93224-93226: Snag Extra Cash With These Tips

Date: 13 Mar 2011 Comments:0

The catch is you have to make the request for your rightful dollars.

Here’s a piece of good news for you. As per the Medicare’s April update, three Holter monitor codes will get a slight boost in pay.

The change has an implementation date of April 4, 2011, and an effective date of Jan. 1, 2011. That means contractors have to be ready to comply with the change by April 4, but the change in practice expense relative value units (PE RVUs) is retroactive to Jan. 1 dates of service.

Medicare isn’t requiring contractors to search their files to adjust claims they have already paid (which is good news for any physician who reports a code seeing a fee decrease). But contractors do have to adjust claims if you bring them to their attention. Take a look at how many 93224-93227 services you provided from January to March to see if making the claim for the small increase in RVUs is worth your time.

93224: The PE RVUs for 93224 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation) will change from 2.30 to 2.53. That’s a difference of .23 RVUs. Multiply that by the 2011 conversion factor (33.9764), and you can expect roughly an additional $7.81 for this code. (Remember that geographic region will affect your fee, as well).

93225: For 93225 (…recording [includes connection, recording, and disconnection]), the PE RVUs only increase by .09, changing from 0.82 to 0.91. So the additional reimbursement should be roughly $3.06.

93226: You may see an additional $4.76 for 93226 (… scanning analysis with report). Its PE RVUs change from 1.21 to 1.35.

Swan-Ganz: If you ever report 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes), the news isn’t as nice. This code will see a decrease in PE RVUs, from 0.77 to 0.73. That means a decrease of about $1.36 per service.

Resources: CMS announced the changes in transmittal 2150, CR 7319 (www.cms.gov/transmittals/downloads/R2150CP.pdf). The agency also released an MLN Matters article on the change, available at www.cms.gov/MLNMattersArticles/Downloads/MM7319.pdf.

In 2013, Reporting Ureteral Stone Diagnoses Will Include More Options

Date: 10 Mar 2011 Comments:0

Here is what you should check in your physician’s documentation.

As the conversion takes place from ICD-9 to ICD-10 in 2013, you will not be treating the codes in a way you always did. Often, you will have more options that may need tweaking the way your physician documents a service and a coder reports it.

Have a look at this common ureteral stone diagnosis, and find out what you’ll report after October 1, 2013.

When your urologist treats a ureteral stone, you now apply ICD-9 code 592.1 (Calculus of ureter) to a specific procedure code (such as 52353, Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]).

ICD-10 difference is that
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92082 or 92083? Choose The Most Appropriate Code with Expert Help

Date: 8 Mar 2011 Comments:0

Even small ophthalmology practices are likely to have a Humphrey visual field analyzer, yet many ophthalmologists don’t know the secrets for securing adequate reimbursement for these services — and they even go so far as to put themselves at risk for costly audits due to lack of documentation.

CPT lists three different visual field examinations — and the higher the code, the higher the reimbursement.:

  • 92081 — Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (e.g., tangent screen, Autoplot, arc perimeter or single stimulus level automated test, such as Octopus 3 or 7 equivalent)
  • 92082 — … intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33)
  • 92083 — … extended examination (e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2 or 30/60-2).

A common mistake ophthalmologists make is billing 92082 when they could legitimately bill 92083.

The key to choosing the correct VF code is in the code descriptors themselves. For example, if the ophthalmologist plots only two isopters on the Goldmann perimeter, CPT would call that “intermediate,” based on its description of 92082. If you plotted three isopters, however, that would be an “extended” examination that would qualify for 92083.

Rule of thumb: An intermediate test is one of the screening tests that you would use if you suspect neurological damage. But ophthalmologists use the threshold exam (92083) when they suspect something that causes a slow, progressive dimming of peripheral vision, like glaucoma. Glaucoma causes a loss of vision like a light bulb slowly becoming dimmer and dimmer, while trauma often causes sudden, complete loss of central or peripheral vision. In screening fields, you are testing whether the retina is “on or off,” while in threshold testing you are testing “how dim a light you can perceive.”

“The bottom line is to document medical necessity for the level of visual field testing that is ordered,” says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director, Best Practices-Network Operations at Mount Sinai Hospital in New York City.

Document Now to Stop Headaches Later

When you send in a CMS-1500 form, Medicare only sees the front part of the form. What Medicare doesn’t see is what’s on the other side of that form, which is your documentation. They assume that your documentation is correct until they do an audit.

If Medicare does an audit and finds that your documentation is not in order, you could find yourself having to pay them back for all the claims they find problems with. That’s why it’s important to carefully document the medical necessity of the visual field exam in the patient’s medical record and the workup findings that were performed and led a physician to suspect a diagnosis, thereby ordering the diagnostic testing, notes Mac.

Following the diagnostic testing, one of the areas ophthalmologists are weak in is the “interpretation and report” portion of several codes, experts say. Code 92083 provides one example: Your record of a visual field states, “Informed patient test for OD showed small area we need to watch; have return in three months.” In a postpayment audit, Medicare will not accept this as an adequate interpretation of the test results and complete report to support the billing. Why? “Interpretation and report” requires assessment of both eyes.

Remember: All three visual field codes have a technical and professional component, notes David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas. When you bill 92083, you are telling Medicare you performed both the technical component (indicated by modifier TC) and the professional component (modifier 26). It’s best to have a form just for visual fields, in addition to your regular notes.

Overkill? Not at all, stresses Mac. “A formal report is required whenever the professional component of diagnostic services are billed. And in the case of an audit, such a form will be necessary to support the work performed by the physician which constitutes formal documentation of an interpretation and report.”

Know When to Append Modifier 50 on Bilateral CTS Shots

Date: 8 Mar 2011 Comments:0

Your orthopedist injects both of a patient’s wrists to treat carpal tunnel syndrome. Should you just file 20526 with modifier 50 appended and forget about it?

Not so fast: If the physician injects both the patient’s wrists to treat CTS, you will typically append modifier 50 (Bilateral procedure) to 20526 (Injection, therapeutic [e.g. local anesthetic, corticosteroid], carpal tunnel), says Kathleen F. Nelson, CPC, orthopedics professional coder at Fletcher Allen Health Care in Burlington, Vt. There are, however, some exceptions.

“This code carries a ‘1’ bilateral status indicator, which means this injection can be reported bilaterally. For many payers this would mean reporting the bilateral injections by appending modifier 50 to the 20526 CPT code and billing one unit of service,” says Marvel J Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of Denver’s MJH Consulting.

“It is always best to verify the insurance plan’s preference for reporting bilateral services, as there are some variances to ‘modifier 50 and one unit of service’ coding,” Hammer continues.

For example, Oregon Medicaid does not accept modifier 50, relays Jacqui Jones, office manager at an orthopedic practice in Klamath Falls, Ore.

If the carrier does not want you to file 20526-50, it will typically accept 20526-LT (Left side [used to identify procedures on the left side of the body) and 20526-RT (Right side [used to identify procedures on the right side of the body]) instead, Nelson says.

Emergency Reporting: Know When To Use +99140 With These Tips

Date: 8 Mar 2011 Comments:0

Reporting any qualifying circumstances (QC) codes for anesthesia can be tricky, but knowing when to classify a situation as a true emergency can be a real challenge unless you’re well-versed in the emergency conditions guidelines. Check coding definitions and your provider’s documentation to know whether you can legitimately add two extra units for +99140 (Anesthesia complicated by emergency conditions [specify] [List separately in addition to code for primary anesthesia procedure]) to your claim.

CPT includes a note with +99140 stating that “an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body parts.” Your key to knowing a case meets emergency conditions lies in your anesthesiologist’s notes.

“Quite a number of cases come in where the anesthesiologist marks ‘emergency’ but many times the ‘emergency’ isn’t all that clear,” says Leslie Johnson, CCS-P, CPC, director of coding and education for Medi-Corp., Inc., of New Jersey. Documentation supporting an emergency will depend on each case, so read the chart thoroughly when your provider indicates an emergency.

Solution: Talk with your anesthesia providers to clarify what constitutes an emergency and when you can include +99140. If there’s a real reason to report an emergency (such as a ruptured appendix, 540.0), your physician should clearly document the reason. Another diagnosis code to indicate a problem (such as unstable angina, 411.1) could help show the payer you’re reporting an unusual situation. The second diagnosis can also help in an appeal if a payer that ordinarily recognizes +99140 denies the claim.

“An OB patient who comes in for a cesarean section isn’t automatically an emergency,” explains Scott Groudine, M.D., professor of anesthesiology at Albany Medical Center in New York. “However, a diagnosis of fetal distress and prolapsed cord virtually always implies an emergency that can’t wait.” Under these circumstances, you could be justified in reporting +99140.

Remember ‘Unexpected’ Doesn’t Equal ‘Emergency’

Some physicians tend to add “emergency” to unexpected events, such as after hours or weekend cases they get called to attend. Timing alone isn’t enough to merit +99140, according to the Relative Value Guide (RVG).

Remember, when considering whether to report +99140, always ask yourself whether delaying treatment would have led to a significant increase in risk to the patient’s life or limb. If not, you shouldn’t include +99140.

Take for example, an 80-year-old man is admitted to the hospital with a hip fracture. The cardiologist won’t clear the patient for surgery until he has an echocardiogram the next day. Delaying surgery because of the echocardiogram doesn’t constitute an emergency. “Any case where you can wait eight hours for the patient’s stomach to empty or one to two days for cardiac optimization is not a true emergency,” Groudine says.

Follow the Payer’s Guidelines

Even if a case qualifies as an emergency, check the payer in question’s guidelines before automatically including +99140. Not every payer (including Medicare) recognizes qualifying circumstances codes or pays additional units for their use. But for payers that reimburse, you can add two base units to the claim.

Tip: Several state Medicaid plans pay for emergency circumstances but others won’t. You can’t negotiate payment with Medicaid — either they cover qualifying circumstances codes or they don’t — but do discuss qualifying circumstances when negotiating contracts with non-government payers. Include a contractual clause stating whether the payer reimburses based on the ASA’s RVG. If so, you can include a copy of the RVG page to remind the payer of your expected payment. You can also include the RVG page or CPT guidelines stating that an emergency is separately billable if you receive a denial and need to go through the appeal process. Join Supercoder.com to stay updated with the CPT guidelines.

Diagnosis Coding: G Codes Are Your Key To Coding Correct High Risk Colonoscopy

Date: 7 Mar 2011 Comments:0

Get your hemorrhoid report right and stress-free in a snap. We’ll tell you the difference between internal and external hemorrhoids, but you can learn more from this sample physician’s report:

PREPROCEDURE DIAGNOSIS: History of colon polyps and partial colon resection, right colon.


  1. Normal operative site.
  2. Mild diverticulosis of the sigmoid colon.
  3. Internal hemorrhoids.

PROCEDURE: Total colonoscopy.

PROCEDURE IN DETAIL: The 60-year-old patient presents to the office to be evaluated for the preprocedure diagnosis. The patient also apparently had an x-ray done at the hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed. She was prepped the night before and on the morning of the test with oral Fleet’s, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push. Digital rectal exam was done, unremarkable. At that point, the Pentax video colonoscope was inserted. The rectal vault appeared normal. The sigmoid showed diverticula throughout, mild to moderate in nature. The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized. The scope was passed a short distance up the ileum, which appeared normal. The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area. The scope was then retroflexed, and anal verge visualized showed some internal hemorrhoids.

RECOMMENDATIONS: Repeat colonoscopy in three years.

Let Location Guide You

You can easily identify external hemorrhoids (455.3-455.5) because of its place of appearance. This type of hemorrhoid has a fleshy growth and occurs around the anus — specifically, outside the anal verge which is at the distal end of the anal canal. On the other hand, internal hemorrhoids (455.0-455.2) occur inside the anal canal. The veins lining the walls of the rectum become enlarged (blood clot) and bulge out.

Another way to distinguish internal from external hemorrhoids is by looking at their location compared to the dentate line. The line is a mucocutaneous junction about a centimeter above the anal verge and can be seen separating the anus from the rectum. While internal hemorrhoids take place above the dentate line, external hemorrhoids take place below the line.

Ideal: While you may learn to differentiate one hemorrhoid type from the other through years of practice, you could dodge coding errors by asking your physicians to indicate “internal” or “external” in their notes.

By adding the following text note, CPT 2010 gives you the permission to use certain codes for excision of internal and/or external hemorrhoids: “For excision of internal and external hemorrhoids, see 46250-46262, 46320.” This means you can opt for 46255 (Hemorrhoidectomy, internal and external, single column/group) or 46260 (Hemorrhoidectomy, internal and external, 2 or more columns/groups) for excision of multiple internal hemorrhoids.

You may go for 46945 (Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group) or 46946 (Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups) for some internal hemorrhoid excisions.

How it’s done: Known as “transfixion suture excision,” the surgeon places a crisscross stitch and ties off the base of the hemorrhoid with the suture (ligation) to take control of the bleeding. Post this, the surgeon excises and removes the remaining hemorrhoid.

Alternatives: Sometimes a physician would inject solution to cause the hemorrhoid to harden and shrivel. In this case, you should report 46500 (Injection of sclerosing solution, hemorrhoids). For thermal destruction, you should bill 46930 (Destruction of internal hemorrhoid[s] by thermal energy [e.g., infrared coagulation, cautery, radiofrequency]). CPT 46999 (Unlisted procedure, anus) would fit a destruction by cryosurgery.

A patient might present to the office without a hemorrhoid diagnosis, but symptoms such as rectal pain (569.42, Anal or rectal pain) or rectal bleeding (569.3, Hemorrhage of rectum and anus) could give away the condition. During the office visit, the physician will usually perform an inspection of the external and she may add an anoscopy to look specifically for internal hemorrhoids or another cause of bleeding.

You would report the office visit with the following codes:

  • An E/M code for the visit depending on the complexity and documentation (i.e., 99202-99205) along with modifier 25 (Significant, separately identifiable E&M service by the same physician on the same day of a procedure or other service);
  • 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]);
  • 569.42, (Anal or rectal pain) or 569.3, (Hemorrhage of rectum and anus) for the patient’s symptoms.

Sometimes the patient gets diagnosed with hemorrhoids in the course of undergoing another procedure. This is the case in our example where the patient comes for a screening colonoscopy during which the gastroenterologist notices internal hemorrhoids. Generally, unless they’re causing a problem for the patient, the physician will leave the hemorrhoids alone, says Linda Parks, MA, CPC, CCP, business office coordinator, GI Diagnostics Endoscopy Center. “Usually a patient has to have a symptom, like rectal pain, for the GI doc to do anything about the hemorrhoids,” she explains. The physician usually doesn’t do anything with hemorrhoids unless the patient complains he is bothered by it.

You would report the example given above using the following codes:

  • G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) to describe the screening colonoscopy for high-risk patient;
  • V12.72 (Personal history of diseases of digestive-system; colonic polyps) linked to G0105 to prove medical necessity for the visit;
  • 562.10 (Diverticulosis of colon [without hemorrhage]) for the diverticulosis of the sigmoid colon linked to G0105;
  • 455.0 (Internal hemorrhoids without complication) G0105 to describe the internal hemorrhoids.

Reminder: Medicare patients aged 50 and above are entitled to a screening colonoscopy once every 10 years. You should bill non high-risk encounters with G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

CCI UPDATE 97597-97598: CCI Will Correct Debridement Glitch

Date: 3 Mar 2011 Comments:0

Hang on to your claims for these wound care management codes.

As most veteran coders know, you can’t report an add-on code unless you report it along with its “parent code” on the same claim. But an NCCI glitch has made it impossible for you to collect for both the debridement add-on code 97598 and its partner code 97597 — creating denied claims and confusion for practices that perform active wound care management. However, a new announcement indicating that the NCCI is fixing the problem should ease your coding angst.

The American Podiatric Medical Association (APMA) issued a release on its Web site stating that the National Correct Coding Initiative (NCCI) edits currently bundle the following two codes together:

97597 — Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less
+97598 — …each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

This edit bundle has an indicator of “0,” meaning that no modifier can separate these codes. Fortunately, the APMA caught the error and contacted the NCCI director about it.

“The NCCI is currently working on a solution and recommends that APMA members delay submission of claims reporting combination of CPT 97597 and CPT 97598 until the NCCI replacement file is in place and implemented by CMS,” the APMA’s statement says. “The April 1, 2011 version of NCCI does not contain this edit error.”

The APMA has not yet gotten word on whether Medicare contractors will automatically reprocess claims that were paid in error due to this incorrect edit. Keep an eye on Part B Insider as MACs distribute information about whether you’ll have to resubmit the claims denied under this edit or not.

To read the APMA’s complete statement on this issue, visit www.multibriefs.com/briefs/apma/CPT_97597.pdf.

Know the Types of Graft

Date: 2 Mar 2011 Comments:0

Question: What’s the difference between a spinal allograft and an autograft?

Answer: If the surgeon harvests bone from the patient’s own body, you’ll code for an autograft with one of the following codes:

+20936 — Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)

+20937 — … morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)

+20938 — … structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure).

Example: The surgeon removes a portion of bone from the patient’s rib through the same thoracic spinal exposure site, reshapes the bone as necessary, and grafts it onto the spine for reconstruction. For this autograft, report +20936 along with the code for the primary surgical procedure.

The bone the surgeon uses during an allograft, however, comes from another human donor . When the surgeon performs an allograft, he’ll also use synthetic applications. For allografts, report one of these codes:

+20930 — Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)

+20931 — … structural for spine surgery only (List separately in addition to code for primary procedure).

Allograft clue: If operative notes indicate that the bone came from a bone bank, you’ll automatically choose an allograft code.

Ensure Compliance With ICD-10 With These 3 Tips

Date: 1 Mar 2011 Comments:0

When ICD-9 becomes ICD-10 in 2013, you will not always have a simple crosswalk relationship between old codes and the new ones. Often, you’ll have more options that may require tweaking the way you document services and a coder reports it. Check out the following examples of how ICD-10 will change your coding options when the calendar turns to Oct. 1, 2013.

Celebrate Sinusitis Codes’ One-to-One Relationship for ICD-10

When your physician treats a patient for sinusitis, you should report the appropriate sinusitis code for sinus membrane lining inflammation. Use 461.x for acute sinusitis. For chronic sinusitis — frequent or persistent infections lasting more than three months — assign 473.x.

For both acute and chronic conditions, you’ll choose the fourth digit code based on where the sinusitis occurs. For example, for ethmoidal chronic sinusitis, you should report (473.2, Chronic sinusitis; ethmoidal). Your otolaryngologist will most likely prescribe a decongestant, pain reliever or antibiotics to treat sinusitis.

ICD-10 difference: Good news. These sinusitis options have a one-to-one match with upcoming ICD-10 codes. For acute sinusitis diagnoses, you’ll look at the J01.-0 codes. For instance, 461.0 (Acute maxillary sinusitis) translates to J01.00 (Acute maxillary sinusitis, unspecified). Code 461.1 (Acute frontal sinusitis) maps directly to J01.10 (Acute frontal sinusitis). Notice how the definitions are mostly identical. Like ICD-9, the fourth digit changes to specify location.

For chronic sinusitis diagnoses, you’ll look to the J32.- codes. For instance, in the example above, 473.2 maps direction to J32.2 (Chronic ethmoidal sinusitis). Again, this is a direct one-to-one ratio with identical definitions. Like ICD-9, the fourth digit changes to specify location.

Physician documentation: Currently, the physician should pinpoint the location of the sinusitis. This won’t change in 2013.

However, you’ll scrap the 461.x and 473.x options and turn to J01.-0 and J32.- in your ICD-10 manual. Except for the change in code number and the addition of a letter, you should treat these claims the same as before.

Heightened Documentation For Osteoarthritis in 2013

Suppose your diagnoses osteoarthrosis (715.xx-716. xx) in a new patient. These codes specify location, primary, or secondary.

ICD-10 difference: Once Oct. 1, 2013 rolls around, you should look to:

M15 (Polyosteoarthritis)

M16 (Osteoarthritis of hip)

M17 (Osteoarthritis of knee)

M18 (Osteoarthritis of first carpometacarpal joint)

M19 (Other and unspecified osteoarthritis).

These codes are broken down into location, primary, and secondary like your ICD-9 codes, but they also sometimes specify unilateral, bilateral, and posttraumatic indications.

Physician documentation: To submit the most detailed diagnosis, the physician will need to maintain osteoarthrosis documentation but expand it to unilateral, bilateral, and/or post-traumatic specification. Some key terms are “osteoarthritis,” “arthritis,” “arthrosis,” “DJD,” “arthropathy,” “post traumatic arthritis,” and “traumatic arthritis.”

Coder tips: Notice how codes M19.01–M19.93 entail unspecified locations. ICD-10 no longer group unspecified locations alongside the specific locations for each type (as in, the familiar .9 code in most ICD-9 categories). You will find them at the end of the code grouping (M19.90–”M19.93) for each specific type but in an unspecified location.

In addition, traumatic osteoarthritis is now more appropriately indexed and described as post-traumatic osteoarthritis, the true condition.

As the ICD-10 implementation deadline approaches, look to Part B Insider for more tips on how to translate your coding from ICD-9 to ICD-10.

4 Tips Help You Ensure Inhaler Service Success

Date: 1 Mar 2011 Comments:0

Often a nurse or medical assistant helps a patient with an inhaler demo or evaluation, but whenever coding it, you must keep these three areas in mind: the type of device used, documentation requirements, and qualifying modifiers. Follow these four tips from our experts to understand why some payers might deny payment for the service — and what you can do to win deserved dollars.

1. Categorize the Diskus Correctly

Many physician offices use the Advair Diskus for their patients, which is an aerosol generator. “An aerosol generator is a device that produces airborne suspensions of small particles for inhalation therapy,” explains Peter Koukounas, owner of Hippocratic Solutions medical billing service in Fairfield, N.J. If the nurse or medical assistant taught someone to use an Advair Diskus — or any other diskus — you should report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

The physician starts a patient with asthma (493.00, Extrinsic asthma; unspecified or 493.20, Chronic obstructive asthma; unspecified) on Advair. A nurse then teaches the patient how to use the Diskus. According to CPT guidelines, you should report 99201-99215 for the office visit (depending on whether you’re treating a new or established patient). Then report 94664, but don’t append a modifier, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

CMS transmittal R954CP indicates that modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) applies only to E/M services performed with procedures that have a global fee period. Code 94664 does not have a global fee period, which is why you don’t automatically include modifier 25.

Despite what CMS guidelines might state, many payers will only reimburse for the service if you append modifier 25 to the visit code. Check your major insurers’ policies to learn their requirements.

2. Include Treatment in Teaching Session

The physician might administer a medication dose during the teaching session. If so, remember that both services (treatment + teaching) are bundled into 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device]). Because of this, you’ll only report 94640 since the physician performed the administration as part of the demonstration/evaluation.

3. Remember Modifier 59 for Extra Education

Consider this scenario: An asthmatic patient is wheezing and having difficulty breathing during an outpatient visit. She requires one or more bronchodilator treatments for intervention: 493.01 (Extrinsic asthma; with status asthmaticus), 493.02 (Extrinsic asthma; with [acute] exacerbation), 493.21 (Chronic obstructive asthma; with status asthmaticus), or 493.22 (Chronic obstructive asthma; with [acute] exacerbation). During questioning, your physician discovers that the patient didn’t use her MDI device or nebulizer properly prior to her visit. After he treats the patient, he provides her with additional education about how to use the devices.

First, report 94640. If your physician offers multiple treatments, report 94640 the appropriate number of times and append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional). Include the appropriate E/M code without a modifier, unless the payer requires modifier 25 with the E/M. Next, report 94664 with modifier 59 (Distinct procedural service), as the patient required additional instruction for his daily maintenance medication. This is different from the medication provided for immediate intervention (94640).

If the patient required separate education after receiving an inhalation treatment on the same day, you would bill both services (treatment + education), appending modifier 59 to 94664.

The Correct Coding Initiative (CCI) edit on 94640 and 94664 has a “1” in the modifier column, signaling that you can override the edit with the proper modifier. So Medicare and payers that follow CCI edits will require modifier 59 on the component code (94664) to indicate that the teaching is a distinct procedural service from the inhalation treatment.

4. Prove Medical Necessity

Reporting 94664 can garner almost $16 for your physician, based on the national Medicare non-facility rate payment schedule. Do your part in achieving reimbursement by encouraging physicians to document medical necessity for 94664.

Ask your physicians to document in the plan or treatment portion of the written record that the patient requires a teaching session on the use of his MDI, diskus, nebulizer, etc. In addition, don’t forget to document why the session is necessary. “Remember, if you don’t document what occurred, the payers will consider it didn’t happen,” Plummer reminds.

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