"CPT Coding" & "HCPCS Coding" & "Procedure Coding" & "Medicare Secondary Payer" Articles


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Q/A: For E/M, How do I Count Tests Ordered in One Department and Performed in Another?

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Question: I am in an ENT office as part of a large clinic with separate practices including audiology, CT, and allergy, all billing under the same TAX ID. Sometimes tests are ordered which are done in other departments that my office does not bill for, would those be considered an outside source? Answer: This is a great question and one that has been asked by many coders and auditors.

How to Combat COVID-Related Risk Adjustment Losses with the Medicare Annual Wellness Exam

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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 ...

58% of Improper Payments due to Medical Necessity for Ventilators

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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 ...

Coding Lesions and Soft Tissue Excisions

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There are several considerations to be aware of before assigning a code for lesions and soft tissue excisions. The code selection will be determined upon the following: Check the pathology reports, if any, to confirm Morphology (whether the neoplasm is benign, in-situ, malignant, or uncertain) Technique Topography (anatomic location) The size Tissue Level Type of closure required Layers ...

Properly Reporting Imaging Overreads (Including X-Rays)

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hile many provider groups offer some imaging services in their offices, others may rely on external imaging centers. When the provider reviews images performed by an external source (e.g., independent imaging center), that is typically referred to as an overread or a re-read. Properly reporting that work depends on a variety of factors as discussed in this article.

Evaluation & Management (E/M) Webinar Q/A

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Find answers to some questions asked by attendees of our recent webinar regarding the changes released by the AMA in their March 9, 2021 Errata and Technical Corrections document in relation to Evaluation & Management (E/M).

How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment

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The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.

Understanding Skin Biopsy Codes

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A biopsy is a procedure to obtain only a portion of a lesion for a pathologic exam. According to the AMA, "The use of a biopsy procedure code (e.g., 11102, 11103) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other ...

How Reporting E/M Based on Time May Lose Money

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Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...

Critical Evaluation and Management Changes Recently Announced by AMA

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On March 9, 2021, the American Medical Association (AMA) announced some pretty significant changes in relation to reporting Evaluation and Management (E/M) services, particularly for Office or Other Outpatient Services (99202-99215). The AMA Editorial Panel had previously met to discuss how to address concerns and made changes surrounding Office or Other Outpatient Services which are retroactive to January 1, 2021. Learn more about those changes in this article.

How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment

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The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.

COVID-19 Vaccines

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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 ...

Why CMS Created G2212 for Prolonged Services Instead of 99417

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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.

2021 Medicare Physician Fee Schedule Updates - Do You Really Need to Worry?

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How To Properly Report Prolonged Services Using 99417 or G2212

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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 ...

New Procedure Codes for the Janssen COVID-19 Vaccine

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On January 19, 2021, the AMA announced two new CPT codes for reporting the Janssen Pharmaceutica (a division of Johnson & Johnson) COVID-19 vaccine. Of course, just as with the other COVID-19 vaccines, they must be given FDA approval for Emergency Use Authorization (EUA) to be administered before the codes can be reported. As is ...

AMA Announcement of Additional COVID Vaccine Codes and Guideline Changes in December

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On Friday, December 17, 2020, the AMA announced several changes in relation to the addition of new codes for the COVID-19 vaccine under development by AstraZeneca and University of Oxford. Codes 91302, 0021A, and 0022A were published on the AMA website and will be effective once they have received Emergency Use Authorization (EUA) from the FDA.

Good and Bad News Regarding the 2021 Medicare Physician Fee Schedule

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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?

Instructions for Looking up IOM References in innoviHealth's HCPCS Publication

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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.

CMS Final Rule Changes E/M Reporting Guidelines

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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.

CMS Final Rule Changes E/M Reporting Guidelines

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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.

Common Medical to Dental Procedures and Where to Find Them

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With healthcare integrating and consolidating the delivery of healthcare systems, it only makes sense using medical insurance affords better management of care, dental providers are quickly picking up the slack on dental policies and utilizing healthcare coverage, understanding this affords better care for their patients. There are many common dental procedures that ...

CDT and CPT - The Same but Different!

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Reporting a CPT code for an evaluation of a patient is based on time and if the patient is a new or established patient. Evaluation and Management codes are different than other codes, it is important to understand how they are used, prior to 2021 they were based on a ...

Final Rule on Communications Technology and 2021 Physicians Fee Schedule

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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. ...

Clinical Documentation in Find-A-Code!

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Clinical documentation is one of the most important aspects of coding, Find-A-Code offers documentation tips and requirements in several places. You can find general information with our TIPS and articles or information directly from a particular payer or source. Below are a few examples to help you get started. Commercial Payer ...

How Might the New 2021 E/M Guideline Changes Impact Risk Adjustment?

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While provider organizations are busy learning the new E/M guideline changes being implemented January 1, 2021, Medicare Advantage Organizations (MAOs) are contemplating how the documentation changes for these services may impact risk adjustment coding. To be clear, the new E/M guidelines only pertain to Office and Other Outpatient E/M Services ...

COVID Vaccine Codes Announced

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On November 10, 2020, the American Medical Association (AMA) announced the addition of two new codes which will be used for the new COVID-19 vaccines along with 4 new administration codes to be used when reporting the administration of these vaccines.

What is the Difference Between the Medicare 1995 and 1997 Documentation Guidelines for E/M Services?

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When Medicare determined that providers could follow EITHER the 1995 OR the 1997 Documentation Guidelines for Evaluation and Management Services to determine which level of E/M service to report, because CMS had not clarified that portions of the 1995 and 1997 guidelines could be used together to determine the level of ...

Significant COVID-19 Code Changes as of October 6

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Significant COVID-19 Code Changes as of October 6

More COVID-19 Codes Added as of September 8, 2020

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The American Medical Association (AMA) recently announced the addition of two more CPT codes in relation to COVID and the Public Health Emergency (PHE). Codes 99702 and 86413 were posted to the AMA website on Tuesday, September 8, 2020 and new guidelines have been added as well.

Not Following the Rules Costs Chiropractor $5 Million

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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?

Ultrasound - A Complete Exam Must Include the Following

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Real time scanning of the kidneys Abdominal aorta Common iliac artery origins Inferior vena cava Alternaltively, if ultrasonography is being performed to evaluate the urinary tract, examination of the kidneys and urinary bladder constitutes a complete exam. Code 76775 is used when a limited retroperitoneal ultrasound examination is performed. ...

Coding Injections for Pain Management

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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 ...

Modifier 50 — Four "Must Know" Tips For Getting Paid

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Modifiers added to an HCPCS or CPT© code alters the code description, providing clarity about the service for proper claim processing and reimbursement. Here are four things you must know about modifier 50 to ensure proper payment. - Modifiers are either informational or payment related. Informational modifiers provide additional...

Impact of 2021 Proposed Medicare Fee Schedule on Chiropractic Offices

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On August 3, 2020, the proposed Medicare Physician Fee Schedule for 2021 was released. This 1,355 page document includes some sweeping changes to the Medicare program. There are a few items in particular which should be noted by chiropractic offices.

Coding with PCS When There is No Code

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ICD-10-PCS covers ALMOST everything! But not quite! What if a body system does not contain a body part for toes or fingers? What about an elbow? When it does not cover what you are looking for, where do you turn?  To the guidelines, of course! There are ICD-10-PCS guidelines just as ...

Use the Correct Diagnosis Codes and Revenue Codes to Get Paid for PAD Rehab

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The initial treatment in rehabilitation for patients suffering from Intermittent Claudication (IC) is Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD).  Rehabilitation using SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest.   When reporting 93668 for peripheral arterial disease rehabilitation the following ...

Are NCCI Edits and Modifiers Just for Medicare?

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The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...

Payment Adjustment Rules for Multiple Procedures and CCI Edits

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Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...

HCPCS Codes Were NOT all Created for the Same Purpose

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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 ...

Additional COVID-19 Testing Codes Announced

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New coronavirus antigen testing codes announced. These are effective immediately.

CMS- Reminder COVID Assessment and Specimen Collection

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On March 1, 2020, new codes and rules were released to bill for COVID-19 symptom and exposure assessments, as well as specimen collection. CMS has recently sent out reminders on billing for these services, the proper use of the CS modifier on claims, and how they are handling denials due ...

Outpatient Facility Pricing

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Our newest feature launch offers UCR pricing for Outpatient Facility. We recently released pricing information based on databases of insurance claims from private-sector health care providers.Usual, customary, and reasonable charges (UCR) are medical fees used when there are no contractual pricing agreements and are used by certain healthcare plans and third-party payers to generate ...

MEGA - NCCI Edit Changes - WHO Knew?

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There was no huge announcement when CMS released new files in April. The files that were released on April 7, 2020, actually replaced files to update the NCCI edits on Procedure to Procedure (PTP) edits and Medically Unlikely Edits (MUE).  The updated files included; 291,902 Deleted Procedure to Procedure (PTP) edits 197  Deleted Medically Unlikely ...

Watch for Payer Telehealth Coverage Changes

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As our country moves forward with a phased approach to reopening, be sure to pay close attention to individual payer policies regarding how long these changes will remain in effect. Keep in mind that private payer, federal programs (Medicare, Medicaid), and Medicare Advantage plans can all have different timelines as well as different coverage.

Additional Practice Reopening Tips

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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.

Packaging and Units for Billing Drugs

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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 ...

Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?

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On April 10th, CMS released a memo with the subject line, “Applicability of diagnoses from telehealth services for risk adjustment,” suggesting there may be some telehealth services that might not qualify for risk adjustment. However, in the memo CMS states: “Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face ...

Special COVID Laboratory Specimen Coding Information

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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.

Emergency Room and Ancillary Services

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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 ...

New CPT® Codes Approved for COVID-19 Antibody Identification

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On April 10, 2020, the American Medical Association approved and published a revision of code 86318 and added two new codes 86328 and 86769 for reporting Coronavirus [COVID-19] antibody testing.

Medicare Released the Amount they Will pay for COVID Testing Eff 4/14/2020

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CPT Coding Guidance on New Lab Code for COVID-19

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According to the AMA, "The Addition of one Category I Pathology and Laboratory code (87635) for severe acute respiratory syndrome coronavirus 2 (SARS-2-CoV-2) (Coronavirus disease [COVID-19]) accepted at the March 2020 CPT Editorial Panel meeting. *Note that code 87635 will be a child code under parent code 87471. It is represented here ...

More Telehealth Changes Announced by CMS Chiropractic Offices Should Know About

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On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). The announcement included far more information than is presented in this article which only summarizes the changes to telehealth. In fact, it does change a little of the information included in our March 31st webinar.

More Telehealth Changes Announced by CMS

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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

CMS-Coverage for Therapeutic Shoes for Individuals with Diabetes

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Therapeutic shoes and inserts can play a vital role in a diabetic patient's health. Medicare may cover one pair every year and three pairs of custom inserts each calendar year if the patient qualifies and everything is handled correctly.  Medicare Benefit Policy Manual explains what is needed for a person with diabetes to ...

Providing Telehealth Services During COVID-19 Crisis

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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.

Interprofessional Consult Services

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The recent coronavirus crisis has brought non-face-to-face services to the forefront of coding and billing conversations. With the entire healthcare industry focused on caring for patients during an unprecedented and fast-moving pandemic, the goal of increasing patient access while reducing the risk of spreading infection has become paramount. In this climate, ...

New Biofeedback Codes to replace 90911 Eff 2020-01-01

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CMS announced 90912 and 90913 are to be used starting January 2020 in place of 90911. According to CMS MLN, these new codes, designated as “sometimes therapy”, are reported to furnish these services outside a therapy plan of care when appropriate. Codes are permitted to be used by physicians and Non-Physician Practitioners (NPPs), ...

LATEST COVID-19 INFORMATION FOR BILLING NON-FACE-TO-FACE SERVICES

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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 ...

"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools

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Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...

Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)

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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 ...

Implementing Telehealth Visits

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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 ...

Additional Coronavirus Testing Code Announced

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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.

Acupuncture Clarification

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In the ChiroCode Newsletter released yesterday regarding Medicare coverage of acupuncture, one sentence in particular has let to some confusion. Read more about it here.

New HCPCS Code for Coronavirus Testing Announced

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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.

Medicare Begins Covering Acupuncture Services

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Medicare is changing their policy regarding coverage of acupuncture, but in order to provide these services, you must follow their rules.

A 2020 Radiology Coding Change You Need To Know

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The radiology section of the 2020 CPT© has 1 new, 18 revised, and 14 deleted codes. Interestingly, six of the 14 deleted codes were specific to reporting single-photon computerized tomographic (SPECT) imaging services of the brain, heart, liver, bladder, and others. If your organization reports radiology services, it is...

Medicare Announces Coverage of Acupuncture Services

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On January 21, 2020, a CMS Newsroom press-release read, This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...

Q/A: How do we Bill Massage Services?

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Question: We are adding a massage therapist soon and have some questions about billing their services.

Billing for Telemedicine in Chiropractic

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Many large private payers recognize the potential cost savings and improved health outcomes that telemedicine can help achieve, therefore they are often willing to cover it. While there are several considerations, there could be certain circumstances where telemedicine might apply to chiropractic care.

Q/A: Can Chiropractors Bill 99211?

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Can chiropractic offices bill code 99211? Technically it can be used by chiropractors, but in most instances, it is discouraged. Considering that 99211 is a low complexity examination for an established patient, this code is not really made for the physician to use. In fact, in 2021, changes are coming for this code...

Who Knew? There are Three Types of Add-On Codes

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Using add-on codes with HCPCS/CPT is not as simple as 123! Although there are three different groups of add-on codes assigned by CMS, these are used to identify code edits. It is easy to see the add-on code with some codes; we can see the instructional notes and phrases such ...

CPT 2020 Changes to Psychiatry Services

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As of January 1, 2020, CPT made changes to the health and behavior assessment and intervention codes (96150-96155) and therapeutic interventions that focus on cognitive function (97127). If you code and audit services in this category, you must pay close attention to the changes as they include the removal and ...


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