BILLING CPT J1950 with covered diagnosis DX

 J1950 with related ICDS

For J1950 INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG (e.g., Lupron Depot®):

174.0  MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST

174.1  MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST

174.2  MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST

174.3  MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST

174.4  MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST

174.5  MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST

174.6  MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST

174.8  MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST

174.9  MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE

175.0  MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST

175.9  MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST

218.0  SUBMUCOUS LEIOMYOMA OF UTERUS

218.1  INTRAMURAL LEIOMYOMA OF UTERUS

218.2  SUBSEROUS LEIOMYOMA OF UTERUS

218.9  LEIOMYOMA OF UTERUS UNSPECIFIED

259.1  PRECOCIOUS SEXUAL DEVELOPMENT AND PUBERTY NOT ELSEWHERE CLASSIFIED

617.0  ENDOMETRIOSIS OF UTERUS

617.1  ENDOMETRIOSIS OF OVARY

617.2  ENDOMETRIOSIS OF FALLOPIAN TUBE

617.3  ENDOMETRIOSIS OF PELVIC PERITONEUM

617.4  ENDOMETRIOSIS OF RECTOVAGINAL SEPTUM AND VAGINA

617.5  ENDOMETRIOSIS OF INTESTINE

617.6  ENDOMETRIOSIS IN SCAR OF SKIN

617.8  ENDOMETRIOSIS OF OTHER SPECIFIED SITES

617.9  ENDOMETRIOSIS SITE UNSPECIFIED

V10.3  PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST

Medicare modifier 22 - INCREASED PROCEDURAL SERVICES

Modifier 22 INCREASED PROCEDURAL SERVICES

Quick Tips

• Hospital ASC and Outpatient Coders

Modifier 22 is not applicable in hospital ASC or hospital outpatient facilities in accordance with CPT modifiers approved for ambulatory surgery center (ASC) outpatient hospital use.

• Do not bombard the Medicare contractor or other third-party payer with unnecessary  documentation. All attachments to the claim for justification of the unusual services

should explain the unusual circumstances in a concise, clear manner. The information for the
justification of unusual services should be easy to locate within the attached documentation. Highlight this information, if necessary, to facilitate the medical reviewer’s access to the pertinent supporting data.


Key points :

Claims submitted to Medicare, Medicaid, and other third-party payers containing modifier 22 for
unusual procedural services that do not have attached supporting documentation that illustrates the unusual distinction of the services will generally be processed as if the procedure codes were not appended with this modifier. Some third-party payers might suspend the claims and request additional information from the provider, but this is the exception rather than the rule.

Outpatient CPT codes with TIME

Prolonged Service Codes for Out patient

	Prolonged Services – Outpatient
E/M Base Service	Base Time	Minimum time for 99354	Minimum time for 99355
Consultations
99241	15	45	90
99242	30	60	105
99243	40	70	115
99244	60	90	135
99245	80	110	155
New Patients
99201	10	40	85
99202	20	50	95
99203	30	60	105
99204	45	75	120
99205	60	90	135
Established Patients
99211	5	35	80
99212	10	40	85
99213	15	45	90
99214	25	55	100
99215	40	70	115

Prolonged Service Codes for In patient - CPT codes with time

Prolonged Service Codes for In patient

E/M Base Service	Base Time	Minimum time for 99356	Minimum time for 99357
Initial Hospital Visits
99221	30	60	105
99222	50	80	125
99223	70	100	145
Established Patient Visits
99231	15	45	90
99232	25	55	100
99233	35	65	110
Consultations
99251	20	50	95
99252	40	70	115
99253	55	85	130
99254	80	110	155
99255	110	140	185

Heel Surgery CPT Codes 28100, 28118, 28060 and covered DX

Heel Surgery

CPT Codes
• 28100 talus or calcaneus exostectomy
• 28118 ostectomy calcaneus
• 28119 ostectomy calcaneus for spur with or without plantar fascial release
• 28008 fasciotomy foot or toe
• 28060 fasciectomy, plantar fascia, partial

 Common diagnoses:
• 726.73 calcaneal spur
• 727.3 bursitis
• 728.71 plantar fasciitis

Global period of incision drainage - CPT 10060,10140 and covered DX

Incision and Drainage Global Period “10” Days

10060 I&D of abscess
10061 I&D multiple or complicated
10120 Removal of foreign body, subQ
10121 Removal of foreign body complicated
10140 I&D of hematoma
10160 Puncture aspiration of abscess, hematoma, bulla or cyst

• Should have anesthesia, culture if medically appropriate and F/U.

• Common diagnoses
–681.11 paronychia/onychia
–681.10 cellulitis/abscess toe
–682.6 cellulitis/abscess, ankle
–682.7 cellulitis/abscess, foot
–924.20 contusion, foot
–924.21 contusion, ankle
–924.3 contusion, toe

Comparison of Modifier 57 and -25 Modifier

Modifier -57
• Decision for major surgery based upon the E/M done today
• Major procedure for Medicare/Medicaid
• Any procedure for commercial insurance

Modifier -25
• Separately and identifiable E/M service on same day as a minor surgical procedure.
• Document your E&M well and keep any procedure documentation as a separate part of your note.
• Used with minor procedure for Medicare or for commercial insurance

Medicare Modifiers

-A1 Dressing for one wound
-A2 Dressing for two wounds
-A3 Dressing for three wounds
-A4 Dressing for four wounds
-A5 Dressing for five wounds
-A6 Dressing for six wounds
-A7 Dressing for seven wounds
-A8 Dressing for eight wounds
-A9 Dressing for nine or more wounds
-GA Waiver of liability statement (ABN) on file with ABN waiver signed
-GY item or service statutorily excluded, does not meet the definition of any Medicare benefit
or for non-Medicare insurance, is not a contract benefit No need to get ABN waiver
-GZ item or service expected to be denied as not reasonable and necessary

Medicare DME modifiers and HCPCS modifiers

DME Modifiers

-KX Requirements specified in medical policy have been met.

-EY No physician or other licensed health care provider order for this item or service (Items
billed to the DMERC before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code)

HCPCS Modifiers

-GJ “OPT OUT” physician providing emergency / urgent care
-GP Services were provided under an outpatient physical therapy plan of care
-GWService not related to hospice patient’s terminal care (used when a hospice patient is seen,but services are unrelated to the terminal condition)

- AQ (replaces QB ad QU) Physician services provided in health provider shortage area (HPSA)
-QW CLIA waived test
-LT Left foot
-TA Left great toe
-T1 2nd toe, left foot
-T2 3rd toe, left foot
-T3 4th toe, left foot
-T4 5th toe, left foot
-RT Right foot
-T5 Right great toe
-T6 2nd toe, right foot
-T7 3rd toe, right foot
-T8 4th toe, right foot
-T9 5th toe, right foot
-Q5 Service provided by substitute physician under reciprocal billing arrangement
-Q6 Services provided by a locum tenens physician
-AS Assistant at Surgery of a physician assistant, nurse practitioner or clinical nurse practitioner
• -GC Service performed in part by resident under direction of teaching physician (informational only)
• -GE Service performed by a resident without the presence of a teaching physician [primary care exception] (informational only)
-Q7 One Class A finding
-Q8 Two Class B findings
-Q9 One Class B and Two Class C findings

Infectious “V” Codes and Status Joint “V” Codes

Infectious “V” Codes

V03.7 Need for prophylactic vacc. tetanus toxoid
V09.0 Inf w/microorg resistant to penicillins
V09.1 Inf w/microorg resistant to cephalosporins & other b-lactam antibiotics
V09.2 Inf w/microorg resistant to macrolides
V09.3 Inf w/microorg resistant to tetracyclines
V09.4 Inf w/microorg resistant to aminoglycosides
V09.50 Inf w/microorg resistant to quinolones & fluroquinonoles
V09.80 Inf w/microorg resistant to other specified drugs (i.e., VRE & VRSA)


Status Joint “V” Codes

V43.66 Ankle joint replacement
V43.69 Other joint replacement
V45.4 Arthrodesis status

CPT code 95165, 95144, 95170 Billing Samples

Allergen Immunotherapy Coding Guidelines - Palmetto GBA Medicare

CPT code 95165 Billing ExceptionsIf the antigens, i.e., mold and pollen, cannot be mixed together, Palmetto GBA calculates the practice expense (PE) for mixing a multi-dose vial of antigens based on the following observed practice method:

• Physicians usually prepare a 10 cc vial and remove aliquots with a volume of 1 cc
• 10, 1 cc aliquot doses equal the entire PE component for the service
• Size or number of aliquots removed do not alter the PE for the service

CPT code 95165 Billing Samples

• To bill a 10 cc multi-dose vial filled to 6 cc with antigen, submit CPT code 95165 with 6 in the days/units field
• If a physician removes ½ cc aliquots from a 10 cc multi-dose vial for a total of two doses, submit CPT code 96165 with 10 in the days/unit field. (Billing for more than 10 doses represents an overpayment for the practice expense vial preparation.)
• If a physician prepares two 10 cc multi-dose vials, submit CPT code 95165 with 20 in the days/unit field. (The number of aliquots removed from the vials does not change the number of doses billed.)

CPT codes 95144-95170 Component Billing

• Services for CPT codes 95144-95170 represent a single dose
• To bill, specify number of doses in the days/units field
• Use a code below the venom treatment number only for 'catch up' purposes
• If a physician prepares the allergen and administers the injection on the same date of service, bill the appropriate injection code (CPT codes 95115-95117) and the appropriate preparation code (CPT codes 95145-95170)
• Do not bill CPT code 95144 and an injection code (CPT codes 95115-95117)

CPT code 95144 Billing Samples

 Sample 1:

• Allergist bills CPT code 95144 and two in the days/units field to indicate preparation of two single-dose vials of extract
• Primary care bills CPT code 95117 and 1 in the days/units field to indicate the administration of two or more injections

Sample 2 *Component Billing:Allergist prepares a 10-dose vial and develops a schedule to administer one dose per encounter over a predetermined period of time.

• Bill CPT code 95145 with 10 in the days/units field for the preparation
• Bill CPT code 95115 for one injection

Allergen Immunotherapy Coding Guidelines - cpt 95115, 95117 and 95144, 95165

Allergen Immunotherapy Coding Guidelines - Palmetto GBA Medicare

Definitions

• For allergen immunotherapy purposes a dose describes the amount of antigen(s) administered in a single injection from a multi-dose vial
• CPT codes 95115-95117 describe the professional allergenic extract administration. (Injection only) CPT code 95144 describes the allergist’s preparation and provision of single-dose vials for administration by another physician
• CPT codes 95145-95170 represent the antigen preparation (preparation only)
• CPT codes 95120-95134 describe complete service codes for the combined supply of antigen and allergy injection provided during a single encounter. Medicare does not cover complete service codes. See the component-billing sample.
• CPT code 95165 includes single or multiple antigens

CPT codes 95115 - 95117

• Bill one CPT code 95115 or 95117 per date of service (DOS) and 1 unit in Box 24-G, days or units field
• Do not bill CPT code 95115 and 95117 on the same DOS
• Do not bill CPT code 95115 and 95117 if the antigen is self-administered by the patient

Code 95144

• To bill CPT code 95144, designate the number of single-dose vials prepared and provided
• CPT code 95144 indicates only single-dose vials
• CPT code 95144 may only be used when a physician prepares an extract to be injected by another entity

CPT Code 95165

• To bill CPT code 95165, designate the number of doses
• CPT code 95165 does not include antigen administration
• To bill for antigen preparation and administration, use component billing (samples below)
• If a multi-dose vial contains less than 10 cc, bill the number of 1 cc aliquots that may be removed from the vial up to a maximum of 10 doses per multi-dose vial
• If medically necessary, physicians may bill for preparation of more than one multi-dose vial

Allergy Testing - CPT 95004 - 95078

Allergy Testing - CPT 95004 - 95078

1. The MPFSDB fee amounts for allergy testing services billed under codes 95004-95078 are established for single tests. Therefore, the number of tests must be shown on the claim. EXAMPLE If a physician performs 25 percutaneous tests (scratch, puncture, or prick) with allergenic extract, the physician must bill code 95004 and specify 25 in the units field of Form CMS-1500 (paper claims or electronic format). To compute payment, the Medicare carrier multiplies the payment for one test (i.e., the payment listed in the fee schedule) by the quantity listed in the units field.

2. Part B providers indicate the number of tests (one for each antigen) in Box 24G of the HCFA 1500 claim form. On EMC claims enter the number in the service field.

3.  Interpretation of CPT codes: 95004 -95078; use the code number which includes the number of tests which were performed and enter 1 unit for each test performed. For example, if 18 scratch tests are done, code 95004 with 18 like services. If 36 are done, code 95004 with 36 like services.

4. When photo patch tests (e.g. CPT code 95052) are performed (same antigen/same session) with patch or application tests, only the photo patch testing should be reported. Additionally, if photo testing is performed including application or patch testing, the code for photo patch testing (CPT code 95052) is to be reported, not CPT code 95044 (patch or application tests) and CPT code 95056 (photo tests).

5. Non-covered testing: Non-covered services include, but are not limited to, the following services (some are not represented by specific CPT-4 codes). Some of these are based on statute and this is noted in italics.

Venom Doses billing CPT 95146,95149, 95148 , 95170

Venom Doses and Catch-Up Billing

Since physicians prepare most venom doses in separate vials, a respective dose of CPT code 95146-95149 represents a portion of two, three, four or five venoms. Medicare built savings into the reimbursement for the higher venom codes. Therefore, if a patient receives two-venom, three-venom, four-venom or five-venom therapy, physicians should allow the highest possible venom level.

In multi-venom therapy the physician provides a portion of each venom amount. Due to patient reaction, venom administration may not remain synchronized and dosage adjustments must be made. If the physician makes an adjustment, he must synchronize the preparation to the highest-level venom as soon as possible.

Sample: A physician prepares ten doses of CPT code 95148 in two vials. One contains 10 doses of three-vespid mix and another contains 10 doses of wasp venom. Because of dose adjustment, the three-vespid mix covers 15 doses. The physician must prepare five doses of CPT code 95145 for the 'catch-up.'

• Bill CPT code 95148 with 10 in the days/units field for a patient in four-venom therapy
• Bill CPT code 95145 with 5 in the days/units field

Treatment Boards To report treatment boards, use the antigen preparation vial CPT codes (95145-95149, 95165 and 95170) AND the component billing method. Use CPT code 95165 in place of 95144 to bill for other than stinging/biting insects.
Sample: Allergist prepares a 10-dose vial for non-stinging allergen and administers one injection.

• Bill CPT code 95165 with 10 in the days/units field for the preparation.
• Bill CPT code 95115 for one injection.

CPT Code 95170 Applies ONLY to fire ant extract

Evaluation and Management (E/M) Services and ImmunotherapyTo identify a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided, select the appropriate E/M code and append with CPT modifier 25.

PERITONEAL MESOTHELIOMA STAGING

There is currently no established staging system for peritoneal mesothelioma, and if the disease is staged, it is normally done in accordance with the TNM system, the most common general cancer staging system. This system refers to the status of the tumor (T), lymph nodes (N) and metastases (M). There are general categories which may also be somewhat helpful in determining stage.

The first category shows a localized lesion able to be completely resected (entirely removed). In the second category, the disease is contained within the abdominal cavity on peritoneal and organ surfaces where debulking (the removal of as much, but not all of the tumor) is possible. Category three shows disease contained within the abdominal cavity with invasion of organs such as the colon or liver. Category four shows disease extending outside the abdominal cavity.

Mesothelioma specialist Clare Verschraegen wrote that she categorizes peritoneal mesothelioma into four categories. The least developed is when the tumor has not spread and can be removed with surgery. This is equivalent to stage I in the Butchart classification.

The next is when the cancer has spread to the periconal and organ surfaces and surgery will result only in a debulking of the tumor, not removal of all malignant tissue. The next stages are when the cancer metasticises to other organs, and when it gets into the lymph nodes.

DIAGNOSIS OF PERITONEAL MESOTHELIOMA

As with all mesotheliomas, the diagnosis of peritoneal mesothelioma can be challenging. CT findings may help differentiate between the two clinical types of peritoneal mesothelioma, termed “dry” or “wet”, since their appearances are very different upon imaging. In the “dry” type, CT may reveal multiple small masses or a single dominant localized mass. There is normally little or no ascites. In the “wet” type, CT may reveal widespread small nodules, but no dominant mass. Ascites is usually present.

If fluid is present, it may be removed in a procedure called paracentesis. Unfortunately, as is the case with pleural mesothelioma, fluid analysis offers limited diagnostic value. It is normally a tissue biopsy obtained in a laproscopic exploratory that will yield a definitive diagnosis.

SYMPTOMS OF PERITONEAL MESOTHELIOMA

Clinical symptoms at the time of presentation may include abdominal pain, abdominal mass, increased abdominal girth, distention of the abdomen, ascites (fluid in the abdomen), fever, weight loss, fatigue, anemia and digestive disturbances. Some patients complain of more non-specific symptoms for a number of months prior to a confirmed diagnosis. In a percentage of cases, peritoneal mesothelioma is found incidentally when the patient has sought help for another health problem such as gallbladder, hernia or pelvic mass.

Experienced doctors report that patients typically experience symptoms 6 months to 2 years before diagnosis. When the patient goes to the doctor, the patient, the family, and the doctor all usually think something else is wrong. Men often first show up with an inguinal hernia (a bulge in the groin) or an umbilical hernia (bulge around the belly button.) The first indication of a problem for some women comes during a pelvic examination when a tumor mass is discovered.

Late-stage peritoneal mesothelioma symptoms include bowel obstruction and increased tendency of the blood to clot. Blood tests show increased platelet count in half of peritoneal patients, although this is of little use in diagnosis because it can be caused by so many disorders. Anemia and low albumin levels are also found.

What is PERITONEAL MESOTHELIOMA

PERITONEAL MESOTHELIOMA

Peritoneal mesothelioma, a cancer of the lining of the abdominal cavity, is less common than the pleural form, comprising approximately one-fifth to one-third of the total number of mesothelioma cases diagnosed. According to the SEER (Surveillance, Epidemiology, and End Results) database, these diagnoses are approximately 54.7 per cent male versus 45.3 per cent female, with the median age being 65-69. The latency period appears to be shorter for asbestos-exposed individuals with symptoms appearing 20-30 years after exposure rather than the 30-40 year latency more commonly associated with pleural mesothelioma.

musculoskeletal therapeutic injection CPT 20550 , 20551,20552

The musculoskeletal therapeutic injection codes 20550 through 20553 have been revised to read as follows:

• 20550, Injection(s); tendon sheath, ligament;
• 20551, Tendon origin/insertion;
• 20552, Single or multiple trigger point(s), one or two muscle(s);
• 20553, Single or multiple trigger point(s), three or more muscle(s).

What are the practical implications of these changes? You should report 20552 and 20553 only once per session, regardless of the number of injections or muscles involved. You should also report 20550 and 20551 only once per tendon sheath, ligament, or tendon origin/insertion, regardless of the number of injections involved. Also note that the words "ganglion cyst" have been removed from 20550, as well as from 20600 and 20605. This is because CPT 2003 includes a new code, 20612, for "Aspiration and/or injection of ganglion cyst(s) any location."


Colposcopy coding has also changed. In the past, there were only three codes for pelvic endoscopy: 57452, 57454 and 57460. Although these codes were listed under the vagina section of CPT, they were typically used for colposcopy involving the cervix. Accordingly, for 2003, these codes have been revised and moved to the cervix uteri section of CPT, and two new codes, 57420 and 57421, have been added to the vagina section. Two new codes for colposcopy of the vulva, 56820 and 56821, have also been added, along with three new codes for procedures done in conjunction with colposcopy of the cervix uteri. A review of all three sections of CPT may be in order if you do colposcopy in your practice.

CMS CONCLUSION for CPT 95165

CMS CONCLUSION for CPT 95165

The CMS commented on the working draft of this report and concurred with our findings. They indicated, however, that CMS will take no action at this time to address CPT code 95165. The CMS believes that using a 10 cc vial and 1 cc aliquots as the basis for practice expense calculations are not significantly different from using a 5 cc vial and 0.5 cc aliquots. Also, according to CMS, allocating the time and resources spent creating a dilution board to each individual dose would result in a minuscule, if any, change in payment. The clinical staff time required per dose, as stated in the report, requires more study before it could be used as a basis for changing reimbursement. The amount of antigen in a vial, however, is a practice expense issue that CMS has indicated they may address in the future.

With CMS’ comments in mind, we conclude that although the agency did not have accurate data when it calculated the practice expense component for CPT code 95615, there is no compelling need for immediate change. Therefore, CMS could use the information in this report to help refine the practice expense inputs for CPT code 95165 as they see fit, perhaps in conjunction with the next meeting of the Practice Expense Advisory Committee. Since some physicians modified their practice based on the changes in reimbursement, CMS could continue to emphasize that physicians need modify only their billing to comply with the new definition in any guidance it plans to offer in the future. We also noted that most physicians rely on their specialty societies, rather than CMS or its carriers, for information about Medicare policy changes. Therefore, to ensure physicians are getting accurate information, CMS and the carriers may want to work directly with the societies to explain any policy changes and revisions.

BILLING CPT 95165 - professional services

CPT Code 95165

Medicare allowed approximately $98 million in charges for allergen immunotherapy codes in 2000. Nearly half of these charges, $47 million, were for CPT code 95165, professional services for the provision of antigens for allergen immunotherapy; single or multiple antigens, per dose. This code describes the preparation of antigen serums for use in immunotherapy, but not their injection. General allergists submitted about two-thirds of the claims for CPT code 95165, and ENT allergists account for about 20 percent. Most of the remainder come from internists, general practitioners, family doctors, and various group practices. Although per unit allowed charges are fairly constant across different specialties, ENT allergists bill more units (and receive greater reimbursement) per claim than other specialties

The interpretation of CPT code 95165 has been controversial. The code is unlike others in that it includes the concept of a ‘dose,’ which is not defined in the CPT manual. Traditionally, providers and payers defined a dose as the amount of antigen given in a single injection. In May 1998, CMS updated the carrier manual to define a dose as “the total amount of antigen to be administered to a patient during one treatment session, whether mixed or in separate vials.” Private payers, however, did not adopt this change; as a result, they paid 590 percent more per unit of CPT code 95165 than Medicare in 1999.2 After this change was instituted, the Relative Value Scale Update Committee recommended that CMS return to the traditional definition for the 1999 fee schedule update. At the time, though, CMS did not feel a revision was appropriate because the Committee failed to comment on the direct practice expense inputs to the code. In November 2000, after receiving many comments from specialty organizations, CMS revised the inputs for CPT code 95165. In this revision, effective January 1, 2001, CMS defines a dose, for billing and practice expense calculations, as “a one cc aliquot [part] from a single multidose vial.”3 All practice expense inputs for CPT code 95165 are based on this definition, although no allocation is made for resources and work used to create treatment or dilution boards.

RISK FACTORS BY SPECIALTY AND SURGERY CLASS

For rarely-billed Medicare procedures, we did not apply the 5 percent threshold for inclusion of services or specialties as utilized in previous MP RVU updates. Rather, we are proposing to use the risk factor of the dominant specialty by services for each procedure for which the number of allowed services is less than 100. This approach reflects the risk factors of the specialty that most frequently furnishes these low volume  procedures.
(3) Calculate a risk factor for each specialty. Differences among specialties in malpractice premiums are a direct
reflection of the malpractice risk associated with the services furnished by a given specialty. The relative differences in national average premiums between various specialties can be expressed as a specialty risk factor. These risk factors are an index calculated by dividing the national average premium for each specialty by
the national average premium for the specialty with the lowest average premium, allergy/immunology. Table 7
shows the risk factors by specialty and surgery class.


TABLE 7—RISK FACTORS BY SPECIALTY AND SURGERY CLASS

Medicare code	Medicare name	Non-surgical RF	Minor-surgical RF	Major-surgical RF
1	General Practice ....................................................................................	1.50	2.26	3.56
2	General Surgery .....................................................................................	5.87	5.87	5.87
3	Allergy Immunology ................................................................................	1.00	1.00	1.00
4	Otolaryngology .......................................................................................	1.44	2.37	3.55
5	Anesthesiology .......................................................................................	2.22	2.22	2.22
6	Cardiology ..............................................................................................	1.87	2.65	6.09
7	Dermatology ...........................................................................................	1.14	2.06	3.96
8	Family Practice ......................................................................................	1.57	2.23	3.79
10	Gastroenterology ....................................................................................	2.03	2.48	4.09
11	Internal Medicine ....................................................................................	1.72	2.52	2.52
13	Neurology ...............................................................................................	2.20	2.90	10.28
14	Neurosurgery .........................................................................................	9.94	9.94	9.94
16	Obstetrics Gynecology ...........................................................................	1.67	2.37	4.64
18	Ophthalmology .......................................................................................	1.07	1.68	1.90
19	Oral Surgery ...........................................................................................	1.00	1.00	1.00
20	Orthopedic Surgery ................................................................................	5.46	5.46	5.46
22	Pathology ...............................................................................................	1.74	2.26	2.26
24	Plastic and Reconstructive Surgery .......................................................	5.51	5.51	5.51
25	Physical Medicine and Rehabilitation ....................................................	1.14	1.14	1.14
26	Psychiatry ...............................................................................................	1.22	1.22	1.22
28	Colorectal Surgery .................................................................................	3.99	3.99	3.99
29	Pulmonary Disease ................................................................................	2.08	2.08	2.08
30	Diagnostic Radiology .............................................................................	2.62	2.62	2.62
33	Thoracic Surgery ....................................................................................	6.51	6.51	6.51
34	Urology ...................................................................................................	2.64	2.64	2.64
35	Chiropractic ............................................................................................	1.00	1.00	1.00
36	Nuclear Medicine ...................................................................................	1.55	1.55	1.55
37	Pediatric Medicine ..................................................................................	1.49	2.41	2.41
38	Geriatric Medicine ..................................................................................	1.43	2.23	4.22
39	Nephrology .............................................................................................	1.61	2.27	4.17
40	Hand Surgery .........................................................................................	3.49	3.49	3.49
44	Infectious Disease ..................................................................................	2.09	2.52	2.52
46	Endocrinology	1.51	2.23	4.46
48	Podiatry	1.98	1.98	1.98
62	Psychologist ...........................................................................................	1.00	1.00	1.00
65	Physical Therapist ..................................................................................	1.00	1.00	1.00
66	Rheumatology ........................................................................................	1.56	1.56	1.56
67	Occupational Therapist ..........................................................................	1.00	1.00	1.00
68	Clinical Psychologist ..............................................................................	1.00	1.00	1.00
71	Registered Dietitian/Nutrition Professional ............................................	1.54	1.54	1.54
72	Pain Management ..................................................................................	2.21	2.21	2.21
77	Vascular Surgery ...................................................................................	6.50	6.50	6.50
78	Cardiac Surgery .....................................................................................	6.89	6.89	6.89
79	Addiction Medicine .................................................................................	1.00	1.00	1.00
81	Critical Care (Intensivists) ......................................................................	2.15	2.15	2.15
82	Hematology ............................................................................................	1.59	2.03	2.03
83	Hematology/Oncology ............................................................................	1.72	1.72	1.72
84	Preventive Medicine ...............................................................................	1.16	1.16	1.16
85	Maxillofacial Surgery ..............................................................................	1.00	1.00	1.00
86	Neuropsychiatry .....................................................................................	1.22	1.22	1.22
90	Medical Oncology ..................................................................................	1.76	1.76	1.76
91	Surgical Oncology ..................................................................................	5.87	5.87	5.87
92	Radiation Oncology ................................................................................	2.30	2.30	2.30
93	Emergency Medicine .............................................................................	2.29	3.77	4.87
94	Interventional Radiology ........................................................................	2.62	2.62	2.62
98	Gynecological/Oncology ........................................................................	1.76	1.76	1.76
99	Unknown Physician Specialty ................................................................	1.50	2.26	3.56

How to Bill J Codes Correctly by the “UNITS” with example

Example#1: J1100-Dexamethasone, 1 mg Your bottle says 4 mg/ml

If you use 0.25 cc (1 mg) = 1 Unit
If you use 0.5 cc (2 mg) = 2 Units
If you use 0.75 cc (3 mg) = 3 Units
If you use 1.0 cc (4 mg) = 4 Units

Example#2 J1030 methylprednisolone acetate, 40 mg (Depo-Medrol)
Your bottle says 40 mg/ml

If you use 0.25 cc 10 mg = 1 Unit
If you use 0.5 cc 20 mg = 1 Unit
(J1020=methylprednisolone acetate, 20 mg )
If you use 0.75 cc 30 mg = 1 Unit
If you use 1.0 cc 40 mg = 1 Unit

Example#3 J3301 triamcinolone acetonide, (Kenalog-10, Kenalog-40) per 10 mg
Your bottle says Kenalog 40 =40 mg/ml

If you use 0.25 cc 10 mg/40 mg = 1 Unit
If you use 0.5 cc 20 mg/40 mg = 2 Units
If you use 0.75 cc 30 mg/40 mg = 3 Units
If you use 1.0 cc 40 mg/40 mg = 4 Units

Example#4 J0702 betamethasone acetate and betamethasone phosphate, per 3 mg
(Celestone Soluspan 6 mg/ml)

If you use 0.25 cc 1.5 mg/6 mg = 1 Unit
If you use 0.5 cc 3 mg/6 mg = 1 Unit
If you use 0.75 cc 4.5 mg/6 mg = 1 Unit
If you use 1.0 cc 6 mg/6 mg = 2 Units

Personal History “V” Codes

Personal History “V” Codes

V10.81 Personal Hx of malignant neoplasm (bone)
V10.82 Personal Hx of malignant melanoma of skin
V10.83 Personal Hx of other malignant neoplasm of skin
V12.02 Personal Hx of poliomyelitis
V12.2 Personal Hx of endocrine disorder
V12.51 Personal Hx of pulmonary embolism
V12.52 Personal Hx of thrombophlebitis
V12.59 Personal Hx of other diseases of circulatory system-stroke
V12.71 Personal Hx of peptic ulcer disease
V13.3 Personal Hx of disease of skin & subcutaneous tissue
V13.4 Personal Hx of arthritis
V13.5 Personal Hx of other musculoskeletal disorder
V14.0 Personal Hx of Penicillin allergy
V14.1 Personal Hx of other antibiotic allergy
V14.3 Personal Hx of other anti-infective agent
V14.4 Personal Hx of anesthetic allergy
V14.5 Personal Hx of narcotic allergy
V14.6 Personal Hx of analgesic allergy
V15.81 Noncompliance with medical treatment
V15.88 Personal Hx of risk for falling
V17.7 Family Hx of arthritis
V17.81 Family Hx of osteoporosis
V17.89 Family Hx of other musculoskeletal diseases
V18.0 Family Hx of diabetes
V18.3 Family Hx of other blood disorders

Status Amputation “V” Codes and Aftercare “V” Codes

Status Amputation “V” Codes

V49.71 Great toe
V49.72 Other toe(s)
V49.73 Foot
V49.74 Ankle (Disarticulation of ankle)
V49.75 Below knee
V49.76 Above knee (Disarticulation of knee)
V49.77 Hip (Disarticulation of hip)

Aftercare “V” Codes

V53.7 Orthopedic devices
V54.01 Aftercare encounter for removal of internal fixation device
V54.09 Other aftercare involving internal fixation device
V54.19 Aftercare for healing traumatic fracture of other bone
V54.29 Aftercare for healing pathologic fracture of other bone
V54.81 Aftercare following joint replacement (must use with site code V43.69)
V54.89 Other orthopedic aftercare
V54.9 Unspecified orthopedic aftercare
V57.1 Care involving rehab procedures – other PT
V57.81 Orthotic training Gait training in the use of artificial limbs
V58.30 Encounter for change or removal of non-surgical wound dressing
 V58.31 Encounter for change or removal of surgical wound dressing
 V58.32 Encounter for removal of sutures
 V58.41 Encounter for planned post-operative wound closure
 V58.43 Aftercare following surgery for injury and trauma
 V58.49 Other specified aftercare following surgery

High Risk Medication DX Codes - V58.61

High Risk Medication Codes

V58.61 Long-term (current) use of anticoagulants
V58.62 Long-term (current) use of antibiotics
V58.64 Long-term (current) use of non-steroidal anti-inflammatories (NSAID)
V58.65 Long-term (current) use of steroids
V58.66 Long-term (current) use of aspirin
V58.67 Long-term (current) use of insulin
V58.69 Long-term (current) use of high risk medications

CPT 97601, 97602 - Not covered CPT codes

NONCOVERED MEDICAID PROCEDURE CODES

Per the November/December 2001  Medicaid Bulletin # 159, page 4, "Effective for dates of service on or after April 1, 2001, the following procedure codes have been designated by the Texas Health & Human Services Commission (HHSC) as not a payable benefit of the Medicaid program. These guidelines are effective for claims in process on or after December 1, 2001.

�  97601- Removal of devitalized tissue from wound, selected debridement, without anesthesia (for example high pressure waterjet, sharp selective debridement with scissors, scapula and tweezers), including topical applications, wound assessment, and instruction(s) for ongoing care, per session.

 � 97602  Removal of devitalized tissue from wound; non-selective debridement, without anesthesia (for example, wet-to-moist dressings, enzymatic, abrasion), including topical application(s); wound assessment, and instruction(s) for ongoing care, per session.

MODIFIER OF THE MONTH

According to the American Medical Association definition in the 2001 CPT book, modifier -78 is appropriate in the following surgical situation. Return to the Operating Room for a Related Procedure During the Postoperative Period: The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier

� 78 to the related procedure, or by using the separate five digit modifier 09978. (For repeat procedures on the same day. Many coders are confused as to when to use the modifier

� 58 (staged procedure) and when to use modifier -78. Staged procedures are intended to be completed in two or more sessions. Procedures using modifier -78 are completed in a single session. Intent is also important when selecting the most appropriate modifier. Modifier 78 is used when a subsequent procedure is unexpectedly scheduled. If the surgery is planned, modifier 58 is used. Cases involving modifier 78 involve a complication from the first surgery that requires a second procedure to treat the patient.

Medicare payment for Payment for 20550/20551

Issue: Payment for 20550/20551

I have received several inquires regarding Medicare (FCSO) policies (LCD) on injection codes
20550, 20551.

History: Recently, I argued a case with an ALJ (Administrative Law Judge) regarding apparent
confusion with the LCD that was referenced for injections. To avoid belaboring the issue, I
indicated that the policy under certain circumstances was inappropriately applied to adjudicate
claims for 20550 and 20551 resulting in denials to providers. After lengthy discussion and
substantiation of the argument, the judge agreed. I then took the argument to Medicare (FCSO)
and they agreed to honor my request and make appropriate changes.
My argument was that criteria for trigger point injections were erroneously being applied to
20550/51.

Resolution: Rather than writing a new policy on these codes, they were to modify the existing
LCD to avoid the confusion of applying trigger point injection criteria to these non-trigger point
CPT codes.

Conclusion: This change is the result of my request to remove the restrictions from these codes.
This modified LCD should result in reimbursement of 20550/51 under appropriate
circumstances, eliminating denials that in the past resulted in non-payment for these services. By
removing these codes from the LCD, it eliminates the issues encountered (denials as stated). The
exclusion of these codes from the LCD is extremely favorable and in no way implies that these
codes are not billable. (An LCD is written when there are issues with provider utilization, i.e.,
abuse, over utilization etc. Therefore, one will note that many codes do not have an LCD. This
is a good thing. It is a bad thing when an LCD is written for a CPT code. That implies a
problem has been encountered and the payer is applying strict guidelines/parameters for
payment.)

20550: Injection of tendon sheath, ligament or trigger points -- LCD revision

20550: Injection of tendon sheath, ligament or trigger points -- LCD revision

LCD ID number: L29199 (Florida)
LCD ID number: L29351 (Puerto Rico/U.S. Virgin Islands)

The local coverage determination (LCD) for injection of tendon sheath, ligament or trigger points was effective for services rendered on or after February 2, 2009, for Florida, and on or after March 2, 2009, for Puerto Rico and the U.S. Virgin Islands as a Medicare administrative contractor (MAC) LCD for jurisdiction 9 (J9). Since that time, the LCD has been revised to remove CPT codes 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar fascia) and 20551 (Injection(s); single tendon origin/insertion). The language pertaining to these CPT codes was removed from the Indications and Limitations of Coverage and/or Medical Necessity, ICD-9 Codes that Support Medical Necessity, and Documentation Requirements sections of the LCD.

The remaining CPT codes 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle[s]) and 20553 (Injection(s); single or multiple trigger point(s), 3 or more muscle[s]) in the LCD address trigger point injections, therefore, the LCD number and title were changed to 20552 - Injection of Trigger Points.

Are there any restrictions on these codes? CPT 20550, 20551, 20552,20553

 Each of the carrier's three states (ID, NC and TN) have their own respective policies for these CPT codes including diagnosis requirements (see attached links). The most significant issue as far as billing of these services came about with the 2002 change in the CPT codes-especially for trigger point injections. Prior to January 1, 2002, each trigger point injected could be billed using CPT code 20550. After January 1, 2002, billing of trigger points switched from per injection to single or multiple injections per number of muscles (CPT code 20552 for single or multiple injections of one or two muscles vs. CPT code 20553 for single or multiple injections of three or more muscles). Also revised were codes for single or multiple injections tendon sheath or ligament (CPT code 20550) and tendon origin/insertion (CPT code 20551).

Since that time, we have noted that some providers who had been billing multiple trigger point injections along the spine have now moved to billing for multiple tendon origin/insertion codes - same locations/same beneficiaries (previously treated with trigger point injections). For these injections of tendon sheaths/origins/insertions to be medically necessary, there must be an inflammatory process in a given tendon (tendonitis) or tendon sheath tenosynovitis). Unless there is a systemic underlying illness (autoimmune or the like), the inflammation of multiple tendons, tendon sheaths, and muscle insertions - especially along the spine - should be extraordinarily rare.

Healthnet - Non participating provider tips

Information for Non-participating Providers

Implementation Processes

Currently, Health Net automatically denies claims for services rendered to a member who is no longer eligible as of the date of service. To comply with AB 1324, Health Net is modifying its existing claims adjudication process to no longer automatically deny claims for lack of eligibility, if the services have been provided in good faith and valid authorizations are submitted with the claims.

The Health Net system enhancements that are necessary to make this change to its claims adjudication process may not be complete by the AB 1324 effective date of January 1, 2008. Health Net is working diligently on systems implementation to ensure that claims are processed in accordance with the legislation. Initially some claims subject to AB 1324 may be denied inappropriately. To address this issue, Health Net has an interim process in place to identify these inappropriately denied claims and proactively adjust them to pay within the required 45-business-day time frame from the original date of receipt.

Non-participating providers have the Health Net provider dispute resolution process available to dispute any denied claims.

CLINICAL LABORATORY BLOOD DRAW MINIMIZATION

1.      Increasing the number of point of care glucose and electrolyte testing devices which use a
         fingerstick sample to perform test instead of drawing a whole tube of blood to send to the lab.

2.       Doing a thorough search in our LIS to see if blood can be used from an earlier draw whenever there is an add-on test requested to prevent patient from being drawn again.

3.       The Clinical Lab coordinated an intradisciplinary committee to reduce mislabeled and unlabeled specimens to prevent patient redraws . The lab audits and sends out notification for corrective action in cases of non-compliance.

4.       Designing our LIS system to identify minimum volumes of blood to be drawn for all tests and
print out the appropriate number of labels to match the different types of blood tubes to be drawn.

5.       Purchasing testing equipment in the nursery laboratory which uses a lesser volume of blood than previous equipment.

6.       Participating in Nursery quality control meetings weekly which address methods of improvement for reducing the volume of blood collection.

7.       Participating in the IRB to have a voice in encouraging research studies to be conservative in blood collection.

8.       Communicating with nurse managers and staff education to improve blood draw techniques to minimize hemolyzed, clotted  and unsatisfactory specimens to prevent redraws.

9.       Assuring the competence and accuracy of phlebotomists by prompt communications when
specimen collection problems occur and providing solutions and corrective action when needed.

10.      Saving blood specimens in the proper environment for the maximum usage time span  to increaseopportunities for not having to redraw a specimen.


TROUBLESHOOTING HINTS FOR BLOOD COLLECTION

If a blood sample is not attainable:   

• Reposition the needle. 

• Ensure that the collection tube is completely pushed onto the back of the needle in the hub.

• Use another tube as vacuum may have been lost.

• Loosen the tourniquet.

• Probing is not recommended.  In most cases, another puncture in a site below the first site is advised.

• A patient should never be stuck more than twice unsuccessfully by a phlebotomist.

The Supervisor should be called to assess the patient.