Tuesday, August 23, 2016

CPT CODE 99243 - Office visit consultation level 3

CPT CODE 99243 - Office consultation for a new or established patient

Fee amount - In the range of $95 - $120

99241 Office consultation for a new or established patient, which requires these three key components:

• a problem focused history;
• a problem focused examination; and
• straightforward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.


Billing and Coding Guidelines


The Centers for Medicare and Medicaid Services’ (CMS) decision as of January 1, 2010 to no longer reimburse physicians for CPT consultation codes 99241-99245 or 99251-99255.

In summary, CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and management code (99201-99215 or 99381-99397) rather than a consultation code for Medicare claims depending on the status of the patient (new vs. established).

Per CMS, a physician who sees a patient in the hospital should bill an "initial hospital care" code (99221-99223) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial hospital service allowing the Medicare Administrative Contractor (MAC) to differentiate between the admitting physician and other physicians providing care. All physicians should use the subsequent hospital care codes (99231-99233) for their follow-up care.

Likewise, per CMS, a physician who sees a patient in a skilled nursing facility should bill an “initial nursing facility care” code (99304-99306) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial nursing f facility care service, allowing the MAC to identify the physician as the admitting physician of record who is overseeing the patient’s care. All physicians should use the subsequent nursing facility care codes (99307-99310) for their follow-up care.

CPT codes 99241-99245 and CPT 99251-99255 have a status indicator of “I” in the January 2010 National Physician Fee Schedule. The status indicator of “I” is defined as:
“I” = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.

For Commercial plans, there will be no change in reimbursement for CPT codes 99241-99245 and 99251-99255 at this time. Physicians may continue to submit claims for these services, and will be reimbursed according to UnitedHealthcare payment policies.

For example UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP® MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, these plans will follow CMS regulations and implement the change, effective January 1, 2010. The change also includes the revalued relative-value units (RVUs) for E&M CPT codes and a new coding edit, consistent with CMS, to deny the CPT consult code as a non-payable service.

For AmeriChoice Medicaid health plans, in state Medicaid plans that follow Medicare rules for their fee schedules, AmeriChoice will be aligning with CMS and implement the change, effective January 1, 2010.

For all other Medicaid states, AmeriChoice will follow the UnitedHealthcare commercial position and continue to pay for the consult codes, until directed by each state to pursue other strategies.

Insurance will consider services when resubmitted with the recommended new or established evaluation and management code (99201-99205; 99281-99285; 99221-99223, 99304-99306) as per CMS guidelines for physicians who see patients in the office or an outpatient/inpatient setting.

This policy shall apply to participating and non-participating professional providers.

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Denial process

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

CPT CODE 99243 has to be rebilled as 99203, 99213 or 99283 for Medicre and Medicare HMOs.


BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:

99241 to 99212
99242 to 99212
99243 to 99213


CPT CODE 99243 - Office visit consultation level 3





Saturday, August 20, 2016

CRITICAL CARE SERVICES (CODES 99291-99292)



A. Use of Critical Care Codes

Pay for services reported with CPT codes 99291 and 99292 when all the criteria for critical care and critical care services are met. Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.

Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.

Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.

Consult the American Medical Association (AMA) CPT Manual for the applicable codes and guidance for critical care services provided to neonates, infants and children.



B. Critical Care Services and Medical Necessity

Critical care services must be medically necessary and reasonable. Services provided that do not meet critical care services or services provided for a patient who is not critically ill or injured in accordance with the above definitions and criteria but who happens to be in a critical care, intensive care, or other specialized care unit should be reported using another appropriate E/M code (e.g., subsequent hospital care, CPT codes 99231 - 99233).

As described in Section A, critical care services encompass both treatment of “vital organ failure” and “prevention of further life threatening deterioration of the patient’s condition.” Therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient’s bedside emergently, this is not a requirement for providing critical care service. The treatment and management of the patient’s condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration (i.e., the patient shall be critically ill or injured at the time of the physician’s visit).

Wednesday, August 17, 2016

CPT CODES 81001, 81002, 81003 AND 81025

CPT CODES: 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific  gravity, urobilinogen, any number of these constituents;  non-automated, with microscopy

 81001 automated, with microscopy - Fee schedule amount $3-$4

 81002 non-automated, without microscopy Fee schedule amount $3-$4

 81003 automated, without microscopy Fee schedule amount $3-$4

 81005 Urinalysis, qualitative or semi-quantitative, except immunoassays Fee schedule amount $3-$4

 81007 Urinalysis, bacteriuria screen, by non-culture, commercial kit Fee schedule amount $3-$5

 81015 Urinalysis, microscopic only Fee schedule amount $3-$5

 81025 Urine pregnancy test, by visualcolor comparison methods Fee schedule amount $8-$11

 81050 Volume measurement for timed collection, each  Fee schedule amount $4-$5



CPT CODE 81002, 81001, 81025 FEE amount




Indications and Limitations of Coverage and/or Medical Necessity

Urinalysis is one of the most useful indicators of health and disease, and is especially helpful in the detection of renal or metabolic disorders. It aids in diagnosing and following the course of treatment in diseases of the kidney and urinary system and in detecting disorders in other parts of the body such as metabolic or endocrinologic abnormalities in which the kidneys function normally.

The components of a urinalysis include an evaluation of physical characteristics (color, odor, and opacity); determination of specific gravity and pH; detection and measurement of protein, glucose, and ketone bodies; and examination of sediment for blood cells, casts, and crystals. Some laboratories include screening for leukocyte esterase and nitrate and do not perform a microscopic examination unless one of the chemical screening (macroscopic) tests is abnormal or unless a specific request for microscopic examination is made.

Diagnostic laboratory methods include visual examination; reagent strip screening; refractometry for specific gravity; and microscopic inspection of centrifuged sediment.

Urinalysis can be performed either by automated instruments or the use of tablets, tapes or dipsticks. Dipsticks are chemically impregnated reagent (reactive) strips that allow for quick determination of pH, protein, glucose, ketones, bilirubin, hemoglobin, nitrate, leukocyte esterase, and urobilinogen. The tip of the dipstick is impregnated with chemicals that react with specific substances in the urine to produce colored end products. Color standards are provided against which the actual color can be compared. The reaction rates of the impregnated chemicals are standard for each dipstick, and color changes must be matched at the correct time after each stick is dipped into the urine specimen.

Normally, the color is straw to dark yellow, specific gravity 1.005-1.035, pH 4.5-8.0, normal urobilinogen, and negative for protein, glucose, ketones, bilirubin, hemoglobin, erythrocytes (RBCs), Nitrite (bacteria), and leukocytes (WBCs).

A urinalysis study will be considered medically reasonable and necessary for the following conditions:

- Clinical symptomatology which may indicate a urinary system condition such as urgency; frequency; dysuria; flank pain; suprapubic discomfort; hematuria; fever of unknown origin; chills; swelling in the periorbital, abdominal and pedal areas of the body; heavy foaming urine, etc.;

- Physical examination reveals distended bladder with associated symptoms listed above;

- Patients on medications that are nephrotoxic (e.g., aminoglycosides); or

- Evaluation of patient’s response to treatment, such as antibiotic therapy for a UTI.

Conditions in which a urinalysis may be medically necessary are not limited to the following: urinary tract infection, glomerulonephritis, kidney stone, interstitial nephritis, nephrotic syndrome, acute renal failure, polynephritis, diabetic neuropathy, polycystic kidney disease, hyperplasia of prostate, rheumatoid arthritis, and renoparenchymal hypertension.

Even though a patient has a condition stated above, it is not expected that a urinalysis be performed frequently for stable chronic symptoms that are associated with that disease.


CPT CODE(S) TEST NAME IN THE MANUFACTURER LAB

81000 — Urinalaysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy

81001 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy

81002 Dipstick or tablet reagent urinalys non-automated for bilirubin, glucose, hemoglobin, ketone, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen

81003 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy

Various Screening of urine to monitor/diagnose various diseases/conditions, such as diabetes, the state of the kidney or urinary tract, and urinary tract infections

Other Urine Tests

If the lab performs urinalysis by another method, you might use one of the following codes:

** 81005 — Urinalysis; qualitative or semiquantitative, except immunoassays

This code describes a test that is different from 81002 or 81003 because the lab uses a colorimetric analyzer rather than a dipstick, and because the test results may be semiquantitative. You also should distinguish this code from urinalysis by immunoassay (83518, Immunoassay for analyte other than infectious agent antibody or infections agent antigen; qualitative or semiquantitative, single step method [e.g., reagent strip]).

** 81007 — Urinalysis; bacteriuria screen, except by culture or dipstick

Report this code if the lab screens for bacteria in the urine using a method other than dipstick or culture. For dipstick use 81000 or 81002; for culture see 87086 and 87088 (Culture, bacterial … urine).

** 81015 — Urinalysis; microscopic only

Use this for stand-alone urine microscopy — if the lab performs other urine tests use the complete code such as 81000 or 81001.



Billing and Coding Guidelines and Tips

Note that the tests mentioned on the first page of the list attached to CR8212 (CPT codes: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.

Note: Medicare contractors will not search files to either retract payment or retroactively pay claims based on the changes in CR8212, however, claims should be adjusted if you bring them to your contractor’s attention.


Use CLIA modifier: If the lab that performs the test operates under a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver, you should report most urinalysis tests with modifier QW (CLIA waived test). Exception: Because it is the simplest urine dipstick (manual, without microscopy), 81002 is one of the original CLIAwaived tests and does not require modifier QW.

Example: The physician-office lab performs urinalysis for ketones, protein, hemoglobin, and glucose using the Bayer Clinitek Status Urine Chemistry Analyzer.

Solution: Because the lab uses the automated analyzer for common constituents, report the service as 81003-QW.

Don’t combine 81015 with 81002 or 81003.

Pregnancy test: For a colorimetric urine pregnancy test, report 81025 (Urine pregnancy test, by visual color comparison methods).


Services billed to Medicare must be documented as billed and be medically necessary. Without documentation the service was performed, no payment can be made. Periodic self audits of your Medicare billing and documentation is recommended to avoid this type of error.

UnitedHealthcare follows ACOG coding guidelines and considers CPT laboratory codes 81000 and 81002 as included in the global antepartum or global OB service when submitted with an OB diagnosis code in an office setting.

The following services are included in the global obstetrical package related to both vaginal and Caesarean delivery and will not be reimbursed separately when performed by the OB provider.
• Pregnancy test (CPT codes 81025, 84702, 84703

As noted in the Provider Manual, EmblemHealth uses manifold types of commercially available claims review software to support the correct digest of proclaim that result in ingenuous, widely recognized and transparent payment policies.* One of these policies hasten CPT code 81002 and CPT code 81003 (Urinalysis, by dip stick or tablet test) when recital with an Evaluation and Management service (e.g., CPT codes 99201-99205, 99211-99215 and 99381-99397). CPT digest 81002 and 81003 will not be separately reimbursed unless Modifier 25 is annex to the E/M service indicating that a diagnostic, non-screening, urinalysis was transact.


Monday, August 15, 2016

ICD-10 codes that support medical necessity for chiropractor services


The chiropractic local coverage determinations (LCDs) for MACs include ICD-10 coding Information for ICD-10 codes that support the medical necessity for chiropractor
services. There may be additional documentation information in your LCD. There are links to the chiropractic LCDs in the Additional information section of this article.

The group 1 (primary) codes are the only covered ICD-10-CM codes that support medical necessity for chiropractor services.

*** Primary: ICD-10-CM codes (names of vertebrae)

*** The precise level of subluxation must be listed as the primary diagnosis.

The groups 2, 3, and 4 ICD-10-CM codes support the medical necessity for diagnoses and involve short, moderate, and long term treatment:

*** Group 2 codes: Category I - ICD-10-CM diagnosis (diagnoses that generally require short-term treatment)

*** Group 3 codes: Category II - ICD-10-CM diagnosis (diagnoses that generally require moderate-term treatment)

*** Group 4 codes: Category III - ICD-10-CM diagnosis (diagnoses that may require long-term treatment) ICD-10 codes that do not support medical necessity are all ICD-10-CM codes not listed in LCDs under ICD-10-CM codes that support medical necessity.



Additional information

If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/index.html under - How Does It Work.

Saturday, August 13, 2016

Use of the AT modifier for chiropractic billing

Background

In 2014, the comprehensive error testing program (CERT) that measures improper payments in the Medicare feefor- service program reported a 54 percent error rate for chiropractic services. The majority of those errors were due to insufficient documentation/documentation errors. Year after year these error rates appear. CMS is providing an explanation of the AT modifier to assist providers with correctly documenting claims for chiropractic services provided to Medicare beneficiaries. The active treatment (AT) modifier defines the difference between active treatment and maintenance treatment. Effective October 1, 2004, the AT modifier is required under Medicare billing to receive reimbursement for CPT® codes 98940-98942. For Medicare purposes, the AT modifier is used only when chiropractors bill for active/ corrective treatment (acute and chronic care). The policy requires the following:

1. Every chiropractic claim for CPT® 98940/98941/98942, with a date of service on or after October

1, 2004, should include the AT modifier if active/corrective treatment is being performed; and

2. The AT modifier should not be used if maintenance therapy is being performed. MACs deny chiropractic claims for CPT® 98940/98941/98942, with a date of
service on or after October 1, 2004, that does not contain the AT modifier. The following categories help determine coverage of treatment. (See the Necessity for Treatment, Chapter 15, Section 240.1.3, of the Medicare Benefit Policy Manual (pages 226-227)).

1. Acute subluxation: A patient’s condition is considered acute when the patient is being treated for a new injury (identified by X-ray or physical examination).

the result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient’s condition.

2. Chronic subluxation: A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition); however, the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered. Both of the above scenarios are covered by CMS as long as there is active treatment which is well documented and improvement is expected.


Maintenance: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when maintenance therapy has been provided.

 Be aware that once the provider cannot determine there is any improvement, treatment becomes maintenance and is no longer covered by Medicare.


Key points

For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However,  the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, MACs may deny if appropriate after medical review determines that the medical record does not support active/corrective treatment.

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