Understanding Shingrix Zoster Vaccine CPT Code 90750 Key points to remember in properly billing and coding for Shingrix: Keypoints to remember!
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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 Understanding the 2020 CPT codes 99421, 99422, 99423 Online Digital Evaluation and Management, E/M Services for Physicians and Non-Physicians Practitioners Your Billable Codes for Digital CPT Codes are as follows: CPT Code 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 Code 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 Code 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. These codes are for use when E/M services are performed, of a type that would be done face-to-face, through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice. Report these services once during a 7-day period, for the cumulative time.  According to CPT®: “The seven-day period begins with the physician’s or other qualified health care professional’s (QHP) initial, personal review of the patient-generated inquiry. Physician’s or other QHP’s cumulative service time includes review of the initial inquiry, review of patient records or data pertinent to assessment of the patient’s problem, personal physician or other QHP interaction with clinical staff focused on the patient’s problem, development of management plans, including physician or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent separately reported E/M service.” So how about the Clinicians who may not independently bill for evaluation and management visits? Here are your codes: For Commercial Insurance Payers, use the following codes: CPT Code 98970 Qualified nonphysician health care professional 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 Code 98971 Qualified nonphysician health care professional 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 Code 98972 Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 minutes or more Reference: Per CPT, CPT© E/M services codes 98970—98972 that says: Per CPT; “For online digital E/M services provided by a qualified nonphysician health care professional who may not report the physician or other qualified health care professional E/M services (eg, speech-language pathologists, physical therapists, occupational therapists, social workers, dietitians), see 98970, 98971, 98972).” And how about for Medicare Beneficiaries?For Medicare Beneficiaries, they have a set of HCPCS Codes that we can use (CMS does not recognize CPT Codes 98970-98972) - continue reading below 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.  References: CPT 2020, CMS Guideline and Finial Ruling. Need more help? Contact us today! (732) 982-4800January 1, 2020 - we now have a new Pain Management Code CPT 64625 - SI Ablation Description of CPT Code 64625 Radiofrequency ablation, nerves innervating the sacroiliac joint, with imaging guidance (Fluoroscopic or Computed Tomography). Keypoints to REMEMBER!
 Need help? Contact our office today!The Patients Access plays a very important role in capturing and collection of patient service revenue.  Patients Access and a Successful Revenue Cycle Management The Patients Access plays a very important role in capturing and collection of patient service revenue. There are 3 parts of Revenue Cycle where the Patient Access Management is very important and the Patient Access Team plays a very valuable role. 1. Pre-service Phase
2. Time of Service
3. Post-service Phase
 Focusing on Customer Service and Patient Satisfaction is very important.  Customer Service and Patient Satisfaction 1. Treating patient with respect and dignity 2. Treating patient as you would want to be treated 3. Communicating in a manner the patient can easily understand 4. Value your patient's time and focus on efficiency 5. Show empathy to your patient What pieces of information do we gather:
Additional Useful information that you can also gather from the patient:
So what's next after obtaining all the necessary information? 1. Patient access team member must start confirming coverage for the patient 2. Verify if the provider is in-network or out-of-network with the patient's plan 3. Check eligibility if the patient is eligible for coverage on the date of service 4. Ask the patient if they have a secondary insurance coverage 5. Complete clarifying the benefits for services with the insurance company 6. Check the patient's copayment or any co-responsibility and if the patient has an out of pocket amount that has to be met (family or individual 7. You can ask the insurance company for specific benefits for specific services. I always suggest giving insurance company specific CPT code(s) or Diagnosis code(s) if available - document everything 8. Collect the copay at the time of service if you are contracted with the patient's insurance plan; 9. Verify if there is a deductible or coinsurance and how much have been met, you can collect them at the time of service as well 10. Make sure you be knowledgeable enough on how to answer the patient about their concern and questions about their copay or any other co-responsibility. Let's look at how the Patient Access team verifies patient who has a Medicaid Coverage: Viewing a patient's ID card alone does not ensure their Medicaid eligibility, nor does having a referral or pre-certification on file. As a member of the Patient Access team, insurance can be verified during pre-service or on the date of service. It is imperative in my opinion that the Patient Access team must verify eligibility during the MONTH that patient is scheduled to be seen or is coming for service. Because their coverage may always change. If you fail to verify eligibility, there is a very high risk of claim denial for sure. Possible scenarios? the patient may not be eligible at the time of service, or the HMO was not contracted with your practice at that time of service. Result? claim may not get paid. Resulting in lose of revenue.  What happens if we did not correctly verify the patient identity?
About 40% of data used for revenue cycle management are gathered by Patients Access Teams. About 40% of data used for revenue cycle management are gathered by Patients Access Teams. Mistakes and errors will greatly affect the billing and coding process thus causing payments delay. Delayed reimbursement will significantly affect your cash flow. Patients satisfaction, prompt payments are the best results of your high quality customer service and are all based on how good your team with their communication skills.  Let's decribe this code: CPT 76140 Consultation on x-ray examination made elsewhere, written report. (2D reformatting is no longer separately reported. To report 3D rendering, see 76376, 76377)  So the question is, can a Provider bill for X-ray review using CPT Code 76140? Sharing to you coding clarification here. (Source are from CPT Assistant as published by the AMA). CPT is a trademark and owned by the American Medical Association. CPT Assistant October 1997
Using CPT Code 76140 76140 Consultation on x-ray examination made elsewhere, written report. You would use this code when a physician's opinion or advice regarding a specific film is requested by another physician and upon examination of the film, the consulting physician renders his or her consultation (ie, or his/her opinion or advice) to the requesting physician in the form of a written report. If a patient presents to an office for a new patient visit and brings to the physician his or her medical records, including x-rays, you should not report code 76140. Although the x-rays may have been taken elsewhere, the physician does not perform a consultation as intended by code 76140. Rather, the review or re-read of the x-rays would be considered part of the face-to-face E/M service provided to the patient. Again, the E/M codes include work done before, during, or after the E/M visit. Review of x-rays is part of the E/M service. Remember, 76140 represents a consultation, in which a physician only renders an opinion or gives advice regarding the film in the form of a written report. In general, when reporting 76140, the physician is not concurrently providing an E/M face-to-face service to the patient. CPT CODE 20552, 20553 TRIGGER POINT INJECTIONS. Medicare guideline. CPT Codes and Description
Understanding Trigger Point Injection Trigger point injection is one of many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS) and each of these single muscle syndromes are responsive to appropriate treatment, which includes injection therapy. An injection is achieved with the insertion of a needle and the administration of agents, such as local anesthetics, steroids and/or local inflammatory drugs. The diagnosis of trigger points requires a detailed history and thorough physical examination. The following clinical symptoms may be present when making the diagnosis:
The goal is to treat the cause of the pain and not just the symptom of pain. Limitations Acupuncture is not a covered service, even if provided for the treatment of an established trigger point. Use of acupuncture needles and/or the passage of electrical current through these needles is not covered (whether an acupuncturist or other provider renders the service). Medicare does not cover Prolotherapy. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered. When a given site is injected, it will be considered one injection service, regardless of the number of injections administered. Utilization Guidelines It is expected that trigger point injections would not usually be performed more often than three sessions in a three month period. If trigger point injections are performed more than three sessions in a three month period, the reason for repeated performance and the substances injected should be evident in the medical record and available to the Contractor upon request. This contractor may request records when it is apparent that patients are requiring a significant number of injections to manage their pain. Documentation in the medical record must support the medical necessity and frequency of the trigger point injection(s).  20552, 20553 DX Crossover based on Medical NecessityM53.82 Other specified dorsopathies, cervical region M54.2 Cervicalgia M54.5 Low back pain M54.6 Pain in thoracic spine M60.80 Other myositis, unspecified site M60.811 Other myositis, right shoulder M60.812 Other myositis, left shoulder M60.819 Other myositis, unspecified shoulder M60.821 Other myositis, right upper arm M60.822 Other myositis, left upper arm M60.829 Other myositis, unspecified upper arm M60.831 Other myositis, right forearm M60.832 Other myositis, left forearm M60.839 Other myositis, unspecified forearm M60.841 Other myositis, right hand M60.842 Other myositis, left hand M60.849 Other myositis, unspecified hand M60.851 Other myositis, right thigh M60.852 Other myositis, left thigh M60.859 Other myositis, unspecified thigh M60.861 Other myositis, right lower leg M60.862 Other myositis, left lower leg M60.869 Other myositis, unspecified lower leg M60.871 Other myositis, right ankle and foot M60.872 Other myositis, left ankle and foot M60.879 Other myositis, unspecified ankle and foot M60.88 Other myositis, other site M60.89 Other myositis, multiple sites M60.9 Myositis, unspecified M75.80 Other shoulder lesions, unspecified shoulder M75.81 Other shoulder lesions, right shoulder M75.82 Other shoulder lesions, left shoulder M79.11 Myalgia of mastication muscle M79.12 Myalgia of auxiliary muscles, head and neck M79.18 Myalgia, other site M79.7 Fibromyalgia Take-away! Remember that these codes CPT 20552, 20553 are NOT billable as unilateral. Modifier 50 (bilateral) will NOT apply. Bill by the number of muscles! POLICY SOURCE: NOVITAS PART B LCD L35010 TRIGGER POINT INJECTIONS
READER'S QUESTION: Does Medicare Cover Radiofrequency Ablation for Pain Management in New York? Here's the Coverage Information from Medicare Part BIndications:
General Procedure Requirements:
 Diagnostic Facet Joint Injections
Therapeutic Injections
Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave technologies):
Limitations of Coverage: A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and RF ablations may be performed per year in the cervical/thoracic spine and five (5) in the lumbar spine.
Let's describe the CPT codes 64633-64636 CPT CODE 64633 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT CPT CODE +64634 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); 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 CPT CODE +64636 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Source reference: LCD ID L35936 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy NGS Medicare Part B
National Government Services, Inc. MAC - Part A 06101 - MAC A J - 06 Illinois National Government Services, Inc. MAC - Part B 06102 - MAC B J - 06 Illinois National Government Services, Inc. MAC - Part A 06201 - MAC A J - 06 Minnesota National Government Services, Inc. MAC - Part B 06202 - MAC B J - 06 Minnesota National Government Services, Inc. MAC - Part A 06301 - MAC A J - 06 Wisconsin National Government Services, Inc. MAC - Part B 06302 - MAC B J - 06 Wisconsin National Government Services, Inc. A and B and HHH MAC 13101 - MAC A J - K Connecticut National Government Services, Inc. A and B and HHH MAC 13102 - MAC B J - K Connecticut National Government Services, Inc. A and B and HHH MAC 13201 - MAC A J - K New York - Entire State National Government Services, Inc. A and B and HHH MAC 13202 - MAC B J - K New York - Downstate National Government Services, Inc. A and B and HHH MAC 13282 - MAC B J - K New York - Upstate National Government Services, Inc. A and B and HHH MAC 13292 - MAC B J - K New York - Queens National Government Services, Inc. A and B and HHH MAC 14111 - MAC A J - K Maine National Government Services, Inc. A and B and HHH MAC 14112 - MAC B J - K Maine National Government Services, Inc. A and B and HHH MAC 14211 - MAC A J - K Massachusetts National Government Services, Inc. A and B and HHH MAC 14212 - MAC B J - K Massachusetts National Government Services, Inc. A and B and HHH MAC 14311 - MAC A J - K New Hampshire National Government Services, Inc. A and B and HHH MAC 14312 - MAC B J - K New Hampshire National Government Services, Inc. A and B and HHH MAC 14411 - MAC A J - K Rhode Island National Government Services, Inc. A and B and HHH MAC 14412 - MAC B J - K Rhode Island National Government Services, Inc. A and B and HHH MAC 14511 - MAC A J - K Vermont National Government Services, Inc. A and B and HHH MAC 14512 - MAC B J - K Vermont How to Document radiofrequency ablation (RFA) of nerves CPT (64635, +64636) Radiofrequency ablation (RFA), also called radiofrequency neurotomy is an interventional pain management procedure that involves heating a part of a pain-transmitting nerve with a radiofrequency needle to create a heat lesion. Some of our pain physicians offices are asking the question - How to Document radiofrequency ablation (RFA) of nerves CPT (64635, +64636. What is the proper way of reporting this kind of procedure on the medical record when performed? Here's a guidance from CPT Assistant Article published on May 2020, quotes: Question: When performing radiofrequency ablation (RFA) of nerves (64635, 64636), is it necessary that the operative report documents the specific facet joints at which the RFA with imaging occurred as well as the nerves treated or denervated? Answer: Yes, RFA procedures should clearly state which nerves were ablated and which joints were treated. Codes 64635, Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint, and 64636, Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure), are reported for each joint treated, not each nerve treated. Stating the specific nerve and the level it innervates eliminates confusion and ensures accurate reporting. Reference: CPT Assistant Published on May 2020 NEED MORE HELP? Call our office at (609) 481-3494 The World Health Organization or the WHO made a code for ICD-10 (not ICD-10-CM) which is the U07.2, COVID-19, virus not identified, intended to give the ability to capture suspected uncertain patients. The reason you are getting errors in billing this code is that because U07.2 Covid-19, virus not identified has not been imported into ICD-10-CM (not yet) and its coming up as invalid. It is actually a valid code. So the guidance is to code the signs and/or symptoms and/or (for example) reporting ICD-10-CM Code Z20.828 - this code is a very code that we can report. Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. I always suggest that if you have cases where you only see one code such as the U07.2 Covid-19, virus not identified , we need to go back the our providers and let them if they can give you a more appropriate codes based on signs and symptoms and as documented on their medical record.  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 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 |
ABOUT THE AUTHOR:
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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