CPT code 87635, 87426, 87428, 87811

Procedure code and Description


 CPT 87635 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique


CPT 87426 - Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19])


CPT 87428 severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B


CPT 87811 - Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])



COVID-19 Billing Guides Updated with CPT Codes 87426 and 86413


Nevada Medicaid has updated the COVID-19 General Billing Guide and COVID-19 Community-Based Testing Billing Guide with the following new Current Procedural Terminology (CPT) codes. These codes have also been added to the Medicaid Management Information System (MMIS) and are active for billing. The Centers for Medicare &

Medicaid Services (CMS) has not established reimbursement rates; therefore, claims will suspend for payment with error code 853 (HCPCS Annual Update – suspend claims) and will be automatically reprocessed once rates have been established by CMS.


Claims for codes 87426 and 86413 that denied with error code 4032 (Procedure code not on file) may be resubmitted back to the dates indicated below.


o Note: Code 87426 is an add-on code under 87301. 87426 became effective by the American Medical Association on June 25, 2020. Claims may only be submitted back to this date.


o Note: 86413 became effective by the American Medical Association on September 8, 2020. Claims may only be submitted back to this date.



Background


Currently, there are two existing CPT codes to report antigen testing using immunoassay technique for influenza type A or B (87400) and SARS-CoV-2 (87426). However, there is no code that describes multiplex immunoassay antigen testing for these three viral targets, ie, SARS-CoV, SARS-CoV-2 [COVID-19], and influenza virus types A and B. A code to report a multiplex viral pathogen panel using an antigen immunoassay technique would facilitate reporting SARS-CoV-2 testing, along with influenza types A and B in the differential diagnosis



The following clinical example and procedural description reflect a typical clinical situation for which this new code would be appropriately reported. Because of the early deployment and utilization of these tests, clinical indications are subject to further refinement as knowledge of the novel coronavirus evolves. The Panel will continue to review and may clarify these indications as more information becomes available.


Clinical Example (87428)


A 50-year-old female presents with fever, cough, and shortness of breath. A nasopharyngeal swab is collected for SARS CoV-2, influenza A, and influenza B antigen testing. 


Description of Procedure (87428)


Place the swab and swirl it in a supplied reagent tube to disrupt and release viral nucleoprotein antigens; transfer an aliquot of that sample to the test cassette sample well; and place it in the analyzer. Report the qualitative results to the ordering health care professional.


COVID-19 Diagnostic Testing Reimbursement


The Centers for Medicare & Medicaid Services (CMS) has established two Healthcare Common Procedure Coding System (HCPCS) codes for coronavirus testing. HCPCS code U0001 is for CDC approved labs to use, and HCPCS code U0002 is for CDC non-approved labs to use when reporting SARS-CoV-2 testing. 


COVID-19 Testing


CMS has established two new HCPCS codes for high throughput technology testing. HCPCS code U0003 and U0004 are to be used when making use of high throughput technologies, as described by CMS2020-01-R. These codes are effective on/ or after 4/14/2020. CMS has established new specimen collections codes for Clinical diagnostic laboratories billing for COVID-19 testing:


** HCPCS G2023- for specimen collection for severe acute respiratory syndrome, any specimen source and


** HCPCS G2024- for specimen collection for severe acute respiratory syndrome, from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source.


Clinical diagnostic laboratories should use these codes to identify specimen collection for COVID-19 testing, effective with item date of service on/or after March 1, 2020. 

The AMA published CPT code 87635 in an effort to help report and track testing services related to SARS-CoV-2 in an effort to assist in reporting and reimbursement.

Medica’s reimbursement rates are based upon rates that were recently announced by the Centers for Medicare and Medicaid Services for COVID-19 testing. Medica will reimburse contracted and noncontracted providers for COVID-19 testing, unless otherwise specified by law. It is not considered medically necessary if a COVID-19 antibody test is to be used as part of ‘return-to-work’ programs, public health surveillance testing or any efforts not associated with disease diagnosis or treatment.


Reimbursement Rates for Coronavirus Diagnostic Testing:

** HCPCS U0001: $35.92

** HCPCS U0002: $51.33

** HCPCS U0003: $75.00 (effective date 4/14/2020)

** HCPCS U0004: $75.00 (effective date 4/14/2020)

** HCPCS U0005: $25.00 (Effective 1/1/2021)

** CPT 87635: $51.33

** HCPCS G2023: $23.46

** HCPCS G2024: $25.46

** HCPCS C9803: $24.67


Diagnosis Codes to be used for confirmed Coronavirus:

** B97.29: Other coronavirus

** B34.2: Coronavirus Infection

** U07.1: 2019 COVID acute respiratory disease

Diagnosis Codes recommended by the CDC for suspected Coronavirus exposure:

** Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out

** Z20.828: Contact with and (suspected) exposure to other viral communicable diseases

** Z11.52: Encounter for screening for COVID-19 (Effective 1/1/21)

** Z20.822: Contact with and (suspected) exposure to CIVUD-19 (Effective 1/1/21)


CPT 99401, 99402, g0446, g0447 and G0473

 CPT CODE and Description


• 99401 – preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 15 minutes

• 99402 – preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 30 minutes

HCPCS codes related to obesity screening and counseling are: 

• G0446 – annual, face-to-face intensive behavioral counseling (IBT) for cardio-vascular disease (CVD), individual, 15 minutes

• G0447 – face-to-face behavioral counseling for obesity, 15 minutes

• G0473 – face-to-face behavioral counseling for obesity, group (2–10), 30 minutes. 


Overview


This policy describes Optum’s requirements for the reimbursement and documentation of “Obesity Screening and Counseling” –CPT codes 99401 and 99402, and HCPCS procedural codes G0446, G0447 and G0473.


The purpose of this policy is to ensure that Optum reimburses for services that are billed and documented, without reimbursing for billing submission or data entry errors or for non-documented services.


Reimbursement Guidelines


For eligible adult health plan members with obesity, defined as Body Mass Index (BMI) equal to or greater than 30 kg/m2 , Optum will align reimbursement with Medicare including:


° One face-to-face visit every week for the first month;

° One face-to-face visit every other week for months 2-6; and

° One face-to-face visit every month for months 7-12 [if the member meets the 3kg (6.6 lbs.) weight loss requirement during the first 6 months.


For adult members who do not achieve a weight loss of at least 3 kg (6.6 pounds) during the first 6 months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period. 


These visits must be provided by a qualified health care provider.


For eligible children and adolescent (6-18 years) health plan members with overweight, defined as having an age/gender-specific BMI at or above the 85th percentile, Optum will align reimbursement with the recommendations of the U.S. Preventive Services


COUNSELING, RISK FACTOR REDUCTION, AND BEHAVIOR CHANGE INTERVENTION CODES


▶ Used to report services provided for the purpose of promoting health and preventing illness or injury.


▶ They are distinct from other E/M services that may be reported separately when performed. However, one exception is you cannot report counseling codes (99401–99404) in addition to preventive medicine service codes (99381–99385 and 99391–99395).


▶ Counseling will vary with age and address such issues as family dynamics, diet and exercise, sexual practices, injury prevention, dental health, and diagnostic or laboratory test results available at the time of the encounter.


▶ Codes are time-based, where the appropriate code is selected according to the approximate time spent providing the service.  Codes may be reported when the midpoint for that time has passed. For example, once 8 minutes are documented, one may report 99401.


▶ Extent of counseling or risk factor reduction intervention must be documented in the patient chart to qualify the service based on time.


▶ Counseling or interventions are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.


▶ Cannot be reported with patients who have symptoms or established illness



Background Information


Obesity screening and counseling is one of a number of distinct preventive services mandated by national and state regulations [US Dept. of Labor]. The USPSTF recommends screening all adults for obesity [Moyer]. The screening of children >6 years old is also recommended in a separate report [USPSTF]. The USPSTF did not find sufficient evidence for screening children younger than age 6 years. Many different types of providers – not limited to but including chiropractors, physical and occupational therapists – can offer screening and counseling for obesity [Frerichs, Ndetan]. Screening for obesity is typically performed by calculating body mass index (BMI). Counseling and behavioral interventions generally consist of problem-solving (assisting by providing specific suggested actions and motivational counseling) and facilitating access to social support services (arranging for services and follow-up) [ChiroCode, MLN].

Medicare covers screening for adult beneficiaries with obesity, defined as Body Mass Index (BMI) equal to or greater than 30 kg/m2

, who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. Those who meet these criteria are eligible for:


• One face-to-face visit every week for the first month;

• One face-to-face visit every other week for months 2-6; and

• One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs.) weight loss requirement during the first 6 months [MLN].


For beneficiaries who do not achieve a weight loss of at least 3 kg (6.6 pounds) during the first 6 months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period. Medicare does not allow the billing of other services provided on the same day as an obesity counseling visit, but private plans have a wide array of policies on such care. They vary with regard to how the visit should be coded, how many visits are allowed in a year, and in reimbursement design [Elliott].


For children and adolescents ages 6-18 years, the USPSTF uses the following terms to define categories of increased BMI:


• Overweight = an age/gender-specific BMI between the 85th and 95th percentiles

• Obesity = an age/gender-specific BMI at or above the 95th percentile.


The USPSTF did not find any evidence describing the appropriate timing of screening intervals. 



Service Procedure Codes Diagnosis Codes


Screening for obesity in adults, children and adolescents Preventive Medicine Individual Counseling:


• 99401 – 99404 (Diagnosis Code Required) Behavioral Counseling or Therapy:

• G0446, G0447, G0473 (Diagnosis Code Not Required) 

• ICD‐10: Z68.41, Z68.42, Z68.43, Z68.44, Z68.45 

Obesity:

• ICD‐10: E66.01, E66.09, E66.1, E66.8, E66.9 

Most used Anesthesia CPT codes and time units

Anesthesia CPT codes and Time units

00100 ANESTHESIA PROC SALIVARY GLANDS INCLUDING BIOPSY 5
00102 ANES-PROC INVOLVING PLASTIC REPAIR CLEFT LIP 6
00103 ANESTHESIA RECONSTRUCTIVE PROCEDURES OF EYELID 5
00104 ANESTHESIA FOR ELECTROCONVULSIVE THERAPY 4
00120 ANES-PROC EXTERNAL MIDDLE&INNER EAR INCL BX; NOS 5
00124 ANES-PROC EXT MID&INNR EAR INCL BX; OTOSCOPY 4
00126 ANES-PROC EXT MID&INNR EAR INCL BX; TYMPANOTOMY 4
00140 ANESTHESIA FOR PROCEDURES ON EYE; NOS 5
00142 ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY
00144 ANESTHESIA PROCEDURES ON EYE; CORNEAL TRANSPLANT 6
00145 ANESTHESIA PROCEDURES EYE; VITREORETINAL SURGERY 6
00147 ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY
00148 ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY 4
00160 ANESTHESIA PROC NOSE&ACCESSORY SINUSES; NOS 5
00162 ANES-PROC NOSE&ACCESS SINUSES; RADICAL SURGERY 7
00164 ANES-PROC NOSE&ACCESS SINUSES; BX SOFT TISSUE 4
00170 ANES-INTRAORAL INCLUDING BIOPSY; NOS 5
00172 ANES-INTRAORAL INCLUDING BX; REPAIR CLEFT PALATE 6
00174 ANES-INTRAORL INCL BX; EXC RETROPHARYNG TUMR 6
00176 ANES-INTRAORAL INCLUDING BIOPSY; RADICAL SURGERY 7
00190 ANESTHESIA PROCEDURES FACIAL BONES OR SKULL; NOS 5
00192 ANES-PROC FACIAL BONES/SKULL; RADICAL SURGERY 7
00210 ANES-INTRACRAN; NOT OTHERWISE SPECIFIED 11
00212 ANES-INTRACRAN; SUBDURAL TAPS 5
00214 ANES-INTRACRAN; BURR HOLES INCL VENTRICULOGRAPHY 9
00215 ANES-INTRACRAN;PLASTY/ELEV SKULL FX-XTRADURL 9
00216 ANES-INTRACRAN; VASCULAR PROCEDURES 15
00218 ANES-INTRACRAN; PROCEDURES IN SITTING POSITION 13
00220 ANES-INTRACRAN; CEREBROSP FL SHUNTING PROCEDURES 10
00222 ANES-INTRACRAN; ELECTROCOAGULAT INTRACRAN NERVE 6
00300 ANES-INTEG SYST MUSC&NERV HEAD NECK TRUNK;NOS 5
00320 ANES-PROC ESOPH THYRD TRACHEA&LYMPH; NOS 1 YR/> 6
00322 ANES-PROC ESOPH THYROID TRACH LYMPH;BX THYROID 3
00326 ANES-ON THE LARYNX&TRACHEA CHILDREN < 1 YEAR AGE
00350 ANESTHESIA PROCEDURES MAJOR VESSELS OF NECK; NOS 10
00352 ANES-PROC MAJOR VESSELS NECK; SIMPLE LIGATION 5
00400 ANES-PROC INTEG SYS EXTREM ANT TRNK&PERIN; NOS 3
00402 ANES-INTEG SYST EXTREM TRUNK PERIN;BREAST RECON 5
00404 ANES-INTEG EXTREM TRUNK;RADL/MOD RAD BREAST PROC 5
00406 ANES-INTEG EXTREM TRUNK;RADL BRST W/NODE DISSECT 13
00410 ANES-INTEG EXTREM TRUNK PERINEM;CONVERT ARRYTH 4
00450 ANESTHESIA PROCEDURES CLAVICLE AND SCAPULA; NOS 5
00452 ANES-PROC CLAVICLE&SCAPULA; RADICAL SURGERY 6
00454 ANES-PROC CLAVICLE&SCAPULA; BIOPSY CLAVICLE 3
00470 ANESTHESIA FOR PARTIAL RIB RESECTION; NOS 6

Time  Units

In calculating units of time, use 10 minutes per unit. If a medical provider bills for a portion of 10 minutes, round the time up to the next 10 minutes and reimburse one unit for the portion of time. (See Subsection A, Payment Ground Rules for Anesthesia Services, for additional information on reporting of time units.)

Multiple Procedures

Anesthesia reimbursement for multiple procedures is based on the procedure with the highest base value, plus modifying units (if appropriate), plus total time units for all combined surgical procedures.

No additional base value shall be reimbursed for anesthesia rendered during additional surgical procedures (other than the primary procedure) performed on the same day during the same operative setting.

Reimbursement Guidelines

Anesthesia services must be submitted with an appropriate anesthesia payment modifier toindicate the number of providers and roles involved in the anesthesia service. Effective for claims processed on or after July 1, 2018, regardless of date of service, claims for anesthesia services submitted without an appropriate payment modifier will be denied as a billing error for lack of a required modifier. A corrected claim will need to be submitted with the appropriate modifier(s) added.

One anesthesia provider at a time shall be reimbursed per patient. The only exception is supervised anesthesia services by a CRNA under the medical direction of a physician.

If two anesthesia services claims are received for the same patient, same date of service, and the payment modifiers do not agree about the medical direction or supervision performed, the first claim processed will be allowed. The second claim processed is subject to denial as a billing error due to lack of consistent information about who performed the service. No adjustment for reimbursement to the second anesthesia provider can be made until a corrected claim is received from the first (allowed) anesthesia provider so that the payment modifiers on both claims agree about who performed which responsibilities in the anesthesia service. The billing office for the denied claim is responsible to contact the billing office for the other anesthesia provider involved (supervised CRNA or physician providing medical direction) and arrange for the submission of the needed corrected claim.


Finger Modifier Guidelines and usage examples




A. Policy

Aetna Better Health of Louisiana implements comprehensive and robust policies to ensure alignment with Louisiana Department of Health (LDH) and to warrant that regulatory standards are met. According to the AMA CPT Manual, the HCPCS Level II Manual and our policy, the anatomic specific modifiers, such as fingers, toes and coronary artery designate the area or part of the body on which the procedure is performed. It is correct coding to append modifiers to the greatest specificity at all times.

B. Overview

CPT and HCPCS Level II guidelines support the use of anatomic specific modifiers to develop policies which validate the area or part of the body on which a procedure is performed.

Procedure codes that do not specify right or left require an anatomical modifier. If an anatomical modifier is necessary to differentiate right or left and is not appended, the claim will be denied. Likewise, if a modifier is appended to a procedure code that does not match the appropriate anatomical site, the claim will be denied.

C. Definitions

Modifier is a code that provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code. Anatomical modifiers designate the area or part of the body on which the procedure is performed and assist in prompt, accurate adjudication of claims.

Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.

D. Reimbursement Guidelines

When submitting claims, always append an anatomical modifier, when applicable. Louisiana Department of Health Medicaid policy for both the commercial and Medicaid Advantage lines of business is that a claim is incomplete without an anatomical modifier, when applicable

E. Codes/Condition of Coverage

These codes are not all inclusive and for more please refer AMA CPT Manual, the HCPCS Level II Manual. These modifiers can be used with diagnostic, as well as therapeutic services.

Anatomical Modifiers:

Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.




LT, RT Modifiers LT and RT are only considered valid for procedure codes specific to body parts that exist only twice in the body, once on the left and once on the right (paired body parts). For example, eye procedures (e.g. cataract surgery) and knee procedures (e.g. total knee replacement).

Modifiers LT and RT should be used when a procedure was performed on only one side of the body, to identify which one of the paired organs was operated upon. LT and RT are not considered valid for toe procedures, excision of lesions, tendon/ligament injections (20550), or needle placements, etc. (Use finger and toe modifiers for finger and toe procedure codes; use eyelid modifiers for eyelid procedures.)

If the code description is for a structure that occurs multiple times on one side ofthe body (e.g. fingers, tendons, nerves, etc.) and is not specific enough for you to be able to mark on a body diagram where the left or right procedure is performed without looking at the medical record (e.g. place an “x” on the left shoulder for  73030-LT), then LT and RT are not valid modifiers. (Modifier -59 may be needed to indicate a separate lesion, separate nerve, separate tendon, etc. for nonpaired procedure codes.)



** To report an unplanned, unrelated procedure performed during postoperative period that is unrelated and not a result of the first surgery.
** To explain surgery/procedure.

Note
** Carrier may deny if modifier 79 is not included on the submitted claim.
** Claim should be submitted with a different diagnosis and documentation should support the medical necessity.
** The unrelated procedure starts a new global period.
** For repeat procedures on the same day, see modifier 76.
** Do not report modifier 79 with modifiers 58 or 78.
** Modifier 79 is an information modifier (not subject to payment reduction). Example
** January 22 – Patient is seen for an injury to the right index finger. The patient’s finger is amputated at the DIP joint.
** 26951 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure.
** March 15 – Same patient has an amputation of the right leg at femur.
** 27590 – 79 Amputation, thigh, through femur, any level.


Blue Cross Requires use of Anatomical Modifiers

Effective February 1, 2019, Blue Cross and Blue Shield of Minnesota (Blue Cross) will change the Reimbursement Policy titled “General Coding-Modifier Policy”. Submission of anatomical modifiers to specify locations will be required when submitting claims.

Anatomical Modifiers

The following modifiers indicate a specific anatomic site. Because these modifiers affect edits and payment, effective February 1, 2019 Blue Cross requires the anatomical modifier(s) be submitted in the first modifier position, if applicable.

E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
FA Left hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LT Left side (used to identify procedures performed on the left side of the body)
RC Right coronary artery
RT Right side (used to identify procedures performed on the right side of the body)
TA Left foot, great toe
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit





Modifier Guidelines

procedures have been inappropriately billed by a surgical assistant. If guidelines are not met, the claim will suspend.

• Modifier 95 is used to designate when a service is a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional.

• Modifier AS designates that services were provided by a physician assistant, nurse practitioner or nurse midwife for an assistant at surgery. Blue Cross and Blue Shield of North Carolina uses ClaimCheck® as its primary source for determining those procedures available for assistant surgeon billing by physician assistants, nurse practitioner or nurse midwife. Automatic edits are performed to determine if any procedures have been inappropriately billed by the physician assistant, nurse practitioner or nurse midwife.

• Modifier AX – item furnished in conjunction with dialysis services. J0604 and J0606 are drugs used for bone and mineral metabolism for the treatment of End Stage Renal Disease.

They are eligible for Transitional Drug Add-On Payment Adjustment when billed with AX modifier.

• HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate sitespecific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”).
• Modifier GQ designates services performed via asynchronous telecommunications system and will not be allowed.
• Modifier GT designates services performed via interactive audio and video telecommunication systems and will be allowed with codes specified in the Corporate Reimbursement Policy titled, “Telehealth.”
• Modifier MS - six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
• For Modifiers PA (surgical or other invasive procedure on wrong body part), PB (surgical or other invasive procedure on wrong patient), and PC (wrong surgery or other invasive procedure on patient), refer to Corporate Reimbursement Policy titled “Nonpayment for Serious Adverse Events”
• Modifier RA – Replacement of a DME item
• Modifier SZ – Effective 1/1/2017 in order to support Control/Home Plans’ compliance with the Federal requirement to separate visit limits for habilitative and rehabilitative services, Par/Host Plans may need to require that their providers are using the HCPCS modifier “SZ” when billing for habilitative services. (See policy titled “Rehabilitative Therapies”)
• Modifier RB – Replacement of a part of DME furnished as part of a repair


7 HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate site-specific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”). Notification given 11/28/17 for effective date of 1/27/18.

CPT code 12001,12018 - Laceration repair


CPT Codes for Laceration Repair 

Laceration 

Simple/Superficial-Scalp, Neck, Axillae, External Genitalia, Trunk, Extremities : 2.5 cm or less - cpt 12001



Simple Repairs

CPT Codes 12001 – 12018

** Usually included in all minor and major Usually included in all minor and major surgical procedures

** Cannot be reported separately when performed in conjunction with minor/major procedure

** However, can be reported if that is the only service provided e.g. simple closure of laceration


Intermediate Repairs (12001 – 12057)

Use for repair of wounds or defects which:



**  Require layered closure, one/more deeper layers SC tissue & superficial (nonmuscle) fascia

**  Need prolonged support y g (sum of lengths)

Need obliteration of “dead” space

Need prolonged support



Guidelines:

**  Code by site and length

**  Report in addition to excision code

Note: Not appropriate to be

**  used with excision of benign to control tension

**  used with excision of benign lesions 0.5 cm or less (11400, 11420, 11440) for Medicare & Aetna




Surgical Team

Under some circumstances highly complex procedures are carried out under the “surgical team” concept. Each participating physician would report the basic procedure with the addition of modifier -66.

Starred Surgical (*) Procedures

Certain services listed in the schedule are marked with a star (*) after the CPT® code.

These are relatively small surgical procedures for which the usual global package does not apply. Payment for the starred (*) service includes anesthesia for infiltration, digital block, or topical application.

When the starred (*) service is performed at the time of the initial visit, and theservice is the major service rendered during the visit, an office visit will be paid when billed with CPT® code 99025. Example: procedure code 12001 (repair of laceration) and procedure code 99025 (initial new patient exam) would both be paid.

When the starred (*) service is performed at the time of an initial or other visit involving significant identifiable service(s), the appropriate E/M service is listed in addition to the starred (*) service. Example: when an initial consult is performed and a joint injection is also performed, it is appropriate to bill and be paid for both the consult and the injection.

When a starred (*) service is performed at the time of a follow-up visit and the surgical procedure constitutes the major service, the evaluation and management service is not paid in addition to the surgical procedure. When the starred (*) service requires hospitalization, an appropriate hospital visit is listed, in addition to the starred (*) surgical procedure and its follow-up care.

Note: When follow-up days are listed as "0" the follow-up services shall be billed as independent procedures.

Note: When billing starred (*) surgical procedures for injection codes into bursa, joints, etc., the Injectable medications may be billed separately using 99070 or the appropriate J code listed in Medicare’s Level II codes. The drug shall be reimbursed at AWP.



HELPFUL CODING HINTS

As part of Oxford’s ongoing effort to provide the best service possible to all providers, Oxford periodically reviews claims data to identify issues that can delay processing. This article is the second in a series of updates that will be featured in this publication on a regular basis. One of the areas frequently noted to cause difficulty is the inappropriate use of repair CPT codes in the ranges of 12001 through 13160 (Repair; simple, intermediate, complex). These codes cannot be billed for more than a quantity of one per each group of anatomic site and classification, and are frequently billed incorrectly with multiple quantities (e.g., 12001 quantity 2.) To ensure timely and correct reimbursement, physicians, when repairing multiple wounds, should total the sums of the lengths of the repairs performed in each anatomic site and bill with the appropriate corresponding repair code.

According to the AMA CPT 2001 description, “when multiple wounds are repaired, add together the lengths of those in the same classification and from all anatomic sites that are grouped together into the same code descriptor.” The following example illustrates this rule: The physician performs a simple repair 1 cm in length on the trunk and a simple repair 1.5 cm in length on the arm. The provider should bill CPT code 12001 with a quantity of one, since the total length of the repairs is equal to 2.5 cm. The AMA CPT 2001 description for code 12001 is “simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less.”

Providers should not add lengths of repairs from different groupings of anatomic sites (e.g., ears and legs) and should not add together lengths of different classifications (e.g., simple and complex repairs). Please remember to add the total lengths of repairs for each group of anatomic sites. The codes within the same classification and anatomic site cannot be billed in multiple quantities.




HCPC Code 12001


To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a nonfacility setting using the data provided by CMS:


Step 1. Access the Medicare Physician Fee Schedule Look-up on the CMS website at www.cms.hhs.gov.

Step 2. To find the RVU for the procedure: Provide your search criteria selecting the year, “Single HCPCS Code” and “Relative

Value Units.” To find the GPCI: Provide your search criteria selecting the year, “Single HCPCS Code” and “Geographic Practice Cost Index (GPCI).”

Step 3. To find the RVU for the procedure: On the next page, select “Default Fields.” To find the GPCI: On the next page, select “Specific Locality” and “Default Fields.”

Step 4.

To find the RVU for the procedure:

Continue the process by providing the HCPCS (for this example we are using 12001  Repair superficial wounds in a non-facility setting), and select the appropriate modifier if applicable.

To find the GPCIs for the procedure: Continue the process by selecting the “Carrier Locality” (for this example we are selecting “Rest of Texas”).

Step 5.

To find the RVU for the procedure: Submit your search criteria to find the RVUs for the procedure.

To find the GPCIs for the procedure: Submit your search criteria to find the GPCIs for the locality.

 Step 6. Proceed with the calculations. [(Work RVU x Work GPCI)

+ (PE RVU x PE GPCI)
+ (MP RVU x MP GPCI)]
x Division Conversion Factor
= Division MAR


The MAR for CPT code 12001 (Repair superficial wounds) in a non-facility setting provided for the “Rest of Texas” in 2009 is $184.66.

To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a facility setting, follow the steps above using the Facility RVUs in place of the Non-facility RVUs.

To calculate the Division MAR for procedure code 12001 (Repair superficial wounds) in a nonfacility setting using the Trailblazer website:

Step 1. Go to the TrailBlazer Health Enterprises, LLC website at www.TrailBlazerhealth.com.

Step 2. If you have already registered on this site, sign in. If you have not, you must register to use the site. There is no cost to use this website.

Step 3. Use the Search function on the Homepage to search for ‘Fee Schedules’ and locate the Medicare Fee Schedule.

Step 4. Select the year of the fee schedule you want (2009), your state (Texas), and yourlocality (Rest of Texas) in the appropriate windows.

Step 5. Enter the procedure code (CPT) (and modifier if applicable) about which you seek information.

Step 6. Find the Medicare CF and divide it into the Division CF (2009 CF – $53.68) to derive the Division multiplier.

Step 7. Find the non-facility Participating Amount and multiply the amount by the Division ratio.




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