Presentation on theme: "Preventative Medicine Visits Procedures Modifiers"— Presentation transcript:
1 Preventative Medicine Visits Procedures Modifiers HCA Session IIPreventative Medicine VisitsProceduresModifiers
2 Preventative Medicine Visits CPT Code 99381-87 (new) 99291-97 (est) Preventative Medicine Visit Codes include payment for:The review of “stable” chronic problemsRoutine Screenings (eg. Pap smear, breast & pelvic, manual rectal exam)Risk Factor CounselingBillable 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, ImmunizationsProcedures Performed (exception Medicaid – they will only pay for procedure)Some ScreeningsLabs (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)MedicareEffective 1/1/05 MC will pay physical / new MC enrollee / within 6 mths G0344Also: 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/MedicaidWill 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 ExaminationG0107: Blood Occult (Use only when there aresigns/symptoms)79095: Bone Density (Heel)G0104: Low Risk Flex SigG0105: High Risk Flex SigG0120: Barium EnemaG0202: Screening Mammography
6 Preventative Medicine Visits Re: Screenings Q0091: Pap Smear Collection (Annual f/High Risk; every other yr f/ LowRisk) Not reimburseable when billed w/physical.X8012: Medicaid pap smear collection codeDiagnosis Code:V Special Screening for Malignant Neoplasms; Vagina – Noprevious history of any abnormalities.V Abnormal Pap Smear (abn pap 3 mths back, redid pap –normal; this visit is f/u visit – 3rd visit)V Low Risk of Malignant Neoplasm – History of abnormal paps.V High Risk of Malignant Neoplasm – 7 or more sexual partners inlifetime, 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 systemmust be reviewed and documented.) Not reimburseable when billedw/a managed care gyn physical. Code G0101 only if “both” thebreast & 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 (Age50 & over)Diagnosis Codes:V 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 billedw/physical.Annual BenefitDiagnosis Code: V76.51Use CPT when there are signs/symptoms
10 Preventative Medicine Visits Re: Screenings 79095: Bone Density ScreeningEvery 2 years for those at risk of “losing bonemass”Medicare will cover 80% of the cost of one bone massmeasurement every 2 years.Medicare will also cover follow-up measurements
11 Preventative Medicine Visits Re: Screenings G0104: Low Risk Flex Sig once every 48 mthsG0105: High Risk Flex Sig - once every 24 mthsG0120: Barium Enema alternative to Flex Sig / ScreenColonoscopyFlexible 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 MammographyAnnual BenefitOne 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 / Immunizations (1) (ea. addl)Administration Code / Therapeutic or Dx (eg. Gyn – Depo, B12)Administration Code / IV Infusion (IM) 18 new codes forForeign Body RemovalEar Wax Removal (hearing loss pays;impacted cerumen does not)EKGsEKG Routine (mod 76 repeat)
14 Procedures Lesions Lesion / Skin Tags 11200 (up to 15) 11201 (ea. addl grp of 10)Lesions / Common or Plantar Wart (1) plus17003 (for ea. addl – indicate)Example: 6 removed bill x1 and x5 = 6Lesions / Flat Warts, Molluscum /Milia up to 14or more report code.Lesion / VulvaLesion / VaginalLesion / Penis (cryo)
15 Procedures Gyn / Contraceptive Management Diaphragm or Cervical Cap FittingInsertion of IUDRemoval of IUDFitting and Insertion of pessary or otherintravaginal support deviceAirway ManagementNebulizer TreatmentNebulizer Treatment (subsequent)Inhaler Instructions (teaching)SpirometryBronchospasm Evaluation
16 Procedures Incision & Drainage ; Puncture Incision & Drainage (abcess, cyst)Incision & Drainage of Pilonidal CystIncision & Removal of Foreign Body, subcut 10120Incision & Drainage of Hematoma, seromaor fluid collectionPuncture aspiration of abscess, hematoma,bulla or cyst
17 Procedures Paring/Cutting/Trimming/Excision Paring/Cutting of benigh hyperkeratotic lesion(corn or callus) single lesionParing/Cutting or benign hyperkeratotic lesioncorn/callus 2-4 lesionTrimming of non-dystrophic nails, any # 11719Debridement of 1-5 nailsDebridement of 6-10 nailsAvulsion (toenail plate)Excision of nail / nail matrixWedge Excision of nail fold
18 Procedures Epitaxis Control Nasal Hemorrhage, Anterior Packing; SimpleControl Nasal Hemorrhage, PosteriorPacking, InitialPacking, SubsequentNo Modifier is NecessaryExcisionsExcisions Lesion (trunk, arms, legs) Benign Malignant0.6 to 1.0cm1.1 to 2.0cm2.1 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 orankle (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:20526 Injection of carpal tunnel with local anes or corticosteroid20550 Injection(s); single tendon sheath, or ligament,plantar fascia)20551 Injection(s); single tendon origin/insertion20612 Aspiration and/or injection of ganglion cyst(s) any location25111 Excision of Ganglion, wrist (dorsal or volar); primary25112 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 groupsUse Injection(s); single or multiple trigger point(s), three or more muscle(s) – regardless of the # of injections within those muscle groups
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:CPT99058: Emergency Services99050: Services requested after “posted hours”99052: Services requested between 10:00pm and 8:00am99054: Services requested on Sundays or Holidays
24 ModifiersModifiers are 2 digit codes which accompany a 5 digit CPT code inorder to further describe a situation to support additional paymentwhen more then one service is being reported in the same sessionon the same day.Primary Care Modifiers25, 76, GE, GC
25 Modifier 25Modifier –25Should only be appended to evaluation and management (E/M)service codes HCPCS codes G0101(Breast & Pelvic Screening)and ProceduresYou do not need a modifier 25 when billing an office visit andalso billing for:1) Diagnostics (eg. EKG)2) Immunizations3) Screenings
26 Modifier 25 Examples 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 76Modifier 76Use modifier 76 when you repeat a service already performedwith the same diagnosis code within a 30 day period.Example: Chest pain order EKG and did a repeat 2wks later same diagnosis “ chest pain” – affix modifier 76 on93000.
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