Primary Care|Family Care - Articles

Continuous Glucose Monitors (CGMs) -- New Codes
May 2nd, 2022 - Wyn Staheli, Director of Content
New codes for continuous glucose monitors (CGMs) became effective on April 1, 2022. The following information is excerpted from MLN Matters MM12564 regarding CGMs. Be sure to review this information and implement policies to ensure accurate reporting/billing. On December 28, 2021, we published the Medicare DMEPOS final rule in the Federal Register. This addressed the ...

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Understanding Skin Biopsy Codes
March 23rd, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
A biopsy is a procedure to obtain only a portion of a lesion for a pathologic exam. According to the AMA, "The use of a biopsy procedure code (e.g., 11102, 11103) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other ...
Are NCCI Edits Just for Medicare?
July 14th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...
March 26th, 2020 - Namas
Healthcare providers and the population at large are concerned about safe access to care considering the COVID-19 pandemic. As a result, we have received many inquiries this week about how to bill for “telehealth” services. Let’s first address that true telehealth services have some pretty stringent requirements from CMS, including that ...
Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)
March 21st, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...
Implementing Telehealth Visits
March 20th, 2020 - Namas
The following is a step-by-step guide on how to convert office-based encounters to telehealth encounters during the current COVID-19 pandemic. These rules may change post-pandemic, as many changes relaxing existing rules were made on a temporary basis by CMS and commercial payers to facilitate patient access and minimize risk of infection. Step ...
Reporting the Health Effects of Vaping Now and in April 2020
December 19th, 2019 - Wyn Staheli, Director of Research
To report vaping related conditions/disorders, use the official CDC guidelines to ensure proper documentation of vaping related health conditions. There is also a new code that will become effective April 1, 2020.
Vaccine Administration - When The Right Vaccine Code is Not Enough
September 30th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Understanding how to apply immunization administration codes properly will support correct reimbursement for vaccinations. Reporting the right vaccine code alone is not enough to guarantee proper billing. The majority of the time, providers can charge for the vaccine/product as well as the administration of the vaccine; always consult your payer ...
Medical ID Theft
August 16th, 2019 - Namas
Medical ID Theft "So, do you guys think you can do something with that?" John asked angrily at our first meeting with him in August 2017 as he slammed a stack of medical bills, EOBs and collection letters - three inches high - down in front of my partner and I. ...
The OIG Work Plan: What Is It and Why Should I Care?
August 9th, 2019 - Namas
The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...
5 Ways to Minimize HIPAA Liabilities
July 12th, 2019 - BC Advantage
Last year was historic for HIPAA enforcement. The HHS Office of Civil Rights collected a record $23.5 million in settlements and judgments against providers guilty of HIPAA violations. To avoid becoming part of that unwanted statistic, it’s important to pay extra close attention to five key areas of HIPAA vulnerability. Take ...
How to Properly Report Monitoring Patients Taking Blood-thinning Medications
June 18th, 2019 - Wyn Staheli, Director of Research
Codes 93792 and 93792, which were added effective January 1, 2019, have specific guidelines that need to be followed. This article provides some guidance and tips on properly reporting these services.
Coverage for Hearing Aids and Auditory Implants
April 23rd, 2019 - Brandon Dee Leavitt QCC, CMCS, CPC, EMT
For hearing impairment, Medicare is firm in its stance on when it will and will not cover hearing correction. In the PUB 100-02 Medicare Benefit Policy Manual, Chapter 16, Medicare cites the Social Security Act by explaining:  "..."hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids" ...
Attestations Teaching Physicians vs Split Shared Visits
February 1st, 2019 - BC Advantage
Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...
Q/A Neonate Coding When Child is Transferred (2019/01/17)
January 28th, 2019 - Codapedia
Codapedia Forum - Questions & Answers Q/A: Neonatologist was at the birth of a very critical child, she billed 99468 and then it was decided to transfer the child to another facility, she also billed 99291 and 99292 x 3. Her time was denied, how should she have billed for the initial ...
Home Oxygen Therapy
January 22nd, 2019 - Raquel Shumway
Home Oxygen Therapy Guidelines
Home Oxygen Therapy -- CMN for Oxygen
June 14th, 2018 - Raquel Shumway
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.
Q/A: Coding for Lesion Removal and Repair
June 5th, 2018 - Chris Woolstenhulme QCC, CMCS, CPC, CMRS
The CPT book does not indicate repairs, measuring .5 cm and less, during lesion removal. Does this mean that...
Preventive Medicine: Hepatitis C Virus (HCV) Screening
May 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page Hepatitis C Virus (HCV) Screening Procedure Codes G0472: Hepatitis c antibody screening, for individual at high risk and other covered indication(s) 87522: Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed 86804: Hepatitis C antibody; confirmatory test (eg, ...
Preventive Medicine: Hepatitis B Virus (HBV) Vaccine and Administration
May 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page Hepatitis B Virus (HBV) Vaccine and Administration Procedure Codes G0010: Administration of hepatitis b vaccine 90739: Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use 90740: Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use 90743: Hepatitis ...
Preventive Medicine: General Procedures
May 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page General Procedures Procedure Codes 36415: Collection of venous blood by venipuncture 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) 90472: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List ...
Pre-Existing or Gestational?
February 1st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
It is important to make a clear distinction between pre-existing conditions and conditions brought on by the pregnancy (gestational) or pregnancy related conditions. Condition Detail: Was the condition pre-existing (i.e., present before pregnancy)? Trimester: When did the pregnancy-related condition develop? Casual Relationship: Establish the relationship between the pregnancy and the complication (e.g., preeclampsia) Code examples: O99.011 Anemia ...
Influenza, Are You Billing Correctly?
January 31st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
With this year's Flu season being the most widespread on record, providers are seeing more patients and giving more immunizations for influenza than normal. Here are a few things to keep in mind during this flu season.  Know the rules with your payers to ensure proper reimbursement and correct billing. For example, did you ...
Medicare's Integrated Behavioral Healthcare Services and Collaborative Care Program
January 18th, 2018 - Wyn Staheli, Director of Research
Over the last several years, primary care has begun to integrate behavioral health services to better address shortfalls in patient quality of care. Some of the first codes were the Health and Behavior Assessment/Intervention (96152-96155) codes, which were added in 2002. Since then, many different models have been experimented with and have ...
Preventative Services: Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
January 11th, 2018 - Find-A-Code
The following information from the Medicare Learning Network provides guidance on Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
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 ...
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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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...
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. ...
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...
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...
Preventive medicine service and office visit on the same day
January 30th, 2015 - Codapedia Editor
Modifier 25 for Preventive medicine service and office visits The CPT® book describes modifier 25 as the modifier to be used on an E/M service when "a Significant, Separately Identifiable Evaluation and Management Service” is performed by the same physician on the same day of the...
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.
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...
Incident to Services for Medicare Patients
April 24th, 2013 - Codapedia Editor
Incident to services is a Medicare provision which allows physician offices to bill for services provided by a Non-Physician Practitioner or nurse or medical assistant under the physician's provider number. The service is then paid at 100% of the Medicare Fee Schedule. NPPs may bill services under...
Medicare Wellness Visits--update
April 24th, 2013 - Codapedia Editor
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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...
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...
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...
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...
Primary Care Billing Profiles
October 14th, 2009 - Codapedia Editor
For most primary care physicians, Evaluation and Management services comprise the highest percentage of services performed, and account for most of the revenue. Primary care physicians should regularly compare their profile with the norm for their specialty. These specialty norms are included as a...
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...
Prolonged services for office and outpatient visits
July 31st, 2009 - Codapedia Editor
This is an article describing using prolonged services codes in an office setting. There is a separate article in Codapedia about using prolonged services codes in an inpatient setting. There is an article describing using non-face-to-face codes, as well. Prolonged services codes are add-on...
Prolonged Services in an inpatient setting
July 31st, 2009 - Codapedia Editor
This article will describe the coding for using prolonged services in an inpatient setting. The codes are 99356: Prolonged physician service in the inpatient setting, first hour and 99357 each additional 30 minutes. See the CPT® book for the complete descriptions. These codes are used as add...
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...
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...
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,...
E/M service with no exam
April 13th, 2009 - Codapedia Editor
Does an E/M service require an exam? It depends on the category of service. Established patients and subsequent hospital visits require two out of three of the key components, history, exam and medical decision making. Any two components at the level of documentation required determines the level...
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...
Using denial tracking to improve collections
April 10th, 2009 - Codapedia Editor
Here are some examples of denials that a practice should track to be sure that they are paid correctly by the insurance company. Set up a denial type for each of these. Fee Schedule Issues: Wrong amount paid per the contracted fee schedule. May be too high or too low Modifier 80...
Department of Transportation DOT exams
March 31st, 2009 - Codapedia Editor
How does a physician report performing a Department of Transportation physical? With CPT® code 99455 and ICD-9 code V70.5, 99455 is for a work related or medical disability examination by the treating physician. (9945 is for this examination by other than the treating physician.) See the...
Do headings matter in an E/M note
March 30th, 2009 - Codapedia Editor
When documenting the history components in an Evaluation and Management service, the clinician is not required to use the headings that the Documentation Guidelines define. That is, the history section does not need to be labeled: History of the Present Illness, Review of Systems, and past medical,...
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: ...
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...
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...
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...

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