Select the title to see a summary and a link to the full article.
October 18th, 2019
Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible
By 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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 10th, 2019
There are a few payers that have joined with CMS in discontinuing payment for consultation codes. Most recently, Cigna stated that, as of October 19, 2019, they will implement a new policy to deny the following consultation codes: 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254 and 99255.
United Healthcare announced they ...
Vaccine Administration - When The Right Vaccine Code is Not Enough
By Chris Woolstenhulme, QCC, CMCS, 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 ...
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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 16th, 2019
The new 2020 CPT codes are on the way! We are going to see 248 new codes, 71 deletions, and 75 revisions. Health monitoring and e-visits are getting attention; 6 new codes play a vital part in patients taking a part in their care from their own home. New patient-initiated ...
Are You Aware of Medicare Advantage Plans Timely Filing Rules?
By Aimee Wilcox | Published August 20th, 2019
The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial.
As any company who has billed Medicare services can attest, the one-year timely filing ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
How to Properly Report Prolonged Evaluation and Management Services
By Aimee Wilcox | Published August 13th, 2019
Have you ever had a patient take more time with the provider than they were scheduled for? Do you understand which codes to report and the rules that govern them to allow for better reimbursement?
Prolonged Service codes were created just for that reason but you must carefully follow the documentation ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 13th, 2019
There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...
Will Medicare Change Their Rules Regarding Coverage of Services Provided by a Chiropractor?
By Wyn Staheli, Director of Research | Published August 13th, 2019
Two separate pieces of legislation introduced in the House of Representatives (H.R. 2883 and H.R. 3654) have the potential to change some of Medicare’s policies regarding doctors of chiropractic. Find out what these two bills are all about and how they could affect Medicare policies.
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 ...
CMS Proposes to Reverse E/M Stance to Align with AMA Revisions
By Wyn Staheli, Director of Research | Published August 6th, 2019
On July 29, 2019, CMS released their proposed rule for the Medicare Physician Fee Schedule for 2020. Last year’s final rule “finalized the assignment of a single payment rate for levels 2 through 4 office/outpatient E/M visits beginning in CY 2021.” It also changed some of the documentation requirements (e.g., ...
By Marge McQuade, CMSCS, CHCI, CPOM | Published July 9th, 2019
ICD-10-CM codes represent the first line of defense when it comes to medical necessity. Correctly chosen diagnosis codes support the reason for the visit as well as the level of the E/M services provided. The issue of medical necessity is one of definitions and communication. What is obvious to the ...
By Wyn Staheli, Director of Research | Published July 9th, 2019
Othoses often have extra components. When can you bill those components separately? For example, can you bill for a suspension sleeve (L2397) with a knee orthosis (e.g., L1810)?
Will the New Low Level Laser Therapy Code Solve Your Billing Issues?
By Wyn Staheli, Director of Research | Published July 8th, 2019
Low level laser therapy (LLLT), also known as cold laser therapy, is a form of phototherapy which uses a device that produces laser beam wavelengths, typically between 600 and 1000 nm and watts from 5–500 milliwatts (mW). It is often used to treat the following:
Inflammatory conditions (e.g., Rheumatoid Arthritis, Carpal ...
By Wyn Staheli, Director of Research | Published July 1st, 2019
Question:
I heard that I need to have an interpreter if someone who only speaks Spanish comes into my office. Is this really true?
Answer:
Yes! There are both state and federal laws that need to be considered. The applicable federal laws are:
Title VI of the Civil Rights Act of 1964,
Americans with Disabilities ...
How to Properly Report Monitoring Patients Taking Blood-thinning Medications
By Wyn Staheli, Director of Research | Published June 18th, 2019 - Last Review/Update June 19th, 2019
Codes 93792 and 93792, which were added effective January 1, 2019, have specific guidelines that need to be followed. This article provides some guidance and tips on properly reporting these services.
By Namas | Published June 14th, 2019 - Last Review/Update June 18th, 2019
A United Approach
As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...
What Medical Necessity Tools Does Find-A-Code Offer?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...
By Brittney Murdock, QCC, CMCS, CPC | Published June 13th, 2019
When viewing CPT codes, Find-A-Code offers detailed anatomy images and tables to help with coding.
For example 28445 offers a table with information to assist classification of gustilo fractures:
Click on the image preview from the code information page to expand the image.
Documentation of E/M services for Neurology (Don't Forget the Cardiology Element)
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 13th, 2019
According to Neurology Clinical Practice and NBIC, the neurologic exam is commonly lacking in documentation due to the extensive requirements needed to capture the appropriate revenue.
With the lack of precise documentation, it results in a lower level of E/M than that which is more appropriate, which can cost a physician a lot ...
Medicare Approves Reimbursement for Virtual Communication (G2012)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Medicare has taken a stand to recognize communication technology-based services by approving two newly defined physicians' services that will significantly help providers who deal with phone calls and patient triage. One of these services includes:
Virtual check-in (G2012), which allows the provider to be reimbursed for communicating with the patient via ...
Medicare Now Reimburses for Remote Monitoring Services (G2010)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Medicare's 2019 Final Rule approved HCPCS code G2010 for reimbursement, which allows providers to be paid for remote evaluation of images or recorded video submitted to the provider (also known as "store and forward") to establish whether or not a visit is required. This allows providers to get paid for ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 6th, 2019 - Last Review/Update June 11th, 2019
Have you ever tried to quickly recall the elements required to support a comprehensive ophthalmologic exam versus an intermediate one? Make coding decisions quickly by creating a cheat sheet containing vital information that allows you to quickly select the right code.
According to Article A19881 which was published in 2004 and ...
Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 29th, 2019 - Last Review/Update June 4th, 2019
Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?
Your New Patient Exam Code Could Determine How Many Visits You Get
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published May 27th, 2019 - Last Review/Update June 6th, 2019
The initial exam is where the provider gathers the information to determine the need for all the care that follows. It is billed most often as an office or outpatient evaluation and management (E/M) code from the 4th edition of the AMA’s Current Procedural Terminology book. There are actually five ...
Electrical Stimulation and Electromagnetic Therapy Devices
By Raquel Shumway | Published May 13th, 2019 - Last Review/Update May 20th, 2019
Electrical Stimulation and Electromagnetic Therapy Devices can be used for pain, muscle atrophy, help spinal cord injuries, treat symptoms caused by other medical conditions and can be used in the treatment of wounds. This Regence BC/BS article lists codes and devices and gives guidance on coding from Medicare Advantage viewpoint.
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published May 8th, 2019
There are two levels of codes used for services and procedures:
Level I Codes are used for Services and Procedures provided by physicians.
5 digit numerical code, example, 99213 - Office or other outpatient visits
Level II Codes are used to bill Medical equipment supplies and transport services.
4 digit Alpha/Numerical code example, ...
By Brittney Murdock, QCC, CMCS, CPC | Published May 1st, 2019
Crosswalk from CPT Anesthesia codes (00100-01999) to Surgery and Procedure Codes! Let's look at anesthesia code 00100 as an example. The ASA Crosswalks are available under the Cross-A-Code bar. Click to expand. Look for the ASA CROSSWALK or ASA Reverse CROSSWALK bar. You will also see the CMS and ASA...
Q/A: I’m Being Audited? Is There a Documentation Template I can use?
By Wyn Staheli, Director of Research | Published April 29th, 2019
Question: Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942?
Answer: When you submit a claim with code 98942 you are stating that you have determined that it was medically necessary to adjust all 5 of ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 24th, 2019
Biofeedback is used for many reasons, and most commonly used for pain management. Each payer should be consulted with to verify coverage when treating with Biofeedback to verify if the treatment is considered experimental or investigational.
The majority of payers will list Biofeedback on an exclusions list. Others such as BC ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.
Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
In 2018, Medicare announced their plans for revamping the Evaluation and Management coding structure and was met with a rapid response from the medical community, including the AMA and many other organizations. As a result, the Medicare changes implemented in 2019 were mostly documentation-related changes that generally benefited providers but were not ...
What is Medical Necessity and How Does Documentation Support It?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
By By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow Clinical Director, PayDC Chiropractic EHR Software President, Gwilliam Consulting LLC drgwil@gmail.com | Published April 22nd, 2019
Chiropractic is unique from other types of health care and auditors need to be aware of the nuances of this field. Chiropractic has become the focus of more and more audits as doctors seem to struggle to create records that properly support the care provided to the patient throughout the entire episode.
By Namas | Published April 19th, 2019 - Last Review/Update April 23rd, 2019
Auditing Ophthalmology and Optometry Exams
If you work in an ophthalmology group or audit ophthalmology then you are most likely aware of the caveats that exist in this specialty. Ophthalmology and Optometry practitioners can select from either the E/M code set or the Ophthalmologic exam code set. Having this knowledge in ...
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 ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Wyn Staheli, Director of Research | Published April 1st, 2019 - Last Review/Update April 2nd, 2019
One constant in our industry is change. Policies change, contracts change, and there are updates. Also, people aren’t perfect and mistakes can be made. So this article will cover a variety of topics.
Published Articles
We appreciate feedback from our valued customers. We have received feedback regarding two of our articles which ...
CPT Codes That Include Moderate Sedation (Appendix G)
By Find-A-Code | Published April 1st, 2019 - Last Review/Update April 2nd, 2019
The CPT codes that include moderate sedation have been removed from the CPT code set. These codes include: 99151, 99152, 99153, 99155, 99156, 99157.
Please refer to the guidelines for information on how to report these moderate sedation services.
...
By Find-A-Code | Published April 1st, 2019 - Last Review/Update April 2nd, 2019
The following includes a list of vaccine product codes that are currently pending FDA approval. When approval status has been granted by the FDA, updated information will be available HERE
90587
90666
90667
90668
90689
90697
...
Electrodiagnostic Medicine Listing of Sensory, Motor and Mixed Nerves (Appendix J as per AMA)
By Find-A-Code | Published April 1st, 2019 - Last Review/Update April 2nd, 2019
Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves.
This summary assigns each sensory, motor, and mixed nerve with its appropriate nerve conduction study code in order to enhance accurate reporting of codes 95907-95913. Each nerve constitutes one unit of service.
Motor Nerves Assigned to Codes 95907-95913
Upper extremity, cervical plexus,andbrachial plexus motor nervesAxillary ...
By Namas | Published March 29th, 2019 - Last Review/Update April 4th, 2019
Prolonged Services
I find in my own audit reviews that the prolonged service code set is often mistreated: they are avoided and not used even when the scenario supports them, or they get overused and improperly documented. Prolonged services are used in conjunction with all types of Evaluation and Management (E/M) ...
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
...
The Impact of Medical Necessity on High Level E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2019
I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"
The quick answer is, "it depends."
Code 99233 has the following minimal component requirement:
Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...
By 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 ...
Spotlight: Services Excluded from Global Surgery Payment
By Brittney Murdock, QCC, CMCS, CPC | Published March 11th, 2019
The following services are excluded from global surgery payment according to Noridian Medicare. These services may be paid for separately. The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial...
By Wyn Staheli, Director of Research | Published March 7th, 2019
Providers need to ensure that they are reporting radiology dates of service the way the payer has requested. Unlike other many other professional services which only have one date of service (DOS), radiology services can span multiple dates. Medicare requirements may differ from professional organization recommendations.
By Wyn Staheli, Director of Research | Published March 4th, 2019 - Last Review/Update March 6th, 2019
Code 95992 has some very limited payer payment guidelines which need to be understood for proper reimbursement. Many payer policies consider this service bundled with Evaluation and Management Services, therefore, it would not be separately payable if there was an E/M service performed on the same date. Some providers have reported having trouble ...
By Namas | Published March 4th, 2019 - Last Review/Update March 7th, 2019
National Alliance of Medical Auditing Specialists (NAMAS) hosts a forum where auditing and compliance professionals can get answers to their questions, and exchange information with other professionals across the country. Recently, we've received the following question regarding fracture care that we'd like to share below.
Q: I recently noticed CPT 26600, ...
By Brittney Murdock, QCC, CMCS, CPC | Published March 4th, 2019
A global period is a period of time starting with a surgical procedure and ending some period of time after the procedure. Many surgeries have a follow-up period during which charges for normal post- operative care are bundled into the global surgery fee. Global surgery is not restricted to hospital...
UnitedHealthcare to Discontinue Coverage of Consultations
By Wyn Staheli, Director of Research | Published March 4th, 2019 - Last Review/Update March 7th, 2019
In United Healthcare's March provider bulletin, they announced that beginning on June 1, 2019, they will be phasing out coverage of consultation services (99241-99255).
By Brittney Murdock, QCC, CMCS, CPC | Published March 4th, 2019
Many denials can be avoided when you understand how a payer looks at a code. Find-A-Code puts a lot of this information all on one page. Under Additional Code Information on CPT codes you will find a lot of questions can be answered. In addition to the global policy, uniform...
By 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 ...
Separately Report a "Separate Procedure" with Confidence
By 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 ...
Proposed Rule: Expanded Telemedicine Benefits for Medicare Advantage Beneficiaries
By Aimee Wilcox | Published February 14th, 2019
Telemedicine continues its rise, with new technologies allowing for better communication and access to more aspects of healthcare than ever before. Each year Medicare has made strides, albeit small strides, in their telemedicine coverage while commercial payers continue to make great strides, constantly improving and expanding telemedicine service offerings to ...
Detection by Nucleic Acid (DNA or RNA) - Amplified Probe Technique
By Chris Woolstenhulme, QCC, CMCS, 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 ...
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 ...
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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 5th, 2019
State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals.
Physician or other qualified healthcare professionals: Must have a State license, education training showing qualifications as well as facility privileges.
Examples of Qualified Healthcare professionals:
(NOTE: this list is not all-inclusive, please refer to your payer ...
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 ...
By Wyn Staheli, Director of Research | Published February 1st, 2019 - Last Review/Update February 4th, 2019
Question: How do I code it so that PT services in a chiropractic office don’t count against their PT visit max? Is there a way to code claims so that they are considered chiropractic only? But still get compensated enough? We have been running into some issues as of late ...
Q/A Neonate Coding When Child is Transferred (2019/01/17)
By Codapedia | Published January 28th, 2019
Codapedia Forum - Questions & Answers
Q/A: Neonatologist was at the birth of a very critical child, she billed 99468 and then it was decided to transfer the child to another facility, she also billed 99291 and 99292 x 3. Her time was denied, how should she have billed for the initial ...
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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 23rd, 2019
We have it all! Search our WK Drug Database for drugs and pharmaceuticals. When it comes to support and guidance the WK Drug Database offers a paramount search and is conveniently presented in one place.
Pricing
GPIs
NDCs
Billing Codes
Indications/Diseases
Packaging Information
Active and Inactive
and more...
Additionally, learn more about drugs and pharmaceuticals that can be used to detect, treat, or monitor ...
By 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 ...
By NAMAS | Published January 14th, 2019 - Last Review/Update January 16th, 2019
Beginning January 1st, 2019 all of our RHC and FQHC organizations have a new CPT code to
consider implementing for their Medicare populous (check per Advantage Plan Administration for coverage). In its current form, this code is not reportable by organizations not meeting the RHC/FQHC designation.
The code isG0071 and is termed ...
By 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 ...
Are You Protecting Your Dental Practice From Fraud?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 10th, 2019
With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...
Nine New Codes for Fine Needle Aspirations (FNA) in 2019
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 4th, 2019
If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...
By 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 ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 3rd, 2019
Many articles have been published regarding the 2019 proposed Evaluation and Management coding changes, but hopefully you have taken the time to review those in detail and be ready for them. If not, here is a link to a Find-A-Code article written by Wyn Staheli (Director of Research) entitled, “Are You Ready ...
By Wyn Staheli, Director of Research | Published January 3rd, 2019
The new year is upon us and so it’s time to double check and make sure we are ready. Those with Premium Membership can use the ChiroCode Online Library and search all the official code sets: ICD-10-CM, CPT, and HCPCS. It also includes the updated NCCI edits and RVUs for ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 3rd, 2019
For 2019 a new code has been introduced (81443) which represents genetic testing for 15 genes associated with severe, inherited conditions. The results of this test may be used to identify carrier status during prenatal genetic counseling, confirm a clinical diagnosis, or identify at-risk family members for the following severe ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 3rd, 2019
The AMA has released the New, Revised and Deleted CPT codes these are currently available on Find-A-Code. View the entire list of changes on the CODE tab and select CPT. Be sure to review all of the changes effective January 01, 2019.
168 New Codes
72 Deleted Code
51 Revised Codes
Here are ...
By Wyn Staheli, Director of Research | Published December 20th, 2018
Recently we posted a Q/A with stated that Cox-flexion distraction was not billable with code 97012. We received a comment from a customer stating that was not entirely correct because there is an add-on to the standard Cox table which satisfied the mechanical requirements to use code 97012. This article ...
By Wyn Staheli, Director of Research | Published November 29th, 2018
While equipment for home strengthening is arguably good for the patient and the prognosis of their condition(s), payers have very strict guidelines as to what is considered medically necessary when it comes to Durable Medical Equipment (DME). While I have seen some workers compensation policies which do pay for DME ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 26th, 2018
Immunotherapy (Allergy Shots) is a medical treatment to used to treat and prevent reactions or desensitize the immune system to specific allergens that trigger allergy symptoms. Payers have specific coverage guidance and rules for reporting injections, the specific type of antigen(s) provided and how they should be reported.
Below are the coding guidelines from ...
By BC Advantage | 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...
Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
By Wyn Staheli, Director of Research | Published November 7th, 2018
The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...
Documentation Requirements for Allergy Testing 10/29/2018
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 30th, 2018
Per CMS, First Coast Service Options LCD 33261:
Medical record documentation (e.g., history & physical, office/progress notes, procedure report, test results) must include the following information, and be available upon request:
A complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient.
The medical necessity for performing ...
Below is a list of common CPT codes for Allergy and Immunology. Each code is listed with the following information:
Medicare Unlikely Edits (MUEs) for both a Non-Facility (NF) and Facility (F) setting.
Professional/Technical Component (PC/TC) Indicator.
Key Indicator or Procedure Code Status Indicator, which is a Medicare assigned "Indicator" to each code in ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 29th, 2018
Allergy testing may be performed due to exaggerated sensitivity or hypersensitivity. Using findings based on the patient’s complaint and face-to-face exam. Testing may be required to identify and determine a patient's immunologic sensitivity or reaction to certain allergens using certain CPT codes.
According to CMS, LCD 33261, allergy testing can be ...
By Wyn Staheli, Director of Research | Published October 16th, 2018
Pelvic floor dysfunction is often the underlying cause of conditions such as pelvic pain; urinary or bowel dysfunction; and/or sexual symptoms. Treatment generally begins with an evaluation and testing (e.g, EMG) followed by a variety of services (e.g., biofeedback, manipulation, pelvic floor electrical stimulation), depending on the findings.
Coverage by payers ...
By Wyn Staheli, Director of Research | Published October 16th, 2018
Question:
I am a certified DOT medical examiner and have applied to get my CLIA lab (waiver) for urinalysis, finger prick blood tests for A1c, cholesterol and glucose. I realize I cannot diagnose patients with these tests, but I am using them to make decisions in the DOT process and with ...
By BC Advantage | Published October 5th, 2018 - Last Review/Update October 17th, 2018
Time, as it applies to E/M codes, has often been viewed as an "if/then" proposition. "If" the documentation shows that a majority of the encounter was based on counseling and/or coordination of care, "then" we choose the highest level of service based on the total time of the encounter.
However, a ...
By Christine Woolstenhulme, QMC, QCC, CMCS, CPC, CMRS | Published October 2nd, 2018
Life Care Planners play a vital and underappreciated including understanding the progression of a disease and lifetime clinical treatment options, research, delete (I combined this into the paragraph above) compiled into one easy-to-use resource. a unified providing a single destination for procedure coding coding to find information on...
By 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 ...
By BC Advantage | Published September 26th, 2018 - Last Review/Update October 17th, 2018
The terms “rhizotomy” and “Radiofrequency Ablation” (RFA) both mean “destruction of a nerve.” Another term for this is “neurolysis.” The CPT coding choices for a rhizotomy procedure reflect the methods chosen to destroy the nerve(s). Nerve Destruction choices include the following: Chemical Neurolytic Blocks - These require substances that are...
The Potential Impacts of a Flat Rate EM Reimbursement on our Industry
By BC Advantage | Published September 26th, 2018 - Last Review/Update October 17th, 2018
The proposed E&M changes by CMS would decrease provider administrative work burden by, per CMS, 51 hours a year; however, how will reducing documentation requirements truly affect the professionals of the healthcare industry? First, let’s discuss the 30,000-foot overview of the most impactful E&M changes—which is the change to the...
2019 Code Changes are Just Around the Corner - Are You Ready?
By Wyn Staheli, Director of Research | Published September 24th, 2018 - Last Review/Update January 28th, 2019
The leaves are beginning to change and it’s time once again for the annual code changes for 2019. ICD-10-CM codes are out and will be effective October 1, 2018. CPT code changes also just came out and will be effective January 1, 2019. The ChiroCode DeskBook and ICD-10-CM Coding for Chiropractic books have been ...
By Noridian Medicare | Published August 30th, 2018
There are many factors that can contribute to your success in filing claims and getting reimbursed. The information below is from the CMS website.
Completing Item 12, Patient's or Authorized Person's Signature, on the CMS-1500 form for a non-assigned claim
A signature on file (SOF) indicates the supplier has obtained the beneficiary's one-time authorization on ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 27th, 2018
For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...
By Wyn Staheli, Director of Research | Published August 16th, 2018
Why would a chiropractor be concerned about depression screenings when you aren’t trained to be a mental health provider? The answer lies in patient outcomes. Many quality care organizations recommend depression screenings for patients with a chronic condition. According to The National Institute of Mental Health, “People with other chronic ...
By Wyn Staheli, Director of Research | Published August 16th, 2018
Medicare's guidelines for reporting of timed codes is found in Medicare Claims Processing Manual Chapter 5, Section 20.2. Also known as the '8 minute' rule, it describes how to calculate time for appropriate reporting when more than one timed code is performed at the same time.
It should be noted that while ...
By Wyn Staheli, Director of Research | Published August 16th, 2018
The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. ...
By Wyn Staheli, Director of Research | Published August 16th, 2018 - Last Review/Update January 30th, 2019
Are there any alternative procedure codes for billing mechanical massage (e.g., muscle master vibromassage, genie rub, etc)? I know that 'by the book' mechanical devices are not covered under 97124, but wondered if you have suggested a go-around code.
On July 16th 2018, anyone subscribed to the CMS Quality Payment Program received an e-mail containing a letter to doctors from Seem Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS). There are some widespread changes proposed in this letter of which you need to be aware.
Where ...
CMS Proposes Changes to Evaluation & Management Requirements
By Wyn Staheli, Director of Research | Published July 25th, 2018
It is no secret that providers have long argued that E/M coding is burdensome and does not truly reflect the services provided. This fact is acknowledged by CMS with the following statement "Prior attempts to revise the E/M guidelines were unsuccessful or resulted in additional complexity due to lack of ...
Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?
By NAMAS | Published July 18th, 2018
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed.
For ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 16th, 2018 - Last Review/Update July 17th, 2018
According to CMS changes are coming for E/M codes. A recent proposal from CMS stated: "The E/M visit code set is outdated and needs to be revised and revalued." Since podiatry tends to furnish a lower level of E/M visits, CMS is proposing new G-codes to report E/M office/outpatient visits. The proposed ...
Documentation: Face to Face for Home Health Certification
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 9th, 2018
As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. The ...
By ChiroCode | Published June 20th, 2018 - Last Review/Update January 30th, 2019
Question
The code, 97124, Is specifically for massage but I have read that Insurance will more likely pay for 97140. Could we bill for whichever one pays? I believe that we have to indicate which area is used for CMT and which area for massage. Is it enough to document that ...
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.
By Chris Woolstenhulme QCC, CMCS, CPC, CMRS & Marge McQuade | Published June 13th, 2018 - Last Review/Update September 24th, 2018
Q: Our clinic is owned by a hospital, but there is equipment in the clinic to do ECG/EKG’s. When the test is done here in the clinic, and the provider does the interpretation and report, is 93000 the correct code to bill? The equipment is owned by the clinic and ...
Inappropriate Use of Units Costs Practice Over $800,000
By Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | Published June 11th, 2018
A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut improperly submitted multiple units for drug screening urine tests. The proper billing of units has proven to be problematic for more than just lab tests. Is your billing of drugs & biologicals, injections and timed codes appropriate?
Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?
By Sharon Hoglund, CPC, CPMA, CEMC, CEMA | Published June 8th, 2018 - Last Review/Update July 3rd, 2018
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed...
By 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 ...
By Dr Evan Gwilliam, Clinical Director for PayDC chiropractic EHR software | Published June 4th, 2018 - Last Review/Update January 30th, 2019
Q: I have a payor who is denying modalities, claiming that they are “excessive”. At a single encounter I billed for:
98940- Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
97110- Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
G0283- Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
97010- Application of a modality to 1 or more areas; hot or cold packs
Is this excessive? How do I know how much is too much?
By Nancy J Beckley, MS, MBA, CHC | Published June 4th, 2018
New evaluation codes for physical therapy (PT) and occupational therapy (OT) codes were made effective 1/1/2017. Three new physical therapy evaluation codes replaced 97001, and three new occupational evaluation codes replaced 97003. Chart 1 - Short Code Descriptors The PT and OT reevaluation codes remain the same but were...
By Amy C. Pritchett, BSHA, CCS, CPC, CPMA, CPC-I, CEDO, CANPC, CASCC, CEDC, CRC, ICDCT-CM/PCS | Published May 30th, 2018 - Last Review/Update June 4th, 2018
It is that time of year again! The time to throw out the old and bring in the new. With the release of the CPT 2018 updates, we will see major changes in coding throughout the E/M section.
AMA vs Medicare rules and the use of the PT modifier
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Annual Wellness Visit
Procedure Codes G0438: Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit G0439: Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit 99385: Initial comprehensive preventive medicine evaluation and management of an individual including ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Bone Mass Measurements
Procedure Codes G0130: Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) 76977: Ultrasound bone density measurement and interpretation, peripheral site(s), any method 77078: Computed tomography, bone mineral density study, 1 or more ...
Preventive Medicine: Breast Cancer Genetic Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Breast Cancer Genetic Screening
Procedure Codes 81211: BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Breastfeeding Supplies
Procedure Codes A4286: Locking ring for breast pump, replacement E0602: Breast pump, manual, any type E0603: Breast pump, electric (ac and/or dc), any type E0604: Breast pump, hospital grade, electric (ac and / or dc), any type S9443: Lactation classes, non-physician provider, per session
ICD-10-CM ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Cardiovascular Disease Screening Tests
Procedure Codes 80061: Lipid panel. This panel must include the following:
Cholesterol, serum, total
Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
Triglycerides
82465: Cholesterol, serum, total 83718: Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) 84478: Triglycerides 83721: Lipoprotein, direct measurement; LDL cholesterol 83719: Lipoprotein, ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Colorectal Cancer Screening
Procedure Codes G0104: Colorectal cancer screening; flexible sigmoidoscopy G0105: Colorectal cancer screening; colonoscopy on individual at high risk G0106: Colorectal cancer screening; screening sigmoidoscopy, barium enema G0121: Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0122: Colorectal cancer screening; barium ...
Preventive Medicine: Counseling to Prevent Tobacco Use
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Counseling to Prevent Tobacco Use
Procedure Codes 99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
ICD-10-CM 99406-99407: No specific diagnoses
Frequency 99406-99407: 2 attempts a year, ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Depression Screening
Procedure Codes G0444: Annual depression screening, 15 minutes 96127: Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
ICD-10-CM G0444, 96127: No specific diagnoses
Frequency G0444:Once annually 96127: No specific frequency guidelines
Additional Information 96127
Only covered for ages ...
Preventive Medicine: Diabetes Self-Management Training
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Diabetes Self-Management Training
Procedure Codes G0108: DSMT, individual, per 30 minutes G0109: GDSMT, group (2 or more), per 30 minutes
ICD-10-CM G0108-G0109: Contact payer for more specific guidelines
Frequency G0108-G0109
Initial year: Up to 10 hours of initial training within a continuous 12-month period
Subsequent years: Up to 2 ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Therapy for Fall Prevention
Procedure Codes 97110: Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility 97112: Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Glaucoma Screening
Procedure Codes G0117: Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist G0118: Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist
ICD-10-CM G0117-G0118: Z13.5
Frequency G0117-G0118: Once a year
Additional information G0117-G0118
Coverage as is indicated with ...
Preventive Medicine: Hepatitis B Virus (HBV) Vaccine and Administration
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Hepatitis B Virus (HBV) Vaccine and Administration
Procedure Codes G0010: Administration of hepatitis b vaccine 90739: Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use 90740: Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use 90743: Hepatitis ...
Preventive Medicine: Hepatitis C Virus (HCV) Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Hepatitis C Virus (HCV) Screening
Procedure Codes G0472: Hepatitis c antibody screening, for individual at high risk and other covered indication(s) 87522: Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed 86804: Hepatitis C antibody; confirmatory test (eg, ...
Preventive Medicine: Influenza Virus Vaccine and Administration
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Influenza Virus Vaccine and Administration
Procedure Codes Q2034: Influenza virus vaccine, split virus, for intramuscular use (agriflu) Q2035: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (afluria) Q2036: Influenza virus vaccine, split virus, when administered to individuals ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Initial Preventive Physical Examination (Medicare Only)
Procedure Codes G0402: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment G0403: Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation ...
Preventive Medicine: Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity Prevention
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity Prevention
Procedure Codes G0270: Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Lung Cancer Screening
Procedure Codes G0296: Counseling visit to discuss need for lung cancer screening (ldct) using low dose ct scan (service is for eligibility determination and shared decision making) G0297: Low dose ct scan (ldct) for lung cancer screening S8092: Electron beam computed tomography (also ...
Preventive Medicine: Pneumococcal Vaccine and Administration
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Pneumococcal Vaccine and Administration
Procedure Codes G0009: Administration of pneumococcal vaccine 90670: Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use 90732: Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
ICD-10-CM G0009, ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Prostate Cancer Screening
Procedure Codes G0102: Prostate cancer screening; digital rectal examination G0103: Prostate cancer screening; prostate specific antigen test (PSA)
ICD-10-CM G0102-G0103: Z12.5
Frequency G0102-G0103: Once annually
Additional Information G0102-G0103
Only for males aged 50 and older
G0102
Copayment and deductible may apply, consult your payer
Find-A-Code™ - Preventive Services - ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Screening Mammography
Procedure Codes 77052: Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (list separately in addition to code for primary procedure) 77057: Screening mammography, bilateral ...
Preventive Medicine: Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
Procedure Codes 76706: Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA) 76770: Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete 76775: Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real ...
Preventive Medicine: Screening Children for Visual Acuity
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Screening Children for Visual Acuity
Procedure Codes 99173: Screening test of visual acuity, quantitative, bilateral
ICD-10-CM 99173: Z00.121, Z00.129, Z00.100, Z00.101
Frequency 99173: No specific frequency guidelines
Additional Information 99173
Not covered by Medicare for preventative care
Some policies will only cover as preventive for children, consult your payer
Find-A-Code™ - Preventive ...
By 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.
...
By Find-A-Code | Published May 9th, 2018 - Last Review/Update August 2nd, 2018
Preventive Medicine Topics Page
Dental Caries in Children
Procedure Codes 99188: Application of topical fluoride varnish by a physician or other qualified health care professional
ICD-10-CM 99188: No specific diagnoses
Frequency 99188: No specific frequency guidelines
Additional Information 99188
Covered for children from birth until their seventh birthday
Find-A-Code™ - Preventive Services - The information ...
As per MLN MM8304,
This article is based on Change Request (CR) 8304, which instructs DME MACs to implement requirements, which are effective July 1, 2013, for detailed written orders for face-to-face encounters conducted by the physician, PA, NP or CNS for certain DME items as defined in 42 CFR 410.38(g).
Due to concerns ...
By Wyn Staheli, ChiroCode Director of Research & Dr. Evan Gwilliam, Clinical Director PayDC Software | Published April 23rd, 2018 - Last Review/Update February 28th, 2019
In August of 2017, a Brooklyn chiropractor was ordered to repay $672,805 to Medicare because the reviewer found that 100% of the claims reviewed (from 2011-2012) did not meet medical necessity requirements. The chiropractor enlisted help from two reputable experts who disputed the findings of Medicare’s Professional Reviewer (MPR). However, the OIG maintained that the findings of the original auditor were valid.
Since none of us have ½ million in cash just laying around, it is essential to learn, understand, and make changes where appropriate to help audit-proof patient documentation.
Read here to learn more.
Coverage Criteria for Nonwearable Automatic Defibrillators
By Find-A-Code | Published April 19th, 2018
According to Noridian and CGS Administrators LCD L33690, a nonwearable automatic defibrillator (E0617) is covered for beneficiaries in two circumstances. They meet either (1) both criteria A and B or (2) criteria C, described below:
The beneficiary has one of the following conditions (1-8):A documented episode of cardiac arrest due to ventricular fibrillation, not due to a ...
Indications for Serotypes A and B Botulinum Toxins
By Find-A-Code | Published April 16th, 2018
According to Novitas LCD L27476, the following indications apply:
1. Blepharospasm and strabismus2. Spastic dystonia or focal dystonias to relieve pain, to assist posturing and walking, to increase range of motion, to assist in the outcome of physical therapy, and/or to reduce spasm thus allowing adequate perineal hygiene.3. Spasmodic dysphonia4. Achalasia and cardiospasm when ...
Billing Nutrition Counseling in a Chiropractic Setting
By Wyn Staheli, Director of Research | Published April 12th, 2018
Billing nutrition counseling services may not be as straight-forward as you might think. Some providers mistakenly choose Medical Nutrition Therapy (MNT) codes (97802-97804, G0270, G0271) because it states nutrition therapy in the title. However, according to CPT guidelines, when MNT assessment and/or intervention is performed by a physician or qualified healthcare professional ...
By Wyn Staheli, Director of Research | Published April 12th, 2018
Billing nutrition counseling services may not be as straight-forward as you might think. Some providers mistakenly choose Medical Nutrition Therapy (MNT) codes (97802-97804, G0270, G0271) because it states nutrition therapy in the title. However, according to CPT guidelines, when MNT assessment and/or intervention is performed by a physician or qualified healthcare professional who may report evaluation and management ...
Coverage Criteria for Peripheral Venous Examinations
By Find-A-Code | Published April 9th, 2018
According to National Government Services LCD L33627, indications for venous examinations are separated into three major categories: deep vein thrombosis (DVT), chronic venous insufficiency, and vein mapping. Studies are medically necessary only if the patient is a candidate for anticoagulation, thrombolysis or invasive therapeutic procedure(s).
Since the signs and symptoms of ...
As per Palmetto GBA LCD L33444, exercise testing is done to evaluate functional capacity and to assess the severity and type of impairment of existing as well as undiagnosed conditions. The pulmonary stress test will be considered medically necessary for these conditions:INDICATIONS:Evaluation of exercise tolerance• Determination of functional impairment or capacity • ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 29th, 2018
Find-A-Code presented a webinar on “Coding and Auditing Telemedicine Services,” on March 29, 2018, which did not include the new and updated CMS information published in the MNL Matters Number: MM10393 on January 2, 2018. New and exciting changes were introduced in this article, which is addressed below.
Originating Site Fee
Each ...
Documentation for Evaluation and Management (E/M) Services
By Nicole, QCC | Published March 26th, 2018
According to WPS, when billing or coding for E/M services you should follow a few guidelines.
Documentation must support the level of service billed and the medical necessity for the level billed. Below are additional tips for services which commonly incur CERT error findings for insufficient documentation.
Critical Care Visits
Clear indication of patient ...
Q/A: Why is Code 99080 Being Denied when Billed with an E/M Service?
By Wyn Staheli, Director of Research | Published March 21st, 2018 - Last Review/Update January 30th, 2019
In order to understand and answer the question, "Why code 99080 is being denied when billed with an E/M Service, it is important to first review the requriements of selecting the appropriate level of Evaluation and Management service and how that relates to reporting a 99080 special report service. Continue reading for better understanding.
By 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.
When is 97112 Neuromuscular Re-education Billable?
By Dr. Evan Gwilliam, VP for PayDC | Published March 13th, 2018 - Last Review/Update January 31st, 2019
Q: I just received a note from an attorney regarding a patient who was rear ended about 40 mph and ended up with neuropathy in her upper and lower extremities. We treated her for about 3 months after previous care failed to give much relief. I used flexion distraction and deep muscle stimulation to break up adhesions from the injury and used the 97112 code of neuromuscular re-education. The insurance company said that code was not warranted for her spinal sprain diagnosis and denied all of the services. Do you know how I could justify it? It greatly improved her condition with each visit and the patient said we provided the greatest relief she received.
By 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?
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them:
For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation.
For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s ...
By 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 ...
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 ...
Medicare Changes Requirements for Implantable Cardioverter Defibrillators (ICDs)
By Wyn Staheli, Director of Research | Published February 26th, 2018
Whenever there is a high-cost item, CMS has historically evaluated usage to determine appropriateness of billing and this is another example. A Decision Memo was released on February 15, 2018 which included the following changes:
Changes to who qualifies for a device and the required waiting periods
Patient registry no longer required
Cardiac magnetic resonance ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 21st, 2018
HCPCS level II codes classify products into categories for the purpose of claims processing. HCPCS level II codes are alphanumeric with a descriptive terminology that identifies the item or service used primarily for billing purposes.
There are several types of HCPCS level II codes such as:
Permanent National Codes
Dental Codes
Miscellaneous Codes
Temporary National ...
By ChiroCode | Published February 20th, 2018 - Last Review/Update February 4th, 2019
Question
Are there consultation codes that can be used for new and existing patients when a review of systems and detailed history is performed but no examination due to the patient's reluctance to make a decision to continue with the visit but has taken up 30-45 minutes of the doctors time?
By Chris Woolstenhulme, QCC, CMCS, 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 ...
Payment Rates Increase for Behavioral Health Office Services
By Wyn Staheli, Director of Research | Published February 13th, 2018
Behavioral health providers may see some improvement in payment rates for office-based behavioral health services. This is due to the fact that the overhead expense evaluation portion of the RVU was increased. The following information is from the Federal Register (see References):
We agree with these stakeholders that the site of service ...
Physical Therapists: Rules For Nerve Conduction And Needle Electromyographic (EMG) Codes
By Find-A-Code | Published February 1st, 2018
According to Noridian L35081, nerve conduction code 95905 does not have levels of supervision 21, 22, 6a, 66, 77 or 7a assigned to it and is therefore not allowed by Physical Therapists. Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Tests Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore, if authorized by state law, ...
Patients Undergoing a Bone Marrow Transplant (BMT)
By Find-A-Code | Published February 1st, 2018
Accoring to Wisconsin Physicians Service Insurance Corporation L34699, when using J2820 for patients undergoing a bone marrow transplant (BMT), 2 diagnosis codes are required:1) Z76.82 Awaiting organ transplant status2) Pick a code from one of these categories:
C81- Hodgkin Lymphoma
C82- Follicular Lymphoma
Non-follicular Lymphoma
C83.1- Mantle cell lymphoma
C83.3- Diffuse large B-cell lymphoma
C83.7- Burkitt lymphoma
C83.8- Other (Intravascular large B-cell lymphoma, Primary effusion B-cell lymphoma, or Lymphoid granulomatosis)
Mature T/NK-cell lymphomas
C84.4- Peripheral T-cell ...
By Natalie Tornese, CPC | Published February 1st, 2018
The following information is from BC Advantage.
Colonoscopy is a common procedure performed byGastroenterologists. CPT defines a colonoscopy examination as "the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis" ...
CMS Changes Definitions for Therapeutic Shoe Inserts
By Wyn Staheli, Director of Research | Published February 1st, 2018
CMS recently revised their definitions for custom fabricated and therapeutic inserts in order to meet current technology standards. Healthcare providers need to be sure to review the revisions in order to appropriately bill Medicare for inserts. For example, for custom fabricated, molded-to-patient, they have added the following:
iii. For inserts used with ...
By Wyn Staheli, Director of Research | Published February 1st, 2018
There are differences between the purposes of strapping and taping and using the correct codes depends on the application - literally.
Strapping: This application is for the purpose of immobilizing an area. It is clinically indicated for the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures, or other deformities involving soft tissue.
Coding: ...
By Wyn Staheli, Director of Research | Published February 1st, 2018
CMS and some other payers have adopted policies of reducing payments when certain multiple diagnostic imaging procedures (see Applicable Codes below) are performed in a single session by the same healthcare provider and/or group. They have done the same when there are multiple units for a procedure code. The rationale ...
By Wyn Staheli, Director of Research | Published February 1st, 2018
There has been some controversy over the use of the ICD-10-CM subluxation codes commonly referred to as traumatic (S13.1-, S23.1-, and S33.1-). Are they appropriate for chiropractors to use? The answer to that question is complicated. The problem basically lies in the lack of official guidance and differing opinions on ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2018
According to CMS ICN 909160, claims are determined to have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed, meaning the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary.
Claims ...
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 ...
Paravertebral Joint/Nerve Blocks - Diagnostic and Therapeutic
By Find-A-Code | Published January 29th, 2018
According to Medicare article A50443, a facet joint level refers to the zygapophyseal joint or the two medial branch nerves innervating that zygapophyseal joint. Use CPT codes 64491 and 64492 in conjunction with 64490. Do not report CPT code 64492 more than once per day. Use CPT codes 64494 and 64495 in conjunction with 64493. Do not report CPT code 64495 more than once per day. For injection of ...
The following information is according to Novitas Solutions L35084.
Mesenteric vessels: This includes
Acute mesenteric ischemia
Chronic mesenteric ischemia
Mesenteric thrombosis
Dissection or any other vascular insufficiency resulting in gastrointestinal symptoms
Stenting of the mesenteric vessels is covered only when angioplasty of the vessels would not suffice and after the patient has had a thorough medical evaluation and management of symptoms, and for whom surgical intervention is the likely ...
By Wyn Staheli, Director of Research | Published January 25th, 2018
Psychiatric Partial Hospitalization Programs (PHPs) are a more comprehensive level of care than Intensive Outpatient Programs (IOPs - click here to read more about IOPs). When the patient requires a minimum of 20 hours per week and hospitalization is not clinically indicated, a PHP can be the most effective type of ...
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
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?
By Wyn Staheli, Director of Research | Published January 18th, 2018
For 2018, there were some changes to the guidelines for prolonged services (99358 and 99359). Providers need to be aware that there were technical corrections made which may not be included in their CPT code book - but they are in FindACode.com effective January 1, 2018. Please note that the ...
Medicare's Integrated Behavioral Healthcare Services and Collaborative Care Program
By Wyn Staheli, Director of Research | Published January 18th, 2018
Over the last several years, primary care has begun to integrate behavioral health services to better address shortfalls in patient quality of care. Some of the first codes were the Health and Behavior Assessment/Intervention (96152-96155) codes, which were added in 2002. Since then, many different models have been experimented with and have ...
The following information is according to Novitas Solutions L35084.
Lower extremity arteries (abdominal aorta, iliac, superficial femoral and infrapopliteal arteries): This includes:
Lifestyle-limiting claudication
Focal hemodynamically significant lesion
Ischemic rest pain
Non-healing tissue ulceration
Focal gangrene
Stent placement in infrapopliteal vessels is not expected to be often indicated and in those cases the rationale for stent placement must be explained in the record.
CPT codes:
37221
37223
37226
37227
37230
37231
37234
37235
ICD-10-CM codes:
Type 1 diabetes mellitus
E10.51 - with diabetic peripheral angiopathy without gangrene
E10.59 - with other circulatory ...
The following information is according to Novitas Solutions L35084.
Renal artery: Stenting may be indicated for renal artery stenosis causing renovascular hypertension (see below) or renal insufficiency as well as post-transplant renal artery stenosis, arterial aneurysm or dissection. Renal artery angioplasty with or without stenting is covered for renal artery stenosis manifested by at least one of the following conditions:
Recurrent (“flash”) pulmonary edema without cardiac ...
According to Novitas Solutions L35084
Brachiocephalic arteries (including subclavian, except carotid bifurcation): Stenting may be indicated for treatment of flow-limiting stenosis resulting in conditions such as:
Subclavian steal syndrome
Upper extremity claudication
Ischemic rest pain of the arm and hand
Non-healing tissue ulceration
Focal gangrene.
CPT codes:
37236
37237
ICD-10-CM codes:
G45.8 - Other transient cerebral ischemic attacks and related syndromes
Unspecified atherosclerosis of native arteries of extremities
I70.201 - right leg
I70.202 - left leg
I70.203 - ...
Medicare Requiring Specific Modifiers on Therapy Services
By Wyn Staheli, Director of Research | Published January 15th, 2018
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:
Services furnished under the Outpatient ...
By Wyn Staheli, Director of Research | Published January 15th, 2018 - Last Review/Update January 30th, 2019
Q: When patients have a true Medicare secondary insurance we've always billed other Medicare non-covered codes such as G0283 for electric stimulation with modifier GY because we are aware Medicare will not pay for that service but the secondary insurance does. We just were notified by our MAC that GY is not a valid modifier and I have to enter a GP or other therapy modifier. What is the new proper modifier to enter?
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 ...
A facet joint is supplied by two medial branch nerves. Each medial branch nerve supplies sensation to one half of each facet joint above and below the spinal nerve of origin. Therefore, both of the two related medial nerve branches for each facet joint must be treated. The CPT codes 64635-64636 have a ...
Moderate (Conscious) sedation is a drug-induced state of relaxation in which the patient is typically awake and can respond to verbal commands, but might not be able to speak. A combination of medicines is used and often includes a sedative as well as an anesthetic to block pain.
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 ...
Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive
By Find-A-Code | Published January 9th, 2018
According to Palmetto GBA, Medicare will cover the cost of the injection and the injected hyaluronate polymer for patients who meet the following clinical criteria:
Knee pain associated with radiographic evidence of osteophytes in the knee joint, sclerosis in bone adjacent to the knee, or joint space narrowing.
Morning stiffness of less than 30 minutes in duration or crepitus on motion of the ...
Non-Coronary Vascular Stents: Inferior vena cava and iliofemoral veins
By Find-A-Code | Published January 9th, 2018
The following information is according to Novitas Solutions, L35084.
Inferior vena cava and iliofemoral veins: This includes vena cava and iliofemoral venous occlusions and stenosis due to the following
Post-radiation venous stenosis
Congenital stenoses or webs
Extrinsic venous compression (May-Thurner syndrome)
Thrombophlebitis and symptomatic post-traumatic venous stenosis.
CPT codes:
37238
37239
ICD-10-CM codes:
Phlebitis and thrombophlebitis
I80.10 - of unspecified femoral vein
I80.11 - of right femoral vein
I80.12 - of left femoral vein
I80.13 - of femoral vein, bilateral
I80.211 - of right iliac vein
I80.212 - of left iliac vein
I80.213 - of iliac vein, bilateral
I80.219 - of unspecified iliac vein
I80.8 - of ...
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.
By Christine Woolstenhulme | Published January 9th, 2018
This code is commonly used to bill for AcuKnee products. Per AcuKnee, “NMES and electrotherapy may be covered by most insurance providers, provided the following criteria are met;”
Documentation of chronic pain or muscle atrophy 3 months or longer
Must document improvement
Must have physician document medical necessity/Prescription
Appropriate authorization from your insurance provider
Suggested codes when billing
64550 initial electrotherapy education and placement
E0720 Electrotherapy unit itself
E0731 Garment ...
When coding surgical procedures, the approach is the technique you use to reach the site of the procedure, or how you get in to do the operation. The fifth character of PCS code is used to indicate the approach when using.
There are seven approaches. They are listed below with their ...
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, ...
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 ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 5th, 2018
Your organization may be leaking revenue without realizing the leak can be stopped. If your organization purchases single-use packets or single dose vials for individual patient use and ends up discarding some of the drug, Medicare has now authorized payment for the discarded or wasted portion. Stop leaking revenue today by reading this article and implementing the guidance provided here.
Beware of Limitations When Using Electrical Stimulation - Ultrasound
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 4th, 2018
Ultrasound is often used to reduce inflammation, and improve the flexibility of connective tissue. This is done by applying sound waves to produce heat and/or vibration. Be aware of the many limitations when reporting this code. Be sure to consult your local carrier LCDs and carefully determine the correct code and the requirements for ...
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 ...
According to CGS Administrators, most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.
97032 is a constant attendance electrical stimulation modality ...
According to CGS Administrators, for initial evaluations, PTs shall use code 97161-97163 and OTs shall use code 97164-97167. Physicians and other qualified non-physician providers should use the evaluation and management codes 99201-99350 for evaluations.Consider the following points when billing for an evaluation.
These evaluation codes are untimed, billable as one unit.
Do ...
According to CGS Administrators, the reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment, or terminating services. Reevaluation provides additional objective information not included in other documentation, such as treatment or progress notes.Reevaluations are distinct from therapy ...
According to CGS Administrators, CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention.
CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes ...
According to CGS Administrators, the objective of these treatments is to cause vasodilation and relieve pain from muscle spasm. Because heating is accomplished without physical contact between the modality and the skin, it can be used even if skin is abraded, as long as there is no significant edema.Diathermy achieves ...
According to CGS Administrators, therapeutic ultrasound is a deep heating modality that produces a sound wave of 0.8 to
3.0 MHz. In the human body ultrasound has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone may receive ...
According to CGS Administrators, hydrotherapy involves the patient’s immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.Qualified professional/auxiliary personnel one-on-one supervision of the patient is required. If the level of care does not require the skills of ...
Beginning July 1, 2017, there are 293 procedure codes with 10 and 90 day global days which will require practices with ten or more providers in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio and Oregon to use 99024 for subsequent visits within the global period. Many of these procedures are ...
2017-2018 Influenza (Flu) Resources for Health Care Professionals
By Find-A-Code | Published January 4th, 2018
Per CMS: Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies. Annual Part B deductible and coinsurance amounts do not apply.
Payment allowance limits for personal flu and pneumococcal vaccines are 95 percent of the Average Wholesale Price (AWP), except where the vaccine is furnished ...
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 ...
According to CGS Administrators, traction is generally limited to the cervical or lumbar spine with the expectation of relieving pain in or originating from those areas.Specific indications for the use of mechanical traction include cervical and/or lumbar radiculopathy and back disorders such as disc herniation, lumbago, and sciatica.This modality is typically used in conjunction with ...
According to the official ICD-10-CM Guidelines, in situations of maltreatment (e.g., adult and child abuse, neglect, etc.), the sequence of coding is important. Regardless of whether it is suspected or confirmed, it is important to document the type of abuse. Use the following sequence:
An appropriate code from category T74- (confirmed) or T76- (suspected)
Any accompanying mental ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 28th, 2017
Once a patient has been evaluated for symptoms associated with sleep apnea, testing is ordered to identify severity and determine treatment.
There are several types of sleep tests, but coverage is based on meeting the criteria for Type I (inpatient facility based) or Type II-IV and Other (home-based sleep tests). All ...
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 ...
Codes G0442 (screening) and G0443 (15 min counseling) are typically a covered preventive service for most payers. As a preventive service, copayment/coinsurance and deductibles are typically waived. These are NOT considered treatment services or sessions for alcoholism or other substance abuse. If the screening results indicate that the patient is dependent and is open to the ...
Moderate Sedation Services - CPT has 6 Codes to One Dental Code
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 28th, 2017
When billing a medical code instead of the dental code D9223 -Deep sedation/general anesthesia - each 15 minute increment, consider the following medical codes: (Be sure to review the AMA guidelines to see if they fit the procedure you are doing). If a dental office is doing conscious sedation for a patient ...
Lung Cancer Screening Counseling and Shared Decision Making Visit, and Annual Screening for Lung Cancer with LDCT
By Find-A-Code | Published December 20th, 2017
Effective February 5, 2015, a CMS National Coverage Determination (NCD) added lung cancer screening counseling and shared decision making visit, and for certain beneficiaries, annual screening for lung cancer with Low Dose Computed Tomography (LDCT), as an additional screening service benefit under the Medicare program if all eligibility criteria described ...
AT and GA Modifiers When Billing CMT and Non-covered Codes to Medicare
By 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?
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...
E/M DOCUMENTATION Does Your Coding Match Your Documentation???
By Marge McQuade CMSCS, CHCI, CPOM | Published December 12th, 2017
No matter what your specialty we are all faced with making sure our physician uses the correct E& M Code for what he/she documented. Remember if it wasn’t documented it wasn’t done!!!! That said, when looking at documentation to code E/M services, it’s good to educate the providers to document...
Why You Should Stop Using ROM as an Outcome Measure
By Dr. Ron Feise, Practice Consultant and Coach with RJF Consulting - www.chiroevidence.com | Published November 30th, 2017 - Last Review/Update January 30th, 2019
We received this email from a chiropractic colleague: “I recently attended a
continuing education seminar accredited by a chiropractic college. The presenter
was talking about outcome measures and highly recommended cervical and
lumbar range of motion (ROM) as a good outcome measure for patients with
spinal conditions. But I am hesitant to use ROM, because it seems to be
inconsistent with a patient’s status.”
What does the current research demonstrate?
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 ...
Can an Unlicensed Person Perform Physical Therapy Services Such as 97110?
By Wyn Staheli, Director of Research | Published November 16th, 2017 - Last Review/Update January 30th, 2019
Can an unlicensed person perform code a 97110 service as long as they're under doctor supervision? I use only PT, ATC, or DC's to perform these codes and I've been told that I don't need such highly qualified therapists to perform therapy.
Medicare Offering FREE Resources- Educate Beneficiaries About the New Medicare Cards
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 15th, 2017
Medicare is offering FREE resources to help you notify patients about the new Medicare cards. MLN connects newsletter announced the following.
"CMS is starting to conduct a major education campaign about the new card for people with Medicare. Help alert your patients by displaying a poster in your office and giving your patients tear-off sheets or fliers.
Register ...
Escharotomy Procedural Cross-Walking CPT to ICD-10-PCS
By Brandon Dee Leavitt QCC, CMCS, CPC, EMT | Published November 10th, 2017 - Last Review/Update November 17th, 2017
An Escharotomy is used for "local treatment of burned surface" per the AMA Guidelines, when incisions are performed on the burn site. Notice, when cross-walking 16035 or 16036 to inpatient codes, Find-A-Code crosswalks lead to Body System H, Operation 8 - Division of the skin, and Operation N - Release of the skin.
A division or release of the skin would be a ...
By 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 ...
By Wyn Staheli, Director of Research | Published November 6th, 2017
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of 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 ...
By Grant Huang, CPC, CPMA | Published November 3rd, 2017 - Last Review/Update January 31st, 2018
With CMS looking to gradually revise its E/M documentation requirements to reduce the burden and complexity they pose to providers, it's a great time to review the trickiest E/M component: medical decision making (MDM)....
By David Klein CPC, CPMA, CHC | Published October 31st, 2017 - Last Review/Update February 5th, 2019
Recent events regarding delegation of services to ancillary personnel have given rise to concerns regarding the delivery of outpatient physical medicine by Chiropractors, specifically regarding the appropriate use of one-on-one codes as opposed to group therapy code CPT 97150 - Therapeutic procedure(s), group (2 or more individuals). This advisory provides guidance on how to properly use one-on-one and group therapy codes, both independently and together.
Speech-Language Pathology Services Policy from UniCare
By Find-A-Code | Published October 27th, 2017
Medically Necessary:
Rehabilitative speech-language pathology (SLP) services are considered medically necessary when ALL of the following criteria are met:
The services are used in the treatment of communication impairment or swallowing disorders resulting from illness*, injury, surgery, or congenital abnormality; and
Based on a plan of care, the therapy sessions achieve a specific ...
Q&A: Blue Cross Blue Shield Updating Their Policy on the Application of Therapies by a Chiropractic Assistant
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 24th, 2017
ChiroCode recently received the following inquiry: Blue Cross Blue Shield is updating their policy on the application of therapies by a chiropractic assistant. It is as follows: "Physical Therapy and Chiropractic Billing Guidelines Reminder Physician or Chiropractor “Incident To” Billing of Therapy Services (New) Beginning January 1, 2018, physicians and...
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 23rd, 2017
The Office of the Inspector General was created to protect the integrity of the U.S. Department of Health and Human Services. They investigate fraud, waste, and abuse in HHS programs and make recommendations to various enforcement agencies. Every few years they investigate chiropractic services. Here is a summary of the reports the ...
By David Glaser, JD | Published October 13th, 2017 - Last Review/Update January 31st, 2018
An earlier coding tip explained that the oft-repeated "if it isn't written, it wasn't done" is good risk management advice, but not a legal truism.....
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 20th, 2017
CMS recently released a new LCD for Jurisdiction F, Bladder/Urothelial Tumor Markers (L36680).
Documentation Requirements
The medical record must clearly identify the number and frequency of bladder marker testing. Medical record documentation must be legible, must be maintained in the patient’s medical record (hard copy or electronic copy), and must meet the ...
Double Dipping in the History of the Evaluation and Management Note
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published September 14th, 2017
There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history.
The subcomponents of history include:
Chief Complaint ...
Auditing Prolonged Evaluation and Management Services
By Aimee Wilcox | Published September 12th, 2017 - Last Review/Update September 18th, 2017
At times, there are patients who require prolonged face-to-face time with the provider to discuss or be counseled about their condition, plan of care, risks, complications, alternative therapies, or other medical issues. When E/M services go wild, taking significantly longer than the typical time associated with it, that direct face-to-face ...
Global Surgical Package: When to Bill and When Not to Bill, that is the Question
By Stephanie Allard, CPC, CEMA, RHIT | Published September 8th, 2017 - Last Review/Update January 31st, 2018
The global surgical package is inclusive of the services that would normally be provided to the patient following surgery. Depending on the global period assigned to a CPT code, the pre-operative, intra-operative and post-operative services could be included in the global surgical package.....
By ChiroCode | Published September 1st, 2017 - Last Review/Update January 31st, 2019
Question
In our office when the doctor initially sees a new patient, we bill a new patient code. (99201, 99202, 99203, or 99204) At that time, the doctor gives the patient an X-ray script and informs them to return to the office with their disk for an ROF (review of findings) to go over their results and also to determine their treatment plan, etc. When this happens, can a separate E/M code be billed, like 99211, 99212, 99213, 99214 or is there another code that can be used?
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance from the Department of Health and Human Services on Cardiovascular Disease Screening Tests:
80061 -
Lipid panel, this panel must include the following:
82465 - Cholesterol, serum, total
83718 - Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
84478 - Triglycerides
Z13.6
All Medicare beneficiaries without apparent signs or symptoms ...
Health Risk Assessment as Part of Annual Wellness Visit
By Wyn Staheli | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Health Risk Assessment is a voluntary assessment which may be completed by either the patient or a caregiver. It is typically used in conjunction with an Annual Wellness Visit to help promote better health choices and provide disease prevention services.
Preventive Services: Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)....
Preventive Services: Lung Cancer Counseling and Annual Screening for Lung Cancer With LDCT
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Lung Cancer Screening Counseling, and Annual Screening for Lung Cancer With Low Dose Computed Tomography (LDCT)....
Preventive Services: Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests....
Preventive Services: Screening for STIs and High Intensity Behavioral Counseling (HIBC) to Prevent STIs
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.....
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening Pelvic Examinations (includes a clinical breast examination)....
By Wyn Staheli, Director of Research | Published August 29th, 2017
Performance Measurement Codes for Chiropractic:
Although there are hundreds of Performance Measurement (PM) services and events, only two may be reported for chiropractors for the 2017 reporting year.
Pain Assessment and Follow-Up
131
ENCOUNTER: 90791, 90792, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 96116, 96118, 96150, 96151, 97161, 97162, 97163, 97164, 97165, 97166, 97167, ...
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 24th, 2017 - Last Review/Update February 5th, 2019
We have one doctor in our practice who qualifies under the MIPS guidelines so he is continuing to use the PQRS and G-codes. We are having the rest of our doctors do the same, just in case, and because it is good practice, but is that completely unnecessary and can it possibly do us more harm than good?
Can They Deny Electrical Stimulation by Saying There is no Evidence that it Works?
By Dr Ronald J. Farabaugh | Published August 24th, 2017 - Last Review/Update February 5th, 2019
Topic: Electrical Stimulation (EMS)
Question: An orthopedic surgeon/IME recommended a denial for all electrical stimulation
(EMS) by stating that "according ODG electrical stimulation is experimental therefore not
medically necessary or eligible for reimbursement." Is that true?
By ChiroCode | Published August 17th, 2017 - Last Review/Update January 31st, 2019
Watch this short video, "Secrets of 97140 Manual Therapy," to learn all that you need to know about the proper support for 97140.
ChiroCode_DeskBook_Tips_97140 from Innoventrum on Vimeo.
...
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 ...
United HealthCare Ending Consultation Reimbursements: Effective October 1st, 2017
By NAMAS | Published August 15th, 2017
While Medicare discontinued payment allowance for consultation services (ranges 99241-99245 and 99251-99255) in January 2010, many commercial carriers have continued to cover these services. United Healthcare is now joining Medicare's opinion on consultation services.
In the June 2017 edition of the United HealthCare Bulletin, United Healthcare has announced that effective October ...
Do Other States Lower Payments for Crowns by Delta or Blue Cross?
By Christine Taxin | Published August 11th, 2017
Question: A subscribers from the State of Michigan has asked this:
Has anyone from other states seen the fees for crowns lowered by Delta or Blue Cross?
Answer: First look at your contracts, and see if there is anything in it that allows for fees to be lowered. Next, look up your ...
Delegation to Staff is not Allowed. Can I Bill for Group Exercises if I Supervise?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 8th, 2017 - Last Review/Update February 5th, 2019
My state does not allow me to delegate the supervision of therapeutic exercises (97110). I am the licensed chiropractor. If I provide the constant attendance myself, can I do it for a group of patients? If so, how do I document and bill for this?
List of Common Unclassified Injectable drugs (this list in not all-inclusive)
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 4th, 2017
This is a list of some of the most common Injectable unclassified drugs used with J3490
Antilirium – 1 mg/ml
Ascorbic Acid – 500 mg/ml
Ascorbic Acid – 250 mg/ml
Bacitracin, Intramuscular – 50,000 unit vials
Bacitracin, Intramuscular – 10,000 unit vials
Brevital Sodium – 500 mg/5 ml
Caffeine and Sodium Benzoate – 250 mg/ml
Capastat Sulfate – 1 ...
By Wyn Staheli | Published August 4th, 2017 - Last Review/Update October 4th, 2017
Medicare has proposed making some changes to policies regarding telehealth services. They are adding some new codes to their covered list of telehealth services and propose eliminating the requirement to use the GT modifier. Since many payers adopt similar policies, watch for further announcements from other third-party payers.
Proposed Codes
HCPCS code G0296 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 1st, 2017
Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed may be denied ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 1st, 2017
A dressing change may not be billed as either a debridement or other wound care service under any circumstance (e.g., CPT 97597, 97598, 97602).
Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. These services are reimbursed as part of a billable procedure code that, commonly but not necessarily, ...
By Wyn Staheli, Director of Research | Published August 1st, 2017
Annual Wellness Visits (AWVs) are a preventive medicine service. It is a comprehensive evaluation and management service which is covered by payers as part of the Affordable Care Act (ACA)'s covered services and there are typically no deductibles or co-pays.
36522 Photopheresis Extracorporeal; Not Payable Without Certain ICD-10-CM Codes
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 28th, 2017
When Outpatient hospitals bill CPT code 36522: (Photopheresis, extracorporeal), it must be billed with the following diagnosis codes:
C84.00 - C84.09 Mycosis fungoides;
C84.10 – C84.19 Sezary’s disease;
T86.20 – T86.298 Complications of heart transplant;
T86.30 – T86.39 Complications of heart-lung transplant;
T86.00 - T86.09 Complications of transplanted bone marrow.
Review your local LCD for billing and coding help.
...
HCPCS Codes - ASP Reporting is done in Units not NDC
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 26th, 2017
HCPCS CODES FOR WHICH ASP REPORTING IS DONE IN UNITS OF MEASURE OTHER THAN AN NDC Updated November 14, 2016
A9587 GALLIUM GA-68, DOTATATE, DIAGNOSTIC, 0.1 MILLICURIE 0.1 millicurie
A9588FLUCICLOVINE F-18, DIAGNOSTIC, 1 MILLICURIE 1 millicurie
A9606 RADIUM RA-223 DICHLORIDE, THERAPEUTIC, PER MICROCURIE 1 microcurie
C9132 PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY 1 IU
C9140 INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (AFSTYLA), 1 I.U. 1 IU
J0256 INJECTION, ALPHA 1 PROTEINASE INHIBITOR ...
By Valora Gurganious, MBA, CHBA | Published July 7th, 2017 - Last Review/Update January 25th, 2018
Technology is ubiquitous in modern society, and just when we thought that computers could not replace the "human touch" of a healthcare provider, technology is making specialized care accessible to patients anywhere there is an internet connection.
Focus Audit Results on the Documentation, Not the Encounter
By Scott Kraft, CPC, CPMA | Published June 30th, 2017
As an auditor, your job is to assess the quality of the documentation created by the provider to determine whether it meets the requirements to bill the code assigned to the service. This task often set us up a potentially adversarial role with the provider, particularly when it comes to ...
Documentation: Carrying Forward or Ineffective Use of Templates
By Shannon DeConda | Published June 30th, 2017
I often receive questions such as the below from our members regarding E&M scoring:
"I have heard that if information is 'cloned' or 'moved forward' from a previous visit, we should not count that info in scoring. However, I have also read that if a provider moves the info forward and ...
Consultation or Transfer of Care, What are the Differences?
By Dee MiMauro, CPC, COC, CPMA | Published June 30th, 2017
According to 2017 Current Procedural Terminology (CPT), a Consultation is a type of E&M service provided by a physician at the request of another physician or other appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of ...
By Michael Loss, CPC, CPMA | Published June 30th, 2017
Auditing laceration repair is generally an adventure. Most of my auditing work is reviewing the work of our coders rather than providers, but I have audited physicians as well. My present position has limited communication with providers, however we do attempt to get important information back to our clients for ...
CMS will be rolling out an Expanded Diabetes Prevention Plan January 1, 2018 as well as new Durable Medical Equipment (DME) supply codes for Continuous Glucose Monitors (CGM) July 1, 2017. These services will offer your practice the opportunity to better assist your diabetic patient's needs.
Remember that prior to providing ...
New payments for Psychiatric Collaborative Care Services (COCM) from Medicare
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 29th, 2017
Medicare has agreed to make separate payments to physicians and non-physicians for Behavioral Health Integration (BHI) services beginning Jan. 1st, 2017.
Any condition new or pre-existing behavioral health or substance use disorders are eligible. Beneficiaries may have comorbid, chronic, or other medical conditions they are being treated for as well.
Using the ...
Prescription Drug Management: Is it a Level 3 or a Level 4?
By J. Paul Spencer, CPC, COC | Published June 29th, 2017
If you place four auditors around a table and place a typical established patient visit in front of them, what tends to follow is a scene that resembles less about building consensus and more along the lines of a National Geographic special regarding the hunting habits of hyenas. Perhaps no ...
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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 20th, 2017
Due to the cost and refills that is required with portable oxygen systems separate payment classes were added in 2007 for oxygen generating portable equipment. Each year, Payment Classes for Oxygen Generating Portable Equipment, Stationary Oxygen Contents, and Portable Oxygen Contents, are adjusted to make additional payment classes for oxygen ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 14th, 2017 - Last Review/Update July 27th, 2017
Treatment of this type is generally used for patients requiring the application of a drying heat. For example, this treatment would be considered reasonable and necessary for the treatment of severe psoriasis where there is limited range of motion.
Only 1 unit of CPT code 97028 is covered per date of service.
Supportive Documentation ...
By ChiroCode | Published June 14th, 2017 - Last Review/Update January 30th, 2019
Q. We currently are using an outside radiologist to read all of our x-rays, therefore we have an official report on each x-ray. If we go back to reading our own x-rays, do we need to have a separate official report made? Or is it sufficient to just put the x-ray findings as part of the SOAP? Also, we are questioning the way we are billing our x-rays. Some of us feel like you should be able to bill for taking the x-rays and then reading them as well.
By 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?
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By 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, ...
Is 97112, Neuromuscular Re-education Only for Stroke Recovery?
By ChiroCode | Published June 1st, 2017 - Last Review/Update January 31st, 2019
This code is not reserved for stroke recovery, but it could certainly apply when treating some symptoms of a stroke. It is often used for many other conditions so long as medical necessity is present and clearly supported. Consider using this on patients with documented loss of coordination or balance. These might not be everyday cases in a chiropractic clinic, but they certainly would occur from time to time.
By 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?
By ChiroCode | Published April 28th, 2017 - Last Review/Update January 31st, 2019
Q: An insurer told me that chiropractors cannot bill 99204 or 99214 because those exams "require a level of decision making that would typically only occur in an emergency room." Is this true? Do I have any recourse?
Prescribers, including dentists, who write prescriptions for Part D drugs are to be enrolled in an approved status or validly opted out with Medicare, in order for their patients’ prescriptions to be covered under Medicare Part D.
Full enforcement of Part D prescriber enrollment requirement will begin on January 1, 2019. ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 21st, 2017 - Last Review/Update July 28th, 2017
All radiology services require proper orders, identifying the diagnosis for which the imaging is being ordered. “Rule out” or “Possible” won’t work for reimbursement purposes because professional services cannot code unconfirmed diagnoses. As such, for those types of services, include the symptom(s) as the diagnosis for which you are seeking ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 20th, 2017 - Last Review/Update July 28th, 2017
When billing dermal filler injections, separate payment may be made under the OPPS and ASC payment systems for HCPCS G0429- Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (lds) (e.g., as a result of highly active antiretroviral therapy).
Use in addition: Q2026- Injection, radiesse, 0.1 ml, and Q2028 - Injection, sculptra, 0.5 mg
With a diagnosis of B20 - ...
Office of Inspector General (OIG) - Compliance Program Guidance
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 14th, 2017
The compliance program guidance documents are listed below.
09-30-2008Supplemental Compliance Program Guidance for Nursing Facilities (73 Fed.Reg. 56832; September 30, 2008)
Compliance Program Guidance for Nursing Facilities (65 Fed. Reg. 14289; March 16, 2000)
11-28-2005Draft Compliance Program Guidance for Recipients of PHS Research Awards (70 Fed.Reg. 71312; November 28, 2005)
NSTC Launches Government-Wide Initiative ...
Moderate Sedation Services - CPT has 6 Codes to One Dental Code
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 30th, 2017 - Last Review/Update August 1st, 2017
When billing a medical code instead of the dental code D9223 -Deep sedation/general anesthesia - each 15 minute increment, consider the following medical codes: (Be sure to review the AMA guidelines to see if they fit the procedure you are doing). If a dental office is doing conscious sedation for a patient ...
Expect the biggest set of CCI changes you’ll see in 2014 to take effect on Jan. 1, as the edits are synched up to CPT® and HCPCS code changes that start next year. There are 61,120 new edit pairs coming next year, along with 13,107 deletions and 137 modifier changes....
Newly Revised "Common Procedure Codes" section in the 2016 ChiroCode DeskBook
By Evan M. Gwilliam, DC MBA BS CPC CCPC NCICS CPC-I CCCPC MCS-P CPMA | Published March 29th, 2017
The force used to create a degree of tension of soft tissues and/or to allow for separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration (time), and angle of pull (degrees) using mechanical means. Terms often used in describing pelvic/cervical traction ...
Respiratory Assist Devices (RAD) E0470 and E0471 - Billing Reminders
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 28th, 2017 - Last Review/Update July 28th, 2017
Add the KX modifier to all claims for RADs and accessories for the first through third months if all thecoverage criteria have been met.
Add the KX modifier to all claims for the fourth month and thereafter if all the coverage criteria have been met and if the physician signed and dated a ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 27th, 2017 - Last Review/Update July 28th, 2017
Dynamic splinting systems or devices are used to assist in restoring physical function and are commonly used for treating TMJ. Injury or joint stiffness are diagnoses that may qualify for medically necessity.
If physical therapy has proven ineffective to restore or improve range of motion, mechanical devices are often a next step.
This ...
Are There any Alternatives for Code 97112 Neuromuscular Re-education?
By ChiroCode | Published March 24th, 2017 - Last Review/Update January 31st, 2019
Q: Are there any alternatives for code 97112 Neuromuscular Re-education? This code is counted toward both Chiropractic and Physical Therapy visits with BCBS, and we want to preserve the insurance benefits.
Caution needs to be observed when reporting post-operative pain management (POPM). In accordance with NCCI edits policies, postoperative pain management is considered bundled in the surgical code(s). There are only a few instances where it may be billed separately.
Medicare Global Surgery Rules prevent separate payment for postoperative pain management when ...
By Chris Woolstenhulme, QCC, CMCS, 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, ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 7th, 2017 - Last Review/Update July 28th, 2017
If a procedure such as an excision of a polyp took significant additional time, work, and effort, you could append modifier 22 (unusual procedural service) to add to your fee when using 58100 "Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure)."
If a coloposcopy is performed in conjunction, use 58110 in addition to the ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 7th, 2017 - Last Review/Update July 28th, 2017
If you are coding for endocervical curettage only, use 57505 "Endocervical curettage (not done as part of a dilation and curettage)."
If an endometrial sampling (biopsy) was performed in conjunction with a colposcopy, use 57420 "Colposcopy of the entire vagina, with cervix if present," 57421 for "with biopsy(s) of vagina/cervix, or 57452-57461 for "colposcopy of the cervix including upper ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published March 3rd, 2017 - Last Review/Update February 8th, 2019
Q: If a patient is treated with chiropractic manipulation and it is clinically appropriate but doesn't qualify as medically necessary care, what is the proper way to communicate this when billing the insurance company for the service?
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 1st, 2017 - Last Review/Update January 16th, 2018
Care Plan oversight services is commonly done but rarely billed. The following codes can only be billed once every 30 days. The use of the following codes are determined by the complexity and approximate time spent by the physician or other health care professional within a 30-day period.
G0179
MD re-certification HHA PT
May be ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 1st, 2017 - Last Review/Update July 28th, 2017
Multi-layered, sustained, graduated, high compression bandage systems are used primarily to treat lymphedema and venous or stasis leg ulcers. A number of graduated, high-compression bandage systems products have been developed, including Profore®, Dyna-Flex®, Surepress®, Setopress®, and other similar product systems.Providers should note that the treatment of lymphedema with the application ...
Documentation: Face to Face for Home Health Certification
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 27th, 2017 - Last Review/Update August 16th, 2017
As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. ...
The date of service (DOS) is the reference point for determining the frequency of code submission and subsequent reimbursement during that period, generally if the service was provided in a different calendar month, the service would qualify for reimbursement.
Modifiers will not override a time span code if it is billed with ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 23rd, 2017 - Last Review/Update August 2nd, 2017
Care Plan oversight services is commonly done but rarely billed. The following codes can only be billed once every 30 days. The use of the following codes are determined by the complexity and approximate time spent by the physician or other health care professional within a 30-day period.
G0179
MD re-certification HHA ...
By 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% ...
By Wyn Staheli, Director of Research | Published February 21st, 2017
Telehealth (also known as telemedicine) is playing an ever increasing roll in the reimbursement process. Internet services continue to expand and many insurance payers/providers are now covering (paying for) telehealth services. Telepsychiatry (providing behavioral health services in a telehealth environment) has been highly successful because video conferencing makes providing psych ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 15th, 2017 - Last Review/Update August 2nd, 2017
Claims are determined to have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed - meaning the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary.
Claims are also ...
Beware of Limitations When Using Electrical Stimulation - Ultrasound
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 10th, 2017 - Last Review/Update August 2nd, 2017
Ultrasound is often used to reduce inflammation and improve the flexibility of connective tissue. This is done by applying sound waves to produce heat and/or vibration. Be aware of the many limitations when reporting this code. Be sure to consult your local carrier LCDs and carefully determine the correct code and the ...
Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 2nd, 2017 - Last Review/Update August 2nd, 2017
Verify your local coverage determination and medical necessity requirements for the following codes:
Hyaluronate Polymers (L33432) - Noridian Medicare
J7320 - Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg
J7321 - Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose
J7322 - Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg
J7323 - Hyaluronan or ...
Anesthesia Code Changes in 2017- Epidural Steroid Injections (ESI)
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 23rd, 2017
Pay close attention to the new 2017 Anesthesia codes there are a few notable changes. There is a new code set for Epidural Steroid Injections (ESI). The difference in the new codes set has a clear distinction on a single injection or a catheter placement for continuous infusion/intermittent bolus and if ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 23rd, 2017
Pay careful attention to the mammography code changes for 2017.
The following codes have been Deleted:
77055 Mammography; unilateral 77056 Mammography; bilateral 77057 Screening mammography, bilateral (2-view study of each breast)
Below are the Replacement Codes:
77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral 77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral 77067 Screening ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 23rd, 2017 - Last Review/Update March 8th, 2017
Deleted Codes for Drug Screening, the following codes are no longer valid for services performed on or after January 01, 2017.
Deleted Codes for 2017
80300
Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (eg, immunoassay) capable of being read by direct optical ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 21st, 2017
One of the significant code changes for 2017 included Moderate sedation services. Codes 99143-99145 and 99148-99150 are no longer active codes in 2017. The moderate sedation codes have been replaced with six new codes 99151-99157.
For example:
Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
G-Codes eff Jan 01,2017 for additional payment for Psych - Collaborative Care
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 2nd, 2017 - Last Review/Update July 26th, 2017
Medicare has agreed to make separate payments to physicians and non-physicians for Behavioral Health Integration (BHI) services beginning Jan. 01, 2017.
Any condition new or pre-existing behavioral health or substance use disorders are eligible. Beneficiaries may have comorbid, chronic, or other medical conditions they are being treated for as well.
Using the ...
By Brittney Murdock, QCC, CMCS, CPC | Published December 30th, 2016
The payment rates for most separately payable medical and surgical services are determined by multiplying the prospectively established scaled relative weight for the service’s clinical APC by a conversion factor (CF) to arrive at a national unadjusted payment rate for the APC.
By 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.?
By Wyn Staheli, Director of Research | Published December 19th, 2016
Benchmarking is simply a standard or point of reference against which things may be compared or assessed. For all businesses, it is a way of comparing your business processes to another business in the same industry to determine where shortfalls exist or improvements can be made to maintain profitability.
NAMAS: 2017 CPT Updates Bring Big Changes to Physical Therapy
By Find-A-Code | Published December 16th, 2016
For 2017, the new physical therapy (PT), occupational therapy (OT), and athletic training (AT) evaluation codes are the first major changes to the physical medicine and rehab codes in over twenty years. The new evaluation codes (97161-97168) replace the current PT and OT evaluation codes 97001 and 97003. The...
By Wyn Staheli, Director of Research | Published December 7th, 2016
Workers’ Compensation is for work related illness or injuries on the job. The employer pays for insurance which covers medical costs incurred, and replaces lost wages. Fees are based on a specific fee schedule that varies by state.
There are three possible scenarios regarding workers’ compensation: the patient is covered by ...
Billing for Prosthesis Designed and Prepared by the Dentist
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 6th, 2016 - Last Review/Update August 2nd, 2017
For maxillofacial services, if a prosthesis is provided, and is designed and prepared by the dentist, the Medicare Part B carrier may be billed with CPT codes 21076 through 21089. If the prosthesis is prepared by an outside laboratory, the laboratory bill goes to the Durable Medical Equipment Regional Carrier (DMERC), with Level ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 6th, 2016 - Last Review/Update August 1st, 2017
Implants, which could be considered dental but are being inserted to secure, attach, or support the maxillofacial prosthesis, will be covered when the prosthesis is to be used secondary to maxillofacial surgery or repair of traumatic injury. Use CPT code 21299 to bill the implants with an explanation of the intended use. ...
2017 CPT Updates Bring Big Changes to Physical Therapy
By Misty Tinch, RHIT, CPC, CPMA | Published December 4th, 2016 - Last Review/Update August 17th, 2017
For 2017, the new physical therapy (PT), occupational therapy (OT), and athletic training (AT) evaluation codes are the first major changes to the physical medicine and rehab codes in over twenty years. The new evaluation codes (97161-97168) replace the current PT and OT evaluation codes 97001 and 97003. The new ...
By BC Advantage | Published November 29th, 2016 - Last Review/Update December 8th, 2016
E/M stands for "evaluation and management". E/M coding is the process by which provider-patient encounters are translated into five digit CPT codes to facilitate billing. CPT stands for "current procedural terminology." These are the numeric codes which are submitted to insurers for payment. Most billable procedures have their own CPT ...
New Mapping Tool - CPT/HCPCS Medicare Denial Rates & Average Charges
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 29th, 2016
Use this tool as a part of an important strategy to improve your processes and stay ahead of denials. Check your most commonly used codes to give your practice a heads up on denial rates and average charges. This is a quick way to view a group of codes or ...
By ChiroCode | Published November 19th, 2016 - Last Review/Update March 5th, 2019
(from page 210 in chapter 3.5 of the 2017 DeskBook) One of the biggest problems providers face when audited is that many services are deemed not medically necessary and are routinely denied. Much of the proof falls back on the medical record.
Here are some specific situations as they may ...
By Raquel Shumway | Published November 9th, 2016 - Last Review/Update March 5th, 2019
Question: The Doctor says he was told by a billing company a few years ago to avoid the 97112. So he has been doing 97110 instead. They do the items listed in 97110, but often some of the ones in 97112 as well. His question was, should he actually be avoiding 97112? Or is there simply something he needs to be mindful of when using it?
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 2nd, 2016 - Last Review/Update August 1st, 2017
Subungual abscess
Contusion of the nail
Crushing injury of the toe or finger
Painful onychauxis
Painful onychomycosis
Onychocryptosis (ingrown nail)Onychocryptosis occurs most frequently in the big toes. The condition is categorized into:Simple onychocryptosis
Complicated onychocryptosis
The simple or uncomplicated category is caused by pressure on the nail groove by an essentially healthy nail caused by injudicious cutting ...
Auditing Same Day Psychotherapy and E&M Services: The Time Trap
By Scott Kraft, CPC, CPMA | Published October 28th, 2016 - Last Review/Update August 17th, 2017
A problem-focused E/M service and the provision of psychotherapy on the same date of service are both separately payable, when medically necessary. A typical scenario is when the
provider treats the patient's diagnoses by documenting the appropriate level of history, exam and medical decision making - such as a decision to ...
Sedation used on a Dental Patient for a medical procedure
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 27th, 2016 - Last Review/Update August 1st, 2017
When you need to bill a medical code instead of the dental code D9223, consider the following medical codes, and be sure to review the AMA guidelines to see if they fit the procedure you are doing. If a dental office is doing conscious Sedation for over 5 years old there is ...
Using Physical Status Modifiers with Anesthesia Codes
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Jessica Franzese, CPC, CPMA | Published October 14th, 2016 - Last Review/Update August 17th, 2017
Injection and infusion codes can be tricky. In this auditing tip, we'll break them down and help to make them a little easier to understand. Let's start first with the basics. Injections and infusion codes can be found in the medicine section of the CPT® book, codes 96360-96549. They are ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 5th, 2016
Did you know you could be charging for Advanced Care Planning (ACP). Effective January 1, 2016, payment for the service described by CPT code 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or ...
Upper Eyelid Blepharoplasty and Blepharoptosis Repair
By Chris Woolstenhulme, QCC, CMCS, 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 ...
Upper Eyelid Blepharoplasty and Blepharoptosis Repair (update eff 10/01/2017)
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Jeanette Anderson, CPC, CPMA | Published September 30th, 2016 - Last Review/Update August 17th, 2017
Medicare Condition Code 44 is used when an inpatient admission needs to be changed to outpatient status. There are some instances where a Medicare patient was admitted to the hospital with an inpatient status, but upon review it is deemed more appropriate for the entire encounter to be an outpatient ...
By Grant Huang, CPC, CPMA | Published September 16th, 2016 - Last Review/Update August 17th, 2017
Wound care can be a tricky arena for auditors, but if there's any one element that providers tend to skimp on, it's wound measurements. Getting wound measurements right is crucial, but providers can sometimes be slapdash with documenting their measurements. Let's review what's required in terms of measurements for the ...
To code a complete exam - you must include the following:
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 15th, 2016
Real time scanning of the kidneys
Abdominal aorta
Common iliac artery origins
Inferior vena cava
Alternaltively, if ultrasonography is being performed to evaluate the urinary tract, examination of the kidneys and urinary bladder constitutes a complete exam. Code 76775 is used when a limited retroperitoneal ultrasound examination is performed.
...
Smoking and tobacco cessation counseling, covered indications and # of visits
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 23rd, 2016 - Last Review/Update August 2nd, 2017
Nationally Covered Indications:Effective for claims with dates of service on or after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries1. Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;2. Who are competent and alert at the time that ...
Functional Limitation Reporting Codes and Modifiers
By Chris Woolstenhulme, QCC, CMCS, 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 ...
Differentiate the Extraordinary Work Performed During the Intraoperative or Postoperative Periods
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2016 - Last Review/Update August 2nd, 2017
The code for complex cataract surgery (CPT code 66982) is intended to differentiate the extraordinary work performed during the intraoperative or postoperative periods in a subset of cataract operations including, and not limited to, the following:
A miotic pupil which will not dilate sufficiently to allow adequate visualization of the lens in ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2016 - Last Review/Update August 2nd, 2017
The following information from one Medicare payer includes indications and limiatations of coverage as well as Medical Necessity standards for visual field examinations.
92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2016 - Last Review/Update August 4th, 2017
92225
Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial
92226
Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; subsequent
92227
Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2016 - Last Review/Update August 4th, 2017
The following information from one Medicare payer provides guidance on properly coding and documenting blepharoplasty procedures.
Blepharoplasty proceduresandrepairofblepharoptosis are covered when performed for the following functional indications. All other uses would be considered cosmetic.
1. Lower lid blepharoplasty (CPT 15820 and 15821) is considered as medically necessary when documentation:
supports horizontal lower eyelid laxity of medial and ...
Guidance for the Use of Codes in Physical Medicine - Pub-100
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2016 - Last Review/Update August 4th, 2017
The following provides guidance about the use of codes 96105, 97026, 97150, 97545, 97546, and G0128.
• CPT Codes 96105, 97545, and 97546.
Providers report code 96105, assessment of aphasia with interpretation and report in 1-hour units. This code represents formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination. If this formal assessment is performed during treatment, ...
Make sure your smoking cessation services are being coded right
By Codapedia | Published July 29th, 2016
Coding, billing and getting paid for providing smoking cessation services when covered by your payers is almost a no-brainer for any physician practice because, in most cases, cessation services are already being provided to patients who smoke cigarettes. Yet practices consistently don’t take advantage of this opportunity and, when they...
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...
Medicare no longer requires facility certification for bariatric surgery
By Codapedia | Published July 29th, 2016
Thanks to a recent tweak to Medicare policy, facilities are no longer required to be certified in order for bariatric surgery procedures to be covered, CMS announced in a recent transmittal modifying its National Coverage Determination (NCD) on the procedure. The change took effect September 24.Left unchanged in the NCD...
There is no CPT® code for the Mini Mental Status Exam. Physicians use the mini mental status exam (MMSE to test a patient's cognitive function. The test is made up of a set of questions, testing the patient’s memory, orientation and arithmetic calculation skills. There is a copyrighted form of...
Either a physician or an NPP may bill for discharge services from a skilled nursing facility or a nursing facility. There are two discharge day management codes from a nursing facility. 99315 is for discharge day management 30 minutes or less, and 99316 is for discharge day management over 30...
Subsequent nursing facility visits (99307--99310) are services billed for either mandated or medically necessary visits in a skilled nursing facility or nursing facility. (Place of service 31 for a skilled nursing facility or 32 for a nursing facility). These codes may also be used in place of service 54 (Intermediate...
CPT® code 99318 is used to bill an annual nursing facility assessment. It requires three of three of these components: a detailed interval history, a comprehensive exam, and low or moderate medical decision making. This visit is payable once per year for a resident in a nursing facility. It may...
Coding Selective and Non Selective Catheter Placement of Lower Extremity
By Codapedia | Published July 29th, 2016
- In diagnostic catheterization, codes are given simply at the final position of the catheter. This can be simply understood if we know the anatomy of Aorta. As we know, most of the major arteries arise from Aorta for example, Inominate artery, Left common carotid artery, Left subclavian artery, celiac...
Hospital services are all defined by CPT® as per day codes, that is, all of the care provided to a hospitalized patient during the calendar day. If a physician (or that physician's covering partner of the same specialty) sees the patient a second time during the calendar day, a second...
CPT® released three new E/M services in 2011, to be used for the second and subsequent days that a patient is in observation status in the hospital. The codes are 99224--99226 and they are out of sequence in the CPT® book. They require the same level of documentation as the...
According to the CPT® book, E/M services are divided into categories and subcategories. Office services are divided into new and established patient visits. Consultations are divided into outpatient/office consults and inpatient consultations. The E/M services typically have three to five levels of services and these levels are not interchangeable from...
I had a wheezer in the office, can I bill a 99215?
By Codapedia | Published July 29th, 2016
At a coding session at a recent Pri-Med conference a Pediatrician asked this question: "I had wheezer in the office, and he was in the office a long time. I examined him, we did pulxe oximetry measurements, which we never get paid for both before and after a nebulizer treatment....
Sports or camp or college physicals are exams requested by a parent or patient as a screening prior to going to camp or college or playing a sport. They vary in their scope. If the patient presents for a well child visit, and also needs their camp physical filled out,...
Anesthesia services are billed using CPT® codes 00100-01999. These CPT® codes are cross-walked to surgical codes. The crosswalk is available from the American Society of Anesthesiologists at www.asahq.org. Each anesthesia code has a base unit assigned to it. The anesthetist also bills the number of time units, with a single...
According to the American Medical Association’s CPT® book, a new patient is a patient who “has never received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. There is an excellent chart in the front...
OIG Work Plan to look at excessive patient billing, place of service errors
By | Published July 28th, 2016
The 2014 OIG Work Plan has finally been released and, while it doesn’t have a lot of new issues for physician practices, there are definitely some areas worth your attention to avoid future compliance hassles. If you’ve been wondering where it’s been, the OIG decided to change the timing of...
Does anyone remember the good old days, when you didn't need to know the patient's insurance to select a category of code? Now, correct selection of an E/M category of code requires the clinician and coder to consider: Where the service was performed The status of the patient (Observation vs...
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...
E-prescribing pay cuts loom for some in 2014, 2015
By Codapedia | Published July 28th, 2016
Some practices may find 2014 immediately off to the wrong foot when their Medicare payments are reduced by 2 percent for failing to participate successfully in Medicare’s E-prescribing Incentive Program. Unfortunately, at this point successfully claiming an exemption may be the only way to stave off the cut for non-reporters,...
- As we know there are OB CPT® codes using for coding Pregnancy procedures. The procedures are divided on weeks of gestation. There are separate CPT® codes for first and second trimesters. The first trimester of pregnancy is week 1 through week 12, or about 3 months. The second trimester...
Do you know New CPT® Code changes in 2016: Read this
By Codapedia | Published July 28th, 2016
- With New year in 2016, we will be having new CPT® codes in diagnostic radiology. Since, we will be having CPT® codes which will replace old CPT® codes, some of the codes will be deleted. Diagnostic Radiology have the lot of changes which I hope will help medical coder...
There are sample audited notes in resource section. 99213 is an established patient visit which requires 2 of 3 of the following components: An expanded, problem focused history, which is 1-3 HPI elements and 1 system in ROS reviewed An expanded, problem focused exam, which is 6 bullets from 1997...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 22nd, 2016 - Last Review/Update August 4th, 2017
There are several types of testing that distinguishes between influenza virus types A and B and several changes in codes in 2016.
For direct observation to detect an infectious agent by immunoassay use:
87804- Infectious agent antigen detection by immunoassay with direct optical observation; Influenza.
If the specimen is tested for both Type ...
NAMAS - Study the Rules Before Auditing E&M Services by Teaching Physicians
By Find-A-Code | Published June 28th, 2016
If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ...
Study the Rules Before Auditing E&M Services by Teaching Physicians
By Sara San Pedro, CPC, CEMC, CPMA | Published June 24th, 2016 - Last Review/Update August 17th, 2017
If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ...
What Are Unproven, Investigational or Experimental Procedures?
By Brandy Brimhall CPC CMCO CPCO CCCPC CPMA | Published June 23rd, 2016
Many specialties, including chiropractors, perform services that may be deemed "experimental, investigational and unproven." Individual payer coverage determinations, as well as state boards, generally offer specific information defining this type of procedure and any other notice or guideline that providers must be aware of and adhere to.The terms "unproven, experimental ...
Q&A: Will Using Lower Level Codes Reduce Our Chances of Being Audited?
By ChiroCode | Published June 16th, 2016 - Last Review/Update March 5th, 2019
Q&A: If we use low level codes on each visit (such as 98940, 99212, 99202), will our chances of being audited be less than if we billed higher level codes?
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 9th, 2016 - Last Review/Update August 2nd, 2017
Because Drugs are not a part of the Medicare fees schedule, Drug pricing by Medicare is done according to Average Sales pricing (ASP) and is used to pay Part B claims. Average Wholesale pricing was used for part B Medicare payments until 2005, then ASP pricing/payment structure was implemented.
How ASP ...
Pass-Through Payments, how they work and Device Category Codes List
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 9th, 2016 - Last Review/Update August 4th, 2017
If you want to know if a DRUG is a Pass through drug - Find-A-Code has that information on the code information page under FEES and APC Fee information
A pass through payment for a drug is Medicare reimbursement paid in addition to an ASC's facility fee, however, CMS limits the eligibility ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 6th, 2016 - Last Review/Update August 2nd, 2017
Most third-party payers (eg, commercial insurers, Medicare, Medicaid) cover REMICADE® (infliximab) for its approved U .S . Food and Drug Administration indications (see Indications on page 5 of this guide) . However, benefits may vary depending upon a patient’s insurer or specific insurance plan (or “product”) offered by a payer.
When third-party ...
By Jeanette Anderson, CPC, CPMA | Published May 27th, 2016 - Last Review/Update August 16th, 2017
When billing annual Medicare physicals, it's very important to know the status of the patient, determining when they became eligible, and/or if they've seen another provider for any of these services as the initial visit codes are once in a lifetime codes and will be denied if they have already ...
May be a Payable Code for Dental Procedures under Medical Policy
By Christine Taxin | Published May 25th, 2016
The following list may be payable Codes for Dental Procedures under a patients Medical Policy. Be sure to verify with the payer for benefit coverage and exclusions.
ICD-10-CM Diagnosis Codes
B00.2 Herpesviral gingivostomatitis and pharyngotonsilitis
K00.0 Andontia
K00.1 Supernumerary Tooth
K00.2 Abnormalites of size and form of tooth
K00.3 Mottled Teeth
K00.4 Disturbances in tooth formation
K00.5 Hereditary ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published May 9th, 2016 - Last Review/Update August 4th, 2017
Unclassified HCPCS codes can only be used when there is not a specific HCPCS code available for the drug being billed.
Each NDC associated with an unclassified drug code should be submitted on a separate claim line following the instructions specified in the Manual for Physicians and Providers- Coding and Filing ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published May 9th, 2016 - Last Review/Update August 4th, 2017
The following are tips to help you when billing NOC drugs and biologicals, such as J3490, J3590, and J9999. Providers submit NOC codes in the 2400/SV101-2 data element in the 5010 professional claim transaction (837P).
When billing an NOC code, providers are required to provide a description in the 2400/SV101-7 data element. The 5010 ...
By Wyn Staheli, Director of Research | Published May 3rd, 2016
Screening, Brief Intervention, and Referral to Treatment (SBIRT) services are an effective tool for healthcare providers to identify, reduce, and prevent problematic substance use disorders. Healthcare practices can help their patients and improve their integrated care standards with the proper use of the SBIRT.
By Chris Woolstenhulme, QCC, CMCS, 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 ...
Coverage Criteria and Medical Necessity with Medicare
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 4th, 2016 - Last Review/Update August 3rd, 2017
Negative Pressure Wound Therapy (NPWT) is defined as the application of sub-atmospheric pressure to a wound to remove exudate and debris from wounds. NPWT is delivered through an integrated system of a suction pump, separate exudate collection chamber and dressing sets to a qualified wound. In these systems, exudate is ...
Written Order Prior to Delivery (WOPD) is Required for Payment by Medicare
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 4th, 2016 - Last Review/Update August 3rd, 2017
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare ...
By John Burns, CPC, CPC-I, CEMC, CPMA | Published March 25th, 2016 - Last Review/Update August 16th, 2017
Most payers do indeed recognize smoking and tobacco cessation services as a covered health insurance benefit. We have found that some providers perform these services without fully understanding the reimbursement opportunities, while others claim such services without adequately documenting to support them. Medicare, for example, will pay for two (2) ...
Added Thoughts on Medical Necessity & Determining Appropriate Levels of Care
By Stephen R. Levinson, M.D., CHCA ASA, LLC | Published March 23rd, 2016
February’s Find-A-Code Newsletter provided a superb summary of the importance of Medical Necessity in determining the appropriate level of care warranted during a given Evaluation and Management service. The author also accurately identified the “Nature of the Presenting Problem(s)” as the E/M system’s measure of medical necessity, because it medically ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
Clear the Smoke on Debridement and Active Wound Care Codes
By Codapedia | Published February 26th, 2016
Confused about when to choose a debridement code and an active wound code? CPT® 2011 is here to your rescue with revised debridement code guidelines that clarify how to choose between the two code groups — and the key word that will tighten up your coding is depth. “Depth is...
By Scott Kraft | Published February 26th, 2016 - Last Review/Update August 16th, 2017
2016 brings changes to how physician practices bill for the removal of impacted cerumen, including a new CPT code. The rules that apply to the two cerumen removal codes now available for use mean that auditors will need to scrutinize the documentation closely in order to ensure codes are being ...
Pricing is for a single shoe or individual inserts
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 25th, 2016
If you are contracted with a payer be sure you recognize that the pricing is for a single shoe or insert.
When billing orthotics it seems to be less confusing to bill two line items, one for the Left - LT and one for the Right Rt.
...
Nebulizer Therapy Billing Reminders - Modifiers, Dispensing Fees, and Orders
By Chris Woolstenhulme, QCC, CMCS, 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 ...
ABN is required - (if you anticipate payer will deny or is not medically necessary)
By Chris Woolstenhulme, QCC, CMCS, 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, ...
PRESCRIPTION (ORDER) REQUIREMENTS (Confirm with your Local Payer)
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 4th, 2017
All items billed to Medicare require a prescription. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items dispensed and/or billed that do not meet these prescription requirements and those below must be ...
Coverage Criteria and Medical Necessity for a Mobility Device
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 4th, 2017
General Coverage Criteria for a Mobility DeviceAccording to CMS, all of the following basic criteria (A-C) must be met for a power mobility device (K0800-K0898) or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below.
The beneficiary has a mobility limitation ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 4th, 2017
According to CMS, delivery of the PMD must be within 120 days following completion of the F2F.
Exception: within 6 months from the date of an affirmed ADMC.
• The PMD will be denied if the underlying condition is reversible and length of need is < 3 months.
• The KX modifier ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
TeleMedicine Terms and Definitions and who can bill - Using Modifiers
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 15th, 2016
The Patient Access and Medicare Protection Act (PAMPA) was recently signed into law on December 28, 2015. Beginning January 1, 2016, the DME fee schedule rates are adjusted to reflect information from the DMEPOS competitive bidding program as required by section 1834(a)(1)(F)(ii) of the Social Security Act. These adjustments are ...
List of approved ICD-10 codes for Mental Health Providers - Washington State Medicaid
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 15th, 2016
The agency covers the below outpatient services to treat conditions that fall within the ICD diagnosis code range for mental health. For billing purposes, providers are required to use the most specific code available.
The agency also covers preventative mental health care, if the most specific code is used.
See the agency’s ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 12th, 2016 - Last Review/Update August 4th, 2017
Reason for referral.
Tests administered, scoring/interpretation, and time involved.
Present evaluation.
Diagnosis (or suspected diagnosis that was the basis for the testing if no mental/neurocognitive illness was found).
Recommendations for interventions, if necessary.
Identity of person performing service.
...
Patient Status: Hospital Inpatient vs. Observation
By Jeanette Anderson, CPC, CPMA | Published February 12th, 2016 - Last Review/Update August 16th, 2017
As an auditor, we must ensure that the documentation supports the selected use of codes for reimbursement. When auditing hospital encounters, the patient status serves as the basis for the code selection and therefore must be clearly documented. This ensures that the hospital is able to collect appropriate reimbursement.
During an ...
Will Incident-To in Your Organization Pass a Compliance Audit?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2016
Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.
Therapeutic Shoes for Individuals with Diabetes- Document, Prescribe, Furnishing
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 1st, 2016
This managing physician must:
• Document in the patient’s medical record that the patient has diabetes;
• Certify that the patient is being treated under a comprehensive plan of care for
diabetes, and that the patient needs diabetic shoes; and
• Document in the patient’s record that the patient has one or more of ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 1st, 2016 - Last Review/Update August 7th, 2017
Prescribed to:
Reduce pain by restricting mobility of the trunk: OR
Facilitate healing following an injury to the spine or related tissue; OR
Otherwise support weak and/or deformed spinal muscles.
Documentation and billing practices be sure you are meeting all the requirements to bill a spinal orthoses.
Spinal Orthoses billed with HPCPCS L0450, L0454, L0621, L0625 and L0628 must be billed with ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 1st, 2016 - Last Review/Update August 4th, 2017
According to Noridian, CMS has determined that elastic garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. Therefore, effective for claims with dates of service on or after April 1, 2009, these items will be denied as Medicare noncovered, no benefit category.
This ...
Announcing Find-A-Codes newest addition - Medical /Lab Test Information
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2016
Announcing Find-A-Codes Newest product: Medical /Lab Test Information, available with your Find-A-Code subscription.Test information includes:
overview of the test
utility - when/why/how the test is used
diseases the test is often used to detect or monitor
specimen collection methods/procedures
testing methodology
usual turnaround time
interpretation of test results
reference ranges for test results (normal, abnormal, etc.)
diagnosis and billing ...
Wound Care & Debridement- Provided by Physician, NPP or as Incident-to Services
By Chris Woolstenhulme, QCC, CMCS, 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 ...
Certificate for Provider - Performed Microscopy Procedures
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2016
Effective January 19, 1993, a laboratory that holds a certificate for provider-performed microscopy procedures may perform only those tests specified as provider-performed microscopy procedures and waived tests, as described below, and no others.
HCPCS Code Test
Q0111
Wet mounts, including preparations of vaginal, cervical or skin
specimens
Q0112
All potassium hydroxide (KOH)
preparations
Q0113
Pinworm examinations
Q0114
Fern test
Q0115
Post-coital direct, qualitative ...
CMS does not pay for an Evaluation and Management service prior to a screening colonoscopy. If a patient calls or is sent from another physician to schedule a screening colonoscopy, do not bill any type of E/M service prior to the procedure. Some commercial carriers also...
Don’t expect to see payment any time soon for ‘telephone consults’
By Codapedia | Published January 6th, 2016
Four new CPT® codes that got some attention when the 2014 CPT® changes were released late last year were a new E/M code series, 99446-99449, designed to be reported when a consulting provider offered a telephone or Internet E/M service that included a verbal and written...
Preventive Medicine Services for Medicare Patients
By Codapedia | Published January 6th, 2016
The most widely known fact about Medicare and preventive medicine is that fee-for-service Medicare does not cover an annual physical exam. This is because in its beginning, Medicare was prohibited from paying for routine services. Over the years, Congress has mandated the payment of some screening...
Doing--and coding--for minor procedures in primary care
By Codapedia | Published January 6th, 2016
I asked a Family Physician recently if he did minor procedures in his practice. He said, “I send them all to my partner. Tim loves doing minor procedures, and he’s fast. I don’t bother with them myself.” His partner, by inclination or design, was the designated...
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...
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...
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...
Binocular Microscopy Question: Our physicians want to report binocular microscopy in addition to minor ear procedures when they use the microscope in the office. For example, removing ear wax or placing tubes, and mastoid debridements. Can binocular microscopy be reported in addition to the minor procedure...
Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (code G0105) examination
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 4th, 2017
According to the Pub-100, screening barium enema examinations may be paid as an alternative to a screening colonoscopy (code G0105) examination. The same frequency parameters for screening colonoscopies (see those codes above) apply. In the case of an individual who is at high risk for colorectal cancer, payment may be made for ...
Colorectal Cancer Screening; Barium Enema; as an Alternative to G0104, Screening Sigmoidoscopy
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 7th, 2017
G0106 - Colorectal Cancer Screening; Barium Enema; as an Alternative to G0104, Screening Sigmoidoscopy Screening barium enema examinations may be paid as an alternative to a screening sigmoidoscopy (code G0104). The same frequency parameters for screening sigmoidoscopies (see those codes above) apply.In the case of an individual aged 50 or over, payment may be ...
Characteristics of High Risk and How Often Test can be Performed
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 7th, 2017
According to Medicares Pub-100, 60 - Colorectal Cancer Screening Ref: AB-03-114;
Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month ...
Service is considered colorectal cancer screening services, age limit, every 48 months
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 7th, 2017
G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy
Screening flexible sigmoidoscopies (code G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below.For claims with dates of service on or after January 1, 2002, contractors or carriers pay for screening ...
The Comprehensive Error Rate Testing (CERT) program Medicare uses to assess the accuracy of provider billing has uncovered a big source for mistakes – documentation problems when a patient is receiving psychotherapy services on the same date as an E/M encounter, according to CMS. There are...
CMS: Lot of errors billing psychotherapy services when E/M visit is involved
By Codapedia | Published December 11th, 2015
The Comprehensive Error Rate Testing (CERT) program Medicare uses to assess the accuracy of provider billing has uncovered a big source for mistakes – documentation problems when a patient is receiving psychotherapy services on the same date as an E/M encounter, according to CMS. There are...
CMS NCD drops clinical trial requirement for FDG PET scans for solid tumors
By 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...
Hospital discharge, nursing facility admit billable on same day by same provider in most instances
By Codapedia | 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...
Any patient post-discharge whose medical and/or psychosocial problems are complex enough to require TCM services qualifies for these codes. Here are the specifics: 1. Location: “TCM is for higher-risk patients being discharged from an inpatient or observation status to their home, rest home, or assisted living...
Well Woman Exam CodingThere are options for billing pelvic exams and Pap smears for non-Medicare payers, albeit inconsistently by health plan. Some health plans will pay G0101, Q0091, S0610 and/or S0612. Some will pay one or another, some will pay a combination of two, others...
Basics about CPT® code for Angiogram For percutaneous surgery, it is very important to code the angiography codes for studying the arteries or veins. In interventional radiology, we have many CPT® codes for angiograms that are specific are each artery or vein. These Angiogram procedure codes...
Established patient visits all require 2 out of 3 of history, exam, medical decision making 99212: History required is problem focused: 1-3 HPI elements Exam required is problem focused: 1 body area/organ system examined from the 1995 exam, or one bullet from the multi-specialty exam...
Recovery Audit Contractors (RACs) may be about to take a break while CMS awards new contracts, but don’t rest on your laurels. CMS has handed out yet another auditor contract for a single auditor, known as a Supplemental Medical Review Contractor (SMRC) to do nationwide claims...
What is the difference between the two sets of Guidelines?
There are two major differences. The first is in the history of the present illness (HPI). In the 1995 Guidelines, in order to document a history of the present illness at a detailed level, the clinician must document ...
I can count on two consistent issues in coding audits. Doctors report that their patients are, in general, sicker than patients in other practices. Coders report that their physicians are, in general, worse documenters than physicians in other practices and select codes that are too high based on ...
Does an E/M service require an exam? It depends on the category of service.
Established patients and subsequent hospital visits require two out of three of the key components, history, exam and medical decision making. Any two components at the level of documentation required determines the level of ...
By Evan M. Gwilliam DC MBA BS CPC CCPC NCICS CCCPC CPC-I MCS-P CPMA, Christine Woolstenhulme, CMRS | Published November 13th, 2015
Chapter 21 of ICD-10-CM is titled "Factors Influencing Health Status and Contact with Health Services". They cover codes in the categories from Z00 to Z99. This chapter is used for encounters with health care providers where the patients have no current illnesses or injury. For example, a patient may present at ...
Modifiers – Reimbursement or Informational? Modifier Training
By WPS Medicare | Published October 20th, 2015
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 ...
The JW Modifier is Only Applied to the Amount of Drug or Biological that is Discarded
By Chris Woolstenhulme, QCC, CMCS, 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, ...
By Chris Woolstenhulme, QCC, CMCS, 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. ...
Conditions or Exceptions that might justify coverage of foot care
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 8th, 2015 - Last Review/Update August 7th, 2017
When using G0127 keep in mind routine foot/nail care is generally excluded from coverage under Medicare, however there are some exceptions:
Click here to read the entire article
Although not intended as a comprehensive list, the following metabolic, neurologic,and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that might ...
By 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 ...
Listed is a summary of the revisions and additions to Chapter 13 of the Medicare Claims Processing Manual and Chapter 15 of the Medicare Benefit Policy Manual.
CHAPTER 13
Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of ...
Documentation and Medical Necessity - Ablative Treatment for Spinal Pain - UHC Medical Policy
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 21st, 2015 - Last Review/Update August 7th, 2017
According to UnitedHealthcares policy: For chronic cervical, thoracic and lumbar pain, Thermal radiofrequency ablation of facet joint nerves is proven and medically necessary when confirmed by the following:
Temperature 60 degrees Celsius or more;
Duration of ablation 40 - 90 seconds
Positive response to medial branch block injection at the side and level of the proposed ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 21st, 2015 - Last Review/Update August 7th, 2017
The medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s).
TC - Technical component Modifier may be ...
Medicare Makes Moderate Sedation Payable
Christine Taxin
Should your primary care physicians ever find cause to perform moderate sedation, you’ll be interested in a new Medicare policy that may make it payable as of Oct. 1. Medicare Pub. 100-04 Transmittal 1324 finally makes Medicare policy consistent with the fee schedule pricing for ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 20th, 2015
Covered Bariatric Surgery Procedures
Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity.
The patient must have a body-mass index (BMI) 35, have at least one co-morbidity related to ...
Billing injections on the same day as an E/M service
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 19th, 2015
But increasingly, payers are being just as reflexive when it comes to denying the E/M service, saying that it's bundled into the injection.
What's the truth? While there are many instances when the E/M service is bundled into the injection service, there are probably just as many instances when these denials ...
A Dental Guide to Cross-Coding for Oral Cancer Screening
By Christine Taxin Adjunct Professor, University of New York School of Dentistry - Links2Success.biz | Published August 19th, 2015
Dental professionals are a patient’s primary source of screening within the oral cavity; thus attention must be paid to the most common oral malignancy: squamous cell carcinoma. Historically such malignancies were attributed only to patients with a history of extensive alcohol and tobacco use. However, other risk factors such as ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2015
Documentation Requirements for Therapy Services, indicates that the amount of time for each specific intervention/modality provided to the patient is not required to be documented in the Treatment Note. However, the total number of timed minutes must be documented. These examples indicate how to count the appropriate number of units ...
Orthognathic Surgery - Medical Policy Criteria - Regence
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2015
Orthognathic surgery involves the surgical manipulation of the facial skeleton, particularly the maxilla and mandible, to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies, which may be caused by congenital or developmental anomalies or by traumatic injury.
[1] Note: This policy does not address the surgical ...
By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017
This code would be used rarely in a chiropractic office. 99211 is a low complexity examination for an established patient. It can be used by chiropractors, but in most instances, it is discouraged.
The 99211 code, also known as the nurse’s code, is not really made for the physician to use. In fact, the AMA, CPT ...
By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017
Stop losing hard-earned dollars. Too often, dollars are left on the table at billing time. Adjunctive codes for associated services should be added when they are appropriate. Here are a few examples of coding that are often overlooked.
97014 & 97032 Electrical Stimulation Supplies
According to the Relative Value Update Committee (RUC), ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 7th, 2015 - Last Review/Update August 7th, 2017
Notes: Most Aetna HMO plans exclude coverage for treatment of temporomandibular disorders (TMD) and temporomandibular joint (TMJ) dysfunction
For plans that cover treatment of TMD and TMJ dysfunction, requests for TMJ surgery require review by Aetna's Oral and Maxillofacial Surgery patient management unit. Reviews must include submission of a problem-specific history ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 7th, 2015 - Last Review/Update August 7th, 2017
HCPCS codes E0935 (Continuous passive motion exercise device for use on knee only), and E0936 (Continuous passive motion exercise device for use other than knee) are reimbursed on a daily basis consistent with CMS guidelines.
The following HCPCS codes are also reimbursed on a daily basis:
E0193 -Powered air flotation bed (low air loss therapy)
E0194 -Air fluidized bed
E0277 –Powered ...
Orthognathic Surgery - Medical Policy Criteria - Regence
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 7th, 2015 - Last Review/Update August 7th, 2017
Orthognathic surgery involves the surgical manipulation of the facial skeleton, particularly the maxilla and mandible, to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies, which may be caused by congenital or developmental anomalies or by traumatic injury.
[1] Note: This policy does not address the surgical ...
Method for Computing Fee Schedule Amount (Rev. 1, 10-01-03)
By Find-A-Code | Published August 3rd, 2015
B3-15006
The CMS continually updates, refines, and alters the methods used in computing the fee schedule amount. For example, input from the American Academy of Ophthalmology has led to alterations in the supplies and equipment used in the computation of the fee schedule for selected procedures. Likewise, new research has changed ...
Hospice Pre - Election Evaluation and Counseling Services (Rev. 2258)
By Find-A-Code | Published July 20th, 2015
Effective January 1, 2005, Medicare allows payment to a hospice for specified hospice pre-election evaluation and counseling services when furnished by a physician who is either the medical director of or employee of the hospice.
Medicare covers a one-time only payment on behalf of a beneficiary who is terminally ill, (defined ...
Mandatory Assignment on Carrier Claims (Rev. 2487, Issued: 06-08-12)
By Find-A-Code | Published July 17th, 2015
The following practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed amount as payment in full for their practitioner services. The beneficiary’s liability is limited to any applicable deductible plus ...
Coding Requirements for Specimen Collection (Rev. 3056, 12-01-14)
By Jared Staheli | Published July 10th, 2015
The following HCPCS codes and terminology must be used:
• 36415 – Collection of venous blood by venipuncture.
• G0471 – Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency ...
Certificate for Provider-Performed Microscopy Procedures (Rev. 865, 07-03-06)
By Jared Staheli | Published July 10th, 2015
Effective January 19, 1993, a laboratory that holds a certificate for provider-performed microscopy procedures may perform only those tests specified as provider-performed microscopy procedures and waived tests, as described below, and no others.
HCPCS Code
Test
Q0111
Wet mounts, including preparations of vaginal, cervical or skin specimens
Q0112
All potassium hydroxide (KOH) preparations
Q0113
Pinworm examinations
Q0114
Fern test
Q0115
Post-coital direct, ...
Certificate of Waiver (Rev. 1652, 01-05-09) - CLIA
By Jared Staheli | Published July 10th, 2015
Effective September 1, 1992, all laboratory testing sites (except as provided in 42 CFR 493.3(b)) must have either a CLIA certificate of waiver, certificate for providerperformed microscopy procedures, certificate of registration, certificate of compliance, or certificate of accreditation to legally perform clinical laboratory testing on specimens from individuals in the ...
HCPCS Subject To and Excluded From CLIA Edits (Rev. 865, 07-03-06)
By Jared Staheli | Published July 10th, 2015
At this time, all claims submitted for laboratory tests subject to CLIA are edited at the CLIA certificate level. However, the HCPCS codes that are considered a laboratory test under CLIA change each year. The CMS identifies the new HCPCS (non-waived, nonprovider-performed procedure) codes, including any modifiers that are subject ...
Clinical laboratory tests include some services described as anatomic pathology services in CPT (i.e., certain cervical, vaginal, or peripheral blood smears). The CPT code 85060 is used only when a physician interprets an abnormal peripheral blood smear for a hospital inpatient or a hospital outpatient, and the hospital is responsible ...
National Minimum Payment Amounts for Cervical or Vaginal Smear Clinical Laboratory Tests (Rev. 1, 10-01-03)
By Jared Staheli | Published July 10th, 2015
For cervical or vaginal smear clinical laboratory tests, payment is the lesser of the local fee or the national limitation amount, but not less than the national minimum payment amount (NMPA). However, in no case may payment for these tests exceed actual charges. The Part B deductible and coinsurance do ...
Organ or Disease Oriented Panels (Rev. 1451, 07-07-08)
By Jared Staheli | Published July 10th, 2015
Organ or disease panels must be paid at the lower of the billed charge, the fee amount for the panel, or the sum of the fee amounts for all components. When panels contain one or more automated tests, the contractor determines the correct price for the panel by comparing the ...
CPT Codes Subject to and Not Subject to the Clinical Laboratory Fee Schedule (Rev. 1, 10-01-03)
By Jared Staheli | Published July 10th, 2015
For fee schedule purposes, clinical laboratory services include most laboratory tests listed in codes 80048-89399 of CPT-1996. The CMS issues an update to the laboratory fee schedule each year, with information about whether prices have been determined by CMS or whether the individual carrier must determine the allowable charge.
Codes not ...
Procedures Not Subject to Fee Schedule When Billed With Blood Products (Rev. 1, 10-01-03)
By Find-A-Code | Published July 10th, 2015
The following codes are not subject to fee schedule limitations when submitted for payment on the same bill with charges for blood products. Rather, assume they are to be used for blood matching and not for diagnostic purposes.
Codes: 86901, 86905, 86930-86932, 86920-86922, 86890, 86870, 86891, 86880-86886, 86971, and 86930.
If no ...
Not Otherwise Classified Clinical Laboratory Tests (Rev. 1, 10-01-03)
By Find-A-Code | Published July 10th, 2015
The following codes for unlisted or not otherwise classified (NOC) clinical laboratory tests are not subject to the NLA:
81099 87999 84999 88299 85999 89399 86999
The NOC codes shall suspend for review and the carrier shall determine a price for them.
...
Hospital Outpatient Payment Under OPPS for New, Unclassified Drugs and Biologicals After FDA Approval But Before Assignment of a Product-Specific Drug or Biological HCPCS Code (Rev. 3085)
By Jared Staheli | Published July 9th, 2015
Section 621(a) of the MMA amends Section 1833(t) of the Social Security Act by adding paragraph (15), Payment for New Drugs and Biologicals Until HCPCS Code Assigned. Under this provision, payment for an outpatient drug or biological that is furnished as part of covered outpatient department services for which a ...
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 ...
A Local B/MAC/Carrier Receives a Claim for an RRB Beneficiary (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier) receives a Form CMS-1500 or electronic claim that is identified as a RRB claim for Medicare payment that should be processed by the RRB contractor, the claim shall be returned as unprocessable. Use the following messages:
CARC 109 – Claim not covered ...
Pharmacy Supplying Fee and Inhalation Drug Dispensing Fee (Rev. 754, 01-03-06)
By Jared Staheli | Published July 9th, 2015
Section 303(e) (2) of the MMA implements a supplying fee for immunosuppressive drugs, oral anti-cancer chemotherapeutic drugs, and oral anti-emetic drugs used as part of an anti-cancer chemotherapeutic regimen. Effective January 1, 2005, Medicare paid a separately billable supplying fee of $24.00 to a pharmacy, dialysis facility in the State ...
Reporting of Hematocrit and/or Hemoglobin Levels (Rev. 1412, 04-07-08)
By Jared Staheli | Published July 9th, 2015
Effective January 1, 2008, the following claims must report the most recent hematocrit or hemoglobin reading:
1. All claims billing for the administration of an ESA (HCPCS J0881, J0882, J0885, J0886 and Q4081).
2. All claims for the administration of a Part B anti-anemia drug (other than ESAs) used in the treatment ...
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 ...
Hospitals Billing for Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) for Non-ESRD Patients (Rev. 1412, 04-07-08)
By Jared Staheli | Published July 9th, 2015
NOTE: For EPO and Aranesp billing instructions for beneficiaries with ESRD, see the Claims Processing Manual, Chapter 8, sections 60.4 and 60.7.
For patients with chronic renal failure who are not yet on a regular course of dialysis, EPO and Aranesp administered in a hospital and billed as an outpatient service ...
Claims Processing Rules for ESAs Administered to Cancer Patients for Anti-Anemia Therapy (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
The national coverage determination (NCD) titled, “The Use of ESAs in Cancer and Other Neoplastic Conditions” lists coverage criteria for the use of ESAs in patients who have cancer and experience anemia as a result of chemotherapy or as a result of the cancer itself. The full NCD can be ...
Claims Processing Rules for Hospital Outpatient Billing and Payment - Drugs, Biologicals, and Radiopharmaceuticals (Rev. 2903, 04-07-14)
By Jared Staheli | Published July 9th, 2015
A. General Billing and Coding for Hospital Outpatient Drugs, Biologicals, and Radiopharmaceuticals
Hospitals should report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used. It is also of great importance that hospitals billing ...
Claims Processing Rules for Hospital Outpatient Billing and Payment - HCPCS Codes Replacements (Rev. 2903, 04-07-14)
By Jared Staheli | Published July 9th, 2015
The HCPCS code list of retired codes and new HCPCS codes reported under the hospital OPPS is published quarterly via Recurring Update Notification. The latest payment rates associated with each APC number may be found in the OPPS PRICER file available on the CMS Web site, as well as in ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 8th, 2015
The following table contains repair units of service allowances for commonly repaired items billed under HCPCS code K0739 (Repair or Non-routine Service for Durable Medical Equipment Other than Oxygen Equipment Requiring the Skill of a Technician, Labor Component, Per 15 Minutes). This applies to non-rented and out-of-warranty items.
When billing for ...
Effective January 1, 2003, contractors pay drug claims on the basis of the prices shown on the SDP files, if present.
On a quarterly basis, CMS furnishes three SDP files to all FIs, carriers, and ROs except regional home health intermediaries (RHHIs) and durable medical equipment regional carriers (DMERCs), as follows:
1. ...
Assignment Required for Drugs and Biologicals (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
A. Local Carriers
Under §114 of the Benefits Improvement Act of 2000, effective for claims with dates of service on or after February 1, 2001, payment for any drug or biological covered under Part B of Medicare may be made only on an assignment-related basis. Therefore, no charge or bill may ...
Claims Processing Requirements - General (Rev. 3085, Implementation: Upon Implementation of ICD- 10)
By Jared Staheli | Published July 8th, 2015
A/B MACs (B) are billed with the ASC X12 837 professional claim format or, if approved, with the paper form CMS-1500. A/B MACs (A) are billed with the ASC X12 837 institutional claim format or, if approved, with the paper Form CMS-1450.
See Chapters 24, 25 and 26 for detailed claims ...
HCPCS Service Coding for Oral Cancer Drugs (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
The following codes may be used for drugs other than Prodrugs, when covered:
Generic/Chemical Name
How Supplied
HCPCS
Busulfan
2 mg/ORAL
J8510
Capecitabine
150mg/ORAL
J8520
Capecitabine
500mg/ORAL
J8521
Methotrexate
2.5 mg/ORAL
J8610
Cyclophosphamide *
25 mg/ORAL
J8530
Cyclophosphamide *
(Treat 50 mg. as 2 units
50 mg/ORAL
J8530
Etoposide
50 mg/ORAL
J8560
Melphalan
2 mg/ORAL
J8600
Prescription Drug chemotherapeutic NOC
ORAL
J8999
Each tablet or capsule is equal to one unit, except for 50 mg./ORAL of cyclophosphamide (J8530), which is shown as ...
HCPCS and NDC Reporting for Prodrugs (Rev. 136, 04-09-04)
By Jared Staheli | Published July 8th, 2015
FI claims
For oral anti-cancer Prodrugs HCPCS code J8999 is reported with revenue code 0636.
DMERC claims
The supplier reports the NDC code on the claim. The DMERC converts the NDC code to a “WW” HCPCS code for CWF. As new “WW” codes are established for oral anticancer drugs they will be ...
Oral Anti-Emetic Drugs Used as Full Replacement for Intravenous Anti-Emetic Drugs as Part of a Cancer Chemotherapeutic Regimen (Rev. 2931, 07-07-14)
By Jared Staheli | Published July 8th, 2015
See the Medicare Benefit Policy Manual, Chapter 15, and the National Coverage Determination (NCD) Manual, Section 110.18, for detailed coverage requirements.
Effective for dates of service on or after January 1, 1998, Medicare Part B (including (institutional claims processed by Part A Medicare Administrative Contractors (MACs) and physician/supplier claims processed by ...
HCPCS Codes for Oral Anti-Emetic Drugs (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 8th, 2015
The physician/supplier bills for these drugs with the ASC X12 837 professional claim format, or if approved, with the paper form CMS-1500. The facility bills with the ASC X12 837 institutional claim format, or if approved, with the paper Form CMS-1450. The following HCPCS codes are assigned:
Code
Description
J8501
APREPITANT, oral, 5 mg ...
Claims Processing Jurisdiction for Oral Anti-Emetic Drugs (Rev. 2931, 07-07-14)
By Jared Staheli | Published July 8th, 2015
The following chart shows which drugs are billed to the A/B MAC, or carrier and which drugs are billed to the DME MAC.
Per the Balanced Budget Act of 1997, effective for claims with dates of service on or after January 1, 1998, the claims processing jurisdiction rules in Chart 1 ...
Requirements for Billing A/B MAC (A) for Immunosuppressive Drugs (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 8th, 2015
Hospitals not subject to OPPS bill on ASC X12 837 institutional format or paper Form CMS-1450 (if approved) with bill type 12x (hospital inpatient Part B) or l3x (hospital outpatient) as appropriate.
For claims with dates of service prior to April 1, 2000, providers report the following entries:
• Occurrence code 36 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 7th, 2015 - Last Review/Update August 7th, 2017
Question: When going through radiology codes for TMJ, I saw different codes for imaging studies of the TMJ. Can you please tell me the difference between 70328, 70330 and 70332?
Michigan Subscriber
Answer: If the documentation indicates a TMJ x-ray in two projections of one side, one film with the mouth open, and one with the mouth ...
Policy for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11)
By Jared Staheli | Published July 7th, 2015
Claims with dates of service on and after October 14, 2011, the Centers for Medicare & Medicaid Services (CMS) will cover annual alcohol misuse screening (HCPCS code G0442) consisting of 1 screening session, and for those that screen positive, up to 4 brief, face-to-face behavioral counseling sessions (HCPCS code G0443) ...
Institutional Billing Requirements for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11)
By Jared Staheli | Published July 7th, 2015
For claims with dates of service on and after October 14, 2011, Medicare will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and brief, face-to-face behavioral counseling for alcohol misuse, 15 minutes, G0443 for:
• Rural Health Clinics (RHCs) - type of bill (TOB) 71X only – based on ...
Professional Billing Requirements for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11,
By Jared Staheli | Published July 7th, 2015 - Last Review/Update February 5th, 2018
For claims with dates of service on and after October 14, 2011, CMS will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and behavioral counseling for alcohol misuse, 15 minutes, G0443, only when services are submitted by the following provider specialties found on the provider’s enrollment record:
01 - ...
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 ...
Professional Billing Requirements for Screening for Depression in Adults (Rev. 2431, 10-14-11)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the following claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare Summary Notice (MSN) messages when denying payment for G0444 when reported more than once in a 12- month period.
o CARC 119 – “Benefit maximum for this time period or occurrence has ...
Institutional Billing Requirements for Screening for Depression in Adults (Rev. 2431, 10-14-11)
By Jared Staheli | Published July 7th, 2015
For claims with dates of service on and after October 14, 2011, Medicare will allow coverage for annual screening depression in adults, HCPCS G0444 for:
• Rural Health Clinics (RHCs) type of bill (TOB) 71X only – based on the all-inclusive payment rate.
• Federally Qualified Health Centers (FQHCs) TOB 77X only ...
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 ...
Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
For services furnished on or after November 29, 2011, Medicare will cover Intensive Behavioral Therapy for Obesity. Medicare beneficiaries with obesity (BMI ≥30 kg/m2 ) who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other ...
Institutional Billing Requirements for Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Effective for claims with dates of service on and after November 29, 2011, providers may use the following types of bill (TOB) when submitting HCPCS code G0447: 13x, 71X, 77X, or 85X. Service line items on other TOBs shall be denied.
Effective for claims with dates of service on and after ...
Professional Billing Requirements for Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
CMS will allow coverage for Face-to-Face Behavioral Counseling for Obesity, 15 minutes, (G0447), Face-to-face behavioral counseling for obesity, group (2-10), 30 minute(s) (G0473), along with 1 of the ICD-9 codes for BMI 30.0-BMI 70 (V85.30- V85.39 and V85.41-V85.45), only when services are submitted by the following provider specialties found on ...
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 ...
Screening for Hepatitis C Virus (HCV) (Rev. 3215, 06-02-14)
By Jared Staheli | Published July 7th, 2015
Effective for services furnished on or after June 2, 2014, Medicare covers screening for hepatitis C Virus (HCV) with the appropriate U.S. Food and Drug Administration (FDA) approved/cleared laboratory tests, used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act regulations, when ordered by the beneficiary’s ...
Institutional Billing Requirements for Screening for Hepatitis C Virus (HCV) (Rev. 3215, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Effective for claims with dates of service on and after June 2, 2014, providers may use the following types of bill (TOBs) when submitting claims for screening for HCV screening, HCPCS G0472: 13X, 71X, 77X, and 85X. Service line-items on other TOBs shall be denied.
The service shall be paid on ...
Professional Billing Requirements for Screening for Hepatitis C Virus (HCV) (Rev. 3215, 01-05-15)
By Jared Staheli | Published July 7th, 2015
For claims with dates of service on or after June 2, 2014, Medicare will allow coverage for HCV screening, HCPCS G0472, only when services are ordered by the following provider specialties found on the provider’s enrollment record:
01 - General Practice
08 - Family Practice
11 - Internal Medicine
16 - Obstetrics/Gynecology
37 - Pediatric ...
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 ...
Payment Allowance Limit for Drugs and Biologicals Not Paid on a Cost or Prospective Payment Basis (Rev. 131, 03-26-04)
By Jared Staheli | Published July 7th, 2015
Prior to January 1, 2004, drugs and biologicals not paid on cost or prospective payment are paid based on the lower of the billed charge or 95 percent of the average wholesale price (AWP) as reflected in published sources (e.g., Red Book, Price Alert, etc.). Examples of drugs that are ...
Healthcare Common Procedure Coding System (HCPCS) Coding for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The HCPCS codes listed below were developed for the IPPE benefit effective January 1, 2005, for individuals whose initial enrollment is on or after January 1, 2005.
G0344: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 6 months of Medicare enrollment
Short Descriptor: Initial ...
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 ...
Coinsurance and Deductible for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.
The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009. Coinsurance continues to apply for the IPPE provided on or after January 1, 2009.
As a result of the Affordable Care Act, ...
Medicare Summary Notices (MSNs) for the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
When denying additional claims for G0344, G0366, G0367 and G0368, contractors shall use MSN 18.22 - This service was denied because Medicare only covers the one-time initial preventive physical exam with an electrocardiogram within the first 6 months that you have Part B coverage, and only if that coverage begins ...
HCPCS Coding for Diabetes Screening (Rev. 457, 04-04-05)
By Jared Staheli | Published July 6th, 2015
The following HCPCS codes are to be billed for diabetes screening:
82947 – Glucose, quantitative, blood (except reagent strip)
82950 – post-glucose dose (includes glucose)
82951 – tolerance test (GTT), three specimens (includes glucose)
...
Carrier Billing Requirements for Diabetes Screening (Rev. 457, 04-04-05)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service January 1, 2005 and later, carriers shall recognize the above HCPCS codes for diabetes screening.
Carriers shall pay for diabetes screening once every 12 months for a beneficiary that is not pre-diabetic. Carriers shall pay for diabetes screening at a frequency of once every 6 months ...
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 ...
Effective for dates of service January 1, 2005 and later, FIs shall recognize the above HCPCS codes for diabetes screening.
FIs shall pay for diabetes screening once every 12 months for a beneficiary that is not pre-diabetic. FIs shall pay for diabetes screening at a frequency of once every 6 months ...
HCPCS Coding for Cardiovascular Disease Screening for Diabetes Screening (Rev. 408, 01-03-05)
By Jared Staheli | Published July 6th, 2015
The following HCPCS codes are to be billed for Cardiovascular Disease Screening:
80061 – Lipid Panel
82465 – Cholesterol, serum or whole blood, total
83718 – Lipoprotein, direct measurement, high density cholesterol
84478 – Triglycerides
...
Carrier Billing Requirements for Diabetes Screening (Rev. 408, 01-03-05)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service, January 1, 2005, and later, carriers shall recognize the above HCPCS codes for Cardiovascular Disease Screening.
Carriers shall pay for Cardiovascular Disease Screening once every 60 months.
A claim that is submitted for Cardiovascular Disease Screening shall be submitted in the following manner:
The line item shall contain ...
Effective for dates of service, January 1, 2005, and later, intermediaries shall recognize the above HCPCS codes for Cardiovascular Disease Screening.
FIs shall pay for Cardiovascular Disease Screening once every 60 months.
A claim that is submitted for Cardiovascular Disease Screening shall be submitted in the following manner:
The line item shall contain ...
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
...
Advance Beneficiary Notice for Ultrasound Screening for Abdominal Aortic Aneurysm (Rev. 1113, 01-02-07)
By Jared Staheli | Published July 6th, 2015
Medicare contractors will deny an AAA screening service billed more than once in a beneficiary’s lifetime.
If a second G0389 is billed for AAA for the same beneficiary or if any of the other statutory criteria for coverage listed in section 1861(s)(2)(AA) of the Social Security Act are not met, the ...
Coding and Payment of DSMT Services (Rev. 1255, 07-02-07)
By Jared Staheli | Published July 6th, 2015
The following HCPCS codes are used to report DSMT:
• G0108 - Diabetes outpatient self-management training services, individual, per 30 minutes.
• G0109 - Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes.
The type of service for these codes is 1.
Payment to physicians and providers for outpatient DSMT ...
Healthcare Common Procedure Coding System (HCPCS) for HIV Screening Tests (Rev. 2199, 07-06-10)
By Jared Staheli | Published July 6th, 2015
Effective for claims with dates of service on and after December 8, 2009, implemented with the April 5, 2010, IOCE, the following HCPCS codes are to be billed for HIV screening:
• G0432- Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening,
• G0433 - Infectious agent antibody ...
Billing Requirements for HIV Screening Tests (Rev. 2199, 07-06-10)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service December 8, 2009, and later, contractors shall recognize the above HCPCS codes for HIV screening.
Medicare contractors shall pay for voluntary HIV screening as follows in accordance with Pub. 100-03, Medicare National Coverage Determinations Manual, sections 190.14 and 210.7:
• A maximum of once annually for beneficiaries ...
Payment Method for HIV Screening Tests (Rev. 2199, 07-06-10)
By Jared Staheli | Published July 6th, 2015
Payment for HIV screening is under the Medicare Clinical Laboratory Fee Schedule for TOBs 12X, 13X, 14X, 22X, and 23X beginning January 1, 2011. For TOB 85X payment is based on reasonable cost. Deductible and coinsurance do not apply. Between December 8, 2009, and April 4, 2010, these services can ...
Healthcare Common Procedure Coding System (HCPCS) Coding for the AWV (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The HCPCS codes listed below were developed for the AWV benefit effective January 1, 2011, for individuals whose initial enrollment is on or after January 1, 2011.
G0438 - Annual wellness visit; includes a personalized prevention plan of service (PPPS); first visit
G0439 – Annual wellness visit; includes a personalized prevention plan ...
A/B Medicare Administrative Contractor (MAC) and Carrier Billing Requirements for the AWV (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service on and after January 1, 2011, contractors shall recognize HCPCS codes G0438 and G0439 shown above in section 140.1 for billing AWVs. The type of service (TOS) for each of the new codes is 1. AWV services are paid under the Medicare Physician Fee Schedule ...
Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Advance Beneficiary Notices (ABNs) for the AWV (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Messages for Carriers, FIs, and A/B MACs:
When paying claims for an AWV, contractors shall use the following Medicare Summary Notices (MSNs):
MSN: 18.25: “Your Annual Wellness Visit has been approved. You will qualify for another Annual Wellness Visit 12 months after the date of this visit.”
Spanish Version “Su Visita Anual de ...
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 ...
Carrier Billing Requirements for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
Carriers shall pay for counseling to prevent tobacco use services billed with code G0436 or G0437 for dates of service on or after January 1, 2011. Carriers shall pay for counseling services billed with code 99199 for dates of service performed on or after August 25, 2010 through December 31, ...
Fiscal Intermediary (FI) Billing Requirements for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
The FIs shall pay for counseling to prevent tobacco use services with codes G0436 and G0437 for dates of service on or after January 1, 2011. FIs shall pay for counseling services billed with code 99199 for dates of service performed on or after August 25, 2010, through December 31, ...
Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Group Codes for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
When denying claims for counseling to prevent tobacco use services submitted without diagnosis codes 305.1 or V15.82, contractors shall use the following messages:
MSN 15.4: The information provided does not support the need for this service or item.
MSN Spanish Version: La informaciónproporcionada no confirma la necesidadparaesteservicio o artículo
RARC M64 - Missing/incomplete/invalid ...
Coding Requirements for IBT for CVD Furnished on or After November 8, 2011 (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
The following is the applicable Healthcare Procedural Coding System (HCPCS) code for IBT for CVD:
G0446: Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes
Contractors shall not apply deductibles or coinsurance to claim lines containing HCPCS code G0446.
...
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 ...
Provider Specialty Edits for IBT for CVD on Professional Claims (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
Contractors shall pay claims for HCPCS code G0446 only when services are submitted by the following provider specialty types found on the provider’s enrollment record:
01= General Practice
08 = Family Practice
11= Internal Medicine
16 = Obstetrics/Gynecology
37= Pediatric Medicine
38 = Geriatric Medicine
42= Certified Nurse Midwife
50 = Nurse Practitioner
89 = Certified Clinical Nurse Specialist
97= ...
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 ...
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 ...
Healthcare Common Procedure Coding System (HCPCS) Codes for Screening for STIs and HIBC to Prevent STIs (Rev. 2476, 02-27-12)
By Jared Staheli | Published July 6th, 2015
Effective for claims with dates of service on and after November 8, 2011, the claims processing instructions for payment of screening tests for STI will apply to the following HCPCS codes:
• Chlamydia: 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810, 87800 (used for combined chlamydia and gonorrhea testing)
• Gonorrhea: 87590, ...
Billing Requirements for Screening for STIs and HIBC to Prevent STIs (Rev. 2476, 02-27-12)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service November 8, 2011, and later, contractors shall recognize HCPCS code G0445 for HIBC. Medicare shall cover up to two occurrences of G0445 when billed for HIBC to prevent STIs. A claim that is submitted with HCPCS code G0445 for HIBC shall be submitted with ICD-9 ...
Payment for Colorectal Cancer Screening (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 5th, 2015
Payment is under the MPFS except as follows:
• Fecal occult blood tests (82270* (G0107*) and G0328) are paid under the clinical diagnostic lab fee schedule except reasonable cost is paid to all non-OPPS hospitals, including CAHs, but not IHS hospitals billing on TOB 83x. IHS hospitals billing on TOB 83x ...
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 ...
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;
• ...
Common Working Files (CWF) Edits for Colorectal Cancer Screening (Rev. 1062, 01-02-07)
By Jared Staheli | Published July 5th, 2015
Effective for dates of service January 1, 1998, and later, CWF will edit all colorectal screening claims for age and frequency standards. The CWF will also edit FI claims for valid procedure codes (G0104, G0105, G0106, 82270* (G0107*), G0120, G0121, G0122, and G0328) and for valid bill types. The CWF ...
Ambulatory Surgical Center (ASC) Facility Fee for Colorectal Cancer Screening (Rev. 1160, 07-02-07)
By Jared Staheli | Published July 5th, 2015
CPT code 45378, which is used to code a diagnostic colonoscopy, is on the list of procedures approved by Medicare for payment of an ambulatory surgical center facility under §1833(I) of the Act. CPT code 45378 is currently assigned to ASC payment group 2. Code G0105, colorectal cancer screening; colonoscopy ...
Billing Requirements for Claims Submitted to FIs for Colorectal Cancer Screening (Rev. 1953, 10-04-10)
By Jared Staheli | Published July 5th, 2015
Follow the general bill review instructions in Chapter 25. Hospitals use the ANSI X12N 837I to bill the FI or on the hardcopy Form CMS-1450. Hospitals bill revenue codes and HCPCS codes as follows:
Screening Test/Procedure
Revenue Code
HCPCS Code
TOB
Fecal Occult blood test
030X
82270***
(G0107***),
G0328
12X, 13X,
14X**, 22X, 23X,
83X, 85X
Barium enema
032X
G0106,
G0120,
G0122
12X, 13X,
22X, 23X,
85X****
Flexible Sigmoidoscopy
*
G0104
12X, 13X,
22X, 23X,
83X, ...
MSN Messages for Colorectal Cancer Screening (Rev. 1062, 01-02-07)
By Jared Staheli | Published July 5th, 2015
The following MSN messages are used (See Chapter 21 for the Spanish versions of these messages):
A. If a claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a barium enema is being denied because of the age of the beneficiary, MSN message 18.13 is used.
This service is ...
Remittance Advice Notices for Colorectal Cancer Screening (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
All messages refer to ANSI X12N 835 coding.
A. If the claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the patient is less than 50 years of age, use:
• Claim adjustment reason code 6 “the procedure code is inconsistent ...
HCPCS and Diagnosis Coding for Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
The following HCPCS codes should be reported when billing for screening glaucoma services:
G0117 - Glaucoma screening for high-risk patients furnished by an optometrist (physician for carrier) or ophthalmologist.
G0118 - Glaucoma screening for high-risk patients furnished under the direct supervision of an optometrist (physician for carrier) or ophthalmologist.
The carrier claims type ...
Special Billing Instructions for RHCs and FQHCs for Glaucoma Screening Services (Rev. 371, 04-04-05)
By Jared Staheli | Published July 5th, 2015
Screening glaucoma services are considered RHC/FQHC services. For claims with dates of service before April 1, 2005, RHCs and FQHCs bill the FI under bill type 71X or 73X along with revenue code 0770 and HCPCS codes G0117 or G0118 and RHC/FQHC revenue code 0520 or 0521 to report the ...
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 ...
Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Codes (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
Vaccines and their administration are reported using separate codes. The following codes are for reporting the vaccines only.
HCPCS
Definition
90653
Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use
90654
Influenza virus vaccine, split virus, preservative-free, for intradermal use, for adults ages 18 – 64;
90655
Influenza virus vaccine, split virus, preservative free, for children 6- 35 ...
HCPCS and Diagnosis Codes for Mammography Services (Rev. 3232, 01-05-15)
By Jared Staheli | Published June 25th, 2015
The following HCPCS codes are used to bill for mammography services.
HCPCS Code
Definition
77051*(76082*)
Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images, diagnostic mammography (list separately in addition to code for primary procedure). Code ...
Dental and Oral Surgical Procedures - UNITEDHEALTHCARE Coverage
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 19th, 2015 - Last Review/Update August 8th, 2017
The following is found in Oxfords Dental policy.
Oxford's Dental Department will review requests for dental services rendered:
for the following services when delivered in conjunction with dental services:
Dental services
Oral surgical services
Anesthesia services delivered in conjunction with dental services.
by practitioners of the following specialties: oral/maxillofacial surgery
pediatric dentistry
endodontics
orthodontices
NOTE: All other specialties require Medical Director ...
Elimination of "Kit" Codes and Pricing of Replacement Codes (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Prior to 2002, most suppliers billed for dialysis supplies using codes describing "kits" of supplies. The use of kit codes allowed suppliers to bill for supply items without separately identifying the supplies that are being furnished to the patient. Effective January 1, 2002, these kit codes were deleted and suppliers ...
Billing for Unlisted Drug Codes J3490 J9999 and C9399
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 15th, 2015 - Last Review/Update August 17th, 2017
When billing for unlisted drug codes J3490 and J9999 you must indicate the name, strength, and dosage of the drug in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in theANSI 837 claim file). It is extremely important to review the complete long descriptors in the HCPCS code, for the applicable HCPCS codes ...
Billing for Unlisted Drug Codes J3490 J9999 and C9399
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 15th, 2015 - Last Review/Update August 8th, 2017
When billing for unlisted drug codes J3490 and J9999 you must indicate the name, strength, and dosage of the drug in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in theANSI 837 claim file). It is extremely important to review the complete long descriptors in the HCPCS code, for the applicable HCPCS codes you can ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 9th, 2015 - Last Review/Update August 17th, 2017
CMS has determined that the following procedures will be covered for beneficiaries who have a body-mass index (BMI) ≥ 35, have at least one co-morbidity related to obesity, have been previously unsuccessful with medical treatment of obesity, and this medical information must be documented in the patient's medical record.
Submitted claims ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 9th, 2015 - Last Review/Update August 8th, 2017
CMS has determined that the following procedures will be covered for beneficiaries who have a body-mass index (BMI) ≥ 35, have at least one co-morbidity related to obesity, have been previously unsuccessful with medical treatment of obesity, and this medical information must be documented in the patient's medical record.
Submitted claims ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published May 11th, 2015 - Last Review/Update February 18th, 2016
Teletherapy isodose planning codes 77305-77315 and brachytherapy isodose planning codes 77326-77328, which are frequently reported with the basic radiation dosimetry calculation code 77300, were identified in the codes inherently performed together 75 percent of the time or greater, as the planning codes now universally require performance of dosimetry calculation as ...
By Wyn Staheli, Director of Research | Published April 23rd, 2015 - Last Review/Update June 9th, 2016
April is Alcohol Awareness Month and April 9 is National Alcohol Screening Day. Because alcohol misuse contributes to a variety of both social and medical problems, this day was set aside as a way to reach out, educate and increase awareness in communities. By screenings and other initiatives, at-risk individuals ...
2015 Guidelines, Diagnosis Pregnancy and Antepartum
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 17th, 2015 - Last Review/Update February 3rd, 2017
Services provided to diagnose pregnancy are to be reported separately and not considered a part of antepartum care given to the patient. Be sure to report the E/M visits separately as of the 2015 revised guidelines.
The services normally provided in uncomplicated maternity cases include antepartum care, delivery as well as ...
Medicare Updates Preventive Exam and Wellness Visit Information
By Wyn Staheli, Director of Research | Published April 15th, 2015 - Last Review/Update June 9th, 2016
Medicare has updated their provider educational tools for the Initial Preventive Physical Examination (IPPE) and the Annual Wellness Visit (AWV). These tools were designed to help providers gain a greater understanding of these services. Learn what the required elements for these services as well as important coverage and coding information.
CLICK ...
G0105 - Colorectal Cancer Screening; Colonoscopy on Individual at High Risk
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 9th, 2015 - Last Review/Update August 8th, 2017
Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). ...
Plantar Fasciitis: Medical Necessity and Cross Codes
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 16th, 2015 - Last Review/Update August 9th, 2017
Prior to treatment you must determine Medical Necessity.
Be sure conservative therapy/treatment was previously done and documented for at least 6 months and proven to be unsuccessful.
NSAIDS - at least 4 weeks ineffective or contraindicated
Physical Therapy such as taping and stretching
Activity modification
Splints used at night for more that 4 weeks
Corticosteroid injection
Arch Supports, ...
Billing Imminuzation for Pneumococcal, Influenza, and Hepatitis B with Medicare
By Chris Woolstenhulme, QCC, CMCS, 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 ...
Wound Care - Are you using the most appropriate codes?
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 9th, 2015 - Last Review/Update August 9th, 2017
If you often use 11042-11047, be sure you are using the correct codes. If you are preparing the site for surgery, these would not be the correct codes to use. In addition, when using codes 11042-11047, be sure to document the size of the wound; use this set of codes only if ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 26th, 2015 - Last Review/Update March 2nd, 2016
Be sure you know and understand the levels of supervision required so as not to result in non-compliance audits, possible fines and take-backs. Supervision requirements may also affect your documentation requirements; be sure to document the presence during the procedure or performance if it requires personal supervision.
Find-A-Code has levels of supervision ...
Aetna Policy on Bathroom and Toilet Equipment and Supplies - Coverage
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 25th, 2015 - Last Review/Update February 18th, 2016
Clinical Policy Bulletin:Bathroom and Toilet Equipment and Supplies
Number: 0429
Policy Aetna's HMO-based and health network plans (HMO, QPOS, Health Network Only, Health Network Option, Golden Medicare, and U.S. Access) generally follow Medicare's criteria for durable medical equipment (DME) items that are used in the bathroom. Most DME items used in the bathroom are ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update March 1st, 2016
Information on Medicare Vaccine Coverage
Medicare Part B Vaccine Coverage
Medicare Part D Vaccine Coverage
Vaccine Coding
Vaccines Administered at Well-child Visits
When vaccines are provided as part of a well-child encounter, the ICD-9 guidelines instruct that code V20.2 (routine infant or child health check) includes immunizations appropriate to the patient's age. A code from ...
UnitedHealthcare to Require Functional Limitation Reporting
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update March 1st, 2016
Effective August 1, 2014, the UnitedHealthcare Medicare Advantage Plans from UnitedHealthcare will implement the new Medicare Outpatient Therapy Functional Limitation Reporting requirement. The reporting scenarios will be similar to Medicare functional limitation reporting.
Announced in the UnitedHealthcare May 2014 Bulletin, contracted physical, occupational, and speech therapist claims with dates of service ...
Implementation of a Prospective Payment System (PPS) for Federally Qualified Health Centers (FQHCs)
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update March 1st, 2016
CMS is establishing five specific payment codes to be used by FQHCs submitting claims under the PPS:
1. G0466 – FQHC visit, new patient A medically-necessary, face to face encounter (one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes ...
Billing Requirements for G0466, G0467, G0468, G0469 or G0470 - MLN
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 13th, 2015 - Last Review/Update March 1st, 2016
AETNA
Clinical Policy Bulletin: Chiropractic Services
Number: 0107
http://www.aetna.com/cpb/medical/data/100_199/0107.html
Policy
Note: Some plans have limitations or exclusions applicable to chiropractic care. Please check benefit plan descriptions for details.
Aetna considers chiropractic services medically necessary when all of the following criteria are met:
The member has a neuromusculoskeletal disorder; and
The medical necessity for treatment is clearly documented; and
Improvement is ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 9th, 2015 - Last Review/Update August 9th, 2017
The information contained below is provided for informational purposes only and is not intended to provide specific guidance on how to code, bill, or charge for any product or service. The following list provides possible codes that may relate to the use of JETREA for its approved indication and is ...
Coding And Billing For JETREA® - Hospital Outpatient Department
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 9th, 2015 - Last Review/Update August 9th, 2017
The information contained below is provided for informational purposes only and is not intended to provide specific guidance on how to code, bill, or charge for any product or service. The following list provides possible codes that may relate to the use of JETREA for its approved indication and is ...
By | Published February 5th, 2015 - Last Review/Update April 5th, 2018
For detailed information on this government program, as it relates to Chiropractic services, see Section C-Medicare in theChiroCode DeskBook.
You need to understand the following concepts:
Enrollment/Revalidation
How Medicare Payment Works
Medicare as Secondary Payer (MSP) - resource 218 and 219
MAC Jurisdictions
Medicare Coverage of Chiropractic Services
Maintenance Care vs Active Care - resource
Medicare Appeals
Physician Quality Reporting System (PQRS) - resource 317
Advance ...
By | Published January 29th, 2015 - Last Review/Update February 1st, 2017
A clean claim is vital to the processing and payment of your claims. The "cleaner" the claim, the faster you will receive payment. It is the responsibility of the provider to understand what is needed and required by the carrier; then provide that information.
You need to understand the following concepts:
Claim Followup ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By | Published January 17th, 2015 - Last Review/Update January 30th, 2017
Proper documentation of a patient's condition(s) is essential to the reimburement process. Section G-Diagnosis Coding of the ChiroCode Deskbook contains a more thorough discussion of diagnosis coding. ICD-9-CM is the HIPAA required code set for diagnosis coding until October 1, 2015 when ICD-10-CM becomes the new standard. We recommend the ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 16th, 2015 - Last Review/Update March 1st, 2016
Billing for Split Unit of Blood
(Rev. 1487, Issued: 04-08-08, Effective: 04-01-08, implementation: 04-07-08)
HCPCS code P9011 was created to identify situations where one unit of blood or a blood product is split, and some portion of the unit is transfused to one patient while the other portions are transfused to other patients ...
CMS Announces New HCPCS Modifiers to be Implemented January 2015
By | Published December 23rd, 2014 - Last Review/Update January 30th, 2017
Beginning January 5, 2015 CMS (Centers for Medicare and Medicaid Services) requires new HCPCS modifiers to be used in place of modifier 59 for all Medicare claims.
These new subset modifiers are known as -X{ESPU} and are defined as follows:• XE - separate encounter, a service that is distinct because it ...
New G-Codes Released by CMS for FQHC PPS (Federally Qualified Health Centers)
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Vacuum pumps coded L7900 must demonstrate a capability to generate a negative pressure in the range of greater than 3.9 and less than 17 inches of mercury (100 and 432 mmHg, respectively). All devices coded L7900 for reimbursement by Medicare must include a vacuum limiter such that a maximum vacuum ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
In the case of collagen dressings coded A6021, A6022, A6023 and A6024, the predominate component must be collagen.
Effective for claims with dates of service on or after June 1, 2013, the only products which may be billed to Medicare using code A6021, A6022, A6023 and A6024 are those for which ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have evaluated the MyoPro® upper extremity assist device and determined that it falls within the Durable Medical Equipment (DME) benefit category. Claims for MyoPro® should be submitted using the DME miscellaneous code E1399.
Suppliers are reminded that when submitting claims for items ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC Publication
Ventilator technology has evolved to the point where it is possible to have a single device capable of operating in numerous modes, from basic continuous positive pressure (CPAP and bi-level PAP) to traditional pressure and volume ventilator modes. This creates the possibility that one piece of equipment ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
The DME MACs have recently noted confusion on the part of DMEPOS suppliers regarding the proper billing of lithium batteries. There are two types of lithium batteries Lithium batteries and Lithium Ion batteries. Lithium ion batteries are commonly used in consumer electronic devices and are rechargeable. Standard lithium batteries are disposable, non-rechargeable batteries. ...
Coverage and Correct Coding of Continuous Glucose Monitoring Devices
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC Publication
Continuous glucose monitoring (CGM) devices measure glucose in the interstitial fluid, not capillary blood, providing interstitial glucose readings every few minutes. CGM systems are composed of several components — disposable sensors that are inserted in the subcutaneous tissue, a transmitter that relays information to the receiver, and a ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
In February 2012, The Center for Medicare and Medicaid Services (CMS) issued guidance that initially identified specific Healthcare Common Procedure Coding System (HCPCS) codes that were considered Off-the-Shelf (OTS) orthoses. The list of HCPCS codes that were finalized as part of this review as OTS orthotics, effective January 1, 2014, ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
The Cefaly® device (Cefaly Technology) is a transcutaneous electrical nerve stimulator (TENS) that is applied to the forehead using a self-adhesive electrode positioned bilaterally over the upper branches of the trigeminal nerve. The Cefaly® device is intended to stimulate the upper branches of the trigeminal nerve and has received Food ...
Correct Coding: Braces (Orthoses) Attached to Wheelchairs
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC and PDAC Publication
Recently, claims for braces attached to wheelchairs have been submitted using HCPCS code K0108 - WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED. K0108 is not the correct HCPCS code to use for these items.
CMS has clarified the distinction between braces (orthoses) and durable medical equipment (DME) under Medicare Part ...
By | Published December 3rd, 2014 - Last Review/Update January 30th, 2017
The Rule of Coding: Service Codes define "what" you do; diagnosis codes define "why" you're doing it. Billing for laser or any other service must be properly defined and supported by both a service code and a diagnosis code.
Coverage for laser, as with any other service, is strictly dependent upon the ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 24th, 2014 - Last Review/Update August 9th, 2017
The PDAC (Medicares - Pricing, Data Analysis and Coding) receives frequent inquiries regarding a billable HCPCS code and a payable HCPCS code. One may think the two are the same; however, this is not the case.
A billable HCPCS code is one that is submitted on a claim to the DME ...
By 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 ...
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 21st, 2014 - Last Review/Update January 30th, 2017
The Rule of Coding: Service Codes define "what" you do; diagnosis codes define "why" you're doing it. Billing for laser or any other service must be properly defined and supported by both a service code and a diagnoses code.
Coverage for laser, as with any other service, is strictly dependent upon the ...
By | Published November 7th, 2014 - Last Review/Update January 30th, 2017
Is it appropriate to use 97022, whirlpool, to report dry hydromassage?
The CPT code 97022 is defined simply as “Application of a modality to 1 or more areas; whirlpool”. The CPT book does not expand on the code. However, in 2002, the CPT manual added this phrase to the general guidelines:
Do not select a ...
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.”
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 22nd, 2014 - Last Review/Update January 27th, 2017
Is it appropriate to use 97022, whirlpool, to report dry hydromassage?
The CPT code 97022 is defined simply as “Application of a modality to 1 or more areas; whirlpool”. The CPT book does not expand on the code. However, in 2002, the CPT manual added this phrase to the general guidelines:
Do ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Piriformis Injections
The piriformis muscle is a small muscle that attaches at the sacrum, travels across the pelvis and attaches to the top of the femur. It is an external rotator of the hip and leg, which allows the leg and hip to move outward. The sciatic nerve is comprised of ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Computed Tomography (CT) Enterography
CT enterography is not a specific procedure but rather a protocol used with CT abdomen, CT pelvis or CT abdomen and pelvis. It uses CT imaging and two types of contrast to better visualize the anatomy of the interior small intestines.
For years endoscopic techniques were the ...
Evaluation and Management (EM) in the Skilled Nursing Facility
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Evaluation and Management (EM) in the Skilled Nursing Facility
The first time I remember visiting a skilled nursing facility was after my grandmother's stroke. She was rehabilitating there, trying to learn to speak again. Once she was back to her normal activities, she returned to our home where she was taken ...
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 16th, 2014 - Last Review/Update November 29th, 2017
What is the ABN form used for?
The Advanced Beneficiary Notice of Non-Coverage (ABN) is the Notice of Liability that is required to be provided to Medicare patients in the event that the service(s) rendered to them are expected to not be covered. For chiropractic, reason for non-coverage is generally due ...
By 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 ...
By Wyn Staheli, Director of Research | Published September 15th, 2014 - Last Review/Update July 12th, 2016
Many procedure codes are considered "timed codes," that is, the number of units are determined by the amount of time spent performing the service. Medicare Claims Processing Manual, Chapter 5 clarification included here.
By | Published September 15th, 2014 - Last Review/Update January 30th, 2017
This code would be used rarely in a chiropractic office. 99211 is a low complexity examination for an established patient. It can be used by chiropractors, but in most instances, it is discouraged.
The 99211 code, also known as the nurse's code, is not really made for the physician to use. In fact, the AMA, ...
Q & A: What is the Definition of "New Patient" for Billing Evaluation and Management (E/M) Services?
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 26th, 2014 - Last Review/Update August 9th, 2017
Q: What is the definition of "new patient" for billing evaluation and management (E/M) services?
A: Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice ...
How do I find a HCPCS code for a laxative given to a patient in our office?
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update August 9th, 2017
A Laxative is considered a “Self Administered Drug” (SAD). Insurance will usually pay for the care you provide but will only cover certain drugs in the outpatient setting such as drugs administered through an IV. Therefore it would not be appropriate to report this under the Outpatient Prospective Payment System ...
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
By Chris Woolstenhulme, QCC, CMCS, 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 ...
The Proper Use of Evaluation and Management CPT Code 99211
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published August 6th, 2014 - Last Review/Update January 25th, 2017
The Proper Use of Evaluation and Management CPT Code 99211 When properly used and reported, evaluation and management service code 99211 can be useful, time saving and profitable. The description for code 99211 reads, “Office or other outpatient visit for the evaluation and management of an established patient, that may ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 31st, 2014 - Last Review/Update January 25th, 2017
The sphenoplatatine ganglion, more often referred to as the pterygopalatine ganglion (also Meckel’s ganglion or nasal ganglion) is located within the pterygopalatine fossa. You can locate that place by putting your fingers at the temporomandibular joint in front of your ears and then slightly moving your fingers up until ...
By 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” ...
By 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
This code would be used rarely in a chiropractic office. 99211 is a low complexity examination for an established patient. It can be used by chiropractors, but in most instances, it is discouraged. The 99211 code, also known as the nurse's code, is not really made for the physician to use. ...
By 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 ...
By Michelle Herbert, CPC | Published July 31st, 2014 - Last Review/Update January 25th, 2017
Question: is there a sample note to code 37765, our surgeon does Answer: Most third party payers are requiring a pre authorization on these vein codes. Provider documentation must include the failed conservative treatment. The following is the documentation and authorization requirements 1. A 3â€month trial of conservative therapy such ...
Microphlebectomy for the Treatment of Varicose Veins
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 31st, 2014 - Last Review/Update January 27th, 2017
Varicose veins can be troubling for the many people who suffer from them. Pain, itching, heavy and tired legs and swelling can make varicosities next to intolerable. Fortunately, there are several treatment options available. Microphlebectomy, sometimes referred to as "stab phlebectomy," is often performed on varicosities that are too small to ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 31st, 2014 - Last Review/Update January 25th, 2017
People with kidney stones may suffer from severe abdominal pain, low back pain, painful urination, hematuria, nausea and vomiting while others with kidney stones, small enough to pass on their own, may have no symptoms at all. There are several tools used to diagnose kidney stones: Urinalysis can show the ...
Repeat Procedures on the Same Day - When to Report Modifiers -76 and -77
By 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 ...
When It's Appropriate to Document a Comprehensive Patient History
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 31st, 2014 - Last Review/Update January 25th, 2017
When It’s Appropriate to Document a Comprehensive Patient History by Aimee Wilcox, MA, CST, CCS-P Have you ever wondered when it is appropriate to document a comprehensive past medical, family and social history (PFSH) or if the necessity of doing so will be questioned during an audit? Well, providers ...
By | Published July 24th, 2014 - Last Review/Update January 29th, 2016
Are Medicare fees going up? Or down? Results for the following:
Sequestration
Chiropractic Demonstration Project
Electronic Health Record/Meaningful Use
Physician Quality Reporting System - PQRS
Value-Based Modifier
By | Published July 24th, 2014 - Last Review/Update January 25th, 2017
PAMA (up 0.5%)
On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of 2014 (PAMA). Within this law, Congress instituted changes that went into effect on July 1, 2014. The law provided for a 0.5% update for claims with dates of service on or after ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 16th, 2014 - Last Review/Update January 25th, 2017
If you work in pain management, anesthesia or interventional radiology, you are probably keenly aware of the changes that have occurred over the past three years with facet joint injection coding and its effect on your bottom line. A facet joint injection is a diagnostic procedure used to determine if ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 16th, 2014 - Last Review/Update January 25th, 2017
Mammography is a method of taking x-ray images of the breasts to identify tumors or abnormalities in the tissues that may indicate breast cancer. Screening Mammography: Screenings are performed on otherwise healthy individuals to look for cancer or precursors to cancer of the breasts. Early detection of breast cancer ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 16th, 2014 - Last Review/Update January 27th, 2017
CT enterography is not a specific procedure but rather a protocol used with CT abdomen, CT pelvis or CT abdomen and pelvis. It uses CT imaging and two types of contrast to better visualize the anatomy of the interior small intestines. For years endoscopic techniques were the only tools available ...
By Michelle Herbert, CPC | Published July 16th, 2014 - Last Review/Update January 25th, 2017
Medicare covers a one-time Initial Preventive Physical Examination (IPPE), also referred to as the “Welcome to Medicare†visit.  IPPE is a unique benefit available only to patients newly enrolled in the Medicare Program and must be received within the first 12 months of the effective date of their Medicare Part ...
By Wyn Staheli, Director of Research | Published January 1st, 2014 - Last Review/Update October 4th, 2017
There are numerous types of behavioral health screening tools for healthcare providers. Some, like the AUDIT and SBIRT are especially applicable to primary care providers caring for Medicare beneficiaries.
This page includes some general information and resources for some of these screening tools. Let us know if you would like others included ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By | Published July 25th, 2013 - Last Review/Update January 27th, 2017
A notice in the July 19, 2013 Federal Register, has a VERY important clause for all Doctors of Chiropractic! The Centers for Medicare and Medicaid Services (CMS) has asked for comment on whether or not Doctors of Chiropractic should be paid for Evaluation and Management (E/M) services. Keep in mind ...
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, ...
May 14th, 2019: Confusing Codes for Chiropractors - 97110 versus 97112 versus 97530
In this webinar, you'll get a deep dive into three therapeutic procedure codes. Dr. Gwilliam, a chiropractor and certified professional coder, will take you thorough the ins and outs of therapeutic exercises, activities, and neuromuscular reeducation. They will be compared and contrasted with examples to make sure everyone leaves with the confidence to document and bill them correctly.
Chiropractic Manipulative Treatment and Medicare - Part 2
In this CE webinar, Dr. Gwilliam will continue his discussion from the webinar delivered Dec. 18 about chiropractic manipulative treatment. But this time, it is all about Medicare. If you don't treat Medicare beneficiaries, you should probably listen anyway. Usually whatever Medicare wants is the same thing as all the other payers. Find out the difference between acute, chronic, and maintenance, as well as when to use certain modifiers.
Chiropractic Manipulative Treatment (CMT) Coding and Documentation (Part 1)
The most used codes in chiropractic are 98940, 98941, 98942, and 98943. In this webinar, Dr. Gwilliam will go over the fundamentals of these codes and make sure you are proficient with them. They probably play a bigger part of your practice than any other code, so it is worth it to make sure you are reporting them correctly. By the end of this presentation you will be able to diagnose, document, and code properly for CMT, as well as avoid common mistakes.
Neuromuscular Reeducation, Massage Therapy - Proper Use, Documentation and Coding
In this webinar, Dr. Howard Levinson (Forensic Consultant) will address the erroneous use and billing of Neuromuscular Reeducation, Massage Therapy and Hydrotherapy in chiropractic clinics. He will offer strategies regarding how these services may be used appropriately in the chiropractic setting and provide documentation and coding information.
Coding and Auditing for Upper Extremity Procedures
In this webinar, Aimee will review coding and auditing information for procedures commonly performed on the upper extremities and how to locate vital information that could help prevent coding errors and reduce risk in case of an audit.
Presented by Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA June 19, 2018 Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET Are you getting denials from payers for things that they say are bundled into chiropractic manipulative treatment (CMT) codes? ...
The Most Expensive Documentation Mistakes Chiropractors Make
Notes need to give payers the information they need in order to adjudicate your claims. Do your notes include what they need to see? Can you standardize and simplify your note taking process to decrease your administrative burden? In this webinar, Dr. Gwilliam, Certified Coder, Certified Professional Medical Auditor, and Clinical Director for PayDC Chiropractic EHR Software, will show you how to make it easy. He will review examples and boost your confidence that you are doing things correctly.
Coding and Documenting Physical Therapy Treatment Modalities
Presented by Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA May 22nd, 2018 Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET Ever wonder how to get paid for that e-stim or ultrasound? Do payers give you a hard time and ...
Total knee replacement now acceptable ASC procedure also, not auditing for a year.
Knee replacement coding, knee joint injections, auditing using FAC, LCDs, drugs, modifiers.
Learn:
- Which history and exam findings determine which x-ray views to order
- How biomechanical measurements result in better patient care
- The results of a new chiropractic survey how digital radiography impacts patient care plans.
Coders and billers in orthopedic practices must
understand the knee extensively. Join Dee to
master the anatomy of the knee joint, and
understand how it applies to ICD-10-CM
diagnosis coding.
Documenting Diagnoses Like a Peer Reviewer, Take 2
In his last ChiroCode Webinar, Dr. Gwilliam went over the details of three conditions that are covered by the Diagnosis and Documentation cards available in the ChiroCode store. By popular demand, Dr. Gwilliam has agreed to come back and cover three more. The goal is to show you how to ensure that the code you select matches the documentation created at the encounter. You don’t need to research all of the guidelines for each code in the ICD-10 Tabular List. It has already been done for you. You’ll find out which objective tests to perform and even which CPT codes make the most sense to link to the diagnoses you pick. If you can’t wait for the presentation, pick up your copy of the cards from ChiroCode.com/store today!
Are you responsible for selecting or reviewing Evaluation and Management service levels? Do you wonder how well you know the rules and how to apply them? Join Aimee in this webinar to review and then applly the rules of E/M coding. She will also do a live demonstration of the new Find-A-Code E/M Calculator Tool to assess the level of E/M service for two office visits, one new (99201-99205) and the other established (99212-99215).
Do you report or audit Telemedicine services now or are you considering offering them? Come and learn more about the rules and guidelines surrounding Telehealth services including, documentation requirements, eligible CPT and HCPCS Level II codes, modifiers, and the newest updates to Medicare Telehealth policies.
In this webinar, Dr. Marty Kotlar (certified coding and compliance expert) will discuss how to add
Acupuncture services to a Chiropractic office. Topics include how to find and employ acupuncturists, CPT/ICD-10 coding, 15 minute increments vs the 8 minute rule, how to bill for office visits on same day as acupuncture and how to create an acupuncture billing and coding policy manual.
Ever wonder what an auditor is looking for when they review your surgical coding? Join Aimee and review the basic rules and documentation requirements. We’ll tear apart a couple of operative reports, code them, review NCCI edits, modifiers, and more. Get an idea of how you are doing and things you may want to incorporate into your practice to be better prepared when an audit comes your way. Also, we’ll review our cool Code-A-Note tool and how it can help you locate CPT and ICD-10-CM codes quickly. This tool is great for new coders, coders new to a specialty, difficult coding situations, or anyone who just wants a second opinion on their code options.
Which is the Most Profitable E/M Code for PI: 99203 or 99204?
There is a lot of myth surrounding the use of the E/M codes. Dr. Grant will discuss how to best use these codes in a PI case to avoid the potential for a fraud claim by an insurer or a malpractice action by your patient.
Let Dr. Gwilliam, ChiroCode's Vice President, walk you through Chapter 5.2 on all the common procedure codes used in chiropractic. This is part 2 of 7.
...
Chapter 5.2 - Part 2 Modality Coding (97014, 97012)
Let Dr. Gwilliam, ChiroCode's Vice President, walk you through Chapter 5.2 on all the common procedure codes used in chiropractic. This is part 3 of 7.
...
Let Dr. Gwilliam, ChiroCode's Vice President, walk you through Chapter 5.2 on all the common procedure codes used in chiropractic. This is part 4 of 7.
...
Chapter 5.2 - Part 4 Therapeutic Procedure Coding (97140)
Let Dr. Gwilliam, ChiroCode's Vice President, walk you through Chapter 5.2 on all the common procedure codes used in chiropractic. This is part 5 of 7.
...
Let Dr. Gwilliam, ChiroCode's Vice President, walk you through Chapter 5.2 on all the common procedure codes used in chiropractic. This is part 6 of 7.
...
Let Dr. Gwilliam, ChiroCode's Vice President, walk you through Chapter 5.2 on all the common procedure codes used in chiropractic. This is part 7 of 7.
...
DeskBook 101: Evaluation and Management Self Audit
Presented by Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA
April 19, 2016
Tuesday @ 10:15 AM PST, 11:15 AM MST, 12:15 PM CST, 1:15 EST
Chapter 5.3 of the 2016 ChiroCode DeskBook is all new, with tables and examples to help you become an expert on E/M coding for chiropractic. E/M codes are a top target by auditors because many providers use them incorrectly, or trust their EHR system templates to do the work for them. In this webinar, find out how to audit your own E/M codes so you don't have to fear the auditors.
Find-A-Code's 2020 specialty specific Reimbursement Guides give you the coding, billing, and documentation support you need to get paid properly and keep it.
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