, 10-14-11)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the appropriate CARC, RARC, group codes, or MSN messages when denying payment for annual depression screening in adults:
• For RHCs and FQHCs when screening for depression, HCPCS code G0444, with another encounter/visit with the same line-item date of service, use group code CO and :
o CARC 97 ...
July 7th, 2015
Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
For services furnished on or after November 29, 2011, Medicare will cover Intensive Behavioral Therapy for Obesity. Medicare beneficiaries with obesity (BMI ≥30 kg/m2 ) who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other ...
July 7th, 2015
Institutional Billing Requirements for Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Effective for claims with dates of service on and after November 29, 2011, providers may use the following types of bill (TOB) when submitting HCPCS code G0447: 13x, 71X, 77X, or 85X. Service line items on other TOBs shall be denied.
Effective for claims with dates of service on and after ...
July 7th, 2015
Professional Billing Requirements for Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
CMS will allow coverage for Face-to-Face Behavioral Counseling for Obesity, 15 minutes, (G0447), Face-to-face behavioral counseling for obesity, group (2-10), 30 minute(s) (G0473), along with 1 of the ICD-9 codes for BMI 30.0-BMI 70 (V85.30- V85.39 and V85.41-V85.45), only when services are submitted by the following provider specialties found on ...
July 7th, 2015
Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages for Policy for Intensive Behavioral Therapy (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for obesity counseling sessions:
• Denying services submitted on a TOB other than 13X and 85X:
CARC 171 – Payment is denied when performed by this ...
July 7th, 2015
Screening for Hepatitis C Virus (HCV) (Rev. 3215, 06-02-14)
By Jared Staheli | Published July 7th, 2015
Effective for services furnished on or after June 2, 2014, Medicare covers screening for hepatitis C Virus (HCV) with the appropriate U.S. Food and Drug Administration (FDA) approved/cleared laboratory tests, used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act regulations, when ordered by the beneficiary’s ...
July 7th, 2015
Institutional Billing Requirements for Screening for Hepatitis C Virus (HCV) (Rev. 3215, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Effective for claims with dates of service on and after June 2, 2014, providers may use the following types of bill (TOBs) when submitting claims for screening for HCV screening, HCPCS G0472: 13X, 71X, 77X, and 85X. Service line-items on other TOBs shall be denied.
The service shall be paid on ...
July 7th, 2015
Professional Billing Requirements for Screening for Hepatitis C Virus (HCV) (Rev. 3215, 01-05-15)
By Jared Staheli | Published July 7th, 2015
For claims with dates of service on or after June 2, 2014, Medicare will allow coverage for HCV screening, HCPCS G0472, only when services are ordered by the following provider specialties found on the provider’s enrollment record:
01 - General Practice
08 - Family Practice
11 - Internal Medicine
16 - Obstetrics/Gynecology
37 - Pediatric ...
July 7th, 2015
Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages for Screening for Hepatitis C Virus (HCV) (Rev. 3215, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for HCV screening, HCPCS G0472:
• Denying services submitted on a TOB other than 13X, 71X, 77X, or 85X:
CARC 170 - Payment is denied when ...
July 7th, 2015
Payment Allowance Limit for Drugs and Biologicals Not Paid on a Cost or Prospective Payment Basis (Rev. 131, 03-26-04)
By Jared Staheli | Published July 7th, 2015
Prior to January 1, 2004, drugs and biologicals not paid on cost or prospective payment are paid based on the lower of the billed charge or 95 percent of the average wholesale price (AWP) as reflected in published sources (e.g., Red Book, Price Alert, etc.). Examples of drugs that are ...
July 6th, 2015
Healthcare Common Procedure Coding System (HCPCS) Coding for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The HCPCS codes listed below were developed for the IPPE benefit effective January 1, 2005, for individuals whose initial enrollment is on or after January 1, 2005.
G0344: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 6 months of Medicare enrollment
Short Descriptor: Initial ...
July 6th, 2015
A/B Medicare Administrative Contractor (MAC) and Contractor Billing Requirements for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service on and after January 1, 2005, through December 31, 2008, contractors shall recognize the HCPCS codes G0344, G0366, G0367, and G0368 shown above in §80.1 for an IPPE. The type of service (TOS) for each of these codes is as follows:
G0344: TOS = 1
G0366: TOS ...
July 6th, 2015
Coinsurance and Deductible for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.
The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009. Coinsurance continues to apply for the IPPE provided on or after January 1, 2009.
As a result of the Affordable Care Act, ...
July 6th, 2015
Medicare Summary Notices (MSNs) for the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
When denying additional claims for G0344, G0366, G0367 and G0368, contractors shall use MSN 18.22 - This service was denied because Medicare only covers the one-time initial preventive physical exam with an electrocardiogram within the first 6 months that you have Part B coverage, and only if that coverage begins ...
July 6th, 2015
HCPCS Code for Ultrasound Screening for Abdominal Aortic Aneurysm (Rev. 1113, 01-02-07)
By Jared Staheli | Published July 6th, 2015
Effective for services furnished on or after January 1, 2007, the following code, modifiers, and type of service (TOS) are used for AAA screening services:
G0389: Ultrasound, B-scan and or real time with image documentation; for abdominal aortic aneurysm (AAA) screening
Short Descriptor: Ultrasound exam AAA screen
Modifiers: TC, 26
TOS: 4
...
July 6th, 2015
Advance Beneficiary Notice for Ultrasound Screening for Abdominal Aortic Aneurysm (Rev. 1113, 01-02-07)
By Jared Staheli | Published July 6th, 2015
Medicare contractors will deny an AAA screening service billed more than once in a beneficiary’s lifetime.
If a second G0389 is billed for AAA for the same beneficiary or if any of the other statutory criteria for coverage listed in section 1861(s)(2)(AA) of the Social Security Act are not met, the ...
July 6th, 2015
Coding and Payment of DSMT Services (Rev. 1255, 07-02-07)
By Jared Staheli | Published July 6th, 2015
The following HCPCS codes are used to report DSMT:
• G0108 - Diabetes outpatient self-management training services, individual, per 30 minutes.
• G0109 - Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes.
The type of service for these codes is 1.
Payment to physicians and providers for outpatient DSMT ...
July 6th, 2015
Healthcare Common Procedure Coding System (HCPCS) for HIV Screening Tests (Rev. 2199, 07-06-10)
By Jared Staheli | Published July 6th, 2015
Effective for claims with dates of service on and after December 8, 2009, implemented with the April 5, 2010, IOCE, the following HCPCS codes are to be billed for HIV screening:
• G0432- Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening,
• G0433 - Infectious agent antibody ...
July 6th, 2015
Billing Requirements for HIV Screening Tests (Rev. 2199, 07-06-10)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service December 8, 2009, and later, contractors shall recognize the above HCPCS codes for HIV screening.
Medicare contractors shall pay for voluntary HIV screening as follows in accordance with Pub. 100-03, Medicare National Coverage Determinations Manual, sections 190.14 and 210.7:
• A maximum of once annually for beneficiaries ...
July 6th, 2015
Healthcare Common Procedure Coding System (HCPCS) Coding for the AWV (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The HCPCS codes listed below were developed for the AWV benefit effective January 1, 2011, for individuals whose initial enrollment is on or after January 1, 2011.
G0438 - Annual wellness visit; includes a personalized prevention plan of service (PPPS); first visit
G0439 – Annual wellness visit; includes a personalized prevention plan ...
July 6th, 2015
A/B Medicare Administrative Contractor (MAC) and Carrier Billing Requirements for the AWV (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service on and after January 1, 2011, contractors shall recognize HCPCS codes G0438 and G0439 shown above in section 140.1 for billing AWVs. The type of service (TOS) for each of the new codes is 1. AWV services are paid under the Medicare Physician Fee Schedule ...
July 6th, 2015
Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Advance Beneficiary Notices (ABNs) for the AWV (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Messages for Carriers, FIs, and A/B MACs:
When paying claims for an AWV, contractors shall use the following Medicare Summary Notices (MSNs):
MSN: 18.25: “Your Annual Wellness Visit has been approved. You will qualify for another Annual Wellness Visit 12 months after the date of this visit.”
Spanish Version “Su Visita Anual de ...
July 6th, 2015
Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Coding for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
The CMS has created two new G codes for billing for tobacco cessation counseling services to prevent tobacco use for those individuals who use tobacco but do not have signs or symptoms of tobacco-related disease. These are in addition to the two CPT codes 99406 and 99407 that currently are ...
July 6th, 2015
Carrier Billing Requirements for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
Carriers shall pay for counseling to prevent tobacco use services billed with code G0436 or G0437 for dates of service on or after January 1, 2011. Carriers shall pay for counseling services billed with code 99199 for dates of service performed on or after August 25, 2010 through December 31, ...
July 6th, 2015
Fiscal Intermediary (FI) Billing Requirements for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
The FIs shall pay for counseling to prevent tobacco use services with codes G0436 and G0437 for dates of service on or after January 1, 2011. FIs shall pay for counseling services billed with code 99199 for dates of service performed on or after August 25, 2010, through December 31, ...
July 6th, 2015
Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Group Codes for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
When denying claims for counseling to prevent tobacco use services submitted without diagnosis codes 305.1 or V15.82, contractors shall use the following messages:
MSN 15.4: The information provided does not support the need for this service or item.
MSN Spanish Version: La informaciónproporcionada no confirma la necesidadparaesteservicio o artículo
RARC M64 - Missing/incomplete/invalid ...
July 6th, 2015
Coding Requirements for IBT for CVD Furnished on or After November 8, 2011 (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
The following is the applicable Healthcare Procedural Coding System (HCPCS) code for IBT for CVD:
G0446: Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes
Contractors shall not apply deductibles or coinsurance to claim lines containing HCPCS code G0446.
...
July 6th, 2015
Correct Place of Service (POS) Codes for IBT for CVD on Professional Claims (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
Contractors shall pay for IBT CVD, G0446 only when services are provided at the following POS:
11- Physician’s Office
22-Outpatient Hospital
49- Independent Clinic
72-Rural Health Clinic
Claims not submitted with one of the POS codes above will be denied.
The following messages shall be used when Medicare contractors deny professional claims for incorrect POS:
Claim Adjustment ...
July 6th, 2015
Provider Specialty Edits for IBT for CVD on Professional Claims (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
Contractors shall pay claims for HCPCS code G0446 only when services are submitted by the following provider specialty types found on the provider’s enrollment record:
01= General Practice
08 = Family Practice
11= Internal Medicine
16 = Obstetrics/Gynecology
37= Pediatric Medicine
38 = Geriatric Medicine
42= Certified Nurse Midwife
50 = Nurse Practitioner
89 = Certified Clinical Nurse Specialist
97= ...
July 6th, 2015
Correct Types of Bill (TOB) for IBT for CVD on Institutional Claims (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
Effective for claims with dates of service on and after November 8, 2011, the following types of bill (TOB) may be used for IBT for CVD: 13X, 71X, 77X, or 85X. All other TOB codes shall be denied.
The following messages shall be used when Medicare contractors deny claims for G0446 ...
July 6th, 2015
Frequency Edits for IBT for CVD Claims (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
Contractors shall allow claims for G0446 no more than once in a 12-month period.
NOTE: 11 full months must elapse following the month in which the last G0446 IBT for CVD took place.
Contractors shall deny claims IBT for CVD claims that exceed one (1) visit every 12 months.
Contractors shall allow one ...
July 6th, 2015
Healthcare Common Procedure Coding System (HCPCS) Codes for Screening for STIs and HIBC to Prevent STIs (Rev. 2476, 02-27-12)
By Jared Staheli | Published July 6th, 2015
Effective for claims with dates of service on and after November 8, 2011, the claims processing instructions for payment of screening tests for STI will apply to the following HCPCS codes:
• Chlamydia: 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810, 87800 (used for combined chlamydia and gonorrhea testing)
• Gonorrhea: 87590, ...
July 6th, 2015
Billing Requirements for Screening for STIs and HIBC to Prevent STIs (Rev. 2476, 02-27-12)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service November 8, 2011, and later, contractors shall recognize HCPCS code G0445 for HIBC. Medicare shall cover up to two occurrences of G0445 when billed for HIBC to prevent STIs. A claim that is submitted with HCPCS code G0445 for HIBC shall be submitted with ICD-9 ...
July 5th, 2015
Payment for Colorectal Cancer Screening (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 5th, 2015
Payment is under the MPFS except as follows:
• Fecal occult blood tests (82270* (G0107*) and G0328) are paid under the clinical diagnostic lab fee schedule except reasonable cost is paid to all non-OPPS hospitals, including CAHs, but not IHS hospitals billing on TOB 83x. IHS hospitals billing on TOB 83x ...
July 5th, 2015
Deductible and Coinsurance for Colorectal Cancer Screening (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 5th, 2015
There is no deductible and no coinsurance or copayment for the fecal occult blood tests (G0107 and G0328), flexible sigmoidoscopy (G0104), colonoscopy on individual at high risk (G0105), and colonoscopy on individual not meeting criteria of high risk (G0121). When a screening colonoscopy becomes a diagnostic colonoscopy anesthesia code 00810 ...
July 5th, 2015
HCPCS Codes, Frequency Requirements, and Age Requirements (If Applicable) - Colorectal Cancer Screening (Rev. 3096, 11-18-14)
By Jared Staheli | Published July 5th, 2015
Effective for services furnished on or after January 1, 1998, the following codes are used for colorectal cancer screening services:
• 82270* (G0107*) - Colorectal cancer screening; fecal-occult blood tests, 1-3 simultaneous determinations;
• G0104 - Colorectal cancer screening; flexible sigmoidoscopy;
• G0105 - Colorectal cancer screening; colonoscopy on individual at high risk;
• ...
July 5th, 2015
Common Working Files (CWF) Edits for Colorectal Cancer Screening (Rev. 1062, 01-02-07)
By Jared Staheli | Published July 5th, 2015
Effective for dates of service January 1, 1998, and later, CWF will edit all colorectal screening claims for age and frequency standards. The CWF will also edit FI claims for valid procedure codes (G0104, G0105, G0106, 82270* (G0107*), G0120, G0121, G0122, and G0328) and for valid bill types. The CWF ...
July 5th, 2015
Ambulatory Surgical Center (ASC) Facility Fee for Colorectal Cancer Screening (Rev. 1160, 07-02-07)
By Jared Staheli | Published July 5th, 2015
CPT code 45378, which is used to code a diagnostic colonoscopy, is on the list of procedures approved by Medicare for payment of an ambulatory surgical center facility under §1833(I) of the Act. CPT code 45378 is currently assigned to ASC payment group 2. Code G0105, colorectal cancer screening; colonoscopy ...
July 5th, 2015
Billing Requirements for Claims Submitted to FIs for Colorectal Cancer Screening (Rev. 1953, 10-04-10)
By Jared Staheli | Published July 5th, 2015
Follow the general bill review instructions in Chapter 25. Hospitals use the ANSI X12N 837I to bill the FI or on the hardcopy Form CMS-1450. Hospitals bill revenue codes and HCPCS codes as follows:
Screening Test/Procedure
Revenue Code
HCPCS Code
TOB
Fecal Occult blood test
030X
82270***
(G0107***),
G0328
12X, 13X,
14X**, 22X, 23X,
83X, 85X
Barium enema
032X
G0106,
G0120,
G0122
12X, 13X,
22X, 23X,
85X****
Flexible Sigmoidoscopy
*
G0104
12X, 13X,
22X, 23X,
83X, ...
July 5th, 2015
MSN Messages for Colorectal Cancer Screening (Rev. 1062, 01-02-07)
By Jared Staheli | Published July 5th, 2015
The following MSN messages are used (See Chapter 21 for the Spanish versions of these messages):
A. If a claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a barium enema is being denied because of the age of the beneficiary, MSN message 18.13 is used.
This service is ...
July 5th, 2015
Remittance Advice Notices for Colorectal Cancer Screening (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
All messages refer to ANSI X12N 835 coding.
A. If the claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the patient is less than 50 years of age, use:
• Claim adjustment reason code 6 “the procedure code is inconsistent ...
July 5th, 2015
HCPCS and Diagnosis Coding for Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
The following HCPCS codes should be reported when billing for screening glaucoma services:
G0117 - Glaucoma screening for high-risk patients furnished by an optometrist (physician for carrier) or ophthalmologist.
G0118 - Glaucoma screening for high-risk patients furnished under the direct supervision of an optometrist (physician for carrier) or ophthalmologist.
The carrier claims type ...
July 5th, 2015
Special Billing Instructions for RHCs and FQHCs for Glaucoma Screening Services (Rev. 371, 04-04-05)
By Jared Staheli | Published July 5th, 2015
Screening glaucoma services are considered RHC/FQHC services. For claims with dates of service before April 1, 2005, RHCs and FQHCs bill the FI under bill type 71X or 73X along with revenue code 0770 and HCPCS codes G0117 or G0118 and RHC/FQHC revenue code 0520 or 0521 to report the ...
June 25th, 2015
Table of Preventive and Screening Services (Rev. 3232, 01-05-15)
By Jared Staheli | Published June 25th, 2015
Service
CPT/HCPCS Code
Long Descriptor
USPSTF Rating
Coins./ Deductible
Initial Preventive Physical Examination, IPPE
G0402
Initial preventive physical examination; face to face visits, services limited to new beneficiary during the first 12 months of Medicare enrollment
*Not Rated
WAIVED
Initial Preventive Physical Examination, IPPE
G0403
Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with ...
June 25th, 2015
Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Codes (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
Vaccines and their administration are reported using separate codes. The following codes are for reporting the vaccines only.
HCPCS
Definition
90653
Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use
90654
Influenza virus vaccine, split virus, preservative-free, for intradermal use, for adults ages 18 – 64;
90655
Influenza virus vaccine, split virus, preservative free, for children 6- 35 ...
June 25th, 2015
CWF A/B Crossover Edits for FI/AB MAC and Carrier/AB MAC Claims (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
When CWF receives a claim from the carrier/AB MAC, it will review Part B outpatient claims history to verify that a duplicate claim has not already been posted.
CWF will edit on the beneficiary HIC number; the date of service; the influenza virus procedure codes 90653, 90654, 90655, 90656, 90657, 90660, ...
June 25th, 2015
HCPCS and Diagnosis Codes for Mammography Services (Rev. 3232, 01-05-15)
By Jared Staheli | Published June 25th, 2015
The following HCPCS codes are used to bill for mammography services.
HCPCS Code
Definition
77051*(76082*)
Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images, diagnostic mammography (list separately in addition to code for primary procedure). Code ...
June 18th, 2015
Completion of Certificate of Medical Necessity Forms (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
1. SECTION A: (This may be completed by supplier.)
a. Certification Type/Date - If this is an initial certification for this patient, the date (MM/DD/YY) is indicated in the space marked "INITIAL". If this is a revised certification (to be completed when the physician changes the order, based on the patient's ...
June 18th, 2015
Completion of the Elements of PEN CMN (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The patient's name, address, and HICN and the nature of the certification (i.e., initial, renewed, or revised) must be entered on all certifications by the supplier, physician, or physician's designated employees. The supplier identifying information is required on all PEN certifications.
All medical and prescription information must be completed from the ...
June 18th, 2015
Application of DMEPOS Fee Schedule (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Services that are paid under the DME fee schedule are identified in the DMEPOS fee schedule file available free on the CMS Web Site at: http://www.cms.hhs.gov/providers/pufdownload/default.asp
The DMEPOS fee schedule applies to claims to FIs as follows.
BILL TYPE/ DEFINITION
ORTHOTICS/ PROSTHETICS
DME/ OXYGEN
12X (Hospital inpatient Part B)
Subject to fee schedule
Not covered, therefore, ...
June 18th, 2015
Provider Billing for Prosthetic and Orthotic Devices (Rev. 2629, 02-05-13)
By Jared Staheli | Published June 18th, 2015
See § 01 for definition of provider.
These items consist of all prosthetic and orthotic devices excluding parenteral/enteral nutritional supplies and equipment and intraocular lenses.
Prosthetics and orthotic devices are included in the Part A PPS rate unless specified as being outside the rate. For SNFs, customized prosthetic devices that are not ...
June 18th, 2015
Billing for Inexpensive or Other Routinely Purchased DME (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
This is equipment with a purchase price not exceeding $150, or equipment that the Secretary determines is acquired by purchase at least 75 percent of the time, or equipment that is an accessory used in conjunction with a nebulizer, aspirator, or ventilators that are either continuous airway pressure devices or ...
June 18th, 2015
Billing for Certain Customized Items (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Due to their unique nature (custom fabrication, etc.), certain customized DME cannot be grouped together for profiling purposes. Claims for customized items that do not have specific HCPCS codes are coded as E1399 (miscellaneous DME). This includes circumstances where an item that has a HCPCS code is modified to the ...
June 18th, 2015
Oxygen Equipment and Contents Billing Chart (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The following chart indicates what oxygen fee schedule component is billable/payable under various transaction scenarios for providers and suppliers:
1. Situation: Beneficiary Uses a Stationary System Only
a. Rental Cases (Beneficiary Uses a Stationary System Only)
Type of System
Stationary Monthly Payment
Oxygen Content Fee
Portable Add-On
Portable Contents Fee
Concentrator
Yes
No
No
No
E1377 E1378 E1379 E1380 E1381 E1382 E1383 E1384 ...
June 18th, 2015
Billing for Maintenance and Servicing (Providers and Suppliers) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
General
Payment is not made for maintenance and servicing if the beneficiary rents the equipment since payment for maintenance and servicing are included in the rental payments. An exception to this is the 6-month service fee for capped rental items that the beneficiary has elected not to purchase (see §40.2 and ...
June 18th, 2015
Billing for Supplies and Drugs Related to the Effective Use of DME (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
Suppliers and providers bill supplies that are necessary for the effective use of DME, including drugs, with the appropriate HCPCS code identifying the supply. HHAs must also report revenue code 0294, "Supplies/Drugs for DME Effectiveness."
Suppliers and providers, other than HHAs, bill supplies and drugs (not including drugs that are necessary ...
June 18th, 2015
Institutional Provider Reporting of Service Units for DME and Supplies (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
Provider outpatient departments report service units using the ASC X12 837 institutional claim format or on the Form CMS 1450 the number of items being billed for orthotic and prosthetic devices.
For purchased DMEPOS items (excluding items requiring frequent and substantial servicing, capped rental items, and oxygen which cannot be purchased) ...
June 18th, 2015
Special Considerations for SNF Billing for TPN and EN Under Part B (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
The HCPCS code and any appropriate modifiers are required. SNFs bill the A/B MAC (B) for TPN and EN under Part B, using the ASC X12 837 professional claim format, or the Form CMS-1500 paper claim if applicable.
The following HCPCS codes apply.
B4034 B4035 B4036 B4081 B4082 B4083 B4084 B4085 B4150 ...
June 17th, 2015
Elimination of "Kit" Codes and Pricing of Replacement Codes (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Prior to 2002, most suppliers billed for dialysis supplies using codes describing "kits" of supplies. The use of kit codes allowed suppliers to bill for supply items without separately identifying the supplies that are being furnished to the patient. Effective January 1, 2002, these kit codes were deleted and suppliers ...
June 17th, 2015
Daily Payment for Continuous Passive Motion (CPM) Devices (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
The CPM devices (HCPCS code E0935) are classified as items requiring frequent and substantial servicing and are covered as DME as follows (see the Medicare National Coverage Determinations Manual.):
• Continuous passive motion devices are covered for patients who have received a total knee replacement. To qualify for coverage, use of ...
June 17th, 2015
Payment of DMEPOS Items Based on Modifiers (Rev. 489, 07-05-05)
By Jared Staheli | Published June 17th, 2015
The following modifiers were added to the HCPCS to identify supplies and equipment that may be covered under more than one DMEPOS benefit category:
• AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply;
• AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic; and
• AW ...
June 15th, 2015
Billing for Unlisted Drug Codes J3490 J9999 and C9399
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 15th, 2015 - Last Review/Update August 17th, 2017
When billing for unlisted drug codes J3490 and J9999 you must indicate the name, strength, and dosage of the drug in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in theANSI 837 claim file). It is extremely important to review the complete long descriptors in the HCPCS code, for the applicable HCPCS codes ...
June 15th, 2015
Billing for Unlisted Drug Codes J3490 J9999 and C9399
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 15th, 2015 - Last Review/Update August 8th, 2017
When billing for unlisted drug codes J3490 and J9999 you must indicate the name, strength, and dosage of the drug in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in theANSI 837 claim file). It is extremely important to review the complete long descriptors in the HCPCS code, for the applicable HCPCS codes you can ...
April 15th, 2015
Medicare Updates Preventive Exam and Wellness Visit Information
By Wyn Staheli, Director of Research | Published April 15th, 2015 - Last Review/Update June 9th, 2016
Medicare has updated their provider educational tools for the Initial Preventive Physical Examination (IPPE) and the Annual Wellness Visit (AWV). These tools were designed to help providers gain a greater understanding of these services. Learn what the required elements for these services as well as important coverage and coding information.
CLICK ...
April 9th, 2015
G0105 - Colorectal Cancer Screening; Colonoscopy on Individual at High Risk
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 9th, 2015 - Last Review/Update August 8th, 2017
Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). ...
March 16th, 2015
Plantar Fasciitis: Medical Necessity and Cross Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 16th, 2015 - Last Review/Update August 9th, 2017
Prior to treatment you must determine Medical Necessity.
Be sure conservative therapy/treatment was previously done and documented for at least 6 months and proven to be unsuccessful.
NSAIDS - at least 4 weeks ineffective or contraindicated
Physical Therapy such as taping and stretching
Activity modification
Splints used at night for more that 4 weeks
Corticosteroid injection
Arch Supports, ...
March 9th, 2015
Billing Imminuzation for Pneumococcal, Influenza, and Hepatitis B with Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 9th, 2015 - Last Review/Update August 9th, 2017
The current diagnosis pointer for, Influenza, Pneumococcal or Hepatitis B vaccines is ICD-10-CM code Z23. Listed are tips for coding, and also the diagnosis pointers used for claims previous to 10/01/15:
Influenza: G0008
Procedure codes:
90630
90653-90662
90672-90674
90685-90688
Medicare codes:
Q2034-Q2039
Expired diagnosis code:
V04.81
Pneumococcal: G0009
Procedure codes:
90670
90732
Expired diagnosis code:
V03.82
Hepatitis B: G0010
Procedure codes
90739-90747
Expired diagnosis code
V05.3
Both Influenza and Pneumococcal Vaccines received in same visit: G0008 with G0009
Procedure codes:
(See previous)
Expired diagnosis code:
V06.6 (effective 10/01/06 - 09/30/15)
Extra Tips:
Be sure ...
February 25th, 2015
Aetna Policy on Bathroom and Toilet Equipment and Supplies - Coverage
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 25th, 2015 - Last Review/Update February 18th, 2016
Clinical Policy Bulletin:Bathroom and Toilet Equipment and Supplies
Number: 0429
Policy Aetna's HMO-based and health network plans (HMO, QPOS, Health Network Only, Health Network Option, Golden Medicare, and U.S. Access) generally follow Medicare's criteria for durable medical equipment (DME) items that are used in the bathroom. Most DME items used in the bathroom are ...
February 21st, 2015
Implementation of a Prospective Payment System (PPS) for Federally Qualified Health Centers (FQHCs)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update March 1st, 2016
CMS is establishing five specific payment codes to be used by FQHCs submitting claims under the PPS:
1. G0466 – FQHC visit, new patient A medically-necessary, face to face encounter (one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes ...
February 21st, 2015
Billing Requirements for G0466, G0467, G0468, G0469 or G0470 - MLN
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update February 18th, 2016
Basic Billing Requirements
When reporting an encounter/visit for payment, the claim (77X TOB) must contain a FQHC specific payment code (G0466, G0467, G0468, G0469 or G0470) that corresponds to the type of visit.
FQHC specific payment specific codes G0466, G0467 and G0468 must be reported under revenue code 052X or under ...
February 13th, 2015
Chiropractic Services - Aetna Clinical Policy Bulletin
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 13th, 2015 - Last Review/Update March 1st, 2016
AETNA
Clinical Policy Bulletin: Chiropractic Services
Number: 0107
http://www.aetna.com/cpb/medical/data/100_199/0107.html
Policy
Note: Some plans have limitations or exclusions applicable to chiropractic care. Please check benefit plan descriptions for details.
Aetna considers chiropractic services medically necessary when all of the following criteria are met:
The member has a neuromusculoskeletal disorder; and
The medical necessity for treatment is clearly documented; and
Improvement is ...
February 9th, 2015
Coding And Billing For JETREA - Physician Office
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 9th, 2015 - Last Review/Update August 9th, 2017
The information contained below is provided for informational purposes only and is not intended to provide specific guidance on how to code, bill, or charge for any product or service. The following list provides possible codes that may relate to the use of JETREA for its approved indication and is ...
February 9th, 2015
Coding And Billing For JETREA® - Hospital Outpatient Department
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 9th, 2015 - Last Review/Update August 9th, 2017
The information contained below is provided for informational purposes only and is not intended to provide specific guidance on how to code, bill, or charge for any product or service. The following list provides possible codes that may relate to the use of JETREA for its approved indication and is ...
February 5th, 2015
Medicare Resources
By | Published February 5th, 2015 - Last Review/Update April 5th, 2018
For detailed information on this government program, as it relates to Chiropractic services, see Section C-Medicare in theChiroCode DeskBook.
You need to understand the following concepts:
Enrollment/Revalidation
How Medicare Payment Works
Medicare as Secondary Payer (MSP) - resource 218 and 219
MAC Jurisdictions
Medicare Coverage of Chiropractic Services
Maintenance Care vs Active Care - resource
Medicare Appeals
Physician Quality Reporting System (PQRS) - resource 317
Advance ...
January 16th, 2015
Billing for Split Unit of Blood
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 16th, 2015 - Last Review/Update March 1st, 2016
Billing for Split Unit of Blood
(Rev. 1487, Issued: 04-08-08, Effective: 04-01-08, implementation: 04-07-08)
HCPCS code P9011 was created to identify situations where one unit of blood or a blood product is split, and some portion of the unit is transfused to one patient while the other portions are transfused to other patients ...
December 23rd, 2014
CMS Announces New HCPCS Modifiers to be Implemented January 2015
By | Published December 23rd, 2014 - Last Review/Update January 30th, 2017
Beginning January 5, 2015 CMS (Centers for Medicare and Medicaid Services) requires new HCPCS modifiers to be used in place of modifier 59 for all Medicare claims.
These new subset modifiers are known as -X{ESPU} and are defined as follows:• XE - separate encounter, a service that is distinct because it ...
December 4th, 2014
New G-Codes Released by CMS for FQHC PPS (Federally Qualified Health Centers)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Medicare has established 5 new codes for reporting FQHC (Federally Qualified Health Center) services effective Oct 01, 2014. Very specific guidelines are to be followed for proper reimbursement.
G0466 — A medically-necessary, face to face encounter (one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services ...
December 4th, 2014
Vacuum Erection Devices (VED)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Vacuum pumps coded L7900 must demonstrate a capability to generate a negative pressure in the range of greater than 3.9 and less than 17 inches of mercury (100 and 432 mmHg, respectively). All devices coded L7900 for reimbursement by Medicare must include a vacuum limiter such that a maximum vacuum ...
December 4th, 2014
Collagen Surgical Dressings - Coding Verification Review Requirement
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
In the case of collagen dressings coded A6021, A6022, A6023 and A6024, the predominate component must be collagen.
Effective for claims with dates of service on or after June 1, 2013, the only products which may be billed to Medicare using code A6021, A6022, A6023 and A6024 are those for which ...
December 4th, 2014
Correct Coding MyoPro® (Myomo, Inc.) Assist Device
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have evaluated the MyoPro® upper extremity assist device and determined that it falls within the Durable Medical Equipment (DME) benefit category. Claims for MyoPro® should be submitted using the DME miscellaneous code E1399.
Suppliers are reminded that when submitting claims for items ...
December 4th, 2014
Correct Coding and Coverage of Ventilators
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC Publication
Ventilator technology has evolved to the point where it is possible to have a single device capable of operating in numerous modes, from basic continuous positive pressure (CPAP and bi-level PAP) to traditional pressure and volume ventilator modes. This creates the possibility that one piece of equipment ...
December 4th, 2014
Correct Coding: Lithium Batteries
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
The DME MACs have recently noted confusion on the part of DMEPOS suppliers regarding the proper billing of lithium batteries. There are two types of lithium batteries Lithium batteries and Lithium Ion batteries. Lithium ion batteries are commonly used in consumer electronic devices and are rechargeable. Standard lithium batteries are disposable, non-rechargeable batteries. ...
December 4th, 2014
Coverage and Correct Coding of Continuous Glucose Monitoring Devices
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC Publication
Continuous glucose monitoring (CGM) devices measure glucose in the interstitial fluid, not capillary blood, providing interstitial glucose readings every few minutes. CGM systems are composed of several components — disposable sensors that are inserted in the subcutaneous tissue, a transmitter that relays information to the receiver, and a ...
December 4th, 2014
Off the Shelf - OTS Orthotics New Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
In February 2012, The Center for Medicare and Medicaid Services (CMS) issued guidance that initially identified specific Healthcare Common Procedure Coding System (HCPCS) codes that were considered Off-the-Shelf (OTS) orthoses. The list of HCPCS codes that were finalized as part of this review as OTS orthotics, effective January 1, 2014, ...
December 4th, 2014
Correct Coding - Cefaly®
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
The Cefaly® device (Cefaly Technology) is a transcutaneous electrical nerve stimulator (TENS) that is applied to the forehead using a self-adhesive electrode positioned bilaterally over the upper branches of the trigeminal nerve. The Cefaly® device is intended to stimulate the upper branches of the trigeminal nerve and has received Food ...
December 4th, 2014
Correct Coding: Braces (Orthoses) Attached to Wheelchairs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC and PDAC Publication
Recently, claims for braces attached to wheelchairs have been submitted using HCPCS code K0108 - WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED. K0108 is not the correct HCPCS code to use for these items.
CMS has clarified the distinction between braces (orthoses) and durable medical equipment (DME) under Medicare Part ...
December 3rd, 2014
Coding for Laser Therapy
By | Published December 3rd, 2014 - Last Review/Update January 30th, 2017
The Rule of Coding: Service Codes define "what" you do; diagnosis codes define "why" you're doing it. Billing for laser or any other service must be properly defined and supported by both a service code and a diagnosis code.
Coverage for laser, as with any other service, is strictly dependent upon the ...
November 24th, 2014
Billable HCPCS Codes vs. Payable HCPCS Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 24th, 2014 - Last Review/Update August 9th, 2017
The PDAC (Medicares - Pricing, Data Analysis and Coding) receives frequent inquiries regarding a billable HCPCS code and a payable HCPCS code. One may think the two are the same; however, this is not the case.
A billable HCPCS code is one that is submitted on a claim to the DME ...
November 21st, 2014
Coding for Laser Therapy
By | Published November 21st, 2014 - Last Review/Update January 30th, 2017
The Rule of Coding: Service Codes define "what" you do; diagnosis codes define "why" you're doing it. Billing for laser or any other service must be properly defined and supported by both a service code and a diagnoses code.
Coverage for laser, as with any other service, is strictly dependent upon the ...
November 5th, 2014
Is Modifier -59 going away?
By | Published November 5th, 2014 - Last Review/Update January 30th, 2017
Anyone who uses modifier 59 needs to be aware that due to problems with the incorrect usage of this modifier (which by the way is also revised for 2015,) CMS has added four new HCPCS modifiers. An announcement by CMS stated that "CMS is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.”
The new codes are:
August 12th, 2014
How do I find a HCPCS code for a laxative given to a patient in our office?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update August 9th, 2017
A Laxative is considered a “Self Administered Drug” (SAD). Insurance will usually pay for the care you provide but will only cover certain drugs in the outpatient setting such as drugs administered through an IV. Therefore it would not be appropriate to report this under the Outpatient Prospective Payment System ...
August 7th, 2014
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2014 - Last Review/Update January 25th, 2017
Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount.  We have given you some basic information to get you started including modifiers and how CMS views DMEPOS, please ...
July 16th, 2014
Coding Screening Mammograms
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 16th, 2014 - Last Review/Update January 25th, 2017
Mammography is a method of taking x-ray images of the breasts to identify tumors or abnormalities in the tissues that may indicate breast cancer. Screening Mammography: Screenings are performed on otherwise healthy individuals to look for cancer or precursors to cancer of the breasts. Early detection of breast cancer ...
July 16th, 2014
G0402: Medicare Preventive Visit
By | Published July 16th, 2014 - Last Review/Update January 25th, 2017
Medicare covers a one-time Initial Preventive Physical Examination (IPPE), also referred to as the “Welcome to Medicare†visit.  IPPE is a unique benefit available only to patients newly enrolled in the Medicare Program and must be received within the first 12 months of the effective date of their Medicare Part ...
January 1st, 2014
Testing & Screening Tools
By Wyn Staheli, Director of Research | Published January 1st, 2014 - Last Review/Update October 4th, 2017
There are numerous types of behavioral health screening tools for healthcare providers. Some, like the AUDIT and SBIRT are especially applicable to primary care providers caring for Medicare beneficiaries.
This page includes some general information and resources for some of these screening tools. Let us know if you would like others included ...
November 8th, 2013
Modifiers –Reimbursement or Informational?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 8th, 2013 - Last Review/Update November 3rd, 2017
Modifiers are used to help describe the encounter, and used to further explain the procedure to the payer. Modifiers will be used if the procedure does not fit or clearly explain the entire encounter.
There are two types of modifiers:
Informational modifiers that do not impact reimbursement
Pricing or Payment modifiers that ...
December 31st, 2001
Commonly Asked Chiropractic Coding Questions
By ChiroCode | Published December 31st, 2001 - Last Review/Update August 19th, 2015
Commonly Asked Questions:
1. Retention of Records
2. 97140 Denials
3. Exercise Equipment
4. Coding for BioFreeze
5. 97014 or G0283
6. Billing for additional insurance forms
7. Report of Findings
8. Laser therapy
9. Spinal Decompression
10. Diagnosis Coding – 4th and 5th digit
11. Re-Reading X-rays
12. Outcomes Assessment Questionnaires
13. Accounts Receivable
14. 15-Minute Units
15. E/M and CMT
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