Posts Tagged ‘coding’

Report Surgical H&P With Caution

In Uncategorized on August 23, 2013 at 5:36 pm

History and physicals before surgery can be potholes in the road for reimbursement if reported incorrectly.  Carefully review the circumstances under which the physical is performed to prevent claim denials.

In most cases, if the surgeon performs a history and physical (H&P) to clear a patient for a scheduled surgery, you should not report a separate service.  An H&P is a routine, standard procedure prior to surgery, and is separately reimbursable only if the service satisfies your payer’s medical-necessity requirements.  In practical terms, a pre-surgical H&P is a bundled, global service, unless the patient presents with a new chief complaint that requires work above and beyond that normally required for such a service.

For example, a patient may develop a new problem or otherwise have had a significant change of status in the days before his surgery, which would require the surgeon to perform a more extensive evaluation.  In such a circumstance, you may report the appropriate E/M service level, as supported by the key components of history, exam, and medical decision-making.  Any new diagnosis or patient problems must be documented to establish medical necessity for the visit.  Also, remember that pre-surgical visits (related to the surgery) that occur within 24-hours of the surgery are generally encompassed in the surgical global period, and are not separately compensable.

The rules change for services provided within 24 hours of an unscheduled and/or emergency procedure.  In these cases, a surgeon making the decision for surgery during the visit would report an appropriate E/M service code with modifier 57 Decision for surgery appended.

As always, please contact us at any time with questions regarding this, or other matters.


Coding Clarification – 99000 Mis- and Over-Use

In Uncategorized on August 22, 2013 at 6:32 pm

Upon a recent audit of provider claims, MEDIC, Inc. identified an apparent overuse of 99000.  As such, M.E.D.I.C., Inc. feels that there is a general need to clarify the use of CPT code 99000.  This code should NOT be used when a blood sample is drawn at the office and sent out to the lab.  Rather the 99000 should be used if a specimen is collected (for example cultures of wounds, urine, C&S) for a lab test done at an out lab.

When reviewing revenue detail reports related to the 99000, it is evident that few 99000 claims are actually paid, and those that were were classified as self pay (i.e., they were patient responsibility, not billed to insurance).

Additionally, this code is not billed as a stand-alone code—it is always with an office visit – and when the 99000 is charged with an office visit, rarely if ever does one see a payment.  Per the CCI edits, it is deemed inclusive to the office visit.  In fact, Medicare does not even include the 99000 on their fee schedule.

You can certainly continue to use this code, but most carriers are going to follow the CCI edits and refuse to pay it, and you will not have any basis for appeal.  It is inapproptiate to merely attach the -25 modifier.  Essentially, this code is used primarily for reporting purposes rather than reimbursement.

Please see the following comments addressing the 99000 as well:

  • AMA Comment:  The codes listed in the special services, procedures and reports section (99000-99091) identify various services and reports that are adjunctive to the basic services rendered. These codes describe circumstances under which practitioner services are performed.

Modifier -25 indicates that a separately identifiable E/M service was performed on the same day as another independent procedure or service by the same physician. When a code from the special services, procedures and reports section is reported with an E/M service, modifier -25 should not be appended to the E/M service, as the codes from the 99000-99091 series do not describe separately identifiable services, but rather adjunctive services or circumstances that further describe the basic service rendered.

  • From the AAFP Website:  Most people use 99000 incorrectly. It is not used for obtaining a specimen.  CPT code 99000, “Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory,” is intended to be reported when the practice incurs costs to handle and/or transport a specimen to a lab. For example, if the practice employs a messenger service to transport a specimen, that service can be coded using 99000. In contrast, if lab staff pick up a specimen at no additional cost to the practice, it would not be appropriate to report code 99000. 

Finally, 99000 is not intended for reporting the obtaining of a specimen.  Reimbursement for obtaining a Pap smear or a throat culture is factored into the relevant lab procedure code.  Obtaining a blood specimen by venipuncture may be reported separately, using code 36415, “Routine venipuncture or finger/heel/ear stick for collection of specimen(s).”  However, 99000 may be used to reflect the work involved in the preparation of a specimen prior to sending it to the laboratory (e.g., centrifuging a specimen, separating serum, labeling tubes, etc.).  For in-office tests, you should submit only the appropriate code for the test itself.  Note that Medicare and many other payers consider code 99000 to be a bundled service that is not separately payable.

Coding & Billing Medicare Influenza Vaccines – Q Code Selection

In Uncategorized on October 12, 2011 at 1:14 pm

As 2011 is drawing to a close, and new coding guidelines are being published and disseminated, M.E.D.I.C., Inc. wanted to take this opportunity to alert you to updates regarding seasonal influenza vaccine pricing.  As of September 1, 2011, payment allowances for flu vaccines have changed. 

In 2011, CMS stopped accepting CPT code range 90654-90662 for the influenza vaccine (note that commercial carriers still accept them, but Medicare will not).  Rather, those codes have been replaced by a series of Q codes which relate to the brand name of the vaccine:  Q2035 relates to Afluria; Q2036 relates to Flulavel; Q2037 relates to Fluvirin; Q2038 relates to Fluzine; and Q2039 relates to those not otherwise specified… all are defined as “Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use.”

Per CMS (, the pricing allowance from September 1st, 2011 through August 31st, 2012 will be as follows:  95% of the Average Wholesale Price, as listed below: 

  • Q2035 (Afluria): $11.543
  • Q2036 (Flulaval): $8.784
  • Q2037 (Fluvirin): $13.652
  • Q2038 (Fluzone): $13.306
  • Q2039 (N.O.S.): locally priced

Because the compensation differs for each product, providers must be sure to alert their billing staff/billing company to the specific brand of flu vaccine that is being administered to patients, so that they can ensure that claims are submitted to Medicare with the appropriate corresponding code.  In the event that the Q2039 “not otherwise specified” code is used, the claim will likely be denied, and additional information in the form of visit notes will be sought.  So, please – be sure to provide the brand specificity at the outset to ensure efficient processing and payment of your claims.

Furthermore, in addition to the Q codes, the HCPCS code G0008 for the Administration of the Influenza Vaccine must still be used for the administration of the flu vaccine for all Medicare patients.

Annual Part B deductible and coinsurance amounts do not apply for the influenza virus and the pneumococcal vaccinations. 

All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine.

When billing flu shots to commercial carriers (i.e., non-Medicare), the Q codes are not applicable.  Practices will generally  code the following (but remember, the code used will depend on the route of administration (intramuscular vs. intranasal), the age of patient, the formulation, and whether the vaccine is preservative free, and split or live virus — each of which relate to influenza vaccine codes 90654-90668):

  • CPT 90471 – Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid), and
  • CPT 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use

RAC Approved Issue #1 — Coding Services Supplemental To Principal Procedure Code (Add-On Codes)

In Uncategorized on May 10, 2011 at 9:15 pm

As discussed in the last post, this blog is going to dedicate some time to highlighting all of the approved issues for Region C’s Recovery Audit Contractor — Connolly.  Without further ado, the first item on Connolly’s list of “approved issues,” as identified by Connoly and CMS, which applies to physicians (as opposed to inpatient or outpatient facilities, ASCs, or DME suppliers) is:  the use of an add-on code without the primary code.  This audit issue is applicable to all of the states within Connolly’s Region C purview, and is applies to dates of service 10/1/2007  forward (however, it is important to note that the date of claim subject to a RAC audit cannot exceed three years from the current date — so, all the date of service must be no further back than May 8, 2008 for an audit sent today).

Pursuant to the CMS Manual, and the AMA’s CPT-Professional Edition, an add-on code designates a procedures which is commonly carried out in addition to the promary procedure performed (as distinguished from incidental services that are necessary to accomplish the primary procedure (e.g., lysis of adhesions in the course of an open cholecystectomy), which are not separately billed).  These additional/supplemental codes enable physicians and others to separately identify a service that is performed in certain situations as an additional service, such as additional digit(s), lesion(s), neurorrhaphy(s), vertebreal segment(s), tendon(s), joint(s), or additional time.  These add-on codes are generally readily identified by terminology such as “each additional” or “list separately in addition to code for primary procedure,” or by a “+” symbol.  

Use of an add-on code is only appropriate when the same physician who provided the primary service also provided the additional add-on service.  Additionally, it is imperative that an add-on code never be reported as a stand-alone code — i.e., the add-on code must never be the only CPT code reported, rather, it must accompany the promary procedure code that it represents and enhances.  Finally, the add-on codes must never have the following modifiers appended to them:  -25, -51, or -59.  While all of these elements of the add-on codes are critical to compliant coding, it is the use od the add-on code as a stand alone code – without the primary CPT code – that will trigger a RAC investigation, for billing and subsequent payment of an add-on code without its respective primary code(s), results in unwarranted overpayments, repayment of which will be demanded by the RAC.