Medicare Payment, Reimbursement, CPT code, ICD, Denial Guidelines

Time 2021-01-07 22:06:46

Web Name: Medicare Payment, Reimbursement, CPT code, ICD, Denial Guidelines

WebSite: http://www.medicarepaymentandreimbursement.com

ID:159967

Keywords:

Reimbursement,CPT,Medicare,

Description:

Medicare Payments, Reimbursement, Billing Guidelines, Fees Schedules , Eligibility, Deductibles, Allowable, Procedure Codes , Phone Number, Denial, Address, Medicare Appeal, EOB, ICD, Appeal.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 minutesHCPCS 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.OverviewThis 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 GuidelinesFor 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 ServicesCOUNSELING, 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 illnessBackground InformationObesity 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 CodesScreening 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, Z68.45Obesity: ICD 10: E66.01, E66.09, E66.1, E66.8, E66.900100 ANESTHESIA PROC SALIVARY GLANDS INCLUDING BIOPSY 500102 ANES-PROC INVOLVING PLASTIC REPAIR CLEFT LIP 600103 ANESTHESIA RECONSTRUCTIVE PROCEDURES OF EYELID 500104 ANESTHESIA FOR ELECTROCONVULSIVE THERAPY 400120 ANES-PROC EXTERNAL MIDDLE INNER EAR INCL BX; NOS 500124 ANES-PROC EXT MID INNR EAR INCL BX; OTOSCOPY 400126 ANES-PROC EXT MID INNR EAR INCL BX; TYMPANOTOMY 400140 ANESTHESIA FOR PROCEDURES ON EYE; NOS 500142 ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY00144 ANESTHESIA PROCEDURES ON EYE; CORNEAL TRANSPLANT 600145 ANESTHESIA PROCEDURES EYE; VITREORETINAL SURGERY 600147 ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY00148 ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY 400160 ANESTHESIA PROC NOSE ACCESSORY SINUSES; NOS 500162 ANES-PROC NOSE ACCESS SINUSES; RADICAL SURGERY 700164 ANES-PROC NOSE ACCESS SINUSES; BX SOFT TISSUE 400170 ANES-INTRAORAL INCLUDING BIOPSY; NOS 500172 ANES-INTRAORAL INCLUDING BX; REPAIR CLEFT PALATE 600174 ANES-INTRAORL INCL BX; EXC RETROPHARYNG TUMR 600176 ANES-INTRAORAL INCLUDING BIOPSY; RADICAL SURGERY 700190 ANESTHESIA PROCEDURES FACIAL BONES OR SKULL; NOS 500192 ANES-PROC FACIAL BONES/SKULL; RADICAL SURGERY 700210 ANES-INTRACRAN; NOT OTHERWISE SPECIFIED 1100212 ANES-INTRACRAN; SUBDURAL TAPS 500214 ANES-INTRACRAN; BURR HOLES INCL VENTRICULOGRAPHY 900215 ANES-INTRACRAN;PLASTY/ELEV SKULL FX-XTRADURL 900216 ANES-INTRACRAN; VASCULAR PROCEDURES 1500218 ANES-INTRACRAN; PROCEDURES IN SITTING POSITION 1300220 ANES-INTRACRAN; CEREBROSP FL SHUNTING PROCEDURES 1000222 ANES-INTRACRAN; ELECTROCOAGULAT INTRACRAN NERVE 600300 ANES-INTEG SYST MUSC NERV HEAD NECK TRUNK;NOS 500320 ANES-PROC ESOPH THYRD TRACHEA LYMPH; NOS 1 YR/ 600322 ANES-PROC ESOPH THYROID TRACH LYMPH;BX THYROID 300326 ANES-ON THE LARYNX TRACHEA CHILDREN 1 YEAR AGE00350 ANESTHESIA PROCEDURES MAJOR VESSELS OF NECK; NOS 1000352 ANES-PROC MAJOR VESSELS NECK; SIMPLE LIGATION 500400 ANES-PROC INTEG SYS EXTREM ANT TRNK PERIN; NOS 300402 ANES-INTEG SYST EXTREM TRUNK PERIN;BREAST RECON 500404 ANES-INTEG EXTREM TRUNK;RADL/MOD RAD BREAST PROC 500406 ANES-INTEG EXTREM TRUNK;RADL BRST W/NODE DISSECT 1300410 ANES-INTEG EXTREM TRUNK PERINEM;CONVERT ARRYTH 400450 ANESTHESIA PROCEDURES CLAVICLE AND SCAPULA; NOS 500452 ANES-PROC CLAVICLE SCAPULA; RADICAL SURGERY 600454 ANES-PROC CLAVICLE SCAPULA; BIOPSY CLAVICLE 300470 ANESTHESIA FOR PARTIAL RIB RESECTION; NOS 6Time UnitsIn 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 ProceduresAnesthesia 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 GuidelinesAnesthesia 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.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. OverviewCPT 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. DefinitionsModifier 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 GuidelinesWhen 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 applicableE. Codes/Condition of CoverageThese 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 ModifiersEffective 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 ModifiersThe 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, eyelidE2 Lower left, eyelidE3 Upper right, eyelidE4 Lower right, eyelidFA Left hand, thumbF1 Left hand, second digitF2 Left hand, third digitF3 Left hand, fourth digitF4 Left hand, fifth digitF5 Right hand, thumbF6 Right hand, second digitF7 Right hand, third digitF8 Right hand, fourth digitF9 Right hand, fifth digitLC Left circumflex coronary arteryLD Left anterior descending coronary arteryLT Left side (used to identify procedures performed on the left side of the body)RC Right coronary arteryRT Right side (used to identify procedures performed on the right side of the body)TA Left foot, great toeT1 Left foot, second digitT2 Left foot, third digitT3 Left foot, fourth digitT4 Left foot, fifth digitT5 Right foot, great toeT6 Right foot, second digitT7 Right foot, third digitT8 Right foot, fourth digitT9 Right foot, fifth digitModifier Guidelinesprocedures 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 repair7 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.Simple/Superficial-Scalp, Neck, Axillae, External Genitalia, Trunk, Extremities : 2.5 cm or less - cpt 12001Simple RepairsCPT 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 lacerationIntermediate 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 spaceNeed prolonged supportGuidelines:** Code by site and length** Report in addition to excision codeNote: 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 AetnaSurgical TeamUnder 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 (*) ProceduresCertain 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 HINTSAs 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 12001To 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 RelativeValue 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 MARThe 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.CPT code and DescriptionU0001 - 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel should be used when specimens are sent to the CDC and CDC-approved local/state health department laboratories.U0002 - 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC should be used when specimens are sent to commercial laboratories, e.g. Quest or LabCorp, and not to the CDC or CDC-approved local/state health department laboratories.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. Use of code 87635 will help the labs to efficiently report and track testing services related to SARS-CoV-2 and will streamline the reporting and reimbursement for this test in the US.There are two new HCPCS codes for healthcare providers who need to test patients for Coronavirus. Providers using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001). A second new HCPCS code (U0002) can be used by laboratories and healthcare facilities to bill Medicare as well as by other health insurers that choose to adopt this new code for such tests. HCPCS code (U0002) generally describes 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types or subtypes (includes all targets). The Medicare claims processing system will be able to accept these codes on April 1, 2020 for dates of service on or after February 4, 2020. CPT code and reimbursement rateU0001 - $35.92U0002 - $51.33Modifiers:The appropriate modifier should be assigned based on the below information,GT - Via Interactive Audio and Video Telecommunications systemsGQ - Via Asynchronous Telecommunications systems.95 - Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications system (reported only with codes from Appendix P)G0 -Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute strokePOS: Telemedicine service can be billed under POS 02. Diagnosis:The codes for classifying coronavirus (not associated with SARS) include,Pneumonia due to coronavirus: J12.89 (Other viral pneumonia) and B97.29 (Other coronavirus as the cause of diseases classified elsewhere)Sepsis due to coronavirus: A41.89 (Other specified sepsis) and B97.29Other infection caused by coronavirus: B34.2 (Coronavirus infection, unspecified)If the provider documents suspected , possible or probable COVID-19, do not assign code B97.29. Assign a code(s) explaining the reason for encounter (such as fever, or Z20.828). Medicaid will start to cover these services effective from March 16th, 2020 and the date of service would be February 4th, 2020.FAQs on Essential Health Benefit Coverage and the Coronavirus (COVID-19)Q1. Do the Essential Health Benefits (EHB) currently include coverage for the diagnosis and treatment of COVID-19?A1. Yes. EHB generally includes coverage for the diagnosis and treatment of COVID-19.However, the exact coverage details and cost-sharing amounts for individual services may vary by plan, and some plans may require prior authorization before these services are covered. Nongrandfathered health insurance plans purchased by individuals and small employers, including qualified health plans purchased on the Exchanges, must provide coverage for ten categories of EHB.1 These ten categories of benefits include, among other things, hospitalization and laboratory services. Under current regulation, each state and the District of Columbia generally determines the specific benefits that plans in that state must cover within the ten EHB categories.This standard set of benefits determined by the state is called the EHB-benchmark plan. All 51 EHB-benchmark plans currently provide coverage for the diagnosis and treatment of COVID19.2 Many health plans have publicly announced that COVID-19 diagnostic tests are covered benefits and will be waiving any cost-sharing that would otherwise apply to the test. Furthermore, many states are encouraging their issuers to cover a variety of COVID-19 related services, including testing and treatment, without cost-sharing, while several states have announced that health plans in the state must cover the diagnostic testing of COVID-19 without cost-sharing and waive any prior authorization requirements for such testing.Q2. Is isolation and quarantine for the diagnosis of COVID-19 covered as EHB?A2. All EHB-benchmark plans cover medically necessary hospitalizations. Medically necessary isolation and quarantine required by and under the supervision of a medical provider during a hospital admission are generally covered as EHB. The cost-sharing and specific coverage limitations associated with these services may vary by plan. For example, some plans may require prior authorization before these services are covered or may apply other limitations. Quarantine outside of a hospital setting, such as a home, is not a medical benefit, nor is it required as EHB. However, other medical benefits that occur in the home that are required by and under the supervision of a medical provider, such as home health care or telemedicine, may be covered as EHB, but may require prior authorization or be subject to cost-sharing or other limitations. Q3. When a COVID-19 vaccine is available, will it be covered as EHB, and will issuers be permitted to require cost-sharing?A3. A COVID-19 vaccine does not currently exist. However, current law and regulations require specific vaccines to be covered as EHB without cost-sharing, and before meeting any applicable deductible, when the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends them. Under current regulations, if ACIP recommends a new vaccine, plans are not required to cover the vaccine until the beginning of the plan year that is 12 months after ACIP issues the recommendation. However, plans may voluntarily choose to cover a vaccine for COVID-19, with or without cost-sharing, prior to that date.In addition, as part of a plan s responsibility to cover prescription drugs as EHB, as described above to cover ACIP-recommended vaccines, if a plan does not provide coverage of a vaccine (or other prescription drugs) on the plan s formulary enrollees may use the plan s drug exceptions process to request that the vaccine be covered under their plan, pursuant to 45 CFR 156.122(c)Does Aetna cover the cost of COVID-19 testing for members?CVS Health recently announced Aetna will waive co-pays and apply no cost-sharing for all diagnostic testing related to COVID-19 and there will be no member out of pocket cost. This policy will cover the cost of physician-ordered testing for patients who meet CDC guidelines, which can be done in any approved laboratory location. Aetna will waive the member costs associated with diagnostic testing at any authorized location for all Commercial, Medicare and Medicaid lines of business. Self-insured plan sponsors will be able to opt-out of this program at their discretion.How will doctors and hospitals have access to COVID-19 lab testing?Patients who have concerns that they may have been exposed to COVID-19 or may have symptoms of COVID-19 should contact their physician or local/state Department of Health for testing. The test specimens will be obtained and then sent to a laboratory. We are not currently able to do specimen collection or testing at MinuteClinic or CVS Retail pharmacies. The CDC states that coronavirus testing may be performed on patients with a doctor s approval.CPT code - 99201, 99202, 99203, 99204 - 99205 - office visit code.CPT CODE and Description CPT 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires thes...CPT code 11400, 11401, 11402 and 11406 - Excision benign lesion Procedure code and description 11400- Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion d...J code list and How to Bill J Codes Correctly by the UNITS with example - This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...Holter Monitoring CPT CODE 93224, 93225, 93226 & 93227 and payable DXProcedure code and description 93224 - External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage;...heart Cardiac Catheterization CPT code - 93451, 93458, 93530 - 93568, covered DXProcedure code and description 93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injecti...Revenue code list with descriptionFL 42 - Revenue Code Required. The provider enters the appropriate revenue codes from the following list to identify specific accommodation ...Can provider collect Medicare deductible upfront?Yes, we could collect the payment but it has to be refunded promptly if you are collecting excess payment or collected incorrectly. See the ...All the contents and articles are based on our search and taken from various resources and our knowledge in Medical billing. All the information are educational purpose only and we are not guarantee of accuracy of information. Before implement anything please do your own research. If you feel some of our contents are misused please mail us at medicalbilling167 at gmail dot com. We will response ASAP.

TAGS:Reimbursement CPT Medicare 

<<< Thank you for your visit >>>

Hot Websites