Modifier Coding Articles and Resources
News and Important InformationCode SetsCPT ModifiersCPT Modifiers HCPCS ModifiersHCPCS Modifiers Find-A-Code's Tools & ResourcesNCCI Editor ValidatorNCCI Edits Validator NCCI Edits Policy ManualMedicare NCCI Edits Manual, Transmittals, & Documents Additional Links and ResourcesBilling Requirements for OPPSBilling Requirements for OPPS Providers with Multiple Service Locations Commercial Modifier TablesCommercial Modifier Tables Modifier Reference PolicyUnited Health Care Modifier Reference Policy, Professional Select the title to see a summary and a link to the full article. August 4th, 2021 Understanding How Place of Service Codes WorkBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 4th, 2021
The Place of service (POS) codes are used by CMS, Medicaid, and other private insurance to indicate where medically related items and services are sold or dispensed for a patient. POS codes are used for professional billing and are required to be reported on each claim submitted on a CMS-1500 ... May 4th, 2021 Comparison of Add-On Code GuidelinesBy Wyn Staheli, Director of Research | Published May 4th, 2021 Add-on codes are codes that are not intended to be reported alone. They are reported with another primary procedure to identify that additional services have been provided in conjunction with that primary procedure. Generally, they include the words “List separately in addition to code.” Interestingly, there are some differences in the instructions/guidelines regarding the use of these codes in the CPT® codebook, the NCCI Policy Manual, and on the CMS website. This article outlines the differences between each of these. April 29th, 2021 Coding Lesions and Soft Tissue ExcisionsBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 29th, 2021 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 ... April 12th, 2021 Failure to Follow Payer’s Clinical Staff Rules Costs Provider $273KBy Wyn Staheli, Director of Research | Published April 12th, 2021 Clinical staff (e.g., LPN, RN, MA) provide essential services which allow providers to leverage their time and improve reimbursement opportunities and run their practices more efficiently. There is, however, an ongoing question of how to appropriately bill for clinical staff time. This is really a complex question which comes down to code descriptions, federal or state licensure, AND payer policies. Failure to understand licensing and payer policies led a Connecticut provider organization down a path that ended in a $273,000 settlement with both federal and state governments. April 8th, 2021 Properly Reporting Imaging Overreads (Including X-Rays)By Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research | Published April 8th, 2021 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. April 1st, 2021 Evaluation & Management (E/M) Webinar Q/ABy Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research | Published April 1st, 2021 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). January 5th, 2021 CMS Final Rule Changes E/M Reporting GuidelinesBy 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 GuidelinesBy 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. October 8th, 2020 Significant COVID-19 Code Changes as of October 6By Wyn Staheli, Director of Research | Published October 8th, 2020 - Last Review/Update October 13th, 2020 Significant COVID-19 Code Changes as of October 6 August 10th, 2020 Coding Injections for Pain ManagementBy 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 ... August 10th, 2020 Modifier 50 — Four "Must Know" Tips For Getting PaidBy Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published August 10th, 2020 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... July 14th, 2020 Are NCCI Edits and Modifiers Just for Medicare?By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 14th, 2020 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 ... July 9th, 2020 Payment Adjustment Rules for Multiple Procedures and CCI EditsBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2020 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 ... June 10th, 2020 MEGA - NCCI Edit Changes - WHO Knew?By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 10th, 2020 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 ... May 20th, 2020 Where is the CCI Edit with Modifier 25 on E/M?By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 20th, 2020 If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.
The use of Modifier 25 is one example ... May 13th, 2020 Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 13th, 2020
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 ... April 7th, 2020 More Telehealth Changes Announced by CMS Chiropractic Offices Should Know AboutBy Wyn Staheli, Director of Research | Published April 7th, 2020 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. April 2nd, 2020 More Telehealth Changes Announced by CMSBy 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 31st, 2020 CMS-Coverage for Therapeutic Shoes for Individuals with DiabetesBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 31st, 2020 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 ... March 30th, 2020 Providing Telehealth Services During COVID-19 CrisisBy 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 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 VisitsBy 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 ... January 14th, 2020 Billing for Telemedicine in ChiropracticBy Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published January 14th, 2020 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. January 7th, 2020 Denials due to MUE Usage - This May be Why!By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 7th, 2020 CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ... December 30th, 2019 Medicare Changes Bilateral Reporting Rules for Certain SuppliesBy 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. November 19th, 2019 Q/A: How do I Code a Procedure for the Primary Insurance so the Secondary Can Get Billed?By Wyn Staheli, Director of Research | Published November 19th, 2019 Question: How do you modify a code submitted to the primary insurance company to let them know it is not covered by them so you can bill to a secondary? October 18th, 2019 Medically Unlikely Edits (MUEs): Unlikely, But Not Always ImpossibleBy Namas | Published October 18th, 2019 - Last Review/Update October 23rd, 2019 Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ... September 30th, 2019 Vaccine Administration - When The Right Vaccine Code is Not EnoughBy 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 ... September 30th, 2019 Q/A: How Do I Bill a House Call?By Wyn Staheli, Director of Research | Published September 30th, 2019 Question
If a provider makes a house call to/for a patient, is there a way that it is represented on the claim form? A modifier, or something else?
Answer
Modifiers are not used to identify that a service was performed in the patient's home. However, other modifier rules must be followed (e.g., modifier GP ... August 19th, 2019 Understanding Payment IndicatorsBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 19th, 2019 Understanding how payment works with Medicare payment indicators and the impact a modifier has on payment is vital to pricing. Even if you are not billing Medicare, most carriers follow Medicare's policies for participating and non-participating rules. Here is an article from Regence on their policy statement, describing the rules ... 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 ... July 15th, 2019 Q/A: Do I Use 7th Character A for all Sprain/Strain Care Until MMI?By Wyn Staheli, Director of Research | Published July 15th, 2019 Question:
It is in regards to the Initial and Subsequent 7th digit (A and D) for sprains and strains. Recently, I have been told that I should continue with the A digit until the patient has reached Maximum Medical Improvement (MMI) and then switch over to the D place holder. Is ... June 18th, 2019 How to Properly Report Monitoring Patients Taking Blood-thinning MedicationsBy 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. May 27th, 2019 Q/A: For Physical Therapy Claims, What is the Correct Modifier Order?By Wyn Staheli, Director of Research | Published May 27th, 2019 - Last Review/Update June 6th, 2019 Question
Page 116 of the 2019 ChiroCode Deskbook shows examples for Medicare modifiers. Is this the specific order for the modifiers to be entered? Our practice management software system is advising the GP or GY should be used as Modifier 1 and not as Mod 2 or Mod 3.
Also, it shows the ... April 1st, 2019 Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?By Wyn Staheli, Director of Research | Published April 1st, 2019 I submitted a claim to the VA and it’s being denied. Why?
There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic ... April 1st, 2019 Spinal Cord Stimulator Used for Chronic PainBy 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 ... March 26th, 2019 CPT Codes Exempt from Modifier 51 (Appendix E)By Find-A-Code | Published March 26th, 2019 - Last Review/Update April 2nd, 2019 The following CPT codes are exempt from the use of modifier 51. These procedures are usually performed with another procedure, however, they may also be a stand-alone procedure.
17004
93456
93618
20697
93503
93631
20974
93600
94610
20975
93602
95905
31500
93603
95992
36620
93610
99151
44500
93612
99152
61007
93615
93451
93616
... March 26th, 2019 CPT Codes That Should Not Be Reported With Modifier 63 (Appendix F)By Find-A-Code | Published March 26th, 2019 - Last Review/Update April 2nd, 2019 The following codes should not be reported with modifier 63.
30540
33946
46735
30545
33947
46740
31520
33978
46742
33470
33949
46744
33502
36415
47700
33503
36420
47701
33505
36450
49215
33506
36456
49491
33610
36460
49492
33611
36510
49495
33619
36660
46196
33647
39503
49600
33670
43313
49605
33690
43314
49606
33694
43520
49610
33730
43831
19611
33732
44055
53025
33735
44126
54000
33736
44127
54150
33750
44128
54160
33755
46070
63700
33762
46705
63702
33778
46715
63704
33786
46716
63706
33922
46730
65820
... March 18th, 2019 How to Report Imaging (X-Rays) of the ThumbBy Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 18th, 2019 If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ... March 4th, 2019 Billing Guidelines for RepositioningBy 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 1st, 2019 Understanding NCCI EditsBy Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019 Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ... February 22nd, 2019 Q/A: What's the Difference Between Q5 and Q6 for a Substitute Provider?By Wyn Staheli, Director of Research | Published February 22nd, 2019 - Last Review/Update March 5th, 2019 It is important to understand that modifiers Q5 and Q6 are not interchangeable. So when do you use each of them? February 22nd, 2019 Separately Report a "Separate Procedure" with ConfidenceBy Namas | Published February 22nd, 2019 - Last Review/Update February 28th, 2019 Many procedures in the CPT® code book are designated "separate procedures," but that doesn't mean you can report those procedures separately in every case. First, you must consider other procedures performed during the same encounter.
"Separate" Might Not Mean What You Think It Does
You can always identify a designated separate procedure by the inclusion of "(separate ... February 13th, 2019 Detection by Nucleic Acid (DNA or RNA) - Amplified Probe TechniqueBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 13th, 2019 This question was asked on the following lab codes used for testing during pregnancy. "Can the codes below be billed together? 87491- 59, 87591-59. 87081, 87150."
YES- CPT code 87081 is used when a specific pathogen is suspected and is appropriate.
YES- (X2) 87150 is used for culture, typing, and identification by nucleic ... 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 7th, 2019 Q/A: Do Digital X-rays Have Their Own Codes?By Wyn Staheli, Director of Research | Published February 7th, 2019 - Last Review/Update February 8th, 2019 Question
Are you aware if digital x-ray of the spine requires a different code than plain x-ray? If so, where can I find the information specific to digital x-ray codes?
Answer
There are no separate codes for digital x-rays. However, there may be modifiers that are required to be submitted with the usual ... February 1st, 2019 Q/A: Can I Bill a Review of X-Rays?By Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | Published February 1st, 2019 It is not unusual for a healthcare provider to review x-rays taken and professionally read by another entity. Questions arise regarding how to bill this second review. It is essential to keep in mind that the global (complete) service of taking an x-ray is composed of both a professional and ... February 1st, 2019 Physical Therapy Caps Q/ABy 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 How to Report Co-Surgeons Using Modifier 62By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2019 Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session.
An easy way to explain this is to visualize a patient requiring cervical fusion where ... January 22nd, 2019 Home Oxygen TherapyJanuary 22nd, 2019 CPT Modifiers 96 & 97 for Habilitative and Rehabilitative Services (2018-01-01)By Find-A-Code | Published January 22nd, 2019 Effective January 1, 2018, CPT modifiers 96 "habilitative services" and 97 "rehabilitative services" will be in effect. There have been questions on whether modifier 96 will be preferred over HCPCS modifier SZ, which describes the same types of habilitative (but not rehabilitative) services, but payers have not yet indicated which modifier ... January 14th, 2019 AMA Issues new CMT InformationBy Wyn Staheli, Director of Research | Published January 14th, 2019 As many of you may already be keenly aware, there have been ongoing problems with many payers (e.g., BCBS of Ohio) regarding the appropriateness of reporting an E/M visit on the same day as CMT (CLICK HERE to read article). The AMA recently released an FAQ which renders their opinion ... January 4th, 2019 Nine New Codes for Fine Needle Aspirations (FNA) in 2019By 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 Dry NeedlingBy Wyn Staheli, Director of Research | Published January 3rd, 2019 The correct coding of dry needling, also known as trigger point needling, has been a subject of confusion for quite some time. The American Chiropractic Association (ACA) and the American Physical Therapy Association (APTA) have been working together for several years to obtain appropriate codes to describe this service. In ... December 18th, 2018 Reporting Unilateral or Bilateral CodesBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 18th, 2018 - Last Review/Update December 20th, 2018 Generally, Audiology tests are coded as if they were performed on both ears, if the testing was performed only on one ear, you are required to append a modifier to acknowledge there was a reduced service or a unilateral assessment, using modifier 52 - Reduced Services. (Be sure to read... November 26th, 2018 Reciprocal Billing and Locum Tenens Arrangements ChangesBy Wyn Staheli, Director of Research | Published November 26th, 2018 CMS has made changes to their payment policies for reciprocal billing arrangements and Fee-For-Time compensation arrangements (formerly referred to as locum tenens arrangements). Providers need to be aware of these changes and update their policies as appropriate. November 9th, 2018 Billing 99211 Its not a freebieBy | Published November 9th, 2018 - Last Review/Update November 29th, 2018 It seems like a simple code to bill, but CPT 99211 (established patient office visit) is by no means a freebie when it comes to documentation and compliance. This lowest level office visit code is sometimes called a "nurse visit" because CPT does not require that a physician be present... November 8th, 2018 Muscle Testing and Range of Motion InformationBy Wyn Staheli, Director of Research | Published November 8th, 2018 Be sure to understand the unique code requirements for Muscle and Range of Motion Testing. October 26th, 2018 Capped Rental ItemsBy | Published October 26th, 2018 - Last Review/Update January 9th, 2019 CMS Gives guidance on Capped Rental Items:
Items in this category are paid on a monthly rental basis not to exceed a period of continuous use of 13 months.
Based on Supplier Standard 5, suppliers are required to advise beneficiaries of the rent/purchase option for capped rentals and inexpensive or routinely purchased items. ... October 2nd, 2018 Use My Code Set to Save Priced ProceduresBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 2nd, 2018 Use My Code Set to save priced procedures to refer to commonly used procedures. Once your CCI edits are done and you have your list of Codes, add notes to My Codes. Add all important information to the Code, for viewing again instead of re-working your most commonly used procedures.... October 1st, 2018 When to Use Modifier 25 and Modifier 57 on Physician ClaimsBy BC Advantage | Published October 1st, 2018 - Last Review/Update October 17th, 2018 The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M. After that, the similarities end, and it is important to know the... September 28th, 2018 Chiropractic OIG Audit Recommendations - Lessons LearnedBy Wyn Staheli, Director of Research | Published September 28th, 2018 The OIG recently concluded an audit on a chiropractic office located in Florida and had some significant findings. They recommended the following:
Refund to the Federal Government the portion of the estimated $169,737 overpayment for claims for chiropractic services that did not comply with Medicare requirements and are within the 4-year ... August 16th, 2018 Using Modifiers 96 and 97By 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. ... August 13th, 2018 Using ModifiersBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 13th, 2018 Modifiers offer supplemental information and provide additional details without changing the procedure codes definition and are always two digits. Modifiers are required for proper billing and at times used with NCCI edits, however, two or more NCCI -associated modifiers on the same line will be denied. In addition, NCCI modifiers ... June 14th, 2018 Home Oxygen Therapy -- CMN for OxygenBy 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 7th, 2018 The Range of Motion ConundrumBy Gregg Friedman, DC, CCSP | Published June 7th, 2018 - Last Review/Update January 30th, 2019 As both a chiropractor for 31 years and one who reviews a lot of medical records for the medicolegal arena and has been teaching documentation for many years, the range of motion question comes up frequently. Although we used to get reimbursed very well for a specific range of motion code back in ... May 22nd, 2018 AMA vs Medicare rules and the use of the PT modifierBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 22nd, 2018 Be sure to review the specific payer policy you are submitting claims to. Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary. The use of the PT modifier is ... May 9th, 2018 Preventive Medicine: General ProceduresBy 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: Colorectal Cancer ScreeningBy 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 MethodsBy 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: Human Papilomavirus (HPV) Vaccine and ScreeningBy Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018 Preventive Medicine Topics Page
Human Papilomavirus (HPV) Vaccine and Screening
Procedure Codes 87623: Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) 87624: Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, ... May 9th, 2018 Preventive Medicine: Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity PreventionBy 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: Use of Modifier 33By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018 Preventive Medicine Topics Page
The Use of Modifier 33
Modifier 33 is used to indicate Preventive Services to report quality metrics and is informational only, it has no impact on reimbursement. Modifier 33 should be reported only to private payers, Medicare and Medicaid do not recognize this modifier.
... April 30th, 2018 Q/A: Should I be Using Modifier 96 on PT Claims?By Wyn Staheli, Director of Research | Published April 30th, 2018 - Last Review/Update January 30th, 2019 As chiropractors we feel the new modifier 97 is more appropriate than 96 for our PT codes such as stim and traction. Yet Carefirst is asking for 96 only. Should we use this code on all the PT codes and for all the other insurance companies? April 17th, 2018 Q/A: Modifiers for InjectionsBy Nicole Olsen QCC | Published April 17th, 2018 - Last Review/Update July 9th, 2018 I'm currently receiving a rejection for my billing with BCBS. We've entered 20550 and 20600 as services for the visit.... April 12th, 2018 Billing Nutrition Counseling in a Chiropractic SettingBy 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 CounselingBy 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 ... March 29th, 2018 Medicare Telemedicine Changes for 2018By 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 EncounterBy 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 26th, 2018 Q/A: Which Modifiers to Use When Billing 44005 and 36556 TogetherBy Chris Woolstenhulme QCC, CMCS, CPC, CMRS | Published March 26th, 2018 - Last Review/Update April 11th, 2018 I have a denial for 44005 and 36556 being billed together. I added modifiers 51, 59, and Q6 to 36556 but I am afraid it will deny again? March 21st, 2018 Q/A: Billing for GI AnesthesiaBy Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 21st, 2018 - Last Review/Update March 27th, 2018 Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary. March 13th, 2018 CPT Code for DOT examsBy Wyn Staheli, Director of Research | Published March 13th, 2018 - Last Review/Update January 31st, 2019 Question: I have a provider that provides Department of Transportation (DOT) exams. I have found ICD-10 code Z02.4 (encounter for examination for drivers license) but I am unsure which CPT Code to use. Would I still use 99203 or 99204? March 9th, 2018 Documentation for Negative Pressure Wound TherapyBy 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 DressingsBy 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 SuppliesBy 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 NutritionBy 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 Ostomy SuppliesBy 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 5th, 2018 Increased Therapy Denials Create Administrative BurdenBy Wyn Staheli, Director of Research | Published March 5th, 2018 Recently, many healthcare providers have begun to experience a downpour of denials when billing therapy services. The states which seem to be experiencing the most difficulty are Illinois, Oklahoma and Texas, particularly for claims submitted to BCBS plans owned by Health Care Service Corporation (HCSC). Since HCSC also owns Blues ... March 1st, 2018 Anthem Will Not Give Modifier 25 a Pay CutBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 1st, 2018 Anthems original plan was to take a 50% reduction when providers reported claims using modifier 25, it was then lowered to a 25% reduction and has now been fully rescinded, to the relief of providers. The policy was to go into effect March 1, 2018, however, due to strong opposition from ... March 1st, 2018 New Bipartisian Budget Act of 2018 ProvisionsBy Wyn Staheli, Director of Research | Published March 1st, 2018 On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References.
Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ... February 28th, 2018 Telemedicine Billing and ReimbursementBy 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 27th, 2018 CPT Modifers 96 & 97 for Habilitative and Rehabilitative ServicesBy Jared Staheli | Published February 27th, 2018 Effective January 1, 2018, CPT modifiers 96 "habilitative services" and 97 "rehabilitative services" will be in effect. CMS has added modifiers 96 and 97 to their edits (see MLN Matters MM10385 here) and modifier SZ is deleted as of December 31, 2017. Private payers should simply adjust their policies to use ... February 26th, 2018 OIG Issues Renewed Focus on Chiropractic ServicesBy Wyn Staheli, Director of Research | Published February 26th, 2018 The OIG recently released a "Portfolio" regarding chiropractic service which stated (emphasis added):
This portfolio presents an overview of program vulnerabilities identified in prior Office of Inspector General (OIG) audits, evaluations, investigations, and legal actions related to chiropractic services in the Medicare program. It consolidates the findings and issues identified in ... February 13th, 2018 New Modifiers Released in 2018By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 13th, 2018 There were 13 new modifiers released in 2018, be sure you are using them if appropriate.
FY
X-ray taken using computed radiography technology/cassette-based imaging
JG
Drug or biological acquired with 340b drug pricing program discount
QQ
Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was ... February 13th, 2018 Payment Rates Increase for Behavioral Health Office ServicesBy 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 How to Code Screening and Diagnostic ColonoscopyBy 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" ... 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 29th, 2018 Anesthesia Documentation Modifiers - Jurisdictions: J8A, J5A, J8B, J5BBy Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2018 Documentation Modifiers direct prompt and correct payment of the anesthesia claims submitted. Documentation modifiers (AA, QK, AD, QY, QX and QZ) must be billed in the first modifier field.
If a QS modifier applies, it must be in the second modifier field. Processing delays and denials may occur for claims submitted ... January 29th, 2018 Anesthesia and Fee CalculationBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 29th, 2018 - Last Review/Update June 3rd, 2021 Fees for anesthesia services are not calculated the same as for other types of procedures. There are four elements to consider when calculating anesthesia fees. Medicare accepts base units and time units; however, depending on the third party payer, they may or may not accept physical status units and/or qualifying circumstances units.
Base Unit (of the CPT code)
Time (in ... January 18th, 2018 What's the definition of an Office Visit and Can I Bill it With a Chiropractic Treatment?By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published January 18th, 2018 - Last Review/Update February 4th, 2019 What is the definition of Office Visit? Can It be billed with a Chiropractic Treatment? What about using code 99123 E&M code for office visits? Can we bill of office visits even though we are giving chiropractic care? January 16th, 2018 Patient Relationship CodesBy Wyn Staheli, Director of Research | Published January 16th, 2018 Section 1848(r)(4) of MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, include codes for the following:
care episode groups
patient condition groups
patient relationship categories
Previously, CMS decided to use procedure code modifiers to report patient relationship codes on Medicare ... January 15th, 2018 Medicare Requiring Specific Modifiers on Therapy ServicesBy 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 ModifierBy 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 Advance Beneficiary Notice of Noncoverage (ABN) Modifier GuidelinesBy Find-A-Code | Published January 11th, 2018 The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, GX, GY, or GZ, as ... 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 9th, 2018 Diagnosis billing with J0888By 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 Should ROM Testing be Reported with Evaluation and Management Services?By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 9th, 2018 Reporting the performance of range of motion testing (95851-95852) at the same encounter of an Evaluation and Management (EM) service, produces an NCCI edit resulting in payment for the EM service and denial of the ROM testing. Read the article to learn what other codes ROM testing is considered incidental to. January 9th, 2018 Outpatient Rehabilitation ModifiersBy 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 9th, 2018 Preventive Medicine with a New PatientBy Find-A-Code | Published January 9th, 2018 When coding for preventive care, be sure to use the correct encounter code with the procedure as well as the appropriate modifier if required.
New Patient: A patient that has not received any professional services i.e., E&M or any other face to face service from the physician or group within the ... January 5th, 2018 Medicare Reimburses for Discarded/Wasted DrugsBy 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 Acute Post-Operative Pain ManagementBy Find-A-Code | Published January 4th, 2018 CPT codes 62320, 62322 should be used when the analgesia is delivered by a single injection.These codes should only be used when the catheter or injection is not used for administration of anesthesia during the operative procedure. Modifier 59 should be used when billing these services to indicate that the catheter or injection was a ... January 4th, 2018 Filing a CMS-1500 Claim form to Medicare PUB-100 40.1.1.1By Find-A-Code | Published January 4th, 2018 An independent clinical laboratory may file a paper claim form shall file Form CMS-1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90.
An independent clinical laboratory that submits claims in paper format) may not combine non-referred (i.e., ... January 4th, 2018 Physical Therapist can now bill for a substitute Physical TherapistBy Find-A-Code | Published January 4th, 2018 As of 6/13/2017 Medicare contractors shall accept claims from Physical Therapists, Provider Specialty 65 – Physical Therapist in Private Practice, for services provided by a substitute physical therapist under a fee-for-time compensation arrangement when submitted with the Q6 modifier.
The A/B MAC Part B may pay the patient’s regular physician for physicians' ... January 4th, 2018 Billing Negative Pressure Wound Therapy (NPWT) (disposable device)By Find-A-Code | Published January 4th, 2018 Per CMS: Disposable NPWT services are billed using the following Current Procedural Terminology® (CPT®) codes:
97607 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or ... January 4th, 2018 Modifiers 54-55, split surgical and postoperative careBy Find-A-Code | Published January 4th, 2018 54 -Surgical care only; Surgeon is performing only the preoperative and intra-operative care
55 - Postoperative management only; Physician, other than surgeon, assumes all or part of postoperative care
Modifiers should be placed on the surgical code
Used on 10 day and 90 day surgical procedures
Both the surgeon and the physician providing the postoperative ... December 28th, 2017 Cleft Surgical ServicesBy Raquel Shumway | Published December 28th, 2017 Cleft palate and cleft lip diagnoses medical in nature and as such should be reported using the Current Procedural Terminology (CPT) codes instead of the Current Dental Terminology (CDT) codes. As such, Evaluation and Management (EM) services should be reported for the initial encounter with the patient and follow-up care ... December 28th, 2017 AnesthesiaBy Raquel Shumway | Published December 28th, 2017 Anesthesia services fall into one of the following categories ranging from lowest to greatest:
Local or topical anesthesia (not covered here)
Moderate (conscious) sedation (See “Moderate Sedation” on page xx)
Regional anesthesia
General anesthesia
Anesthesia is the administration of a drug or gas to induce partial or complete loss of consciousness. General anesthesia may only ... December 28th, 2017 DME Documentation RequirementsBy Wyn Staheli | Published December 28th, 2017 Properly documenting DME orders is crucial for reimbursement. It should be noted that without meeting the payer requirements, the claim will be denied. For Medicare, the beneficiary will not be responsible for paying for the item if the provider and/or supplier do not meet requirements. Commercial payers have similar policies so carefully ... December 13th, 2017 AT and GA Modifiers When Billing CMT and Non-covered Codes to MedicareBy Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published December 13th, 2017 - Last Review/Update February 5th, 2019 Questions regarding using modifiers when billing CMT and non-covered codes to Medicare. We have used AT (Active) and GA (signed ABN) when billing active care for CMT codes 98940-98942 (e.g., 98941-ATGA) in the past. Currently we are told not to bill GA with AT. How do we bill? December 12th, 2017 THE EOB SAYS “BUNDLED” - NOW WHAT?By Marge McQuade CMSCS, CHCI, CPOM | Published December 12th, 2017 Payers often bundle separate codes together so that they can pay you less. Just because the EOB says the codes are bundled doesn’t mean you have to let the insurance company get away with it. Fight Back!!! How does bundling work? If a patient presents for evaluation of diabetes, and... 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 ... November 7th, 2017 Four Final Rules Affecting CMS Payments for 2018By Wyn Staheli, Director of Research | Published November 7th, 2017 It’s a season for changes. CMS just finalized four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018
HHAs: Payment Changes for 2018
Quality Payment Program Rule for Year 2
This ... October 31st, 2017 Modifier NUBy Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published October 31st, 2017 - Last Review/Update February 5th, 2019 Is it necessary to use the modifier NU for all supplies? or is NU part of the code itself? Where should the NU be noted on the 1500 form? October 18th, 2017 Physicians Reciprocal Billing ArrangementsBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 18th, 2017 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 AssessmentBy Find-A-Code | Published September 30th, 2017 - Last Review/Update October 1st, 2017 Coding tips regarding Annual Wellness Visit and Health Risk Assessments September 22nd, 2017 New Policy from UnitedHealthcareBy Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA | Published September 22nd, 2017 - Last Review/Update January 31st, 2018 In the June 2017 UHC Network Bulletin, there was an article that addressed UHC's decision to no longer pay for consultation services..... September 8th, 2017 Global Surgical Package: When to Bill and When Not to Bill, that is the QuestionBy 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: Colorectal Cancer ScreeningBy 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: Diabetes ScreeningBy Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018 The following information from the Medicare Learning Network provides guidance on Diabetes Screening..... August 17th, 2017 Q/A: What are the Rules for a Fill-in (locum tenens) Doctor?By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 17th, 2017 - Last Review/Update February 5th, 2019 A locum tenens provider is one that works in the place of the regular physician for a short duration of time. Guideline typically allows this time period to be a 60 day maximum, when a substitute doctor would be brought in to your office to cover your original doctor's actual schedule during the time he/she is absent.
Read further for more information August 16th, 2017 If It’s Not a Consultation, What Is It?By Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC | Published August 16th, 2017
You thought you had a consultation supported in your documentation, and now you find out that you cannot bill the consultation codes (99241-99245, 99251- 99255). So, what are the top reasons for a consultation not to be supported?
If the payer does not support these codes
If the documentation does not support ... August 4th, 2017 Proposed Telehealth Changes for 2018By 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 ... July 21st, 2017 Billing for Face-to-Face CounselingBy ChiroCode | Published July 21st, 2017 - Last Review/Update January 31st, 2019 Question: How should I bill for face-to-face Counseling time spent with the patient? July 7th, 2017 Telemedicine: The Next Frontier in Care DeliveryBy 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 27th, 2017 Modifier JW With Drug CodesBy 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 21st, 2017 Q/A: What Modifier Can I Use When Billing Massage Code 97124 With 97140?By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published June 21st, 2017 - Last Review/Update February 8th, 2019 Q. Can you tell me what modifier I can use when billing massage code 97124 with 97140? I was using -59, but I am not sure that is correct June 13th, 2017 Modifier GY for ChiropracticBy ChiroCode | Published June 13th, 2017 - Last Review/Update January 31st, 2019 Q. Is there a modifier that can be added on to CPT codes to show we performed the service even though they are bundled charges or Medicare doesn't pay for them? For example 97140 billed to BCBS or 99202 billed to Medicare. Is the GY modifier for all insurance companies or just Medicare? June 8th, 2017 Facet Joint InjectionsBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 8th, 2017 - Last Review/Update July 26th, 2017
Medicare will consider facet joint blocks to be reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to document and confirm suspicions of posterior element biomechanical pain of the ... June 5th, 2017 Modifier 59By Find-A-Code | Published June 5th, 2017 - Last Review/Update July 26th, 2017 Definition - The “-59” modifier is used to indicate a distinct procedural service. The physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. This may represent a different session or patient encounter, different procedure or surgery, different site, ... May 30th, 2017 GA and GY for Medicare BillingBy ChiroCode | Published May 30th, 2017 - Last Review/Update January 31st, 2019 We are using the ABN for non-covered services (such as therapy codes) when the patient is under active care. We are also using the ABN for CMT codes when the patient is under maintenance care. We are now confused about when to use the modifiers GA & GY when billing CMT & therapy codes. Would you please explain when & why each should be used for Active and Maintenance Care? May 4th, 2017 Therapy Caps, Limits and ProvidersBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 4th, 2017 - Last Review/Update July 26th, 2017
The annual combined therapy cap is per beneficiary each calendar year. For 2017, this includes Medicare Part B outpatient therapy cap for Occupational Therapy (OT) $1,980, Physical Therapy (PT) and Speech-Language Pathology Services (SLP) $1,980.
In addition there is an exception process, if the therapy services are higher than the limited amounts, the beneficiary ... May 2nd, 2017 Plain Film Xray Penalty 2017By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published May 2nd, 2017 - Last Review/Update January 31st, 2019 Watch Another quick tip from the ChiroCode HelpDesk - Plain Film Xray Penalty 2017. Even though this news comes from Medicare, who does not reimburse chiropractic physicians for x-rays, private payers nearly always follow their example. This represents the trend of X-ray reimbursement for all of healthcare. April 26th, 2017 Modifiers: Reporting Wound DressingsBy 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 6th, 2017 Excluded from the Global OB PackageBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 6th, 2017 - Last Review/Update July 28th, 2017
First three antepartum E&M visits
Laboratory tests
Maternal or fetal echography procedures (CPT codes 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76820, 76821, 76825, 76826, 76827 and 76828)
Amniocentesis, any method (CPT codes 59000 or 59001)
Amniofusion (CPT code 59070)
Chorionic villus sampling (CPT code 59015)
Fetal contraction stress test (CPT code 59020)
Fetal non-stress test (CPT code 59025)
External cephalic version (CPT code 59412)
Insertion of cervical dilator (CPT code 59200) more than 24 hr before delivery
E&M services which is unrelated ... March 13th, 2017 Reporting Unilateral ProceduresBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 13th, 2017 - Last Review/Update July 28th, 2017
Some procedures are unilateral such as D7840-Condylectomy. It is important to consult with your payer on reporting requirements. Some payers require two separate line items with a LT or RT HCPCS Modifier, while others require only one modifier to be appended to the claim.
When billing a medical code for a Condylectomy, ... March 3rd, 2017 Using Add-On CodesBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 3rd, 2017 - Last Review/Update July 28th, 2017
There are certain procedures that are carried out in addition to the primary procedure called add-on codes. They describe a specific type of supplemental procedure done in addition that are labeled as add-on codes.
The AMA gives instructions and guidelines with notations such as "List separately in addition to primary procedure" or ... March 3rd, 2017 Chiropractic ManipulationBy 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 Using Modifier EYBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
Some Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items require a detailed Written Order Prior to Dispensing (WOPD), while others require a Detailed Written Order (DWO) prior to billing. The specific requirements for an order are specified in the Medical Policy (Local Coverage Determination and/or Policy Article) for the ... February 23rd, 2017 Telehealth Growth ContinuesBy Wyn Staheli, Director of Research | Published February 23rd, 2017
Telehealth is proving to be the wave of the future as the number of practices offering these services continues to grow. An online poll by Medical Economics asked those who visited their site about the implementation of telehealth services implemented by their individual practices this year. As of February 2, 2017, the results were significant:
30% ... February 22nd, 2017 Global PeriodsBy Wyn Staheli, Director of Research | Published February 22nd, 2017 What are the types of global periods? February 21st, 2017 Telehealth Psychiatric ServiceBy 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 11th, 2017 Podiatry Class FindingsBy Wyn Staheli, Director of Research | Published February 11th, 2017 The following modifiers are required when reporting medically necessary routine foot care services per Medicare guidelines:
Q7: One Class A finding
Q8: Two Class B findings
Q9: One Class B and two Class C findings
Appropriate: With foot care (podiatry) codes to indicate covered foot care
Inapproriate:
With any code not related to foot care
When the foot ... January 12th, 2017 Sleep Studies: Billing with Reduced HoursBy 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 6th, 2017 Assistant-At-Surgery ServicesBy Brittney Murdock, QCC, CMCS, CPC | Published January 6th, 2017
An "assistant at surgery" is a physician who actively assists the physician in charge of a case in performing a surgical procedure. The "assistant at surgery" provides more than just ancillary services.
Codes eligible for reimbursement for an assistant surgeon are designated by the Centers for Medicare and Medicaid Services (CMS) ... December 21st, 2016 Covered colonoscopy is attempted but cannot be completed due to extenuating circumstancesBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2016 - Last Review/Update August 4th, 2017
Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure. However, the frequency standards associated with screening colonoscopies will not be applied by CWF. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to ... December 21st, 2016 Q/A: E/M Bundled with CMTBy ChiroCode | Published December 21st, 2016 - Last Review/Update February 28th, 2019 What do you do when you are continually getting denials when billing office visit E/M code 99213-25 along with a CMT on dates that we do re-exams? What do you do when an appeal does not seem to work even though clear evidence has been provided that all conditions for the 99213 have been satisfied.? November 28th, 2016 Product Wastage Documentation Requirements and Reporting: Using JW ModifierBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 28th, 2016 - Last Review/Update August 1st, 2017 When using the JW modifier for Part B drug claims for discarded drugs and biologicals, any amount of wasted material should be clearly documented in the medical record with the following information:
Date, time, and location of treatment
Approximate amount of product unit used
Approximate amount of product unit discarded
Reason for the wastage
Manufacturer’s serial/lot/batch ... November 28th, 2016 JW Modifier required, starting Jan. 01, 2017By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 28th, 2016 - Last Review/Update August 1st, 2017
Effective January 1, 2017, claims for discarded drugs or biologicals amount not administered to any patient shall be submitted using the JW modifier. Also, effective January 1st, 2017, providers must document the discarded drugs and biologicals in the patient's medical record.
A single use vial that is labeled to contain 100 ... October 26th, 2016 Using Physical Status Modifiers with Anesthesia CodesBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 26th, 2016 - Last Review/Update August 1st, 2017
These six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in the CPT codebook to distinguish among various levels of complexity of the anesthesia service provided.Example: 00100-P1Physical Status modifiers are represented by the initial letter ‘P’ followed by a single digit from 1 to 6 ... October 3rd, 2016 Upper Eyelid Blepharoplasty and Blepharoptosis RepairBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 3rd, 2016 - Last Review/Update August 1st, 2017
The Centers for Medicare & Medicaid Services (CMS) payment policy does not allow separate payment for a blepharoplasty procedure (CPT codes 15822, 15823) in addition to a blepharoptosis procedure (CPT codes 67901-67908) ontheipsilateral upper eyelid. Any removal of upper eyelid skin in the context of an upper eyelid blepharoptosis surgery is considered apart of ... October 3rd, 2016 Upper Eyelid Blepharoplasty and Blepharoptosis Repair (update eff 10/01/2017)By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 3rd, 2016 - Last Review/Update August 2nd, 2017 The Centers for Medicare & Medicaid Services (CMS) payment policy does not allow separate payment for a blepharoplasty procedure (CPT codes 15822, 15823) in addition to a blepharoptosis procedure (CPT codes 67901-67908) ontheipsilateral upper eyelid. Any removal of upper eyelid skin in the context of an upper eyelid blepharoptosis surgery is considered apart of ... August 16th, 2016 Functional Limitation Reporting Codes and ModifiersBy 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 3rd, 2016 How do I tell if a code is defined as unilateral or bilateralBy Codapedia | Published August 3rd, 2016 There are some procedures which are defined as unilateral procedures, and some defined as bilateral procedures. If the procedure is defined as unilateral but performedbilaterally, then the physician is paid 150% of the fee schedule amount when performed on both sides. If the code is defined as bilateral, there is... July 29th, 2016 Preventive medicine and office visit, same dayBy Codapedia | Published July 29th, 2016 Can I use modifier 25 on an E/M service on the same day as a preventive medicine exam Let’s review what a preventive medicine service is, in order to answer that question. Preventive medicine services are: • The description given by CPT® for “annual physicals” • Divided into new and... July 29th, 2016 Hospice Care-Billing for physician services when a patient is on hospiceBy Codapedia | Published July 29th, 2016 Patients who sign up with hospice waive their rights to receive Medicare Part B services, and must look to the hospice organization to provide care related to the terminal illness. The hospice provider receives a daily payment to care for the patient on hospice. The patient’s own attending physician, (who... July 29th, 2016 Coding for pulmonary servicesBy Codapedia | Published July 29th, 2016 This is an overview of billing for services provided by Pulmonologists. Medicare recognizes Pulmonary Disease as a specialty. The resources section of this article contains the E/M Frequency data from CMS for the latest year available, and the fifty most commonly billed CPT® codes. What are the most common... July 29th, 2016 Repeat Injections, Can I bill an E/M?By Codapedia | Published July 29th, 2016 When reporting an office visit in conjunction with an injections/arthrocentesis we need to consider a few factors. First we need to be certain we are accurately applying modifier -25 which is required when a procedure is performed the same day as a procedure. In order to report modifier -25, the... July 29th, 2016 Using denial tracking to improve collectionsBy Codapedia | Published July 29th, 2016 Here are some examples of denials that a practice should track to be sure that they are paid correctly by the insurance company. Set up a denial type for each of these. Fee Schedule Issues: Wrong amount paid per the contracted fee schedule. May be too high or too low... July 29th, 2016 Modifier 25By Codapedia | Published July 29th, 2016 Modifier 25: Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. Refer to the CPT® book for the complete definition. Modifier 25 is appended to the E/M service, never to a procedure. The decision about whether to bill for both... July 29th, 2016 Modifier 22By J. Paul Spencer, CPC, COC | Published July 29th, 2016 - Last Review/Update August 17th, 2017
Depending on a surgeon's area of expertise, documentation becomes an important tool not simply as a marker of care quality, but for the proper capture of charges and reimbursement. This past January 1st marked the 20th anniversary of CMS' adoption of Correct Coding Initiative (CCI) bundling edits, which have over ... July 28th, 2016 QW Modifier for CLIA waived testsBy Codapedia | Published July 28th, 2016 QW is a HCPCS modifier defined as: CLIA waived test. Append it to lab services that are on the CLIA waived test list. Download the up to date list of CLIA waived tests from CMS's web site. The link is the citation. There are two issues: Some tests do not... July 28th, 2016 Pre-op visits: True or False?By | Published July 28th, 2016 Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he is going to take the... July 28th, 2016 OIG Work Plan 2012-Do your own review of these areasBy | Published July 28th, 2016 The Office of Inspector General released its Work Plan for 2012. As in past years, the Work Plan describes the areas of interest that the OIG will investigate in the coming year. There are sections for hospitals, nursing homes, and of course, physicians. There is a pdf file attached to... July 28th, 2016 Using Modifer -59By Codapedia | Published July 28th, 2016 By Crystal Reeves, CPC, CMPE, Principal Modifier -59 is probably one of the most misunderstood, misused, and most-feared of all CPT® modifiers. Some practices avoid using it all together because they don’t want to be guilty of unbundling. Some practices do not use it because they are not at all... July 15th, 2016 Compliance Plans: The Truth About TemplatesBy Sean Weiss, VP and Chief Compliance Officer at DoctorsManagement | Published July 15th, 2016 - Last Review/Update August 17th, 2017
This is not an article about building an effective compliance plan. It is about the most efficient and accurate way to build it and some of the nuances to be aware of when using a template to build your plan. As a compliance officer and someone that spends my days ... June 7th, 2016 Multiple surgical proceduresBy Codapedia | Published June 7th, 2016 Multiple Surgical Procedures In some groups, the coder performs all of the steps below. The responsibilities indicated here are opinion of the author, not law, regulation or national policy. Physician Responsibility: 1. List all codes for the procedures performed 2. Note whether the procedures performed were done via the same... May 27th, 2016 Documentation Criteria: Medicare PhysicalsBy 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 ... April 25th, 2016 The Use of Modifier 50By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 25th, 2016 - Last Review/Update August 4th, 2017
Modifier Review: Modifier -50
Modifier 50 is used to report a procedure performed bilaterally.
Example: The patient underwent bilateral tympanostomy with insertion of ventilating tubes.
If you look up the CPT code 69433, you will see it is a unilateral procedure and there are instructions telling you to append modifier -50 if it is ... April 13th, 2016 Telehealth BasicsBy Wyn Staheli, Director of Research | Published April 13th, 2016 Telehealth and telemedicine are covered for many payers for services such as consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system. March 7th, 2016 Discarded Drugs and BiologicalsBy 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 Guidance For Modifier 24 UsageBy Sara San Pedro, CPC, CEMC, CPMA | Published March 4th, 2016 NAMAS Weekly Auditing and Compliance Tips Modifier 24 (Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period) has generated more scrutiny lately because of the attention it is receiving from Recovery Auditors and payors. An assignment of modifier 24 will oftentimes trigger a medical record... March 4th, 2016 Guidance for Modifier 24 UsageBy Sara San Pedro, CPC, CEMC, CPMA | Published March 4th, 2016 - Last Review/Update August 16th, 2017
Modifier 24 (Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period) has generated more scrutiny lately because of the attention it is receiving from Recovery Auditors and payors. An assignment of modifier 24 will oftentimes trigger a medical record request, so we must be confident when ... February 24th, 2016 Nebulizer Therapy Billing Reminders - Modifiers, Dispensing Fees, and OrdersBy 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 ABN is required - (if you anticipate payer will deny or is not medically necessary)By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 3rd, 2017
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1st, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, ... February 17th, 2016 Getting Paid When Reporting Unlisted CodesBy 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 ModifiersBy 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 ... January 29th, 2016 Wound Care & Debridement- Provided by Physician, NPP or as Incident-to ServicesBy 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 6th, 2016 Modifiers in Postoperative PeriodsBy Codapedia | Published January 6th, 2016 Modifiers in Postoperative Periods Introduction Documenting the events of a patient visit is not always the simplest and most straightforward of processes. Many variables affect which information must be included in order to report a procedure or service accurately. Global periods are one of those... January 6th, 2016 Modifier 52 vs. 53 - What's the Difference?By Codapedia | Published January 6th, 2016 So you’ve read the descriptions for both Modifiers 52 and 53, but you’re still on the fence as to which one is appropriate for a certain surgical case. This brief article will try to better differentiate between these two often-confused modifiers. Modifier 53... January 6th, 2016 Minor Surgical Procedures - How to document and billBy Codapedia | Published January 6th, 2016 When performing minor surgical procedures, it is important to document what was done, how it was done, where it was done, why it was done, how deep, how long, and how many. In billing and reporting a procedure, document in the medical record the key components... January 6th, 2016 Pre-op visits: True or False?By Codapedia | Published January 6th, 2016 Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he... January 6th, 2016 Reporting Administration Codes with VaccinesBy 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... January 6th, 2016 Coding Excisions and Wound RepairsBy Codapedia | Published January 6th, 2016 Chart audits frequently examine coding associated with lesion removals and wound repairs. In order to assign the appropriate procedure code, certain documentation must be included in the medical record, such as lesion type, excision size, wound repair, and location. Without these important details, providers... December 18th, 2015 Class Finding Modifier SheetBy Find-A-Code | Published December 18th, 2015 - Last Review/Update December 12th, 2018 Definition:
Modifier Q7: One Class A finding
Modifier Q8: Two Class B findings
Modifier Q9: Once class B and two class C findings
Appropriate Usage:
With foot care (podiatry) codes to indicate covered foot care
Inappropriate Usage:
One any code not related to foot care
When the foot care is for routine care, and not medically necessary
Class Findings
Class A Findings
Non ... December 11th, 2015 CMS NCD drops clinical trial requirement for FDG PET scans for solid tumorsBy Codapedia | Published December 11th, 2015 Patients no longer need to be in a CMS-approved clinical trial for physician practices to get paid for doing as many as four FDG PET scans for solid tumors – one for an initial treatment strategy and three to guide subsequent treatments, according to CMS... December 11th, 2015 Hospital discharge, nursing facility admit billable on same day by same provider in most instancesBy | Published December 11th, 2015 Medicare will typically pay for a hospital discharge service (billed with 99238-99239) and a nursing facility admission visit (99304-99306) when billed on the same date of service (DOS) by the same provider without the need for a modifier. As always, however, there are a couple... December 11th, 2015 Modifier -24 - Indications for UseBy Codapedia | Published December 11th, 2015 Modifier 24 is used to indicate that an Evaluation and Management service was provided by the surgeon to a patient within the global period of a major or minor surgery. The claim must be accompanied by documentation that supports that the service is not... December 3rd, 2015 Post-operative Hospital VisitsBy | Published December 3rd, 2015 In 1992, CMS developed the concept of the Global Surgical Package, which pays for surgical services with a single payment. The full description of services that are included in this payment is described in the Medicare Claims Processing Manual, Chapter 12, Section 40 and... October 20th, 2015 Modifiers – Reimbursement or Informational? Modifier TrainingBy WPS Medicare | Published October 20th, 2015 October 19th, 2015 The JW Modifier is Only Applied to the Amount of Drug or Biological that is DiscardedBy 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 ModifierBy 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 5th, 2015 Reporting Laterality Still Requires ModifiersBy Wyn Staheli, Director of Research | Published October 5th, 2015 One of the significant coding changes with ICD-10-CM was including laterality within the code itself. This concept should help reduce billing errors and claim denials. Interestingly, CMS issued a statement regarding the reporting of laterality in their provider newsletter (emphasis added).
Implementation of ICD-10-CM will not change the reporting of Current Procedural Terminology ... August 28th, 2015 ICD-10 Preparation for PediatriciansBy Daniel Schwartz | Published August 28th, 2015 - Last Review/Update February 3rd, 2017 Pediatricians are great at making boo-boos less painful for their patients, but without proper planning, they may not be able to alleviate the potential pains associated with the upcoming ICD-10 transition. What is ICD-10 Exactly and Why is This Transition Happening Now? Starting October 1st, providers will no longer be... August 19th, 2015 G-Codes for Functional Reporting and Severity/Complexity ModifiersBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 19th, 2015 Beginning January 1, 2013, Functional Reporting requires therapy practitioners and providers to report non-payable G-codes and modifiers to convey information about the beneficiary’s functional status including projected goal status throughout the episode of care.
For the severity modifiers, providers should include a description of how the modifiers were determined.
Functional ... August 10th, 2015 Compound Drugs - How to billBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015 Pharmacy compounding is a has been done for many years, it is a tradition that offers customized care to meet the specific needs of individual patients. Modern technology and innovative techniques with research have allowed more pharmacist to customize medication to meet a patients needs.
Through compounding, a prescriber and pharmacist can adjust ... August 10th, 2015 Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapyBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015 - Last Review/Update August 7th, 2017 Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech - language pathology services. They should never be used with codes that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy ... August 10th, 2015 Was Your Claim Denied as a Duplicate Service?By | Published August 10th, 2015 - Last Review/Update January 27th, 2017 On occasion (if not more often), every practice receives a notice of claim denial that reads, ‘duplicate service.’ When the insurance denies a service as duplicate but your records indicate that is not true, how should you act?
First, gather all pertinent information on the claim to determine a possible cause. The following are some reasons why the ... August 10th, 2015 Fill-in Doctor: Locum TenensBy ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017 It is a common practice for a solo doctor to find someone to cover for them while they are away from the office for a temporary or extended period of time, such as medical leave, or vacation. Some offices fail to code properly for the services rendered by the “fill-in” doctor. When completing the CMS 1500 ... July 10th, 2015 Specimen Drawing for Dialysis Patients (Rev. 3056, 12-01-14)By Jared Staheli | Published July 10th, 2015
See the Medicare Benefit Policy Manual, Chapter 11, for a description of laboratory services included in the composite rate. With the implementation of the ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD-related laboratory services are included in the ESRD PPS base ... July 10th, 2015 Certificate of Waiver (Rev. 1652, 01-05-09) - CLIABy 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 Technical Component (TC) of Physician Pathology Services to Hospital Patients (Rev. 2714, 06-25-13)By Jared Staheli | Published July 10th, 2015 Section 542 of the Benefits Improvement and Protection Act of 2000 (BIPA) provides that the Medicare A/B MAC/carrier can continue to pay for the TC of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a covered hospital. This provision applies to TC ... July 9th, 2015 Method of Payment for Clinical Laboratory Tests - Place of Service Variation (Rev. 2971, 07-07-14)By Jared Staheli | Published July 9th, 2015 The following apply in determining the amount of Part B payment for clinical laboratory tests:
Laboratory tests not payable on the Clinical Diagnostic Laboratory Fee Schedule (CLFS) will be based on OPPS (for hospitals subject to OPPS) and current methodology for hospitals not subject to OPPS.
Independent laboratory or a physician or ... July 9th, 2015 Paper Claim Submission to A/B MACs (B) (Rev. 3089, 01-01-15) - Billing for Clinical Laboratory TestsBy Jared Staheli | Published July 9th, 2015
An independent clinical laboratory may file a paper claim form shall file Form CMS- 1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90.
An independent clinical laboratory that submits claims in paper format) may not combine non-referred ... July 9th, 2015 Automated Multi-Channel Chemistry (AMCC) Tests for ESRD Beneficiaries (Rev. 3116, 04-06-15)By Jared Staheli | Published July 9th, 2015
Instructions for Services Provided on and After January 1, 2011
Section 153b of the MIPPA requires that all ESRD-related laboratory tests must be reported by the ESRD facility whether provided directly or under arrangements with an independent laboratory. When laboratory services are billed by providers other than the ESRD facility and ... 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 8th, 2015 Discarded Drugs and Biologicals (Rev. 1962, 07-30-10)By Jared Staheli | Published July 8th, 2015
The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.
When a physician, hospital or other provider or supplier must discard the remainder of a single ... July 8th, 2015 Discarded Erythropoietin Stimulating Agents for Home Dialysis (Rev. 1581; 12-01-08)By Jared Staheli | Published July 8th, 2015 Multiuse vials are not subject to payment for discarded amounts of drug or biological, with the exception of self administered erythropoietin stimulating agents (ESAs) by Method I home dialysis patients. The renal facility must bill the program using the modifier JW for the amount of ESAs appropriately discarded if the ... July 8th, 2015 Reporting Modifiers in the Compound Drug Segment (Rev. 1, 10-01-03)By Jared Staheli | Published July 8th, 2015
Certain informational modifiers are required on compound ingredients. The NCPDP format does not currently support reporting modifiers in the compound segment. Therefore, the narrative portion in the prior authorization segment must be used to report these modifiers. The following must be entered in positions 001-003 of the narrative (Example, MMN ... 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 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 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 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 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 Modifier Requirements for Pre-diabetes (Rev. 457, 04-04-05)By Jared Staheli | Published July 6th, 2015
A claim that is submitted for diabetes screening and the beneficiary meets the definition of pre-diabetes shall be submitted in the following manner:
The line item shall contain 82497, 82950 or 82951 with a diagnosis code of V77.1 reported in the header. In addition, modifier “TS” (follow-up service) – shall be ... 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 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 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 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 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;
• ... 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 22nd, 2015 Chiropractic Policy Addendum: Maintenance Therapy CR2717By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 22nd, 2015 - Last Review/Update August 7th, 2017
The Centers for Medicare & Medicaid Services (CMS) has further defined Chiropractic Maintenance Therapy. Section 2251.3 of the Medicare Carriers Manual (MCM) has been amended to clarify Medicare requirements for treatment of chiropractic therapy.
"MCM 2251.3 Necessity for Treatment.--
A. The patient must have a significant health problem in the form of a neuromusculoskeletal ... June 18th, 2015 Reporting the Ordering/Referring NPI on Claims for DMEPOS Items Dispensed Without a Physician’s Order (Rev. 1368, 04-07-08)By Jared Staheli | Published June 18th, 2015 Chapter 5, section 5.2.1 of the Medicare Program Integrity Manual (PIM) states that, in order for Medicare to make payment for an item of Durable Medical Equipment Prosthetic, and Orthotic Supplies (DMEPOS), the DMEPOS supplier must obtain a prescription from the
For Coordination of Benefit purposes, DMEPOS suppliers shall use the ... June 18th, 2015 DME MACs – Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades (Rev. 2993, Upon Implementation of ICD- 10)By Jared Staheli | Published June 18th, 2015 This section provides the DME MACs billing instructions regarding the use of ABNs and claims modifiers for upgrades for items of DMEPOS.
Federal Regulations at 42 CFR 411.408 and Chapter 30 of this manual establishes the basis for a supplier to issue an ABN to a beneficiary. The purpose of the ... June 18th, 2015 Providing Upgrades of DMEPOS Without Any Extra Charge (Rev. 2993, Upon Implementation of ICD-10)By Jared Staheli | Published June 18th, 2015 Instead of using ABNs and charging beneficiaries for upgraded items, suppliers in certain circumstances may decide to furnish beneficiaries with upgraded equipment but charge the Medicare program and the beneficiary the same price they would charge for a nonupgraded item. The reason for this may be that a supplier prefers ... June 18th, 2015 Billing for Oxygen and Oxygen Equipment (Rev. 1493; 04- 07-08)By Jared Staheli | Published June 18th, 2015 The following instructions apply to all claims from providers and suppliers to whom payment may be made for oxygen. The chart in §130.6.1 indicates what is payable under which situation.
... 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 Showing Whether Rented or Purchased (Rev. 2993, Upon Implementation of ICD- 10)By Jared Staheli | Published June 18th, 2015 Claims must specify whether equipment is rented or purchased. For purchased equipment, the itemized bill or claim must also indicate whether equipment is new or used. If the provider or supplier fails to indicate on an assigned claim whether equipment was new or used, the contractor processing the claims assumes ... June 17th, 2015 DMEPOS Clinical Trials and Demonstrations (Rev. 2993, Upon Implementation of ICD- 10)By Jared Staheli | Published June 17th, 2015 The definition of the QR modifier is “item or service has been provided in a Medicare specified study.” When this modifier is attached to a HCPCS code, it generally means the service is part of a CMS related clinical trial, demonstration or study.
The DME MACs shall recognize the “QR” modifier ... June 17th, 2015 Elimination of Method II Home Dialysis (Rev. 2487, 06-19-12)By Jared Staheli | Published June 17th, 2015 Effective for dates of service on and after January 1, 2011, Section 153b of the Medicare Improvements for Patients and Providers Act (MIPPA) eliminated Method II home dialysis claims. Specifically, Method II home dialysis is no longer recognized as a beneficiary option for dates of services beginning January 1, 2011, ... 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 17th, 2015 Payment for Replacement of Oxygen Equipment in Bankruptcy Situations (Rev. 1961, 10-04-10)By Jared Staheli | Published June 17th, 2015 When a supplier files for Chapter 7 or 11 bankruptcy under Title 11 of the United States Code and cannot continue to furnish oxygen to its Medicare beneficiaries, the oxygen equipment is considered lost in these situations and payment may be made for replacement equipment. For replacement oxygen equipment, a ... May 11th, 2015 Modifier 33By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 11th, 2015 - Last Review/Update January 30th, 2017 Modifier 33 for Preventive Care
With the implementation of modifier 33 and its complicated and unique description, many coders have wondered how to properly apply it. Let's review the information we have on the modifier and see if we can better understand how and when to use it.
Modifier 33 was created ... May 11th, 2015 How To Report Co-Surgeons and Assistant Surgeon ModifiersBy Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 11th, 2015 - Last Review/Update January 30th, 2017 Some surgeries require the expertise of more than one surgeon or may require the assistance of another surgeon to ensure adequate care is given and the surgery is a success.
Let's review a couple terms:
Co-Surgeon: When two surgeons act as primary surgeon for a specific procedure. Each acts as the primary surgeon ... March 9th, 2015 Billing Imminuzation for Pneumococcal, Influenza, and Hepatitis B with MedicareBy 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 26th, 2015 Codes for Coverage: Locum Tenens & Reciprocal BillingBy ChiroCode | Published February 26th, 2015 - Last Review/Update January 27th, 2017 Presenting Problem
Some doctors fail to code properly for a temporary doctor who is covering an office, or for mutual coverage with a colleague.
History/Subjective
It is a common practice for doctors in solo practice to find someone to “cover” for them while they are away from the office for a temporary or extended period of time.
During such ... February 21st, 2015 Billing Requirements for G0466, G0467, G0468, G0469 or G0470 - MLNBy 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 20th, 2015 Modifier Resource and Training VideoBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 20th, 2015 - Last Review/Update February 18th, 2016 WPS Medicare developed these fact sheets to help you with your billing needs.
Informational Only Modifier Fact Sheet
Introduction to Modifiers
Pricing or Payment Modifier Fact Sheet
The Physician Fee Schedule Relative Value File Fact Sheet
Ranking Modifiers: Payment Modifier versus Informational Modifier
Ambulance Modifiers
Anesthesia Documentation Modifiers (AA, AD, QK, QX, QY, QZ)
Anesthesia Physical Status ... January 28th, 2015 Modifier XU Fact SheetBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 28th, 2015 - Last Review/Update August 8th, 2017
Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service
Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
Documentation indicates the service was not part of the usual components of the main service
Use Modifier ... January 28th, 2015 Modifier XS Fact SheetBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 28th, 2015 - Last Review/Update August 9th, 2017
Separate Structure, A Service That Is Distinct Because It Was Performed on A Separate Organ/Structure
Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
Documentation indicates the services were provided on different organs/structures
Use Modifier XS with the Column 2 procedure code in the NCCI files
Use Modifier XS only when there ... January 28th, 2015 Modifier XP Fact SheetBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 28th, 2015 - Last Review/Update August 9th, 2017
Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner
Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
Documentation indicates the services were provided by different practitioners in the same group practice
Use Modifier XP with the Column 2 procedure code in the ... January 28th, 2015 Modifier XE Fact SheetBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 28th, 2015 - Last Review/Update August 9th, 2017
Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
Documentation indicates the services were provided during separate patient/provider encounter
Use Modifier XE with the Column 2 procedure code in the NCCI files
Use Modifier XE only when there ... December 23rd, 2014 CMS Announces New HCPCS Modifiers to be Implemented January 2015By | 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 ... November 21st, 2014 Modifier 50By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published November 21st, 2014 - Last Review/Update January 30th, 2017 Modifier Review: Modifier -50
Modifier 50 is used to report a procedure performed bilaterally.
Example: The patient underwent bilateral tympanostomy with insertion of ventilating tubes.
If you look up the CPT code 69433, you will see it is a unilateral procedure and there are instructions telling you to append modifier -50 if ... 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: October 9th, 2014 Medicare Caps on Therapy ServicesBy Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 23rd, 2017 Medicare has set annual therapy caps at $1920 and they start over Jan. 1 of each year. Medicare combined the therapy limits SLP (Speech-Language Pathology) and PT (Physical Therapy) for a combined total of $1920.00 in 2014. There is also a therapy cap limit for OT (Occupational Therapy) Services of $1920. ... October 9th, 2014 Modifier 24By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 9th, 2014 - Last Review/Update January 30th, 2017 Modifier -24
When a patient is seen during a global (postoperative) period for something unrelated to the surgery for which the global period applies, modifier -24 is appended to the evaluation and management (EM) service.
The insurance may deny payment for the EM service; however, if the notes for that service ... September 30th, 2014 Fill In Doctor: Locum TenensBy | Published September 30th, 2014 - Last Review/Update January 30th, 2017 It is a common practice for a solo doctor to find someone to cover for them while they are away from the office for a temporary or extended period of time, such as medical leave, or vacation. Some offices fail to code properly for the services rendered by the “fill-in” ... August 7th, 2014 Durable Medical Equipment, Prosthetics, Orthotics and SuppliesBy 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 31st, 2014 Fill In Doctor: Locum TenensBy Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published July 31st, 2014 - Last Review/Update January 25th, 2017 It is a common practice for a solo doctor to find someone to cover for them while they are away from the office for a temporary or extended period of time, such as medical leave, or vacation. Some offices fail to code properly for the services rendered by the “fill-in” ... July 31st, 2014 GP Modifier for Physio Therapy ServicesBy Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published July 31st, 2014 - Last Review/Update January 25th, 2017 The -GP modifier needs to be appended to physio-therapy codes when submitting Medicare claims. However, be aware of differing policies for different types of payers. Chiropractors typically use the following Physical Medicine codes from the CPT book: 97010 thru 97799 (except for 97597-97610 for active wound care management). The current ... July 31st, 2014 Repeat Procedures on the Same Day - When to Report Modifiers -76 and -77By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 31st, 2014 - Last Review/Update January 25th, 2017 Have you ever had a claim deny as a ‘duplicate service’ only to find out upon further review that it was actually performed twice on the same day? This occurs more often than you realize and it is fairly easy to correct the error and get the claim paid. Modifiers ... July 16th, 2014 Coding Screening MammogramsBy 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 ... 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 ... July 8th, 2013 Denials for 97140 (Manual Therapy)? Here's the story.By | Published July 8th, 2013 - Last Review/Update January 27th, 2017 The ChiroCode Institute has received several inquiries over the last few months regarding a denial for 97140 (Manual therapy—such as myofascial release or trigger point therapy) when billed with 98940-98942 (Chiropractic Manipulative Treatment - CMT) on the same visit. Most payers follow Medicare’s guidelines for the use of this code, ... December 31st, 2001 Commonly Asked Chiropractic Coding QuestionsBy 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 There are more articles. View all articles... View articles for the current subject by subtopic:
(There are no webinars at this time, please check back later.) Assistant Surgery ModifiersBilateral Surgeries: Claim SubmissionBilling with a GP ModifierCommonly Used Medicare Modifiers - GA, GX, GY, GZContinued Use of Modifier 59 after Jan 1, 2015FAQ on the use of the AT and GA modifiers togetherGlobal Surgery Fact Sheet by CMSMedicare Claims Processing Manual Chapter 5 - Part B Outpatient Rehabilitation and CORF/OPT ServicesMedicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)Modifier 50 UsageModifier 59 MLN Matters #MM8863NCCI Instructions for Modifier 59New Modifiers to Identify Occupational Therapy (OT) and Physical Therapy (PT) Services Provided by a Therapy AssistantQ/A: Should I be Using Modifier 96 on PT Claims?Quick Reference Chart by CMS: G-codes and Modifiers for Therapy Functional Reporting (There are no podcasts at this time, please check back later.)
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