Ugh. Blue Shield is doing a thing with the 81002.

This may just be Blue Shield of California, I am not sure, but they have been bundling my urine dips (81002) into the office visit recently. 

 

So, public service announcement, bill your UAs to Blue Shield with a 25 modifier on the office visit and a 59 modifier on the 81002 as in the example below.

 

B34.4             Z68.28                 Z51.89                                99213 – 25

R10.9                                                                                      81002 – 59 

 

Also make sure that your code is set up to be a “lab” code and that your CLIA prints on it properly. Some of my providers have run into issues with that. 

Questions? Comments? Criticism? Glowing emails as to how I have saved your office from certain destruction? Please direct those to (909) 610-9524 or newgenerationbilling@gmail.com

The medical assistant will see you now

A few weeks ago, a colleague gave me an interesting dilemma. One of her providers, a pediatrician, wanted to bill a 99212 with vaccines even when the patient did not see the doctor. Since the medical assistants spent some time counseling the patient, the doctor wanted to make sure the practice was paid for that time. My colleague’s question was whether or not a 99212 would be acceptable to report to the insurance company in that manner. 

Well, short story shorter, the only office visit we can bill when the provider does not see the patient is a 99211. E&M University has an excellent breakdown of the requirements for each of the codes. 

The requirements for a 99212 include a problem focused history, a problem focused exam, and straightforward medical decision making. While the MA’s can take the history, the only person medically qualified to do an exam or any medical decision making is a provider. And counseling only does not include an exam or any decision making. 

The requirements for a 99211 are incredibly broad. In fact, there are no specific requirements. Anything the patient comes in for that does not require the presence of the physician can be a 99211. Blood pressure checks, ear lavages, EKGs, vaccinations, that sort of thing. 

However, the office does deserve to be reimbursed for any time spent counseling. For pediatricians, there is a code that includes the administration of vaccines and the time spent counseling the patient/guardian. You would use code 90460 for the first vaccine and 90461 for any subsequent vaccines. These codes are also nice because they do not specify the method of administration. You can use 90460 and 90461 for vaccines administered intramuscularly, nasally, or orally.  

If the vaccine is administered with no counseling, you would use the regular 90471 and 90472 codes for your intramuscular administrations.  

As an additional consideration, the 99212 gets paid a very small amount anyway. Probably less than $35.00. AND a copay gets applied that you’ll most likely end up waiving anyway. Getting your provider paid for at least the 90460 and one 90461 will be a higher reimbursement than billing with an incorrect code. And it is my job to make sure that I get my providers the highest reimbursement possible. 

As always, if you have any questions or any clarifications, send me an email at newgenerationbilling@gmail.com. 

Place of service listing

Hi guys! We recently started billing for a new provider who works in the emergency room. I hadn’t done that kind of billing in years, so I needed to double check the place of service code. And I figure, if I’m searching for it, some of you probably are as well. I found this comprehensive Place of service list from the CMS site. I put it on the links and tools page as well.

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.

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.

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.