Category Archives: CPT

Modifiers 24 and 79

A few months ago we had to do some training on our ophthalmologist account regarding when to bill the 24 modifier versus the 79 modifier in the global period to a surgery or in-office procedure. I figure, if our employees are having questions, some of you might be too, and I want you to get the maximum reimbursement for your services. First, the exact descriptions of the modifiers from the CPT book:

24 – Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Post-operative Period:
The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.

79 – Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:
The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)

Many of our doctors do both minor and major surgeries, and we all know that patients need to come back in for follow up care on their various incisions, wounds, and ulcers to make sure everything is healing properly. The insurance companies will not pay for these follow up visits, or any visit done in a certain amount of time after the procedure without the proper modifiers as they consider the follow up visit to be an integral part of the original procedure. This time period is called the global period and the length of time varies depending on the procedure performed.  The issue with this no-payment rule comes in when the doctor diagnosis the patient with something additional during the follow up visit, or the patient needs another procedure. At that point, the doctor needs to do a complete visit including review of systems and exam and make a medical decision, and we can all agree that she should be paid for that. Here is how you get her paid. Modifier 24 goes on the office visit and you make sure you have a primary diagnosis that is different than the diagnosis on the original procedure. If the patient needs any in-office procedures, put a 79 on the procedure and make sure the diagnosis is different than the one on the original procedure. If the patient needs another major surgery in that time period, unrelated to the original, use modifier 79 as the first modifier on the surgery.  Just to avoid confusion, whether you use the modifier 24 or the modifier 79, the modifier would go on the visit subsequent to the surgery or in-office procedure.

To answer a popular question, yes, you can use modifier 79 when you are billing for the same surgery on a different body part. For example, if the patient had a cataract surgery on the left eye in January and he is getting cataract surgery on his right eye in February, you can use the same diagnosis of cataracts, the same CPT code for the surgery, and add the 79 modifier. Here is how that would look:

Date                          ICD9 code            CPT Code    Modifiers

01/13/14                 366.17                    66984             LT

02/18/14                366.17                    66984              79    RT

As for using the 24 modifier, there are all kinds of good, justifiable reasons to bill with that modifier and get your office visit paid separately. Here are just a few:

1) Patient is requesting a refill on medication for her chronic condition (hypertension, diabetes, hypothyroidism, migraines, neuralgia)

2) The patient came in with an unrelated chief complaint on his follow up visit

3) Patient came in for the follow up and the doctor identified symptoms of something else during the exam

This is by no means a comprehensive list, so if you are not sure whether or not your particular patient meets the requirements for using a 24 on the office visit, send me a quick email and I’ll let you know how I would bill it. Here is an example of how a charge like that would look.

Date                          ICD9 code                             CPT Code    Modifiers

01/13/14                  366.17                                    66984             LT

02/18/14                 250.60    362.01                  99214             24

I also have another chart for you (I love charts!) detailing the global period for each procedure. It is LONG. I do not suggest you print this one out, but save it on your own computer for reference. Oh, and, the global period for any given code is either going to be 10 days or 90 days, if it has one at all. FYI. As always, I saved the chart to my Links and Tools page for you.

EDIT: Just a quick FYI, global surgery rules do not apply to assistant surgeons. So, anyone who is billing a code for a provider assisting with a surgery, these rules don’t actually apply to you. Just go ahead and use modifiers 80-82 the way you’ve been doing. In fact, if we do send in a claim with modifier 79 (or 78 for that matter), the claim will actually be returned as unprocessable. Thank you, Adam, for helping to clear up the confusion.

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Filed under Billing, Claims, CPT, Doctor's Office, Follow up, Health Care, ICD9, Medical Billing, Modifiers, Office Visit

Modifier 25 and 59 update

I have an Updated modifier chart for you guys. We have been finding that the insurances are denying the immunization administration (90471) without a 25 modifier on the office visit and a 59 on the 90471. If you were using the old one, please replace it with the updated rules. For a more detailed explanation of how these modifiers work, please see the post from 01/11/13.

And this new chart is fancy and it’s typed and has examples. Hope it helps. I have also had a few inquiries on when to use the modifier 24 and 79, so my next post will be about how to use those effectively. Also, if anyone has a question for us, please do not hesitate to email or comment.

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Filed under 96372, Billing, Claims, CPT, Doctor's Office, Medical Billing, Modifiers, Office Visit

Quick Workers Comp Tools

Have you ever wished that you could have a list of all the lists and tools and links you need for Workers Comp in one place? Well now you can! You’re welcome.

Doctor’s First Report

PR-2 Report

OMFS Schedule

OMFS DME Prices

NDC Numbers for substances

OMFS Fee schedule for pharmeceuticals

EAMS

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Filed under Claims, CPT, Doctor's Office, Follow up, Health Care, Medical Billing, OMFS, Workers Compensation

Everything you ever wanted to know about pap smears

**DISCLAIMER**  

***This post was written in 2014 and the rules have changed since then. I am going to be putting up a new post with the new rules updated to ICD10 very soon. There are some major changes to the way the insurances accept the charges and this an old post with the old rules. If you have any questions, and can’t wait for the new post, please email me directly and I will try and help you out.*** 

The first thing about paps is that every insurance pays them differently. To tell the truth, I don’t have most of it memorized. What I do have is a binder, with one page per insurance, and all of the pap rules are laid out there, in alphabetical order.

Of course, I’m going to give those to you. I suggest you do what I do and put them all in a three ring binder. However, I can only give you the PPO pap smear rules, because your HMO contracts will not be the same as the contracts for my doctors. I can show you a few of my HMO rules, though, so when/if you make your own reference sheets you know what the necessary information is.

You CAN get an office visit and a pap smear paid on the same date on the same claim. You just need to use proper modifiers. Also, most insurances allow patients to self refer for their annual exam, so you shouldn’t have to worry about authorizations.

Here are the Pap rules for PPO insurances. For your HMO insurances, all you need to do is call the provider relations department and get a copy of the doctor’s contract. The contract will be fairly short, and very clear about which codes are paid. However, you will need to ask the provider relations people which diagnosis they need to see on the claims.

If you want to review the high risk rules you can find those on the MR website. Here is a link, for the curious.

Remember to follow the blog; you’ll get an email every time I get a new post up. Also, if you have a specific question, please don’t hesitate to email me.

 

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Filed under Billing, Claims, CPT, Doctor's Office, Health Care, ICD9, Medical Billing, Modifiers, Pap smears, Well woman exam

Please post your payments

This is along the lines of the cash in the office post. One of my doctors has lost an insane amount of money, and I would like you all to learn from his mistake.

I have a small Internal Med with an emphasis in Cardiology in Montclair. I go to their office once a week, after hours, and do all the charges and claims in about an hour. This isn’t bragging, they are small, and I am fast, and they only have me enter charges and send electronic claims. I have been doing their billing for four years and, until recently, I had never even seen one of their EOBs. They don’t want to pay me to post the payments, because they think it will cost them too much money.

I finally signed them up for a user name and password on the Online Provider Services Medicare website, against the office manager’s strenuous objections. On the first EOB I pull up, I immediately notice that ALL the EKGs I billed had been translating as 93005 instead if 93000.  The reimbursement for a 93005 is $8.93 (allowed $11.16 minus the 20% coinsurance) and the reimbursement for the 93000 is $15.14 (allowed $18.93 less $3.79 for the coinsurance). That means my Internal Med has been losing $6.21 on every EKG for at least the last four years. He probably does 20 EKGs per week. So, ($6.21) x (20 EKGs per week) x (52 weeks) x (4 years) = $25,833.60. This does not account for the fact that over the last four years Medicare reimbursements have been decreasing.

Even after this, I have not been able to convince them that it would be more cost efficient in the long run to have me post the payments as well as the charges. Please, please, please use this as a warning and properly reconcile your EOBs with your payments. Every EOB for every charge.

Also, do it by line item and not by charge, because it is too easy to miss something important. Something like this.

$25k. Gah.

P.S. If you have any questions about what you should be getting paid for things, use the Medicare Fee Schedule Look-Up. Most companies will pay a similar amount, so you are mostly safe using that as a standard.

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Filed under Accounts receivable, Billing, Claims, CPT, Denials, Doctor's Office, Follow up, Health Care, Medical Billing, Medicare, Office policy, Uncategorized

Psych Secrets

This post is about doing billing for the psychiatrist or psychologist in your life. It’s going to be a long one, guys.

The new CPT codes for mental health services for 2013 are going to have to be a whole post themselves. If you absolutely, positively need an easy explanation before I can get the post up, please remember, you can call or email. The diagnosis that are categorized as mental health conditions range from between ICD9 code 290-319 (ICD10 F01-F99) and if you are not a psych or a therapist and you bill any of these dx primary, you might end up with a denial, so please be careful.

The most important part of the process is the insurance verification. I know that a lot of health plans show the mental health benefits online. Unfortunately, the information they give you online is incomplete, so you are going to be making some calls. The number for the mental health information line is on the back of the card. Also called behavioral health, the people at this number will become your new best friends. Well, at least until you have to call about a claim. Here is where you learn some new terminology. Below is a list of the questions to ask when you’re on the phone with eligibility.

1. Does this plan require authorization?
2. Do the claims carve out?
3. Are there different benefits for parity and non-parity?

A plan carves out when the financial responsibility for mental health services changes from the health plan to another company. For example, Health Net carves out the mental health to CHIPA quite often. So you would send your psychotherapy claim to CHIPA rather than Health Net. You would get your authorization from CHIPA as well. Parity diagnosis are the “serious” ones. I wish I could give you a better definition. Parity dx include most of the chemical imbalances and a few others. Here is the full list, edited for ICD10:

1. Anorexia – 307.1 (ICD10 F50.00 through F50.02)
2. Bipolar Disorder – 296.40 through 296.80 (ICD10 F30.0 through F31.9)
3. Bullimia – 307.51 (ICD10 F50.2)
4. Major Depression – 296.20 through 296.36 (ICD10 F32.0 through F33.9)
5. Obsessive-Compulsive Disorder 300.3 (ICD10 F42)
6. Schizoaffective Disorder – 295.70 through 295.75 (ICD10 F25.0 through F25.9)
7. Schizophrenia – 295.00 through 295.65 (ICD10 F20.0 through F24)

When I was first learning psych billing, I printed this list and taped it to my wall. One of the most useful tools I had.   You also need to know whether you are calling for inpatient or outpatient benefits and substance abuse or mental health. Please remember, all of this information, it is most efficient to get from one phone call. In our office we actually have an insurance verification form that we fill out when we get benefits for new patients. You can use our insurance verification form or you can make your own, but taking a few moments to write down this information saves you from having to call back multiple times. 

Once you have this information, sending the claim out is pretty straightforward. However, if your doctor is contracted with Medicare or Medi-Cal, please give me a call or shoot me an email. There is a LONG explanation regarding getting paid by those companies and it won’t translate well into blog form.

There have been a lot of changes in the psych billing world in the past few years, and it is quite possible that any number of things could have slipped through the cracks in your office. If you still have a lot of money sitting on your AR and your reimbursements aren’t as high as you think they should be,  we can come in and take a look for you, we do that for free. If everything looks fine, we give you a high-five and a few of our cards to pass out to your colleagues. If you do need help, you can hire us to fix it, or we’ll tell you how to fix it yourself. Email me at newgenerationbilling@gmail.com.

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Filed under Authorizations, Billing, CPT, Doctor's Office, Health Care, ICD9, Medi-Cal, Medical Billing, Medicare, Psych

Modifer 25 and 59

We are training several new employees right now. Glad to be expanding, progressing as expected, blah, blah, blah. But they are having a great deal of trouble with understanding when to use the modifiers 25 and 59. If we are having issues in here, some of you out there might be as well, and I want to make your life easier. First, for you technical types here are the exact descriptions from the CPT book.

Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service:
It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

Modifier 59 – Distinct Procedural Service:
Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

Now for some practical application. The modifier 25 goes on the office visit.  Here are the situtations in which you need a modifier: 1) If a patient gets a procedure on the same day as an office visit, 2) medication injected same day as an office visit, 3) pap smear done same day as an office visit, 4) physical done same day as an office visit. Don’t worry, we’re about to go through and lay out how we are supposed to use them.

If you need to bill an office visit and a procedure, you would use a modifier 25 on the office visit line. A procedure counts as any CPT code between 10000 and 69999. Plus, you need a different diagnosis on the procedure than you have on the office visit. Here is an example:

A patient comes in with ear pain and the doctor diagnoses her with an ear infection and does an ear lavage. If you want to get both the 99213 and the 69210 paid on the same visit here is how you would enter that charge:

Ear pain/otalgia (ICD9 388.70) (ICD10 H92.09)           99213  –  25

Ear infection (ICD9 382.9) (ICD10 H66.90)                   69210

When you put it in with a different dx on the office visit and  a 25 modifier the insurance will pay each line item separately.

Paps and physicals work in a similar way. The medical dx go on the office visit and the V-codes go on the preventive service. I could write a whole post on paps (and probably will) but we are going to keep it simple here.

465.9 (ICD10 J06.9)    462 (ICD10 J02.9)                      99213  –  25

V70.0                                                                               99395

When you need to bill an office visit and an injection on the same day, you have two options. The cpt 96372 is for an intramuscular injection of a J-code. You can bill the office visit and the substance all day and they will all get paid separately with no modifiers. The injection administration is what the insurances like to include in the office visit. However, you will get paid about $20.00 for each administration billed correctly and that can add up. Say a patient comes in with knee pain and the doctor diagnoses him with osteoarthritis and wants to give him an injection of Toradol. You put the symptom on the office visit with a 25 modifier and the substance and the admin have the condition. Then, you put a 59 modifier on the 96372. So, it would be three line items and it would look like this:

Knee pain       719.46 (ICD10 M25.569)                        99213  –  25

Osteoarthritis  715.96 (ICD10 M17.9)                            J1885

Osteoarthritis  715.96 (ICD10 M17.9)                            96372  –  59

I have attached an Updated modifier chart that will tell you when a service needs a modifier. We printed this out and gave it to all the new people and it seemed to clear up most of the confusion.

As always, call or email if you have any specific questions about something that didn’t make it through here on the blog.

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Filed under Billing, Claims, CPT, Health Care, ICD9, Medical Billing, Modifiers