1. Preventative Medicine Visits Procedures Modifiers
HCA Session II
Preventative Medicine Visits
Procedures
Modifiers

2. Preventative Medicine Visits CPT Code 99381-87 (new) 99291-97 (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:
V Special Screening for Malignant Neoplasms; Vagina – No
previous 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 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:
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 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 / Immunizations (1) (ea. addl)
Administration Code / Therapeutic or Dx (eg. Gyn – Depo, B12)
Administration Code / IV Infusion (IM) 18 new codes for
Foreign Body Removal
Ear Wax Removal (hearing loss pays;
impacted cerumen does not)
EKGs
EKG 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) plus
17003 (for ea. addl – indicate)
Example: 6 removed bill x1 and x5 = 6
Lesions / Flat Warts, Molluscum /Milia up to 14
or more report code.
Lesion / Vulva
Lesion / Vaginal
Lesion / Penis (cryo)

15. Procedures Gyn / Contraceptive Management
Diaphragm or Cervical Cap Fitting
Insertion of IUD
Removal of IUD
Fitting and Insertion of pessary or other
intravaginal support device
Airway Management
Nebulizer Treatment
Nebulizer Treatment (subsequent)
Inhaler Instructions (teaching)
Spirometry
Bronchospasm Evaluation

16. Procedures Incision & Drainage ; Puncture
Incision & Drainage (abcess, cyst)
Incision & Drainage of Pilonidal Cyst
Incision & Removal of Foreign Body, subcut 10120
Incision & Drainage of Hematoma, seroma
or fluid collection
Puncture aspiration of abscess, hematoma,
bulla or cyst

17. Procedures Paring/Cutting/Trimming/Excision
Paring/Cutting of benigh hyperkeratotic lesion
(corn or callus) single lesion
Paring/Cutting or benign hyperkeratotic lesion
corn/callus 2-4 lesion
Trimming of non-dystrophic nails, any # 11719
Debridement of 1-5 nails
Debridement of 6-10 nails
Avulsion (toenail plate)
Excision of nail / nail matrix
Wedge Excision of nail fold

18. Procedures Epitaxis Control Nasal Hemorrhage, Anterior
Packing; Simple
Control Nasal Hemorrhage, Posterior
Packing, Initial
Packing, Subsequent
No Modifier is Necessary
Excisions
Excisions Lesion (trunk, arms, legs) Benign Malignant
0.6 to 1.0cm
1.1 to 2.0cm
2.1 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 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:
20526 Injection of carpal tunnel with local anes or corticosteroid
20550 Injection(s); single tendon sheath, or ligament,plantar fascia)
20551 Injection(s); single tendon origin/insertion
20612 Aspiration and/or injection of ganglion cyst(s) any location
25111 Excision of Ganglion, wrist (dorsal or volar); primary
25112 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
12001 simple repair scalp, neck,axillae,ext genitalia,trunk and/or
extremities (includes hands/feet) 2.5cm or less.
12011 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 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
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
93000.