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Medical Coding Tips Two


Specimen Handling Venipuncture Injections
Malignant Lesions E & M Scoring Card Preventative Medicine
Upcoding! Asthma Codes Diabetes
Specimen Collection Charges Billing for Surgical Trays  
Medical Management Tips    

Specimen Handling
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 is $3.00.

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.

Malignant Lesions                                                       Back to Index
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 dermis).

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.

Preventive Medicine                                                Back to Index
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 visit.

Asthma Codes                                                     Back to Index
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.

Specimen Collection Charges                            Back to Index
If blood specimens are collected in your office, you can bill for the specimen collection under CPT 36415. 

Reporting 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.

Modifier -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 services?

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 condition.

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.

Change 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.

E & M Coding                                                     Back to Index
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 before?

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.

What does "Unbundling" mean?                         Back to Index
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.

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