Effective November 1, 2021 United Healthcare will require you to request Prior Authorization for the following services for Interventional Pain Management. This is effective November 1, 2021.  Notice that mostly are for your Cervical & Thoracic regions. Notice that it is also required for your Genicular Nerve Block (but NOT for the Genicular Nerve RFA) and SI (but for the RFA). Codes that require Prior Authorization from UHC:United Healthcare Pain Management Injection Requiring Prior Authorization Effective November 1, 2021  United Healthcare Pain Management Injection Requiring Prior Authorization Effective November 1, 2021 CPT Code Description 62292 INJECTION PX CHEMONUCLEOLYSIS 1/MLT LUMBAR 64620 DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE G0260 INJ PROC SI JNT;ANES STEROID&TX AGT&ARTHROGRPH 62320 NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN 62322 NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN 62324 NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN 62325 NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN 62326 NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN 62327 NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN 62350 IMPLANT SPINAL CANAL CATHETER 62351 IMPLANT SPINAL CANAL CATHETER 62360 INSERT SPINE INFUSION DEVICE 62361 IMPLTJ/RPLCMT FS NON-PRGRBL PUMP 64451 INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG 64454 INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG 64480 NJX AA&/STRD TFRML EPI CERVICAL/THORACIC EA ADDL 64484 NJX AA&/STRD TFRML EPI LUMBAR/SACRAL EA ADDL 64491 NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL 64492 NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL 64494 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL 64495 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL 64520 INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC 64634 DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA 64636 DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL 64640 DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE Read more about this update here: https://www.uhcprovider.com/content/dam/provider/docs/public/resources/network-bulletin/pain-inject-management-nb-appendix-auwww.uhcprovider.com/content/dam/provider/docs/public/resources/network-bulletin/pain-inject-management-nb-appendix-august-2021.pdfgust-2021.pdf
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Today is October 8, 2021. Have you not noticed your claims are being rejected by your practice management clearinghouse as "Invalid ICD-10 Code"?  ICD-10 M54.5 DELETED EFFECTIVE OCTOBER 1, 2021 ICD-10 Pain Management Code M54.5 Deleted Effective October 1, 2021! Yes?! Well, it is because the ICD-10 code M54.5 for Low Back Pain is now deleted effective all date of service from October 1, 2021! So make sure you are aware of this and correct your claims by choosing the billable and appropriate ICD-10 code that will describe your deleted code M54.5. Belo are some potential code replacements that you can use beginning October 1, 2021
New Codes you can potentially use:  Low Back Pain ICD-10 M54.5 DELETED EFFECTIVE OCTOBER 1, 2021 Remember that when changes like this happens, this is not just for CMS Medicare claims but it applies to all commercial payers (at least the big insurance payers!). Read more about this updates and change by clicking here https://www.cms.gov/medicare/icd-10/2022-icd-10-cm Some of my Pain Practice Offices are still confused on how to bill for MILD Procedure. As we all remember, there was no assigned CPT Code for this procedure, we used to report the unlisted code. In this Blog, I will describe the billing and coding for this procedure using the Vertos Device (www.vertosmed.com First, let's describe what is MILD? MILD stands for MINIMALLY INVASIVE LUMBAR DECOMPRESSION.  HOW TO BILL FOR MILD - MINIMALLY INVASIVE LUMBAR DECOMPRESSION CPT 0275T is a Category III Code assigned for this procedure. 0275T - Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy, and/or foraminotomy), any method, under indirect image guidance (eg. fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar. (For percutaneous decompression of the nuleus pulposus of intervertebral disc utilizing needle based technique, use 62287) So how do you report and bill for this MILD Procedure? Billing on HCFA 1500 form? Physician Claim:
The following information has to appear and included in your claim submission:
My additional recommendation (especially for Medicare beneficiaries): Enter the "referring physician" on Box 17 the same as the "rendering physician" on Box 24J since the assessment and treatment plan is that from the "Rendering Physician".  Image/Guidance Source: www.vertosmed.com Video Source is owned by: VERTOS MED - www.vertosmed.com Do you need additional help with billing?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 2020 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. Understanding the 3 Genicular Nerve Branches of 64624 Image Source: https://ainsworthinstitute.com/genicular-neurotomy/ What is the CPT code for Knee Genicular Nerve Branches Block or Injection?Understanding the 3 Genicular Nerve Branches of 64454 Source: https://ainsworthinstitute.com/genicular-neurotomy/ 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! Billing Tip: Always make sure you understand and you know the Medical, Clinical, Utilization and Reimbursement Policy of your Payers. Read other blog posts:HOW TO BILL FOR 20553 WITH 76942 ULTRASOUNDPAIN MANAGEMENT NERVE BLOCKS January 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! How to Negotiate your Physician Group or Individual Provider's Contract with the Insurance Payers  Many physician groups or even individual solo practice offices are not happy with their contracted rates or the way they are being reimbursed by the insurance payers? Is it time to negotiate? when is the best time to negotiate your contract? There is no better time than NOW! But there are important steps that you need to do before doing so. Negotiating your contract is not only by picking up the phone and calling the insurance payer's provider services department and asking them that you would like to negotiate your contracted fees. Unfortunately, it doesn't work that way! But there are important steps that you need to do before doing so. Negotiating your contract is not only by picking up the phone and calling the insurance payer's provider services department. It doesn't work that way! Here are my tips: How to Negotiate your Physician Group or Individual Provider's Contract with the Insurance Payers
You need to present your reasoning why you think its time to negotiate your fees! All of the above, you can present it to the Insurance Payer through the Network Area Manager. Put them all together. Document everything! You can initiate the process by calling, and then by sending a formal letter of intent to renegotiate your contract rates or fee schedule. Don't forget to involve your billers and coders in this project! Let your patients leave feedback, reviews and about their experience in your practice! All these will surely help get you a better deal. It's a bit of a process but just be patient and work on it.  Do you need help on how to Negotiate your Physician Group or Individual Provider's Contract with the Insurance Payers? You should contact us today!Understanding the Genicular Nerves (image below) Do you remember the struggle when we didn't have the specific code for the Genicular Nerve Knee Block and for the ablation or the RFA? Prior to January 1, 2020, we used to code them using 64450 for the Peripheral Nerve Block and the you used the 64640 for the Ablation. Not only that, you need to know the nerves that were blocked or were RFA'ed. But Effective January 1, 2020, we have now a specific code for the Genicular Nerve Knee Block and the Genicular Nerve Knee Ablation. You can read more about that change in our blog. CLICK HERE. CPT 64454 Genicular Nerve Block Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed CPT 64624 Genicular Nerve Ablation or RFA Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed Unfortunately many of our Pain and Orthopedic Physicians are still struggling getting reimbursed for these services even though we already have these specific codes in place since 2020. And why is that? There are common issues why: 1) Their billing staff are still using the old codes CPT 64450, CPT 64640 instead of the CPT Code 64454 and 64624 for the Genicular Nerve Block and Radiofrequency Ablation; 2) What I found is that, this is considered as Investigational and Experimental based on the following guideline when being reported: Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including but not limited to any of the following:
But I have also read that there are two CMS Contractors who covers for this procedure based on Medical Necessity. See Group 1 Diagnosis Codes Cross Over: Group 1 DX Codes:
Read more about guidelines: National Government Services Inc Billing and Coding: Peripheral Nerve Blocks (A57452) First Coast Service Options, Inc Billing and Coding: Peripheral Nerve Blocks (A57788) More Guidelines from Payers which consider the procedure to be Investigational: Aetna Healthcare Anthem Blue Cross Blue Shield How do you handle Denial and Appeal for Genicular Nerve Ablation or Genicular Nerve Block? Here are my tips: Avoid the denials in the first place! by knowing your payers' guidelines; If the Provider says its Medically Necessary for the patient to receive the genicular nerve block or genicular nerve ablation, try getting a Predetermination based on Medical Necessity from your Payer! They will not allow you to submit Prior Authorization because for sure, it does not need Prior Authorization because its not a covered benefit based on their policy because the payer considers it "investigational" or "experimental"; Insist on reviewing Predetermination based on Medical Necessity instead! Already having denied claims? - pursue the claims by sending appeals, get your patient get involved with the appeals process. Be prepared with your medical documentation! How's the Patient's Pain Relief? Duration of Pain Relief? Improved ADL? - include that all in your documentation! Searched Keywords: GENICULAR NERVE BLOCK DENIAL AND APPEAL CPT BILLING CODE 64454 This is how it looks like when you get paid for Genicular Nerve Knee RFAgenicular-nerve-block-denial-and-appeal.html. Does this not look nice?  Example of Genicular Nerve Knee RFA Paid Claim HOW TO GET PAID FOR GENICULAR NERVE KNEE INJECTIONS Need help how to Appeal your claims? Contact Us today! Need help how to obtain Pre-determination before you render the Genicular Nerve Block to your patients? You should contact us today! Pain Management coding and billing can be confusing. You must have at least a little knowledge with Anatomy and Physiology to be successful in this area of billing and coding.  Your Billing Codes for the Peripheral Nerve Ablation are listed below. 64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, intraorbital, mental, or interior alveolar branch 64605 Desctruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale 64610 Desctruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring 64620 Destruction by neurolytic agent, intercostal nerve 64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed 64630 Destruction by neurolytic agent, pudendal nerve 64640 Destruction by neurolytic agent, other peripheral nerve or branch 64680 Destruction by neurolytic agent, with or without radiologic monitoring; celliac plexus 64681 Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus Below are the list of billing codes for Peripheral Nerve Block Injection.  64400 Injection, anesthetic agent; trigeminal nerve, any division or branch 64418 Injection, anesthetic agent; suprascapular nerve 64420 Injection, anesthetic agent; intercostal nerve, single 64421 Injection, anesthetic agent; intercostal nerves, multiple, regional block 64425 Injection, anesthetic agent, ilioinguinal, iliohypogastric nerves 64430 Injection, anesthetic agent, pudendal nerve 64447 Injection, anesthetic agent; femoral nerve, single 64450 Injection, anesthetic agent; other peripheral nerve or branch 64454 Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed 64505 Injection, anesthetic agent; sphenopalatine ganglion 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) 64517 Injection, anesthetic agent; superior hypogastric plexus 64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) 64530 Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring Key points to remember:
Effective January 1, 2020, we have now a specific code for the Genicular Nerve Knee Block and the Genicular Nerve Knee Ablation. You can read more about that change in our blog. CLICK HERE. Understanding the Genicular Nerve (image below) 64454 I have been getting inquiries about their claims getting denied by the insurance payers including some contractors of Medicare. What I found is that, this is considered as Investigational and Experimental. I commonly see the following guideline: Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including but not limited to any of the following:
I have seen two CMS Contractor who covers for this procedure based on Medical Necessity. See Group 1 Diagnosis Codes Cross Over: Group 1 DX Codes: M25.561 Pain in right knee M25.562 Pain in left knee Read more about guidelines: National Government Services Inc Billing and Coding: Peripheral Nerve Blocks (A57452) First Coast Service Options, Inc Billing and Coding: Peripheral Nerve Blocks (A57788) More Guidelines from Payers which consider the procedure to be Investigational: Aetna Healthcare Anthem Blue Cross Blue Shield How do you handle Denial and Appeal for Genicular Nerve Ablation or Genicular Nerve Block? Here are my tips:
Searched Keywords: GENICULAR NERVE BLOCK DENIAL AND APPEAL CPT BILLING CODE 64454 How to Get Paid for Genicular RFA Ablation Denial Need help how to Appeal your claims? Contact Us today! Need help how to obtain Pre-determination before you render the Genicular Nerve Block to your patients? You should contact us today! Searched Keyword: Revenue Cycle Management Company for Interventional Pain Management Don't miss this FREE Webinar! Because in 2021, there's a major changes in the way you code and document the level of Evaluation and Management for the Office Visits. I am also going to talk about the Prolonged Services. Seats are limited! Make sure you register asap! You can register here: -->> https://bit.ly/2Nnk5md and make sure to bookmark your calendar!- February 9th, Tuesday at 2:00PM EST. #cptcoding2021 #emchanges2021 #medicalpracticemanagement #evaluationandmanagement #painmanagementphysicians #orthopedicsurgeons #surgerycenters #surgeons #healthcaremanagement #healthcareconsultant #medicalbillingandcoding #revenuecyclemanagement # #webinar #healthcare #training #medicalpracticeindustry #ehrs REGISTER TODA AND LEARN THE!  ASC Billing for Out of Network Facility Claims When you are an out of network Ambulatory Surgery Center, it is always a struggle to get paid and have your claims get processed appropriately. It upsets the patients and much more, the ASC loses revenue. This blog post is about ASC Billing. And I am going to give you some ASC Billing Scenarios and how to tackle them. It is always wise that you have a system in place in the practice. Because I will tell you, ASC Billing is not easy. But once you understand the process, its not really too bad. These tips can be used for any practice services. Mostly I kept these in mind for our clients Pain Management Billing, Anesthesia Billing and Orthopedic Spine Billing. ASC Billing Tip: We should always remember, if the Professional Services are not Authorized, it's unlikely the ASC Facility will get paid/processed for their portion.  In the perfect world of ASC, the ASC always relies on the Providers' services being verified and authorized. They have to work together, hand in hand. So here are my ASC Billing Tips for an Out of Network Facility:
NEXT; ASC Billing tip: Educate your patient about the Ambulatory Surgery Center being out of network. Because your dilemma will be, the patient will likely get the check because the payer may send it to their members! I can name some of the Insurance Payers that does this! So it is always wise to let them know checks might be directly sent to them by their insurance company. All they have to do is to endorse (sigh the back of the check) and send the check to the practice. And also don't forget to let your patient know about their out of network benefits (deductible & coinsurance). It's very important that your patients knows what to expect about the ASC being an out of network facility. ASC Billing Claims Submission tips:
So what's next for ASC Billing when claims are Denied, Rejected or Inappropriately Processed? You don't want to miss that revenue opportunity for the Out of Network Facility Fee. Out of network fees are always based on UCR (Usual and Customary Rates) based on your location. Normally I have seen up to 300% or (even more!) of Medicare Fee Schedule. At times, you will also be negotiating fees with 3rd party claims repricing companies. So be careful when negotiating your fees. You can call our office and we can guide you how to negotiate your fees. Don't be fooled. Remember, they are not the insurance company, they are just the claims repricing companies. If you don't agree with what they want to negotiate with you, send it back to the patient's primary insurance company. You can always call us if you need help in negotiating out of network fees. Contact us here. What we should do for all our UNPAID Claims:
I mean, you need to know the determination that was made on your claims and then you can take action. But moving forward, just make sure you have a team in your practice that only does Patients Access and Prior Authorization. References Source: https://www.cms.gov/Center/Provider-Type/Ambulatory-Surgical-Centers-ASC-Center Commercial Payers Public Domain Websites CPT Coding Guidelines through the American Medical Association  The $20 billion Provider New Phase 3 Relief Funding is now open and you have from October 5, 2020 to November 6, 2020 to submit your application. The HHS through HRSA (Health Resources and Services Administration) had announced the $20 billion New Phase 3 Relief Funding which began yesterday, October 5, 2020.  Who are covered? Read Provider Eligibility. HHS is making a large number of providers eligible for Phase 3 General Distribution funding, including:
Understanding the Provider Relief Phase 3 Funding Payment Methodology.  All eligible providers will be considered for payment against the below criteria.
All payment recipients will be required to attest to receiving the Phase 3 General Distribution payment and accept the associated Terms and Conditions. Pay Attention with the Deadline.  Healthcare Providers will have from October 5, 2020 through November 6, 2020 to apply for Phase 3 General Distribution funding. Funding for this Phase 3 General Distribution was made possible through the bipartisan CARES Act and the Paycheck Protection Program and Health Care Enhancement Act, which allocated $175 billion in relief funds to hospitals and other healthcare providers. Source of Information: https://www.hhs.gov/about/news/2020/10/1/trump-administration-announces-20-billion-in-new-phase-3-provider-relief-funding.html
Understanding Billing for DME Services or 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:
 Pointers on DME Billing Services and Coding
Other related blog posts: NEW CPT Code 99072 and CPT Code 86413 DURING COVID19 PANDEMIC  These 2 new CPT Codes 99072 and 86413 were published on September 8th 2020 and are effective immediately.  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  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?  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. One of our blog readers asked why their claim for Trigger Point injection is being denied due to missing modifier.  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 20553Denials Reasons for Trigger Point Injection CPT 20552, 20553 and what you should be looking for:
 Need more help? Call us at 732-982-4800 today!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.  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 
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.  |
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Ms. Pinky Maniri-Pescasio is the Founder of GoHealthcare Consulting. She is a National Speaker on Practice Reimbursement and a Physician Advocate. She has served the Medical Practice Industry for more than 25 years as a Professional Consultant. search hereArchives
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