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HCA Session II Preventative Medicine Visits Procedures Modifiers.

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Presentation on theme: "HCA Session II Preventative Medicine Visits Procedures Modifiers."— Presentation transcript:

1 HCA Session II Preventative Medicine Visits Procedures Modifiers

2 Preventative Medicine Visits CPT Code (new) (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: E&M 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 ( ; ) Medicare will pay for services (eg. medically necessary follow- up or new problems) billed w/physicals. Mod 25 needs to be affixed to codes.

4 Preventative Medicine Visits continued HMOBlue/HPHC/TUFTS/Medicaid Will pay for physicals. They will also pay for services billed with a physical. Affix Mod 25 on codes. Exception Medicaid– pays for physical Only - No E&M 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 E&M code ( ) 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 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 – 3 rd 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 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 / Immunizations90471 (1) (ea. addl) Administration Code / Therapeutic or Dx90782 (eg. Gyn – Depo, B12) Administration Code / IV Infusion90780 (IM) 18 new codes for 2005 Foreign Body Removal Ear Wax Removal69210 (hearing loss pays; impacted cerumen does not) EKGs EKG Routine93000 (mod 76 repeat)

14 Procedures Lesions Lesion / Skin Tags11200 (up to 15) (ea. addl grp of 10) Lesions / Common or Plantar Wart17000 (1) plus (for ea. addl – indicate) Example: 6 removed bill x1 and x5 = 6 Lesions / Flat Warts, Molluscum /Milia17110 up to or more report code. Lesion / Vulva56501 Lesion / Vaginal57061 Lesion / Penis (cryo)54056

15 Procedures Gyn / Contraceptive Management Diaphragm or Cervical Cap Fitting57170 Insertion of IUD58300 Removal of IUD58301 Fitting and Insertion of pessary or other intravaginal support device57160 Airway Management Nebulizer Treatment94640 Nebulizer Treatment (subsequent) Inhaler Instructions (teaching) Spirometry94010 Bronchospasm Evaluation94060

16 Procedures Incision & Drainage ; Puncture Incision & Drainage (abcess, cyst) Incision & Drainage of Pilonidal Cyst10080 Incision & Removal of Foreign Body, subcut10120 Incision & Drainage of Hematoma, seroma or fluid collection10140 Puncture aspiration of abscess, hematoma, bulla or cyst10160

17 Procedures Paring/Cutting/Trimming/Excision Paring/Cutting of benigh hyperkeratotic lesion (corn or callus) single lesion11055 Paring/Cutting or benign hyperkeratotic lesion corn/callus 2-4 lesion11056 Trimming of non-dystrophic nails, any #11719 Debridement of 1-5 nails11720 Debridement of 6-10 nails11721 Avulsion (toenail plate)11730 Excision of nail / nail matrix11750 Wedge Excision of nail fold11765

18 Procedures Epitaxis Control Nasal Hemorrhage, Anterior Packing; Simple30901 Control Nasal Hemorrhage, Posterior Packing, Initial30905 Packing, Subsequent30906 No Modifier is Necessary Excisions Excisions Lesion (trunk, arms, legs)BenignMalignant 0.6 to 1.0cm to 2.0cm to 3.0cm

19 Procedures Aspiration and/or Injection “ Small Joint ”, bursa or ganlion cyst (eg. fingers, toe) “ Intermediate joint ”, bursa or ganglion cyst (eg. temporomandibular, acromioclavicular, wrist, elbow or ankle (olecranon bursa) “ 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: Injection of carpal tunnel with local anes or corticosteroid Injection(s); single tendon sheath, or ligament,plantar fascia) Injection(s); single tendon origin/insertion Aspiration and/or injection of ganglion cyst(s) any location Excision of Ganglion, wrist (dorsal or volar); primary Excision of Ganglion, wrist (dorsal or valar) recurrent

21 Procedures Trigger Point Injections Use Injection(s); single or multiple trigger point(s), one or two muscle(s) – regardless of the # of injections in those muscle groups Use 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 simple repair scalp, neck,axillae,ext genitalia,trunk and/or extremities (includes hands/feet) 2.5cm or less simple repair of face, ears, eyelids, nose, lips and/or mucous membrances 2.5cm or less.

23 Services Billable In Addition to E&M Tufts, HPHC, NHP pay for the services listed below. Medicare, Medicaid, Blues DO NOT PAY. Bill the services below along with a when applicable: CPT 99058: Emergency Services 99050: Services requested after “posted hours” 99052: Services requested between 10:00pm and 8:00am 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 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 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 and did a repeat 2 wks later same diagnosis “ chest pain” – affix modifier 76 on


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