Can I Bill for a Bilateral Trigger Point Injection using CPT 20552-20553? The answer is NO. See reasons below: I know it has always been a challenge on how do we properly bill and code for Trigger Point Injections using 20552 and 20553. Because these codes are being reported based on the number of muscles.
Let's describe these 2 injection codes:
Many are still so confused on how to bill for Trigger Points. Here are my Coding and Billing Tips: 1. There is NO anatomical modifier; these 2 codes are not unilateral - so modifier 50, LT or RT is not applicable; 2. Code and bill based on the number of muscles (not number of injections!) 3. You can append modifier 59 if it meets the guideline and necessity 4. Possible Imaging Used (may be any of the following): 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation 77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) 77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation
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How to Bill for Multiple EKG Performed by the Same Physician on the Same Day You can append the Modifier 76 - same service performed on the same day by the same physician. We apply this Modifier on the second line. The first line DO NOT require a modifier. The second line of the same CPT code will be appended with modifier 76.
Understanding Telemedicine:
Telemedicine is the delivery of medical healthcare services using HIPAA-compliant and secure electronic communications, information technology, or other electronic or technological means to bridge the gap between a health care provider who is located at a distant site and a patient who is located at an originating site, either with or without the assistance of an intervening health care provider for the purpose of diagnosis, consultation, and/or treatment of a patient. We need to understand though that Telemedicine does not include the use:
What a "Distant site" means - it is a site which the health care provider, working within their scope of practice and a valid license or certification, is located while providing health care services by means of HIPAA-compliant telemedicine technology. What an "Originating site" means - it is a site at which a patient is located at the time that health care services are provided to the patient by means of telemedicine. Synchronous means live (real-time live), two-way interaction between a person and a provider using audio-visual telecommunications technology. Asynchronous also known as “store and forward” or “non-interactive telecommunication” means the acquisition and transmission of images, diagnostics, data, and medical information either to, or from, and originating site or to, or from, the healthcare provider at a distant site which allows for the patient to be evaluated without being physically present. What are the covered services in Telemedicine? Well it depends on your insurance payers. But you can find Medicare's guidelines here, CLICK HERE. Other Payers?, you can scroll down as I have added several payers. Common Modifiers used for Telehealth ServicesModifier 95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. Please refer to Appendix P within the American Medical Association’s Current Procedural Terminology (CPT®) code manual to review the CPT codes for which a "95" modifier can be used to indicate that the service was provided via a real-time, interactive audio and video telecommunications system. Modifier GT Via interactive audio and video telecommunications systems Modifier GQ Services provided via asynchronous ** always check with your payers if the above Modifiers are acceptable based on their policy. Place of Service code use 02 *** check with your payers if POS 02 is applicable for telemedicine services based on their policy Commercial and Private Payers Policy Blue Cross Blue Shield of New Jersey - Telemedicine Services
The following lists of codes is provided as an informational tool only, to help identify some of the applicable CPT® codes/code ranges and HCPCS codes that may be utilized in reporting telemedicine services. The inclusion of a specific code does not indicate eligibility for coverage in all situations. CPT Codes 90785, 90863, 96116, 90791-90792, 90832-90838, 90839-90840, 90845-90847, 90951-90961, 90963-90966, 90967-90970, 96150-96154, 96160-96161, 97802-97804, 99201-99205, 99211-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99354-99357, 99406-99407, 99408-99409, 99495-99496, 99497-99498 HCPCS Codes G0108-G0109, G0270, G0296, G0396-G0397, G0406, G0407, G0408, G0420-G0421, G0425-G0427, G0438-G0439, G0459, G0473, G0506, G0508-G0509, G0513-G0514, S0199 The following services are not eligible for reimbursement under this policy:
Medicare's Telehealth and Telemedicine Services during Covid-19. Understanding Provider and Non-Provider Services. Understanding “EXPANSION OF TELEHEALTH WITH 1135 WAIVER”  So, under this Waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020 (date of service). Due to the Coronavirus (COVID-19) Public Health Emergency, doctors and other health care providers can use telehealth services to treat COVID-19 (and for other medically reasonable purposes) from offices, hospitals, and places of residence (like homes, nursing homes, and assisted living facilities) as of March 6, 2020. Medicare will pay for these services for patients who have seen the health care provider or another health care provider in the same practice. These visits are considered as in-person visits and are paid at the rate as regular, in person visits. Starting services rendered on March 6, 2020 and for the duration of the Covid-19 Public Health Emergency, Medicare will make payment for Telehealth Medicine Professional services rendered to Medicare beneficiaries in:
Deductible and Coinsurance will normally apply to these services. But the HHS Office of the Inspector General or the OIG is providing flexibility for healthcare Providers to reduce or waive cost-sharing for telehealth visits paid by the federal healthcare programs. It is imperative during this public health emergency that patients avoid / should not travel, when possible, to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness. Accordingly, the Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act. Prior to this Waiver: Medicare could only pay for telehealth on a limited basis: that is; when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service. Changes in last year (2019), Medicare started reimbursing for brief communications or Virtual Check-Ins, which are short patient-initiated communications with a healthcare practitioner. Medicare Part B separately pays clinicians for E-visits, which are non-face-to-face patient-initiated communications through an online patient portal as well. Effective date of service March 6, 2020: Providers can provide and render Telehealth Medicine including Evaluation and Management visits (E/M common office visits), Mental Health Counseling and Preventive Health Screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to the doctor’s office or hospital which puts themselves and others at risk for Covid-19. Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings. While they must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility or hospital for the visit, effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Since the 1135 Waiver requires an established relationship, HHS however will not conduct an audit for all claims submitted during this public health emergency. Question: Will I get Paid? as a Provider? Answer: YES based on MEDICAL NECESSITY! We have 3 types of VIRTUAL SERVICES:
Telehealth Visits: What’s required? The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home. Distant site practitioners and clinicians who can furnish and get reimbursement for covered telehealth services is subject to State Law. REMEMBER! - report using PLACE OF SERVICE is 02 Let’s identify the Providers Billable Services: 3 types of VIRTUAL SERVICES:
Telehealth Visits: What’s required? The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home. Distant site practitioners and clinicians who can furnish and get reimbursement for covered telehealth services (check your State Law as this is subject to State Law) may include the following:
Covered Telehealth Services CY 2020 (Updated 11/01/19) Source: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes Virtual Check-ins visits may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. Virtual Check-ins visits: Virtual check-ins can be used for the treatment for the Coronavirus (COVID-19) from anywhere, including places of residence (like homes, nursing homes, and assisted living facilities). Virtual check-in services will be initiated by the patient; however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation. Must render only to established Medicare patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. Services render via:
Here are your billable codes for Virtual Check-ins visits are as follows: HCPCS code G2012 Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. Requirements:
*** As being recommended by CMS to use G2012 for telehealth services. More information, click here. HCPCS code G2010 Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M Evaluation and Management service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment. Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare Telehealth or Telemedicine visits, which require audio and visual capabilities for real-time communication. e-visits services are only rendered via an online patient portal. e-VISITS Services: E-visits services are only rendered via an online patient portal. These services can only be reported when the billing practice has an established relationship with the patient. This is not limited to only rural settings. There are no geographic or location restrictions for these visits. Practitioners who may furnish these services include:
Your Billable Codes for e-visits are as follows: CPT 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes CPT 99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes CPT 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes. Clinicians who may not independently bill for evaluation and management visits . For example are:
They can also provide these e-visits and bill using the following codes: HCPCS Code G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes HCPCS Code G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes HCPCS Code G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes. For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html For Medicare Beneficiaries, you can learn more about telehealth services here - https://www.medicare.gov/coverage/telehealth  HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA): Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html HEADS-UP! - Use of GT modifier on Medicare claims was eliminated in 2018. According to CMS, the place of service code 02 is sufficient. To read more on Medicare Payment for Telemedicine. - CLICK HERE Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners 190 - Medicare Payment for Telehealth Services 190.1 - Background 190.2 - Eligibility Criteria 190.3 - List of Medicare Telehealth Services 190.3.1 - Telehealth Consultation Services, Emergency Department or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits 190.3.2 - Telehealth Consultation Services, Emergency Department or Initial Inpatient Defined 190.3.3 - Follow-Up Inpatient Telehealth Consultations Defined 190.3.4 – Payment for ESRD-Related Services as a Telehealth Service 190.3.5 – Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services 190.3.6 – Payment for Diabetes Self-Management Training (DSMT) as a Telehealth Service 190.3.7 – Payment for Telehealth for Individuals with Acute Stroke 190.4 - Conditions of Payment 190.5 - Originating Site Facility Fee Payment Methodology 190.6 - Payment Methodology for Physician/Practitioner at the Distant Site 190.6.1 - Submission of Telehealth Claims for Distant Site Practitioners 190.6.2 - Exception for Store and Forward (Non-Interactive) Telehealth 190.7 - A/B MAC (B) Editing of Telehealth Claims Timeline and Important Links: (source: CMS.GOV) For more information on telehealth benefits in the Medicare program, read the fact sheet: https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf.
Summary of CMS Public Health Action on COVID-19 to date: March 6, 2020, CMS issued frequently asked questions and answers (FAQs) for healthcare providers regarding Medicare payment for laboratory test and other services related to the 2019-Novel Coronavirus (COVID-19). https://www.cms.gov/newsroom/press-releases/covid-19-response-news-alert-cms-issues-frequently-asked-questions-assist-medicare-providers March 5, 2020: CMS issued a second Healthcare Common Procedure Coding System (HCPCS) code for certain COVID-19 laboratory tests, in addition to three fact sheets about coverage and benefits for medical services related to COVID-19 for CMS programs. https://www.cms.gov/newsroom/press-releases/cms-develops-additional-code-coronavirus-lab-tests March 4, 2020: CMS issued a call to action to healthcare providers nationwide and offered important guidance to help State Survey Agencies and Accrediting Organizations prioritize their inspections of healthcare. https://www.cms.gov/newsroom/press-releases/cms-announces-actions-address-spread-coronavirus February 13, 2020: CMS issued a new HCPCS code for providers and laboratories to test patients for COVID-19. https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test February 6, 2020: CMS gave CLIA-certified laboratories information about how they can test for SARS-CoV-2. https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/notification-surveyors-authorization-emergency-use-cdc-2019-novel-coronavirus-2019-ncov-real-time-rt February 6, 2020: CMS issued a memo to help the nation’s healthcare facilities take critical steps to prepare for COVID-19. https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/information-healthcare-facilities-concerning-2019-novel-coronavirus-illness-2019-ncov For the updated information on the range of CMS activities to address COVID-19, visit: https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page How are the Commercial Payers' Policy on Telehealth during this trying time due to Covid-19? A3843 Requires health insurance and Medicaid coverage for testing of coronavirus disease 2019 and for telemedicine and telehealth during coronavirus disease 2019 state of emergency. - NJ State New York State Medicaid Coverage and Reimbursement Policy for Services Related to TRICARE covers the use of interactive audio/video technology services, and are subject to the same referral and authorization requirements and include, but are not limited to: clinical consultations, office visits and telemental health. CLICK HERE for more details. Telehealth visits: what’s required? The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home. Distant site practitioners and clinicians who can furnish and get reimbursement for covered telehealth services (check your State Law as this is subject to State Law) may include the following:
Medicare Covered Telehealth Services CY 2020 (Updated 11/01/19) Code Short Descriptor
90785 Psytx complex interactive 90791 Psych diagnostic evaluation 90792 Psych diag eval w/med srvcs 90832 Psytx pt&/family 30 minutes 90833 Psytx pt&/fam w/e&m 30 min 90834 Psytx pt&/family 45 minutes 90836 Psytx pt&/fam w/e&m 45 min 90837 Psytx pt&/family 60 minutes 90838 Psytx pt&/fam w/e&m 60 min 90839 Psytx crisis initial 60 min 90840 Psytx crisis ea addl 30 min 90845 Psychoanalysis 90846 Family psytx w/o patient 90847 Family psytx w/patient 90951 Esrd serv 4 visits p mo <2yr 90952 Esrd serv 2-3 vsts p mo <2yr 90954 Esrd serv 4 vsts p mo 2-11 90955 Esrd srv 2-3 vsts p mo 2-11 90957 Esrd srv 4 vsts p mo 12-19 90958 Esrd srv 2-3 vsts p mo 12-19 90960 Esrd srv 4 visits p mo 20+ 90961 Esrd srv 2-3 vsts p mo 20+ 90963 Esrd home pt serv p mo <2yrs 90964 Esrd home pt serv p mo 2-11 90965 Esrd home pt serv p mo 12-19 90966 Esrd home pt serv p mo 20+ 90967 Esrd home pt serv p day <2 90968 Esrd home pt serv p day 2-11 90969 Esrd home pt serv p day 12-19 90970 Esrd home pt serv p day 20+ 96116 Neurobehavioral status exam 96150 Assess hlth/behave init 96151 Assess hlth/behave subseq 96152 Intervene hlth/behave indiv 96153 Intervene hlth/behave group 96154 Interv hlth/behav fam w/pt 96160 Pt-focused hlth risk assmt 96161 Caregiver health risk assmt 97802 Medical nutrition indiv in 97803 Med nutrition indiv subseq 97804 Medical nutrition group 99201 Office/outpatient visit new 99202 Office/outpatient visit new 99203 Office/outpatient visit new 99204 Office/outpatient visit new 99205 Office/outpatient visit new 99211 Office/outpatient visit est 99212 Office/outpatient visit est 99213 Office/outpatient visit est 99214 Office/outpatient visit est 99215 Office/outpatient visit est 99231 Subsequent hospital care 99232 Subsequent hospital care 99233 Subsequent hospital care 99307 Nursing fac care subseq 99308 Nursing fac care subseq 99309 Nursing fac care subseq 99310 Nursing fac care subseq 99354 Prolonged service office 99355 Prolonged service office 99356 Prolonged service inpatient 99357 Prolonged service inpatient 99406 Behav chng smoking 3-10 min 99407 Behav chng smoking > 10 min 99495 Trans care mgmt 14 day disch 99496 Trans care mgmt 7 day disch 99497 Advncd care plan 30 min 99498 Advncd are plan addl 30 min G0108 Diab manage trn per indiv G0109 Diab manage trn ind/group G0270 Mnt subs tx for change dx G0296 Visit to determ ldct elig G0396 Alcohol/subs interv 15-30mn G0397 Alcohol/subs interv >30 min G0406 Inpt/tele follow up 15 G0407 Inpt/tele follow up 25 G0408 Inpt/tele follow up 35 G0420 Ed svc ckd ind per session G0421 Ed svc ckd grp per session G0425 Inpt/ed teleconsult30 G0426 Inpt/ed teleconsult50 G0427 Inpt/ed teleconsult70 G0436 Tobacco-use counsel 3-10 min G0437 Tobacco-use counsel>10min G0438 Ppps, initial visit G0439 Ppps, subseq visit G0442 Annual alcohol screen 15 min G0443 Brief alcohol misuse counsel G0444 Depression screen annual G0445 High inten beh couns std 30m G0446 Intens behave ther cardio dx G0447 Behavior counsel obesity 15m G0459 Telehealth inpt pharm mgmt G0506 Comp asses care plan ccm svc G0508 Crit care telehea consult 60 G0509 Crit care telehea consult 50 G0513 Prolong prev svcs, first 30m G0514 Prolong prev svcs, addl 30m G2086 Off base opioid tx first m G2087 Off base opioid tx, sub m G2088 Off opioid tx month add 30 Source: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes When Medicare is a Primary Insurance for the patient, the patient's part responsibility (coinsurance/deductible) normally crosses over to its secondary insurance for secondary coverage (if Medicare has the secondary insurance on file or if its set up to cross over based on the patient's coordination of benefits).
As you will notice on your Remittance advise, "Claim Information forwarded to: (insurance company here) Meaning, Medicare will forward the information to the secondary insurance. If not, try to find out if there is a secondary insurance for the patient, then you need to send the paper claim (using the HCFA 1500 form for Office/Provider/Professional Claims) to the secondary and attach a copy of the Medicare EOB (explanation of benefits). If your Practice Software can bill secondary to Medicare electronically, then that's great! Send them by electronic. If your practice management software is capable of doing this by electronic submission with attached copy of the EOB - much better!After you submit the claim to the secondary insurance, the secondary insurance EOB will then tell you if there is a copay being applied towards the patient being a secondary insurance after Medicare.You will then obviously collect that copay based on your contract with the secondary insurance company (and this is also based on the patient's contract with his/her secondary insurance). Medicare patients are mostly aware of their responsibility after the secondary insurance picks up. Bottom line here: (1) Medicare must process (not deny or reject!) the claim first being the primary; (2) Secondary insurance must then process the claim with Medicare's claim information; (3) Then, if there is a copay being applied towards the patient's responsibility -- you have to bill your patient for that copay!But honestly, I do not collect secondary insurance copay not until the secondary insurance had processed the claim (after Medicare's allowance!). WHY? because it is possible that the patient may no longer have an active policy (at the time of service) with the secondary insurance, or maybe, there is no more copay because the patient had met his/her out of pocket limit. So to streamline this issue (of which not all offices are doing it) - you must always check benefits and eligibility for your patient's primary, secondary or even tertiary insurance coverage!It may be a lot of work too, but what I do is that, when I am billing the patient a copay (from the secondary insurance's determination and per the EOB) or even for their coinsurance! I do my best to attach a copy of the EOB on the statement. That way, the patient has a copy of the said EOB and he/she will understand why I am billing him/her. How do you describe CPT 99204? Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive examination; medical decision making of moderate complexity. Counseling and/ or coordination of care with other physicians, other qualified health care professionals, 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 of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. How do you report CPT 99205? - read below. Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 components: A comprehensive history; A comprehensive examination; Medical decision making of the complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family needs. Usually, the presenting problems(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family CPT 99204 and or CPT 99205 Key Points:
5 Mindful ways to Improving Patient Access Access is a significant concern in the United States and all over the world when it comes to patient care. We all know that the patients have to wait for months to get the physician they want, and a good doctor has more patients than they can manage. The patients waiting for months to get the physician surely lead to delayed treatment and also can jeopardize their health and their life. On the other hand, it will certainly reduce the patient satisfaction scores for the doctors and the medical service providers. As these scores have to be shared with third parties such as pharmaceuticals and drug companies as well as the insurance companies, managing the scores is extremely significant for the doctors. So here are a few ways that you can make sure your patients are not sitting and waiting for you to give them an appointment for half a year. Step 1: Learn how to Measure The first appointment available is a valuable commodity. So make sure that you have a good system to call people who are on the waiting list. Not just the first appointment available, but the second and third appointments available can also be prescheduled. You should inform the patients that are on the waiting list that they can be called in for a consult at short notice. When a person is coming up for the next available appointment, you can inform them that they are next on the list. That will allow individuals to prepare for showing up without feeling like it was impractical to ask on such short notice. Call people up or have a reminder system in place that will inform people on the list when they are next on the list of first appointment available. There are many openings happening every day, and placing then effectively can reduce overextended waiting lists considerably. Step 2: Denied Appointment Requests The patients who were denied an appointment is also a crucial list that needs to be monitored closely. There are many reasons that a patient is denied care, and those reasons should be listed clearly. If there is no appointment available or the appointment is not given for another reason, the reasons should be listed. That process will allow the nurses and administration to solve the problem and will allow them to develop a system that reduces denied appointments. Step 3: Implementation of the Data The main focus of all of the points mentioned above is to have a system that focuses on developing data sheets on appointment schedules so that you can decide how to have a more productive appointment culture. Here are a few steps you should take in the implementation process:
● Ask your administration about how they feel that they are being pushed too hard in the appointment process. ● Develop a severity scale of the patient’s complaint in the form of a questionnaire. The patient will answer the questionnaire on the phone, and the nurse or staff can decide how urgently they need to see the doctor. Step 4: Effective Ways to Problem Solving Find effective and simple solutions that will increase patient access on a daily basis. A few and simple tips on the matter are as follows: ● Have four backup appointments for every day that the patients have already been informed of. That way, the patient can simply come in if another patient cancels their appointment, and they will already be prepared for it. ● Patients on their second consult or with small concerns can come and see the doctor while the first patient is getting their physical. ● If there is a list of symptoms common in the specialty of the doctor, then nurses can provide that list to the administrator. If a patient complains of these symptoms, then they will be called in by the nursing staff on an urgent basis. ● Avoid letting worthy patients go to waiting lists for chronic complainers. Patients who have a tendency to over complaint can be seen and managed by the nursing staff. Step 5: Execute Now, all it is left is to reorganize these concepts and make sure that they are implemented effectively. You will see amazing results with a small number of initiatives. We are here for any ideas that you want to discuss. We are experts in the field. Share your experiences with us in the comments section, and we would love to get back to you! How to Bill for Knee Genicular Nerve Branches RFA or Ablation, Destruction Billing for the Genicular Nerve Branches RFA have been a struggle since it was not too clear to us on how we should be billing for this service. The good news is, we have a new code for this effective January 1, 2020. New CPT 2020 Changes. New Pain Management 202 Codes. When your physician is performing an RFA on Genicular nerves, use code 64624 (Destruction by neurolytic agent of genicular nerve branches). Take note of the word "branches". These changes are explained as follows: Destruction by Neurolytic Agent (eg, Chemical, Thermal, Electrical or Radiofrequency), Chemodenervation on the Somatic Nerves CPT CODE 64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (Do not report 64624 in conjunction with 64454 - Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed Pay attention to this, the CPT 64624 requires the destruction of each of the following genicular nerve branches: (make sure your Provider had documented this!)
If a neurolytic agent for the purposes of destruction is not applied to all of these nerve branches, you can report CPT 64624 but you MUST append the MODIFIER 52: 64624-52 What is Modifier 52? Modifier 52 is usually used for reduced services. It may occur under certain circumstances that a service or procedure is partially reduced or eliminated at the physician’s discretion. There can be several reasons behind the physician’s decision. In this situation, service provided can be identified by its usual procedure number and the addition of the modifier 52, which indicates that the service was reduced.  What is the CPT code for Knee Genicular Nerve Branches Block or Injection? When your Physician is Blocking the Knee Genicular Nerves - here's your code: (pay attention with the imaging! it is included!).
CPT 64454 - Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches; (make sure your Provider had documented this!)
If all 3 of these genicular nerve branches are not injected, report 64454 with Modifier; 64454-52 What is Modifier 52? Modifier 52 is usually used for reduced services. It may occur under certain circumstances that a service or procedure is partially reduced or eliminated at the physician’s discretion. There can be several reasons behind the physician’s decision. In this situation, service provided can be identified by its usual procedure number and the addition of the modifier 52, which indicates that the service was reduced. Article Source: CPT Assistant December 2019 page 8 Destruction by Neurolytic Agent (Genicular Injection; Radiofrequency Neurotomy Sacroiliac Joint) For Current Procedural Terminology Got additional questions or concerns? call us today! When your Pain Physician performed a Peripheral Nerve Blocks (unilateral) at the Dorsal Ramus Nerve levels L5, S1, S2 and S3, we would always look on CPT Codes 64450 (Injection, anesthetic agent; other peripheral nerve or branch) for the S1, S2 and S3.  Here's the good news! Effective January 1, 2020, we now have a more specific code instead of using the "other peripheral" nerve block. Our 2020 Pain Management New Code is:
64451, Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or CT computed tomography), should be reported once for this procedure. The fluoroscopic guidance should not be separately reported as it is included in the work described with code 64451.  Here are the 7 Common Reasons that I know make sense why many physicians cannot make more money! 1. Reimbursements are NOT being Maximized due to Poor Medical Coding Knowledge, Skill and Analysis Let me show you some example: a. Bilateral Procedure billed anatomically at only "one side" b. Surgery Converted to Open Procedure (the OP report documents from "Lap" to "Open" was performed) - how will you bill and code for this encounter? You may not know this, you cannot bill for both lap and open (check your CCI Edits!) together. And the guideline says, you have to report "Open" on your claim upon submission. c. Unbundling/bundling services that are billable based on the "Edits" and medical necessity d. No knowledge on how to utilize and use Modifiers e. Too naive that payments processed at 100% of the charged amount ("allowed amount") is NOT GOOD! - it would've allowed more! 2. Out of Network Physician Services Payments can be a Big Challenge! Non-contracted physicians can be very challenging. Especially when they send the payments directly to their member / the patient! Any one experienced this? That's why it is very important that you "Accept Assignment" and make your patient sign a re-assignment of benefits so you get paid directly by the insurance company! 3. Lack of Effective Collection Techniques and Staff Traininga. Copay is always due at the time of service - do many physicians do collect copay upfront? b. How often are patient statements being sent out? c. ... there's a lot more to site! 4. Now, isn't it Time to Negotiate Fees and Update the Fee Schedule?When was the last time or have you ever thought of renegotiating your contracted fees? Wouldn't it be time to analyze and review your contracts? Maybe its time to renegotiate your fees. 5. Missing "Revenue-Making" Opportunity for Additional Services in the PracticeOne good example, they know they can make big profit-margin on medically coded LSO Back Braces. And yet, they hesitate to even look at it. The truth is, it is always based on Medical Necessity! and Real-Time-Accurate Documentation, Period. You have to know your guidelines, policies and limitations. They are all out there, well documented. For instance, as a Physician, you are exempted to the Accreditation Process and Surety Bond - as long as you ONLY provide the LSO braces to your own patients as part of your services. 6. Low Productivity is also one of the Reasons! a. Physician Services b. Accounts Receivables Collection 7. Too Much Cost Running the Practice a. Staffing b. Technology c. Supplies d. Lease There you go the 7 reasons I think why Physicians can not make more money! And there is only one recommendation I can give to every physician out there - become a Leader. Build a team within your practice rather than employee and managers. Provide training and education to everyone including your self. Here are my 3 Useful Tips (and so easy to implement in your office): 1. Always check and verify patient's insurance benefits and eligibility (imperative!) 2. Always know your payers' clinical and reimbursement guidelines, policies and limitations (do your best!) 3. Hire the most qualified and experienced billing and coding staff or choose the right billing service company that are experienced based on your specialty. (very important to consider!) Be open to every possibility and strategic planning that you can definitely run a profitable practice while focusing on delivering high quality patient care.I hope you found value in this article. Your comment will be highly appreciated. Is your practice STRUGGLING?! Call us at 609-481-3494 When to use Medicare's ABN Advanced Beneficiary Notice Claim Reporting Modifiers  ABN is NOT something you can routinely give to Medicare Beneficiaries (your patients!) There are guidelines we need to follow and the ABN can only be used when (any of the following applies);
Here are your Medicare ABN Modifiers that you can utilize  GA: (Waiver of liability statement issued as required by payer policy, individual case). Use this modifier to report when you issue a mandatory ABN for a service as required and it is on file. You do not need to submit a copy of the ABN, but you must have it available on request. GX: (Notice of liability issued, voluntary under payer policy). Use this modifier to report when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded or is not a Medicare benefit. You may use this modifier in combination with modifier GY. GY: (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit). Use this modifier to report that Medicare statutorily excludes the item or service or the item or service does not meet the definition of any Medicare benefit. You may use this modifier in combination with modifier GX. GZ: (Item or service expected to be denied as not reasonable and necessary). Use this modifier to report when you expect Medicare to deny payment of the item or service due to a lack of medical necessity and no ABN was issued. WHEN NOT TO USE AN ADVANCE WRITTEN NOTICE OF NONCOVERAGE Do not use an advance written notice of noncoverage for items and services you furnish under Medicare Advantage (Part C) or the Medicare Prescription Drug Benefit (Part D). You are not required to notify the beneficiary before you furnish items or services that are not a Medicare benefit or that Medicare never covers, such as:
 call us today! (609) 481-34942019 New CPT Codes Medicare Payments for Virtual Services Remote Monitoring Interprofessional Consultation CMS - The Centers for Medicare & Medicaid Services (CMS) published the 2019 Medicare Physician Fee Schedule Final Rule, which includes a significant expansion of Medicare reimbursement for virtual (non-face-to-face) services furnished by physician practices in November 2018. In the Final Rule, CMS noted “[i]n recent years, we have sought to recognize significant changes in healthcare practice, especially innovations in the active management and ongoing care of chronically ill patients. . . .” However, CMS’ efforts to promote these innovations have been limited by its interpretation of the statutory restrictions on Medicare reimbursement for telehealth services. While CMS previously interpreted the geographic and site-of-service restrictions found in Section 1834(m) of the Social Security Act as applying to any virtual service, CMS now recognizes that these rules apply only “to a discrete set of physicians’ services that ordinarily involve, and are defined, coded, and paid for as if they were furnished during an in-person encounter between a patient and a healthcare professional.” By contrast, “services that are defined by, and inherently involve the use of, communication technology” are not subject to the Section 1834(m) restrictions. In making this distinction, CMS opened the door to new payment for remote patient monitoring (RPM), virtual check-ins, and interprofessional internet consultations.  Understanding Remote Patient Monitoring Services This is what we know, in 2018, Medicare began reimbursing for Remote Patient Monitoring using the CPT® code 99091. Then, this year 2019, CMS will now reimburse for Remote Patient Monitoring using the new codes (see below) and in addition to the earlier CPT® code 99091 Let's look at our codes here: CPT® Code 99453: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment. Approximate Allowable/Reimbursement Fee Schedule: $21.00 CPT® Code 99454: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. Approximate Allowable/Reimbursement Fee Schedule: $69.00 CPT® Code 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month. Approximate Allowable/Reimbursement Fee Schedule: $54.00 Keypoints: 1. The first two codes are reimbursement for the practice expense associated with rendering the Remote Patient Monitoring RPM services; no physician work is required to bill for either of this code. 2. Remember that the Remote Patient Monitoring Services may be billed for the same patient, on the same month as chronic care management (CCM) services, provided that the time spent for CPT® code 99457 is in addition to (and not the same as) the time spent for CPT® 99490, 99487, or 99489. In the Final Rule, CMS summarized the numerous comments it received regarding the new Remote Patient Monitoring Services codes, especially that pertaining to what types of technology that meet the requirements/guidelines for Remote Patient Monitoring. CMS thus stated “to issue guidance to help inform practitioners and stakeholders on these issues.” CMS offered no timeframe for the publication of such guidance. Without this guidance, providers likely will be unwilling to make investments in Remote Patient Monitoring programs. Here comes the Virtual Check-Ins: Introducing HCPCS G2012! n the past years, its been hard to get paid for separate payment for patient telephone calls that determines if an office visit or other service is justified. If the physician should want to see the patient, CMS considers the check-in as bundled into the service for the encounter. Earlier this year, CMS acknowledged the problems this reimbursement model creates: To the extent that these kinds of check-ins become more effective at addressing patient concerns and needs using evolving technology, we believe that the overall payment implications of considering the services to be broadly bundled becomes more problematic. Effectively, the better practitioners are in leveraging technology to furnish effective check-ins that mitigate the need for potentially unnecessary office visits, the fewer billable services they furnish. Given the evolving technological landscape, we believe this creates incentives that are inconsistent with current trends in medical practice and potentially undermines payment accuracy. In an effort to address these misaligned incentives, CMS now will pay for virtual check-ins using HCPCS G2012 (approximate allowable amount: $13). The reimbursable service is narrowly defined: Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified healthcare professional who can report evaluation and management [E/M] services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. CMS set the reimbursement for this service at approximately $15, citing “low work time and intensity.” For now, there are no frequency limits on this service, although CMS noted it may impose such limits if it detects over-utilization. In the Final Rule, CMS clarified “that telephone calls that involve only clinical staff (cannot) be billed using HCPCS G2012, since the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.” Also, CMS elected to require “verbal consent that is noted in the medical record for each billed service” and to limit eligibility to established patients. In addition to reimbursement for synchronous communication, CMS will also pay for—under another new code, HCPCS G2010—remote evaluation of patient-submitted recorded video and/or images. This reimbursable service also is narrowly defined: Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. CMS clarified that patient follow-up may take place “via any mode of communication, including secure text messaging, phone call, or live/asynchronous video chat, so as not to restrict a clinician’s interaction with patients.” Again, the provider must document the beneficiary’s consent in the record (regardless of whether such consent is provided verbally, in writing, or by electronic confirmation) and eligibility is limited to established patients. CMS also created a new HCPCS G0071 for virtual communication services furnished by a rural health clinic (RHC) or federally qualified health center (FQHC). Specifically, an RHC or FQHC may receive reimbursement for “at least 5 minutes of communication technology-based or remote evaluation services” furnished for a patient who has had an RHC or FQHC billable visit within the last year. This service is subject to the same limitations as HCPCS G2012 and G2010 with regard to prior and subsequent in-person visits. Payment for HCPCS G0071 is set at the average of the national non-facility payment rates for HCPCS G2010 and G2012. CMS expects usage of virtual check-ins will be limited at first, “result[ing] in fewer than 1 million visits in the first year. . . .” However, CMS predicts usage of these services “will eventually result in more than 19 million visits per year. . . .” Interprofessional Internet Consultation Because specialists receive no reimbursement for time spent consulting with treating practitioners regarding specific patients, specialist input often requires scheduling a separate patient visit when telephonic or internet-based interaction between the specialist and the treating practitioner would suffice. CMS then Introduced the InterProfessional Consultations using a Six New Codes (see below)  Remote Patient Monitoring Services This is what we know. In 2018, Medicare began reimbursing for Remote Patient Monitoring using the CPT® code 99091. Then, this year 2019, CMS will now reimburse for Remote Patient Monitoring using the new codes (see below) and in addition to the earlier CPT® code 99091 Let's look at our codes here: CPT® Code 99453: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment. Approximate Allowable/Reimbursement Fee Schedule: $21.00 CPT® Code 99454: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. Approximate Allowable/Reimbursement Fee Schedule: $69.00 CPT® Code 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month. Approximate Allowable/Reimbursement Fee Schedule: $54.00 Keypoints: 1. The first two codes are reimbursement for the practice expense associated with rendering the Remote Patient Monitoring RPM services; no physician work is required to bill for either of this code. 2. Remember that the Remote Patient Monitoring Services may be billed for the same patient, on the same month as chronic care management (CCM) services, provided that the time spent for CPT® code 99457 is in addition to (and not the same as) the time spent for CPT® 99490, 99487, or 99489. In the Final Rule, CMS summarized the numerous comments it received regarding the new Remote Patient Monitoring Services codes, especially that pertaining to what types of technology that meet the requirements/guidelines for Remote Patient Monitoring. CMS thus stated “to issue guidance to help inform practitioners and stakeholders on these issues.” CMS offered no time frame for the publication of such guidance. Without this guidance, providers likely will be unwilling to make investments in Remote Patient Monitoring programs. Here comes the Virtual Check-Ins: Introducing HCPCS G2012 In the past years, its been hard to get paid for separate payment for patient telephone calls that determines if an office visit or other service is justified. If the physician should want to see the patient, CMS considers the check-in as bundled into the service for the encounter. Earlier this year, CMS acknowledged the problems this reimbursement model creates: To the extent that these kinds of check-ins become more effective at addressing patient concerns and needs using evolving technology, we believe that the overall payment implications of considering the services to be broadly bundled becomes more problematic. Effectively, the better practitioners are in leveraging technology to furnish effective check-ins that mitigate the need for potentially unnecessary office visits, the fewer billable services they furnish. Given the evolving technological landscape, we believe this creates incentives that are inconsistent with current trends in medical practice and potentially undermines payment accuracy. In an effort to address these misaligned incentives, CMS now will pay for virtual check-ins using HCPCS G2012 (approximate allowable amount: $13). The reimbursable service is narrowly defined: Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified healthcare professional who can report evaluation and management [E/M] services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. CMS set the reimbursement for this service at approximately $15, citing “low work time and intensity.” For now, there are no frequency limits on this service, although CMS noted it may impose such limits if it detects overutilization. In the Final Rule, CMS clarified “that telephone calls that involve only clinical staff (cannot) be billed using HCPCS G2012, since the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.” Also, CMS elected to require “verbal consent that is noted in the medical record for each billed service” and to limit eligibility to established patients. In addition to reimbursement for synchronous communication, CMS will also pay for—under another new code, HCPCS G2010—remote evaluation of patient-submitted recorded video and/or images. This reimbursable service also is narrowly defined: Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. CMS clarified that patient follow-up may take place “via any mode of communication, including secure text messaging, phone call, or live/asynchronous video chat, so as not to restrict a clinician’s interaction with patients.” Again, the provider must document the beneficiary’s consent in the record (regardless of whether such consent is provided verbally, in writing, or by electronic confirmation) and eligibility is limited to established patients. CMS also created a new HCPCS G0071 for virtual communication services furnished by a rural health clinic (RHC) or federally qualified health center (FQHC). Specifically, an RHC or FQHC may receive reimbursement for “at least 5 minutes of communication technology-based or remote evaluation services” furnished for a patient who has had an RHC or FQHC billable visit within the last year. This service is subject to the same limitations as HCPCS G2012 and G2010 with regard to prior and subsequent in-person visits. Payment for HCPCS G0071 is set at the average of the national non-facility payment rates for HCPCS G2010 and G2012. CMS expects usage of virtual check-ins will be limited at first, “result[ing] in fewer than 1 million visits in the first year. . . .” However, CMS predicts usage of these services “will eventually result in more than 19 million visits per year. . . .” Interprofessional Internet Consultation Because specialists receive no reimbursement for time spent consulting with treating practitioners regarding specific patients, specialist input often requires scheduling a separate patient visit when telephonic or internet-based interaction between the specialist and the treating practitioner would suffice. CMS Introduced the InterProfessional Consultations usingn Six New Codes (see below) CPT® Code 99451: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified healthcare professional, 5 or more minutes of medical consultative time (reimbursement approximately $34). CPT® Code 99452: Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified healthcare professional, 30 minutes (reimbursement approximately $34). CPT® Code 99446: Interprofessional telephone/internet assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 5-10 minutes of medical consultative discussion and review (reimbursement approximately $18). CPT® 99447: Crossover to CPT® 99446, except 11-20 minutes (reimbursement approximately $36). CPT® 99448: Crossover to CPT® 99446, except 21–30 minutes (reimbursement approximately $54). CPT® 99449: Crossover to CPT® 99446, except 31 or more minutes (reimbursement approximately $73). Because these codes concern services furnished without the beneficiary present, CMS requires the treating practitioner to obtain and document verbal consent in the medical record. CMS notes such consent “includes ensuring that the patient is aware of applicable cost sharing.” Although it did not directly address the matter, it appears CMS expects the consultant to confirm such consent with the treating practitioner and make note of it in the consultant’s record. Although the reimbursement for these virtual medical services are so little, but almost all providers are already been rendering these services (for free) so why not get paid and reimbursed in 2019? The biggest challenge is how do you implement this in your practice? One biggest element is Compliance in terms of meeting the proper/accurate documentation process and the integration with technology.  But be careful ... because there are 46,000 New Pairs with 99451 and 99452 being on the second column with indication "0" preventing you to unbundle. These 2 codes are considered integral to the other procedure being performed in column 1.  Call us TODAY! Just Dial (609) 481-3494UNDERSTANDING HOW TO USE MODIFIER 59, XE, XS, XP, XU - new changes in 2015  This may impact your reimbursement in the coming New Year 2015! Make sure you and your staff knows about these new changes. Let's welcome the new year 2015 with more easy to use Modifier 59 and say hello to its the new 4 X's HCPCS modifers added by CMS. 2015 Medicare Modifier 59 Changes If you are familiar with the CCI Edits or the Correct Coding Initiative Edits? isn't it that Modifier 59 has always been the modifier that comes to our mind to bypass edits with column 2 "1"? We use modifier 59 for the purpose of telling the payers that the procedure(s) was performed as "DISTINCT PROCEDURAL SERVICE" A little background - why are we using Modifier -59. The Procedural Service can be "Distinct" due to the fact that it was a same-day procedure performed on:
The CPT Manual clearly defines Modifier -59 as follows: "Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system. separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than Modifier 59. Only if no more descriptive modifier is available, and the use of Modifier 59 best explains the circumstances, should Modifier 59 be used. NOTE: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see Modifier 25 Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used. If you are audited for misuse of Modifier 59, your documentation will be checked so it must clearly state that the criteria was met CMS introduced the 4 New Modifiers for 2015 (not to replace Modifier 59 - just not yet!). These 4 new modifiers were developed for more specificity when the procedure is truly a DISTINCT procedure! These are Specific Modifiers for Distinct Procedural Services or subsets of Modifier -59. 2015 Medicare Modifier 59 Changes and the 4 New Modifiers 1. XE "Separate encounter, a service that is distinct because it occurred during a separate encounter". 2. XS "Separate structure, a service that is distinct because it was performed on a separate organ/structure". 3. XP "Separate practitioner, a service that is distinct because it was performed by a different practitioner". 4. XU "Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service" CMS will continue to recognize Modifier -59 but you have to make sure you will only utilize this modifier when there is no other specific modifier that may describe your "distinct" procedure service. When using this modifier, Medical Documentation is vital and essential to support medical necessity. This must be well-documented on the patient's medical record. References:
Modifier 58 Staged or Related Procedure or Service During Postoperative Period by Same Physician  Guideline: The same physician planned, at time of original surgery/procedure, a return trip to operating or procedure room within 10 or 90 day post op days WHEN IT IS APPROPRIATE:
Physicians in same specialty, same group are to bill and are reimbursed as a single physician Key to Remember! Use modifier 78 (not 58!) for treatment problems unplanned requiring return trip to operating room If hardware removed in unplanned surgery return for a complication, (e.g. infection of the wound site or rejection of the hardware itself), modifier 78 appropriate It is NOT APPROPRIATE WHEN:
References:
CMS Medicare Website Coding Books Payers Websites UNDERSTANDING HOW TO USE MODIFIER 79  Per the Current Procedure Terminology® (CPT®) manual, the descriptor of modifier 79 is: • "Unrelated procedure or service by the same physician during the postoperative period." As indicated, this modifier is used to bill an unrelated procedure or service performed by the same physician during the postoperative period of a previous surgical procedure. When a patient has surgery performed, there is a postoperative period -- a period after the surgery has been performed when additional surgical care related to the initial surgery is considered already covered (and paid for) by the allowance provided for the initial surgery. The postoperative period can be zero or 10 days (minor surgical procedure) or 90 days (major surgical procedure). (Note that some surgeries are considered so minor that they have a zero day postoperative period, usually a very quick outpatient procedure.) Modifier 79 should be used when a surgical procedure is:
REMEMBER! When the 79 modifier is used, a new postoperative period for the second surgical procedure begins. Additionally, the remainder of the postoperative period of the original surgery is still applicable. References:
Medicare CMS Website American Medical Association CPT Coding Books Payers Websites Still confused with Coding and reporting medial and lateral branch nerve blocks and understanding Pain Management procedures? Coding Billing for Medial and Lateral Nerve Blocks. According to the AMA, the code series for medial branch blocks and the facet joint injections are the same (i.e., CPT series 64490-64495), with reporting based on the number of facet joints injected, not the number of nerves injected. For example: If three (3) medial branch nerves are injected only two (2) facet joint injection codes would be reported despite the fact that three nerves were injected, since each facet joint is connected to two medial nerves. The lateral branch nerve is a peripheral nerve and would be reported with CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch, when a lateral branch nerve block is performed. Please note: CPT code 64450 should only be reported per nerve or branch and not per injection. CPT code 76942, Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation, would be additionally reported when utilizing ultrasound guidance for certain nerve block procedures when it is not inherent in the primary procedure code. The Different kinds or types of NERVE BLOCKS and what are they targeting: NERVE BLOCKS: Brachial plexus block, elbow block, wrist block BODY AREAS: Shoulder, arm, hand, elbow, wrist) NERVE BLOCKS: Cervical epidural, thoracic epidural, lumbar epidural block BODY AREAS: Neck, back NERVE BLOCKS: Cervical plexus block, cervical paravertebral block BODY AREAS: Shoulder, upper neck NERVE BLOCKS: Maxillary nerve block BODY AREAS: Upper jaw NERVE BLOCKS: Ophthalmic nerve block BODY AREAS: Eyelids, scalp NERVE BLOCKS: Sphenopalatine nerve block BODY AREAS: Nose, palate NERVE BLOCKS: Subarachnoid block, Celiac plexus block BODY AREAS: Abdomen, pelvis NERVE BLOCKS: Supraorbital nerve block BODY AREAS: Forehead NERVE BLOCKS: Trigeminal nerve block BODY AREAS: Face CPT 64490, 64493, 64495, 64633 - Billing and Coding for Facet Nerve Block and Nerve Ablation RFA CPT CODE 64490 PARAVERTEBRAL FACET JOINT BILLING AND CODING WITH IMAGING GUIDANCEInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 64491 ----------- second level 64492 ----------- third and any additional level(s) level CPT CODE 64493Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 64494 ----------- second level 64495 ----------- third and any additional level(s) level FACET JOINT BILLING AND CODING WITH ULTRA-SOUND 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level ....................................................................+ 0214T second level ....................................................................+ 0215T third and any additional level(s) 0216TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level ..................................................................+ 0217T second level ..................................................................+ 0218T third and any additional level(s) Billing and Coding for Radiofrequency Facet denervationCPT CODE 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint' +64634 cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) CPT CODE 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint; +64636 lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) Other Searched Keywords: Billing and Coding for RFA of Facet Joint Nerves Billing and Coding for Facet Joint AblationKey Points for CPT 64490, 64493, 64495, 64633 - Billing and Coding for Facet Nerve Block and Nerve Ablation RFA These codes are unilateral
 Let's look at these questions and answers: #1 Question "What are the appropriate code assignments when a patient receives 3 separate nerve blocks into the same lateral branch nerve? Would it be appropriate to report 3 units of this service?" The right CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch, would be appropriately reported only once in this case since all 3 nerve blocks were administered to the same nerve or branch. #2 Question "We are getting conflicting information regarding coding medial and lateral branch blocks S1, S2, and S3, Medial 64493, 64494, Lateral 64493, and 64494. Our Pain Center wants to use facet injection for the medial branch block and other peripheral nerve for the lateral branch block. Are we correct in reporting lateral branch nerve block(s) to the peripheral nerve CPT code?" Yes, you are correct. The lateral branches of the dorsal sacral nerve plexus are considered peripheral nerves. Therefore, for the four lateral branch block injections at S1, S2, S3, and S4, report 4 units of CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch. Report multiple units of the injection for the four lateral branch block injections performed, modifier 59 would not be appended in this case. # 3 Question "A patient was seen at our facility and underwent a left-sided L5 and S1, S2, S3, and S4 lateral branch nerve block for diagnostic purpose with C-arm fluoroscopy. What are the correct codes for a lateral nerve block?" So OK, ... based on the operative report a medial branch nerve block was performed at the L5 and a lateral branch nerve block was performed at the S1, S2, S3 and S4 Therefore, it would be appropriate to report CPT code 64493, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapohphyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, single level, for the L5 medial branch block. For the 4 lateral branch block injections at S1, S2, S3, and S4, report 4 units of CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch. From AMA's CPT Assistant: February 2011 page 4 (In September 2011 questions relating to this article were discussed.) Revisions made to certain pain medicine procedures in the CPT 2011 codebook include new procedure codes, and guidelines were created in the Nervous System section to clarify the reporting of these services. The following code sets are affected: • Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic (64400-64530) • Neurostimulators (Peripheral Nerve) (64550-64595) • Destruction by Neurolytic Agent (eg, Chemical, Thermal, Electrical or Radiofrequency) (64600-64681) Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic Revised Codes The following codes were revised for 2011: 64479Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 64480Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 64483Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 64484Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) What exactly is "transforaminal epidural injection"? codes 64479-64484. TFE describe injections that enter the epidural space through the intervetebral foramen. This technique differs from interlaminar / translaminar epidural injection technique (62321-62327) and the paravertebral facet joint nerve injection technique (64490-64495). Since the vertebral artery (in the cervical spine), radiculomedullary arteries, as well as the spinal cord are in close proximity to the nerve root, this procedure involves a much higher risk with more work than a translaminar epidural injection. If ultrasound is used to guide the transforaminal injections, a code from the category III code set should be used instead of a code from the 64479-64484 code series. Therefore, parenthetical notes instruct users to report Category III codes 0228T, 0229T, 0230T, and 0231T for ultrasound-guided transforaminal epidural procedures. Additionally ultrasound guidance procedure code 76942, Ultrasound guidance for needle placement (eg biopsy, aspiration, injection, localization device), imaging supervision and interpretation, has been revised to clarify that it may not be used as guidance for 64479-64495 injections. Coding Tip Codes 64479-64484 are inherently unilateral procedures. When these procedures are performed bilaterally, they should be appended with modifier 50 or with a HCPCS Level II modifier "RT" or "LT" depending upon payer requirements. Paravertebral Spinal Nerves and Branches New Guidelines The paravertebral facet joint is the site of interaction between the vertebral bone above and below, and can be a source of pain. Injections can be made either into the joint, or at each of the nerves that supply the joint (ie, the medial nerve branches). To coordinate with the revision of codes 64479-64484, new parenthetical notes in the Paravertebral Spinal Nerves and Branches section of the CPT codebook direct users to the appropriate code to identify paravertebral facet joint injections when performed with imaging guidance. When performing a paravertebral facet injection into the T12-L1 joint, or at the nerves innervating that joint, code 64490 is reported. Fluoroscopy and CT imaging guidance and any injection of contrast are inclusive components of codes 64490- 64495. Imaging guidance and localization are required for the performance of paravertebral facet joint injections, as described by codes 64490-64495. If imaging guidance is not used, code 20552, Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s), or code 20553, Injection(s); single or multiple trigger point(s), 3 or more muscle(s), should be reported instead of a code from the 64490-64495 code series. If ultrasound guidance is used, it is appropriate to report Category III codes 0213T-0218T. Coding Tip Paravertebral facet injection codes 64490-64495 and 0213T-0218T are unilateral. When performed bilaterally, they may be appended with modifier 50 or a HCPCS Level II modifier "RT" or "LT" depending on the requirements of the payer. Neurostimulators (Peripheral Nerve) New Codes Code 64573 was deleted and the following four new codes were added for 2011: 64566Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming 64568Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator 64569Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator 64570Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator Code 64566 is reported for a treatment of voiding dysfunction (eg, urge incontinence), posterior tibial nerve stimulation. Code 64566 was created to describe a minimally invasive procedure that includes both the needle insertion through the skin adjacent to the tibial nerve, as well as the placement of an electrode on the surface of the skin. The treatment consists of a series of sessions involving insertions of a percutaneous needle electrode, with intermittent neuromodulation for approximately 30 minutes while the needle electrode remains in place. The neurostimulator includes a lead set with surface electrodes and a needle electrode, which produces an adjustable electrical pulse that travels to the sacral nerve plexus via the tibial nerve. The sacral nerve plexus then regulates the bladder and the pelvic floor functionality. Code 64566 would be reported once for each neurostimulation treatment session. References: 2017 / 2018 Coding Books (CPT is a Trademark and Owned by the American Medical Association) AMA's CPT Assistant Archives CMS Medicare Website (LMN, NCD/LCD, Manuals) Commercial Payers Guidelines  How to Bill Chronic Care Management 99490 and Complex CCM 99487, 99489  Chronic Care Management Services and the New Changes for 2017 CMS Medicare recognizes the Chronic Care Management (CCM) as a critical component of primary care services that contributes to better health and care for individuals. So in 2015, Medicare began paying separately under the Medicare Physician Fee Schedule for CCM services furnished to Medicare patients with multiple chronic conditions. Beginning January 1, 2017, the CCM codes are: Code 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
Keys to Remember: Let’s try to describe what CCM is or Chronic Care Management Services. These are services rendered by a Physician or Non-Physician Practitioners such as Nurse Practitioners, Physician Assistants, Clinical Nurse Specialist, Certified Nurse-Midwife and the CLINICAL Staff --- per month, for patients with two or more chronic medical conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Take note that ONLY (1) One Practitioner can report and bill for Chronic Care Management per month. The included services are: ○ Access and use of a Certified Electronic Health Record (EHR) ○ Continuity of Care with Designated Care Team Member ○ Comprehensive Care Management and Care Planning ○ Transitional Care Management ○ Coordination with Home and Community-Based Clinical Service Providers ○ 24/7 Access to Address Urgent Needs ○ Enhanced Communication (email, and telephone for example) ○ Advance Consent CCM Changes in 2017 are the following:
There is a more complex care and we describe it as Complex Chronic Care Management services; Here are your two new codes for the Complex CCM - Complex Chronic Care Management services: CPT 99487 Complex chronic care management services, with the following required elements: ● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; ● Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; ● Establishment or substantial revision of a comprehensive care plan ● Moderate or high complexity medical decision making ● 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (Novitas Part B NJ North $102.36) CPT +99489 --- (this is an add-code and cannot be billed by itself!) Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure) Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately(Novitas Part B NJ North $50.98) Supervision The CCM codes (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required. Patient Eligibility Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at signifcant risk of death, acute exacerbation/decompensation, or functional decline are eligible for CCM services. ● Billing practitioners may consider identifying patients who require CCM services using criteria suggested in CPT guidance (such as number of illnesses, number of medications or repeat admissions or emergency department visits) or the profile of typical patients in the CPT prefatory language. ● There is a need to reduce geographic and racial/ethnic disparities in health through provision of CCM services. Table 2 provides a number of resources for identifying and engaging subpopulations to help reduce these disparities. The billing practitioner cannot report both complex and regular (non-complex) CCM for a given patient for a given calendar month. In other words, a given patient receives either complex or non-complex CCM during a given service period, not both. Examples of chronic conditions include, but are not limited to, the following: ● Alzheimer’s disease and related dementia ● Arthritis (osteoarthritis and rheumatoid) ● Asthma ● Atrial fbrillation ● Autism spectrum disorders ● Cancer ● Cardiovascular Disease ● Chronic Obstructive Pulmonary Disease ● Depression ● Diabetes ● Hypertension ● Infectious diseases such as HIV/AIDS Initiating Visit For new patients or patients not seen within one year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner (an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visit with the billing practitioner). This initiating visit is not part of the CCM service and is separately billed. Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506 (Comprehensive assessment of and care planning by the physician or other qualifed health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service]). G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation. Patient Consent Obtaining advance consent for CCM services ensures the patient is engaged and aware of applicable cost sharing. It may also help prevent duplicative practitioner billing. A practitioner must obtain patient consent before furnishing or billing CCM. Consent may be verbal or written but must be documented in the medical record, and includes informing them about: ● The availability of CCM services and applicable cost-sharing ● That only one practitioner can furnish and be paid for CCM services during a calendar month ● The right to stop CCM services at any time (effective at the end of the calendar month)   Definition: Indicates an Evaluation and Management (E/M) service resulted in the initial decision to perform surgery either the day before a major surgery (90 day global) or the day of a major surgery. You can access this information on the Medicare Physicians Fee Schedule Data Base.
APPROPRIATE:
INAPPROPRIATE:
Below are information that you need to understand and remember; many are still confused with this: Global period is the day before surgery, the day of the surgery and the number of days following the surgery as indicated on the MPFSDB. Often, a major surgery has a 90 day post operative period and a minor surgery has either a zero or a 10 day post operative period. A preoperative period is the day before the surgery or the day of surgery. When an E/M service resulting in the initial decision to perform major surgery is furnished during the post-operative period of another, unrelated procedure, then the E/M service must be billed with both the 24 and 57 modifiers. See Codes: 92002-92014 E/M Ophthalmology Services 99201-99499 E/M all locations Definition: Bilateral Procedure; procedures/services that occur on identical, opposing structures (such as for example - "LEFT" and "RIGHT" Side)
Many Billers are still really confused on how Modifier 50 really works. APPROPRIATE:
Billed as 64490 -50 1 unit
INAPPROPRIATE:
Coding Tip: Generally speaking, the above information applies when two of the same procedure codes are performed on the same day for the same patient by the same provider. However, there could be instances where two separate procedure codes are used. If so, Medicare's payment or denial would depend on any other type of rules or regulations concerning the individual services in question. This could include the National Correct Coding Initiative (NCCI) that could necessitate additional modifiers, duplicate edits, and global surgery edits. Remember, the Modifier 50 is used as a payment, rather than informational, modifier. The addition of this modifier could affect payment depending on the procedure code and the BILAT SURG indicator. The BILAT SURG indicator for each procedure code can be found on the Medicare Physician Fee Schedule Relative Value File. Following are the indicators and their descriptions. BILAT SURG indicator "0" =150% payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or with modifiers RT and LT, base the payment for the two sides on the lower of: (a) the total actual charge for both sides and (b) 100% of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure. BILAT SURG Indicator "1" =150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules. Reference Manual: The CMS Internet-Only Manual, Publication 100-04, Chapter 12 , Section 40.7.B, indicates "If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), physician must report the procedure with modifier "-50". They report such procedure as a single line item." BILAT SURG Indicator "2" =150% payment adjustment does not apply. Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the total actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code. Example: The fee schedule amount for code YYYYY is $125. The physician reports code YYYYY-LT with an actual charge of $100 and YYYYY-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The RVUs are based on a bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure. BILAT SURG Indicator "3" = the usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for each side or organ or site of a paired organ on the lower of (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side. If the procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure before applying any multiple procedure rules. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral surgeries. BILAT SURG Indicator "9" = The bilateral payment adjustment concept does not apply. Ambulatory Surgical Centers (ASCs) and Modifier 50 Bilateral surgical procedures furnished by certified ASCs may be covered under Part B. While use of the 50 modifier is not prohibited according to Medicare billing instructions, the modifier is not recognized for payment purposes and if used, may result in incorrect payment to ASCs. Bilateral procedures should be reported as a single unit on two separate lines or a single unit with "2" in the unit field on one line, in order for both procedures to be paid correctly. The multiple procedure reduction of 50 percent will apply to all bilateral procedures subject to multiple procedure discounting. Read more examples for appropriate billing procedures in the MLN Matters article, "Revised Payment System for Ambulatory Surgical Centers (ASC) in Calendar Year (CY) 2008" (Revised SE 0742). References: CMS: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Noridian: https://med.noridianmedicare.com/web/jeb/specialties/surgery/bilateral-surgery American Medical Association Coding Guidelines Definition: Unrelated evaluation and management (E/M) service by the same physician* during a postoperative period APPROPRIATE:
INAPPROPRIATE:
*Same physician - Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician." Reporting Multiple Surgery Modifiers on the Same Claim Line The following is an example of appropriate reporting of both modifiers 24 (Unrelated E/M by the same physician during a postoperative period), and 25 (Significant, separately identifiable E/M by the same physician on the same day of the procedure or other service), on the same E/M code. Many are still confused on this. But here... "A physician performs a major surgery and within the global period sees the patient for an unrelated E/M visit. During this unrelated E/M visit, the physician determines the necessity of a minor surgery or other procedure. This minor surgery/other procedure is significant and separately identifiable from the E/M and unrelated to the original major surgery. Both the 24 and 25 modifiers are appropriate to add to the E/M code. The 24 modifier is appropriate because the E/M service is unrelated and during the postoperative period of the major surgery. The 25 modifier is necessary to identify that the minor surgery/procedure performed on the same day is separately identifiable from the E/M service. In addition, the minor surgery procedure code may need a 79 modifier to indicate the procedure is not related to the major surgery." Definition: Increased Procedural Service requiring work substantially greater than typically required.
The RIGHT WAY:
When the modifier 22 is used, two separate documents will be required to support the claim:
Important Information for Billing and Documentation Based on Medicare's Guideline of which most payers does follow Medicare's Guideline. So pay attention on this: If you append a 22 modifier to a procedure you will receive an Additional Documentation Request (ADR) letter requesting medical records to support the use of the 22 Modifier. It is important that both the operative report and a separate concise statement on why it was beyond the normal difficulty be returned with a copy of the ADR letter. Failure to submit the statement and documentation in a timely fashion will result in processing of the claim with the fee schedule rate for the same surgery submitted without the 22 modifier. Documentation Tips: When developing a separate statement avoid using a generalized statement. Comments like "patient was obese" or "surgery took longer than usual" or "multiple adhesions" lack specific details which identify why the procedure was beyond the normal difficulties that could be encountered with the procedure. Further, it is important that your operative note supports the statement on why the surgical procedure was beyond the ordinary range of difficulty. Unassigned Claim For unassigned claims, an increase in the limiting charge is allowed only when a charge above the fee schedule amount is justified. Reference CMS Manual Instruction: The CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 12 , Section 20.4.6 shows the requirements for using this modifier. How to use MODIFIERS for MEDICAL AND GLOBAL SURGERY Encounters - GoHealthcare is a Leader in Revenue Cycle Management. I have shared a lot of guidelines on each of this modifier. But today, this blog post will cover from Modifier 22 to Modifier 99. So are you ready? Make sure to click on "DIG DEEPER" for learn more and read more on clinical scenario samples. All of these guidelines are based on Medicare's Guidelines. References are attached on each guideline. I strongly believe 98% of all the commercial payers does follow Medicare's Guidelines. Period. Modifier 22
Increased Procedural Services (Dig Deeper to learn more ... CLICK HERE) Modifier 23 Unusual Anesthesia Modifier 24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period (Dig Deeper to learn more ... CLICK HERE) Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service Modifier 26 Professional Component Modifier 27 Multiple Outpatient Hospital E/M Encounters on the Same Date Modifier 32 Mandated Services Modifier 33 Preventive Services Modifier 47 Anesthesia by Surgeon Modifier 50 Bilateral Procedure (Dig Deeper to learn more ... CLICK HERE) Modifier 51 Multiple Procedures Modifier 52 Reduced Services Modifier 53 Discontinued Procedure Modifier 54 Surgical Care Only Modifier 55 Postoperative Management Only Modifier 56 Preoperative Management Only Modifier 57 Decision for Surgery (Dig Deeper to learn more ... CLICK HERE) Modifier 58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period (Dig Deeper to learn more ... CLICK HERE) Modifier 59 Distinct Procedural Service (Dig Deeper to learn more ... CLICK HERE) Modifier 62 Two Surgeons Modifier 63 Procedure Performed on Infants less than 4 kg Modifier 66 Surgical Team Modifier 73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia Modifier 74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia Modifier 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional Modifier 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional Modifier 78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period Modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period (Dig Deeper to learn more ... CLICK HERE) Modifier 80 Assistant Surgeon Modifier 81 Minimum Assistant Surgeon Modifier 82 Assistant Surgeon (when qualified resident surgeon not available) Modifier 90 Reference (Outside) Laboratory Modifier 91 Repeat Clinical Diagnostic Laboratory Test Modifier 92 Alternative Laboratory Platform Testing Modifier 95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System Modifier 96 Habilitative Services Modifier 97 Rehabilitative Services Modifier 99 Multiple Modifiers Billing and Coding for Orthopedic Spinal Fusion Let's begin with some terminology to remember;
Understanding the Posterior Lumbar Interbody Spinal Fusion  Techniques:
Image Source: https://www.slideshare.net/drpraveenktripathi/lumbar-interbody-fusion-indications-techniques-and-complications
Your CPT® Codes for PLIF and TLIF Spinal Fusion Coding: CPT Code 22630, +22632 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar +22632 Each Additional interspace (list separately in addition to code for primary procedure code) Here's what occurs when 22630 is performed: The provider performs an arthrodesis, also known as spinal fusion, in the lumbar spine, or lower back, to permanently join two vertebrae, the interlocking bones of the spine. He excises the lamina and disk material and applies bone graft between the disks to fuse them. The procedure helps to alleviate persistent pain caused by various spinal conditions, including herniated intervertebral disks, stenosis, or spinal injuries. Then, in 2012 Code 22633 was introduced to to represent the combination of 22630 and 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) at the same level. The Anterior Interbody Fusion Approach
Videos to watch for Procedure PLIF and TLIF   Your CPT® Codes for ALIF, DLIF and OLIF Spinal Fusion Coding: CPT Code 22558, +22585 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Remember: (For arthrodesis using pre-sacral interbody technique, see 22586, 0195T) +22585 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) Remember: (Use 22585 in conjunction with 22554, 22556, 22558) (Do not report 22585 in conjunction with 63075, even if performed by a separate individual. To report anterior cervical discectomy and interbody fusion at the same level during the same session, use 22552) Here's what occurs when 22558 is being performed: The provider performs arthrodesis, also known as spinal fusion, in the lower back, to permanently join two vertebrae, the interlocking bones of the spine, to alleviate persistent pain caused by a herniated, or bulging, disk, or other spinal condition. He makes an incision in the abdomen to access the spine and remove disk material. Instrumentation may be required to stabilize the Spinal Fusion POSTERIOR INSTRUMENTATION: Add-Code +22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) (Use 22840 in conjunction with 22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22310-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-63307) Add-On Code +22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) Add-On Code +22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) Use 22842 in conjunction with 22100- 22102, 22110- 22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)Text has been updated Add-On Code +22843 7 to 12 vertebral segments (List separately in addition to code for primary procedure) (Use 22843 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081,63085, 63087, 63090, 63101, 63102, 63170-63290,63300- 63307)Text has been updated Add-On Code +22844 13 or more vertebral segments (List separately in addition to code for primary procedure) (Use 22844 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307) ANTERIOR INSTRUMENTATION Add-On Code +22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) (Use 22845 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081,63085, 63087, 63090, 63101, 63102, 63170-63290,63300- 63307)Text has been updated Add-On Code +22846 4 to 7 vertebral segments (List separately in addition to code for primary procedure) Use 22846 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)Text has been updated Add-On Code +22847 8 or more vertebral segments (List separately in addition to code for primary procedure) (Use 22847 in conjunction with 22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040- 63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290,63300-63307)Text has been updated Add-On Code +22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure) (Use 22848 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)  Co-Surgeon Modifier 62 may not be appended with your Instrumentation Codes! Spinal Prosthetic Devices may also be required to be reported CPT Code 22853 22853 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) Notes: (Use 22853 in conjunction with 22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22310-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-63307) (Report 22853 for each treated intervertebral disc space) Code +22853 is one of several new codes within the spine section for the insertion of biomechanical devices that replace deleted code +22851 (Application of intervertebral biomechanical device[s] ...). The new add-on codes are more specific regarding the type and location of the biomechanical devices. CPT® guidelines direct you to report +22853 for each treated intervertebral disc space. Report +22853 in addition to the definitive procedure(s) since it is an add-on code. Do not append modifier 62 (Two surgeons) to 22853. The provider inserts a metallic cage or mesh device between two vertebrae and may use screws or flanges to attach it to the front part of the vertebrae; the device maintains the disc space, provides spinal stability, and yet preserves some range of motion, which helps relieve persistent pain caused by a herniated, or bulging, disk or other spinal condition. The provider performs this procedure during a spinal interbody arthrodesis procedure, which is fusion, or permanent joining, of vertebrae over the joint space. Remember! Code +22853 is an add–on code and must be reported with an appropriate primary procedure, such as 22548–22586 (Anterior or anterolateral approach technique arthrodesis procedures on the spine [vertebral column]), but there are many other codes that can be reported as a primary code. Report one unit of this code for each interspace treated, not for the number of devices inserted. For example, if the provider inserts two cages into a single interspace, you report this code only once. If the provider inserts a device at two separate interspaces, e.g., between C3–4 and C5–6, then you would report this code twice. This code is for the application of a device to expand or maintain an intervertebral disc space. For a similar procedure to cover a defect created by removal of a vertebral body, report 22854 (Insertion of intervertebral biomechanical device(s) [e.g., synthetic cage, mesh] with integral anterior instrumentation for device anchoring [e.g., screws, flanges], when performed, to vertebral corpectomy[ies] [vertebral body resection, partial or complete] defect, in conjunction with interbody arthrodesis, each contiguous defect [List separately in addition to code for primary procedure]). For insertion of a similar device to treat an intervertebral disc space or vertebral body removal defect but without interbody fusion (arthrodesis), report 22859 (Insertion of intervertebral biomechanical device[s] [e.g., synthetic cage, mesh, methylmethacrylate] to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect [List separately in addition to code for primary procedure]). Report Bone Grafting if allowable, CPT Code 20930 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) Notes: (Use 20930 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812) Here's what occurs when 20930 is being performed; The provider applies small pieces of donor or synthetic bone graft material during a spinal surgery to encourage bone growth during the healing period. Coding Tip! Code 20930 is an add on code and used for specified spinal procedures only. Check with your payer to determine if 20930 can be billed separately or if the application of the bone graft material is included in the code for the primary surgical procedure. Do not append modifier 62 to bone graft codes 20900-20938. (For spinal surgery bone graft[s] see codes 20930-20938) Check with your payer if you can separately report this code; +20931 Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) Notes: (Use 20931 in conjunction with 22319, 22532-22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812) A provider uses a structural allograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure. Coding Tips: Code 20931 is an add on code describing application of structural allograft to spinal defects and must be reported with an allowable primary spinal procedure code. Report 20930, Allograft, morselized, or placement of osteopromotive material, for spine surgery only, together with 20931 only in the case of a human donor who is a different person from the recipient. You should never append modifier 50, Bilateral procedure, to 20931. The CMS Physician Fee Schedule Database includes a 9 indictor in the BILAT SURG column for this code. According to further CMS instructions, a 9 indicator in this column means that the concept of a bilateral surgery with spinal grafting does not apply. +20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) Notes: (Use 20936 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812) A provider uses an autograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure. She extracts the autograft from the patient’s own bone, taken from the same surgical incision. Coding Tips: Code 20936 is an add on code describing grafting from a donor area using the same incision during a major operative procedure and must be reported with an allowable primary spinal procedure code. You should never append modifier 50, Bilateral procedure, to 20936. The CMS Physician Fee Schedule Database includes a 9 indictor in the BILAT SURG column for this code. According to further CMS instructions, a 9 indicator in this column means that the concept of a bilateral surgery with spinal grafting does not apply. +20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure) Notes: (Use 20937 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812) The provider uses an autograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure. She extracts the autograft from the patient’s own body during the surgical procedure, through a separate incision. Coding Tips: Code 20937 is an add on code describing preparation and application of a morselized autograft through a separate skin incision and must be reported with an allowable primary spinal procedure code. *** A vertebral segment describes the basic constituent part into which the spine may be divided. It represents a single complete vertebral bone with its associated articular processes and laminae. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies which contains the intervertebral disc, and includes the nucleus pulposus, annulus fibrosus, and two cartilaginous endplates. Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) Notes: (Use 20938 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812) (For aspiration of bone marrow for bone grafting, spine surgery only, use 20939) The provider uses an autograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure. She extracts the autograft from the patient's own body during the surgical procedure, through a separate incision. Reporting Cosurgeries Source: CPT® Assistant July 1996 page 7 Coding Tip Reporting Cosurgeries "We receive many questions concerning how to report surgeries performed by more than one physician. To help you understand the proper coding we present the following information." The General Question "I am a general surgeon who sometimes performs surgeries with other surgeons (cosurgeries), such as orthopedic or neurosurgeons. I open the surgical site, the other surgeon does the definitive portion of the procedure, and then I close. What CPT codes should I report for my services? I have heard from some sources that I should bill for a thoracotomy and wound repair. But other sources have told me to report the same CPT codes as the other surgeon. Which is correct? CPT® ASSISTANT'S REPLY: Here's How to Code: "For situations in which one surgeon performs the opening and closing of a surgery and another physician performs the definitive portion of the procedure, both physicians should report the same CPT codes, and appropriately append either modifier -62 or modifier -66." Illustration A patient's surgery includes arthrodesis of two interspaces of the thoracic spine by anterior interbody technique, with anterior instrumentation of three vertebral segments. Physician "A" performs a thoracotomy at the start of the surgical session, and Physician "B" performs the arthrodesis and spinal instrumentation. Upon completion of the arthrodesis and spinal instrumentation, Physician A closes the operative site. Coding the Illustration (The physicians in the illustration would report the codes indicated below.) Physician A 22556-62 Physician B 22556-62 22558-62 22558-62 22845-62 22845-62 When performing these cosurgeries, it is important to communicate with the other surgeon's office to be certain that you submit the claims properly  CPT® Guideline September 1997 page 8 Coding Communication How to Code Prosthetic Devices It is not often that we devote an entire article to a single code, but sometimes this is the only way to fully explain the use of certain codes-22851, application of prosthetic device (eg, metal cages, methylmethacrylate) to vertebral defect or interspace, is such a code. But before we review how to report this code, it is probably a good idea to first do a brief anatomical review of the vertebral column. The vertebral column (spine) consists of a series of bones known as vertebrae. An adult human possesses 33 vertebrae divided into the following five types: 7 cervical vertebrae; 12 thoracic vertebrae; 5 lumbar vertebrae; 5 sacral vertebrae; and 4 coccygeal vertebrae. The sacral vertebrae are typically fused into a single bone known as the sacrum. The coccygeal vertebrae are sometimes fused into a single bone known as the coccyx. Therefore, the actual number of bones in the vertebral column may be 26-29, depending on if the coccygeal vertebrae are fused. Vertebrae are commonly named by a letter that corresponds to the region of the vertebral column to which the vertebrae belongs, followed by a number that indicates where in the region the vertebrae is located. For example, the most superior cervical vertebra is called C1, with the next cervical vertebrae down designated C2. The most superior thoracic vertebrae is T1, with the next one down designated T2. Fig. 1 - Spinal Prosthetic Devices Between each pair of vertebrae is a disc that cushions the spinal column. If one of the discs degenerates or if one of the 26-29 vertebrae are injured (as in the case of a fracture, degenerative disease, or secondary to tumor destruction) the physician may need to place a prosthetic device (eg, metal cages or methyl-methacrylate) in the vertebral defect or interspace. (Fig. 1) In these instances, a segment of vertebral level may be drilled and metal cages packed with porous implants of bone graft may be inserted or methylmethacrylate may be placed between the affected vertebrae. Proper Reporting of code 22851 It is important to note that CPT® code 22851 is not intended to be reported per cage. CPT® code 22851 should only be reported one time, regardless if one or more metal cages are placed in the intervertebral space at the same level. However, if metal cages are placed at two different levels, (eg, metal cage placed at L3-4 interspace and L5-S1 interspace), then 22851 may be reported more than once to indicate that one or more cages were placed at two or more different levels. It is important to note that a single cage or methylmethacrylate can cover a defect of several vertebral segments (eg, a single cage may replace three entire vertebrae), wherein code 22851 would still only be reported one time. Within the spine section, instrumentation procedure codes (22840-22855) are reported in addition to the definitive procedure(s) without appending the modifier -51. Therefore, if arthrodesis is performed in addition to the placement of the metal cages, then it would be appropriate to report code 22851 in addition to the appropriate arthrodesis code, 22548-22632. In this instance, the modifier -51 would not be appended to code 22851. If metal cages are placed through an anterior approach and pedicle screws are placed through a posterior approach, it would be appropriate to report both code 22851 and one of the codes from the posterior instrumentation series, 22840, 22842-22844. However, if different instrumentation is used in addition to the metal cages or methylmethacrylate through the same approach (eg, an anterior plating system) or pedicle screws and posterior lumbar interbody fusion utilizing cages), then the appropriate instrumentation code would be reported in addition to code 22851. However, 22851 and 22845 should not both be reported if only the metal cage is inserted. If fracture treatment, dislocation, or arthrodesis is performed in addition to spinal instrumentation, then the appropriate fracture treatment, dislocation or arthrodesis code (22325, 22326, 22327, 22548-22812) would be reported separately in addition to code 22851. In this instance, CPT® code 22851 would be reported in addition to the definitive procedure(s) without the modifier -51 appended. If bone grafting is performed in addition to code 22851, then the appropriate bone grafting code, 20930-20938, would be reported additionally. Clinical Sample: CPT® Code 22851 A 50-year-old man undergoes an anterior fusion of L5-S1 for degenerative disease. A retroperitoneal incision is made and an arthrodesis performed using a BAK cage. A distracter is placed in the interspace, a hole is drilled in the interspace, and the BAK cage is placed in the hole. The spacer is removed and replaced with another BAK cage. Both cages are filled with bone graft. (Report arthrodesis and/or bone grafting separately using the appropriate CPT code[s]). The exposed disk space and adjacent vertebrae are prepared with bone-cutting instruments for acceptance of the prosthetic device. Preparation of the recipient site is made according to the protocol of the particular device. If methylmethacrylate is to be used, a screw or pin may be inserted into the adjacent vertebral surfaces to anchor the methylmethacrylate. Provision is made for cooling of adjacent tissues and protection of heat sensitive tissue from the exothermic reaction of the curing of the methylmethacrylate. For cages, the recipient site is prepared by bone dissection, a trial fit with the device or a spacer or template as indicated by the protocol is inserted and removed for any final modifications of the recipient site. The prosthetic device is then screwed, impacted, or injected into place according to protocol for this particular device. (Additional fixation, other provision for arthrodesis, or bone grafting are coordinated with the placement of the prosthetic device and are coded separately.) For devices that incorporate graft material, that material is appropriately placed into the device prior to its final insertion. CPT® ASSISTANT September 2000 page 10 Coding Consultation Musculoskeletal System, Surgery, 22548-22585, 22899 (Q&A) Question "Should I use the anterior or anterolateral approach technique arthrodesis series of codes (22548-22585) to report intra-abdominal laparoscopic, video assisted anterior interbody fusion?" AMA CPT® Comment "The anterior or anterolateral approach technique arthrodesis series of codes (22548-22585) are intended to describe arthrodesis performed via an open surgical approach. There is not a specific CPT code that accurately describes laparoscopic anterior interbody fusion. Therefore, code 22899, Unlisted procedure, spine should be reported. When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, need for the procedure, and the time limit, effort, and equipment necessary to provide the service." CPT® ASSISTANT March 2015 page 9 Frequently Asked Questions:Surgery: Musculoskeletal System Question: "Are CPT codes 22851 and 22845 appropriate to report when modular implants, such as the RSB (RSB LLC; Cleveland, OH) InterPlate® (a modular interbody platform technology), are implanted for spinal fusion procedures?" Answer: "No. The RSB InterPlate® describes a stand-alone interbody fusion device that consists of an interbody spacer with screw fixation or other mechanisms, which engage adjacent vertebrae. Such devices should be reported with code 22558, Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar, and 22851, Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure). An additional anterior instrumentation code (22845) is not applicable because there is no separate construct placed across the vertebral segment." Question: "Would it be appropriate to separately report any of the following with the hammertoe correction code 28285 (2nd digit), if adequately documented? (1) Resection of hypertrophied base of proximal phalanx (28126), if performed through a separate incision at the metatarsophalangeal (MTP joint); (2) flexor tenotomy (28232) performed through a separate incision at the distal interphalangeal (DIP) joint; (3) an additional unit of 28285 if K-wire is inserted through the DIP, MTP, or proximal interphalangeal (PIP) joint." Answer: "No. Code 28126, Resection, partial or complete, phalangeal base, each toe; code 28232, Tenotomy, open, tendon flexor; toe, single tendon (separate procedure); and the insertion of K-wire through DIP, PIP, and MTP joints are all inclusive components of the procedure described by code 28285, Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy), and should not be reported separately." References: 2018 AMA's CPT® Guidelines 2017 AMA's CPT® Guidelines CPT® Assistant Archives Websites: NASS Spine-Health Medtronic Ahima AAPC CMS  |
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Ms. Pinky Maniri-Pescasio is the Founder of GoHealthcare Consulting. She is a National Speaker on Practice Reimbursement and a Physician Advocate. She has served the Medical Practice Industry for more than 25 years as a Professional Consultant. search hereArchives
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