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Category Archives: HCPCS code book
New CPT Codes for Medicare | Medicare Timeline
AARP MedicareRx Plans United Healthcare (PDF download)
United healthcare medigap (PDF download)
CIGNA HealthCare Medicare (PDF download)
United Healthcare Medicaid (PDF download)
medicare healthcare (PDF download)
New CPT Codes for Medicare
PDF download:
Transitional Care Management Services – Centers for Medicare …
One face-to-face visit must be furnished within certain timeframes as described
by the following two new. Current Procedural Terminology (CPT) codes (effective
…
Evaluation and Management Services Guide – Centers for Medicare …
CPT codes should be used to bill for E/M services provided in the outpatient …
For purposes of billing for E/M services, patients are identified as either new or.
frequently-asked questions about billing Medicare for transitional care
Jan 1, 2013 … Effective January 1, 2013, Medicare pays for two CPT codes (99495 and 99496)
that are … which are new services beginning January 1, 2013.
Frequently Asked Questions about Transitional Care Management
A2: There are two CPT codes that may be used to report TCM, effective …. the
Webinar, “What’s new in Medicare and Medicaid payment in 2013” hosted on …
FAQ: New CPT Transitional Care Management (TCM) Codes 99495-6
The primary driver in creating two new CPT Transitional Care Management …
codes. The usual process with new codes is further guidance from Medicare …
Medicare Screening Services 2013 – ACOG
99381-99397, effective January 1, 2011, Medicare began covering a new service
, …. to report one of the preventive medicine E/M services CPT codes (99381.
Medicare Payment of Telemedicine and Telehealth Services
Medicare reimbursement for telemedicine or telehealth services is divided … not
bill or receive payment for the following CPT codes: 90805, 90807, and 90809.
2013 Coding Update – American Society for Gastrointestinal …
New CPT and HCPCS codes for reporting preparation of fecal microbiota. …. For
Medicare, CMS has created a new HCPCS code for preparation of fecal …
2012 CPT Coding Changes – American Gastroenterological …
New/Deleted CPT Codes for Abdominal Paracentesis and Peritoneal Lavage. ….
For Medicare beneficiaries, the PT modifier is used for this purpose.
Ch 6 Coding and Billing Basics final – The American Academy of …
In 2013, a new system for diagnosis coding will be implemented: ICD-10-CM. …..
establishes the CPT codes and the Medicare relative values assigned to those …
Tips and Strategies for Billing for Mental Health Services in a …
CPT Codes: CPT codes were developed and are maintained by the American
Medical Association. They are … CPT and HCPCS Codes for Medicare &
Medicaid Payment for Mental Health Services *. *Source: … 2008, two new
Medicare.
AHS’s Headache Coding Corner – A user-friendly guide to CPT and …
Part 6 – Coding Communication: Non-Face-To-Face New CPT Codes for …
Medicare and commercial insurers have not recognized telephone services as
an …
Global Surgery Fact Sheet
Medicare established a national definition of a … For more information, refer to
the “Medicare Claims …. Terminology (CPT) codes 99291 and 99292) unrelated
…
BILLING AND CODING UPDATE 2013
Watch for bullets (new codes) and triangles (revised … CMS has declined their
recommendation and ….. Reference the CPT book and Medicare resources for.
CPT and ICD-9 Coding for Surgical Residents and New Surgeons in …
Jun 15, 2005 … Medicare New Physicians Guide September 2003. Teaching …. For Medicare
payment purposes, all of the CPT codes have been through a …
What’s Covered – CPT Code List – North Dakota Department of Health
Jan 1, 2014 … The following CPT codes have been removed from the What’s … Description of
Services. CPT. $ Rate. Office Visits. New patient; history, exam, …
Diagnostics Reimbursement Quarterly – Quorum Consulting, Inc.
clinical laboratory CPT codes. This meeting is held every year at the CMS Central
Office in. Baltimore, MD, to coincide with the anticipated release of new CPT …
New Cardiothoracic Surgery CPT Codes for 2013 – Society of …
There were several changes to the cardiothoracic surgery CPT codes for 2013. …
cardiac surgery, there are 13 new codes, and one revised code and four deleted
… Medicare. National Total. Facility RVU. Medicare. National Total. Non-Facility.
CPT Code Changes for 2013 Contents – National Council
Mar 7, 2013 … The CPT time standard applies to the new psychotherapy codes. …. on E/M
codes: http://www.cms.gov/Outreach-and-Education/Medicare- …
2013 CPT Coding Changes – American Psychiatric Association
Q: In looking at the 2013 Medicare Physician Fee Schedule, I noticed that
Medicare is … (CMS) chose to implement the new CPT coding structure for
psychiatry …
NCTracks Update: July 18th | North Carolina Medical Group …
New Claims Billing Process for DME National Miscellaneous HCPCS Codes
Effective July 21, 2014, regardless of date of service, claims billed with A9900, B9998, E1399 and K0108 must include the Prior Approval (PA) number as well as the corresponding approved state/local code. This will allow claims to process appropriately when DME providers submit multi-line PA requests with multiple “W” codes (also known as local or state codes) that map to the same national code and submit a single national code multiple times on the same claim.
Click on the image for a larger view
Prior Approval
All of the above listed state/local HCPCS codes along with their corresponding national miscellaneous HCPCS codes require prior approval as of July 21, 2014(regardless of date of service.) This includes claims with Medicare primary insurance. Both the national miscellaneous HCPCS code and the state/local code must be indicated on the Certificate of Medical Necessity and Prior Approval Form (CMN/PA). Please refer to the Prior_Approval_Request_Inquiry CBT course and/or the Prior Approval Medical Participant User Guide in SkillPort for guidelines on how to submit prior approval requests.
Claim Submission
On an 837P enter the PA in REF segment and enter local/state code in the PWK segment. See the 837P Companion Guide for details at https://www.nctracks.nc.gov/content/public/providers/provider-trading-partners.html.
On the NCTracks Provider portal enter the PA # on the Claim Information tab in the Prior Auth # field. The local/state code is chosen from the service line in the Local Procedure Code drop down menu. For additional details, please refer to the forthcoming Job Aid “PA Using Local W Codes” on the Provider User Guides and Training page of the NCTracks Provider Portal, which will be posted shortly.
There is a new EOB 01673 with the description “Required DME local code and/or prior approval number is missing or invalid. Verify DME local code and/or prior approval number and resubmit as a new claim” that will be assigned to the denied claim if any of the following situations occur:
- PA number on claim is missing or invalid
- PA number on claim does not match to an approved corresponding state/local code
- State/local code on claim is missing or invalid
- State/local code on claim does not match to a prior approval
Upon receiving denial reason EOB 01673, review the approval you have on file, correct your claim as needed, and resubmit as a new claim.
For claims submitted prior to this implementation, if you feel you received a denial in error due to a manual pricing and/or national to state code issue, resubmit following these new guidelines. If you feel your payment received in the past was in error due to a manual pricing and/or national to state code issue, submit a replacement claim following these new guidelines.
The coverage criteria for these items have not changed. Refer to Clinical Policy 5A Durable Medical Equipment and Supplies at http://www.ncdhhs.gov/dma/mp/mpindex.htm.
Filed under: News
Salmon Run: Clustering Medical Procedure Codes with Scalding
A colleague pointed out that there exists an inverse use-case to finding outliers in medical claims. This one is to group procedure codes into clusters, or what Health Insurance companies call Episode Treatment Groups (ETG). Essentially an ETG is a way to cluster a group of services (procedures) into a medically relevant unit.
The CMS.gov dataset provides slightly under 16 million anonymized outpatient claims for Medicare/Medicaid patients. Each outpatient record can have upto 6 ICD-9 procedure codes, upto 10 ICD-9 diagnosis codes and upto 45 HCPCS codes. So just like the outlier case, we can derive a measure of similarity between a pair of codes as the average co-occurrence within claims across the dataset.
I decided to use a variant of the DBSCAN clustering algorithm. This post provides some tips on how to implement DBSCAN in a distributed manner – I used the ideas in this post to develop my implementation. The intuition behind my clustering algorithm goes something like this.
We calculate the similarity sAB between a pair of codes A and B as the number of times they co-occur in the corpus. Clustering algorithms need a distance measure, so we treat the distance dAB as the reciprocal of their similarity, ie 1/sAB. The DBSCAN clustering algorithm works by selecting other points around each point that are within a specified distance ε from each other. Candidate cluster centroids are those that have at least MinPoints codes within this distance ε. My algorithm deviates from DBSCAN at this point – instead of finding density-reachable codes I just find the Top-N densest clusters. Density is calculated as the number of codes within a circular area of the mean radius, i.e. N2 / πΣi=0..Nd2. We then calculate the top N densest code clusters – these are our derived ETGs.
The Scalding code below does just this. We simplify a bit by not calculating using some constants such as π but otherwise the code is quite faithful to the algorithm described above.
// Source: src/main/scala/com/mycompany/cmspp/cluster/CodeCluster.scala
package com.mycompany.cmspp.clusters
import com.twitter.scalding.Job
import com.twitter.scalding.Args
import com.twitter.scalding.TextLine
import com.twitter.scalding.Tsv
import scala.io.Source
class CodeCluster(args: Args) extends Job(args) {
def extractPairs(line: String): List[(String,String)] = {
val cols = line.split(",").toList
val codes = (cols.slice(22, 27) // ICD9 procedure code cols
.map(x => if (x.isEmpty) x else "ICD9:" + x)
::: cols.slice(31, 75) // HCPCS (CPT4) procedure cols
.map(x => if (x.isEmpty) x else "HCPCS:" + x))
.filter(x => (! x.isEmpty))
val cjoin = for {codeA <- codes; codeB <- codes} yield (codeA, codeB)
cjoin.filter(x => x._1 < x._2)
}
val Epsilon = args("epsilon").toDouble
val MinPoints = args("minpoints").toInt
val NumClusters = args("nclusters").toInt
val output = Tsv(args("output"))
val dists = TextLine(args("input"))
.read
// compute pair-wise distances between procedure codes
.flatMapTo('line -> ('codeA, 'codeB)) { line: String => extractPairs(line) }
.groupBy('codeA, 'codeB) { group => group.size('sim) }
.map('sim -> 'radius) { x: Int => (1.0D / x) }
.discard('sim)
// group by codeA and retain only records which are within epsilon distance
.groupBy('codeA) { group => group.sortBy('radius).reverse }
.filter('radius) { x: Double => x < Epsilon }
val codeCounts = dists
.groupBy('codeA) { group =>
group.sizeAveStdev('radius -> ('count, 'mean, 'std))
}
// only retain codes that have at least MinPoints points within Epsilon
.filter('count) { x: Int => x > MinPoints }
.discard('std)
val densities = dists.joinWithSmaller(('codeA -> 'codeA), codeCounts)
.map(('mean, 'count) -> 'density) { x: (Double,Int) =>
1.0D * Math.pow(x._2, 2) / Math.pow(x._1, 2)
}
.discard('radius, 'count)
// sort the result by density descending and find the top N clusters
val densestCodes = densities.groupAll { group =>
group.sortBy('density).reverse }
.unique('codeA)
.limit(NumClusters)
// join code densities with densest codes to find final clusters
densities.joinWithTiny(('codeA -> 'codeA), densestCodes)
.groupBy('codeA) { group => group.mkString('codeB, ",")}
.write(output)
}
object CodeCluster {
def main(args: Array[String]): Unit = {
// populate redis cache
new CodeCluster(Args(List(
"--local", "",
"--epsilon", "0.3",
"--minpoints", "10",
"--nclusters", "10",
"--input", "data/outpatient_claims.csv",
"--output", "data/clusters.csv"
))).run
Source.fromFile("data/clusters.csv")
.getLines()
.foreach(Console.println(_))
}
}
|
I ran this locally with 1 million claims (out of the 16 million claims in my dataset) and got results like this:
And thats all I have for today. I’d like to point out a new book on Scalding, Programming MapReduce with Scalding by Antonios Chalkiopoulos. I was quite impressed by this book, you can read my review on Amazon if you are interested.
Centers for Medicare and Medicaid Services (CMS) Approves the …
From the American Telemedicine Association:
July 8,2014 TO: ATA Members FROM: Jonathan D. Linkous, CEO, American Telemedicine Association I am happy to report that the Centers for Medicare and Medicaid Services (CMS) approved several requests by the American Telemedicine Association to expand healthcare services that are eligible for reimbursement. In the agency’s proposed Medicare rulemaking for 2015, coverage for remote services have been proposed for medical services, remote testing and, for the first time, non-face-to-face chronic care services. On a personal note, after twenty years of hard fought work, the soaring of interest and support for telemedicine has been enormously rewarding. This latest success adds to a string of recent victories by ATA to expand telemedicine services – thanks to our staff, our Board and our members. As a result, Medicaid coverage of telemedicine has increased in 20 states guided in part by ATA’s set of best practices for state telehealth programs. Twenty-one states now mandate private insurance coverage, double over the past two years, largely due to our work with such organizations as the NOBEL Women and the efforts of many of our members. ATA is now partnering with many of the world’s leading medical societies, large employers and insurers to create and deploy unique telemedicine practice guidelines. Finally, ATA is working directly with members of Congress both Republican and Democrat as well as leaders in other countries, to further our efforts to improve quality, access, equity and affordability of healthcare throughout the world. We are winning and should be proud of ourselves! — Jon The new CMS proposals are slated to go into effect January 1, 2015. The 609-page notice of proposed rulemaking is available athttp://www.ofr.gov/OFRUpload/OFRData/2014-15948_PI.pdf. Pages 139-150 are for telehealth services and 170-185 for chronic care management. This notice will be published in the Federal Register of July 11 and open for comment on or before September 2. Details are below. Services to be covered when provided by telehealth —————————————————————— Specifically, CMS agreed to add the following services that can be furnished to Medicare beneficiaries under the telehealth benefit: • Psychotherapy services: CPT codes 90845 (Psychoanalysis); 90846 (family psychotherapy (without the patient present); and 90847 (family psychotherapy (conjoint psychotherapy) (with patient present) • Prolonged services in the office: CPT codes 99354 (prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (list separately in addition to code for office or other outpatient evaluation and management service); and, 99355 (prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code for prolonged service) • Annual wellness visit: HCPCS codes G0438 (annual wellness visit; includes a personalized prevention plan of service, initial visit; and, G0439 (annual wellness visit, includes a personalized prevention plan of service, subsequent visit) Psychological Testing —————————– In addition, CMS made explicit that Medicare’s telehealth restrictions do not apply to CPT codes 96103 (psychological testing) and 96120 (neuropsychological testing). Therefore, these computerized testing services can be furnished remotely without the physician being present and are billable using the same process as other physicians’ services. Chronic Care Management ——————————— For the first time, CMS is proposing reimbursement criteria for non-face-to-face chronic care management (CCM) services, defined as a unique, covered service designed to pay separately for non-face-to-face care coordination services furnished to Medicare beneficiaries with two or more chronic conditions. CMS discussed this new policy in 2013 but did not include a specific reimbursement proposal. The specific code for this service (tentatively called GXXXI) is defined as “chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 20 minutes or more; per 30 days” A payment rate of $41.92 could be billed no more frequently than once per month per qualified patient. Eligible CCM services must be furnished with the use of an electronic health record or other health IT or health information exchange platform which includes an electronic care plan that is accessible to all providers within the practice, including being accessible to those who are furnishing care outside of normal business hours and is available to be shared electronically with care team members outside of the practice. Finally, CMS seeks comment on any changes to the scope of service or billing requirements for CCM services that may be necessary to ensure that the practitioners who bill for these services have the capability to furnish them and that we can appropriately monitor billing for these services.
Anolinx » Job Opening- Medical Informaticist
Good Medicine: Five Reasons to Outsource Medical Coding …
Health care is getting complex. And between the provider and the payer, the patient is getting increasingly concerned and confused about diagnosis, treatment and billing. Current Procedural Terminology (CPT) codes have come to everyone’s rescue. CPT is the uniform code that describes medical, surgical, procedural and diagnostic services provided by healthcare providers. Even a small error in coding can lead to incorrect treatment and payments that could prove disastrous. To ensure this does not happen and to ensure the correct management and analysis of patient billing and provider reimbursement, everyone needs to be ultra-careful about how services are coded.
Importance of getting codes right
The good news is that the codes for medical conditions and treatment are maintained by the American Medical Association (AMA). Coders need to be familiar with the published AMA list and assign them to diagnosis and treatment. The bad news is that medical science is evolving very rapidly forcing the AMA to generate a massive list of new codes each year. This means that without being on top of the latest AMA codes it is impossible to be accurate. Not keeping pace with AMA assigned codes is guaranteed to make reimbursements go off the rails.
However, there is regulatory pressure to keep things on track. Regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) must be adhered to and privacy guidelines for the management of medical records under the American Health Information Management Association (AHIMA) have to be maintained. This makes CPT coding a complex job, better left to professionals and experts who have domain understanding in a variety of areas such as pathology, internal medicine, oncology, neurology, cardiology, radiology, pediatrics, etc
What exactly is the downside of inaccurate CPT coding? Poor coding leads to billing errors, insurance denials, delayed reimbursement for care givers, claims rework, patient insecurity and regulatory penalties. This makes accurate coding one of the central pillars of business success in the healthcare industry.
CPT codes play another critical role. They help payers identify medical fraud that has been on the rise and is a matter of growing concern for the industry. For example, a doctor may charge a patient for chest congestion when all a patient has is a sore throat. In the US alone the federal government recovered $4.3 billion through healthcare fraud investigations in fiscal 2013 according to a report released by the US Department of Health and Human Services (HHS) and the Department of Justice[i]. In essence, CPT codes are a dissuasive measure for potential fraud.
From a patient perspective, accurate CPT codes can literally make the difference between life and death. The codes capture patient symptoms, diagnosis, treatment and condition, assuring continuity and accuracy of future care. And for patients, who are invariably suspicious of medical costs, CPT codes become a simple and dependable way to check across doctors if the cost of care is indeed right or if they are being overcharged. These codes then become a way to negotiate lower care pricing.
Improving patient care through outsourcing
Despite its importance, providers and payers cannot afford to let coding become a distraction from their core capabilities of enabling patient care. Outsourcing coding makes sense to help keep patients and health care providers healthy.
Here are the Top 5 Reasons to Outsource CPT Coding:
- Control operating costs. There are a number of coding tools available, such as the Healthcare Common Procedure Coding System (HCPCS) and ICD-9 along with IT tools such as Kareo, E-Clinical Works and Practice Admin. These are critical to execution speed, accuracy and cost. For providers, acquiring, maintaining and upgrading these tools is expensive and an unnecessary management overhead. They can avoid the risk of technological obsolescence by outsourcing CPT coding.
- Focus on core business. Fast and accurate medical coding depends on an understanding across medical specialties and a deep understanding of compliance requirements. Coders who are certified by bodies such as the American Association of Professional Coders (AAPC) to maintain industry-recognized standards ensure a high level of accuracy. Healthcare providers will not be able to gain the ROI on investments required to maintain a team of dedicated trained and certified coding professionals. Recruiting and retention costs too can be avoided by outsourcing the task. Instead, by outsourcing, caregivers can focus on their core business.
- Reduce claims denials. Poor coding and data inaccuracies result in claims being denied and potential revenue loss. This increases rework of claims and creates delays in reimbursement. Outsourcing the task to experts reduces coding errors and in the event rework is required, it is done substantially faster. This is a large problem that caregivers and payers need to address. According to the US Government Accountability Office, aggregate application denial rate across the US was 19 percent though the percentage depended on the insurer. Some insurers showed an average rate of higher than 40 percent[ii].
- Value added services. Outsourcers are well positioned to provide caregivers regular reports related to claims status and their progress. These reports could also help identify areas of inefficiency in managing coding productivity and outcomes.
- Elastic pay-as-you-go service. Not only can an outsourcer ensure rapid deployment of coding services but also ensure that the service is elastic and aligned to business needs. It is extremely difficult for providers to shrink or expand their coding teams based on business trends and other imperatives. With the process being outsourced, care providers don’t need to worry about volume or infrastructure required to manage those volumes.
Being able to focus on patient care helps create healthier, better informed patients and also represents a key step to building a healthier health care system. Recognizing these benefits, isn’t it time to consider outsourcing CPT coding?
[i] http://www.modernhealthcare.com/article/20140226/NEWS/302269955
[ii] http://www.gao.gov/products/GAO-11-268
Skype ≠ Telemedicine | Nicoletti Notes
I got a call from a vendor trying to develop a video conferencing product for a physician to use to talk to a patient who is at home. He said “I’m having trouble finding codes for telemedicine that the doctor can use.” Aren’t we all.
Talking to your patient using a secure video connection doesn’t meet the criteria for telehealth as developed by CMS. There are no current CPT codes that describe that situation. There is no way to report it to the insurance company and be reimbursed for the service. There are CPT codes for non-face-to-face services such as phone calls and on-line medical evaluations, but they don’t describe a video discussion with a patient and have a status indicator of non-covered. (Insurance won’t pay, bill the patient). Interprofessional telephone/internet consultation codes describe physician-to-physician consults and have a status indicator of bundled. (No one will pay.)
What about CMS’s telehealth benefit? Telehealth is a covered service between a patient in an originating setting that is in a Health Professional Shortage Area or in a county outside of a Metropolitan Statistical Area. The originating site is a physician office, hospital, critical access hospital, rural health clinic, federally qualified health center, skilled nursing facility or community mental health center. Home is not one of the locations. The patient is located in one of these settings and their provider requests that a distant health professional assess and treat the patient through video-conferencing. There are specific CPT codes that may be reported in these instances. Telehealth as currently defined does not mean that a physician or healthcare professional uses a video-conference to treat their own patient.
Now, you’ll tell me we are moving from fee-for-service medicine into caring for our patients in a way that doesn’t require them to drive to our offices. We have mobile apps for monitoring their well being, and our goal is to keep them healthy and not consuming healthcare resources. (That’s a euphemism for driving up costs we’re at risk for.) But, most of us aren’t there yet. Most of our revenue comes from fee-for-service and there is no CPT or HCPCS code that currently describes a physician using video-conferencing to talk with their patient.
You can download CMS’s telehealth fact sheet http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf
The Modifier -25, -24 – medical claim
I am writing this article again as a suggestion from many of my readers on my blog. This article is more comprehensive in a way that scenarios were cited to have a bigger look on the proper use of some of these important modifiers.
In this article, I will be describing the medical claims modifiers – Modifier -25, -24, -51, -57, -59, -26.
Modifier -25, 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service:
This modifier must be appended with an E/M service. This is the modifier you will need to use with the evaluation and management service done on the same day with other procedure done by the same physician. It has to be above and beyond the usual preoperative and postoperative encounter with the procedure. In fact, by using this modifier, it doesn’t have to have a different diagnosis reported. The most important thing is that, the E/M level should meet its key components or if it is selected based on time with the patient (counseling and coordination). You have to be careful in using this modifier. It must meet medical necessity. As you know, there are procedures that already includes all other care and management.
Let’s describe this modifier 25:
A patient came in for her monthly follow up for her chronic back pain. At the same time, patient was complaining with severe headache. The pain doctor performed bilateral occipital block on the patient at the time of service. You will append modifier 25 for the E/M code to indicate that both services were rendered on the same day.
You don’t use modifier 25 with E/M encounter that resulted to Decision for Surgery (we have another modifier for this!)
Modifier -24, 24: Unrelated evaluation and management service by the same physician during postoperative period.
As the modifier indicates, this is another modifier that you can only append with an E/M counter. It indicates that the E/M encounter is not related during the global period.
Let’s describe this modifier 24:
A pain specialist performed facet nerve destruction for the patient. During the normal, postoperative global period, the patient came in to the office with severe knee pain due to fall on ice as evidenced by the patient’s subjective information. The pain specialist will then report that E/M encounter with the patient by appending modifier 24 to indicate that encounter is not related during the postoperative global period.
This modifier, like modifier 25 has no restriction as with the level of E/M code as long as it meets medical necessity, all its components or are time-based.
Modifier -57, 57: Decision for Surgery:
An Evaluation and Management service resulted in the initial decision to perform surgery during the E/M encounter.
Let’s describe this modifier:
An OB/GYN sees a patient who complains with severe abdominal pain. It turned out (through ultra sound, radiology and all other diagnostic testing and documentations), the patient is having an ectopic pregrancy. The OB/GYN performs the laparoscopic surgery on the same day. The E/M encounter will then be reported with modifier 57 which resulted to decision for surgery. The laparoscopic surgery should also be reported as performed on the same day without a modifier.
Modifier -50, 50: Bilateral Procedure
You will append modifier 50 for procedures that are obviously billable as bilateral (or two sides, both sides), performed on the same day, the same operative session, on identical anatomical sites, organs (arms, legs, spine).
A Facet Nerve block is unilateral (can be billed as bilateral). When using a modifier 50, make sure you only bill for one unit on the claim form since there is only 1 procedure is performed bilaterally. Though guidelines from other payers may differ. They may require you to list it twice (line 1 and line 2 on the claim form). You have to be responsible to clarify this with your payors.
You use this modifier with add-on codes too! Do not use this modifier with procedures which are already described as bilateral procedures.
Modifier -51, 51: Multiple Procedures
This modifier is used when reporting multiple procedures performed by the same physician on the same day. Do not use this modifier for “add-on” codes (see appendix D of the CPT Code book). Do not use this modifier for codes with “modifier -51 exempt” symbol (see appendix E of the CPT Code book). Do not use this modifier with an E/M code. This modifier can only be used by the same physician on the same day who performed the procedure.
Coding tip: List the highest reimbursable code (after the main procedure code) based on the fee schedule.
Modifier -59, 59: Distinct Procedural Service
Description of Modifier -59: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.
Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.
Use this modifier only if the other procedure is a separately identifiable procedure code. Procedure that is distinct and can be described as independent procedure, on separate anatomical site, lesion, injury site, different organ system, and different session. Do not use this modifier for E/M code.
Modifier -26, 26: Professional Component
This modifier is used only for the professional component (physician) of a service or a procedure. Certain procedures are a combination of both professional and technical component. By using modifier 26, it indicates that procedure being reported as professional component only.
Professional Component versus the Technical Component. By illustration, procedures rendered at a facility such as outpatient hospital or ASC, these equipments are facility-owned. The facility will then report the technical component for such service while the physician will report the professional component for the that procedure. One very good example, the physician performs Paravertebral Facet Block under Fluoroscopic guidance using CPT code 77003. The physician will report the fluoro with modifier 26 for his/her professional component. While the facility will report the the same procedure with modifier -TC for the technical component.
Modifier -LT or -RT are used to indicate a Left or Right side or anatomical site. So if the pain specialist performed Left Cervical Facet Block, you will append a modifier -LT to report this procedure.The above modifiers are used to describe your claims for the services performed on the patient for appropriate payment. Always consult your local careers and third party payors for local determination, policies and guidelines on these modifiers. Looking at the edits is also very important!
About the Author:
Ms. Pinky is a mom of 3 school children. She is a Systems Engineer, a Technology Researcher and an Independent Medical Billing and Coding Consultant. She and her family is well-traveled all over the world!
Her blogs and websites focuses on stay-at-home moms, dads and students who wants to work at home, build homebased business http://www.mommyisworkingathome.com.
Visit her Interesting Site on Asian Travels and Destinations. Discover Asia’s Culture and Great Food! at http://www.goingplacesinasia.com