Coding Tips Two
When a urine specimen or pap smear is sent to a reference lab, code
99000 should be used to bill for specimen handling. Note that Medicare
does not pay on 99000.
Use Q0091 for
pap smears when billing Medicare. , one
screening every two year for low risk beneficiaries and one screening
every year for high risk beneficiaries.
In instances where unsatisfactory
screening Pap smear specimens have been collected and sent to the
clinical laboratory and the clinical laboratory is unable to
interpret the test results, another specimen is needed. Append
MOD-76 to code Q0091. This will bypass the frequency editing
and allow payment to be made for reconveyance of the specimen.
If the frequency of the Pap Smear is
beyond the frequency paid for by Medicare, the claim will be denied
appropriately as being not reasonable and necessary. Always obtain an
Advance Beneficiary Notice (ABN) is necessary and append MOD-GA to the
code to indicate that an ABN has been obtained.
When blood is drawn to be sent to a reference lab, use code 36415 for
the venipuncture. HCPCS Code G0001 was deleted in 2005. The most
appropriate current code for G0001 is 36415 and the current fee for this
When billing for injections, HCPCS codes beginning with the letter J
should be used to bill for the drug(s). Always note the dosage amount.
If the amount given is twice the amount in the HCPCS book, then list the
code twice or use quantity (2). Many offices fail to bill for
the proper dosage of the drug.
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When a physician removes a malignant lesion, do not automatically code
from the 11600-11646 section of the CPT book. Carefully review the
documentation to see if the physician made a wide excision and if it was
necessary to go into soft tissue (beneath the
Codes from the Musculoskeletal section
may more appropriately describe the service and the reimbursement rate
is substantially higher. For example, the excision of a tumor of the
hand or finger (subcutaneous) may be coded as 26115.
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When a patient visits the office for an annual examination without
complaints, codes from the Preventive Medicine section (99381-99397)
should be used. Many physicians, particularly primary care physicians,
fail to use these codes as often as they should making their practice
profile statistics inaccurate. Practices should never put a diagnosis on
a claim or use the regular visit codes in these circumstances in order
to get the claim paid by the insurance company. If the patient does not
have preventive medicine coverage, he/she is responsible for such
payment of preventive medicine examinations.
Upcoding! Back to Index
Watch out for upcoding of evaluation and management codes. Many
physicians are still mistakenly basing this coding on time spent with
the patient, rather than following the criteria set forth in the
Evaluation and Management section of CPT. Coding must be based on the
written documentation and medical decision making involved with the
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If a patient has asthma, avoid using unspecific ICD-9 code 493.9X. Find out if the
patient has extrinsic asthma (caused by something in one's environment)
which is coded as 493.0X; or if it's intrinsic asthma (caused by an
internal mechanism or element within the body) which is coded as 493.1X.
If a patient receives a nebulizer breathing treatment in the office and
a bronchodilator medication is used use CPT Code 94640, and for additional
treatments on the same date, append MOD-76. Also code the
appropriate HCPCS code for the drug.
Diabetes Back to Index
Be very careful when using code 250.01 for patients with Diabetes. This
code is for insulin dependent diabetics who have no complications or
manifestations of their diabetes. Most patients who have had Type I
Diabetes for several years will have a complication or manifestation of
the disease. Consult the ICD-9 book, section 250, and select the proper
4th digit which accurately describes the patient's condition. Many
insurance companies are returning claims and asking for additional
information when this code is used.
Collection Charges Back to Index
If blood specimens are collected in your office, you can bill for the
specimen collection under CPT 36415.
Surgical Trays (HCPCS A4550) Back to Index
This code is no longer payable by Medicare. While some private
payors may pay for it, most private payors follow Medicare guidelines.
-25 Back to Index
A patient called requesting a physical exam appointment. During the
routine exam the patient states he also has fatigue and joint pain.
Doctor continues routine exam and evaluates and initiates further
testing for other
diagnoses. All documentation is on one record. Can I code for two
You can charge for
both. The physician can bill for 99395 and 99211- 99215 with the
modifier -25 appended. with proper
documentation of the separately identifiable service performed for each
However if a
patient is coming for nail debridement and the E & M only covers the
nail debridement, do not code an E & M service and Mod-25.
The E & M services are included in the payment for the services.
of Practice Coding Scenario Back to Index
A surgeon new to our practice brings his former patient load with him.
Some of the patients he is treating are postoperative. The surgery took
place when he was with the other practice and he is doing the follow-up
after he joined our practice. How can I bill for this follow-up care?
Since the surgery
was performed when he was with the other practice and presumably paid to
him through that practice then the post-op care has already been paid
for. The standard post-op time would still apply (e.g., 10-90 days). You
cannot charge for follow-up care for his post-op patients just because
he changed locations.
& M Coding
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If a physician is covering for another physician in the same group
practice (same specialty), can we code a patient visit as
"new" if the covering physician has never seen the patient
When a physician
is on-call or covering for another physician, the patient's encounter is
classified, as it would have been by the physician who is not available.
Therefore you would code this as an established patient encounter.
does "Unbundling" mean?
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One example of unbundling is separating the surgical approach from the
major surgical service.
In the case of
Total Abdominal Colectomy, CPT 44150, one should not code CPT 44150 and
CPT 49000 for exploratory laparotomy for the same operation because the
exploration of the surgical field is included in CPT 44150.