Monday, September 26, 2016

Determining Start Date of Timely Filing Period -- Date of Service

In general, the start date for determining the 12 month timely filing period is the date of service or “From” date on the claim. For institutional claims (Form CMS-1450, the UB-04 and now the 837 I or its paper equivalent) that include span dates of service (i.e., a “From” and “Through” date span on the claim), the “Through” date on the claim is used for determining the date of service for claims filing timeliness.

Certain claims for services require the reporting of a line item date of service. For professional claims (Form CMS-1500 and 837-P) submitted by physicians and other suppliers that include span dates of service, the line item “From” date is used for determining the date of service for claims filing timeliness. (This includes DME supplies and rental items.) If a line item “From” date is not timely but the “To” date is timely, contractors must split the line item and deny the untimely services as not timely filed. Claims having a date of service on February 29 must be filed by February 28 of the following year to be considered timely filed. What constitutes a claim is defined below.

Time Limitations for Filing Part A and Part B Claims

Medicare regulations at 42 CFR 424.44 define the timely filing period for Medicare fee for service claims. In general, such claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished. (See section §70.7 below for details of the exceptions to the 12 month timely filing limit.)

CPT CODE 87880, 87561

CPT CODE and description

87880 - Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A  - average fee amount - $20 - $30

87561 - Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique

Coding for Reflex Testing

Some clinicians may desire to use both rapid immunoassay and molecular Strep A testing methods in a reflex testing scheme. This scheme is analogous to reflexing a rapid immunoassay to culture in which the molecular test is used in place of culture. For example, the initial test might be performed with a rapid immunoassay and then reflexed to molecular if the immunoassay results are negative but clinical signs suggest Strep A infection.

While the codes described above apply separately to these different testing technologies, both are Strep A tests. There is a Correct Coding Initiative (CCI) edit for CPT® 87880 and 87651. This CCI edit CANNOT be overcome by a modifier. Therefore, for Medicare and any other payer that utilizes CCI edits, billing for both tests of this reflex testing scheme is not permitted.

Coding for CPT® 87880 and 87651 may be permitted by some non-Medicare payers if they do not utilize CCI edits. Providers should contact non-Medicare payers to determine whether billing for both CPT® 87880 and 87651 is permitted.

Note that ordering clinicians must be aware of any reflex testing policy by a laboratory and should only order reflex testing if medically reasonable and necessary

Coding Summary

Test             CLIA         Payer           CPT® Coding

Rapid Immunoassay

Acceava®, BinaxNOW®, or Clearview® brands or other Strep A tests manufactured by Alere

Waived Medicare 87880QW

Waived Non-Medicare 87880

Amerigroup Reminder: We Cover Rapid Strep Tests

Reminder: Rapid strep tests billed with CPT code 87880 are covered. This test should be completed for any child prescribed an antibiotic for pharyngitis

What this means to you: For your information only. No immediate action is  necessary


As part of our annual Healthcare Effectiveness Data and Information Set (HEDIS) audit, we assess appropriate testing for children with pharyngitis. The Centers for Disease Control and Prevention and the National Committee for Quality Assurance guidelines constitute the basis for this HEDIS measure.

As part of our audit, we review members’ medical records, claims and laboratory data.

 During our last audit, many of you said Amerigroup Community Care does not reimburse for rapid strep tests; therefore, you don’t file claims for this service. 

We want you to know Amerigroup does cover the rapid strep test when you file a claim using CPT code 87880. Pharyngitis can be validated through lab results; therefore, it serves as an indicator of appropriate antibiotic use. Attached is a summary sheet for this measure and the appropriate codes to use for diagnosis and payment.

We know many parents and guardians request or insist on antibiotics when they aren’t necessary for treatment. We count on your excellent training and cooperation to comply with this standard for appropriate antibiotic use.

Billing example

Mrs. x’ Visit

• Physician Visit – CPT 99202

• Nursing Work – CPT – (Office)

• Rapid Strep – CPT 87880

• All Linked to ICD-9 Code 462 (Pharyngitis)


• Medicare Pays $36.8729 per RVU

– 1.73 RVUs X 36.8729 = $63.790117

– Rapid Step (CPT 87880) = $16.01

• Total Payment From Medicare = $79.80

CPT CODE 87086, 87186, 87184 - Medicare Guidelines

CPT CODE and description

87086 - Culture, bacterial; quantitative colony count, urine - average fee amount - $10 - $20

87088 - Culture, bacterial; with isolation and presumptive identification of each isolate, urine

87186 - Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate

87184 - Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents

Urine Culture, Bacterial

1. Specific coding guidelines:

a. Use CPT 87086 Culture, bacterial, urine; quantitative, colony count where a urine culture colony count is performed to determine the approximate number of bacteria present per milliliter of urine. The number of units of service is determined by the number of specimens.

b. Use CPT 87088 where a commercial kit uses manufacturer defined media for isolation, presumptive identification, and quantitation of morphotypes present. The number of units of service is determined by the number of specimens.

c. Use CPT 87088 where identification of morphotypes recovered by quantitative culture or commercial kits and deemed to represent significant bacteriuria requires the use of additional testing, for example, biochemical test procedures on colonies. Identification based solely on visual observation of the primary media is usually not adequate to justify use of this code. The number of units of service is determined by the number of isolates.

d. Use CPT 87184 or 87186 where susceptibility testing of isolates deemed to be significant is performed concurrently with identification. The number of units of service is determined by the number of isolates. These codes are not exclusively
used for urine cultures but are appropriate for isolates from other sources as well.

 e. Appropriate combinations are as follows: CPT 87086, 1 per specimen with 87088, 1 per isolate and 87184 or 87186 where appropriate.

f. Culture for other specific organism groups not ordinarily recovered by media used for aerobic urine culture may require use of additional CPT codes (for example, anaerobes from suprapubic samples).

g. Identification of isolates by non-routine, nonbiochemical methods may be coded appropriately (for example, immunologic identification of streptococci, nucleic acid techniques for identification of N. gonorrhoeae).

h. While infrequently used, sensitivity studies by methods other than CPT 87184 or 87186 are appropriate. CPT 87181, agar dilution method, each antibiotic or CPT 87188, macrotube dilution method, each antibiotic may be used. The number of units of service is the number of antibiotics multiplied by the number of unique isolates.


1. CPT 87086 may be used one time per encounter.

2. Colony count restrictions on coverage of CPT 87088 do not apply as they may be highly variable according to syndrome or other clinical circumstances (for example, antecedent therapy, collection time, and degree of hydration).

3. CPT 87088, 87184, and 87186 may be used multiple times in association with or independent of 87086, as urinary tract infections may be polymicrobial.

4. Testing for asymptomatic bacteriuria as part of a prenatal evaluation may be medically appropriate but is considered screening and therefore not covered by Medicare. The U.S. Preventive Services Task Force has concluded that screening for asymptomatic bacteriuria outside of the narrow indication for pregnant women is generally not indicated. There are insufficient data to recommend screening in ambulatory elderly patients including those with diabetes. Testing may be clinically indicated on other grounds including likelihood of recurrence or potential adverse effects of antibiotics, but is considered screening in the absence of clinical or laboratory evidence of infection

Commonly Used ICD-10 Codes Medical Necessity

Effective October 1, 2015, appropriate ICD-10 code(s) are required with each requisition.

Note: This is a partial listing of ICD-10 Codes and is no way indicative of all available codes. For complete list of codes, refer to Medical Necessity guideline

URINE CULTURE (CPT 87086, 87088)

ICD-10 Description ICD-10 ICD-9

Abdominal Tenderness, Unspecified Site R10.819 789.6

Abdominal tenderness, Unspecified Site R10.819 789.69

Acute Cystitis without Hematuria N30.0 595.0

Acute Cystitis with Hematuria N30.01 595.0

Cystitis, Unspecified without Hematuria N30.90 595.9

Cystitis, Unspecified with Hematuria N30.91 595.9

Acute Prostatitis N41.0 601.0

Altered Mental Status, Unspecified R41.82 80.97

Bacteremia R78.81 790.7

Calculus in Bladder N21.0 594.0

Calculus of Lower Urinary Tract, Unspecified N21.9 594.9

Calculus of Prostate N42.0 602.0

Enlarged Prostate w/o Lower Urinary Tract Symptoms N40.0 600.0

Inflammatory Disease of the Prostate, Unspecified N41.9 601.9

Fever, Unspecified R50.9 780.6

Functional Urinary Incontinence R39.81 788.81

Hematuria, Unspecified R31.9 599.7

Hesitancy of Micturition R39.11 788.64

Other Amnesia R41.3 780.93

Other Difficulties with Micturition R39.19 788.69

Other Long-Term (Current) Drug Therapy Z79.899 V58.69

Other Symptoms & Signs Involving Genitourinary

System R39.89 788.99

Pain, Unspecified R52 780.96

Rebound Abdominal Tenderness, Unspecified Site R10.829 789.6

Rebound Abdominal Tenderness, Unspecified Site R10.829 789.69

Sepsis, Unspecified Organism A41.9 38.9

Streptococcal Sepsis, Unspecified A40.9 38.0

Tachycardia, Unspecified R00.0 785

Unspecified Abdominal Pain R10.9 789.00/ 789.09

Unspecified Renal Colic N23 788

Urethral Discharge without Blood R36.0 788.7

Urethral Discharge, Unspecified R36.9 788.7

Urgency of Urination R39.15 788.63

Urinary Tract Infection, Site Not Specified N39.0 599

Sunday, September 25, 2016

CPT CODE 84153, g0103 - Prostate Specific Antigen

CPT CODE and description

84152 – Prostate Specific Antigen (PSA); Complexed (Direct Measurement)

84153 – Prostate Specific Antigen (PSA); Total - average fee amount - $30 - $40

84154 – Prostate Specific Antigen (PSA); Free

G0102 Prostate cancer screening; digital rectal examination

G0103 – Prostate Cancer Screening; Prostate Specific Antigen Test (PSA)

Prostate Specific Antigen (PSA) 

Prostate Specific Antigen (PSA), a tumor marker for adenocarcinoma of the prostate, can predict residual tumor in the post-operative phase of prostate cancer. Three to 6 months after radical prostatectomy, PSA  is reported to provide a sensitive indicator of persistent disease. Six months following introduction of antiandrogen therapy, PSA is reported of distinguishing patients with favorable response from those in whom limited response is anticipated.

PSA when used in conjunction with other prostate cancer tests, such as digital rectal examination, may assist in the decision-making process for diagnosing prostate cancer. PSA also, serves as a marker in following the progress of most prostate tumors once a diagnosis has been established. This test is also an aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment. UnitedHealthcare Community Plan reimburses for Prostate Specific Antigen (PSA) (CPT code 84153), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-9-CM and ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Why doesn’t Medicare cover a Prostate Specific Antigen (PSA) test for my patients with benign prostatic hypertrophy (BPH)?

The code for BPH, 600.00, is not on the ICD-9-CM Codes Covered by Medicare listing for a diagnostic PSA. Medicare does, however, cover an annual screening PSA test for men over 50. Men with BPH receiving an annual PSA screening should have their claims coded with procedure code G0103 in lieu of CPT code 84153. This screening procedure code requires a diagnosis code of V76.44 that must appear on the claim form. If the patient has symptoms of prostate carcinoma along with the BPH, such as hematuria, nocturia, urinary frequency, and slow stream, a diagnostic PSA can be covered.

Prostate Cancer Screening Tests and Procedures, states that the revenue code 770 is to be used with HCPCS code G0102, digital rectal examination; and revenue code 30X is to be used with HCPCS code G0103, prostate specific antigen blood test

Payment Requirements Intermediaries.--

o G0102 - digital rectal examination - Deductible and coinsurance apply. Payment varies depending on the facility providing the service as follows:

12X = Outpatient Prospective Payment System
13X = Outpatient Prospective Payment System
14X = Outpatient Prospective Payment System
22X = Reasonable Cost
23X = Reasonable Cost
71X = All Inclusive Rate
73X = All Inclusive Rate
75X = Medicare Physician Fee Schedule
85X = Cost (Payment should be consistent with amounts you pay for code 84153 or code 86316.)

o G0103 - antigen test - pay under the clinical diagnostic lab fee schedule. Use CPT code 99211 as a guide. Deductible and coinsurance apply.

D. Calculating Frequency.--To determine the 11 month period, start the count beginning with the month after the month in which a previous test/procedure was performed.

Diagnosis Code Description V76.44 Prostate cancer screening digital rectal examinations (DRE) and screening prostate specific antigen (PSA) blood tests must be billed using screening (“V”) code V76.44 (Special Screening for Malignant Neoplasms, Prostate)

Medicare National Coverage Determination Policy


Abn findings on dx imaging of abd regions, inc retroperiton R93.5

Abnormal findings on diagnostic imaging of limbs R93.6

Abnormal findings on diagnostic imaging of prt ms sys R93.7

Abnormal results of function studies of organs and systems R94.8

Benign essential microscopic hematuria R31.1

Bladder-neck obstruction N32.0

Carcinoma in situ of prostate D07.5

Disorder of prostate, unspecified N42.9

Elevated prostate specific antigen [PSA] R97.2

Enlarged prostate with lower urinary tract symptoms N40.1

Enlarged prostate without lower urinary tract symptoms N40.0

Feeling of incomplete bladder emptying R39.14

Frequency of micturition R35.0

Gross hematuria R31.0

Hematuria, unspecified R31.9

Hesitancy of micturition R39.11

Inflammatory disease of prostate, unspecified N41.9

Malignant neoplasm of bladder neck C67.5

Malignant neoplasm of prostate C61

Neoplasm of uncertain behavior of prostate D40.0

Neoplasm of unsp behavior of other genitourinary organs D49.5

Nocturia R35.1

Nodular prostate with lower urinary tract symptoms N40.3

Nodular prostate without lower urinary tract symptoms N40.2

Obstructive and reflux uropathy, unspecified N13.9

Other microscopic hematuria R31.2

Personal history of malignant neoplasm of prostate Z85.46

R39.12 Poor urinary stream

Retention of urine, unspecified R33.9

Sec and unsp malig neoplasm of inguinal and lower limb nodes C77.4

Sec and unsp malig neoplasm of nodes of multiple regions C77.8

Secondary and unsp malignant neoplasm of intrapelv nodes C77.5

Secondary malignant neoplasm of bone C79.51
Secondary malignant neoplasm of bone marrow C79.52

Secondary malignant neoplasm of genital organs C79.82

Straining to void R39.16

Unspecified urinary incontinence R32

Urgency of urination R39.15

Encounter for screening for malignant neoplasm of prostate Z12.5

Saturday, September 24, 2016

CPT CODE 63047, 63045 - 63048 - Billing Guide

CPT code and description

63047 - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar -  average fee amount - $1100 - $1200




Note: Codes 63030 and 63047 are bundled per the NCCI edits with code 22630. CPT® Assistant (January 2001, page 12) states that these codes can be reported in addition to the fusion code if performed for decompression (apply modifier-59 to the decompression code in this instance.)

PLIF and TLIF Procedures

For 2012, the AMA made changes to the Lumbar and Thoracic codes for Posterior Fusion procedures by combining commonly performed procedures into one code.

The 22610 code for an Arthrodesis (Fusion) using the Posterior or Posterolateral Technique, single level; Thoracic now states this code is done WITH the Lateral Transverse Technique (the code previously stated with or without).

Code 22612 for an Arthrodesis, posterior or posterolateral technique, single level; Lumbar now states this code is done WITH the Lateral Transverse Technique (the code previously stated with or without). This code has an instructional note to NOT report the 22612 code with code 22630 for an Arthrodesis, Posterior Interbody Technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar. The codes can only be billed together when the procedures are performed at different spinal levels or alone.

The new CPT code for use instead for the PLIF Posterior Lumbar Interbody Fusion procedure for 2012 would now be 22633 for an Arthrodesis, combined Posterior or Posterolateral Technique with Posterior Interbody Technique, including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment;

Lumbar. Use new Add-on Code 22634 for additional Lumbar levels performed.

In these procedures, the surgeon removes the entire facet joint so that more disc material can be excised during the procedure and producing less nerve retraction. These procedures are only performed on one side of the spine – not bilaterally, which would result in spinal instability.

An Example of coding for the PLIF procedure performed at 2 levels L3-4 and L4-5 using cages and a morcellized autograft harvested from the iliac crest would be:











Rationale EDIT

Anthem Central Region does not bundle 63042 with 22630, does not bundle 63042-50 with 22630, does not bundle 63042-LT with 22630 and does not bundle 63047-RT with 22630. Based on the Complete Global Service Data for Orthopaedic Surgery, CPT Code 22630, code 63042 is not listed as a service that is included when performing 22630. Based on the National Correct Coding Initiative Edits, code 63042 is not listed as a component code to code 22630. Therefore, if 63042 is submitted with 22630—both services reimburse separately, if 63042-50 is submitted with 22630—both services reimburse separately, if 63042-LT is submitted with 22630—both reimburse separately and if 63042-RT is submitted with 22630—both services reimburse separately.

Anthem Central Region bundles 63047 and 63048+ as incidental with 22630. Based on the Complete Global Service Data for Orthopaedic Surgery, CPT code 22630, code 63047 is listed as a service that is included when performing 22630. Based on the National Correct Coding Initiative Edits, code 63047 is listed as a component code to code 22630. Since 63048 is an add on code that only may be reported along with 63047, 63048 follows the same rationale that is used with 63047. Therefore, if 63047 and 63048+ are submitted with 22630—only 22630 reimburses

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