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Billing for Durable medical equipment services

9/30/2020

Understanding Billing for DME Services or Durable Medical Equipment Services

BILLING FOR DURABLE MEDICAL EQUIPMENT SERVICES

Many of our blog readers will contact me and ask why is it too complicated to be billing for durable medical equipment?

Actually it is not complicated, you just need to understand how it works.

Here are some pointers that I would like to point out to you:

Verify the Necessity of the Durable Medical Equipment
- a Detailed Written Order or Prescription fully signed by the referring/rendering/servicing provider must be on file
- look at the provider's treatment plan
- if this is indicated due to accident or injury related case, include the date of incident
Credentialing
- is it the Physician Practice billing for the DME? (Medicare require that you have completed and been approved. Look at form CMS-855s.)
- is it a DME Company billing for the durable medical equipment? (you need to be fully credentialed and identified as a DME Vendor by the payers including that of Medicare) - you don't have to be contracted with the insurance payers.
- You can be out of network vendor or provider with the commercial insurance (not with MEDICARE!) but be careful making sure you have informed your patient that you are out of network provider. Inform the patient about their estimated out of network financial responsibility
Make sure you have checked the patient's benefits and eligibility for the particular DME or Durable Medical Equipment
- watch for its utilization policy and guideline. For example, Medicare Beneficiaries cannot get the same Lumbar Orthosis within the last 5 years
- watch for medical necessity diagnosis cross over
Make sure you understand the difference between billing out of network and in network

Pointers on DME Billing Services and Coding

Make sure you are reporting the correct HCPCS code(s) that best describe the DME or Durable Medical Equipment
Make sure you are reporting the correct place of service and correct DME Billing services modifier(s)
Make sure that your billable date of service should be the date you have dispensed the DME or Durable Medical Equipment to your patient and also that same day the patient had signed receipt of the DME. DO NOT bill based on the date of when you prescribed the DME, I think this is inappropriate
If the date of service is for a rental and are in range of dates, make sure you verify with your insurance payers how do they want it reported. For example;
- does one month rental equal 21 days? or 30 days?
- are you reporting from start to end date and report the number of units as days?
- are you reporting the same date of service for start and end date?
- check your modifiers used for DME Billing Services
Keep a copy of your patient's signed receipt that they have received the DME service
Document the necessity of the durable medical equipment

NEW CPT 99072 CPT 86413 during covid19 pandemic

9/24/2020

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NEW CPT Code 99072 and CPT Code 86413 DURING COVID19 PANDEMIC
These new CPT codes address advancing understanding of COVID-19

NEW CPT 99072 CPT 86413 DURING COVID19 PANDEMIC Gohealthcare Revenue Cycle Management

These 2 new CPT Codes 99072 and 86413 were published on September 8th 2020 and are effective immediately.

NEW CPT 99072 CPT 86413 DURING COVID19 PANDEMIC Gohealthcare Revenue Cycle Management.3

Let's describe these 2 new CPT Codes.

CPT Code 99072     Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease

Take Note:  This new code 99072 is reported only during a PHE (Public Health Emergency) and only for additional items required to support a safe in-person provision of evaluation, treatment, or procedural service(s).

CPT Code 86413     Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative

NEW CPT 99072 CPT 86413 DURING COVID19 PANDEMIC Gohealthcare Revenue Cycle Management.1

According to the AMA:
"The first addition, CPT code 99072, was approved in response to sweeping measures adopted by medical practices and health care organizations to stem the spread of the novel coronavirus (SARS-CoV-2), while safely providing patients with access to high-quality care during in-person interactions with health care professionals. The additional supplies and clinical staff time to perform safety protocols described by code 99072 allow for the provision of evaluation, treatment or procedural services during a public health emergency in a setting where extra precautions are taken to ensure the safety of patients as well as health care professionals. The AMA/Specialty Society RVS Update Committee (RUC) worked with 50 national medical specialty societies and other organizations over the summer to collect data on the costs of maintaining safe medical offices during the public health emergency and submitted recommendations today to the Centers for Medicare and Medicaid Services to inform payment of code 99072."

"The second addition, CPT code 86413, was approved in response to the development of laboratory tests that provide quantitative measurements of SARS-CoV-2 antibodies, as opposed to a qualitative assessment (positive/negative) of SAR-CoV-2 antibodies provided by laboratory tests reported by other CPT codes. By measuring antibodies to SARS-CoV-2, the tests reported by 86413 can investigate a person’s adaptive immune response to the virus and help access the effectiveness of treatments used against the infection."

Must be reported only once per in-person! (read more below)

Code 99072 is to be reported only once per in-person patient encounter per provider identification number (PIN), regardless of the number of services rendered at that encounter. In the instance in which the noted clinical staff activities are performed by a physician or other qualified health care professional (eg, in practice environments without clinical staff or a shortage of available staff), the activity requirements of this code would be considered as having been met; however, the time spent should not be counted in any other time-based visit or service reported during the same encounter.

CPT Guidelines, Q&A from the American Medical Association:

Understanding PHE or Public Health Emergency in coordination with CPT Code 99072

Question: Code 99072 is stated as being applicable “during a PHE.” What information should be used to verify when a PHE is in effect?
Answer: A PHE is in effect when declared by law by the officially designated relevant public health authority(ies).

Understanding Patient Encounters Type for the determination of CPT Code 99072

Question: For what type of patient encounters or services should code 99072 be reported?
Answer: Code 99072 may be reported with an in-person patient encounter for an office visit or other non-facility service, in which the implemented guidelines related to mitigating the transmission of the respiratory disease for which the PHE was declared are required. Use of this code is not dependent on a specific patient diagnosis. For a list of POS codes with facility/non-facility designations that are available in the Medicare Claims Processing Manual, visit https://www.cms.gov/Medicare/Coding/place-of-service-codes.

Understanding Documentation Requirements when reporting CPT Code 99072

Question: What documentation is required to report code 99072?
Answer: Given that code 99072 may only be reported during a PHE, one would not report this code in conjunction with an evaluation and management (E/M) service or procedure when a PHE is not in effect. Therefore, code 99072 is reported justifiably only when health and safety conditions applicable to a PHE require the type of supplies and additional clinical staff time explained in the code descriptor.
Documentation requirements may vary among third-party payers and insurers; therefore, they should be contacted to determine their specifications.

How about CPT Code 99072 with CPT Code 99070?

Question: May code 99072 be reported with code 99070?
Answer: Yes, code 99072 may be reported with code 99070 when the requirements for both codes have been met. Note that eligibility for payment, as well as coverage policy, is determined by each individual insurer or third-party payer.

Reader's QUESTION - how much are you going to be reimbursed for these 2 new codes?
ANSWER: I have not seen any fee schedule but I suggest you ask your insurance payers and local Medicare Part B contractor.

NEW CPT 99072 CPT 86413 DURING COVID19 PANDEMIC Gohealthcare Revenue Cycle Management.88

Reference sources: https://www.ama-assn.org/press-center/press-releases/ama-announces-new-cpt-codes-covid-19-advancements-expand
https://www.ama-assn.org/system/files/2020-09/cpt-assistant-guide-coronavirus-september-2020.pdf
CPT Assistant September 2020 Special Addition
CPT is a trademark and owned by the American Medical Association.

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Modifier for trigger point injection 20553, 20552

9/22/2020

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One of our blog readers asked why their claim for Trigger Point injection is being denied due to missing modifier.

MODIFIER FOR TRIGGER POINT INJECTION CPT Code 20553 CPT Code 20552

Let's describe these 2 Trigger point injection codes:
20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
20553 Injection(s); single or multiple trigger point(s), 3 or more muscles

Widely indicated for Myofascial Pain.

Key point to remember! - these 2 CPT Codes 20552, 20553 DO NOT NEED A MODIFIER!

Denial Reasons for Trigger Point Injection CPT 20553

Denials Reasons for Trigger Point Injection CPT 20552, 20553 and what you should be looking for:

The lack of medical necessity (have you checked the payer clinical policy and guideline?)
When billing with an E/M Evaluation and Management (you will need a modifier on the E/M but not on the Trigger Point Injection CPT code;
When being performed with another procedure being "distinct" (look at your modifier 59);
When being performed with other "multiple" and or "reduced" procedures (look at your modifier 51, 52);
Missing drug name used;
Missing NDC number for the drug used;

Ask a Question GoHealthcare Prior Authorization Credentialing Services

Need more help? Call us at 732-982-4800 today!

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CPT Shingrix 90750 - What's the reimbursement?

9/17/2020

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Understanding Shingrix Zoster Vaccine CPT Code 90750

Key points to remember in properly billing and coding for Shingrix:

Keypoints to remember!

ICD-10 Code is obviously indicated for Z23 - Encounter for Immunization (most payers want to see this ICD-10 Diagnosis code)
CPT Code (Product is SHINGRIX), use CPT Code 90750 - Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection.
CPT Vaccine Administration
1. Use CPT Code 90471 1 vaccine administered
  1. Use CPT Code 90472 Each additional vaccine administered during same encounter
0.5ml is equal to 1 billable unit
Per Medicare policy, shingles vaccines are only covered in Part D plans, not in Part B Part D covered vaccinations are typically administered at a retail site of care (pharmacy)

CPT Code Shingrix 90750 What's the reimbursement?

CPT Code Shingrix 90750 - What's the reimbursement?

I called the manufacturing company of Shingrix at GSK or Global Smith Klein and contacted their Provider Reimbursement support at Phone: 1-855-636-8291. Unfortunately they told me they don't have a national average rate on how much you can get reimbursed per unit for the Shingrix shot. Understandably because it is based on Payer's reimbursement policy.

I did some research some more research and found this:
From Medicaid North Carolina:
ICD-10-CM diagnosis code required for billing is Z23 - Encounter for immunization.
Providers must bill with CPT code: 90750 - Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection.
One Medicaid unit of coverage is 0.5 mL.
The maximum reimbursement rate per unit is $144.20.
Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are 58160-0823-11 and 58160-0819-12.
The NDC units should be reported as “UN1.”

You can read the complete post here - https://medicaid.ncdhhs.gov/blog/2018/02/07/billing-guidelines-zoster-vaccine-recombinant-adjuvanted-suspension-intramuscular

Conclusion: It is always best that your verify your patient's benefits and eligibility for the Shingrix - Zoster Vaccine. As with Medicare, they should be under the beneficiary's Part D benefits.

I hope this post helps.

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Billing for Durable medical equipment services

Other related blog posts:

Call us at 732-982-4800 today!

NEW CPT 99072 CPT 86413 during covid19 pandemic

Need more help? Call us at 732-982-4800

Modifier for trigger point injection 20553, 20552

Denial Reasons for Trigger Point Injection CPT 20553

Need more help? Call us at 732-982-4800 today!

Send us your question!

CPT Shingrix 90750 - What's the reimbursement?

Understanding Shingrix Zoster Vaccine CPT Code 90750

Need more help? Call us at (732) 982-4800

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