Understanding the Genicular Nerves (image below) Do you remember the struggle when we didn't have the specific code for the Genicular Nerve Knee Block and for the ablation or the RFA? Prior to January 1, 2020, we used to code them using 64450 for the Peripheral Nerve Block and the you used the 64640 for the Ablation. Not only that, you need to know the nerves that were blocked or were RFA'ed. But Effective January 1, 2020, we have now a specific code for the Genicular Nerve Knee Block and the Genicular Nerve Knee Ablation. You can read more about that change in our blog. CLICK HERE. CPT 64454 Genicular Nerve Block Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed CPT 64624 Genicular Nerve Ablation or RFA Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed Unfortunately many of our Pain and Orthopedic Physicians are still struggling getting reimbursed for these services even though we already have these specific codes in place since 2020. And why is that? There are common issues why: 1) Their billing staff are still using the old codes CPT 64450, CPT 64640 instead of the CPT Code 64454 and 64624 for the Genicular Nerve Block and Radiofrequency Ablation; 2) What I found is that, this is considered as Investigational and Experimental based on the following guideline when being reported: Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including but not limited to any of the following:
But I have also read that there are two CMS Contractors who covers for this procedure based on Medical Necessity. See Group 1 Diagnosis Codes Cross Over: Group 1 DX Codes:
Read more about guidelines: National Government Services Inc Billing and Coding: Peripheral Nerve Blocks (A57452) First Coast Service Options, Inc Billing and Coding: Peripheral Nerve Blocks (A57788) More Guidelines from Payers which consider the procedure to be Investigational: Aetna Healthcare Anthem Blue Cross Blue Shield How do you handle Denial and Appeal for Genicular Nerve Ablation or Genicular Nerve Block? Here are my tips: Avoid the denials in the first place! by knowing your payers' guidelines; If the Provider says its Medically Necessary for the patient to receive the genicular nerve block or genicular nerve ablation, try getting a Predetermination based on Medical Necessity from your Payer! They will not allow you to submit Prior Authorization because for sure, it does not need Prior Authorization because its not a covered benefit based on their policy because the payer considers it "investigational" or "experimental"; Insist on reviewing Predetermination based on Medical Necessity instead! Already having denied claims? - pursue the claims by sending appeals, get your patient get involved with the appeals process. Be prepared with your medical documentation! How's the Patient's Pain Relief? Duration of Pain Relief? Improved ADL? - include that all in your documentation! Searched Keywords: GENICULAR NERVE BLOCK DENIAL AND APPEAL CPT BILLING CODE 64454 This is how it looks like when you get paid for Genicular Nerve Knee RFAgenicular-nerve-block-denial-and-appeal.html. Does this not look nice?  Example of Genicular Nerve Knee RFA Paid Claim HOW TO GET PAID FOR GENICULAR NERVE KNEE INJECTIONS Need help how to Appeal your claims? Contact Us today! Need help how to obtain Pre-determination before you render the Genicular Nerve Block to your patients? You should contact us today!
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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.  Your Billing Codes for the Peripheral Nerve Ablation are listed below. 64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, intraorbital, mental, or interior alveolar branch 64605 Desctruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale 64610 Desctruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring 64620 Destruction by neurolytic agent, intercostal nerve 64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed 64630 Destruction by neurolytic agent, pudendal nerve 64640 Destruction by neurolytic agent, other peripheral nerve or branch 64680 Destruction by neurolytic agent, with or without radiologic monitoring; celliac plexus 64681 Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus Below are the list of billing codes for Peripheral Nerve Block Injection.  64400 Injection, anesthetic agent; trigeminal nerve, any division or branch 64418 Injection, anesthetic agent; suprascapular nerve 64420 Injection, anesthetic agent; intercostal nerve, single 64421 Injection, anesthetic agent; intercostal nerves, multiple, regional block 64425 Injection, anesthetic agent, ilioinguinal, iliohypogastric nerves 64430 Injection, anesthetic agent, pudendal nerve 64447 Injection, anesthetic agent; femoral nerve, single 64450 Injection, anesthetic agent; other peripheral nerve or branch 64454 Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed 64505 Injection, anesthetic agent; sphenopalatine ganglion 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) 64517 Injection, anesthetic agent; superior hypogastric plexus 64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) 64530 Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring Key points to remember:
Effective January 1, 2020, we have now a specific code for the Genicular Nerve Knee Block and the Genicular Nerve Knee Ablation. You can read more about that change in our blog. CLICK HERE. Understanding the Genicular Nerve (image below) 64454 I have been getting inquiries about their claims getting denied by the insurance payers including some contractors of Medicare. What I found is that, this is considered as Investigational and Experimental. I commonly see the following guideline: Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including but not limited to any of the following:
I have seen two CMS Contractor who covers for this procedure based on Medical Necessity. See Group 1 Diagnosis Codes Cross Over: Group 1 DX Codes: M25.561 Pain in right knee M25.562 Pain in left knee Read more about guidelines: National Government Services Inc Billing and Coding: Peripheral Nerve Blocks (A57452) First Coast Service Options, Inc Billing and Coding: Peripheral Nerve Blocks (A57788) More Guidelines from Payers which consider the procedure to be Investigational: Aetna Healthcare Anthem Blue Cross Blue Shield How do you handle Denial and Appeal for Genicular Nerve Ablation or Genicular Nerve Block? Here are my tips:
Searched Keywords: GENICULAR NERVE BLOCK DENIAL AND APPEAL CPT BILLING CODE 64454 How to Get Paid for Genicular RFA Ablation Denial Need help how to Appeal your claims? Contact Us today! Need help how to obtain Pre-determination before you render the Genicular Nerve Block to your patients? You should contact us today! Searched Keyword: Revenue Cycle Management Company for Interventional Pain Management Don't miss this FREE Webinar! Because in 2021, there's a major changes in the way you code and document the level of Evaluation and Management for the Office Visits. I am also going to talk about the Prolonged Services. Seats are limited! Make sure you register asap! You can register here: -->> https://bit.ly/2Nnk5md and make sure to bookmark your calendar!- February 9th, Tuesday at 2:00PM EST. #cptcoding2021 #emchanges2021 #medicalpracticemanagement #evaluationandmanagement #painmanagementphysicians #orthopedicsurgeons #surgerycenters #surgeons #healthcaremanagement #healthcareconsultant #medicalbillingandcoding #revenuecyclemanagement # #webinar #healthcare #training #medicalpracticeindustry #ehrs REGISTER TODA AND LEARN THE!  ASC Billing for Out of Network Facility Claims When you are an out of network Ambulatory Surgery Center, it is always a struggle to get paid and have your claims get processed appropriately. It upsets the patients and much more, the ASC loses revenue. This blog post is about ASC Billing. And I am going to give you some ASC Billing Scenarios and how to tackle them. It is always wise that you have a system in place in the practice. Because I will tell you, ASC Billing is not easy. But once you understand the process, its not really too bad. These tips can be used for any practice services. Mostly I kept these in mind for our clients Pain Management Billing, Anesthesia Billing and Orthopedic Spine Billing. ASC Billing Tip: We should always remember, if the Professional Services are not Authorized, it's unlikely the ASC Facility will get paid/processed for their portion.  In the perfect world of ASC, the ASC always relies on the Providers' services being verified and authorized. They have to work together, hand in hand. So here are my ASC Billing Tips for an Out of Network Facility:
NEXT; ASC Billing tip: Educate your patient about the Ambulatory Surgery Center being out of network. Because your dilemma will be, the patient will likely get the check because the payer may send it to their members! I can name some of the Insurance Payers that does this! So it is always wise to let them know checks might be directly sent to them by their insurance company. All they have to do is to endorse (sigh the back of the check) and send the check to the practice. And also don't forget to let your patient know about their out of network benefits (deductible & coinsurance). It's very important that your patients knows what to expect about the ASC being an out of network facility. ASC Billing Claims Submission tips:
So what's next for ASC Billing when claims are Denied, Rejected or Inappropriately Processed? You don't want to miss that revenue opportunity for the Out of Network Facility Fee. Out of network fees are always based on UCR (Usual and Customary Rates) based on your location. Normally I have seen up to 300% or (even more!) of Medicare Fee Schedule. At times, you will also be negotiating fees with 3rd party claims repricing companies. So be careful when negotiating your fees. You can call our office and we can guide you how to negotiate your fees. Don't be fooled. Remember, they are not the insurance company, they are just the claims repricing companies. If you don't agree with what they want to negotiate with you, send it back to the patient's primary insurance company. You can always call us if you need help in negotiating out of network fees. Contact us here. What we should do for all our UNPAID Claims:
I mean, you need to know the determination that was made on your claims and then you can take action. But moving forward, just make sure you have a team in your practice that only does Patients Access and Prior Authorization. References Source: https://www.cms.gov/Center/Provider-Type/Ambulatory-Surgical-Centers-ASC-Center Commercial Payers Public Domain Websites CPT Coding Guidelines through the American Medical Association  The $20 billion Provider New Phase 3 Relief Funding is now open and you have from October 5, 2020 to November 6, 2020 to submit your application. The HHS through HRSA (Health Resources and Services Administration) had announced the $20 billion New Phase 3 Relief Funding which began yesterday, October 5, 2020.  Who are covered? Read Provider Eligibility. HHS is making a large number of providers eligible for Phase 3 General Distribution funding, including:
Understanding the Provider Relief Phase 3 Funding Payment Methodology.  All eligible providers will be considered for payment against the below criteria.
All payment recipients will be required to attest to receiving the Phase 3 General Distribution payment and accept the associated Terms and Conditions. Pay Attention with the Deadline.  Healthcare Providers will have from October 5, 2020 through November 6, 2020 to apply for Phase 3 General Distribution funding. Funding for this Phase 3 General Distribution was made possible through the bipartisan CARES Act and the Paycheck Protection Program and Health Care Enhancement Act, which allocated $175 billion in relief funds to hospitals and other healthcare providers. Source of Information: https://www.hhs.gov/about/news/2020/10/1/trump-administration-announces-20-billion-in-new-phase-3-provider-relief-funding.html
Understanding Billing for DME Services or Durable Medical Equipment Services  Many of our blog readers will contact me and ask why is it too complicated to be billing for durable medical equipment? Actually it is not complicated, you just need to understand how it works. Here are some pointers that I would like to point out to you:
 Pointers on DME Billing Services and Coding
Other related blog posts: NEW CPT Code 99072 and CPT Code 86413 DURING COVID19 PANDEMIC  These 2 new CPT Codes 99072 and 86413 were published on September 8th 2020 and are effective immediately.  Let's describe these 2 new CPT Codes. CPT Code 99072 Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease Take Note: This new code 99072 is reported only during a PHE (Public Health Emergency) and only for additional items required to support a safe in-person provision of evaluation, treatment, or procedural service(s). CPT Code 86413 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative  According to the AMA: "The first addition, CPT code 99072, was approved in response to sweeping measures adopted by medical practices and health care organizations to stem the spread of the novel coronavirus (SARS-CoV-2), while safely providing patients with access to high-quality care during in-person interactions with health care professionals. The additional supplies and clinical staff time to perform safety protocols described by code 99072 allow for the provision of evaluation, treatment or procedural services during a public health emergency in a setting where extra precautions are taken to ensure the safety of patients as well as health care professionals. The AMA/Specialty Society RVS Update Committee (RUC) worked with 50 national medical specialty societies and other organizations over the summer to collect data on the costs of maintaining safe medical offices during the public health emergency and submitted recommendations today to the Centers for Medicare and Medicaid Services to inform payment of code 99072." "The second addition, CPT code 86413, was approved in response to the development of laboratory tests that provide quantitative measurements of SARS-CoV-2 antibodies, as opposed to a qualitative assessment (positive/negative) of SAR-CoV-2 antibodies provided by laboratory tests reported by other CPT codes. By measuring antibodies to SARS-CoV-2, the tests reported by 86413 can investigate a person’s adaptive immune response to the virus and help access the effectiveness of treatments used against the infection." Must be reported only once per in-person! (read more below) Code 99072 is to be reported only once per in-person patient encounter per provider identification number (PIN), regardless of the number of services rendered at that encounter. In the instance in which the noted clinical staff activities are performed by a physician or other qualified health care professional (eg, in practice environments without clinical staff or a shortage of available staff), the activity requirements of this code would be considered as having been met; however, the time spent should not be counted in any other time-based visit or service reported during the same encounter. CPT Guidelines, Q&A from the American Medical Association:  Understanding PHE or Public Health Emergency in coordination with CPT Code 99072 Question: Code 99072 is stated as being applicable “during a PHE.” What information should be used to verify when a PHE is in effect? Answer: A PHE is in effect when declared by law by the officially designated relevant public health authority(ies). Understanding Patient Encounters Type for the determination of CPT Code 99072 Question: For what type of patient encounters or services should code 99072 be reported? Answer: Code 99072 may be reported with an in-person patient encounter for an office visit or other non-facility service, in which the implemented guidelines related to mitigating the transmission of the respiratory disease for which the PHE was declared are required. Use of this code is not dependent on a specific patient diagnosis. For a list of POS codes with facility/non-facility designations that are available in the Medicare Claims Processing Manual, visit https://www.cms.gov/Medicare/Coding/place-of-service-codes. Understanding Documentation Requirements when reporting CPT Code 99072 Question: What documentation is required to report code 99072? Answer: Given that code 99072 may only be reported during a PHE, one would not report this code in conjunction with an evaluation and management (E/M) service or procedure when a PHE is not in effect. Therefore, code 99072 is reported justifiably only when health and safety conditions applicable to a PHE require the type of supplies and additional clinical staff time explained in the code descriptor. Documentation requirements may vary among third-party payers and insurers; therefore, they should be contacted to determine their specifications. How about CPT Code 99072 with CPT Code 99070? Question: May code 99072 be reported with code 99070? Answer: Yes, code 99072 may be reported with code 99070 when the requirements for both codes have been met. Note that eligibility for payment, as well as coverage policy, is determined by each individual insurer or third-party payer. Reader's QUESTION - how much are you going to be reimbursed for these 2 new codes?  Reference sources: https://www.ama-assn.org/press-center/press-releases/ama-announces-new-cpt-codes-covid-19-advancements-expand https://www.ama-assn.org/system/files/2020-09/cpt-assistant-guide-coronavirus-september-2020.pdf CPT Assistant September 2020 Special Addition CPT is a trademark and owned by the American Medical Association. One of our blog readers asked why their claim for Trigger Point injection is being denied due to missing modifier.  Let's describe these 2 Trigger point injection codes: 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles Widely indicated for Myofascial Pain. Key point to remember! - these 2 CPT Codes 20552, 20553 DO NOT NEED A MODIFIER!  Denial Reasons for Trigger Point Injection CPT 20553Denials Reasons for Trigger Point Injection CPT 20552, 20553 and what you should be looking for:
 Need more help? Call us at 732-982-4800 today!Understanding Shingrix Zoster Vaccine CPT Code 90750 Key points to remember in properly billing and coding for Shingrix: Keypoints to remember!
CPT Code Shingrix 90750 What's the reimbursement? CPT Code Shingrix 90750 - What's the reimbursement?  I called the manufacturing company of Shingrix at GSK or Global Smith Klein and contacted their Provider Reimbursement support at Phone: 1-855-636-8291. Unfortunately they told me they don't have a national average rate on how much you can get reimbursed per unit for the Shingrix shot. Understandably because it is based on Payer's reimbursement policy. I did some research some more research and found this: From Medicaid North Carolina: ICD-10-CM diagnosis code required for billing is Z23 - Encounter for immunization. Providers must bill with CPT code: 90750 - Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection. One Medicaid unit of coverage is 0.5 mL. The maximum reimbursement rate per unit is $144.20. Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are 58160-0823-11 and 58160-0819-12. The NDC units should be reported as “UN1.” You can read the complete post here - https://medicaid.ncdhhs.gov/blog/2018/02/07/billing-guidelines-zoster-vaccine-recombinant-adjuvanted-suspension-intramuscular Conclusion: It is always best that your verify your patient's benefits and eligibility for the Shingrix - Zoster Vaccine. As with Medicare, they should be under the beneficiary's Part D benefits. I hope this post helps.  Understanding the 2020 CPT codes 99421, 99422, 99423 Online Digital Evaluation and Management, E/M Services for Physicians and Non-Physicians Practitioners Your Billable Codes for Digital CPT Codes are as follows: CPT Code 99421 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes CPT Code 99422 Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes CPT Code 99423 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes. These codes are for use when E/M services are performed, of a type that would be done face-to-face, through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice. Report these services once during a 7-day period, for the cumulative time.  According to CPT®: “The seven-day period begins with the physician’s or other qualified health care professional’s (QHP) initial, personal review of the patient-generated inquiry. Physician’s or other QHP’s cumulative service time includes review of the initial inquiry, review of patient records or data pertinent to assessment of the patient’s problem, personal physician or other QHP interaction with clinical staff focused on the patient’s problem, development of management plans, including physician or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent separately reported E/M service.” So how about the Clinicians who may not independently bill for evaluation and management visits? Here are your codes: For Commercial Insurance Payers, use the following codes: CPT Code 98970 Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes CPT Code 98971 Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes CPT Code 98972 Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 minutes or more Reference: Per CPT, CPT© E/M services codes 98970—98972 that says: Per CPT; “For online digital E/M services provided by a qualified nonphysician health care professional who may not report the physician or other qualified health care professional E/M services (eg, speech-language pathologists, physical therapists, occupational therapists, social workers, dietitians), see 98970, 98971, 98972).” And how about for Medicare Beneficiaries?For Medicare Beneficiaries, they have a set of HCPCS Codes that we can use (CMS does not recognize CPT Codes 98970-98972) - continue reading below HCPCS Code G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes HCPCS Code G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes HCPCS Code G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.  References: CPT 2020, CMS Guideline and Finial Ruling. Need more help? Contact us today! (732) 982-4800January 1, 2020 - we now have a new Pain Management Code CPT 64625 - SI Ablation Description of CPT Code 64625 Radiofrequency ablation, nerves innervating the sacroiliac joint, with imaging guidance (Fluoroscopic or Computed Tomography). Keypoints to REMEMBER!
 Need help? Contact our office today!The Patients Access plays a very important role in capturing and collection of patient service revenue.  Patients Access and a Successful Revenue Cycle Management The Patients Access plays a very important role in capturing and collection of patient service revenue. There are 3 parts of Revenue Cycle where the Patient Access Management is very important and the Patient Access Team plays a very valuable role. 1. Pre-service Phase
2. Time of Service
3. Post-service Phase
 Focusing on Customer Service and Patient Satisfaction is very important.  Customer Service and Patient Satisfaction 1. Treating patient with respect and dignity 2. Treating patient as you would want to be treated 3. Communicating in a manner the patient can easily understand 4. Value your patient's time and focus on efficiency 5. Show empathy to your patient What pieces of information do we gather:
Additional Useful information that you can also gather from the patient:
So what's next after obtaining all the necessary information? 1. Patient access team member must start confirming coverage for the patient 2. Verify if the provider is in-network or out-of-network with the patient's plan 3. Check eligibility if the patient is eligible for coverage on the date of service 4. Ask the patient if they have a secondary insurance coverage 5. Complete clarifying the benefits for services with the insurance company 6. Check the patient's copayment or any co-responsibility and if the patient has an out of pocket amount that has to be met (family or individual 7. You can ask the insurance company for specific benefits for specific services. I always suggest giving insurance company specific CPT code(s) or Diagnosis code(s) if available - document everything 8. Collect the copay at the time of service if you are contracted with the patient's insurance plan; 9. Verify if there is a deductible or coinsurance and how much have been met, you can collect them at the time of service as well 10. Make sure you be knowledgeable enough on how to answer the patient about their concern and questions about their copay or any other co-responsibility. Let's look at how the Patient Access team verifies patient who has a Medicaid Coverage: Viewing a patient's ID card alone does not ensure their Medicaid eligibility, nor does having a referral or pre-certification on file. As a member of the Patient Access team, insurance can be verified during pre-service or on the date of service. It is imperative in my opinion that the Patient Access team must verify eligibility during the MONTH that patient is scheduled to be seen or is coming for service. Because their coverage may always change. If you fail to verify eligibility, there is a very high risk of claim denial for sure. Possible scenarios? the patient may not be eligible at the time of service, or the HMO was not contracted with your practice at that time of service. Result? claim may not get paid. Resulting in lose of revenue.  What happens if we did not correctly verify the patient identity?
About 40% of data used for revenue cycle management are gathered by Patients Access Teams. About 40% of data used for revenue cycle management are gathered by Patients Access Teams. Mistakes and errors will greatly affect the billing and coding process thus causing payments delay. Delayed reimbursement will significantly affect your cash flow. Patients satisfaction, prompt payments are the best results of your high quality customer service and are all based on how good your team with their communication skills.  Let's decribe this code: CPT 76140 Consultation on x-ray examination made elsewhere, written report. (2D reformatting is no longer separately reported. To report 3D rendering, see 76376, 76377)  So the question is, can a Provider bill for X-ray review using CPT Code 76140? Sharing to you coding clarification here. (Source are from CPT Assistant as published by the AMA). CPT is a trademark and owned by the American Medical Association. CPT Assistant October 1997
Using CPT Code 76140 76140 Consultation on x-ray examination made elsewhere, written report. You would use this code when a physician's opinion or advice regarding a specific film is requested by another physician and upon examination of the film, the consulting physician renders his or her consultation (ie, or his/her opinion or advice) to the requesting physician in the form of a written report. If a patient presents to an office for a new patient visit and brings to the physician his or her medical records, including x-rays, you should not report code 76140. Although the x-rays may have been taken elsewhere, the physician does not perform a consultation as intended by code 76140. Rather, the review or re-read of the x-rays would be considered part of the face-to-face E/M service provided to the patient. Again, the E/M codes include work done before, during, or after the E/M visit. Review of x-rays is part of the E/M service. Remember, 76140 represents a consultation, in which a physician only renders an opinion or gives advice regarding the film in the form of a written report. In general, when reporting 76140, the physician is not concurrently providing an E/M face-to-face service to the patient. CPT CODE 20552, 20553 TRIGGER POINT INJECTIONS. Medicare guideline. CPT Codes and Description
Understanding Trigger Point Injection Trigger point injection is one of many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS) and each of these single muscle syndromes are responsive to appropriate treatment, which includes injection therapy. An injection is achieved with the insertion of a needle and the administration of agents, such as local anesthetics, steroids and/or local inflammatory drugs. The diagnosis of trigger points requires a detailed history and thorough physical examination. The following clinical symptoms may be present when making the diagnosis:
The goal is to treat the cause of the pain and not just the symptom of pain. Limitations Acupuncture is not a covered service, even if provided for the treatment of an established trigger point. Use of acupuncture needles and/or the passage of electrical current through these needles is not covered (whether an acupuncturist or other provider renders the service). Medicare does not cover Prolotherapy. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered. When a given site is injected, it will be considered one injection service, regardless of the number of injections administered. Utilization Guidelines It is expected that trigger point injections would not usually be performed more often than three sessions in a three month period. If trigger point injections are performed more than three sessions in a three month period, the reason for repeated performance and the substances injected should be evident in the medical record and available to the Contractor upon request. This contractor may request records when it is apparent that patients are requiring a significant number of injections to manage their pain. Documentation in the medical record must support the medical necessity and frequency of the trigger point injection(s).  20552, 20553 DX Crossover based on Medical NecessityM53.82 Other specified dorsopathies, cervical region M54.2 Cervicalgia M54.5 Low back pain M54.6 Pain in thoracic spine M60.80 Other myositis, unspecified site M60.811 Other myositis, right shoulder M60.812 Other myositis, left shoulder M60.819 Other myositis, unspecified shoulder M60.821 Other myositis, right upper arm M60.822 Other myositis, left upper arm M60.829 Other myositis, unspecified upper arm M60.831 Other myositis, right forearm M60.832 Other myositis, left forearm M60.839 Other myositis, unspecified forearm M60.841 Other myositis, right hand M60.842 Other myositis, left hand M60.849 Other myositis, unspecified hand M60.851 Other myositis, right thigh M60.852 Other myositis, left thigh M60.859 Other myositis, unspecified thigh M60.861 Other myositis, right lower leg M60.862 Other myositis, left lower leg M60.869 Other myositis, unspecified lower leg M60.871 Other myositis, right ankle and foot M60.872 Other myositis, left ankle and foot M60.879 Other myositis, unspecified ankle and foot M60.88 Other myositis, other site M60.89 Other myositis, multiple sites M60.9 Myositis, unspecified M75.80 Other shoulder lesions, unspecified shoulder M75.81 Other shoulder lesions, right shoulder M75.82 Other shoulder lesions, left shoulder M79.11 Myalgia of mastication muscle M79.12 Myalgia of auxiliary muscles, head and neck M79.18 Myalgia, other site M79.7 Fibromyalgia Take-away! Remember that these codes CPT 20552, 20553 are NOT billable as unilateral. Modifier 50 (bilateral) will NOT apply. Bill by the number of muscles! POLICY SOURCE: NOVITAS PART B LCD L35010 TRIGGER POINT INJECTIONS
READER'S QUESTION: Does Medicare Cover Radiofrequency Ablation for Pain Management in New York? Here's the Coverage Information from Medicare Part BIndications:
General Procedure Requirements:
 Diagnostic Facet Joint Injections
Therapeutic Injections
Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave technologies):
Limitations of Coverage: A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and RF ablations may be performed per year in the cervical/thoracic spine and five (5) in the lumbar spine.
Let's describe the CPT codes 64633-64636 CPT CODE 64633 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT CPT CODE +64634 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CODE 64635 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT CPT CODE +64636 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Source reference: LCD ID L35936 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy NGS Medicare Part B National Government Services, Inc. MAC - Part A 06101 - MAC A J - 06 Illinois National Government Services, Inc. MAC - Part B 06102 - MAC B J - 06 Illinois National Government Services, Inc. MAC - Part A 06201 - MAC A J - 06 Minnesota National Government Services, Inc. MAC - Part B 06202 - MAC B J - 06 Minnesota National Government Services, Inc. MAC - Part A 06301 - MAC A J - 06 Wisconsin National Government Services, Inc. MAC - Part B 06302 - MAC B J - 06 Wisconsin National Government Services, Inc. A and B and HHH MAC 13101 - MAC A J - K Connecticut National Government Services, Inc. A and B and HHH MAC 13102 - MAC B J - K Connecticut National Government Services, Inc. A and B and HHH MAC 13201 - MAC A J - K New York - Entire State National Government Services, Inc. A and B and HHH MAC 13202 - MAC B J - K New York - Downstate National Government Services, Inc. A and B and HHH MAC 13282 - MAC B J - K New York - Upstate National Government Services, Inc. A and B and HHH MAC 13292 - MAC B J - K New York - Queens National Government Services, Inc. A and B and HHH MAC 14111 - MAC A J - K Maine National Government Services, Inc. A and B and HHH MAC 14112 - MAC B J - K Maine National Government Services, Inc. A and B and HHH MAC 14211 - MAC A J - K Massachusetts National Government Services, Inc. A and B and HHH MAC 14212 - MAC B J - K Massachusetts National Government Services, Inc. A and B and HHH MAC 14311 - MAC A J - K New Hampshire National Government Services, Inc. A and B and HHH MAC 14312 - MAC B J - K New Hampshire National Government Services, Inc. A and B and HHH MAC 14411 - MAC A J - K Rhode Island National Government Services, Inc. A and B and HHH MAC 14412 - MAC B J - K Rhode Island National Government Services, Inc. A and B and HHH MAC 14511 - MAC A J - K Vermont National Government Services, Inc. A and B and HHH MAC 14512 - MAC B J - K Vermont  How to Document radiofrequency ablation (RFA) of nerves CPT (64635, +64636) Radiofrequency ablation (RFA), also called radiofrequency neurotomy is an interventional pain management procedure that involves heating a part of a pain-transmitting nerve with a radiofrequency needle to create a heat lesion. Some of our pain physicians offices are asking the question - How to Document radiofrequency ablation (RFA) of nerves CPT (64635, +64636. What is the proper way of reporting this kind of procedure on the medical record when performed? Here's a guidance from CPT Assistant Article published on May 2020, quotes: Question: When performing radiofrequency ablation (RFA) of nerves (64635, 64636), is it necessary that the operative report documents the specific facet joints at which the RFA with imaging occurred as well as the nerves treated or denervated? Answer: Yes, RFA procedures should clearly state which nerves were ablated and which joints were treated. Codes 64635, Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint, and 64636, Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure), are reported for each joint treated, not each nerve treated. Stating the specific nerve and the level it innervates eliminates confusion and ensures accurate reporting. Reference: CPT Assistant Published on May 2020 
The World Health Organization or the WHO made a code for ICD-10 (not ICD-10-CM) which is the U07.2, COVID-19, virus not identified, intended to give the ability to capture suspected uncertain patients. The reason you are getting errors in billing this code is that because U07.2 Covid-19, virus not identified has not been imported into ICD-10-CM (not yet) and its coming up as invalid. It is actually a valid code. So the guidance is to code the signs and/or symptoms and/or (for example) reporting ICD-10-CM Code Z20.828 - this code is a very code that we can report. Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. I always suggest that if you have cases where you only see one code such as the U07.2 Covid-19, virus not identified , we need to go back the our providers and let them if they can give you a more appropriate codes based on signs and symptoms and as documented on their medical record.  Can I Bill for a Bilateral Trigger Point Injection using CPT 20552-20553? The answer is NO. See reasons below: I know it has always been a challenge on how do we properly bill and code for Trigger Point Injections using 20552 and 20553. Because these codes are being reported based on the number of muscles.
Let's describe these 2 injection codes:
Many are still so confused on how to bill for Trigger Points. Here are my Coding and Billing Tips: 1. There is NO anatomical modifier; these 2 codes are not unilateral - so modifier 50, LT or RT is not applicable; 2. Code and bill based on the number of muscles (not number of injections!) 3. You can append modifier 59 if it meets the guideline and necessity 4. Possible Imaging Used (may be any of the following): 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation 77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) 77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation How to Bill for Multiple EKG Performed by the Same Physician on the Same Day You can append the Modifier 76 - same service performed on the same day by the same physician. We apply this Modifier on the second line. The first line DO NOT require a modifier. The second line of the same CPT code will be appended with modifier 76.  Understanding Telemedicine:
Telemedicine is the delivery of medical healthcare services using HIPAA-compliant and secure electronic communications, information technology, or other electronic or technological means to bridge the gap between a health care provider who is located at a distant site and a patient who is located at an originating site, either with or without the assistance of an intervening health care provider for the purpose of diagnosis, consultation, and/or treatment of a patient. We need to understand though that Telemedicine does not include the use:
What a "Distant site" means - it is a site which the health care provider, working within their scope of practice and a valid license or certification, is located while providing health care services by means of HIPAA-compliant telemedicine technology. What an "Originating site" means - it is a site at which a patient is located at the time that health care services are provided to the patient by means of telemedicine. Synchronous means live (real-time live), two-way interaction between a person and a provider using audio-visual telecommunications technology. Asynchronous also known as “store and forward” or “non-interactive telecommunication” means the acquisition and transmission of images, diagnostics, data, and medical information either to, or from, and originating site or to, or from, the healthcare provider at a distant site which allows for the patient to be evaluated without being physically present. What are the covered services in Telemedicine? Well it depends on your insurance payers. But you can find Medicare's guidelines here, CLICK HERE. Other Payers?, you can scroll down as I have added several payers. Common Modifiers used for Telehealth ServicesModifier 95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. Please refer to Appendix P within the American Medical Association’s Current Procedural Terminology (CPT®) code manual to review the CPT codes for which a "95" modifier can be used to indicate that the service was provided via a real-time, interactive audio and video telecommunications system. Modifier GT Via interactive audio and video telecommunications systems Modifier GQ Services provided via asynchronous ** always check with your payers if the above Modifiers are acceptable based on their policy. Place of Service code use 02 *** check with your payers if POS 02 is applicable for telemedicine services based on their policy Commercial and Private Payers Policy Blue Cross Blue Shield of New Jersey - Telemedicine Services
The following lists of codes is provided as an informational tool only, to help identify some of the applicable CPT® codes/code ranges and HCPCS codes that may be utilized in reporting telemedicine services. The inclusion of a specific code does not indicate eligibility for coverage in all situations. CPT Codes 90785, 90863, 96116, 90791-90792, 90832-90838, 90839-90840, 90845-90847, 90951-90961, 90963-90966, 90967-90970, 96150-96154, 96160-96161, 97802-97804, 99201-99205, 99211-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99354-99357, 99406-99407, 99408-99409, 99495-99496, 99497-99498 HCPCS Codes G0108-G0109, G0270, G0296, G0396-G0397, G0406, G0407, G0408, G0420-G0421, G0425-G0427, G0438-G0439, G0459, G0473, G0506, G0508-G0509, G0513-G0514, S0199 The following services are not eligible for reimbursement under this policy:
Medicare's Telehealth and Telemedicine Services during Covid-19. Understanding Provider and Non-Provider Services. Understanding “EXPANSION OF TELEHEALTH WITH 1135 WAIVER”  So, under this Waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020 (date of service). Due to the Coronavirus (COVID-19) Public Health Emergency, doctors and other health care providers can use telehealth services to treat COVID-19 (and for other medically reasonable purposes) from offices, hospitals, and places of residence (like homes, nursing homes, and assisted living facilities) as of March 6, 2020. Medicare will pay for these services for patients who have seen the health care provider or another health care provider in the same practice. These visits are considered as in-person visits and are paid at the rate as regular, in person visits. Starting services rendered on March 6, 2020 and for the duration of the Covid-19 Public Health Emergency, Medicare will make payment for Telehealth Medicine Professional services rendered to Medicare beneficiaries in:
Deductible and Coinsurance will normally apply to these services. But the HHS Office of the Inspector General or the OIG is providing flexibility for healthcare Providers to reduce or waive cost-sharing for telehealth visits paid by the federal healthcare programs. It is imperative during this public health emergency that patients avoid / should not travel, when possible, to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness. Accordingly, the Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act. Prior to this Waiver: Medicare could only pay for telehealth on a limited basis: that is; when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service. Changes in last year (2019), Medicare started reimbursing for brief communications or Virtual Check-Ins, which are short patient-initiated communications with a healthcare practitioner. Medicare Part B separately pays clinicians for E-visits, which are non-face-to-face patient-initiated communications through an online patient portal as well. Effective date of service March 6, 2020: Providers can provide and render Telehealth Medicine including Evaluation and Management visits (E/M common office visits), Mental Health Counseling and Preventive Health Screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to the doctor’s office or hospital which puts themselves and others at risk for Covid-19. Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings. While they must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility or hospital for the visit, effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Since the 1135 Waiver requires an established relationship, HHS however will not conduct an audit for all claims submitted during this public health emergency. Question: Will I get Paid? as a Provider? Answer: YES based on MEDICAL NECESSITY! We have 3 types of VIRTUAL SERVICES:
Telehealth Visits: What’s required? The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home. Distant site practitioners and clinicians who can furnish and get reimbursement for covered telehealth services is subject to State Law. REMEMBER! - report using PLACE OF SERVICE is 02 Let’s identify the Providers Billable Services: 3 types of VIRTUAL SERVICES:
Telehealth Visits: What’s required? The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home. Distant site practitioners and clinicians who can furnish and get reimbursement for covered telehealth services (check your State Law as this is subject to State Law) may include the following:
Covered Telehealth Services CY 2020 (Updated 11/01/19) Source: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes Virtual Check-ins visits may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. Virtual Check-ins visits: Virtual check-ins can be used for the treatment for the Coronavirus (COVID-19) from anywhere, including places of residence (like homes, nursing homes, and assisted living facilities). Virtual check-in services will be initiated by the patient; however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation. Must render only to established Medicare patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. Services render via:
Here are your billable codes for Virtual Check-ins visits are as follows: HCPCS code G2012 Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. Requirements:
*** As being recommended by CMS to use G2012 for telehealth services. More information, click here. HCPCS code G2010 Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M Evaluation and Management service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment. Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare Telehealth or Telemedicine visits, which require audio and visual capabilities for real-time communication. e-visits services are only rendered via an online patient portal. e-VISITS Services: E-visits services are only rendered via an online patient portal. These services can only be reported when the billing practice has an established relationship with the patient. This is not limited to only rural settings. There are no geographic or location restrictions for these visits. Practitioners who may furnish these services include:
Your Billable Codes for e-visits are as follows: CPT 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes CPT 99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes CPT 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes. Clinicians who may not independently bill for evaluation and management visits . For example are:
They can also provide these e-visits and bill using the following codes: HCPCS Code G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes HCPCS Code G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes HCPCS Code G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes. For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html For Medicare Beneficiaries, you can learn more about telehealth services here - https://www.medicare.gov/coverage/telehealth  HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA): Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html HEADS-UP! - Use of GT modifier on Medicare claims was eliminated in 2018. According to CMS, the place of service code 02 is sufficient. To read more on Medicare Payment for Telemedicine. - CLICK HERE Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners 190 - Medicare Payment for Telehealth Services 190.1 - Background 190.2 - Eligibility Criteria 190.3 - List of Medicare Telehealth Services 190.3.1 - Telehealth Consultation Services, Emergency Department or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits 190.3.2 - Telehealth Consultation Services, Emergency Department or Initial Inpatient Defined 190.3.3 - Follow-Up Inpatient Telehealth Consultations Defined 190.3.4 – Payment for ESRD-Related Services as a Telehealth Service 190.3.5 – Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services 190.3.6 – Payment for Diabetes Self-Management Training (DSMT) as a Telehealth Service 190.3.7 – Payment for Telehealth for Individuals with Acute Stroke 190.4 - Conditions of Payment 190.5 - Originating Site Facility Fee Payment Methodology 190.6 - Payment Methodology for Physician/Practitioner at the Distant Site 190.6.1 - Submission of Telehealth Claims for Distant Site Practitioners 190.6.2 - Exception for Store and Forward (Non-Interactive) Telehealth 190.7 - A/B MAC (B) Editing of Telehealth Claims Timeline and Important Links: (source: CMS.GOV) For more information on telehealth benefits in the Medicare program, read the fact sheet: https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf.
Summary of CMS Public Health Action on COVID-19 to date: March 6, 2020, CMS issued frequently asked questions and answers (FAQs) for healthcare providers regarding Medicare payment for laboratory test and other services related to the 2019-Novel Coronavirus (COVID-19). https://www.cms.gov/newsroom/press-releases/covid-19-response-news-alert-cms-issues-frequently-asked-questions-assist-medicare-providers March 5, 2020: CMS issued a second Healthcare Common Procedure Coding System (HCPCS) code for certain COVID-19 laboratory tests, in addition to three fact sheets about coverage and benefits for medical services related to COVID-19 for CMS programs. https://www.cms.gov/newsroom/press-releases/cms-develops-additional-code-coronavirus-lab-tests March 4, 2020: CMS issued a call to action to healthcare providers nationwide and offered important guidance to help State Survey Agencies and Accrediting Organizations prioritize their inspections of healthcare. https://www.cms.gov/newsroom/press-releases/cms-announces-actions-address-spread-coronavirus February 13, 2020: CMS issued a new HCPCS code for providers and laboratories to test patients for COVID-19. https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test February 6, 2020: CMS gave CLIA-certified laboratories information about how they can test for SARS-CoV-2. https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/notification-surveyors-authorization-emergency-use-cdc-2019-novel-coronavirus-2019-ncov-real-time-rt February 6, 2020: CMS issued a memo to help the nation’s healthcare facilities take critical steps to prepare for COVID-19. https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/information-healthcare-facilities-concerning-2019-novel-coronavirus-illness-2019-ncov For the updated information on the range of CMS activities to address COVID-19, visit: https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page How are the Commercial Payers' Policy on Telehealth during this trying time due to Covid-19? A3843 Requires health insurance and Medicaid coverage for testing of coronavirus disease 2019 and for telemedicine and telehealth during coronavirus disease 2019 state of emergency. - NJ State New York State Medicaid Coverage and Reimbursement Policy for Services Related to TRICARE covers the use of interactive audio/video technology services, and are subject to the same referral and authorization requirements and include, but are not limited to: clinical consultations, office visits and telemental health. CLICK HERE for more details. Telehealth visits: what’s required? The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home. Distant site practitioners and clinicians who can furnish and get reimbursement for covered telehealth services (check your State Law as this is subject to State Law) may include the following:
Medicare Covered Telehealth Services CY 2020 (Updated 11/01/19) Code Short Descriptor
90785 Psytx complex interactive 90791 Psych diagnostic evaluation 90792 Psych diag eval w/med srvcs 90832 Psytx pt&/family 30 minutes 90833 Psytx pt&/fam w/e&m 30 min 90834 Psytx pt&/family 45 minutes 90836 Psytx pt&/fam w/e&m 45 min 90837 Psytx pt&/family 60 minutes 90838 Psytx pt&/fam w/e&m 60 min 90839 Psytx crisis initial 60 min 90840 Psytx crisis ea addl 30 min 90845 Psychoanalysis 90846 Family psytx w/o patient 90847 Family psytx w/patient 90951 Esrd serv 4 visits p mo <2yr 90952 Esrd serv 2-3 vsts p mo <2yr 90954 Esrd serv 4 vsts p mo 2-11 90955 Esrd srv 2-3 vsts p mo 2-11 90957 Esrd srv 4 vsts p mo 12-19 90958 Esrd srv 2-3 vsts p mo 12-19 90960 Esrd srv 4 visits p mo 20+ 90961 Esrd srv 2-3 vsts p mo 20+ 90963 Esrd home pt serv p mo <2yrs 90964 Esrd home pt serv p mo 2-11 90965 Esrd home pt serv p mo 12-19 90966 Esrd home pt serv p mo 20+ 90967 Esrd home pt serv p day <2 90968 Esrd home pt serv p day 2-11 90969 Esrd home pt serv p day 12-19 90970 Esrd home pt serv p day 20+ 96116 Neurobehavioral status exam 96150 Assess hlth/behave init 96151 Assess hlth/behave subseq 96152 Intervene hlth/behave indiv 96153 Intervene hlth/behave group 96154 Interv hlth/behav fam w/pt 96160 Pt-focused hlth risk assmt 96161 Caregiver health risk assmt 97802 Medical nutrition indiv in 97803 Med nutrition indiv subseq 97804 Medical nutrition group 99201 Office/outpatient visit new 99202 Office/outpatient visit new 99203 Office/outpatient visit new 99204 Office/outpatient visit new 99205 Office/outpatient visit new 99211 Office/outpatient visit est 99212 Office/outpatient visit est 99213 Office/outpatient visit est 99214 Office/outpatient visit est 99215 Office/outpatient visit est 99231 Subsequent hospital care 99232 Subsequent hospital care 99233 Subsequent hospital care 99307 Nursing fac care subseq 99308 Nursing fac care subseq 99309 Nursing fac care subseq 99310 Nursing fac care subseq 99354 Prolonged service office 99355 Prolonged service office 99356 Prolonged service inpatient 99357 Prolonged service inpatient 99406 Behav chng smoking 3-10 min 99407 Behav chng smoking > 10 min 99495 Trans care mgmt 14 day disch 99496 Trans care mgmt 7 day disch 99497 Advncd care plan 30 min 99498 Advncd are plan addl 30 min G0108 Diab manage trn per indiv G0109 Diab manage trn ind/group G0270 Mnt subs tx for change dx G0296 Visit to determ ldct elig G0396 Alcohol/subs interv 15-30mn G0397 Alcohol/subs interv >30 min G0406 Inpt/tele follow up 15 G0407 Inpt/tele follow up 25 G0408 Inpt/tele follow up 35 G0420 Ed svc ckd ind per session G0421 Ed svc ckd grp per session G0425 Inpt/ed teleconsult30 G0426 Inpt/ed teleconsult50 G0427 Inpt/ed teleconsult70 G0436 Tobacco-use counsel 3-10 min G0437 Tobacco-use counsel>10min G0438 Ppps, initial visit G0439 Ppps, subseq visit G0442 Annual alcohol screen 15 min G0443 Brief alcohol misuse counsel G0444 Depression screen annual G0445 High inten beh couns std 30m G0446 Intens behave ther cardio dx G0447 Behavior counsel obesity 15m G0459 Telehealth inpt pharm mgmt G0506 Comp asses care plan ccm svc G0508 Crit care telehea consult 60 G0509 Crit care telehea consult 50 G0513 Prolong prev svcs, first 30m G0514 Prolong prev svcs, addl 30m G2086 Off base opioid tx first m G2087 Off base opioid tx, sub m G2088 Off opioid tx month add 30 Source: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes When Medicare is a Primary Insurance for the patient, the patient's part responsibility (coinsurance/deductible) normally crosses over to its secondary insurance for secondary coverage (if Medicare has the secondary insurance on file or if its set up to cross over based on the patient's coordination of benefits).
As you will notice on your Remittance advise, "Claim Information forwarded to: (insurance company here) Meaning, Medicare will forward the information to the secondary insurance. If not, try to find out if there is a secondary insurance for the patient, then you need to send the paper claim (using the HCFA 1500 form for Office/Provider/Professional Claims) to the secondary and attach a copy of the Medicare EOB (explanation of benefits). If your Practice Software can bill secondary to Medicare electronically, then that's great! Send them by electronic. If your practice management software is capable of doing this by electronic submission with attached copy of the EOB - much better!After you submit the claim to the secondary insurance, the secondary insurance EOB will then tell you if there is a copay being applied towards the patient being a secondary insurance after Medicare.You will then obviously collect that copay based on your contract with the secondary insurance company (and this is also based on the patient's contract with his/her secondary insurance). Medicare patients are mostly aware of their responsibility after the secondary insurance picks up. Bottom line here: (1) Medicare must process (not deny or reject!) the claim first being the primary; (2) Secondary insurance must then process the claim with Medicare's claim information; (3) Then, if there is a copay being applied towards the patient's responsibility -- you have to bill your patient for that copay!But honestly, I do not collect secondary insurance copay not until the secondary insurance had processed the claim (after Medicare's allowance!). WHY? because it is possible that the patient may no longer have an active policy (at the time of service) with the secondary insurance, or maybe, there is no more copay because the patient had met his/her out of pocket limit. So to streamline this issue (of which not all offices are doing it) - you must always check benefits and eligibility for your patient's primary, secondary or even tertiary insurance coverage!It may be a lot of work too, but what I do is that, when I am billing the patient a copay (from the secondary insurance's determination and per the EOB) or even for their coinsurance! I do my best to attach a copy of the EOB on the statement. That way, the patient has a copy of the said EOB and he/she will understand why I am billing him/her. |
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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