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New Pain Management Codes Genicular Nerves and SI Joint Nerves in 2020

7/21/2021

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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!)
  • superolateral
  • superomedial
  • inferomedial

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!)
  • superolateral
  • superomedial
  • inferomedial

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!
  • Do not report 64625 in conjunction with 64635, 77002, 77003, 77012, 95873, 95874
  • For radiofrequency ablation, nerves innervating the sacroiliac joint, with ultrasound,  use 76999
  • For Bilateral procedure, append 50 Modifier with 64625

Need help? Contact our office today!
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How to bill for mild - minimally invasive lumbar decompression

7/13/2021

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updated: 07/13/2022
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
HOW TO BILL FOR MILD - 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:
  • Outpatient Hospital (POS 22)
  • ASC (POS 24)
CPT Category III Code 0275T is billable when reported as patient participating in a clinical study.

The following information has to appear and included in your claim submission:
  • Diagnosis Code (Primary: M48.062 - Spinal Stenosis, lumbar region with neurogenic claudication)
  • Diagnosis Code (Secondary: Z00.6 - Encounter for examination for normal comparison and control in clinical research program
  • National Clinical Trial (NCT) Number (enter on BOX 19) - 03072927 (number only if submission is by electronic. Enter CT03072927 if by paper submission.
  • CPT Category III Modifier - Q0 (** this is the letter Q and the numerical number ZERO, not the letter O).

Insurance Prior Authorization Services, Patients Access and Medical Documentation Reviews and Audits.
Insurance Prior Authorization Services, Patients Access and Medical Documentation Reviews and Audits.
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".
PictureImage/Guidance Source: www.vertosmed.com

HOW TO BILL FOR MILD - MINIMALLY INVASIVE LUMBAR DECOMPRESSION
HOW TO BILL FOR MILD - MINIMALLY INVASIVE LUMBAR DECOMPRESSION
2022 GUIDANCE HOW TO BILL FOR MILD - MINIMALLY INVASIVE LUMBAR DECOMPRESSION BILLING GUIDANCE for the Procedure (NCTØ3Ø72927) - SOURCE VERTOS (SEE ATTACHMENT BELOW)
2022 BILLING GUIDANCE FOR MILD
File Size: 509 kb
File Type: pdf
Download File

Video Source is owned by: VERTOS MED - www.vertosmed.com

Do you need additional help with billing?

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Is it time to negotiate your payers' contract?

6/14/2021

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How to Negotiate your Physician Group or Individual Provider's Contract with the Insurance Payers
Revenue Cycle Management Company for Pain Management
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
  1. First thing first, do you have a copy of your contract? It's very common the Providers would tell me, they have not seen their contracts or they don't have a copy of their contracts. Oh well, it's time to request for a copy of your contract! Call your insurance payer, look for your Area Network Manager or Network Representative. There should be one assigned in your area! Request to get a copy of your contract;
  2. Your contracts should be with accompanied fee schedule or contracted rates. Pay attention to these contracted rates by CPT Code, by Insurance Plan and by Insurance Types!
  3. Review your patients volume and the services you have rendered to the Payer's Members? (past 12-24 months)
  4. Review your EOBs on how are you getting reimbursed, are the fee schedule being followed?
  5. How long have you been contracted with the insurance payer? one year? two years?
  6. How's your current payer's volume? (past 12-24 months)
  7. How's your patients' satisfaction rates? (it helps when you get good reviews from your patients)
  8. How's your patients' outcome?  (again, it helps when you get good reviews from your patients)

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.
Revenue Cycle Management for Pain Management
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!

    Drop us a message today! or CALL us at (800) 267-8752

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How to get paid for genicular knee INJECTIONS

6/14/2021

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​

Understanding the Genicular Nerves (image below)

Prior Authorization for Pain Management
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:
  • Degenerative joint disease;
  • Osteoarthritis of the knee;
  • As a treatment prior to knee replacement;
  • As a treatment following knee replacement;
  • As a treatment for individuals who are not candidates for knee replacement surgery.

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:
  • 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:
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?
How to Get Paid for Genicular RFA Ablation Denial
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! 

    Drop us a message or CALL US today! (800) 267-8752

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billing for peripheral nerve ablation rfa

2/27/2021

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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.
Billing for Peripheral Nerve Ablation Revenue Cycle Management Gohealthcarecllc.com
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.
Looking for Revenue Cycle Management for Pain Management Company
​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:
  • These code(s) can be unilateral (so make sure you append the right anatomical side MODIFIER);
  • Some code(s) may be inclusive with the imaging guidance (you cannot bill it separate);
  • Always check with the payers if your procedure(s) will need Prior Authorization or Precertification
  • Always verify if it is a covered benefits for your patients.
  • You can report for Moderate Conscious Sedation code 99152-99153 if performed by the same physician and patient is older than 5 years old.

    Contact us today if you need help getting paid!

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Genicular nerve block denial and appeal

2/27/2021

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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)

GENICULAR NERVE BLOCK DENIAL AND APPEAL
64454
Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed
64624
Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
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:
  • Degenerative joint disease;
  • Osteoarthritis of the knee;
  • As a treatment prior to knee replacement;
  • As a treatment following knee replacement;
  • As a treatment for individuals who are not candidates for knee replacement surgery.
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:
  • 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 consider 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
How to Get Paid for Genicular RFA Ablation Denial
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!

    Contact us today.

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Searched Keyword: Revenue Cycle Management Company for Interventional Pain Management
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E/M Coding Changes for 2021 - Free Webinar

1/23/2021

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​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!
E/M CODING CHANGES FOR 2021 - FREE WEBINAR
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ASC Billing - Out of network facility claims

1/12/2021

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​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. 
Picture
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:
  • Always Verify if the Professional Services (this is for the Rending Physician) will require Prior Authorization (Commercial Payers, Motor Vehicle and Workers Compensation)
  • If Yes it requires Prior Authorization, make sure you obtain the Prior Authorization with ASC as place of service (very important to take note!). 
  • Obtain Pre Determination if Prior Authorization is not required - they may refuse not to process the Predetermination, but we always tell the insurance payers, we want an approval for Pre-Determination based on Medical Necessity
  • Have a dedicated team in your practice who will only be doing just Prior Authorization/Predetermination so the practice will be successful in getting paid for the ASC claims. We should always remember, if the Professional Services are not Authorized, it's not possible the 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.
Why is this so? Here's the rationale: if you have an Authorization obtained for the Professional Services with ASC, most likely:
  • Your ASC claims will be processed based on the Rendering Physician's prior authorization approval that was obtained.
​
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:
  • Use HCFA 1500 form, MOD SG POS 24 (ASC) as your primary modifier. Remember your ASC billing codes and the use of HCFA 1500 is the same as how you bill under POS 11 (Office) or POS 22 (Outpatient Hospital)​​
  • You can only report the PRIMARY CPT code for the ASC Billing (for example CPT 64635 only)
  • DO NOT report each additional code (for example CPT 64636)
  • You can report the supervision and guidance with $0 amount for the TC (Technical Component) - because these are bundled into the code based on the CPT Coding guideline
  • Submit the spinal stimulator trial electrodes (L-code) when performed at the ASC
  • Submit the DME Durable Medical Equipment (Home) when dispensed at the ASC
  • Moderate Conscious Sedation (CPT 99152, CPT 99153) are not billable at the ASC
  • Use HCFA 1500 form, POS 24 (Professional) - Physician's claim if you are submitting ASC Billing for the Physician or Professional Component
  • Use exactly the same codes for the Primary Procedural codes and the Diagnosis Codes
  • Scrub your claims before you finalize the claims for submission. CMD cannot fully do this for you due to POS 11 versus POS 24. (CPT, DX, Billing Facility, Billing Provider, HCFA 1500)
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:
  • Understand how the claims were processed, it may be unpaid because everything was applied towards the patients out of network responsibility; bottom line, find out what exactly happened with the claims and how it was processed;
  • Connect with the Payers
  • In network versus Out of Network
  • Payments sent to the patient
  • Claims that are not actually “denied” but are just being rejected for coding or medical documentation requirements
  • Appeal the Claims that were denied for NO Prior Authorization obtained
  • Appeal claims that were inappropriately processed (in network versus out of network usual and customary fees)
  • Corrective claims due to ASC Billing and Coding
  • Respond to Medicare Records requests

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
​
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$20 BILLION IN NEW PHASE 3 PROVIDER RELIEF

10/6/2020

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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.
Have you submitted your application yet?
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. 
​Provider Relief Funding Phase 3 Began October 5 2020 20 Billion
Who are covered? Read Provider Eligibility.
HHS is making a large number of providers eligible for Phase 3 General Distribution funding, including:
  1. Providers who previously received, rejected or accepted a General Distribution Provider Relief Fund payment. Providers that have already received payments of approximately 2% of annual revenue from patient care may submit more information to become eligible for an additional payment.
  2. Behavioral Health providers, including those that previously received funding and new providers.
  3. Healthcare providers that began practicing January 1, 2020 through March 31, 2020. This includes Medicare, Medicaid, CHIP, dentists, assisted living facilities and behavioral health providers.
Understanding the Provider Relief Phase 3 Funding Payment Methodology.
​Provider Relief Funding Phase 3 Began October 5, 2020.2
All eligible providers will be considered for payment against the below criteria.
  1. All provider submissions will be reviewed to confirm they have received a Provider Relief Fund payment equal to approximately 2 percent of patient care revenue from prior general distributions. Applicants that have not yet received Relief Fund payments of 2 percent of patient revenue will receive a payment that, when combined with prior payments (if any), equals 2 percent of patient care revenue.
  2. With the remaining balance of the $20 billion budget, HRSA will then calculate an equitable add-on payment that considers the following:
  • A provider’s change in operating revenues from patient care
  • A provider’s change in operating expenses from patient care, including expenses incurred related to coronavirus
  • Payments already received through prior Provider Relief Fund distributions.

​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.
Medical Providers Relief Funding October 5, 2020
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
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Billing for Durable medical equipment services

9/30/2020

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Understanding Billing for DME Services or Durable Medical Equipment Services
BILLING FOR DURABLE MEDICAL EQUIPMENT SERVICES

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

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

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

Pointers on DME Billing Services and Coding

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

Other related blog posts:

DME Billing Modifiers
Physician Medical Billing Denial Management

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NEW CPT 99072 CPT 86413 during covid19 pandemic

9/24/2020

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NEW CPT Code 99072 and CPT Code 86413 DURING COVID19 PANDEMIC 
These new CPT codes address advancing understanding of COVID-19
NEW CPT 99072 CPT 86413 DURING COVID19 PANDEMIC Gohealthcare Revenue Cycle Management
These 2 new CPT Codes 99072 and 86413 were published on September 8th 2020 and are effective immediately.
NEW CPT 99072 CPT 86413 DURING COVID19 PANDEMIC Gohealthcare Revenue Cycle Management.3

Let's describe these 2 new CPT Codes.

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

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

CPT Code 86413     Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative
NEW CPT 99072 CPT 86413 DURING COVID19 PANDEMIC Gohealthcare Revenue Cycle Management.1
According to the AMA:
"The first addition, CPT code 99072, was approved in response to sweeping measures adopted by medical practices and health care organizations to stem the spread of the novel coronavirus (SARS-CoV-2), while safely providing patients with access to high-quality care during in-person interactions with health care professionals. The additional supplies and clinical staff time to perform safety protocols described by code 99072 allow for the provision of evaluation, treatment or procedural services during a public health emergency in a setting where extra precautions are taken to ensure the safety of patients as well as health care professionals. The AMA/Specialty Society RVS Update Committee (RUC) worked with 50 national medical specialty societies and other organizations over the summer to collect data on the costs of maintaining safe medical offices during the public health emergency and submitted recommendations today to the Centers for Medicare and Medicaid Services to inform payment of code 99072."
​

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

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

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

NEW CPT 99072 CPT 86413 DURING COVID19 PANDEMIC Gohealthcare Revenue Cycle Management.3
Understanding PHE or Public Health Emergency in coordination with CPT Code 99072
Question: Code 99072 is stated as being applicable “during a PHE.” What information should be used to verify when a PHE is in effect?
Answer: A PHE is in effect when declared by law by the officially designated relevant public health authority(ies).
Understanding Patient Encounters Type for the determination of CPT Code 99072
Question: For what type of patient encounters or services should code 99072 be reported?
Answer: Code 99072 may be reported with an in-person patient encounter for an office visit or other non-facility service, in which the implemented guidelines related to mitigating the transmission of the respiratory disease for which the PHE was declared are required. Use of this code is not dependent on a specific patient diagnosis. For a list of POS codes with facility/non-facility designations that are available in the Medicare Claims Processing Manual, visit https://www.cms.gov/Medicare/Coding/place-of-service-codes.
​Understanding Documentation Requirements when reporting CPT Code 99072
Question: What documentation is required to report code 99072?
Answer: Given that code 99072 may only be reported during a PHE, one would not report this code in conjunction with an evaluation and management (E/M) service or procedure when a PHE is not in effect. Therefore, code 99072 is reported justifiably only when health and safety conditions applicable to a PHE require the type of supplies and additional clinical staff time explained in the code descriptor. 
Documentation requirements may vary among third-party payers and insurers; therefore, they should be contacted to determine their specifications.
How about CPT Code 99072 with CPT Code 99070?
Question: May code 99072 be reported with code 99070?
Answer: Yes, code 99072 may be reported with code 99070 when the requirements for both codes have been met. Note that eligibility for payment, as well as coverage policy, is determined by each individual insurer or third-party payer.

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


NEW CPT 99072 CPT 86413 DURING COVID19 PANDEMIC Gohealthcare Revenue Cycle Management.88
Reference sources: ​https://www.ama-assn.org/press-center/press-releases/ama-announces-new-cpt-codes-covid-19-advancements-expand
https://www.ama-assn.org/system/files/2020-09/cpt-assistant-guide-coronavirus-september-2020.pdf
CPT Assistant September 2020 Special Addition
CPT is a trademark and owned by the American Medical Association.


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Modifier for trigger point injection 20553, 20552

9/22/2020

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One of our blog readers asked why their claim for Trigger Point injection is being denied due to missing modifier.
MODIFIER FOR TRIGGER POINT INJECTION CPT Code 20553 CPT Code 20552

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

Widely indicated for Myofascial Pain.
Key point to remember! - these 2 CPT Codes 20552, 20553 DO NOT NEED A MODIFIER!
MODIFIER FOR TRIGGER POINT INJECTION CPT Code 20553 CPT Code 20552

Denial Reasons for Trigger Point Injection CPT 20553

Denials Reasons for Trigger Point Injection CPT 20552, 20553 and what you should be looking for:
  • The lack of medical necessity (have you checked the payer clinical policy and guideline?)
  • When billing with an E/M Evaluation and Management (you will need a modifier on the E/M but not on the Trigger Point Injection CPT code;
  • When being performed with another procedure being "distinct" (look at your modifier 59);
  • When being performed with other "multiple" and or "reduced" procedures (look at your modifier 51, 52);
  • Missing drug name used;
  • Missing NDC number for the drug used;
Ask a Question GoHealthcare Prior Authorization Credentialing Services

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CPT Shingrix 90750 - What's the reimbursement?

9/17/2020

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Understanding Shingrix Zoster Vaccine CPT Code 90750

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Key points to remember in properly billing and coding for Shingrix:
​Keypoints to remember!
  1. ICD-10 Code is obviously indicated for Z23 - Encounter for Immunization (most payers want to see this ICD-10 Diagnosis code)
  2. CPT Code (Product is SHINGRIX), use CPT Code 90750 - Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection.
  3. CPT Vaccine Administration
    1. Use CPT Code 90471  1 vaccine administered
      1. Use CPT Code 90472  Each additional vaccine administered during same encounter
  4. 0.5ml is equal to 1 billable unit
  5. Per Medicare policy, shingles vaccines are only covered in Part D plans, not in Part B Part D covered vaccinations are typically administered at a retail site of care (pharmacy)

CPT Code Shingrix 90750 What's the reimbursement?


CPT Code Shingrix 90750 - What's the reimbursement?
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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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2020 CPT Billing for 99421-99423 DIgital E/M

8/12/2020

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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. 
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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? 
For example are the:
Physical therapists
Occupational therapists
Speech Language pathologists
Clinical psychologists
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.
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References: CPT 2020, CMS Guideline and Finial Ruling.

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CPT CODE FOR SACROILIAC SI RFA FOR 2020 CPT 64625

7/26/2020

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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!
  • Do not report 64625 in conjunction with 64635, 77002, 77003, 77012, 95873, 95874
  • For radiofrequency ablation, nerves innervating the sacroiliac joint, with ultrasound,  use 76999
  • For Bilateral procedure, append 50 Modifier with 64625
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Patient Access Management and Revenue Cycle

7/9/2020

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The Patients Access plays a very important role in capturing and collection of patient service revenue.
PATIENT ACCESS MANAGEMENT AND REVENUE CYCLE
​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
  • Scheduling patients
  • Pre-registering patients
  • Verifying insurance coverage and eligibility
  • Verifying pre-certification and referral requirement
  • Discussing patient costs and providing financial counseling services if required

2. Time of Service 
  • Activate the patients record in the Electronic Medical Record and or Practice Management system
  • Attached copy of insurance card front and back on the patient's chart
  • Attached copy of government issued identifications on the patient's chart
  • Patient reviews and sign the consent forms
  • Completed the positive patient identification
  • Financial Clearance
  • Patient Arrival
  • Patient Care Delivery

3. Post-service Phase
  • Claims Submission
  • Patients Responsibility
  • Claims follow up
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Focusing on Customer Service and Patient Satisfaction is very important.
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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:
  • Patient's Name
  • Address
  • Date of Birth
  • Primary Insured's name (Subscriber)
  • Social Security number (Guarantor/Subscriber)
  • The insurance company name
  • The patient's insurance ID and group number
  • Photo ID
  • Copy of the primary and secondary insurance card (front and back)
  • Subscriber's relation to the patient (self, spouse, child, other)

Additional Useful information that you can also gather from the patient:
  • ​Patient's complaints (pain? injury?)
  • Patient's Primary Care Physician (if applicable)
  • Date of Accident? (for Liability Insurance such as Motor Vehicle and Workers Compensation)
  • State where the Accident happened
  • Name of the Injury Attorney (if available)
  • Name of Injury Case Adjuster (if available)
  • Name of Injury Nurse Manager (if available) 

​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. 
PATIENT ACCESS Patient Satisfaction and Patient Quality Care
What happens if we did not correctly verify the patient identity?
  • Medical error including the wrong medication, not knowing about their allergies and or the patient's blood type etc
  • Claims denial resulting to non-payment for services from the insurer
  • Poor patients outcome
  • Poor patients experience since they will receive a bill for the entire cost of the rendered services
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.
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CPT 76140 Can PHYSICIAN BILL for X-ray Review?

7/6/2020

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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)
CPT 76140 CAN PHYSICIAN BILL FOR X-RAY REVIEW
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.
Continue reading by scrolling down
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.

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CPT CODE 20552, 20553 Trigger Point iNJECTIONS

7/2/2020

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CPT CODE 20552, 20553 TRIGGER POINT INJECTIONS. Medicare guideline.
CPT Codes and Description 
  • 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 muscle(s)
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:
  • History of onset of the painful condition and its presumed cause (e.g., injury or sprain)
  • Distribution pattern of pain consistent with the referral pattern of trigger points
  • Range of motion restriction
  • Muscular deconditioning in the affected area
  • Focal tenderness of a trigger point
  • Palpable taut band of muscle in which trigger point is located
  • Local taut response to snapping palpation
  • Reproduction of referred pain pattern upon stimulation of trigger point

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).
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20552, 20553 DX Crossover based on Medical Necessity

​M53.82 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
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Does Medicare Cover Radiofrequency Ablation

7/1/2020

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READER'S QUESTION: ​Does Medicare Cover Radiofrequency Ablation for Pain Management in New York?

Here's the Coverage Information from Medicare Part B

Indications:
  • Patient must have history of at least 3 months of moderate to severe pain with functional impairment and pain is inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (as tolerated).
  • Pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication.
  • There is no non-facet pathology that could explain the source of the patient’s pain, such as fracture, tumor, infection, or significant deformity.
  • Clinical assessment implicates the facet joint as the putative source of pain.​

General Procedure Requirements:
  • Pre-procedural documentation must include a complete initial evaluation including history and an appropriately focused musculoskeletal and neurological physical examination. There should be a summary of pertinent diagnostic tests or procedures justifying the possible presence of facet joint pain.
  • A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. Required elements of the note include a description of the techniques employed, nerves injected and sites(s) of injections, drugs and doses with volumes and concentrations as well as pre and post-procedural pain assessments. With RF neurotomy, electrode position, cannula size, lesion parameters, and electrical stimulation parameters and findings must be specified and documented.
  • Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomographic (CT) guidance. Facet joint interventions performed under ultrasound guidance will not be reimbursed.
  • A hard (plain radiograph with conventional film or specialized paper) or digital copy image or images which adequately document the needle position and contrast medium flow (excluding RF ablations and those cases in which using contrast is contra-indicated, such as patients with documented contrast allergies), must be retained and submitted if requested.
  • In order to maintain target specificity, total IA injection volume must not exceed 1.0 mL per cervical joint or 2 mL per lumbar joint, including contrast. Larger volumes may be used only when performing a purposeful facet cyst rupture in the lumbar spine.
  • Total MBB anesthetic volume shall be limited to a maximum of 0.5 mL per MB nerve for diagnostic purposes and 2ml for therapeutic. For a third occipital nerve block, up to 1.0 mL is allowed for diagnostic and 2ml for therapeutic purposes.
  • In total, no more than 100 mg of triamcinolone or methylprednisolone or 15 mg of betamethasone or dexamethasone or equivalents shall be injected during any single injection session.
  • Both diagnostic and therapeutic IA facet joint injections and medial branch blocks (see criteria below) may be acceptably performed without steroids.​
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Diagnostic Facet Joint Injections
  • Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB injections.
    • A second confirmatory MBB is allowed if documentation indicates the first MBB produced > 80% relief of primary (index) pain and duration of relief is consistent with the agent employed.

  • Intraarticular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be performed due to specific documented anatomic restrictions.

Therapeutic Injections
  • Either intraarticular injections or medial branch blocks may provide temporary or long-lasting or permanent relief of facet-mediated pain. Injections may be repeated if the first injection results in significant pain relief (>50%) for at least 3 months. (See Limitations section for total number of injections that may be performed in one year.)
  • Recurrent pain at the site of previously treated facet joint may be treated without additional diagnostic blocks if >50% pain relief from the previous block(s) lasted at least 3 months.

Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave technologies):
  • Only when dual MBBs provide > 80% relief of the primary or index pain and duration of relief is consistent with the agent employed may facet joint denervation with RF medial branch neurotomy be considered
  • Repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced > 50% improvement of pain and improvement in patient specific ADLs documented for at least 6 months.

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.


  • For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any calendar year, involving no more than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels.
  • Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented.
  • Non-thermal RF modalities for facet joint denervation including chemical, low grade thermal energy (<80 degrees Celsius), as well as pulsed RF are not covered.
  • Intraarticular and/or extraarticular facet joint prolotherapy is not covered.
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)
Related Billing Articles 
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​

Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy

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radiofrequency ablation (RFA) of nerves

6/27/2020

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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?
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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
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy

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U07.2 Covid 19 Virus Not Identified icd-10 coding

6/26/2020

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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.



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HOW TO BILL BILATERAL TRIGGER POINT INJECTION

4/27/2020

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Can I Bill for a Bilateral Trigger Point Injection using CPT 20552-20553? The answer is NO. See reasons below:
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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:
  • 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

Many are still so confused on how to bill for Trigger Points.

Here are my Coding and Billing Tips:

1. There is NO anatomical modifier; these 2 codes are not unilateral - so modifier 50, LT or RT is not applicable;
2. Code and bill based on the number of muscles (not number of injections!)
3. You can append modifier 59 if it meets the guideline and necessity
4. Possible Imaging Used (may be any of the following):

76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)

77021
Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation
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reader's question: how to bill multiple ekg?

4/27/2020

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​How to Bill for Multiple EKG Performed by the Same Physician on the Same Day
You can append the Modifier 76 - same service performed on the same day by the same physician. We apply this Modifier on the second line. The first line DO NOT require a modifier. The second line of the same CPT code will be appended with modifier 76.
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Billing coding telehealth telemedicine services

3/17/2020

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​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:
  • Electronic Mail or e-mail
  • Instant Messaging
  • Phone Texting
  • Facsimile Transmission
  • Audio-only Telephone Conversation

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 Services


Modifier 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
PAYERS LIST IN ANY ORDER
CMS Medicare Guideline
Medicare Telehealth Covered CPT and HCPCS CODES. Click here.
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:
  • Non-direct patient services (e.g. coordination of care rendered before or after patient interaction) will not be considered for reimbursement.
  • Claims submitted with modifier GQ, which signifies services provided via asynchronous telecommunications system, as these services do not include direct in-person patient contact.
  • Any service that is not eligible for separate reimbursement when rendered to the patient in-person.
  • Presentation/origination site facility fee (HCPCS code Q3014).
  • CPT codes 99441-99444.
  • Health care providers providing telemedicine services shall be subject to the same standard of care or practice standards as are applicable to in-person settings.
  • Documentation in the medical record must be maintained and must support the services rendered.
  • Utilization review by Horizon BCBSNJ may be performed.
*** READ THE ENTIRE BCBS NJ POLICY HERE.
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Covid-19 medicare telehealth for providers

3/17/2020

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Medicare's Telehealth and Telemedicine Services during Covid-19. Understanding Provider and Non-Provider Services.
And Understanding
“Expansion of Telehealth with 1135 Waiver” 

COVID-19 Emergency Declaration Health Care Providers Fact Sheet
Understanding “EXPANSION OF TELEHEALTH WITH 1135 WAIVER” 

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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:
  • All Areas; 
  • All Facilities;
  • All settings in the country
  •  and in their HOMES.
Since the 1135 Waiver requires an established relationship, HHS however will not conduct an audit for all claims submitted during this public health emergency.

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
  • Virtual check-ins 
  • e-visits.

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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
  • Virtual check-ins 
  • e-visits.


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:
  • Physician
  • Nurse practitioner
  • Physician assistant
  • Nurse-midwife
  • Clinical nurse specialist
  • Clinical psychologist*
  • Clinical social worker*
  • Registered dietitian or nutrition professional
  • Certified registered nurse anesthetist
 
​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:
  • Phone
  • Audio/visit
  • Secure text messages
  • Email
  • Use of a patient portal

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:
  • The service is communication technology-based
  • The provider can be a physician or other qualified health care professional who reports E/M services
  • Interaction must be between the patient and billing practitioner, not clinical staff.
  • The communication can’t be related to an E/M service from within the previous seven days.
  • The communication can’t lead to an E/M service within 24 hours (or soonest available): The language in the code descriptor states, “nor leading to an E/M service or procedure within the next 24 hours.” Consequently, Medicare will be watching for an uptick in appointments occurring 25 hours or so after the call. Do not game the system to get around the 24-hour limitation.
  • The code represents five to 10 minutes of medical discussion.
  • The medical record must document verbal consent from the patient for each billed service. Cost-sharing applies, and the beneficiary co-payment isn’t waived.
  • The service is available only to established patients, defined as patients who have “received professional services from the physician or qualified health care professional or another physician or qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.”

*** 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:
  • Doctors
  • Nurse practitioners
  • Physician assistants
  • Licensed clinical social workers, in specific circumstances
  • Clinical psychologists, in specific circumstances
  • Therapists, in specific circumstances​
​
  • e-visits 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).
  • These services can only be reported when the billing practice has an established relationship with the patient.
  • For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. 
  • The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. 
  • The patient must verbally consent to receive virtual check-in services. 
  • The Medicare coinsurance and deductible would apply to these services.
  • Medicare Part B also pays for e-visits or patient-initiated online evaluation and management conducted via a patient portal
  • Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:​​
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:
  • Physical therapists
  • Occupational therapists
  • Speech Language pathologists
  • Clinical psychologists

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
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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. 

Medicare Elimination of the GT Modifier for Telehealth Services - READ MLN Matters here.
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
​
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    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 Medical Practice Consultant.

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