Coding - Articles

The Importance of the 7th Character in ICD-10-CM
July 27th, 2017 - Chris Woolstenhulme, CPC, CMRS
There is still confusion on the use of the seventh character. Let's clarify a few common areas. The 7th character represents the physicians encounter, but not the number of visits. Reporting the phase of treatment the patient is seeing the provider for, but not the number of injuries or number of visits. The most common ...
Sleep Testing
July 26th, 2017 - Chris Woolstenhulme, CPC, CMRS
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 ...
Laceration Repairs
June 30th, 2017 - Michael Loss, CPC, CPMA
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 ...
Diagnosing, Documenting, and Coding for Radiculopathy
June 30th, 2017 - Evan Gwilliam, DC, MBA, BS, CPC, CCPC, CPC-I, CPMA, NCICS, MCS-P, QCC, CMHP
Radiculopathy can be an unpleasant condition, but diagnosing, documenting and coding for it does not have to be. It just takes a little research. The brain communicates with the body via the spinal cord which is protected by the bones of the spinal column, called vertebrae. Nerve roots exit in ...
Documentation: Carrying Forward or Ineffective Use of Templates
June 30th, 2017 - Shannon DeConda
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 ...
Focus on Clinical Documentation to Improve Coding and Audit Results
June 29th, 2017 - Betty Stump, MHS, RHIT, CPC, CCS-P, CPMA, CDIP
Auditors spend their day surrounded by the end product of the health care process. Those CPT, HCPCS and ICD-10-CM codes generated as a result of services provided to the patient. Our work is focused on determining if those codes have been correctly assigned based on the content of the medical ...
Profit Depends on Efficiency
June 29th, 2017 - NAMAS
To us, the most fascinating thing about process improvement within a medical practice is how it has a clear clinical counterpart: differential diagnoses. In a typical scenario, a patient presents with a chief complaint ("I don't feel well"), and it's the provider's job to figure out just what is wrong ...
Code Position Matters, Using the X Place Holder
June 28th, 2017 - Chris Woolstenhulme, CPC, CMRS
Using the X Place holder is not optional. Be sure you understand how to use it. If the code you are using requires a the Character such as the A - initial encounter, D - subsequent encounter or S- sequela, you understand the "X" Place holder. Not all Codes requiring a 7th ...
Modifier JW With Drug Codes
June 27th, 2017 - Find-A-Code
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 ...
Psychiatric / Psychological Testing with Bill Type 12X
June 23rd, 2017 - Chris Woolstenhulme, CPC, CMRS
Providers submitting claims with bill type 12X are to report revenue code 0918 (psychiatric / psychological testing). Note: Revenue codes do not apply to physicians; other professionals and suppliers bill these services to the Part B MAC They are used only with providers who bill these services to the fiscal intermediary or Part ...
Modifier 59
June 5th, 2017 - Find-A-Code
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, ...
Bulk Risk Scores
May 25th, 2017 - Chris Woolstenhulme, CPC, CMRS
Do you need help with cases and calculating groups of Risk Scores? Per customers request, Find-A-Code now offers BULK entry for calculating for Risk Scores.  The HCC Risk tool offers two options for calculating risk scores, we now offer a BULK calculation for cases or the calculation for a single enrollee. To use the BULK calculation for cases Create ...
Risk Adjustment Calculator
May 25th, 2017 - Chris Woolstenhulme, CPC, CMRS
Risk Adjustments are used to access an illness or severity and comparing classifications of diseases using diagnosis codes. Find-A-Code gives you the ability to search for risk codes used for calculations on an individual code or calculator for a group of codes to quickly calculate a risk score. Keep in mind prior ...
Modifiers: Reporting Wound Dressings
April 26th, 2017 - Chris Woolstenhulme, CPC, CMRS
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 ...
Radiology
April 21st, 2017 - Chris Woolstenhulme, CPC, CMRS
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 ...
Billing Dermal Filler Injections
April 20th, 2017 - Chris Woolstenhulme, CPC, CMRS
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 - ...
Treating TMJ
April 4th, 2017 - Chris Woolstenhulme, CPC, CMRS
Temporomandibular Joint (TMJ) Syndrome can include a wide variety of conditions that may be characterized as TMJ. Also there are a wide variety of methods for treating these conditions. Many of the procedures are excluded from coverage in the Medicare program for services or devices. There are other services and appliances ...
Respiratory Assist Devices (RAD) E0470 and E0471 - Billing Reminders
March 28th, 2017 - Chris Woolstenhulme, CPC, CMRS
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 ...
Devices Used for Treatment with TMJ
March 27th, 2017 - Chris Woolstenhulme, CPC, CMRS
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 ...
Reporting Unilateral Procedures
March 13th, 2017 - Chris Woolstenhulme, CPC, CMRS
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, ...
Alcohol and Tobacco Use During Pregnancy
March 3rd, 2017 - Chris Woolstenhulme, CPC, CMRS
If a mother uses alcohol or tobacco during pregnancy, be sure to assign O99.31 "Alcohol use complicating pregnancy, childbirth, and the puerperium." Document the time of the encounter (such as the trimester), during childbirth, or during the puerperium. NOTE: You also need to assign a secondary code from category F10- to identify manifestation of the alcohol use. The following ...
Principal Diagnosis
March 2nd, 2017 - Chris Woolstenhulme, CPC, CMRS
The official guidelines for ICD-10-CM have very specific rules in determining principal diagnosis. However, it is imperative to note that it is necessary to be aware of the coding conventions in the ICD-10-CM Tabular List and Alphabetic Index as they take precedence over the official coding guidelines. Also, consider the ...

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Are harder times coming for CFOs? A data driven answer [Infographic]
October 13th, 2016 - Ango Mark
“We really do believe much harder times are coming from a reimbursement standpoint”, Daniel Morissette, Stanford Health Care CFO. With value based model, the most unpredictable payment reform, in their list of financial challenges, CFOs point out their threats and decision making...
Shift Your Focus: The New Generation of Dental Billing
October 3rd, 2016 - Christine Taxin
More and more information emerges each day about the connection between certain serious medical conditions and poor oral health. Consider these headlines found in a recent dental journal: “Periodontal disease may have even more of an impact on overall health than previously thought,” and, “Biomarkers in Saliva Help Detect Early-Stage ...
10 reasons why medical practices prefer working with medical billing service companies!
September 29th, 2016 - Adam Smith
1. Training costs can save a healthcare organization over 8% of its operating expenses. A recent study states that teams who work with EHRs require an average of 53.5 hours of training at a cost of $3000. The cost of training a single physician amounts to $1540. That is a whooping amount for...
Subsequent hospital visits
December 29th, 2015 - Codapedia Editor
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 visit is...
Modifier 52 vs. 53
December 29th, 2015 - Seth Canterbury, CPC, ACS-EM
So you’ve read the descriptions for both Modifiers 52 and 53, but you’re still on the fence as to which one is appropriate for a certain surgical case. This brief article will try to better differentiate between these two often-confused modifiers. Modifier 53 is appropriate when a...
Modifiers in Postoperative Periods
December 29th, 2015 - Allison Singer, CPC
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...
Family meetings without the patient present
December 29th, 2015 - Codapedia Editor
Medicare does not permit a physician practice to bill for family meetings without the patient present. The physician may not bill Medicare, nor may they bill the family member. It is fairly common for the spouse or child of a patient to ask to see the physician to discuss the patient's care. The...
Doing--and coding--for minor procedures in primary care
December 29th, 2015 - Codapedia Editor
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Minor Surgical Procedures
December 29th, 2015 - Codapedia Editor
When performing minor surgical procedures, it is important to document what was done, how it was done, where it was done, why it was done, how deep, how long, and how many. In billing and reporting a procedure, document in the medical record the key components of the procedure as described by the...
Pre-op visits: True or False?
December 29th, 2015 - Codapedia Editor
Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he is going to take the patient to surgery. • The...
What Does It Mean To Scrub An Insurance Claim?
December 29th, 2015 - David Greene, MD
During the rigorous training physicians undergo to learn their craft, very little education is received on how to deal with submitting claims to insurance companies. It’s unfortunately a necessary evil, as surgeons who contract with insurance companies rely on that reimbursement as the...
Reporting Administration Codes with Vaccines
December 29th, 2015 - Allison Singer, CPC
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...
Coding Excisions and Wound Repairs
October 15th, 2015 - Allison Singer, CPC, CPMA
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,...
Use of binocular microscopy in the office
October 15th, 2015 - Mary LeGrand
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...
99213 Established patient visit
October 15th, 2015 - Betsy Nicoletti
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...
How do I tell if a code is defined as unilateral or bilateral
October 15th, 2015 - Codapedia Editor
There are some procedures which are defined as unilateral procedures, and some defined as bilateral procedures. If the procedure is defined as unilateral but performed bilaterally, then the physician is paid 150% of the fee schedule amount when performed on both sides. If the code is defined as...
Subsequent Observation Services
October 15th, 2015 - Codapedia Editor
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 three...
Post-operative Hospital Visits
October 15th, 2015 - Betsy Nicoletti, M.S., CPC
In 1992, CMS developed the concept of the Global Surgical Package, which pays for surgical services with a single payment. The full description of services that are included in this payment is described in the Medicare Claims Processing Manual, Chapter 12, Section 40 and in a CMS Fact Sheet.
Coding for Screening Colonoscopies
October 15th, 2015 - Codapedia Editor
How to code for screening colonoscopies, what modifiers are needed and what diagnosis codes to assign can be challenging for surgeons. An area of particular confusion is screening colonoscopies converted to a diagnostic or therapeutic colonoscopy. To complicate the issue, Medicare uses different...
ICD-10 TRANSITION IS FRUSTRATING FOR MEDICAL PRACTICES
October 14th, 2015 - Adam Smith
The dust has settled. ICD-10 is here. Now what? ICD10 is finally here. And it is not welcome in healthcare circles. Healthcare organizations will have to grapple with thousands of new codes, high overheads and workflow disruptions. The real impact of the revised coding set will be felt in a few...
Multiple surgical procedures
July 27th, 2015 - Codapedia Editor
Multiple Surgical Procedures In some groups, the coder performs all of the steps below. The responsibilities indicated here are opinion of the author, not law, regulation or national policy. Physician Responsibility: 1. List all codes for the procedures performed 2. Note whether the...
Evaluation and Management Services
July 27th, 2015 - Codapedia Editor
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...
Documentation Guidelines
July 27th, 2015 - Codapedia Editor
Clinicians are still allowed to use either the 1995 or the 1997 Documentation Guidelines, whichever set is more beneficial to the clinician. Payers are required to use whichever set is more beneficial to the clinician. Some organizations have a policy stating they will only use one or the other, but that is not required by CMS or any other government payer. In fact, it is permissible to switch back and forth between the two sets of Guidelines from one note to the next.
I had a wheezer in the office, can I bil a 99215?
July 27th, 2015 - Codapedia Editor
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. I was in and...
Visits outside the OB Global Package
July 27th, 2015 - Codapedia Editor
The CPT® book defines which services may be billed outside of the global OB package, and what services are included in the package. The start of the maternity care codes in the CPT® book describes the antepartum care services, including frequency and exam. The American College of...
Modifier 24
July 27th, 2015 - Codapedia Editor
Modifier 24 is appended to an Evaluation and Management service by the same physician during a post op period. See the CPT® book for the complete definition. This modifier may only be used with E/M services. When a physician bills for a surgical procedure, the post op care for that procedure...
Modifier 25
July 27th, 2015 - Codapedia Editor
Modifier 25: Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. Refer to the CPT® book for the complete definition. Modifier 25 is appended to the E/M service, never to a procedure. The decision about whether to bill for...
Sports Physicals
July 27th, 2015 - Codapedia Editor
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, it is pretty easy. Perform...
Can we bill a low level E/M with every procedure?
June 1st, 2015 - Codapedia Editor
Can’t we bill a low level E/M with every procedure? No! Medicare says this: Per CCI (chapter 11, Letter R.): “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. ...
Anesthesia and E/M services
June 1st, 2015 - Codapedia Editor
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...
Observation versus inpatient status
June 1st, 2015 - Betsy Nicoletti
Physicians are often confused about whether to bill for observation status or inpatient status for patients admitted to the hospital. There are specific rules in the Medicare Claims Processing Manual, but sometimes the question is: what is the status of the patient? Commercial carriers have long...
Make sure your smoking cessation services are being coded right
June 1st, 2015 - Scott Kraft
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...
Preventive medicine and office visit, same day
June 1st, 2015 - Codapedia Editor
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” •...
New Patient
March 17th, 2015 - Codapedia Editor
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...
Chief Complaint
March 17th, 2015 - Codapedia Editor
The Documentation Guidelines tell us that all notes require a reason for a visit or a chief complaint. This is how they define the chief complaint: The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. !DG: The medical record should clearly reflect the chief complaint.
Past medical, family and social history
March 17th, 2015 - Codapedia Editor
Rules for documenting the past medical, family and social history in an E/M note
History of the present illness
January 30th, 2015 - Codapedia Editor
When auditing an Evaluation and Management service, the history of the present illness (HPI) is one of the required components in the history section. The history of the present illness may consist of some of the eight elements described in the Documentation Guidelines or in a description of the status of the patient's chronic illnesses. Joan Gilhooey reminds physicians to add some adjectives when their HPI comes up short.
Review of Systems
January 30th, 2015 - Codapedia Editor
Sometimes one symptom can be used in more than one system. For example, dizziness. Although we typically think of this as a neurological symptom, sometimes cardiologists ask about dizziness and relate it to the cardiovascular system. In the citations section of this entry, there are references...
Don’t expect to see payment any time soon for ‘telephone consults’
October 15th, 2014 - Scott Kraft
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 report back to the...
CMS: Lot of errors billing psychotherapy services when E/M visit is involved
October 15th, 2014 - Scott Kraft
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...
Consult Documentation Guidelines
September 3rd, 2014 - Jeannie Cagle, BSN, RN, CPC
By Jeannie Cagle, BSN, RN, CPC For those practices that bill consultation codes, the guidelines can be confusing. Yet, it is worth taking the time to learn the rules to get the additional reimbursement paid for consultation codes over new patient codes. Remember the following: · ...
CMS expands coverage for three drug regimen to fight nausea during chemotherapy
September 3rd, 2014 - Scott Kraft
Physician practices will soon be able to get paid for use of a three-drug antiemetic regimen used to prevent nausea and vomiting by patients receiving chemotherapy for an expanded list of chemotherapy drugs, under a National Coverage Determination recently posted by CMS. The change in coverage is...
New CLIA-Waived Tests
September 3rd, 2014 - Codapedia Staff
Providers can now bill for six new tests (4 drug tests and two lipid/glucose panels) that have been approved by the FDA as waived tests under CLIA. CLIA-waived tests are simple tests performed at the point-of-care using devices that are largely exempt from federal requirements, including most...
‘Two midnight’ rule draws lawsuit – enforcement currently delayed
August 5th, 2014 - Scott Kraft
The American Hospital Association is leading the charge in a lawsuit against CMS’s controversial “two-midnight rule,” instituted last year to attempt to slow down the expanded use of observation status by hospitals by presuming that any stay intended to cover two or more midnights...
2014 brings big volume of changes to CCI edits
January 30th, 2014 - Scott Kraft
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. Many of the...
Medicare no longer requires facility certification for bariatric surgery
January 30th, 2014 - Scott Kraft
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...
A Funny Thing Happened on the Way to an ICD-10 Gap Analysis
October 25th, 2013 - Codapedia Editor
You’ve heard the scary facts, maybe even from me. The number of diagnosis codes is increasing from about 16,000 in ICD-9 to 70,000 in ICD-10. The sky is falling. I usually add, we won’t be able to memorize diagnosis codes any more. And then I did a gap analysis for a women’s...
QW Modifier for CLIA waived tests
October 1st, 2013 - Codapedia Editor
QW is a HCPCS modifier defined as: CLIA waived test. Append it to lab services that are on the CLIA waived test list. Download the up to date list of CLIA waived tests from CMS's web site. The link is the citation. There are two issues: Some tests do not require the QW modifier, and may...
Mini Mental Status Exam
October 1st, 2013 - Betsy Nicoletti
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...
Hospice Care
August 28th, 2013 - Codapedia Editor
Patients who sign up with hospice waive their rights to receive Medicare Part B services, and must look to the hospice organization to provide care related to the terminal illness. The hospice provider receives a daily payment to care for the patient on hospice. The patient’s own attending...
Hospital Observation Services
August 28th, 2013 - Dorothy Steed
Hospital observation services are considered outpatient services. They are typically used when a period of time is needed to evaluate the progress or regression. This may include effectiveness of medication/ infusions, results of diagnostic results or other reasons deemed as medically necessary....
Coding for pulmonary services
August 28th, 2013 - Betsy Nicoletti
This is an overview of billing for services provided by Pulmonologists. Medicare recognizes Pulmonary Disease as a specialty. The resources section of this article contains the E/M Frequency data from CMS for the latest year available, and the fifty most commonly billed CPT® codes. What are...
Repeat Injections, Can I bill an E/M?
July 30th, 2013 - Machell Jones, CPC
When reporting an office visit in conjunction with an injections/arthrocentesis we need to consider a few factors. First we need to be certain we are accurately applying modifier -25 which is required when a procedure is performed the same day as a procedure. In order to report modifier -25, the...
Charge capture: Paper and Electronic Encounter Forms
May 1st, 2013 - Codapedia Editor
Physicians and Non-Physician Practitioners (NPPs) may want to distance themselves from coding, but implementing an Electronic Health Record (EHR) moves them in the opposite direction. If using an EHR, after completing the note, the clinician selects the CPT® and ICD-9 codes (the procedure and...
Psychiatry code update
May 1st, 2013 - Codapedia Editor
I have attached a word document that you can print that explains the use of the new codes.
EMRs - Coding and Compliance Concerns
April 24th, 2013 - Allison Singer, CPC
Introduction The past year has been an exciting time for healthcare professionals, bringing more changes, opportunities and challenges than ever before. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which is a portion of the American Recovery and Reinvestment Act...
CODING ARTHROSCOPIC KNEE PROCEDURES
April 24th, 2013 - Deivakumar Chithirai
Knee Anatomy: The medical compartment includes: Medial Femoral condyle Medial tibial plateau Medial meniscus The lateral compartment includes: Lateral Femoral condyle Lateral tibial plateau Lateral meniscus The...
Who Qualifies for TCM Services?
April 22nd, 2013 - Lacy Gaskins
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,...
Why Get Into Medical Billing?
March 22nd, 2013 - Debra Sanders
I am asked alot or read alot where people want to get into medical billing. Some have gone to school and some haven't. Either way, there is more to it than just saying, I want to do that. I've been in this field for over 15 yrs and still learn something new every day. I even learn something I...
ICD-10: The Wave (or Tsunami) of the Future
March 22nd, 2013 - Allison Singer, CPC
ICD-10: The Wave (or Tsunami) of the Future For many people, simply hearing the words “ICD-10” is enough to cause headaches, indigestion and a sudden compulsion to find a new career. It is the looming healthcare change that many professionals hope will go away completely or be delayed...
Graphical Coding as part of EMR clinical workflow
March 22nd, 2013 - Robert Jordshaugen
The way to ensure a high performing EMR implementation is to fundamentally rethink processes to match what is technologically appropriate, rather than automating existing workflows. Instead of using the existing HIT EMR systems from the major vendors as the workflow driver, start with a sample of...
Updating Superbills for the New Year
July 7th, 2011 - Allison Singer, CPC
Coding Corner - Updating Superbills for the New Year Summer is ending and fall is just around the corner. Kids are going back to school, football season has begun, and for coders, it is the time of year when the first set of major encounter form revisions takes place. Form updates and revisions are...
Clear the Smoke on Debridement and Active Wound Care Codes
January 5th, 2011 - Jennifer Schmutz
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 the...
Can a physician practice open an office in a nursing home?
March 17th, 2010 - Codapedia Editor
,Physician visits in a nursing home are billed with nursing facility codes and place of service. But, what if a physician opens an office there? Are those services billed as office visits? A physician practice may established an office in a nursing home, if it pays rent at market value, and is...
Nursing home discharge services
March 17th, 2010 - Codapedia Editor
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...
Annual Nursing Facility Assessment
March 17th, 2010 - Codapedia Editor
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. ...
Subsequent nursing facility visits
March 17th, 2010 - Codapedia Editor
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...
An Eye on Coding
January 30th, 2010 - Nancy Maguire
An "Eye" on Coding Ophthalmology coding is an interesting specialty, especially when it comes to assigning a level of evaluation and management code. Coders outside this specialty may not realize that there are two sets of codes available to the eye specialist. The first set is one...
No More Consults? CMSs Proposal for 2010
January 30th, 2010 - Codapedia Editor
July, 2010 By now you've seen the headline! CMS proposes to eliminate payment for consults in 2010! Why? How will they pay for the services? First, the AMA develops and owns CPT® codes, and only they can add, delete, or change the definition of CPT® codes. However, Medicare and private...
Who can document the HPI?
January 30th, 2010 - Todd Thomas
A common question amongst coders that routinely deal with E&M services. The E&M Guidelines specify which elements can be recorded by someone other than the physician. "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the...
UPDATE CMS ELIMINATES PAYMENT FOR CONSULTS 1-1-2010
January 30th, 2010 - Codapedia Editor
Updated: Dec 16, 2009 By now, we have all heard that CMS will not pay for consuts starting Jan 1, 2010, but we had lingering questions about how to submit claims. Dec 15, CMS released a transmittal, dated Dec 14, 2009, which answers these questions. The transmittal is attached. For services that...
Can we bill a nurse visit to Medicare in an RHC?
January 30th, 2010 - Codapedia Editor
No, a practice may not bill a nurse visit to Medicare in a Rural Health Clinic (RHC.) Rural Health Clinics are designated by Medicare. In some states, the RHC will also be designated as a RHC by Medicaid. When so designated, the clinic is paid an all-inclusive rate for services performed on that...
Pre-operative medical exams
January 28th, 2010 - Codapedia Editor
Medically necessary pre-operative evaluations are covered services by Medicare and other third party payers. Typically, the surgeon who will perform the surgery asks the patient's primary care physician or sub-specialist to clear the patient prior to a major surgery. This service must be medically...
UPDATE Post op care and hospitalists after the consult changes
December 17th, 2009 - Codapedia Editor
Change: December 15, 2009--Good news! The consult change would seem to allow hospitalists to bill for post op care using the initial hospital care codes. Here is a post by Seth Canterbury, published with his kind permission, about the topic. I read it to allow everyone's initial inpatient visit...
Teaching Physician Rules Primary Care Exception
November 24th, 2009 - Codapedia Editor
CMS has developed a specific set of rules for academic settings. These rules allow a teaching or attending phyisician to bill for services provided jointly by themselves and residents in approved Graduate Medical Education (GME) programs. Different services (endoscopy, E/M, major surgery) have...
CPT® Consult Rule Changes for 2010
November 2nd, 2009 - Codapedia Editor
By now you've heard the news that starting January 1, 2010, Medicare will no longer reimburse consultation services billed with codes 99241--99245, 99251--99255. But, the consult codes remain in the CPT® book for 2010. However, there is quite a bit of new editorial material related to...
H1N1--New Codes from CMS for Sept 1 2009 Swine flu
October 16th, 2009 - Codapedia Editor
On CMS's Open Door Forum call, today, 8/25/09, CMS said: * Change request and MedLearn Matters articles will be coming soon * There will be new codes for the administration/vaccine * Vaccine will be available in mid-October, provider community will have access to it * Vaccine will be FREE: do...
How do you report bilateral procedures? One line or two?
October 14th, 2009 - Mary LeGrand
Bilateral Total Knees—How to Submit the Claim From Question: How do I report bilateral procedures, one line or two? Answer: Great question, unfortunately the payors have made this simple concept of bilateral procedures challenging from a reimbursement standpoint! Survey your payors...
Colonoscopy
September 10th, 2009 - Codapedia Editor
Colonoscopy Screening versus diagnostic—Medicare patients Medicare develops HCPCS codes for some preventive medicine services when it wants to differentiate between a diagnostic test (which has a CPT® code) and a screening test. Colonoscopy is a good example. There are a series of...
Observation initial services
September 8th, 2009 - Codapedia Editor
Observation services are a status of admission to the hospital. Patients who are admitted to the hospital are admitted either to inpatient status or observation status. The status is determined by the physician, although often the case manager at the hospital will have significant input into the...
Unna Boot Application
September 2nd, 2009 - Codapedia Editor
Physicians bill for Unna Boot application using code 29580. The supply code is A6456, Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard. Notice that the code unit is 1 for one yard. Bill for both on the same...
Minimal E/M service on an established patient
August 10th, 2009 - Codapedia Editor
Nurse visits are services provided by nursing staff in a physician office under the general supervision of a physician. The physician does not typically have a face-to-face service with the patient. These services are billed with code 99211. The CPT® book defines 99211 as: Office or other...
Transphenoidal hypophysectomy--how is this coded?
August 10th, 2009 - Kim Pollock
Question: How do we code a transphenoidal hypophysectomy when we do the procedure with an ENT doctor? The ENT doctor says he has his own codes to bill. Answer: There are two codes to report this procedure. First, CPT® 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or...
Facet Joint Injection Services and Modifier 50
August 5th, 2009 - Codapedia Editor
CMS posted a transmittal 7-31-09 about the appropriate use of modifier 50 for Facet Joint Injection Services. It is attached as a resource. Effective date is 8-31-09.
Assistant surgeon
July 19th, 2009 - Codapedia Editor
Some surgical procedures may be performed with both a primary surgeon and an assistant surgeon. Insurance companies typically pay 20% to 25% for the assistant. Medicare allows 16% of the full fee payment for the assistant surgeon.
G0101 Pelvic and breast exam
July 6th, 2009 - Codapedia Editor
Medicare does not pay for routine physical exams annually for patients--a sore spot for Primary Care Providers and Medicare beneficiaries alike. They do pay for an initial Welcome to Medicare visit. (See the Codapedia article about that topic.) Medicare does pay for a screening pelvic and breast...
Chemotherapy Infusion and E/M on the same day
July 3rd, 2009 - Codapedia Editor
Is it appropriate to bill an E/M service with a chemotherapy infusion? Here is how Nancy Maguire answered that question: If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to...
Modifier -24
June 21st, 2009 - Crystal Reeves, CPC, CMPE
Modifier 24 is used to indicate that an Evaluation and Management service was provided by the surgeon to a patient within the global period of a major or minor surgery. The claim must be accompanied by documentation that supports that the service is not related to the postoperative care for the...
What is an Incomplete Colonoscopy?
June 12th, 2009 - Alyce Kalb
A complete colonoscopy according to Current Procedural Terminology published by the AMA is: “Colonoscopy, flexible, proximal to the splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate...
Smoking cessation codes
May 19th, 2009 - Codapedia Editor
There are two CPT® smoking cessation codes that replaced CMS's temporary HCPCS codes (99406--99407). These are time based codes. The first requires up to three minutes of time spent in smoking cessation, and the second 3-10 minutes. The note must document the patient's tobacco use, the adverse...
Lipoma
May 11th, 2009 - Codapedia Editor
From the Q&A section: Question: I have a patient with a large (~15 cm) soft tissue mass in his flank which on initial evaluation is consistent with a large lipoma (95% sure, but I've been tricked with sarcomas before). For the excision, would I use the skin code (11406) or the...
Laparoscopic procedure without a code
May 11th, 2009 - Codapedia Editor
Do not use the open code for procedure when performing the service laparoscopically. Use an unlisted code if none exists. Contact your medical society and the CPT® committee to describe the service and advocate for a code. Here is Nancy Maguire's response to this question on the Q&A...
ROS Checklist
April 22nd, 2009 - Rikki Runyon
Review of Systems CHECKLIST: -General- ? Weight loss or gain ? Fatigue ? Fever or chills ? Weakness ? Trouble sleeping ----------------------------------------------------------------------------------- -Skin- ? Rashes ...
How do I bill for a PAP smear?
April 22nd, 2009 - Codapedia Editor
Physicians often ask what codes to use in order to bill for a pap smear provided during a preventive medicine service or other E/M service. The only CPT® codes for pap smears are for Pathologists, for the physician interpretation of the cytology specimen. So, what does the GYN or primary care...
Services in an assisted living facility
April 22nd, 2009 - Codapedia Editor
According to the CPT® book, assisted living services are reported with codes 99324--99337. Look at that series of codes for new or established patients. It is not correct to bill at an assisted living facility with office visit codes. These codes are used for services provided in: domiciliary,...
69210 Cerumen removal
April 19th, 2009 - Codapedia Editor
The CPT® Assistant clarified the rules for using code 69210 in the July 2005 newsletter. The key points for using this code: Ear lavage alone is insufficient: the ear wax must be removed by curette or instrumentation The billing provider must perform the service, not the nurse or...
How to bill for Well Woman Exams (WWE)
April 15th, 2009 - Charlene Burgett
Well Woman Exam Coding There 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 will pay certain...
Preventive Medicine Services for Medicare Patients
April 10th, 2009 - Codapedia Editor
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...
Psychiatric diagnoses in primary care
April 10th, 2009 - Codapedia Editor
Anyone who has tried to get an appointment with a psychiatrist can tell you how difficult it is to find the right mental health professional, and get an appointment. In fact, much of the frontline of psychiatric diagnosis and treatment happens in primary care offices. The problem is, how can they...
Incident to Billing or Incident to Service
April 10th, 2009 - Jeannie Cagle, BSN RN CPC
By Jeannie Cagle, BSN, RN, CPC This question appeared in a recent list serve. My two responses are based upon two different assumptions: (1) both providers are physicians, and (2) one of the providers is not a physician. The principal points are that each physician has a unique National Provider...
How do I submit a question to CPT® Assistant/AMA?
April 10th, 2009 - Christina Benjamin
I contacted AMA when they first started promoting their CPT® Network and offering a 30-day free trial access to it and they gave me the following information: 1. As a CPT® Assistant subscriber, if I have a question that is directly related to CPT® Assistant, they will answer...
Category of outpatient services
April 10th, 2009 - Codapedia Editor
New patient codes 99201–99205 may be billed in an office, outpatient department or Emergency Department. What is a new patient? The CPT® and Medicare (CMS) definition are the same. From the CPT® book: A new patient is one who has not received any professional services from the...
How to submit a question to CPT® Assistant/AMA?
April 3rd, 2009 - Christina Benjamin
1. As a CPT® Assistant subscriber, if you have a question that is directly related to CPT® Assistant, they will answer it. Questions can be e-mailed to cptassistant@ama-assn.org with subject - call for letters and to attention of Gloria Green per the CPT® Assistant. They ask that...
E-Prescribing and Medicare Bonus Payments
April 1st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE Question Our doctors want to begin e-prescribing in order to get the Medicare bonus payment. How much is the bonus payment, and how do we let Medicare know that we are e-prescribing? Answer The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)...
Using Modifer -59
March 31st, 2009 - Crystal Reeves
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...
Suture removal
March 30th, 2009 - Codapedia Editor
If a physician removes sutures that he/she placed, and the service has a ten day global period, there is no separate payment for the suture removal. It is part of the global service and payment for the minor procedure. However, insurance companies will pay for suture removal performed by a...
Retrospective audits
March 29th, 2009 - Codapedia Editor
Many physician practices took the OIG recommendation to heart, and do annual compliance audits. There are many questions to answer about audits: how many, how often, internal or external auditor, doing the work under attorney client privilege and whether to do the audits prospectively or...
Prospective audits
March 29th, 2009 - Codapedia Editor
Many physician practices took the OIG recommendation to heart, and do annual compliance audits. There are many questions to answer about audits: how many, how often, internal or external auditor, doing the work under attorney client privilege and whether to do the audits prospectively or...
Global Surgical Package
March 29th, 2009 - Codapedia Editor
The concept of paying surgeons a global payment for all services related to a surgery started in 1992, with the implementation of the Resource Based Relative Value System (RBRVS). This concept describes the components of the global package, and established the post op period for surgical services,...
Is time the trump card in selecting an E/M service?
March 29th, 2009 - Codapedia Editor
Is time a trump card in selecting an Evaluation and Management service? Sometimes. Isn't that too frequently the answer in coding? If the visit meets the criteria for using time ot select the code, and if time is a descriptor in the CPT® definition, then yes. The criteria are: ...
Is medical decision making a trump card in E/M services?
March 29th, 2009 - Codapedia Editor
Physicians who treat patients with very serious illnesses sometimes think that they can select the highest level of service in any category based on the high acuity of the patient. After all, isn't a patient with a brain cancer really sick? Shouldn't that patient always be charged a high level...
What does incidental mean on a remittance advice?
March 27th, 2009 - Codapedia Editor
Sometimes, a line item on a claim is denied by the insurance company as "incidental to" another procedure. When you check the NCCI edits, you don't find that these are bundled by NCCI. What does this mean? The insurance carrier is using their own edits in determining bundling. They are...
Second opinions: are they consults?
March 27th, 2009 - Codapedia Editor
There are no longer any CPT® codes for confirmatory consults. If a patient presents to the office with a request for a second opinion, how is that billed? If the patient is requesting a second opinion, bill that service as a new or established patient, whichever category is correct for that...
Modifier 58
March 25th, 2009 - Codapedia Editor
Modifier 58 is appended to a surgical service to indicate that the physician performed a procedure during the global period that was planned at the time of the original procedure (staged), was more extensive than the original procedure, or is the therapeutic service following a diagnostic procedure....
Modifier 78
March 25th, 2009 - Codapedia Editor
Modifier 78 is used to indicate that the physician who performed a surgery which had a 10 or 90 day global period took the patient back to the OR for a related problem, typically, a complication. Do not use it for staged or related procedures--that is reported using modifier 58. For unrelated...
Modifier 79 Unrelated procedure or service
March 25th, 2009 - Codapedia Editor
Modifier 79 is appended to a procedure to indicate that the same surgeon took the patient back to the operating room during the global surgical period for an unrelated problem. The second procedure must be unrelated to the original procedure. See modifier 78 for return trips to the OR that are...
Modifier 77
March 25th, 2009 - Codapedia Editor
Modifier 77 is used to indicate that the same procedure was performed on a patient, but the service was done by a different physician than the first procedure. Use this modifier on the same day or during the global period of the first service. Use the same CPT® code. The procedure report...
Modifier 76 Repeat Procedure or Service by Same Physician
March 25th, 2009 - Codapedia Editor
Modifier 76 is used to report the service when the same procedure is performed by the same physician, on the same patient either the same day of the previous procedure or doing the global period. The modifier tells the payer that this is not a duplicate bill, but that the same procedure was...
Modifier 54 and modifier 55
March 21st, 2009 - Codapedia Editor
The global surgical package includes the care of the patient pre-operatively, intra-operatively and post-operatively. In some cases, however, the surgeon has performed only part of those services. For example, a tourist at a ski resort who falls and requires surgery will return to their own home...
Performing only part of the global OB package
March 21st, 2009 - Codapedia Editor
The CPT® codes that describe obstetrical services start at 59000. There are codes for delivery that include the entire obstetrical package, from pre-natal, through delivery, to post-partum. These global codes are used when the practice performs all of the services. There are codes that...
Global obstetric package
March 21st, 2009 - Codapedia Editor
Payment for obstetrical services is packaged into a single payment when the physician practice provides all of the components of the service. There are CPT® codes for each component, however, when the practice needs to bill only part of the service. Physicians in a group of the same specialty...
Modifier 26
March 21st, 2009 - Codapedia Editor
Modifier 26 is a CPT® modifier used to indicate that the physician practice performed the professional component only of a diagnostic test. There is no CPT® modifier for the technical component. The facility that performs only the technical component uses a HCPCS modifier, TC. Some...
Diagnostic test interpretation
March 21st, 2009 - Codapedia Editor
Many-- but not all-- diagnostic tests are composed of a technical and a professional component. These tests are identified in the Medicare Physician Fee Schedule. When the physician practice performs both components, the service is billed globally, with no modifier. If the technical component is...
Modifier 79
March 18th, 2009 - Codapedia Editor
Modifier 79 is used to indicate that the physician performed a surgical service that required a return trip to the OR for an unrelated problem during the global post op period. Modifier 79 is appended to procedures. See the CPT® book for the complete definition. It is appended when: A...
Modifier 57
March 18th, 2009 - Codapedia Editor
Modifier 57 is a modifier that is appended to an E/M service to indicate that this was the visit at which the physician decided to perform surgery. It is only used on procedures with a 90 day global period, per CMS, although this is not a CPT® rule. It is only used the day of or before a major...
Two surgeons operating on the same patient, same session
March 18th, 2009 - Codapedia Editor
Most surgeries with two surgeons are reported and performed as the primary surgeon (no modifier on the CPT® code) and the assistant surgeon (modifiers 80, 81, 82, and AS). Some surgeries, however, require two surgeons (modifier 62) or a surgical team (modifier 66). How does a physician or...
Ventilator management
March 18th, 2009 - Codapedia Editor
There are two codes for ventilator management for inpatient services: 94002 and 94003. One is for the day when the physician initiates vent management and the second is for a subsequent day. They are mutually exclusive codes in the CCI edits and may not be billed together on the same day. See the...
Can a physician be paid for reviewing old records and x-rays
March 13th, 2009 - Codapedia Editor
A patient presents to the office with 100 pages of old records and a dozen x-ray copies to review prior to consultation. How can a physician be paid for that? There is no separate reimbursement for record review. With the development of RBRVS, the pre and post work of services is included in the...
Coding for visits to patients in Swing Beds
March 12th, 2009 - Codapedia Editor
Physicians should bill for patients in facilities based on the status of the patient in the facility. This is true for Observation, Inpatient and nursing facility status. The status billed by the facility and the E/M codes selected and reported by the physician should match. Some hospitals have...
Visual Acuity Screening
March 12th, 2009 - Codapedia Editor
Many physician practices are denied by third party payers when billing for a visual acuity test with a well child visit. The code for visual acuity testing is 99173. See the CPT® book for a complete definition of this code. This is a screening test of visual acuity, quantitative, bilateral,...
Report for professional component of a diagnostic test
March 12th, 2009 - Codapedia Editor
What does a physician need to document and in what format? If you are a radiologist, you know the answer to this question. Many diagnostic tests have both a professional and a technical component. Whether or not a test has both is found in the Medicare Physician Fee Schedule Data Base. A...
Documentation Time Limits
March 12th, 2009 - Codapedia Editor
How soon does a clinician need to document the service after performing the service? If you are asking this question, it is probably because a physician or other clinician in your practice is behind in documenting their encounters. Here is what CMS says in the Claims Processing: (Publication...
Initial hospital services that dont meet 99221
March 10th, 2009 - Codapedia Editor
Sometimes, when auditing an initial hospital service, either the history or the exam does not meet the level required for the lowest level of initial hospital service. 99221 requires all three of: a detailed history, a detailed exam and straightforward or low medical decision making. The MDM is...
Skin tag removal
March 10th, 2009 - Codapedia Editor
Many physicians report that it is difficult to get insurance companies to pay for skin tag removal. That is because most insurances consider the service to be cosmetic. If you are performing the service, tell the patient prior to providing the service that if their insurance determines the...
Can I bill for coumadin management over the phone?
March 10th, 2009 - Codapedia Editor
A physician asks: "Can I bill for coumadin management for patients in the nursing home? I sometimes get 25 calls a month with PTINR results, and have to make decisions about the patient's coumadin dose. Can I bill for that?" Unfortunately, no. Medicare considers this part of the pre...
Stress test coding
March 10th, 2009 - Codapedia Editor
Stress test codes are different than many other diagnostic tests which have two components: a professional component and a technical component. Stress tests have three components: Technical Interpretation and report (physician service) Supervision (physician service) The...
Telephone calls: CPT® codes with no reimbursement
March 10th, 2009 - Codapedia Editor
Search the Medicare Claims Processing Manual, Chapter 12, for the word "telephone" and the sentences are filled with negatives. Here's the section from the Manual labeled telephone calls: B. Telephone Calls Telephone calls (codes 99371-99373) may not be paid separately. Payment...
Billing for a breast exam
March 9th, 2009 - Codapedia Editor
Sometimes, a patient presents only for a breast exam, perhaps prior to a mammogram. Is that a separately billable service? Newly found lump: A patient who presents with a newly discovered lump and presents to the office can be billed with new or established patient visit codes (depending on the...
Can prolonged services be added to preventive medicine codes?
March 9th, 2009 - Codapedia Editor
There are two sets of prolonged services codes, one set for face-to-face additional time spent with the patient in the office or hospital, and one set for non-face-to-face time. Non-face-to-face time is typically not paid by most insurers. In 2009, CPT® changes its description of these...
PQRI Physician Quality Reporting Initiative: an Overview
March 5th, 2009 - Betsy Nicoletti
PQRI The briefest of historical reviews 2007: 1.5% potential payment with cap on total payment • Half year reporting period • Bonus payment subject to cap • 1.5% of total allowed Medicare Fee Schedule payments • Includes Railroad Retirement Board charges • ...
Using modifier 66 (team surgery) Q&A
March 4th, 2009 - Mary LeGrand
General Surgery Multiple Surgeons, Different Procedures Question: Do I use modifier 66 (team surgery) when our General surgeon is operating on a child during the same session as a plastic surgeon doing a cleft palate repair or a urologist performing a urologic procedure such as a...
Modifier 21
March 4th, 2009 - Codapedia Editor
Modifier 21 was deleted from the 2009 CPT® book. It was a modifier that was not recognized by many payers, and did not give the practice any additional payment. See the add on, prolonged services codes 99354--99357 to report prolonged services. See the Codapedia articles about this topic.
Services denied as incidental to another service
March 3rd, 2009 - Codapedia Editor
Have you received a denial from a payer with these words? "This service was denied as incidental to another service." Notice that the payer does not say that the service was bundled into another service. The explanation of benefits from the commercial payer uses the word...
Teaching patients to use an inhaler or nebulizer
March 3rd, 2009 - Codapedia Editor
Use code 94664 when teaching patients how to use a nebulizer or inhaler. The CPT® definition is: Demonstration and/or evaluation of patient utlization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device. The service may only be reported once/day. It is not a code defined...
Epley Maneuver
March 3rd, 2009 - Codapedia Editor
The Epley Maneuver is reported using code 95992. It is a per day code, and may not be reported with mulitple units in a single day. Audiologists and Physical Therapists may report this service. The CPT® definition of the code is: Canalith repositioning procedure(s) (eg Epley Maneuver, semont...
Care Plan Oversight, non-Medicare
March 3rd, 2009 - Codapedia Editor
Although Medicare developed its own set of HCPCS codes for Care Plan Oversight, there are CPT® codes which describe this service. The amount of time, and the definition of the service are both different from the CMS HCPCS codes. See the article in Codapedia for the Medicae CPO codes. The...
PPD Testing
March 3rd, 2009 - Codapedia Editor
To bill for placing the purified protein derivative (PPD) skin test,use CPT® code 86580. Use this code when the nurse or medical assistant places the test on the patient's skin. The CPT® definition of the code is: Skin test, tuberculosis, intradermal. The code has a technical component...
AAA screening
March 2nd, 2009 - Codapedia Editor
Medicare allows screening for Abdominal Aortic Aneurysm in very limited situations. The screening must be ordered as part of the patient's Welcome to Medicare visit (Initial Preventive Physical Exam). That limits the screening to newly enrolled Medicare patients. If the patient has not had the...
Operating microscope
March 2nd, 2009 - Codapedia Editor
CPT® defines certain operative procedures as including the use of an operating microscope, code 69990. 69990 is an add on code, indicated by the plus sign in front of it in the CPT® book. It is billed as a second procedure, without modifier 51. At the start of the section about this code...
Pessary billing and coding
March 2nd, 2009 - Codapedia Editor
Both CPT® and the American College of Obstetrics and Gynecology (ACOG) instruct us to use 57160 for the fitting and insertion of a pessary the first time the service is provided. Removing, cleaning and reinserting a pessary is part of an evaluation and management service and should not be...
Psychiatric diagnosis codes for office visits
March 2nd, 2009 - Codapedia Editor
Many coders report that using a psychiatric diagnosis code on a claim for an office visit results in a denial. Physicians want to know what they can do about it. Unfortunately, not very much. Primary care practices provide a lot of mental health services in their offices. When they submit these...
Initial OB Visit
March 2nd, 2009 - Codapedia Editor
Physician practices who provide OB services often want to know if they can bill separately for the first OB visit, or if it is part of the global package. The short answer is: once you begin the OB service, it is part of the package. Prior to home pregnancy tests, many patients came in to see if...
Converting a service from a laparoscopic to open procedure
March 2nd, 2009 - Codapedia Editor
Some surgeries are planned to be laparoscopic procedures, but the physician needs to convert the service to an open procedure. In that case, bill only for the open procedure. If there was significant extra work, meeting the criteria for use of modifier 22, and this is documented, then add that to...
Casting supply codes
March 1st, 2009 - Codapedia Editor
HCPCS codes include temporary codes developed by CMS. Sometimes, the temporary codes stick around for a while. There are HCPCS codes for the provision of cast supplies to Medicare patients. A physician office may always be paid for the cost of the casting materials, whether billing global...
IVIG administration fee ended
March 1st, 2009 - Codapedia Editor
The 2009 Proposed Physician Fee Schedule warned that CMS was considering ending payment for G0332, a HCPCS code. The code was defined as: Services for intravenous infusion of immunoglobulin prior to administration (This service is to be billed in conjunction with administration of immunoglobulin). ...
Medically Unlikely Edits
February 28th, 2009 - Codapedia Editor
Medicare developed a set of edits that it has instructed carriers, fiscal intermediaries, DME processors, and now Medicare Administrative Contractors (MACs) to follow. This edits were developed in addition to the National Correct Coding Initiative Edits to keep the payers' claims processing systems...
Certification of Home Health Agency Services for Medicare
February 25th, 2009 - Codapedia Editor
In 2001, Medicare added two new HCPCS codes to describe certification and recertification of home health services performed by a physician. A qualified NPP may not provide this service because only a physician may order home health services for a patient. There are two codes, G0179 and G0180,...
Care Plan Oversight for Medicare Patients
February 25th, 2009 - Codapedia Editor
Medicare has developed two HCPCS codes for providing Care Plan Oversight (CPO) to their patients. There are also CPO codes in the CPT® book for non-Medicare patients. See the article in Codapedia related to the CPO codes for non-Medicare patients. For Medicare patients, the service is...
Consults in a group
February 23rd, 2009 - Codapedia Editor
Can one physician request a consult from another physician in the same group? Sometimes. (Don't we long for yes or no answers?) One physician can request a consult from another physician in the same group, of the same or different specialty, when the conditions of a consult are met, and the...
Nurse visit and flu shots
February 18th, 2009 - Codapedia Editor
Both CPT® and CMS (Medicare) has made it clear that it is not appropriate to report a nurse visit when giving a flu shot. That is: do not bill a nurse visit when the patient presents to the office for a flu shot. Bill only for the administration of the vaccine and for the serum, if the...
Prolonged Services: A General Discussion
February 18th, 2009 - Codapedia Editor
Prolonged services are add on codes, used to indicate that the physician or Non-Physician Practitioner spent 30 minutes more than the typical time for that code with the patient. See the Codapedia articles on prolonged services in the office (face-to-face) and prolonged services in the hospital...
The insurance company denies urinalysis as incidental
February 15th, 2009 - Codapedia Editor
In 1864, Anthony Trollope said, "Perhaps in no career has a man to work harder for what he earns, or to do more work without earning anything." And this was before Relative Value Units and bundling edits! There are commercial payers who do not use the National Correct Coding Initiative...
Healthcare Common Procedure Coding System
February 12th, 2009 - Codapedia Editor
Healthcare Common Procedure Coding System (HCPCS) are a set of standardized codes which health care providers use to report services to insurance companies. The first set, CPT® (Level I HCPCS codes,) are owned, developed and copyrighted by the American Medical Association. These codes are...
Hospitalist Services
February 12th, 2009 - Codapedia Editor
Hospitals are adding hospitalist services at a fast pace. Everyone is recruiting for hospitalists. It's changed the face of primary care. Primary care physicians are now in their offices more hours of the day. Their hospitalized patients are cared for by a group of physicians without office...
Observation discharge
February 12th, 2009 - Codapedia Editor
There is only one code for observation day discharge management, 99217. Unlike discharge day management from inpatient status or nursing homes, there are not two levels based on time. Use 99217 no matter how long the discharge takes. The patient status must be Observation status to use this...
Hospital Discharge Day Services
February 12th, 2009 - Codapedia Editor
Use codes 99238 or 99239 for services provided to a patient being discharged from inpatient status in the hospital. These codes include all of the work performed on the calendar day to discharge a patient, including the exam, discussion with the patient and caregivers, and discharge paperwork. ...
Auditing the exam 1995 Guidelines
February 11th, 2009 - Codapedia Editor
Auditors breathed a huge sigh of relief when the 1997 Guidelines were released. The exam component was specific, clear and defensible in all four areas: problem focused, expanded problem focused, detailed and comprehensive. There were even specific instructions for single specialy exam elements. ...
Mandated visits in a nursing facility
February 11th, 2009 - Codapedia Editor
What are mandated nursing home visits and who mandates them? May either a physician or qualified Non-Physician Practitioner (NPP) perform these? CMS mandates that residents in nursing homes be assessed by a physician or NPP at periodic intervals. This is a requirement for the nursing home's...
Multiple endoscopic procedures
February 10th, 2009 - Codapedia Editor
Medicare uses different rules to pay for multiple surgical procedures and multiple endoscopic procedures. For non-endoscopic procedures, the service with the highest RVU is paid at 100% of the fee schedule, and at 50% for the second to the fifth procedure. Multiple unrelated endoscopic...
Teaching Physician Rules and Minor Surgical Procedures
February 9th, 2009 - Codapedia Editor
When a resident performs a minor surgical procedure, the attending physician must be present for the entire procedure, in order to bill for the service under the attending physician's provider number. Minor surgical procedures performed by medical students are never billable to Medicare or any...
Physicians in a Group
February 9th, 2009 - Codapedia Editor
Medicare and other third party payers pay have specific rules for paying physicians of the same specialty in a group. Here is what the Medicare Claims Processing Manual says: 30.6.5 - Physicians in Group Practice (Rev. 1, 10-01-03) Physicians in the same group practice who are in the same...
Interval History
February 9th, 2009 - Codapedia Editor
Some CPT® codes require an interval history. This article defines an interval history.
Are two E/M services payable on the same day?
February 9th, 2009 - Codapedia Editor
There are times when physicians or NPPs see a patient twice in a single day, and want to know if both are reportable, and if both are paid by insurances or Medicare. In general, only one service is paid, but there are some instances in which both can be paid.
E/M Profiles
January 29th, 2009 - Codapedia Editor
CMS and other payers collect data on the utilization of E/M services within each category of service. For example, for all of the established patient visits billed using codes 99211 to 99215 by Rheumatologists, CMS keeps track of what percentage are level one’s, level two’s, level...
Consultation services
January 29th, 2009 - Codapedia Editor
Let’s start with Medicare’s definition of a consultation Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.10A Carriers pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code...
PT/OT Therapy caps
January 29th, 2009 - Codapedia Editor
The MedLearn Matters article on PT/OT caps is attached as a resource.
Critical Care and the Teaching Physician Rules
January 29th, 2009 - Codapedia Editor
Only the time of the teaching physician--not the resident--may be reported as critical care time. That's the short answer. Review the articles in Codapedia related to the requirements for critical care billing and critical care to neonates and pediatric patients. Only the attending physician...
Critical care
January 29th, 2009 - Codapedia Editor
Critical care services are services provided to a critically ill patient. It sounds like a circular definition.doesn't it? The first requirement for billing critical care is the status or condition of the patient. Although critical care services are often provided in a criticla care unit,...
Welcome to Medicare Visit
January 29th, 2009 - Codapedia Editor
Welcome to Medicare Initial Preventive Physical Examination (IPPE) A new benefit under the Medicare Modernization Act Effective date 1-1-05, changes for 2009 Eligibility: Any Medicare beneficiary who enrolls in Medicare on or after January 1, 2005 Time limits: Eligible for benefit in the...
Consultations
January 28th, 2009 - Codapedia Editor
CPT® defines two sets of consultation codes: outpatient/office consults using 99241 through 99245 and inpatient/nursing facility consults using codes 99251 through 99255. The Center for Medicaid and Medicare Services (CMS) defines a consult in this way Specifically, a consultation service is...

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