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The Appropriate Use Criteria (AUC) program, slated to begin Jan. 1, 2021, has been postponed. A notice on the Centers for Medicare & Medicaid Services (CMS) website states that the educational and operations testing period will now continue through 2021. “We encourage stakeholders to use this period to learn, test and prepare for the AUC […]
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Novitas Solutions recently issued a Modifier 50 Fact Sheet, reminding medical coders of the proper use for this CPT payment modifier. The Medicare Administrative Contractor (MAC) for jurisdictions H and L warns that, effective for Part B claims received on and after Aug. 16, 2019, services will be rejected as unprocessable when modifier 50 Bilateral […]
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A TCM service was started for a patient who was in the hospital and worked up for chest pain. All diagnostic testing was negative. A 2 day outreach, medication reconciliation and a face-to-face visit with the physician was completed. The physician addressed the patient’s resolved chest pain, stable hypertension and stable hyperlipidemia. He ordered the nurse to follow up with the patient in a week to get an updated status on the patient’s condition. Wants to make sure the patient is not having any chest pain symptoms that may prompt the patient to go back to the hospital. The RN called the patient who was feeling fine and reported no chest pain symptoms.
Is it appropriate to report a TCM service for this patient considering clinical non-face-to-face services only included a follow-up phone call to the patient to address current health status?
Thank you!!
Is your outpatient facility on board with new regulations for the ordering and furnishing of advanced diagnostic imaging services? Advanced diagnostic imaging services have long been under scrutiny by the Office of Inspector General for Medicare fraud and abuse, and the Centers for Medicare & Medicaid Services (CMS) responds to the watchdog’s recommendations each year […]
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Question: During the course of a planned surgical procedure, if the surgeon discovers some pathology requiring maneuvers that are NOT a part of the major procedure or global surgery package, something considered by the surgeon to be medically necessary and perhaps unrelated to the planned procedure, is this separately reportable? I do not have a specific example at this time.
What is known: In page 10, chapter 1 of the CMS NCCI Policy manual, it is clearly outlined what is considered integral to a planned surgical procedure… a smaller portion inclusive of a larger procedure. This chapter also covers sequential procedures, conversions, and intraoperative complications and what is not separately reportable.
But, Ch1, page 15 of NCCI Policy Manual states: "If exploration of the surgical field results in additional procedures other than the primary procedure, the additional procedures may generally be reported separately." CMS 2018 NCCI Policy Manual, Ch1, General Correct Coding Policies
Can anyone help me out with this?
First scenario:
During a revascularization procedure, first a diagnostic angiography (for example CPT 75710) is performed which leads to the therapeutic procedure (for example CPT 37220). After/during angioplasty, the physician did a few more angiography to confirm that the procedure is successful, i.e. completely removal of occlusion. Should we report the angiography prior to angioplasty with modifier 59? How should we report the angiography done during/after the angioplasty? — are they considered part of the therapeutic procedure?
Second scenario:
An anesthesiologist performs a nerve block after surgery for post-operative pain management. For example the CPT code for the nerve block is 64486 or 64488. In the CPT descriptor, both codes include "imaging guidance", so CPT 76942 should NOT be reported separately, correct? Also 64486 should be reported with modifier LT/RT and 64488 should be reported with modifier 59 as they are performed for post-op pain management, is this appropriate?
In the case of CPT 64447, we will be reporting it along with CPT 76942, it that the case?
I need your opinions and advice about the appropriate use of Modifier 25. This is a common scenario in which my doc will indicate the need for modifier 25. Please let me know your opinion on it.
The patient is referred to us as a new patient for an injection. We schedule the pt, the dr sees the pt, dictates a complete and perfect level 3 or 4 new patient evaluation. The Dr then, during the same session, performs the injection that the pt was referred for. The Dr completes a separate procedure note for the injection. When the superbill is submitted to the billing team the codes selected are 99204-25, 62321. With the information that I have given, do you believe it is appropriate to bill for the initial evaluation separately? It seems to me that the initial eval shouldn’t be coded in a case such as this. But the argument from the docs/management is that the workup that is being done in the inital eval warrants the separate billing of the E&M. I agree that they are spending a lot of time visiting w/ the pt and doing the appropriate work involved for their coded level of E&M. But I get nervous because the pt was referred for an injection, and they got that injection that same day. Is the extensive separate documentation for the E&M sufficient to bill? Please help!