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Preventative Medicine Visits CPT Code 99381-87 (new) 99291-97 (est). Preventative Medicine Visit Codes include payment for:The review of ?stable" chronic problemsRoutine Screenings (eg. Pap smear, breast
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1. HCAEncounter Form EducationMay 2006
Medicare Physicals
Documentation Requirements
Procedures
Home Health Certification
2. Preventative Medicine Visits CPT Code 99381-87 (new) 99291-97 (est) Preventative Medicine Visit Codes include payment for:
The review of “stable” chronic problems
Routine Screenings (eg. Pap smear, breast & pelvic, manual rectal exam)
Risk Factor Counseling
Billable Separately When Billed on Same Day as Physical are:
99211-99215 E&M Office Visit codes (for re-management of existing problems or new problems (need mod 25)
Do not bill 2 new E&M’s in same day
Injections, Immunizations
Procedures Performed (exception Medicaid – they will only pay for procedure)
Some Screenings
Labs (Indicate signs/symptoms or diagnosis to support testing)
3. Physicals - Medicare
MC does not pay for physicals (99381-87; 99391-97) other then new mc beneficiaries (next slide)
They will pay for 99211-99215 services (eg. medically necessary follow-up or new problems addressed during a physical.
They will pay for problems addressed during a physical when a modifier 25 is affixed.
MC will pay for screenings performed during a physical if the service is performed during a covered period. (eg. paps covered every 2 yrs).
4. Physicals Medicare “New MC Beneficiary”
G0344: Effective 1/1/05 MC will pay physical / new MC enrollee / within 6 mths
G0366: EKG (global)
G0367 (EKG tracking only)
G0368 (EKG Inter & Rep Only)
Medicare does not pay for routine annual physicals (99381-87; 99391-97)
Medicare will pay for 99211-99215 services (eg. medically necessary follow- up or new problems) billed w/physicals. Mod 25 needs to be affixed to 99211-15 codes.
5. Medicare – “New MC Beneficiary” Required Documentation Initial Exam includes review of:
HPI
Attention to risk factors for disease detection
Past medical, Social & Surgical history
Experiences w/illnesses
Hospital stays
Operations
Allergies
Injuries & treatments
Current medication & supplements
FH (hereditary or place the individual at risk) History of alcohol, tobacco,
illicit drug use
Diet
Physical activities
Psych Eval - Depression
Individual’s potential (risk factors) for depression including current or past experiences w/depression or other mood disorders.
Refer to appropriate screening instrument for persons without a current diagnosis of depression recognized by a National Professional Medical Organizations.
6. Medicare – “New MC Beneficiary” Required Documentation
EKG
Performance and interpretation of an EKG.
Functional Abilities / Level of Safety
Mininum review must include assessment of:
Hearing impairment
Activities of daily living
Falls risk
Home safety
Examination
Measurement of individual’s height, weight, blood pressure
Visual acuity screen
Other age-appropriate factors as deemed appropriate by the provider based on the individual’s med/social history and current clinical standards.
7. Medicare – “New MC Beneficiary” Required Documentation Risk Factor Counseling
Education, counseling and referral as deemed appropriate by the provider based on results of the review
Provide Brief Written Plan
A checklist or alternative provided to the individual for obtaining the appropriate screening and other preventive services which are covered separately under Medicare Part B.
11 points checklist:
Immunizations (pneumococcal, Influenza, Hep B and their administration.
Mammography screening
Pap smear & pelvic examination screening
Prostate cancer screening tests
Colorectal cancer screening tests
Diabetes outpatient self-mgmt training services
Bone mass measurements
Glaucoma screening
Medical nutrition therapy for individuals with diabetes or renal disease
Cardiovascular screening blood tests
Diabetes screening tests
8. Injection – Administration CodesBill Administration along w/”J” Supply Code when appropriate Identify Type of Injection
Immunization 90471; 90472
Immunization – Pedi Codes 90465-90468
Infusion “hydrate” up to 1 hr 90760
ea additional 90761
Infusion “therapeutic/diagnostic”
Initial Infusion up to 1hr 90765
ea additional up to 8 hrs 90766
Addl sequential infusion
up to 1 hr 90767
concurrent infusion 90768
Injection, single/initial; IM or SQ (eg. Depo; B12) 90772
Injection, intra-arterial 90773
IV push, initial/single drug 90774
each additional new drug 90775
9. Injection – Administration CodesImmunizations - Pedi The new pediatric administration codes were developed to recognize “physician time”
spent counseling parents on the risks (e.g., reactions) and benefits of vaccination for
children under 8 yrs. of age. Note: Discussions and/or counseling performed by a nurse
with the parents does not qualify for use of 90465-68. Instead the nurse would use the
old codes 90471-72.
90465 - admin under 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day
90466 - ea addl injection (single or combination vaccine/toxoid), per day
90467 - admin under age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day
90468 - ea addl admin (single or combination vaccine/toxoid), per day
10. Telephone Calls (99371-99373)
Telephone Calls (CPT Codes 99371-99373): Simple, intermediate or complex phone
calls made by a physician to the patient or other health care allied professional that are
*medically necessary to manage and coordinate patient care.
Documentation Required:
Date of call
Reason for call
Treatment given
Involved parties named (other then pt)
Follow-up instructions
11. Telephone Calls What Supports Medical Necessity?
AMA Examples of Reimbursable Telephone Services:
Services that involve a new diagnosis or require a new treatment plan (eg. acute respiratory illness) when the equivalent service performed in person would have led to a service charge itself.
Patient maintenance services, such as management of insulin-dependent diabetics with multiple blood-sugar checks and insulin changes.
Treating relapses of a previous condition when this can be adequately assessed by phone, but a significant investment of physician time and judgment are involved (eg. irritable bowel; asthma; congestive heart failure; flare-up of gout)
Reporting laboratory results (for laboratory work not done in conjunction with an office visit) that require a significant change in medication or further diagnostic tests (eg. adjustment of warfarin after a prothrombin time is done; addition of a second drug when treating hyperlipidemia; or ordering gallbladder studies when liver functions are abnormal on routine studies).
12. Telephone Calls - continued Extended personal counseling by telephone when the specific situation of an urgent nature, where a physical exam is not essential or necessary to perform the service, and where failure to perform the service could lead to patient harm.
An established patient with acute exacerbation of a severe anxiety disorder or depression, commonly involving discussion of medications or recommended psychotherapy needs, mental status and mood assessment, and recommendations for further immediate care.
A test result entails a referral for a significantly complex procedure, with the potential for morbidity, complex preparation, and/or hospitalization; however, the discussion, consent and instructions do not require a face-to-face encounter (eg. breast lump found on mammogram; positive treadmill entails a cardiology referral and possible angiogram; patient refusal of a test or treatment previously discussed in detail necessitates further discussion and counseling).
Nursing or rest home calls when the patient has a significant change in condition, such as a change in vital signs, respiratory infection, or fall.
Extended counseling with family when done by telephone (eg. cases in which there are significant intrafamily conflicts or deficits in understanding related to a patient under direct care).
13. Home Health AideCertification – Form 485 G0180: Physician certification services:
Patient is NOT present
Certification covers 60 days
Completed by the ordering provider
You can bill both a G0180 and a G0181 within a 30 day period.
Provider Note includes review & supportive documentation on:
Initial and subsequent reports on patient’s status
patient’s responses to the oasis assessment
adequate contact with the home health
agency to follow-up on initial/subsequent management plan(s) .
G0179: Physician "recertification" srvs - Patient is NOT present documentation ncludes
patient’s status
patient’s responses to the oasis assessment
adequate contact with the home health
14. Procedures
Foreign Body Removal
Ear Wax Removal 69210 (hearing loss pays;
impacted cerumen does not)
Hearing Loss (389.90) pays
Otalgia (388.70) pays
EKGs
EKG Routine 93000 (mod 76 repeat)
15. Procedures Lesions
Lesion / Skin Tags 11200 (up to 15)
11201 (ea. addl grp of 10)
Lesions / Common or Plantar Wart 17000 (1) plus
17003 (for ea. addl – indicate)
Example: 6 removed bill 17000 x1 and 17003 x5 = 6
Lesions / Flat Warts, Molluscum /Milia 17110 up to 14
17115 15 or more report code.
Lesion / Vulva 56501
Lesion / Vaginal 57061
Lesion / Penis (cryo) 54056
16. Procedures Gyn / Contraceptive Management
Diaphragm or Cervical Cap Fitting 57170
Insertion of IUD 58300
Removal of IUD 58301
Fitting and Insertion of pessary or other
intravaginal support device 57160
Airway Management
Nebulizer Treatment 94640
Nebulizer Treatment (subsequent) 94640-76
Inhaler Instructions (teaching) 94664-59
Spirometry 94010
Bronchospasm Evaluation 94060
17. Procedures
Incision & Drainage ; Puncture
Incision & Drainage (abcess, cyst) 10060
Incision & Drainage of Pilonidal Cyst 10080
Incision & Removal of Foreign Body, subcut 10120
Incision & Drainage of Hematoma, seroma
or fluid collection 10140
Puncture aspiration of abscess, hematoma,
bulla or cyst 10160
18. Procedures Paring/Cutting/Trimming/Excision
Paring/Cutting of benigh hyperkeratotic lesion
(corn or callus) single lesion 11055
Paring/Cutting or benign hyperkeratotic lesion
corn/callus 2-4 lesion 11056
Trimming of non-dystrophic nails, any # 11719
Debridement of 1-5 nails 11720
Debridement of 6-10 nails 11721
Avulsion (toenail plate) 11730
Excision of nail / nail matrix 11750
Wedge Excision of nail fold 11765
19. Procedures Epitaxis
Control Nasal Hemorrhage, Anterior
Packing; Simple 30901
Control Nasal Hemorrhage, Posterior
Packing, Initial 30905
Packing, Subsequent 30906
No Modifier is Necessary
Excisions
Excisions Lesion (trunk, arms, legs) Benign Malignant
0.6 to 1.0cm 11401 11601
1.1 to 2.0cm 11402 11602
2.1 to 3.0cm 11403 11603
20. Procedures
Aspiration and/or Injection
20600 “Small Joint” , bursa or ganlion cyst (eg. fingers, toe)
20605 “Intermediate joint”, bursa or ganglion cyst (eg.
temporomandibular, acromioclavicular, wrist, elbow or
ankle (olecranon bursa).
20610 “Major Joint”, bursa or ganglion cyst (eg. shoulder, hip,
knee joint, subaromial bursa).
21. Procedures Tendon/Ligament / Ganglion Cyst / Injections / Excisions
There must be an inflammatory process in a given tendon (tendonitis)
or tendon sheath tenosynovitis)
CPT Codes:
20526 Injection of carpal tunnel with local anes or corticosteroid
20550 Injection(s); single tendon sheath, or ligament,plantar fascia)
20551 Injection(s); single tendon origin/insertion
20612 Aspiration and/or injection of ganglion cyst(s) any location
25111 Excision of Ganglion, wrist (dorsal or volar); primary
25112 Excision of Ganglion, wrist (dorsal or valar) recurrent
22. Procedures
Trigger Point Injections
Use 20552 Injection(s); single or multiple trigger point(s), one or two muscle(s) – regardless of the # of injections in those muscle groups
Use 20553 Injection(s); single or multiple trigger point(s), three or more muscle(s) – regardless of the # of injections within those muscle groups
23. Procedures EXCISION CPT Codes (size, location needed) 11400-11471 (benign) 11600-11646 (malignant) Excision codes are used to reflect “full-thickness” (through dermis) removal of a lesion
Select a cpt code based on lesion diameter plus the most narrow margins
required which equals the excised diameter.
Codes are also based on body area /location (eg. trunk/arms/ legs is 1 body area)
Use Modifier 59 when multiple lesions are removed in a single body area
(eg. reflect different lesions, different site, different methods in same body area)
Use Modifier 58 – for all re-excisions (eg. didn’t get all margins – pt. comes back)
Select a CPT code after the path report has returned as malignant lesions require
different coding and reimburse at a much higher rate.
Simple Suturing codes ( less then 0.5 cm) - (12001-12021) are bundled into excision codes.
You can code additionally for simple (greater then .05cm) intermediate or complex
repairs
Code only the most complex procedure when multiple procedures are performed on
same lesion/same day.
Example: If a physician removes a self-contained cyst and not an “area” of skin code as excision vs. debridement. (eg. Sebaceous Cyst)
24. ProceduresSHAVING CPT Codes11300-11313
(Shaving of Epidermal or Dermal Lesions)
Shaving = sharp removal of epidermal and dermal lesions without
a full thickness dermal excision.
Code Partial thickness removal (not through dermis) as shaving.
Shaving codes are used when lesions are completely removed w/scalpel, scissors.
Typically shaving does not require sutures.
25. ProceduresDEBRIDEMENT CPT Codes11000-11044
Surgical excision of dead, devitalized, or contaminated tissue and
removal of foreign matter from a wound.
26. ProceduresBIOPSY CPT Codes11100 – 11101 Biopsies remove a “portion” of a lesion for diagnostic purposes.
Excisional biopsies removes “all”.
Multiple biopsies on the same lesion may only be coded as a “single lesion”
You cannot code a biopsy and removal in the same day. Different days yes.
Modifier 59 needed when you biopsy “one” lesion & “excise” another on the same day.
Note: modifier 59 should be affixed to biopsy code.
No modifier is necessary if the biopsy and excision are performed on separate days.
You can code an E&M office visit (99211-15) with a biopsy if the patient presents with
If
27. Procedures
Wound Repair
Simple Suturing
12001 simple repair scalp, neck,axillae,ext genitalia,trunk and/or
extremities (includes hands/feet) 2.5cm or less.
12011 simple repair of face, ears, eyelids, nose, lips and/or mucous
membrances 2.5cm or less.