HCA Session II

1
HCASession II

• Preventative Medicine Visits
• Procedures
• Modifiers

2
Preventative Medicine Visits CPT Code 99381-87
(new) 99291-97 (est)

• Preventative Medicine Visit Codes include payment
  for
  
• The review of stable chronic problems
• Routine Screenings (eg. Pap smear, breast
  pelvic, manual rectal exam)
  
• Risk Factor Counseling
• Billable Separately When Billed on Same Day as
  Physical are
  
• 99211-99215 EM Office Visit codes (for
  re-management of existing problems or new
  problems (need mod 25)
  
• Injections, Immunizations
• Procedures Performed (exception Medicaid they
  will only pay for procedure)
  
• Some Screenings
• Labs (Indicate signs/symptoms or diagnosis to
  support testing)

3
Preventative Medicine Visits continued

• Dx Codes V70.0 (well adult) V72.31 (Gyn w/or w/o
  Pap)
  
• Medicare
• Effective 1/1/05 MC will pay physical / new MC
  enrollee / within 6 mths G0344
  
• Also G0366 EKG (global) G0367 (EKG tracking
  only) G0368 (EKG Inter Rep Only)
  
• Medicare does not pay for routine annual
  physicals (99381-87 99391-97)
  
• Medicare will pay for 99211-99215 services (eg.
  medically necessary follow- up or new problems)
  billed w/physicals. Mod 25 needs to be affixed
  to 99211-15 codes.

4
Preventative Medicine Visits continued

• HMOBlue/HPHC/TUFTS/Medicaid
• Will pay for physicals.
• They will also pay for 99211-99215 services
  billed with a physical.
  
• Affix Mod 25 on 99211-15 codes.
• Exception Medicaid pays for physical Only - No
  EM in same day.
  
• Exception Bc/Bs PPO Plans Physical Coverage is
  on age schedule

5
Preventative Medicine Visits Re Screenings

• Medicare will pay for Screenings billed in
  conjunction with a Physical Examination.
  HmoBlue/Tufts/Hphc/Medicaid do not pay for some
  screenings () billed w/a physical. However,
  they will always pay when billed with an EM code
  (99211-99215) or when billed by itself.
• Q0091 Pap Smear Collection (Medicaid X8012)
• G0101 Breast Pelvic Screening (7-11 areas
  of GU system)
  
• G0102 Manual Rectal Examination
• G0107 Blood Occult (Use 82270 only when
  there are
  
• signs/symptoms)
• 79095 Bone Density (Heel)
• G0104 Low Risk Flex Sig
• G0105 High Risk Flex Sig
• G0120 Barium Enema
• G0202 Screening Mammography

6
Preventative Medicine Visits Re Screenings

• Q0091 Pap Smear Collection (Annual f/High
  Risk every other yr f/ Low
  
• Risk) Not reimburseable when
  billed w/physical.
  
• X8012 Medicaid pap smear collection code
• Diagnosis Code
• V76.47 Special Screening for Malignant
  Neoplasms Vagina No
  
• previous history of any
  abnormalities.
  
• V72.32 Abnormal Pap Smear (abn pap 3 mths
  back, redid pap
  
• normal this visit is f/u visit
  3rd visit)
  
• V76.2 Low Risk of Malignant Neoplasm History
  of abnormal paps.
  
• V15.89 High Risk of Malignant Neoplasm 7 or
  more sexual partners in
  
• lifetime, Hx of STD, 3 abn paps
  in 7 yrs, colposcopy, CA dx.)
  

7
Preventative Medicine Visits Re Screenings

• G0101 Breast Pelvic Screening (7 out of the
  11 areas in the GU system
  
• must be reviewed and documented.)
  Not reimburseable when billed
  
• w/a managed care gyn physical. Code
  G0101 only if both the
  
• breast pelvic exam are performed.
  Coverage every 2 years.
  
• Diagnosis Codes
• V76.2 (low risk) or V15.89 (high risk)
• V76.49  Special screening for malignant
  neoplasms other sites (to indicate low risk for
  a patient who does not have a uterus or cervix).
  

8
Preventative Medicine Visits Re Screenings

• G0102 Manual Rectal Examination (Not
  reimburseable when billed w/managed care
  physical) Annual Benefit (Age
  
• 50 over)
• Diagnosis Codes
• V76.44 Special screening for malignant
  neoplasms, prostate
  

9
Preventative Medicine Visits Re Screenings

• G0107 Blood Occult (Routine Screening In
  absence of signs/symptoms). Is
  reimburseable when billed
  
• w/physical.
• Annual Benefit
• Diagnosis Code V76.51
• Use CPT 82270 when there are
  signs/symptoms
  

10
Preventative Medicine Visits Re Screenings

• 79095 Bone Density Screening
• Every 2 years for those at risk of
  losing bone
  
• mass
• Medicare will cover 80 of the cost of one
  bone mass
  
• measurement every 2 years.
• Medicare will also cover follow-up measurements

11
Preventative Medicine Visits Re Screenings

• G0104 Low Risk Flex Sig - once every 48
  mths
  
• G0105 High Risk Flex Sig - once every 24
  mths
  
• G0120 Barium Enema - alternative to
  Flex Sig / Screen
  
• Colonoscopy
• Flexible Sig 1 time every 4 yrs.
• Colonoscopy 1 time every 2 yrs if you are at
  high-risk for colorectal cancer (e.g. have a
  family history of the disease or have had
  colorectal polyps) or 1 time every 10 years if
  you are not at high-risk (but not within 48
  months Of a screening flexible sigmoidoscopy)
• Barium enema - this service is not covered if
  performed in addition to the other tests
  

12
Preventative Medicine Visits Re Screenings

• G0202 w/76083 Screening Mammography
• Annual Benefit
• One screening mammogram a year for women 40
  yrs older.
  
•         
• One baseline mammogram for women 35 to 39
  years of age.
  
•      No Part B deductible is required for these
  services.
  

13
Procedures

• Injections
• Administration Codes / Immunizations 90471 (1)
  94072 (ea. addl)
  
• Administration Code / Therapeutic or Dx 90782
  (eg. Gyn Depo, B12)
  
• Administration Code / IV Infusion 90780 (IM) 18
  new codes for 2005
  
• Foreign Body Removal
• Ear Wax Removal 69210 (hearing loss pays
• impacted cerumen does not)
• EKGs
• EKG Routine 93000 (mod 76 repeat)

14
Procedures

• Lesions
• Lesion / Skin Tags 11200 (up to 15)
• 11201 (ea. addl grp of 10)
• Lesions / Common or Plantar Wart 17000 (1) plus
• 17003 (for ea. addl indicate)
• Example 6 removed bill 17000 x1 and
  17003 x5 6
  
• Lesions / Flat Warts, Molluscum /Milia 17110 up
  to 14
  
• 17115 15 or more report code.
• Lesion / Vulva 56501
• Lesion / Vaginal 57061
• Lesion / Penis (cryo) 54056

15
Procedures

• Gyn / Contraceptive Management
• Diaphragm or Cervical Cap Fitting 57170
• Insertion of IUD 58300
• Removal of IUD 58301
• Fitting and Insertion of pessary or other
• intravaginal support device 57160
• Airway Management
• Nebulizer Treatment 94640
• Nebulizer Treatment (subsequent) 94640-76
  
• Inhaler Instructions (teaching) 94664-59
• Spirometry 94010
• Bronchospasm Evaluation 94060

16
Procedures

• Incision Drainage Puncture
• Incision Drainage (abcess, cyst) 10060
• Incision Drainage of Pilonidal Cyst 10080
• Incision Removal of Foreign Body, subcut 10120
• Incision Drainage of Hematoma, seroma
• or fluid collection 10140
• Puncture aspiration of abscess, hematoma,
• bulla or cyst 10160

17
Procedures

• Paring/Cutting/Trimming/Excision
• Paring/Cutting of benigh hyperkeratotic lesion
• (corn or callus) single lesion 11055
• Paring/Cutting or benign hyperkeratotic lesion
• corn/callus 2-4 lesion 11056
• Trimming of non-dystrophic nails, any 11719
• Debridement of 1-5 nails 11720
• Debridement of 6-10 nails 11721
• Avulsion (toenail plate) 11730
• Excision of nail / nail matrix 11750
• Wedge Excision of nail fold 11765

18
Procedures

• Epitaxis
• Control Nasal Hemorrhage, Anterior
• Packing Simple 30901
• Control Nasal Hemorrhage, Posterior
• Packing, Initial 30905
• Packing, Subsequent 30906
• No Modifier is Necessary
• Excisions
• Excisions Lesion (trunk, arms, legs) Benign Malign
  ant
  
• 0.6 to 1.0cm 11401 11601
• 1.1 to 2.0cm 11402 11602
• 2.1 to 3.0cm 11403 11603

19
Procedures

• Aspiration and/or Injection
• 20600 Small Joint , bursa or ganlion cyst
  (eg. fingers, toe)
  
•   20605 Intermediate joint, bursa or ganglion
  cyst (eg.
  
• temporomandibular, acromioclavicular,
  wrist, elbow or
  
• ankle (olecranon bursa).
•   20610 Major Joint, bursa or ganglion cyst
  (eg. shoulder, hip,
  
• knee joint, subaromial
  bursa).
  
•    

20
Procedures

• Tendon/Ligament / Ganglion Cyst / Injections
  / Excisions
  
•  There must be an inflammatory process in a
  given tendon (tendonitis)
  
• or tendon sheath tenosynovitis)
• CPT Codes
• 20526 Injection of carpal tunnel with
  local anes or corticosteroid
  
• 20550 Injection(s) single tendon
  sheath, or ligament,plantar fascia)
  
• 20551 Injection(s) single tendon
  origin/insertion
  
• 20612 Aspiration and/or injection of
  ganglion cyst(s) any location
  
• 25111 Excision of Ganglion, wrist
  (dorsal or volar) primary
  
• 25112 Excision of Ganglion, wrist
  (dorsal or valar) recurrent

21
Procedures

• Trigger Point Injections
•  
• Use 20552 Injection(s) single or multiple
  trigger point(s), one or two muscle(s)
  regardless of the of injections in those muscle
  groups
• Use 20553 Injection(s) single or multiple
  trigger point(s), three or more muscle(s)
  regardless of the of injections within those
  muscle groups
•  

22
Procedures

• Wound Repair
• Simple Suturing
• 12001 simple repair scalp, neck,axillae,ext
  genitalia,trunk and/or
  
• extremities (includes hands/feet)
  2.5cm or less.
  
• 12011 simple repair of face, ears, eyelids, nose,
  lips and/or mucous
  
• membrances 2.5cm or less.

23
Services Billable In Addition to EM

• Tufts, HPHC, NHP pay for the services listed
  below.
  
• Medicare, Medicaid, Blues DO NOT PAY.
• Bill the services below along with a 99211-99215
  when applicable
  
• CPT
• 99058 Emergency Services
• 99050 Services requested after posted hours
• 99052 Services requested between 1000pm and
  800am
  
• 99054 Services requested on Sundays or
  Holidays
  

24
Modifiers

• Modifiers are 2 digit codes which accompany
  a 5 digit CPT code in
  
• order to further describe a situation to
  support additional payment
  
• when more then one service is being
  reported in the same session
  
• on the same day.
• Primary Care Modifiers
• 25, 76, GE, GC

25
Modifier 25

• Modifier 25
• Should only be appended to evaluation
  and management (E/M)
  
• service codes HCPCS codes G0101(Breast
  Pelvic Screening)
  
• and Procedures
• You do not need a modifier 25 when
  billing an office visit and
  
• also billing for
• 1) Diagnostics (eg. EKG)
• 2) Immunizations
• 3) Screenings

26
Modifier 25 Examples

• Modifier 25 Examples
• 1) When the patient presents for a planned
  procedure and has a different problem that
  requires an E/M service (two different diagnoses
  would be used to distinguish the services)
• 2) the patient presents with a "minor"
  problem and after evaluation the decision is made
  to perform a procedure. In the second example 25
  is used if the procedure is minor in nature,
  meaning that the post-operative period is less
  than 90 days and the primary diagnosis would be
  the same for both.

27
Modifier 76

• Modifier 76
• Use modifier 76 when you repeat a service
  already performed
  
• with the same diagnosis code within a 30
  day period.
  
• Example Chest pain order EKG 93000 and
  did a repeat 2
  
• wks later same diagnosis chest pain
  affix modifier 76 on
  
• 93000.