HCPCS Codes: Two Vital Modifiers Can Aid your Collections for Equipments

Imagine a situation when a patient leaves your office with crutches and you code E0110 to your MAC; however you find denials waiting for you in return. You're not alone. This is a common feature that practices come face to face with while giving out equipment which can lead to slowed claims and recurring denials. Two key modifiers can help your collections for equipments.

NU: When you look from a billing perspective, your work is cut out when you dispense crutches; unless of course you are well-versed with the proper modifiers to append your claim.

You can use the KX modifier if the patient meets the criteria set up by Medicare for the DME. However, the difficult part is that those criteria can change from one state carrier to another; as such it's essential that you have your MAC's policy in writing.

KX: Most probably you'll find the KX modifier handy for more than splints and crutches. Say for example if you are providing refractive lenses for cataract surgery patients, you will need to use KX as your go-to modifier in order to inform the payer that your physician ordered the lenses.

Medicare will shell out money for refractive lenses for aphakic beneficiaries. The payer covers one complete pair of glasses or contact lenses after each cataract surgery with insertion of an artificial intraocular lens.

The key to DME Medicare Administrative Contractor reimbursement for refractive lens features is medical necessity and this entails more than just selecting the right ICD-9 code.

The standard benefit is a flat-top (FT) 25/28 bifocal or trifocal in plastic or glass. A modifier will be important for the claim if the patient or the doctor calls for more features.

The prescribing physician must particularly order the special lens. It cannot be the patient's preference for one type of lens over another. So in case a physician specifically orders a particular type of lens or lens treatment, you need to append modifier KX to the HCPCS code.

HCPCS Codes: Couple of Temporary G codes for the Current Year

This year there are a couple of temporary G codes that you need to use.

In a particular situation, your dermatologist applies a tissue-cultured skin or dermal substitute for Medicare patients with lower extremity ulcers owing to venous stasis or diabetes. If you are to report such a situation, you have a couple of temporary 'G' codes for the present year.

Be it Apligraf or Dermagraft, you should zero in on G0440 and G0441 to report your surgeon's work in the present year. This is a change from using the current CPT codes for the service, which depend on the type of skin or dermal substitutes which are: Apligraf -- 15340-+15341, Dermagraft -- 15360-+15361.

Note: For most non-Medicare payers you should continue to use the 15300-series codes.

Sometimes your surgeon may prefer one skin or dermal substitute product or the other for clinical reasons in particular cases. In such cases coverage quirks for the CPT codes can provide payment cracks that sway product choice.

Challenge: What was worrying for general surgeons, podiatrists, plastic surgeons and wound care specialists was that Apligraf had a 90-day global period in comparison to Dermagraft, which had a 30-day global period. This lead providers to use one product over another to get financial advantage.

What's more, 15340-+15341 include site preparation and debridement, when you can bill those services separately with 15360-+15366.

Utilized for either Apligraf or Dermagraft, codes G0440-G0441 have 0 global days and include the site preparation and debridement services. The just-in codes together with a 0-day global billing period will do away with unequal financial incentives in the selection of products for the treatment of chronic wounds along with ensuring that physicians make their treatment decisions based on clinical benefit only.

In the future: For new or revised codes pertaining to these services, look to CPT 2012.

HCPCS Level II Codes G0440-G0441 Can be Used for Either Apligraf or Dermagraft

Two G codes - G0440-G0441 - to report your surgeon's work this year.

This year you can turn to two G codes - G0440, G0441 - when your surgeon applies a tissue-cultured skin or dermal substitute for Medicare patients with lower extremity ulcers owing to venous statis or diabetes. This is a welcome change from using the CPT codes for the service, which depend on the type of skin or dermal substitute as follows:

Apligraf -- 15340-+15341

Dermagraft -- 15360-+15361 or 15365-+15366
For most non-Medicare payers, you should continue to use the 15300-series codes.

Cause of concern: General surgeons, podiatrists, plastic surgeons and wound care specialists were worried that Apligraf had a 90-day global period in comparison to Dermagraft, which had a 30-day global period. This lead to a lot of confusion as it caused providers to use one product over another to get financial advantage. But with the new G codes around, not anymore.

Codes G0440-G0441 to the rescue: Codes G0440-G0441 can be used for either Apligraf or Dermagraft. These HCPCS medical codes ( Source "http://www.supercoder.com/hcpcs-codes/" )have a 0 global days and include the site preparation and debridement services.

The just-in codes together with a 0-day global billing period will do away with unequal financial incentives in the selection of products for the treatment of chronic wounds as well as help ensure that physicians make their treatment decisions based solely on clinical advantage.

The road ahead: The Centers for Medicare & Medicaid is working on valuing G0440 and G0441 this year to pave the way for CPT 2012 to offer category III codes to replace the temporary G codes.