Audiology billing Guide - CPT code list

August 10, 2016, 12:43 am

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Policy Definition

Audiology is the study of hearing and hearing disorders and includes habilitation and rehabilitation for individuals who have hearing loss

Provider Billing Guidelines and Documentation
Coding3

Code Description Comments

92550–92588 Audiometric tests Bill once with a count of one

92597 Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech

92601–92604 Diagnostic analysis of cochlear implant; with programming; subsequent reprogramming

92605 Evaluation for prescription of non speech generating augmentative and alternative communication device Reimbursed for facility only

92606 Therapeutic service(s) for the use of non speech generating device, including programming and modification

92607–92609 Speech generating and non-speech generating augmentativeand alternative communication device-related services
To bill professional component of service use CPT; to bill DME component, refer to Durable Medical Equipment (DME).

92620, 92621 Evaluation of central auditory function, with report

92625 Assessment of tinnitus

92626 Evaluation of auditory rehabilitation status; first hour

92627 Evaluation of auditory rehab status; ea add’l 15 minutes Bill in conjunction with 92626

92630 Auditory rehabilitation; pre-lingual hearing loss

92633 Auditory rehabilitation; post-lingual hearing loss

92700 Unlisted otorhinolaryngological service or procedure Submit documentation of services rendered

Modifiers

• When billing for monaural hearing aids, a RT or LT modifier in the second modifier field is required for payment. Claims submitted without the RT or LT modifier may be denied.

• When billing for a binaural hearing aid the RT or LT modifier is not required. Claims submitted with a RT or LT modifier will be denied as inappropriately billed.

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Use of the AT modifier for chiropractic billing

August 13, 2016, 11:28 pm

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Background

In 2014, the comprehensive error testing program (CERT) that measures improper payments in the Medicare feefor- service program reported a 54 percent error rate for chiropractic services. The majority of those errors were due to insufficient documentation/documentation errors. Year after year these error rates appear. CMS is providing an explanation of the AT modifier to assist providers with correctly documenting claims for chiropractic services provided to Medicare beneficiaries. The active treatment (AT) modifier defines the difference between active treatment and maintenance treatment. Effective October 1, 2004, the AT modifier is required under Medicare billing to receive reimbursement for CPT® codes 98940-98942. For Medicare purposes, the AT modifier is used only when chiropractors bill for active/ corrective treatment (acute and chronic care). The policy requires the following:

1. Every chiropractic claim for CPT® 98940/98941/98942, with a date of service on or after October

1, 2004, should include the AT modifier if active/corrective treatment is being performed; and

2. The AT modifier should not be used if maintenance therapy is being performed. MACs deny chiropractic claims for CPT® 98940/98941/98942, with a date of
service on or after October 1, 2004, that does not contain the AT modifier. The following categories help determine coverage of treatment. (See the Necessity for Treatment, Chapter 15, Section 240.1.3, of the Medicare Benefit Policy Manual (pages 226-227)).

1. Acute subluxation: A patient’s condition is considered acute when the patient is being treated for a new injury (identified by X-ray or physical examination).

the result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient’s condition.

2. Chronic subluxation: A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition); however, the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered. Both of the above scenarios are covered by CMS as long as there is active treatment which is well documented and improvement is expected.

Maintenance: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when maintenance therapy has been provided.

Be aware that once the provider cannot determine there is any improvement, treatment becomes maintenance and is no longer covered by Medicare.

Key points

For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However, the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, MACs may deny if appropriate after medical review determines that the medical record does not support active/corrective treatment.

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ICD-10 codes that support medical necessity for chiropractor services

August 15, 2016, 11:22 pm

≫ Next: CPT CODES 81001, 81002, 81003 AND 81025

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The chiropractic local coverage determinations (LCDs) for MACs include ICD-10 coding Information for ICD-10 codes that support the medical necessity for chiropractor
services. There may be additional documentation information in your LCD. There are links to the chiropractic LCDs in the Additional information section of this article.

The group 1 (primary) codes are the only covered ICD-10-CM codes that support medical necessity for chiropractor services.

*** Primary: ICD-10-CM codes (names of vertebrae)

*** The precise level of subluxation must be listed as the primary diagnosis.

The groups 2, 3, and 4 ICD-10-CM codes support the medical necessity for diagnoses and involve short, moderate, and long term treatment:

*** Group 2 codes: Category I - ICD-10-CM diagnosis (diagnoses that generally require short-term treatment)

*** Group 3 codes: Category II - ICD-10-CM diagnosis (diagnoses that generally require moderate-term treatment)

*** Group 4 codes: Category III - ICD-10-CM diagnosis (diagnoses that may require long-term treatment) ICD-10 codes that do not support medical necessity are all ICD-10-CM codes not listed in LCDs under ICD-10-CM codes that support medical necessity.

Additional information

If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/index.html under - How Does It Work.

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CPT CODES 81001, 81002, 81003 AND 81025

August 17, 2016, 12:43 am

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CPT CODES: 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy

81001 automated, with microscopy - Fee schedule amount $3-$4

81002 non-automated, without microscopy Fee schedule amount $3-$4

81003 automated, without microscopy Fee schedule amount $3-$4

81005 Urinalysis, qualitative or semi-quantitative, except immunoassays Fee schedule amount $3-$4

81007 Urinalysis, bacteriuria screen, by non-culture, commercial kit Fee schedule amount $3-$5

81015 Urinalysis, microscopic only Fee schedule amount $3-$5

81025 Urine pregnancy test, by visualcolor comparison methods Fee schedule amount $8-$11

81050 Volume measurement for timed collection, each Fee schedule amount $4-$5

Indications and Limitations of Coverage and/or Medical Necessity

Urinalysis is one of the most useful indicators of health and disease, and is especially helpful in the detection of renal or metabolic disorders. It aids in diagnosing and following the course of treatment in diseases of the kidney and urinary system and in detecting disorders in other parts of the body such as metabolic or endocrinologic abnormalities in which the kidneys function normally.

The components of a urinalysis include an evaluation of physical characteristics (color, odor, and opacity); determination of specific gravity and pH; detection and measurement of protein, glucose, and ketone bodies; and examination of sediment for blood cells, casts, and crystals. Some laboratories include screening for leukocyte esterase and nitrate and do not perform a microscopic examination unless one of the chemical screening (macroscopic) tests is abnormal or unless a specific request for microscopic examination is made.

Diagnostic laboratory methods include visual examination; reagent strip screening; refractometry for specific gravity; and microscopic inspection of centrifuged sediment.

Urinalysis can be performed either by automated instruments or the use of tablets, tapes or dipsticks. Dipsticks are chemically impregnated reagent (reactive) strips that allow for quick determination of pH, protein, glucose, ketones, bilirubin, hemoglobin, nitrate, leukocyte esterase, and urobilinogen. The tip of the dipstick is impregnated with chemicals that react with specific substances in the urine to produce colored end products. Color standards are provided against which the actual color can be compared. The reaction rates of the impregnated chemicals are standard for each dipstick, and color changes must be matched at the correct time after each stick is dipped into the urine specimen.

Normally, the color is straw to dark yellow, specific gravity 1.005-1.035, pH 4.5-8.0, normal urobilinogen, and negative for protein, glucose, ketones, bilirubin, hemoglobin, erythrocytes (RBCs), Nitrite (bacteria), and leukocytes (WBCs).

A urinalysis study will be considered medically reasonable and necessary for the following conditions:

- Clinical symptomatology which may indicate a urinary system condition such as urgency; frequency; dysuria; flank pain; suprapubic discomfort; hematuria; fever of unknown origin; chills; swelling in the periorbital, abdominal and pedal areas of the body; heavy foaming urine, etc.;

- Physical examination reveals distended bladder with associated symptoms listed above;

- Patients on medications that are nephrotoxic (e.g., aminoglycosides); or

- Evaluation of patient’s response to treatment, such as antibiotic therapy for a UTI.

Conditions in which a urinalysis may be medically necessary are not limited to the following: urinary tract infection, glomerulonephritis, kidney stone, interstitial nephritis, nephrotic syndrome, acute renal failure, polynephritis, diabetic neuropathy, polycystic kidney disease, hyperplasia of prostate, rheumatoid arthritis, and renoparenchymal hypertension.

Even though a patient has a condition stated above, it is not expected that a urinalysis be performed frequently for stable chronic symptoms that are associated with that disease.

CPT CODE(S) TEST NAME IN THE MANUFACTURER LAB

81000 — Urinalaysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy

81001 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy

81002 Dipstick or tablet reagent urinalys non-automated for bilirubin, glucose, hemoglobin, ketone, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen

81003 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy

Various Screening of urine to monitor/diagnose various diseases/conditions, such as diabetes, the state of the kidney or urinary tract, and urinary tract infections

Other Urine Tests

If the lab performs urinalysis by another method, you might use one of the following codes:

** 81005 — Urinalysis; qualitative or semiquantitative, except immunoassays

This code describes a test that is different from 81002 or 81003 because the lab uses a colorimetric analyzer rather than a dipstick, and because the test results may be semiquantitative. You also should distinguish this code from urinalysis by immunoassay (83518, Immunoassay for analyte other than infectious agent antibody or infections agent antigen; qualitative or semiquantitative, single step method [e.g., reagent strip]).

** 81007 — Urinalysis; bacteriuria screen, except by culture or dipstick

Report this code if the lab screens for bacteria in the urine using a method other than dipstick or culture. For dipstick use 81000 or 81002; for culture see 87086 and 87088 (Culture, bacterial … urine).

** 81015 — Urinalysis; microscopic only

Use this for stand-alone urine microscopy — if the lab performs other urine tests use the complete code such as 81000 or 81001.

Billing and Coding Guidelines and Tips

Note that the tests mentioned on the first page of the list attached to CR8212 (CPT codes: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.

Note: Medicare contractors will not search files to either retract payment or retroactively pay claims based on the changes in CR8212, however, claims should be adjusted if you bring them to your contractor’s attention.

Use CLIA modifier: If the lab that performs the test operates under a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver, you should report most urinalysis tests with modifier QW (CLIA waived test). Exception: Because it is the simplest urine dipstick (manual, without microscopy), 81002 is one of the original CLIAwaived tests and does not require modifier QW.

Example: The physician-office lab performs urinalysis for ketones, protein, hemoglobin, and glucose using the Bayer Clinitek Status Urine Chemistry Analyzer.

Solution: Because the lab uses the automated analyzer for common constituents, report the service as 81003-QW.

Don’t combine 81015 with 81002 or 81003.

Pregnancy test: For a colorimetric urine pregnancy test, report 81025 (Urine pregnancy test, by visual color comparison methods).

Services billed to Medicare must be documented as billed and be medically necessary. Without documentation the service was performed, no payment can be made. Periodic self audits of your Medicare billing and documentation is recommended to avoid this type of error.

UnitedHealthcare follows ACOG coding guidelines and considers CPT laboratory codes 81000 and 81002 as included in the global antepartum or global OB service when submitted with an OB diagnosis code in an office setting.

The following services are included in the global obstetrical package related to both vaginal and Caesarean delivery and will not be reimbursed separately when performed by the OB provider.
• Pregnancy test (CPT codes 81025, 84702, 84703

As noted in the Provider Manual, EmblemHealth uses manifold types of commercially available claims review software to support the correct digest of proclaim that result in ingenuous, widely recognized and transparent payment policies.* One of these policies hasten CPT code 81002 and CPT code 81003 (Urinalysis, by dip stick or tablet test) when recital with an Evaluation and Management service (e.g., CPT codes 99201-99205, 99211-99215 and 99381-99397). CPT digest 81002 and 81003 will not be separately reimbursed unless Modifier 25 is annex to the E/M service indicating that a diagnostic, non-screening, urinalysis was transact.

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CRITICAL CARE SERVICES (CODES 99291-99292)

August 20, 2016, 11:47 pm

≫ Next: CPT CODE 99243 - Office visit consultation level 3

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A. Use of Critical Care Codes

Pay for services reported with CPT codes 99291 and 99292 when all the criteria for critical care and critical care services are met. Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.

Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.

Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.

Consult the American Medical Association (AMA) CPT Manual for the applicable codes and guidance for critical care services provided to neonates, infants and children.

B. Critical Care Services and Medical Necessity

Critical care services must be medically necessary and reasonable. Services provided that do not meet critical care services or services provided for a patient who is not critically ill or injured in accordance with the above definitions and criteria but who happens to be in a critical care, intensive care, or other specialized care unit should be reported using another appropriate E/M code (e.g., subsequent hospital care, CPT codes 99231 - 99233).

As described in Section A, critical care services encompass both treatment of “vital organ failure” and “prevention of further life threatening deterioration of the patient’s condition.” Therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient’s bedside emergently, this is not a requirement for providing critical care service. The treatment and management of the patient’s condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration (i.e., the patient shall be critically ill or injured at the time of the physician’s visit).

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CPT CODE 99243 - Office visit consultation level 3

August 23, 2016, 11:23 pm

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CPT CODE 99243 - Office consultation for a new or established patient

Fee amount - In the range of $95 - $120

99241 Office consultation for a new or established patient, which requires these three key components:

• a problem focused history;
• a problem focused examination; and
• straightforward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Billing and Coding Guidelines

The Centers for Medicare and Medicaid Services’ (CMS) decision as of January 1, 2010 to no longer reimburse physicians for CPT consultation codes 99241-99245 or 99251-99255.

In summary, CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and management code (99201-99215 or 99381-99397) rather than a consultation code for Medicare claims depending on the status of the patient (new vs. established).

Per CMS, a physician who sees a patient in the hospital should bill an "initial hospital care" code (99221-99223) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial hospital service allowing the Medicare Administrative Contractor (MAC) to differentiate between the admitting physician and other physicians providing care. All physicians should use the subsequent hospital care codes (99231-99233) for their follow-up care.

Likewise, per CMS, a physician who sees a patient in a skilled nursing facility should bill an “initial nursing facility care” code (99304-99306) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial nursing f facility care service, allowing the MAC to identify the physician as the admitting physician of record who is overseeing the patient’s care. All physicians should use the subsequent nursing facility care codes (99307-99310) for their follow-up care.

CPT codes 99241-99245 and CPT 99251-99255 have a status indicator of “I” in the January 2010 National Physician Fee Schedule. The status indicator of “I” is defined as:
“I” = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.

For Commercial plans, there will be no change in reimbursement for CPT codes 99241-99245 and 99251-99255 at this time. Physicians may continue to submit claims for these services, and will be reimbursed according to UnitedHealthcare payment policies.

For example UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP® MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, these plans will follow CMS regulations and implement the change, effective January 1, 2010. The change also includes the revalued relative-value units (RVUs) for E&M CPT codes and a new coding edit, consistent with CMS, to deny the CPT consult code as a non-payable service.

For AmeriChoice Medicaid health plans, in state Medicaid plans that follow Medicare rules for their fee schedules, AmeriChoice will be aligning with CMS and implement the change, effective January 1, 2010.

For all other Medicaid states, AmeriChoice will follow the UnitedHealthcare commercial position and continue to pay for the consult codes, until directed by each state to pursue other strategies.

Insurance will consider services when resubmitted with the recommended new or established evaluation and management code (99201-99205; 99281-99285; 99221-99223, 99304-99306) as per CMS guidelines for physicians who see patients in the office or an outpatient/inpatient setting.

This policy shall apply to participating and non-participating professional providers.

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Denial process

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

CPT CODE 99243 has to be rebilled as 99203, 99213 or 99283 for Medicre and Medicare HMOs.

BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:

99241 to 99212
99242 to 99212
99243 to 99213

CPT CODE 99243 - Office visit consultation level 3

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CPT CODE J3301 - Kenalog-40 Injection billing Guide

August 27, 2016, 2:59 am

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CPT CODE J3301 - Kenalog-40 Injection

Kenalog-40 Injection (triamcinolone acetonide injectable suspension, USP) is a synthetic glucocorticoid corticosteroid with anti-inflammatory action.

Each mL of the sterile aqueous suspension provides 40 mg triamcinolone acetonide, with 0.66% sodium chloride for isotonicity, 0.99% (w/v) benzyl alcohol as a preservative, 0.63% carboxymethylcellulose sodium, and 0.04% polysorbate 80. Sodium hydroxide or hydrochloric acid may be present to adjust pH to 5.0 to 7.5. At the time of manufacture, the air in the container is replaced by nitrogen.

Disputed Code : J3301
NDC# 00003-029-320
Maximum Allowable - $8.678

How to bill J3301 with correct units

J3301 triamcinolone acetonide, (Kenalog-10, Kenalog-40) per 10 mg
Your bottle says Kenalog 40 =40 mg/ml

If you use 0.25 cc 10 mg/40 mg = 1 Unit
If you use 0.5 cc 20 mg/40 mg = 2 Units
If you use 0.75 cc 30 mg/40 mg = 3 Units
If you use 1.0 cc 40 mg/40 mg = 4 Units

How to calculate the NDC units?
Billing the correct number of NDC units for the corresponding HCPCS/CPT codes on your claims is essential. There are two ways to calculate NDC units:

Option 1 – Use Our Online NDC Units Calculator Tool

Contracted providers may access the online NDC Units Calculator Tool for assistance with converting HCPCS or CPT units to NDC units. This user friendly tool is available to payer contracted providers at no cost.

Option 2 – Calculate the NDC Units Manually

If you prefer to calculate the NDC units manually, there are several steps you will need to take. Here is a sample manual calculation

[Ciprofloxacin IV, NDC 00409-4765-86, 1200 MG (1 day supply)]:

The amount of the drug to be billed is 1200 MG, which is equal to 6 HCPCS/CPT units.
The NDC unit of measure for a liquid, solution or suspension is ML; therefore, the amount billed must be converted from MG to ML.

According to the NDC description for NDC 00409-4765-86, there are 200 MG of ciprofloxacin in 20 ML of solution (200 MG/20 ML).

Take the amount to be billed (1200 MG) divided by the number of MG in the NDC description (200 MG). 1200 ÷ 200 = 6

Multiply the result (6) by the number of ML in the NDC description (20 ML) to arrive at the correct number of NDC units to be billed on the claim (120). 6 x 20 ML = 120

When submitting NDCs on my claim, what other information need to include?

When submitting NDCs on professional/ancillary electronic (ANSI 837P) or paper (CMS-1500) claims, you must also include the following related information in order for your claim to be accepted and reviewed for possible benefits at the NDC level:

o The applicable HCPCS or CPT code

o Number of HCPCS/CPT units

o NDC qualifier (N4)

o NDC unit of measure (UN, ML, GR, F2)

o Number of NDC units (up to three decimal places)

Note: As a reminder, you also must include your billable charge.

Where to enter NDC data on electronic claim (ANSI 5010 837P) transactions?

Here are general guidelines for including NDC data in an electronic claim:

Field Name	Field Description	Loop ID	Segment
Product ID Qualifier	Enter N4 in this field	2410	LIN02
National Drug Code	Enter the 11-digit NDC billing format assigned to the drug administered	2410	LIN03
National Drug Unit Count	Enter the quantity (number of NDC units)	2410	CTP04
Unit or Basis for Measurement	Enter the NDC unit of measure for the prescription drug given (UN, ML, GR, or F2)	2410	CTP05

Note: The total charge amount for each line of service also must be included for the Monetary Amount in

Loop ID, Segment SV102.

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URIBEL - Drug usage, cost, warning and precautions

August 31, 2016, 4:54 am

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URIBEL- methenamine, sodium phosphate, monobasic, monohydrate, phenyls alicylate, methylene blue, and hyoscyamine sulfate capsule

Uribel is a medicine mainly used to cause relief for the pain and discomfort when urinating as well as the frequent urge to urinate. It is also used to help reduce the chance of infection after a medical procedure in the urinary tract. Uribel is mainly made of two components- Methenamine and Salicylate. Patients who have a tendency to have cramps or spasms in their urinary tract are generally prescribed to use this medicine, however, there might be side effects to it so you must use this if only prescribed by a doctor. You are not able to access this medicine without a prescription anyways; just make sure to use as directed. Keep in mind that complications may arise in small children so it is better not to use this medication for children.

As mentioned earlier, Uribel is made of two major ingredients. The Methenamine is actually a type of antibiotic. There is another variant of this called Methylene blue which is antiseptic in nature. Both of these two are used to help prevent the growth of bacteria in urine and thus it will typically reduce the chance of any infection. Salicylate on the other hand is kind of an Aspirin. It helps to reduce pain and is what helps in giving relief to the user. It also has some additional ingredients like sodium phosphate and benzoic acid which are what helps to make the urine more acidic. What the acidic nature of urine helps with is to make the methenamine work more efficiently. All of these different ingredients work together to give Uribel the helping abilities it has.

The dose and use of Uribel tends to vary from person to person depending on their age, symptoms, nature of ailment etc. Normally this medicine is to be taken orally and with a full glass of water; it is highly advisable not to lie down for at least ten minutes after taking this medication. Some may face stomach aches or pains which is quite typical. If that happens to be the case, then it is recommended to then take Uribel with some food or a meal. The normal frequency when it comes to the dosage of this medicine is four times a day, but it may vary according to the symptoms. The medicine usually takes 1 or 2 days to start the seeing improvement in your condition, so if you do not see any improvement even after 2 to 3 days of use, it is important to with your doctor since Uribel might not be the right medication for you. Also if you face pain or any burning sensation while urinating, consult your doctor immediately as this is a serious reaction that should be taken seriously.

INDICATIONS AND USAGE

Uribel caps ules indicated for the treatment of symptoms of irritative voiding. Indicated for the relief of local symptoms, such as inflammation, hypermotility, and pain, which accompany lower urinary tract infections. Indicated for the relief of urinary tract symptoms caused by diagnostic procedures.

CONTRAINDICATIONS

Hypersensitivity to any of the ingredients is possible. Risk benefits should be carefully considered when the following medical problems exist: cardiac disease (especially cardiac arrhythmias, congestive heart failure, coronary heart disease, and mitral stenosis); gastrointestinal tract obstructive disease; glaucoma; myasthenia gravis, acute urinary retention may be precipitated in obstructive uropathy (such as bladder neck obstruction due to prostatic hypertrophy).

WARNINGS

Do not exceed recommended dosage. If rapid pulse, dizziness or blurring of vision occurs discontinue use immediately.

PRECAUTIONS

Cross sensitivity and/or related problem

patients intolerant of belladonna alkaloids or salicylates may be intolerant of this medication also. Delay in gastric emptying could complicate the management of gastric ulcers.

Pregnancy/Reproduction (FDA Pregnancy Category C)

hyoscyamine and methenamine cross the placenta. Studies concerning the effect of hyoscyamine and methenamine on pregnancy and reproduction have not been done in animals or humans. Thus it is not known whether Uribel caps ules cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Uribel caps ules should be given to a pregnant woman only if clearly needed.

Breast feeding

problems in humans have not been documented; however, methenamine and traces of hyoscyamine are excreted in breast milk. Accordingly, Uribel caps ules should be given to a nursing mother with caution and only if clearly needed.

Prolonged use

there have been no studies to establish the safety of prolonged use in humans. No known long-term animal studies have been performed to evaluate carcinogenic potential.

Pediatric
infants and young children are especially susceptible to the toxic effect of the belladonna alkaloids.

Geriatric Use

use with caution in elderly patients as they may respond to usual doses of hyoscyamine with excitement, agitation, drowsiness or confusion.

CPT code J1980 - Injection, hyoscyamine sulfate, up to 0.25 mg - Please double confirm this one

This medicine has a problem when it comes to it’s reaction with caffeine. So it is highly recommended not to ingest any foods or beverages that contain a large amount of caffeine such as tea, coffee or cola. Having these foods and beverages when you are using Uribel would increase the chance of developing negative side effects as well as it will most likely decrease the effectiveness of this medication a great deal.

Dizziness, vomiting and nausea are some of the the main and most common side effects of this medicine. However, depending on the functionality of your body, some of the other side effects can also be observed; these side effects include drowsiness, dry mouth, blurred vision and in some cases constipation. If you have dry mouth, try to have some hard sugarless candy or sugarless chewing gum and make sure to drink enough of water and fluids throughout the day to keep yourself from becoming dehydrated. In some cases, this medicine can turn your stool and urine to a blue-green color, but no need to be worried since this is a totally normal side effect and harmless in nature. This is something that would go away as soon as you stop using this medicine. A few serious side effects include black/tarry stools, abdominal pain, easy bruising or bleeding etc. Contact your doctor immediately if you have any of these more serious side effects. Also, in very rare cases, patients may experience an attack of extremely high blood pressure, but this rarely happens and there are chances only if the patient is already under a lot of different drugs. It is important to be very clear with your doctor about any other medications you may be taking, even if they are over the counter just to make sure there won’t be any negative reactions.

Uribel increases your serotonin levels. This means that if you are already using any medicine that increases serotonin, using Uribel along with it would increase the chance of high amount of serotonin in your body which might result into serotonin syndrome. Serotonin syndrome symptoms include high body temperature, increased reflexes, agitation, dilated pupils, sweating, tremor and diarrhea and they can vary from mild to sever. Like mentioned before, it is always advisable to inform your doctor about all the medicine that you are currently taking so that the doctor can decide whether Uribel would be suitable for you or not. Otherwise, it may lead to unwanted complication and things can get worse.

Serious allergic reactions are very rare among the side effects of Uribel. In rare of the rarest cases, patient may experience severe allergic reaction and he/she should consult the doctor immediately if the symptom persists. Also, it is highly recommended that you ask your doctor about the possible side effects so that you can distinguish between the harmless and harmful side effects and this would reduce any unnecessary unrest among the patient. It is important to be educated about the harmless and harmful side effects of any medication you are taking to make sure you spot any before it is too late.

If you have any kind of allergy to anything, it is advisable to inform your doctor about that as the doctor would be able to determine if any of the substance in the medicine may cause allergic reaction or not. If you have not taken an allergy test, you should get one done immediately since it would not only let you know to which substances are you allergic to, but also decrease the chance of having allergic reaction due to medication. This would minimize a lot of suffering for you and this can even be a life-saver.

Using alcoholic beverages is a strict no while using this medicine, just like with all other prescription medications. Uribel, in some cases, has the ability to cause blurry vision and dizziness; using alcohol would only increase the intensity of this effect and hence it is extremely unsafe to drive, especially you feel any of these symptoms. Do not get involved into any activity that requires you to be on high alert and also do not use any machinery during medication if you feel drowsy. This would greatly impact your normal power and performance to apprehend things and the result may be devastating to yourself and other who may be around you.

It is also advisable for you to inform the doctor of your medical history in detail so that the doctor would be able to decide the dose that is applicable for you, or even if it is appropriate for you to be prescribed this medicine. If you have any liver or kidney problems, doctors may suggest an alternate medicine so that no complication arises. So be informative about your full medical history to your doctor for your own good and don’t keep anything hidden, not even any small thing.

Children who have the chickenpox or flu should not take this medicine. If they are suffering from any other disease or have received a recent vaccine for any flu, they should also avoid this medicine. Though extremely rare, this medicine may cause Reye’s syndrome in children if not used properly. Also, taking this medicine is also not advisable during pregnancy since it may cause harm to the unborn baby. It is very important to know that this medication mixes in with breast milk, so if you are breast feeding, either you have to stop breast feeding or you have to stop the medication. Please consult your doctor in such scenarios to decide which action to take.

Uribel has been known to have interactions with many substances that include, but is not limited to: atomoxetine, bupropion, buspirone, carbamazepine, cyclobenzaprine, dextromethorphan, maprotiline, methotrexate, mifepristone, potassium capsules/tablets, pramlintide and some other narcotic drugs. Any fatal interaction with any of these substances can cause extreme and serious side effects and this is why it is highly advisable not to take this medication without consulting a doctor first and foremost. This medicine may also interfere with a number of laboratory tests and hence may provide false results. It is recommended that you tell your doctor or laboratory operator that you use this medicine beforehand and they would be able to decide whether it is ok to go ahead with the lab test as well as to determine certain test results to be inaccurate.

As an adult, it is always expected that you take any kind of medicine in the specified amount. Anything more than the specified amount may lead to an overdose and the result of overdose can be fatal at times. If you have skipped any dose by mistake, do take the dose as soon as you remember. But if it is too late, you should skip the dose and continue with the next one. Also, never take two doses at once or too close to each other in order to compensate for the previously missed dose. This would only worsen the situation and would highly increase the chance of an overdose. The symptoms of overdose of Uribel consists of fever, fast heartbeat, severe drowsiness, seizures, unusual excitements or hallucinations. So if you experience any of these overdose symptoms, quickly get in touch with an emergency room or a poison control center.

There are certain cautions you need to follow while storing the medicine. This medicine cannot be kept in your bathroom where you normally keep your all other medicines like aspirins. This must be stored in the normal room temperature, in a dry, moist free area and must not be shared with anyone. Also, never pour this medicine, or any other medicines at that, into drains or flush it down in the toilet. Keep it away from extreme light exposure and also from the reach of children and pets. This may prove extremely harmful to them.

This medicine comes in the typical prescription bottles and normally there are 100 capsules in them. This is not an over the counter medicine and can only be used if prescribed by a doctor. Each capsule of Uribel contains 118 mg of methenamine, 40.8 mg of sodium phosphate monobasic, 36 mg of Phenyl salicylate, 10 mg of methylene blue and 0.12 mg of hyocyamine sulfate. This medication should never be used in treatment of a urinary tract infection. Rather, if you have a bacterial infection, some other antibiotic is normally prescribed for the treatment. It is also very dangerous for children under six years of age since they are more vulnerable and sensitive to the normal side effects. So keep the information stored in your mind that using Uribel for children under six years is a strict no. Also, antacids are known to decrease the functionality of this medicine by reducing the absorption rate in blood. So it is highly recommended to have this medicine at least one hour early before you take antacids.

This medication is likely to make you sweat less and thus it increases the chance of getting a heat stroke. You should avoid any hard work while on this medication and also avoid any activity that may increase the heat of your body. If you live in a hot area, try not to go out frequently and avoid standing under direct sunlight. And if you feel that your body is heating up, quickly look for a shade and take rest to allow your body to cool down. This medicine may also cause side effects like confusion, agitation and constipation among the older adults and the combination of drowsiness and confusion may lead to falling and hence it is also not very suitable for aged people.

Uribel is a widely used drug that is prescribed by doctors to help with a patient’s bladder sensitivity as well as any urinary discomfort. Please keep everything we have gone over in mind when making the decision to take this medication once it is prescribed to you.

Generic drug Brand drug Formulary chapter Effective date

Uro-MP Uribel® 1. Antibiotics & Other Drugs Used for Infection December 22, 2014

BRAND Name GENERIC name PRICING (AWP) INDICATION SIMILAR THERAPIES ON FORMULARY/AWP CODE*

UTA CAPS 120MG

methenamine/hyo scyamine/meth blue/sod phoscaps

$3.71/tab

For treatment of urinary tract infections

Uribel ($2.71/tab) and Ustell ($2.41/tab)

covered as T3 Exclude – 13 along with existing 120mg UTA and 90 days notice

ICD 10 CODE FOR URINARY TRACT INFECTIONS

O23.30 - Infections of prt urinary tract in pregnancy, unsp trimester

CODE Z87.440 - Personal history of urinary (tract) infections

O23.31 - Infect of prt urinary tract in pregnancy, first trimester

O23.32 - Infect of prt urinary tract in pregnancy, second trimester

O23.33 - Infect of prt urinary tract in pregnancy, third trimester

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Critical Care Services and Physician Time

September 2, 2016, 11:51 pm

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Critical care is a time- based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided. More than one physician can provide critical care at another time and be paid if the service meets critical care, is medically necessary and is not duplicative care. Concurrent care by more than one physician (generally representing different physician specialties) is payable if these requirements are met (refer to the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, §30 for concurrent care policy discussion).

The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5).

1. Off the Unit/Floor

Time spent in activities (excluding those identified previously in Section C) that occur outside of the unit or off the floor (i.e., telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care because the physician is not immediately available to the patient. This time is regarded as pre- and post service work bundled in evaluation and management services.

2. Split/Shared Service

A split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time.

Unlike other E/M services where a split/shared service is allowed the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified non-physician practitioner and shall not be representative of a combined service between a physician and a qualified NPP.

When CPT code time requirements for both 99291 and 99292 and critical care criteria are met for a medically necessary visit by a qualified NPP the service shall be billed using the appropriate individual NPI number. Medically necessary visit(s) that do not meet these requirements shall be reported as subsequent hospital care services.

3. Unbundled Procedures

Time involved performing procedures that are not bundled into critical care (i.e., billed and paid separately) may not be included and counted toward critical care time. The physician's progress note(s) in the medical record should document that time involved in the performance of separately billable procedures was not counted toward critical care time.

4. Family Counseling/Discussions

Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service. However, time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met:

a) The patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and

b) The discussion is necessary for determining treatment decisions.

For family discussions, the physician should document:

a.The patient is unable or incompetent to participate in giving history and/or making treatment decisions

b. The necessity to have the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family",

c.Medically necessary treatment decisions for which the discussion was needed, and

d. A summary in the medical record that supports the medical necessity of the discussion

All other family discussions, no matter how lengthy, may not be additionally counted towards critical care. Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, but only if they meet the same criteria as described in the aforementioned paragraph.

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CPT CODE 64550 - Surface neurostimulator

September 3, 2016, 3:20 am

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CPT CODE 64550 - Application of surface (transcutaneous) neurostimulator - Average fee amount $17

Billing Codes

physical and occupational therapists must use the appropriate CPT® and HCPCS codes 64550, 95831-95852, 95992, 97001-97799 and G0283, with the exceptions noted later in the Noncovered and Bundled Codes section. They must bill the appropriate covered HCPCS codes for miscellaneous materials and supplies. For information on surgical dressings dispensed for home use, refer to the Supplies, Materials and Bundled Services section, page 136. If more than 1 patient is treated at the same time use CPT® code 97150. Refer to the Physical Medicine CPT® Codes Billing Guidance section, page 70 for additional information.

Electrical Stimulation Therapy (CPT codes 64550 and 97032, HCPCS code G0283)

CPT code 97032 requires "visual, verbal and/or manual contact "(i.e. constant attendance). A separate CPT code 64550 is available for "initial application of a TENS unit in which electrodes are placed on the skin" for patients that will be operating the TENS unit at home.

Effective for claims with dates of service on or after June 8, 2012, CMS no longer allows coverage under any circumstance except in the setting of an approved clinical study under coverage with evidence development (CED) for TENS used for treatment of chronic low back pain (CLBP) which has persisted for more than three months and is not a manifestation of a clearly defined and generally recognizable primary disease entity.

Daily Maximum for Services

The daily maximum allowable fee for physical and occupational therapy services
(see WAC 296-23-220and WAC 296-23-230 ......................................................... $ 118.07

The daily maximum applies to CPT® codes 64550, 95831-95852 and 97001-97799 and HCPCS code G0283 when performed for the same claim for the same date of service. If physical, occupational, and massage therapy services are provided on the same day, the daily maximum applies once for each provider type.

If the worker is treated for 2 separate claims with different allowed conditions on the same date, the daily maximum will apply for each claim.

If part of the visit is for a condition unrelated to an accepted claim and part is for the accepted condition, therapists must apportion their usual and customary charges equally between the insurer and the other payer based on the level of service provided during the visit. In this case, separate chart notes for the accepted condition should be sent to the insurer since the employer doesn‘t have the right to see information about an unrelated condition.

The daily maximum allowable fee doesn‘t apply to:

* Performance based physical capacities examinations (PCEs),

* Work hardening services,

* Work evaluations or

* Job modification/prejob accommodation consultation services.

Billing and Coding Guidelines

Comment: Several commenters suggested that CPT code 64550 (application of surface neurostimulator) is not an operative/postoperative code and that it may be used for the initial instruction and issuing of a TENS unit for
home use.

Response: CPT 64550 is in the surgery section of the CPT manual. The LCD advises that when one-to-one patient teaching is provided, to ensure safe, effective use of a home TENS unit, the timed code 97032 better reflects the 1:1 nature when providing this skilled service.

CPT Codes 64550, 90901, 92520, 92610, 92611, 92612, 92614, 92616, 95831, 95832, 95833, 95834, 95851, 95852, 95992, 96105, 96110, 96111, 97532, 97597, 97598, 97602, 97605, 97606 and HCPCS Codes 0019T, 0183T

These codes sometimes represent therapy services, as described below:

* They always represent therapy services (limited when limits are in effect) and require therapy modifiers when the service is: • Performed by or, where allowed, under the supervision of therapists; or • Furnished by other qualified personnel and the service provided is integral to an outpatient rehabilitation therapy POC; and * They do not represent therapy services, and therapy limits (when in effect) will not apply when: • It is not appropriate to bill the services under a therapy POC; and • They are billed by practitioners (physicians, clinical nurse specialists, nurse practitioners, and psychologists) who are not therapists; or • They are billed to A/MACs by hospitals for outpatient services furnished by non-therapists.

Medical Necessity:

Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section excludes coverage and payment for items and services that are not considered reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the function of a malformed body member.

1. Heat Treatment, Including the Use of Diathermy (CPT code 97024) and Ultra-Sound (CPT code 97035) for Pulmonary Conditions

2. There is no physiological rationale or valid scientific documentation of effectiveness of diathermy or ultrasound heat treatments for asthma, bronchitis, or any other pulmonary condition and for such purpose this treatment cannot be considered reasonable and necessary within the meaning of §1862(a)(1) of the Act.

3. Electrical stimulation (HCPCS code G0283; CPT code 97032) is considered not reasonable and necessary and is excluded from Medicare coverage for the following:

a. motor nerve disorders such as Bell’s Palsy. (ICD-9 code 351.0)

b. TENS treatments and related services (i.e. CPT code 64550), furnished in physicians/NPP or therapist’s office. (See CMS Pub.100-2 Ch.16 §180, CMS Pub.100-3 §160.3)

c. Electrical Stimulation is not medically necessary for the treatment of strokes when there is no potential for restoration of function.

Improper Coding of Claims

We identified inappropriate claims for TENS services submitted by Totalcare with CPT code 64550. We referred these claims to United for review by its medical policy staff. Based on this review, United officials concluded that TotalCare performed regular, recurrent physical therapy services in an office setting. However, claims for these services were often submitted under code 64550 (the code normally used for TENS services). United further determined that TotalCare should have submitted such claims with a CPT code for physical therapy procedures, which generally correspond to payment rates that are considerably lower than the rates for TENS services (code 64550). This is consistent with information provided by the American Academy of Physical Medicine and Rehabilitation, which concluded that recurrent therapy, provided in an offi ce setting, should not be billed with the CPT code for TENS (code 64550).

As noted previously, CPT code 64550 is intended for the initial application of the TENS unit, and therefore, it generally should not be billed multiple times for the same patient. However, we found many instances where TotalCare billed code 64550 multiple times for individual patients without explanation of the need for the additional TENS sessions. In one instance, TotalCare billed that code 98 times for a patient within one year, with the payments totaling $4,880. In addition, we determined that United paid these claims because it did not have sufficient claims processing controls (for example, claims payment system edits) to limit the number of times code 64550 is allowed per patient.

As a non-participating provider in United’s Empire Plan provider network, TotalCare’s claims for physical therapy services are subject to considerable benefi t rate reductions. However, United did not apply these rate reductions because code 64550 does not correspond to physical therapy. If TotalCare billed appropriately for physical therapy services, United would have paid TotalCare up to $8 for each service claimed. Instead, United paid up to $100 for each service. As a result, United overpaid TotalCare $248,202 for 4,633 inappropriate claims for TENS services during our audit period.

United officials agreed with our audit findings, and they indicated that they have initiated actions to recover the overpayments made to TotalCare. In addition, United has taken steps to prevent such overpayments from occurring in the future. We also discussed our findings with the Departmentof Civil of Service (Department). Department officials likewise agreed with our findings and stated that United should have procedures to identify and deny multiple claims for TENS services (code 64550).

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CPT Code 97760. 97761 and 97762 -Orthotic, prosthetic training

September 4, 2016, 7:53 am

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CPT CODE, DESCRIPTION AND FEE amount

97760 - Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes - Average Fee amount -$40

97761 - Prosthetic training, upper and/or lower extremity(s), each 15 minutes - Average Fee amount - $35

97762 - Checkout for orthotic/prosthetic use, established patient, each 15 minutes - Average Fee amount - $48

Medicare Policy:

Some of the policies implemented in this notification were 1) discussed in the CY 2006 OPPS final rule, or 2) discussed in the CY 2006 MPFS final rule or reflected in its Addendum B. Other policies contained in this notification correct or clarify our previous policy noted in Transmittal 515, CR 3647, issued April 1, 2005 in Pub. 100-04. This CR updates the therapy code list and associated policies for CY 2006, as follows:

1) “Orthotic Management and Prosthetic Management” Services.

In order to create a new category under the section for physical medicine and rehabilitation services, HCPCS/CPT modified the descriptor of one of these codes, CPT 97504 (2005), and renumbered it as well as two other HCPCS/CPT codes. The new therapy code list removes the CY 2005 CPT codes, 97504, 97520 and 97703 and replaces them with CPT codes 97760, 97761 and 97762, respectively, for use in CY 2006.

Constant Attendance Modalities (97010-97039), Therapeutic Procedures (97110-97542), Orthotic Management (97760, 97762), and the unlisted Physical Medicine code (97799) will be limited to a maximum 4 therapeutic modalities per treatment session, not to exceed one hour (4 units) for the combinations of codes submitted.

Generally, CPT code 97116 should not be reported with 97760. However, if a service represented by code 97760 was performed on an upper extremity and a service represented by code 97116© (gait training) was also performed, both codes may be billed with modifier 59 to denote separate anatomic sites.

Orthotic Management and Prosthetic Management:

CPT codes 97760-97762 describe orthotic and prosthetic assessment, management, and training
services. These codes also contain a 15 minute time component

The “Rule of Eight” reporting requirements described in the policy section below apply to all of the 15 minute time-based codes listed above under Modalities, Therapeutic Procedures, Tests and
Measurements, and Orthotic Management and Prosthetic Management. However, this policy focuses
on Constant Attendance Modalities and Therapeutic Procedures

I. “Rule of Eight”

The Health Plan has adopted The Centers for Medicare & Medicaid Services (CMS) reporting guidelines for determining the appropriate number of units to report with respect to physical medicine CPT codes that are subject to a 15-minute time component. The Health Plan refers to this guideline as the “Rule of Eight.”

The “Rule of Eight” addresses the relationship between the direct (one-on-one) time spent with the patient, and the billing and reimbursement of a unit of service. According to the “Rule of Eight”, the provider must spend more than one-half (8 minutes or more) of a given 15-minute time component with the patient in order to properly submit that unit to the Health Plan for reimbursement

II. Reporting Guidelines

The Health Plan requires that the provider maintain visual, verbal, and/or manual contact with the patient throughout the performance of procedures that are reported to Health Plan as direct treatment services.

• The time reported should be the time actually spent in the delivery of the modality and/or therapeutic procedure. This means that pre and post-delivery services should not be counted in determining the treatment time.

• The time that the patient spends not being treated, due to resting periods or waiting for a piece of equipment to become available, is not considered treatment time.
• All treatment time, including the beginning and ending time of the direct treatment, must be recorded in the patient’s medical record, along with the note describing the specific modality or procedure.

III. Determining Units

A. A provider should not report a direct treatment service if only one attended modality or therapeutic procedure is provided in a day, and the procedure is performed for less than 8 minutes.

B. A single 15-minute unit of direct treatment service may be billed when the duration of direct treatment is equal to or greater than 8 minutes, and less than 23 minutes. If the duration of a single modality or procedure is between 23 minutes but less than 38 minutes, then two 15-minute units of direct treatment service may be billed.

The following table indicates the appropriate protocol for reporting each additional unit:

Number of units billed: Number of minutes provided in treatment:

1 unit 8 minutes to < 23 minutes
2 units 23 minutes to < 38 minutes
3 units 38 minutes to < 53 minutes
4 units 53 minutes to < 68 minutes
5 units 68 minutes to < 83 minutes
6 units 83 minutes to < 98 minutes
7 units 98 minutes to < 113 minutes
8 units 113 minutes to < 128 minutes*

TMJ Orthotic Adjustments

Adjustments for TMJ orthotics are normally billed under CPT codes 97760 or 97762. These services are not separately covered with a TMJ diagnosis. These adjustments are considered an integral part of the splint therapy and as such will be denied regardless if billed alone or with another service.

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Counting of Units of Critical Care Services - CPT 99291 AND 99292

September 7, 2016, 11:55 pm

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The CPT code 99291 (critical care, first hour) is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date. Only one unit of CPT code 99291 may be billed by a physician for a patient on a given date. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician and would not each report CPT 99291on the same date of service.

The following illustrates the correct reporting of critical care services:

Total Duration of Critical Care Codes

Less than 30 minutes 99232 or 99233 or other appropriate E/M code

30 - 74 minutes 99291 x 1

75 - 104 minutes 99291 x 1 and 99292 x 1

105 - 134 minutes 99291 x1 and 99292 x 2

135 - 164 minutes 99291 x 1 and 99292 x 3

165 - 194 minutes 99291 x 1 and 99292 x 4

194 minutes or longer 99291 – 99292 as appropriate (per the above illustrations)

Critical Care Services and Other Evaluation and Management Services Provided on Same Day

When critical care services are required upon the patient's presentation to the hospital emergency department, only critical care codes 99291 - 99292 may be reported. An emergency department visit code may not also be reported.

When critical care services are provided on a date where an inpatient hospital or office/outpatient evaluation and management service was furnished earlier on the same date at which time the patient did not require critical care, both the critical care and the previous evaluation and management service may be paid. Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient.
Physicians are advised to submit documentation to support a claim when critical care is additionally reported on the same calendar date as when other evaluation and management services are provided to a patient by the same physician or physicians of the same specialty in a group practice.

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Detailed review of CPT 99291 AND 99292

September 10, 2016, 11:58 pm

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Critical Care Services Provided by Physicians in Group Practice(s)

Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative

services are payable. The medical specialists may be from the same group practice or from different group practices.
Critically ill or critically injured patients may require the care of more than one physician medical specialty. Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time. Medical record documentation must support the medical necessity of critical care services provided by each physician (or qualified NPP). Each physician must accurately report the service(s) he/she provided to the patient in accordance with any applicable global surgery rules or concurrent care rules.

CPT Code 99291

The initial critical care time, billed as CPT code 99291, must be met by a single physician or qualified NPP. This may be performed in a single period of time or be cumulative by the same physician on the same calendar date. A history or physical exam performed by one group partner for another group partner in order for the second group partner to make a medical decision would not represent critical care services.

CPT Code 99292

Subsequent critical care visits performed on the same calendar date are reported using CPT code 99292. The service may represent aggregate time met by a single physician or physicians in the same group practice with the same medical specialty in order to meet the duration of minutes required for CPT code 99292. The aggregated critical care visits must be medically necessary and each aggregated visit must meet the definition of critical care in order to combine the times.

Physicians in the same group practice who have the same specialty may not each report CPT initial critical care code 99291 for critical care services to the same patient on the same calendar date. Medicare payment policy states that physicians in the same group practice who are in the same specialty must bill and be paid as though each were the single physician. (Refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.)

Physician specialty means the self-designated primary specialty by which the physician bills Medicare and is known to the contractor that adjudicates the claims. Physicians in the same group practice who have different medical specialties may bill and be paid without regard to their membership in the same group. For example, if a cardiologist and an endocrinologist are group partners and the critical care services of each are medically necessary and not duplicative, the critical care services may be reported by each regardless of their group practice relationship.

Two or more physicians in the same group practice who have different specialties and who provide critical care to a critically ill or critically injured patient may not in all cases each report the initial critical care code (CPT 99291) on the same date. When the group physicians are providing care that is unique to his/her individual medical specialty and managing at least one of the patient’s critical illness(es) or critical injury(ies) then the initial critical care service may be payable to each.
However, if a physician or qualified NPP within a group provides “staff coverage” or “follow-up” for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the “covering” physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292. The appropriate individual NPI number shall be reported on the claim. The services will be paid at the specific physician fee schedule rate for the individual clinician (physician or qualified NPP) billing the service.

Clinical Examples of Critical Care Services

1. Drs. Smith and Jones, pulmonary specialists, share a group practice. On Tuesday Dr. Smith provides critical care services to Mrs. Benson who is comatose and has been in the intensive care unit for 4 days following a motor vehicle accident. She has multiple organ dysfunction including cerebral hematoma, flail chest and pulmonary contusion. Later on the same calendar date Dr. Jones covers for Dr. Smith and provides critical care services. Medically necessary critical care services provided at the different time periods may be reported by both Drs. Smith and Jones. Dr. Smith would report CPT code 99291 for the initial visit and Dr. Jones, as part of the same group practice would report CPT code 99292 on the same calendar date if the appropriate time requirements are met.

2. Mr. Marks, a 79 year old comes to the emergency room with vague joint pains and lethargy. The ED physician evaluates Mr. Marks and phones his primary care physician to discuss his medical evaluation. His primary care physician visits the ER and admits Mr. Marks to the observation unit for monitoring, and diagnostic and laboratory tests. In observation Mr. Marks has a cardiac arrest. His primary care physician provides 50 minutes of critical care services. Mr. Marks’ is admitted to the intensive care unit. On the same calendar day Mr. Marks’ condition deteriorates and he requires intermittent critical care services. In this scenario the ED physician should report an emergency department visit and the primary care physician should report both an initial hospital visit and critical care services.

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Afluria Vaccine - CPT CODE Q2035 & 90656

September 12, 2016, 3:22 am

≫ Next: CPT code 86485, 86490, 86580

≪ Previous: Detailed review of CPT 99291 AND 99292

Afluria

Afluria is a vaccine that is used to prevent the effects of influenza virus. Influenza virus develops every year and is getting stronger day by day. To cope with this dilemma, this vaccine has also been redeveloped every. It is improved by the health officer of that year.

Influenza is a very serious disease that is caused by a virus. It spreads very quickly. It effects on coming in contact a person suffering from it. More dangerous than that, it is widely spread by the saliva droplets that are expelled into the atmosphere whenever the affected person coughs or sneezes. Getting infected with influenza will be the last thing you want to happen to yourself. Influenza kills hundreds and hospitalizes thousands. It spreads quickly and causes deadly effects.

General Working

Afluria acts like a killed virus vaccine. It introduces your body with a specific virus that helps your body to build its immune system against the disease. It doesn’t actually treat any active infection that was previously developed in the body.

CPT CODE And Description

Q2035 - Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (afluria)

90656 - Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use

FREQUENCY OF ADMINISTRATION

Once per influenza season in the fall or winter Medicare may cover additional seasonal influenza virus vaccinations if medically necessary

Seasonal Influenza Virus Vaccine Administration Code: G0008 Diagnosis Code: V04.81

Effective for dates of service on or after October 1, 2010, HCPCS codes Q2035, Q2036, Q2037, Q2038 and Q2039 will replace the CPT code 90658 for Medicare payment purposes during the 2010 – 2011 influenza season, however, these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011 when CPT code 90658 will no longer be recognized. Only the diagnoses codes and edits that are associated with CPT 90658 must also be applied to these new HCPCS codes.

Effective for dates of service on or after October 1, 2010, the Medicare Part B payment allowance in other situations for Q2036 is$8.784, for Q2037 is $13.253, and for Q2038 is $12.593. Since no national payment limits are available for Q2035 and Q2039, the payment limits will be determined by the local claims processing contractor.

General information

Afluria is available in different forms. The injectable form is actually killed virus vaccine as discussed above. Afluria is also available as nasal sprays which is the live virus vaccine. If you have any mild medical problem, then you can have Afluria vaccine, but if there is some serious infection or disease, then you must wait for it to come back to normal. You must also remember the problems and side effects that are caused by the Afluria vaccine because if you get to have Afluria vaccine, then you have to tell your doctor about the side effects.

Afluria vaccine cannot be considered as the universal relief. It cannot treat everyone. There are some restrictions and limitations of the vaccine. It doesn’t treat the illness caused by the bird flu. Afluria injects the same type of virus that causes the flu. But it doesn’t cause illness. However, one can feel flu in the season.
Receiving Afluria

Receiving Afluria treatment is a bit complicated procedure that one must practice extra precautions before receiving it. Here are some of the tips.

First of all, you must have a complete record of the allergy or reaction caused by Afluria vaccination, if you were subjected to one before.
Tell your doctor about these conditions for safely receiving Afluria vaccination
Bone marrow transplant, Cancer treatment or any other medical treatment that can cause weakness in the immune system.
Any neurological disorder in the history.
If you are allergic to latex rubber

Afluria treatment

Afluria is given in two ways. The first is the injection into the muscle, and another is through nasal sprays. Injecting Afluria vaccine is the most common way of receiving Afluria. It consists of killed virus. You get an appointment with a doctor and get Afluria injected into your muscle. Afluria weakens your immune system so once you get the vaccination, you get addicted to it and must have it after every year. It is mostly carried out during November and October. Your doctor may advise you to get aspirin free medicine for pain and fever for 24 hours after the vaccination.

Missing a dose

The vaccination is carried out once in a year, so it is very easy to make an appointment and get your vaccination if you miss your dose. It is not too much of a worry, but you must get it as early as possible.

Side effects

Afluria doesn’t affect you with the flu virus that it injected into your body, but it can lead you to have the flu during the flu season. Keep the exact record of all the reactions caused by Afluria treatment. If you ever have to get Afluria treatment in future, you must have to tell them to your doctor. Never get a booster shot of Afluria if you had life-threatening side effects during the last time. Side effects demand an immediate reaction. Thus, you must call for a medical emergency if you feel any side effects like swelling of the face and lips, trouble breathing and hives after getting Afluria vaccination. Contact your doctor at the earliest hour if you experience any trouble after Afluria vaccination.

Following are some of the initial feelings you get if Afluria starts to affect you in an unwanted manner.

**Unusual bleeding
**Fever
**Convulsions
**Severe weakness or fatigue.
**Weakened arms and legs after two to four weeks of vaccination
**Here are some of the other side effects of Afluria
**Fussiness in mind
**Crying
**Redness and swelling on the part of the body where the vaccine was injected.
**A headache or weakness
**Muscle and joint pain

Dosage

The dosage of Afluria vaccination varies with age. Young people may get a stronger dose due to the strong immune system while the older people or infants are given a calculated amount of vaccination. Children having age below six months must not be subjected with the Afluria vaccination. Children of age more than the specified period must get a dose after four weeks. If a child gets a vaccination on day 1, then it must have the next shot after four weeks. Children of the age more than nine years must get 0.5 ml of Afluria vaccination. Adults must have a 0.5 ml of the vaccination in the deltoid muscle of the arm.

Specific conditions
Here are some specific medical conditions in which the vaccination must be carried out with ultimate care.

Pregnancy
It is still unknown that how Afluria affects the reproduction process. There are no studies that advocate the positive or negative role of Afluria on the pregnancy and reproduction capacity.
Nursing Mothers

Medicines get excreted in human milk. So extra precautions must be exercised while having an Afluria vaccination during nursing. There is no proper evidence whether it gets excreted or not.

Geriatric Application

Hem agglutination-inhibiting antibody reactions in the elderly people were significantly lower subsequent to the injection of Afluria as compared to young/adult subjects.

Furthermore, usage of Afluria vaccination for children under six months of age is not recommended. Children in this age group are most likely to get the side effects.

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CPT code 86485, 86490, 86580

September 13, 2016, 3:01 am

≫ Next: CPT CODE 90791, 90792 ,90785 - Psychiatric diagnostic evaluation

≪ Previous: Afluria Vaccine - CPT CODE Q2035 & 90656

CPT CODE AND Description

86485 - Skin test; candida
86490 - Skin test; coccidioidomycosis - Average Fee amount $65 - $90
86580 - Skin test; tuberculosis, intradermal - Average Fee amount $7 - $10

ALL CPT required CLIA. Recently Medicare Excluded these CPTs from CLIA Edits

TB Testing – CPT 86580 / ICD9 V74.1

• Since the test is an inoculation screening test, rather than a vaccination, the test includes administering the skin test and you should not code separately for the administration.

• The Resource Based Relative Value System (RBRVS) does not include costs for a reading.

• Patients who do not show a response to the test may never return for a reading so this nurse “reading” cost is not included in the RVUs for 86580.

• If the patient does return for a reading, you may code 99211 for the nurse reading. Make sure to document appropriately

Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) Bundling Update

UnitedHealthcare Community Plan has received additional clarification from Arizona Health Care Cost Containment System (AHCCCS) regarding Tuberculosis Testing services (86580) included in the EPSDT visit. The AHCCCS Medical Policy Manual, Chapter 400, Policy 430, contains language specifically related to lab testing:

Payment for laboratory services that are not separately billable and considered part of the payment made for the EPSDT visit include, but are not limited to: 99000, 36415, 36416, 36400, 36406, and 36410. In addition, payment for all laboratory services must be in accordance with limitations or exclusions specified in AHCCCS health plan contract with the providers1.

Since CPT 86580 falls under Pathology/Laboratory services and is not included in those codes listed above, services using CPT 86580 during the EPSDT visit should be billed and processed separately according to the AHCCCS provider contract.

UnitedHealthcare Community Plan will reflect these changes by March 24, 2015. Any claims previously denied or recovered prior to this correction being implemented will be adjusted to process appropriately according to this new guidance.

Guidelines

1. Currently, CPT Code 86485* - Skin test; Candida – is the code available for the cost of the CANDIN and materials used in the skin test. This code does not include possibly related procedures such as office visits, injection, reading, or patient consultation.

3. Submit reasonable and necessary charges in accordance with, along with the current CPT Code. (current CANDIN estimated price per test is $14.90**).

4. The insurance company may ask for a copy of the invoice for the purchase of CANDIN in order to confirm the price.

Laboratory and Venipuncture Services Bundled Example: If procedure code 80047 (PCTC IND of 9 ) or 86485 (PCTC IND of 3) is reported with a facility place of service, the line item will deny.

Do you know how to code for a PPD/TB Skin Test? Proper coding for this test is quite simple. CPT 86580 is described as Skin Test; tuberculosis, intradermal and includes the administration of the test; therefore, do not attempt to bill any type of administration code in conjunction with CPT 86580. The appropriate diagnosis code for CPT 86580 is V74.1.

Generally, the nurse will administer the skin test and instruct the patient to return to the clinic for a reading a few days later. A nurse visit, CPT 99211 may be reported for the reading. The nurse must remember to document a proper nurse visit note (this is an E&M service)

• To be able to separate purchased vs. state supplied TST use the LU114 code for state supplied TST (report only) and the CPT code 86580 for purchased TST which can have a charge attached.

• If the client has private insurance only and a RN is the provider, you can use the 99211 E&M code. Other providers eligible to bill private insurance would use the appropriate E&M code for the level of service provided.

• When a client receives TB services (must be for a billable TB service) billed with an E&M code and is also seen by another health department provider on the same date of service for a separately identifiable medical condition, the health department may bill the appropriate E&M code, provided the diagnosis on the claim form indicates the separately identifiable medical condition and modifier 25 is deppended to the E & M code for the second visit.

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CPT CODE 90791, 90792 ,90785 - Psychiatric diagnostic evaluation

September 14, 2016, 3:24 am

≫ Next: CPT CODE Q2037, 90657 - Fluvirin

≪ Previous: CPT code 86485, 86490, 86580

CPT CODE and Description

90785 - Interactive complexity (List separately in addition to the code for primary procedure)

90791 - Psychiatric diagnostic evaluation - Average fee amount $120 -$150

90792 - Psychiatric diagnostic evaluation with medical services - $140 - 160

Section I: Psychiatric Diagnostic Evaluation (CPT codes 90791, 90792)

Indications

The diagnostic evaluation (CPT code 90791) is a biopsychosocial assessment.

The diagnostic evaluation with medical services (CPT code 90792) is a biopsychosocial and medical assessment.

Both of these evaluations may include discussion with family or other sources in addition to the patient.

The diagnostic interview is indicated for initial or periodic diagnostic evaluation of a patient for suspected or diagnosed psychiatric illness. A second provider seeing the patient for the first time may also use these codes.

An additional diagnostic evaluation service may be considered reasonable and necessary for the same patient if a new episode of illness occurs, an admission or a readmission to inpatient status due to complications of the underlying condition occurs, or when re-evaluation is required to address a new referral question. Certain patients, especially children and geriatric patients may require more than one visit for the completion of the initial diagnostic evaluation. The indication for the assessment should be based on medical necessity and supported in the medical record.

Interactive procedures may be necessary and considered reasonable and necessary for patients whose ability to communicate is impaired by expressive or receptive language impairment from various causes. These may include conductive or sensorineural hearing loss, deaf mutism, aphasia, language barrier, or lack of mental development (childhood).

The Bariatric Surgical Management of Morbid Obesity LCD (L35022) provides specific criteria that support the medical necessity of the psychiatric diagnostic interview. Please refer to LCD L35022 for the specific criteria.

Coverage for the diagnostic interview is limited to physicians (MDs, DOs), Clinical Social Workers (CSWs), Clinical Psychologists (CPs), Clinical Nurse Specialists (CNSs), Physician Assistants (PAs) and Nurse Practitioners (NPs) certified in the state or jurisdiction for psychiatric services.

Section II: Psychological and Neuropsychological Testing

Indications

These diagnostic tests are used when mental illness is suspected, and clarification is essential for the diagnosis and the treatment plan.

Testing conducted when no mental illness/disability is suspected would be considered screening and would not be covered by Medicare. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing.

Examples of problems that might require psychological or neuropsychological testing include:

Assessment of mental functioning for individuals with suspected or known mental disorders for purposes of differential diagnosis or treatment planning.

Assessment of patient strengths and disabilities for use in treatment planning or management when signs or symptoms of a mental disorder are present.

Assessment of patient capacity for decision-making when impairment is suspected that would affect patient care or management.

Differential diagnosis between psychogenic and neurogenic syndromes (e.g., depression versus dementia).

Detection of neurologic disease based on quantitative assessment of neurocognitive abilities (e.g., mild head injury, anoxic injuries, Acquired Immune Deficiency Syndrome (AIDS) dementia).
Delineation of the neurocognitive effects of central nervous system disorders.

Neurocognitive monitoring of recovery or progression of central nervous system disorders.
When a psychiatric condition or the presence of dementia has already been diagnosed, there is value to the testing only if the information derived from the testing would be expected to have significant impact on the understanding and treatment of the patient. Examples include:

Significant change in the patient’s condition.

The need to evaluate a patient’s capacity to function in a given situation or environment.

The need to specifically tailor therapeutic and or compensatory techniques to particular aspects of the patient’s pattern of strengths and disabilities.

Adjustment reactions or dysphoria associated with moving to a nursing home do not automatically constitute medical necessity for testing. Testing of every patient upon entry to a nursing home would be considered a routine service and would not be covered by Medicare. However, some individuals enter a nursing home at a time of physical and cognitive decline, and may require psychological testing to arrive at a diagnosis and plan of care. Decisions to test individuals who have recently entered a nursing home need to be made judiciously, on a case-by-case basis. Medical necessity of such evaluations should be documented and maintained in the medical record.

Each test administered must be medically necessary. Standardized batteries of tests are only acceptable if each component test is medically necessary.

Depending on the issues to be assessed, a typical test battery may require 7 to 10 hours to perform, including administration, scoring and interpretation.

CPT code 96105 represents formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination. If this formal assessment is performed during treatment, it is typically performed only once during treatment and its medical necessity should be documented. If the test is repeated during treatment, the medical necessity of the repeat administration of the test must also be documented.

Rendering Providers

Physical Therapists (PTs), Occupational Therapists (OTs), and Speech Language Pathologists (SLPs) may perform services represented by CPT codes 96105, 96111 and G0451; under the general supervision of a physician or a CP.

Non-physician practitioners (NPPs), such as NPs, CNSs and PAs who personally perform diagnostic psychological and neuropsychological tests are excluded from having to perform these tests under the general supervision of a physician or a CP (Pub. 100-02, Chapter 15, Section 80.2).

Independently Practicing Psychologists (IPPs) may bill for psychological and neuropsychological tests when the tests are ordered by a physician (Pub. 100-02, Chapter 15, Section 80.2).

Limitations

Routine re-evaluation of chronically disabled patients that is not required for a diagnosis or continued treatment is not medically necessary.

Brief screening measures such as the Folstein Mini-Mental Status Exam or use of other mental status exams in isolation should not be classified separately as psychological or neuropsychological testing, since they are typically part of a more general clinical exam or interview.

Psychological and neuropsychological testing may not be performed on an “incident to” basis (Pub. 100-02, Chapter 15, Section 80.2).

Psychological/neuropsychological testing codes should not be reported by the treating physician for only reading the results of the testing.

Interactive Complexity Add-On

90785 Interactive Complexity -- This add-on code may be used with any of the codes in the Psychiatry section when the encounter is made more complex by the need to involve others along with the patient. It will most frequently be used in the treatment of children. When this add-on is used, documentation must explain what exactly the interactive complexity was (i.e., the need for play equipment with a younger child; the need to manage parents’ anxiety; the involvement of parents with discordant points of view).

Psychiatric Diagnostic Evaluation Codes

90791 Psychiatric Diagnostic Evaluation

This code is used for an initial diagnostic interview exam that does not include any medical services. In all likelihood this code will not be used by psychiatrists . It includes a chief complaint, history of present illness, review of systems, family and psychosocial history, and complete mental status examination, as well as the order and medical interpretation of laboratory or other diagnostic studies. In the past most insurers would reimburse for one 90791 (then a 90801) per episode of illness. The guidelines now allow for billing this on subsequent days when there is medical necessity for an extended evaluation (i.e., when an evaluation of a child that requires that both the child and the parents be seen together and independently). Medicare will pay for only one 90791 per year for institutionalized patients unless medical necessity can be established for others.

90792 Psychiatric Diagnostic Evaluation with Medical Services This code is used for an initial diagnostic interview exam for an adult or adolescent patient that includes medical services. It includes a chief complaint, history of present illness, review of systems, family and psychosocial history, and complete mental status examination, as well as the ordering and medical interpretation of laboratory or other diagnostic studies. In the past most insurers would reimburse for one 90792 (then a 90801) per episode of illness. The guidelines now allow for billing this on subsequent days when there is medical necessity for an extended evaluation (i.e., when an evaluation of a child that requires that both the child and the parents be seen together and independently). Medicare will pay for only one 90792 per year for institutionalized patients unless medical necessity can be established for others. Medicare permits the use of this code or the appropriate level of the E/M codes (see below) to denote the initial evaluation or first-day services for hospitalized patients. Medicare also allows for the use of 90792 if there has been an absence of service for a three-year period.

Usage Guideliens

Two new codes for Initial Assessment

◦ Without medical services – New code 90791
◦ With medical services – New code 90792

** Medical services include biopsychosocial and medical assessment, including history, mental status, other physical exam elements as indicated and recommendations

* *If medical services are not performed with the initial assessment, the doctor/NPP should use the initial assessment code 90791

* Initial assessment is a face-to-face interaction between a clinician and recipient and/or collaterals

* Time Requirements
◦ 90791 minimum of 45minutes
◦ 90792 minimum of 45 Minutes
◦ Time rounding is not permitted
* No more than three initial assessment services will be reimbursed during an episode of service.

* 90792 may only be used by psychiatrists, physicians or psychiatric nurse practitioners (NPP) who perform an initial assessment with medical services

* 90792 may not be claimed on the same day as an E&M code

* Doctor/NPP modifier (i.e., AF, AG, SA) must be added to the claim (for both 90791 or 90792) in order to receive the additional physician reimbursement add-on

Psychiatric interviews/evaluations 90791, 90792

90791 includes the assessment of the patient's psychosocial history, current mental status, review, and ordering of diagnostic studies followed by appropriate treatment recommendations.

90792 is reported if additional medical services such as physical examination and prescription of pharmaceuticals are provided in addition to the diagnostic evaluation. Interviews and communication with family members or other sources are included in these codes.

This procedure is not time defined. The initial evaluation/diagnostic interview session is expected to include face-to-face consumer contact, and encompasses activities critical to the evaluation process, such as communicating with the consumer and the primary care physician and ordering laboratory
tests when clinically appropriate.

Only one initial evaluation/diagnostic interview (90791/90792) may be rendered as part of the initial 12, non-OMS services. A maximum of two diagnostic interviews may be rendered as part of the 150 unit bundle of services for OMS consumers. An additional 90791/90792 may be requested and approved if the additional 90791/90792 is to be provided by a different rendering provider. The different rendering provider may be part of the same OMHC or practice group, or independent of the OMHC or practice group. The primary consideration is that one of the providers is a physician and the other is a non-physician

Interactive complexity code 90785

* Add-on code to the code for a primary psychiatric service.

* May be reported, as appropriate, with 90791, 90792, 90832, 90833, 90834, 90836, 90853, 90837, 99201-99255, 99304-99337, and 99341-99350

* One of the following must exist during the session in order to report 90785:

o Maladaptive communication (for example, high anxiety, high reactivity, repeated questions, or disagreement).

o Emotional or behavioral conditions inhibiting implementation of treatment plan.

o Mandated reporting/event exists (for example, abuse or neglect).

o Play equipment, devices, interpreter or translator required due to inadequate language expression or different language spoken between patient and professional.

↧

CPT CODE Q2037, 90657 - Fluvirin

September 15, 2016, 6:48 am

≫ Next: CPT CODE 96116, 96118, 96119, 96120 -Neuropsychological testing

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Fluvirin

Fluvirin is used in fighting against influenza. It is for the patients above the age of 4 years. It is a strong vaccination and must not be used for younger patients. It triggers the production of antibodies in the body that fight against the certain type of flu viruses. This helps the body in fighting the infection. The virus produced by the vaccination stimulates the immune system of the body and prepares the body to fight against the disease. It is the most suitable remedy for the influenza virus of subtype A and subtype B.

CPT CODE AND Description

Q2037 - Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluvirin)

90657 - Influenza virus vaccine, trivalent (IIV3), split virus, when administered to children 6-35 months of age, for intramuscular use

ADMINISTRATION & DIAGNOSIS CODES FOR CPT Q2037

Seasonal Influenza Virus Vaccine
Administration Code: G0008
Diagnosis Code: V04.81

FREQUENCY OF ADMINISTRATION

Once per influenza season in the fall or winter Medicare may cover additional seasonal influenza virus vaccinations if medically necessary

Before Vaccination

Fluvirin vaccination is kind of a complicated procedure. There are different medical conditions in which Fluvirin interacts differently. Here are some conditions in which you must consult a doctor before having a Fluvirin vaccination. Consultation is necessary if you

•Have allergies from food, air or anything.
•Have allergy from latex rubber
•Are allergic to thimerosal
•Have a sore throat, fever, respiratory tract disease
•Have a severe bleeding problem
•Have an immune system problem like HIV
•Have recent cancer treatment
•Have a recent neural treatment due to any cause
•Take medicine for any other disease or even flu itself. They can be any herbal medicine or dietary supplement.
•Are receiving any other therapy like chemotherapy or radiation treatment
•Are pregnant or planning to be Usage

Doctor’s prescription is the most authentic piece of paper. Fluvirin is a case sensitive vaccination. So, a doctor that is thoroughly aware of your medical history must be knowing better how you should take it or if you should at all take it. Labels on the vaccine also give the exact dosing.

•Vaccination is carried out once in a year, mostly during September to November.
•It is common in children above four years of age. Sometimes children need to have more dosage. In such a situation, discuss about the child's vaccination history with a doctor. Strictly follow the schedule of vaccination proposed by the doctor.
•Fluvirin is injected into your body through your muscle in a doctor’s office. Consult your doctor if there are other place related issues.
•Use Fluvirin in the best physical state. Do not take it if its syringe is broken or damaged. Do not use it if it is frozen, has particles, cloudy or has discolored.
•Missing a dose if not something like a life threatening situation, but if it happens, you must consult a doctor immediately. Make an appointment and get your vaccination.

Safety precautions

Fluvirin must be used after exercising all the possible safety precautions. It is kind of a complicated medicine, which must be used after prescription from a doctor; a doctor that must be knowing your complete medical background. Here are some general safety precautions that must be exercised properly.

•Use of Fluvirin in pregnancy is not studied. There is no definite proof about the reaction of Fluvirin on reproduction capacities. If you are pregnant or planning to be, then you must consult your doctor for further help.

•If you are having cold, fever, or respiratory tract disease, then you must be consulting your doctor prior to getting Fluvirin vaccination.

•Fluvirin does not cure the influenza. It is given before the flu season to make you fight the disease. It will not make you sick, but may cause you feel some during the flu season.

•Fluvirin is an ongoing process. It makes your immune system more addicted to it. Thus, one must get the vaccination every year.

•Fluvirin protects the people that are exposed to influenza virus.

•Tell your doctor before having any medical, dental or surgical treatment that you have had the Fluvirin vaccination

•Fluvirin is not effective for all other respiratory infections. It has no effect on the bird flu.

•Tell the doctor in case you have received any other vaccination recently, chemotherapy or radioactive treatments.

•Tell the doctor if you are allergic to latex rubber. The tip cap of the medicine may be of latex rubber. Thus, you must consult your doctor before having a vaccination in this case.

•Fluvirin’s effectiveness may decrease in aged patients. Thus the dose must be taken as prescribed by the doctor.

Dosage

The dosage of the Fluvirin vaccination also varies with the age. Here is a detailed dosage instruction for age groups.

•Children 4-17 years
Children need a twice dose of Fluvirin. Children aged nine years and older should receive a single 0.5-mL intramuscular injection.
•Adults (17 years and older)

Adults must get a dosage of 0.5 ml. The vaccine must be injected into the gluteal part where may be a major nerve trunk. The needle of > equals to 1 must be used because when the needle is less than this, it finds Impossible to get to the nerve stacks of many adults.

Medicare Guidelines for CPT CODE 90657

CR8047 provides payment allowances for the following seasonal influenza virus vaccine codes when payment is based on 95 percent of the AWP (except for when payment is based on reasonable cost where the vaccine is furnished in a hospital outpatient department, a Rural Health Clinic, or a Federally Qualified Health Center):

** Current Procedural Terminology (CPT) codes 90654, 90655, 90656, 90657, 90660, and 90662; and

** Healthcare Common Procedure Coding System (HCPCS) codes Q2034, Q2035, Q2036, Q2037, and Q2038.

Effective for dates of service on or after August 1, 2012, the Medicare Part B payment allowance for:

** CPT 90655 is $16.456
** CPT 90656 is $12.398
** CPT 90657 is $6.023
** HCPCS Q2035 (Afluria®) is $11.543
** HCPCS Q2036 (Flulaval®) is $9.833
** HCPCS Q2037 (Fluvirin®) is $14.051
** HCPCS Q2038 (Fluzone®) is $12.046

Influenza Vaccine Codes

90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662 90664, 90672, 90673, 90685, 90687, 90686 90688

** Use the proper CPT or HCPCS code based on the vaccine type administered.
** For state-supplied vaccine, bill the CPT code.
** For non-state-supplied vaccine, bill the CPT code and append the -22 modifier.

Note: Please do not report the HCPCS II Q2034-2039. Do not report the Q code in addition to the CPT code (only one or the other can be reported)

Side effects

Like all the medicines, Fluvirin also has some side effects that vary from person to person. Consulting your doctor is a very good practice before getting your Fluvirin vaccination. Here are some side effects that are experienced by some users.

Back pain, cough, body discomfort and weakness, headache, mild fever, bruising, swelling, redness of the skin. Tenderness in the injected part, nausea, muscles or joint pain, and tiredness are some of the most common side effects of the medicine. These are some of the mild side effects that occur from Fluvirin vaccination. But there are some severe reactions that must be addressed by the doctor on an immediate basis.

**Extreme allergic reactions (hives, rash, difficulty breathing, itching, swelling of the mouth, throat, face, lips, or tongue, unusual hoarseness, wheezing),
**Numbness, tingling, or burning, confusion
**Reduced mobility of the muscles of the face
**Decreased sensation or movement in the shoulder or arm
**Dizziness
**Fainting
**Loss of appetite
**Muscle weakness
**Swollen, red, peeling skin, or blistered
**Seizures
**Persistent or severe headache or fever
**Vision changes
**Vomiting
These are some life threatening situations that must be informed to a medical emergency and ambulance. You should contact your doctor too, if you come across such a situation.

↧

CPT CODE 96116, 96118, 96119, 96120 -Neuropsychological testing

September 17, 2016, 3:02 am

≫ Next: CPT CODE 20680, 20670 - Removal of implant

≪ Previous: CPT CODE Q2037, 90657 - Fluvirin

CPT CODE and Description

96116 - Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report - Average fee amount - $75 - $110

96118 - Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report

96119 - Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report,

96120 - Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report

CPT Codes for Diagnostic Psychological and Neuropsychological Tests

The range of CPT codes used to report psychological and neuropsychological tests is 96101- 96120. CPT codes 96101, 96102, 96103, 96105, and 96111 are appropriate for use when billing for psychological tests. CPT codes 96116, 96118, 96119 and 96120 are appropriate for use when billing for neuropsychological tests.

All of the tests under this CPT code range 96101-96120 are indicated as active codes under the physician fee schedule database and are covered if medically necessary.

Coding Guidelines:

References to providers throughout this policy include non-physicians, such as clinical psychologists, independent psychologist, nurse practitioners, clinical nurse specialists and physician assistants when the services performed are within the scope of their clinical practice/education, licensed and authorized under the state law A minimum of 31 minutes must be provided to report any per hour code. Services 96101, 96116, 96118 and 96125 report time as (a) face–to-face with the patent and (b) time spent interpreting and preparing the report.

Typically, the neuropsychological evaluation requires 4-8 hours to perform, including administration, scoring, interpretation, report writing and interpretation to the patient and/or family. If the evaluation is performed over several days, the time should be combined and reported all on the last day of service .

CPT code equivalents of the most common components of the neuropsychological assessment include:

1. Direct clinical observation and interview with the patient, often with caregivers or significant others who serve as sources of information that the patient may be unable to provide (e.g., spouse, parent, adult child, care staff, therapists),
96116;

2. Review of medical records and, in some cases, other relevant records (e.g., work history, educational history, criminal or social services records, etc.), 96118;

Q: Can I perform psychological testing and psychotherapy on the same date of service?

A: No, the following therapy codes will be considered not separately reimbursed if provided on the same date of service as 96101, 96102, 96116, 96118, or 96119: 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90823, 90824, 90826, 90827.

Reimbursement changes for CPT code 96116

Clinical evaluation of thinking and other mental functions is ingrained into every day medical practice. Assessment can be as simple as recognition by the practitioner that a long-standing patient seems unable to report details and grasp the significance of a clinical situation or as complicated as an extensive battery of tests to sort out complex deficits. Several central nervous system assessment codes describe a middle ground. The examination is more detailed than a comprehensive evaluation and management examination, but less systematic and thorough than a comprehensive battery of
psychological or neuropsychological testing. Practices depend on the proper use of Current Procedural Terminology (CPT).

One of these codes is 96116- neurobehavioral status exam. It is defined in the CPT manual as ‘neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist’s or physician’s time, both face to face time with the member and time interpreting test results and preparing the report.’

We are implementing a new reimbursement policy that follows the CPT guidance restricting billable use of this code to psychologists and/or physicians. In addition, there will be a limit of 5 hours/units per year, to help ensure the code is being used consistently. Instances of services exceeding 5 hours/units per year are subject to review for case-specific detail This February 2014 Connecticut 14 of 20 policy applies to all commercial Anthem health plans. (Please note that Medicaid and Medicare plans may have additional regulation and other guidance about utilization.)

96116 Testing & Interpretation Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem Striving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report. $93

6. CPT code 96116 may be utilized by a neuropsychologist in lieu of 90791 to bill for an initial neuropsychological assessment visit, and may be utilized to bill for a 1 hour neurocognitive evaluation.

7. A psychologist who bills for services delivered by a psychometrist, psychometrician or CPA should use CPT code 96102 (for psychological testing) or 96119 (for neuropsychological testing).

8. A psychologist who bills for testing administered by computer should use CPT Code 96103 (psychological testing) or 96120 (for neuropsychological testing).

9. The Wada hemispheric activation test (CPT code 95958) is an open brain pre-surgical procedure when neuropsychological tests are administered along with EEG monitoring to determine the hemisphere of the brain responsible for cognitive functions such as speed and memory. The neuropsychological testing component is sometimes billed using the 65958 CPT code or may be billed using the 96118 neuropsychological testing CPT code. The neuropsychological testing component of the Wada test may be covered as a medical benefit.

96020 – Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered by a psychologist or physician, with review of test results and report. Note that CPT code 96020 should not be used in conjunction with 96101-96103, 96116, or 96120.

Neurobehavioral Status Exam

96116 – Neurobehavioral Status Exam: Clinical assessment of thinking, reasoning and judgment (e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of psychologist's or physician's time, both
8 face-to-face time with the patient and time interpreting test results and preparing the report.

What modifiers are valid when billed with Healthcare Common Procedure Coding System (HCPCS) code 96116?

Effective January 1, 2008, the following modifiers are valid when billed with HCPCS code 96116:

• GT – Via interactive audio and video telecommunications system

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CPT CODE 20680, 20670 - Removal of implant

September 20, 2016, 12:02 am

≫ Next: CPT CODE 27096, G0259, g0260 - SACROILIAC (SI) JOINT INJECTIONS

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cpt code and description

20680 - Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) - average fee amount-$600 - $650

20670 - Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) average fee amount - $400

When to Report the CPT Codes for Removal of Hardware Multiple Times

The June 2009 CPT Assistant has clarified when to report the removal of hardware CPT codes multiple times. It is only indicated when fixation device(s) are removed from separate fractures at different anatomical sites or for two fractures that are considered noncontiguous on the same bone (such as a proximal and distal fracture site).

One example shows that it would be appropriate to report 20680 and 20680-59 for a bimalleolar fracture when screw(s) are removed from the lateral malleolus (distal fibula) and then a plate with screws are removed from the medial malleolus (tibia) through a separate incision. It doesn’t matter what type of implant system was removed the deciding factor was that it was two different fracture sites.

An example of incorrect use would be reporting code 20680 twice when an intramedullary rod (IM rod) is removed. This usually cannot be accomplished through one incision since there are locking screws on both ends of the rod so stab incisions are
made proximal and distal to release the screws – this is still considered a single implant system for fixation of one fracture site. CPT code 20680 would only be reported once in this case.

20670 Removal of implant; superficial, (eg, buried wire, pin or rod) (separate procedure)

20680 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)

Medically Unlikely Edits (MUEs)

The code descriptors for CPT codes 20670 (removal of implant; superficial...) and 20680 (removal of implant; deep...) do not define the unit of service. CMS allows one unit of service for all implants removed from an anatomic site. This single unit of service includes the removal of all screws, rods, plates, wires, etc. from an anatomic site whether through one or more surgical incisions. An additional unit of service may be reported only if implant(s) are removed from a distinct and separate anatomic site.

Question: I am new to oral surgery coding and would like to know how to report this procedure. Our oral surgeon recently removed a previously implanted plate and screws using an intraoral approach. The patient had earlier suffered from a fracture of the body of the mandible on the right side. What CPT® codes should I report for this procedure? Also, do let me know how many units of the code should be reported (one for each screw and one for the plate or just one code)?

Answer: You will have to report the CPT® code 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]) for the removal of the implanted plate and screws.

You will just have to report the removal code once, irrespective of the number of screws and plate that your surgeon removed from the fracture site. You have to just report one unit of the code even if your clinician removed the implanted hardware from the site using different incisions.

So, in your case scenario, you will only have to report one unit of 20680 for the procedure or else your claim will be denied.

Reminder: If your clinician were to remove the implants from two different sites (mandible and the zygomatic arch) and one fracture was not related to the other, then you can report the multiple removal using 20680 and 20680 with the modifier 59 (Distinct procedural service) appended to the second unit. Provide documentation to identify that both the fractures were in
different sites and not linked to one another.

To tell if you should use one unit or two, look at the fracture care codes and check “if they are the same” If they’re different, you may report two units, if the implants are not all parts of the same fixation device.

The hardware has to be two independent entities; otherwise, you should consider this one fixation device and one unit of 20680.

• Hardware Removals

Use code 20680 for Deep Pin Removal procedures, where the physician makes an incision overlying the site of the implant dissects deeply to visualize the implant (which is usually below the muscle level and within bone), and uses instruments to remove the implant from the bone. The incision is repaired in multiple layers using sutures, staples, etc.

Superficial pin or K-wire removals not requiring a layered closure (such as K-wire removals) are billed with code 20670.

CPT Assistant and the AAOS (American Academy of Orthopedic Surgeons) direct that the 20680 code is to be billed once per fracture site, rather than based on the number of pieces of hardware removed or the number of incisions made to remove the hardware from one fracture site or original area of injury. Billing the 20680 code more than once is only appropriate when hardware removal is performed in a different anatomical site unrelated to the first fracture site or area of injury.

* Removal of Hardware from Ankles has its own procedure code, code 27704 for the Removal of an Ankle Implant, which should be used instead of the 20670 or 20680 codes. However, if only one or two screws are removed and it is not an extensive

procedure, use the applicable 20670 or 20680 code, instead, as the 27704 code is for a more involved/extensive procedure.

* Removal of a Finger or Hand Implant should be billed with the 26320 CPT code.

However, if only one or two screws are removed and it is not an extensive procedure, use the applicable 20670 or 20680 code.

* Removal of an Implant from the Elbow or Radial Head should be billed with codes 24160-24164. However, if only one or two screws are removed and it is not an extensive procedure, use the applicable 20670 or 20680 code.

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CPT CODE 27096, G0259, g0260 - SACROILIAC (SI) JOINT INJECTIONS

September 21, 2016, 12:13 am

≫ Next: CPT for shoulder Arthroscopy - 29806 , 29820 - 29828

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cpt code and description

27096 - Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed - average fee amount - $120 - $160

G0259 - Injection procedure for sacroiliac joint; arthrograpy

G0260 - Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

SACROILIAC (SI) JOINT INJECTIONS

The sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain.

The sacroiliac (SI) joint is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain. Low back pain of SI joint origin is a difficult clinical diagnosis and often one of exclusion. Injection of local anesthetic or contrast material is a useful diagnostic test to determine if the SI joint is the pain source. If the cause of pain in the lower back has been determined to be the SI joint, one of the options of treatment is injecting steroids and/or anesthetic agent(s) into the joint. Therapeutic injections of the SI joint would not likely be performed unless other noninvasive treatments have failed.

Image guidance is crucial to identify the optimal site for access to the joint. Fluoroscopy is often the imaging method of choice. Once the specific anatomy is identified, the needle tip is placed in the caudal aspect of the joint and contrast material is injected. Contrast fills the joint to delineate integrity (or lack thereof) of articular cartilage, as well as morphologic features of the joint space and capsule. Procedure code 27096 describes the injection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid. Since fluoroscopy is the key to precision diagnostic injections and accurate therapeutic injections, procedure code 27096 should be billed when imaging confirmation of intra-articular needle positioning has been performed, since this code includes both the injection and the image guidance procedure.

The injection procedure of the SI joint will be considered medically reasonable and necessary when it is used for imaging confirmation of intra-articular needle positioning for arthrography with or without therapeutic injection. In addition, the injection procedure of the SI joint will be considered medically necessary when an injection is given for therapeutic indications, such as injection of an anesthetic and/or steroid, to block the joint for immediate and potentially lasting pain relief. When therapeutic injections of the SI joint are performed, it would be expected that the record reflects noninvasive treatments (i.e., rest, physical therapy, NSAID’s, etc.) have failed.

SACROILIAC (SI) JOINT INJECTIONS

The sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain.

STOP – Impact to You

Some Medicare carriers have been reimbursing incorrectly for sacroiliac joint injection of anesthetic agents or steroids (HCPCS code G0260) when the procedure is performed in an Ambulatory Surgical Center (ASC). Also, due to several inadvertent coding conflicts, physicians at ASCs who perform an injection procedure for a sacroiliac joint, arthrography, and/or anesthetic/steroid (CPT code 27096) may be reimbursed incorrectly as well.

CAUTION – What You Need to Know

Some Medicare carriers may not have been paying the facility fee to ASCs when they billed Medicare for HCPCS code G0260—injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrogrophy. In addition, due to several inadvertent coding conflicts, physicians may not have been paid correctly for HCPCS code 27096—injection procedure for sacroiliac joint, arthrography, and/or anesthetic steroid—when administered in an ASC. Both of these issues apply to services rendered on or after July 1, 2003

Be aware that carriers reimburse a facility fee to the ASC for HCPCS code G0260 for services performed on or after July 1, 2003, and that physicians who perform HCPCS 27096 is an ASC should be reimbursed the non-facility payment amount.

Background

HCPCS code G0260 (sacroiliac joint injection of anesthetic agents or steroids) was added to the list of approved ASC procedures for services performed on or after July 1, 2003 (CMS-1885-FC, 3/28/03). Therefore, when a therapeutic sacroiliac joint injection is administered to a Medicare beneficiary at an Ambulatory Surgical Center, it should be reported by the ASC as HCPCS code G0260. HCPCS code G0260, however, is not payable under the Medicare Physician Fee Schedule (MPFS). Physicians use CPCS code 27096 to bill for sacroiliac joint injection of anesthetic agents or steroids. Since HCPCS code 27096 was not on the list of Medicare approved ASC procedures, physicians may have been overpaid when performing this procedure in an ASC.

To rectify this problem, carriers have been instructed to add CPT code 27096 to their file of ASC approved procedures. Physicians who perform a sacroiliac joint injection of anesthetic agents or steroids (CPT code 27096) will now be reimbursed at the correct rate under the Medicare physician fee schedule. Please note that, for those Medicare carriers who did not make this change in a timely manner, there is a time lag between the effective date of July 1, 2003 and their new implementation date of February 2, 2004. Given this difference, claims that are submitted on or after the effective date for date of service, but prior to the implementation date, will be processed under the old rules. If this has affected your payments, you may wish to submit adjustment claims after February 2 in order to correct the payment.

Sacroiliac (SI) Joint Injections (CPT codes 27096 and G0260)

* Medicare does not have a National Coverage Determination (NCD) for Sacroiliac (SI) Joint Injections.

* Local Coverage Determinations (LCDs) which address sacroiliac injections exist and compliance with these LCDs is required where applicable. For state-specific LCD, refer to the LCD Availability Grid (Attachment F).

* For states with no LCDs, see the Wisconsin Physicians Services Novitas LCD for Transforaminal Epidural, Paravertebral Facet and Sacroiliac Joint Injections (L34892) for coverage guidelines.

(IMPORTANT NOTE: After searching the Medicare Coverage Database, if no state LCD or Local Article is found, then use the above referenced policy.)

These are the only procedure where the CPT codes the ASC facility and the physician will bill may differ – codes are 27096 OR G0260.

27096 - Injection procedure for Sacroiliac Joint, Arthrography and/or Anesthetic/Steroid G0260 - Injection procedure for Sacroiliac Joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without Arthrography to be billed by ASC facilities ONLY.

* The ASC should use the G0260 code to bill SI Joint Injections to Medicare.

* The professional side (Physician claim) for SI Joint Injections should be billed to

Medicare with the 27096 code.

* The G0260 code is on the Medicare ASC list of covered procedures. The 27096 is NOT on the Medicare list of covered procedures. The physician and facility
CPT Codes are Copyrighted by the claim coding will not match in this instance, but this coding is the correct way to code the procedure.

* The 27096 code is for use when the ASC facility is billing SI Joint Injections to ayors other than Medicare, unless they want the G-code instead. The facility would NOT bill the 27096 code to Medicare.

* Radiology codes – for SI Joint Injections performed with Arthrography, the 73542-TC code should be billed. The Fluoroscopy code to use with SI Joint Injections when Arthrography is not performed is code 77003-TC. These codes are billable provided the payor allows the billing of radiology services – which Medicare does NOT reimburse.

* The G-code and 27096 codes are for use billing SI Joint Injections performed with radiologic guidance. If the SI Joint Injection is performed without the use of radiologic guidance, neither the G-code nor the 27096 should be billed. SI Joint

Injections performed without the use of radiologic guidance should be billed using the 20610 code for an Injection into a Major Joint (which reimbursed at a low rate by Medicare). The 20610 code would be used by both the physician and the ASC
facility.

* For a Radiofrequency Treatment of the SI Joint, use code 64640. The most common diagnosis codes for SI Joint Injection procedures are 724.6 for Disorders of the Sacrum and 720.2 for Sacroiliitis. If an injection is administered in the Sacroiliac Joint without the use of Fluoroscopic guidance, report only the procedure code for the SI Joint Injection.

A formal radiologic report must be dictated when using the 73542 code for the Arthrography. Do not report code 77003-TC with code 73542-TC. The injection of contrast material is inclusive. This is a unilateral procedure; when a bilateral procedure is performed, bill it in a Bilateral manner by appending the -RT/-LT or -50 Bilateral Modifiers. Report CPT code 73542-TC for the Arthrography performed with the –TC Modifier.

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