HCPCS codes and Q0091 We received this question from one of our members: “We have a Medicare patient for whom we provided a pelvic and a breast exam and a pap smear. We submitted it to Medicare and it got denied.  Can you tell me why?” Medicare doesn’t pay for “routine services”, but they do […]

I continue to hear that some consultants and coders don’t agree with reporting a problem oriented visit with welcome to Medicare or wellness visit The 2024 Physician Fee Schedule Final Rule commented on this What does CMS say about adding an E/M service to a Welcome to Medicare visit or annual wellness visit? About the […]

Hey, primary care! This one’s for you too. Primary care doctors probably didn’t pay attention when the news broke that CMS is requiring reporting post op visits using code 99024 in nine states.  After all, primary care isn’t doing major surgical procedures.  However, the list includes minor procedures performed frequently in primary care and urgent […]

Lunch and Learn Medical Decision Making is the third key component of evaluation and management services. MDM has three components: The number of diagnoses or treatment options The amount of data that the clinician reviewed The morbidity and mortality from the Table of Risk This short video discusses the requirements for selecting the level of […]

Question: Is it okay to use the time description in the order as the documentation of the psychotherapy time?  The therapist selects 90832, Psychotherapy 16-37 minutes. Answer: That isn’t sufficient.  The therapist should document the actual time of the therapy session.  Selecting the correct code in the order set that says “30 minutes” or “16-37 […]

Although there is a single payment for surgical procedures that have 0, 10 and 90 global days, there are frequent instances in which the surgeon performs an additional service in the post op period, that may be reported separately, and be paid. These will require a modifier. This article discusses only four modifiers–see the coding […]

Some modifier errors are easily avoided by experienced coders or practice management software with an editing function to stop incorrect claims before they are submitted. But, not all software has all of the edits. Sometimes, we rely on our clinicians to enter charges and add common modifiers. And, sometimes, we coders are overwhelmed by volume. […]

Question: Can we bill code 57160 when a patient comes in for a pessary cleaning? Answer: No, report an E/M service based on the key components.  57160 is for the initial fitting and insertion of the pessary. Read this post for more information about pessary billing and coding. See more Everyday Coding Q & A’s […]

Modifiers for co-surgery, team surgery and assistant at surgery CPT® has specific modifiers for co-surgery, team surgery and assistant at surgery. There are specific rules for each situation. CMS has a fact sheet that is helpful, and that reference is at the end of the article. The Medicare Fee Schedule is published annually, and coders can […]

Some people read mystery novels, some people can read body language but medical coders can read claims. Some claim lines are simple to read. The patient comes into a physician office, has an office visit for asthma treatment. A single CPT® code and a single diagnosis code is all she wrote. If the patient also […]

Question: When selecting an E/M service for an established patient, does medical decision making need to be one of the determining factors? Answer: This answer relates to E/M services 99211–99215, and is relevant until Dec. 31, 2020. Then, it is superseded by the CPT E/M definitions. Not according to CMS. Recently, when I was explaining […]

A Video Overview of TCM Codes Finally, payment for services practices typically do for free! Transitional Care Management (TCM) provides payment to medical practices for helping complex patients transition from a facility to a non-facility setting, for example, from the hospital to home. It pays for the provider and clinical staff to perform non-face-to-face services […]

Introduction | HCC and Risk Adjusted Diagnosis Coding Payers are moving to new payment models that take into consideration how sick your patient population is. What is risk adjustment? What are HCC’s? What is HCC coding? What are the proper diagnosis codes? And what does it all mean for your practice?

Definition HCPCS codes that describe collaboration of care services in primary care practices for patients with behavioral health conditions. Explanation CMS is recognizing and paying for non-face-to-face care collaboration services for patients with behavioral health conditions as part of their support for primary care physicians.

This 5 minute video covers the criteria for billing Advance Care Planning services, CPT® codes 99497 and 99498. For additional information on Advance Care Planning, see this article. Also download the CMS ACP fact sheet at the end of this post.   Download CMS Fact Sheet

Care Management for Behavioral Health Conditions Overview CMS developed HCPCS G0507 code for care management performed by clinical staff for patients with behavioral health conditions. Explanation This service describes care management by clinical staff members for patients with behavioral health conditions.  It is a non-face-to-face service, and the 20-minutes of time in the calendar month […]

Lunch and Learn There are three sets of prolonged services codes. The first set describes add-on codes to E/M services, 99354—99357. The second set of newly paid prolonged services codes are for non-face-to-face prolonged care, on the same or different day as an E/M service, 99358—99359. Finally, there is a set of codes for staff […]

Coding. Why does is keep changing? This post was out of date and has been removed. For information about the global surgical package and postoperative care, see these resources: Billing Guide-Global Surgery Modifiers in the Post-op Period | Global Surgical Package Global Surgical Package Or Browse the resource library by topic, keyword, or code See CMS […]

CPT® has two modifiers for telemedicine. CMS and private payers regularly change their instructions about using these modifiers and what place of service to use. Modifier 95 is for use with real-time, audio/visual visits. Modifier 93 is for audio-only telehealth services Modifier 93: Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-only Telecommunication […]

In 2017, CMS developed a HCPCS code, G0505, for cognitive assessment of patients with a cognitive impairment. This code was replaced in 2018 with CPT® code 99483. G0505: Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, by the […]

Words removed from one set of codes, time added to another code. There are two changes in the psychiatry section of CPT® for 2017 behavioral health billing. The first is the description of psychotherapy CPT® codes were revised to remove the words “and/or family.” In 2016, CPT® code 90832 was defined as “Psychotherapy, 30 minutes […]