UPDATE Post op care and hospitalists after the consult changesDecember 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 ExceptionNovember 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 2010November 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 fluOctober 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
How do I report bilateral procedures, one line or two?
Great question, unfortunately the payors have made this simple concept of bilateral procedures challenging from a reimbursement standpoint! Survey your payors...ColonoscopySeptember 10th, 2009 - Codapedia Editor
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 ApplicationSeptember 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 patientAugust 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
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.
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 50August 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 surgeonJuly 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 examJuly 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 dayJuly 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 -24June 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 codesMay 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...LipomaMay 11th, 2009 - Codapedia Editor
From the Q&A section:
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 codeMay 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 ChecklistApril 22nd, 2009 - Rikki Runyon
Review of Systems
? Weight loss or gain ? Fatigue ? Fever or chills
? Weakness ? Trouble sleeping
? 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 facilityApril 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 removalApril 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 PatientsApril 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 careApril 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 ServiceApril 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 servicesApril 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 email@example.com with subject - call for letters and to attention of Gloria Green per the CPT® Assistant. They ask that...E-Prescribing and Medicare Bonus PaymentsApril 1st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE
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?
The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)...Using Modifer -59March 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 removalMarch 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 auditsMarch 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 auditsMarch 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 PackageMarch 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 58March 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 78March 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 serviceMarch 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 77March 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 PhysicianMarch 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 55March 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 packageMarch 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 packageMarch 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 26March 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 interpretationMarch 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 79March 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 57March 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 sessionMarch 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 managementMarch 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-raysMarch 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 BedsMarch 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 testMarch 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 LimitsMarch 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 99221March 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 removalMarch 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?"
Medicare considers this part of the pre...Stress test codingMarch 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:
Interpretation and report (physician service)
Supervision (physician service)
The...Telephone calls: CPT® codes with no reimbursementMarch 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 examMarch 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 OverviewMarch 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&AMarch 4th, 2009 - Mary LeGrand
Multiple Surgeons, Different Procedures
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 21March 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 serviceMarch 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 nebulizerMarch 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 ManeuverMarch 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-MedicareMarch 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 TestingMarch 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 screeningMarch 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 microscopeMarch 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 codingMarch 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 visitsMarch 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 VisitMarch 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 procedureMarch 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 codesMarch 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 endedMarch 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 EditsFebruary 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 MedicareFebruary 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 PatientsFebruary 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 groupFebruary 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 shotsFebruary 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 DiscussionFebruary 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 incidentalFebruary 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 SystemFebruary 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 ServicesFebruary 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 dischargeFebruary 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 ServicesFebruary 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 GuidelinesFebruary 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 facilityFebruary 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 proceduresFebruary 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 ProceduresFebruary 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 GroupFebruary 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 HistoryFebruary 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 ProfilesJanuary 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 servicesJanuary 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 capsJanuary 29th, 2009 - Codapedia Editor
The MedLearn Matters article on PT/OT caps is attached as a resource.Critical Care and the Teaching Physician RulesJanuary 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 careJanuary 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 VisitJanuary 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...ConsultationsJanuary 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...