E/M on Time and EpiPen® Kit Pay

Base E/M on Time for Counseling/Coordination Only

Question: In case the physician documents: "Time spent in the evaluation of the patient with mostly medical decision making time (two thirds) is 75 min" can you choose the E/M code based on time alone?

Answer: No, you cannot code based on time with just the documentation mentioned above.

Here's why: You must only code for an E/M service based on time alone if no less than 50 percent of the visit was spent on counseling or coordination of care.

How it works: According to CPT manual, you can use the code closest to the documented time. If you are coding by time, choose the closest typical time.

Your documented time must be equal to or goes beyond the average time given to bill that level. For a 35 minute visit spent on a medically necessary counseling-dominated visit, according to CPT you could report medical billing code 99215 (Office or other outpatient visit for the evaluation and management of an established patient … Physicians typically spend 40 minutes face-to-face with the patient and/or family).

Tip: CPT maintains that "this includes time spent with parties who have assumed responsibility for the care of the patient or decision-making, whether or not they are family members (for example, foster parents, person acting in loco parentis, legal guardian."

Keep in mind that although the AMA, via CPT Assistant, directs you to code based on the "closest" time, maximum Medicare payers have always considered the times specified in CPT's code descriptors to represent minimums. Under those regulations, the physician would choose the lower medical billing code (for instance 99214, … physician typically spends 25 minutes face-to-face with the patient and/or family …) except the time was greater than or equal to the higher-level code's needed time (such as 40 minutes for 99215).

Seize EpiPen® Kit Pay With J0171

Question: You used the EpiPen® kit in the office for a patient who went through an allergic reaction to contrast dye. How do you bill for using this kit?

Answer: Use of an EpiPen® denotes an injection of epinephrine. As such, it would be suitable to code its administration using medical coding and billing codes 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) and HCPCS codes J0171 (Injection, adrenalin, epinephrine, 0.1 mg).

HCPCS Codes May Spell Respite for Undefined CPT® Services

Even though pediatricians aren't accustomed of using HCPCS codes, the level-two S codes provide potential medical coding and reimbursement for services that CPT does not outline. Once a pediatrician offers a service that CPT does not define, follow the following listed three steps to use HCPCS level-two S codes to resolve the reimbursement hitch.

1. Know Who Admits S Codes

Blue Cross/Blue Shield (BCBS) established the S codes for reporting drugs, supplies and services. You must use these HCPCS codes at that time when no CPT code is present, when the HCPCS code is more precise, or when the third-party payer necessitates it. The codes are entirely for use with private payers. Medicare does not admit them.

In case an S code correctly describes the service provided, make certain the carrier will accept it. You must read material for instance newsletters and carriers' local medical review policies to stay well-informed. It's also significant to evaluate the HCPCS codes in the insurance fee or payment schedule. In case the code is not listed, it's generally not payable.

2. Watch Out for Common Areas of Use

Coders regularly have problems billing for suture removal delivered by a different physician. As far as these services are concerned, you must consider using a HCPCS code.

To bill for suture removal by a physician except the physician who initially closed the wound, you should bill S0630 (Removal of sutures by a physician other than the physician who originally closed the wound) to BCBS of Michigan. To all other carriers, we report a problem-oriented E/M code (99201-99215), and link ICD-9 code V58.3 (Attention to surgical dressings and sutures) with it.

Use the similar diagnosis medical coding for HCPCS codes as you would for the CPT code. There is no dissimilarity.

3. Generate a System of Payer-Appropriate Codes

Using the codes that individual insurers identify can help get claims paid on the first try. On the other hand, keeping track of the numerous codes to use for each carrier can pose a logistical nightmare. To solve this logistical problem, design an encounter form to help your pediatricians and billers keep the codes straight. Group the CPT or HCPCS code by the major insurance companies. Under the category of suture removal by dissimilar physician, the biller chooses from the following:

ALL OTHER INSURANCE

99201-99215 - Sick visit office code (V58.3).

Provided that you did the research described in step 2 and made a chart of your findings (step 3), carriers should not reject your claims. In case you have to appeal, you must send copies of the HCPCS book to prove that the code is not a deleted or an obsolete code.

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HCPCS Codes 2012: Novel HCPCS Code Will Get You $32,000 x 3 – Only If You Bill It Appropriately

HCPCS Codes 2012: Novel HCPCS Code Will Get You $32,000 x 3 – Only If You Bill It Appropriately

In case your urologist carries out a novel treatment carried out for asymptomatic or minimally symptomatic metastatic castrate resistant carcinoma of the prostate by means of the drug Provenge or drug Sipuleucel-T, pay attention to new HCPCS codes 2012.
HCPCS Codes 2012, Medical Coding, Hcpcs Codes

Include correct primary and secondary diagnosis codes to guarantee payment.

In case your urologist carries out a novel treatment carried out for asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) carcinoma of the prostate by means of the drug Provenge or drug Sipuleucel-T, pay attention to new HCPCS codes 2012. Read this article to safeguard your payment and accurate medical coding.

Get to Know the Procedure

Medicare permits a patient one treatment with Provenge in their lifespan, which involves three distinct infusions within a two week period,

Blood is taken from the patient and then it is exposed to prostate cancer cells, preparing the patient's white blood cells to attack the cancer cells when reinfused into the patient. This also stimulates a recruitment of added white blood cells to put an end to the tumor. Provenge is the first in a new class of therapy that is intended to activate a patient's individual antigen-presenting cells to stimulate an immune response against prostate cancer.

Report the New Code 3 Times For Full Treatment

From the HCPCS codes 2012, the code for this particular procedure is Q2043 (Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion). This code signifies the anti-neoplastic treatment for this specific type of tumor.

You must keep in mind that the code descriptor states "per infusion," implying that in case the patient gets three infusions throughout the two-week treatment period, you must report HCPCS code Q2043 three distinct times. You bill this once for every single infusion, and Medicare will reimburse you $32,000 per infusion. The purchased price for the drug is approximately $30,189 per treatment. Medicare will reimburse this cost and above a six percent increase/profit.

Don't miss: While you report Q2043, from the HCPCS codes 2012, for this particular cancer treatment, keep in mind that this HCPCS code covers all additional preparatory procedures, for instance the collection of cells from the patient, the preparation as well as transportation of the cells to a specialized lab, and then the infusion itself.

Support Claim With Appropriate Diagnostic Codes

While reporting HCPCS code Q2043, the diagnosis codes should include 185 (Malignant neoplasm of prostate) as the primary diagnosis and no less than one metastatic diagnostic code as the secondary diagnosis, Potential secondary diagnostic codes involve the following:

196.1 – (Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes)

196.2 – ( intra-abdominal lymph nodes)

196.5 – ( lymph nodes of inguinal region and lower limb)

196.6 – ( intrapelvic lymph nodes)

196.8 – ( lymph nodes of multiple sites)

197.0 – ( Secondary malignant neoplasm of lung)

198.1 – ( other urinary organs)

198.5 – ( bone and bone marrow)

198.7 – ( adrenal gland)

198.82 –( genital organs.)

HCPCS Codes 2011: G0431, G0434 Include Medicare Drug Screens

CMS scrubs out G0430 and won't pay for 80100, 80101, 80104.

Forget all you considered you knew about reporting drug screen tests to Medicare. With new, revised, and deleted codes for 2011, chances are you won't report your lab's drug testing the same way this year. Read on for an expert HCPCS codes insight.

Questions abound: Fast on the heels of 2010 HCPCS code changes and CMS's surprising 2011 HCPCS codes reversals, many lab coders and billers are puzzled.

Let our experts break down the problems – as well as solutions -- to make sure you get all the pay you deserve for Medicare drug screening tests.

'Complexity' Leads Your Choice

In case your lab carries out drug screening meant for single or multiple drug classes by the means of any lab method except chromatography, you have a couple of HCPCS codes choices to report your work for Medicare beneficiaries in 2011:

G0431 (revised) – i.e. Drug screen, qualitative; multiple drug classes as a result of high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter

G0434 (new) -- i.e. Drug screen, not including chromatographic; any number of drug classes, with CLIA waived test or moderate complexity test, per patient encounter.

It seems that you should select between these HCPCS codes based on the CLIA complexity categorization of the definite lab test you're using
You must report only one unit of G0431 or G0434 per patient encounter, despite of the figure of drug classes you distinguish.

The Clinical Laboratory Fee Schedule (CLFS) has priced G0431 at five times G0434 (national limit amount $102.33 versus $20.47).

Chromatography Gets Mixed Signals

Regardless of pricing 80100 on the CLFS, the Medicare Physician Fee Schedule (PFS) registers 80100 (Drug screen, qualitative; multiple drug classes chromatographic method, each procedure) by means of an "I" (invalid) code status indicator. That implies that the code is invalid for Medicare Purposes. Medicare uses a different code for reporting of, and payment for, these services

On the contrary, when Medicare pays for a code on the CLFS, you'll find the code that is listed on the PFS with status indicator "X". That implies that the code may be paid on a dissimilar fee schedule, like the CLFS, as the code signifies a service that is not in the statutory definition of 'physician services.

Best guess: It appears like Medicare desires labs to use G0431 for chromatography in place of using 80100

Problem: Even though the G0431 definition could include chromatography -- a high complexity test -- the code necessitates "multiple drug classes," which the lab may not always carry out. However you couldn't use G0434 as it states "except chromatographic."

For More Info :- http://www.supercoder.com/coding-newsletters/my-pathology-lab-coding-alert/hcpcs-2011-g0431-g0434-encompass-medicare-drug-screens-article

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.

Seal Your CPC Exam with These Tips

Taking your CPC exam? Reading this article will certainly help you in your exam taking efforts.

There has been an information boom in recent years, so much so that it makes it difficult for you to sift through so much information, adding to your confusion. This article will throw some light on how you should prepare for your CPC exam given the huge information boom.

a) A good option is to head to a certification training camp

Even if you are a good specialty medical coder, you will not be able to pass the CPC exam just by cramming on the coding information which is not so familiar. This is where the training certification camps come to your rescue. Such camps offer a qualified instructor who can cover each area of the CPC exam: Be it ICD-9 Codes, CPT and HCPCS codes ( Source "http://www.supercoder.com/hcpcs-codes/") and everything in between.

b) Tell your doctors you will stick around for a year if they foot your CPC camp bill

CPC camps come for a price. Normally physicians might not be willing to pay the training money for fear of the employee leaving the practice in search of greener pastures after getting the certification. A one-year commitment will certainly make your employers more secure about spending money on your training.

What you should do: Tell your employer that if they shell out money for your training and you pass it, you will stick around for at least a year.

Benefit: It shows that you can know the investment the employer could be making in you and that you want to pay that investment back. The fact of the matter is that lots of medical coders do stick with their employer even after they have their CPC certification in hand; they grow their careers as the practices they work for grow.

Four Tips to Overcome MUE Denials

So are your receiving denials from Medicare? One possibility could be you are running up against medically unlikely edits (MUEs).

Medical claims billing: The MUEs, which are designed to prevent overpayments, caused by gross billing mistakes, normally a result of result of clerical or billing systems' mistakes, many a time confuse veteran coders too.

Here are four aspects of these edits to see to it that you are not letting MUEs wreak havoc on your practice's coding and payments.

First, understand what MUEs are and how they work.

Some practices are of the opinion that they don't need to worry much about MUEs. The reality is any practice filing a claim with Medicare should know what MUEs are and how they function. One needs to be aware of MUEs as they occur. The MUE list covers specific CPT or HCPCS codes, followed by the number of units that CMS will pay. In fact, the agency had developed the MUEs to bring down paid claims error rates in the Medicare program. While some MUEs deal with anatomical impossibilities, others limit codes as per the CMS policy.

Second, you can't use ABNs to transfer responsibility for payment to the beneficiary.

The agency makes this rule very clear in its FAQs. What's more, if services are denied claim based on an MUE, an ABN can't be used to shift liability and bill the beneficiary for the denied services. It's a provider/supplier liability.

Third, you can certainly override an MUE contrary to popular belief that you can never override an MUE.

According to the agency, MUEs reflect the maximum number of units the vast majority of properly reported claims for a particular code would have; as such you don't need to override them. However, you can override an MUE when your doctor carries out and documents a medically necessary number of services that cross the limit.

Fourth, you can appeal if you receive a claim denial owing to MUEs

Yes, you can certainly appeal the claims and you can address inquiries regarding the rationale for an MUE. However, the warning is that you may not get the answer you want, and it'll take some time to receive your response.

For further details on this and for other medical claims billing and coding updates, sign up for a good coding resource like Supercoder. Such a site comes with SuperScrubber for Batch Processing to save you both the time and money lost re-working denied claims.

Gear Up Your Ambulatory Surgical Center for ICD-10

Deferring your ambulatory surgical center ICD-10 learning for a later date? Well, CMS thinks it's high time you took your preparation seriously. The ICD-10 implementation does not mean you just need to get yourself a new coding manual; it includes changes that should be started as soon as possible.

There's no denying that a lot of practices have tucked ICD-10 preparedness into the back of their minds, CMS wants to keep it on the forefront of yours. Keeping this in mind, the agency has come up with a free service that allows you to get an email notification whenever the information on its ICD-10 page gets updated. So the next time the agency announces an ICD-10 webinar, transcript, article or tip sheet, you will get instant notification via email.

The site had some time back posted an executive summary of its ICD-10 vendor conference where vendors told the agency that they have implemented plans in place for both Version 5010 and ICD-10 and are quite sure that they can meet the implementation guidelines. However vendors did show their concern that there is no testing period for ICD-10 prior to October 1, 2013 deadline.

In this direction, vendors were keen on listening to what the payers are doing to get ready for ICD-10 as any mistake on the part of the MAC could slow payments to practices.

In addition, vendors noted that medical providers, more particularly those in small to mid-sized practices – are not training eyes on ICD-10 as yet; but then the vendors think that providers should get ready for the transition because if you don't comply, you'll not get your rightful reimbursements.

Remember: While training your ambulatory surgical center staff working with diagnosis coding in any form, consider the following:

Key players – be it physicians, business office support-coders, billers, collections/denials)

Extent of training

Method of training

Continuing education

For more ways to keep your ambulatory surgical center up to date with ICD-10 and for other ASC coding updates, sign up for a one-stop medical coding guide like Supercoder. Such a site comes with a tool - ASC Authority – to help you keep your ambulatory surgical center compliant and capturing all allowed procedures.

ASC authority features more than 20 details of HCPCS codes, Ambulatory Payment Classification codes, and Fee Schedule facts all in one page. To top it all, the ICD-10 Bridge will help your ambulatory surgical center make the right transition from ICD-9 to ICD-10.

Use Medicine Series Vaccine Administration with Counseling Codes On Older Patients

By now, we all are aware that CMS has created HCPCS codes (Q2035, Q2036, Q2037, Q2038, and Q2039) and payment allowances to replace 90658. Apart from this, you will be able to use medicine series vaccine administration with counseling codes on older patients and when a nurse provides the counseling, thanks to CPT 2011. Since counseling for adolescents can involve as much time as counseling on vaccines for younger children, the American Academy of Pediatrics suggested that the age limitation on the vaccine administration with counseling codes be raised. Just-in codes extend vaccine administration with counseling to patients through 18 years of age.

Busy practices will be excited at being able to use their registered nurses (RN) or licensed practicing nurses (LPN) to capture the higher RVU some private payers associate with the vaccine administration with counseling. The just-in vaccine administration with counseling code descriptor expands who can provide the vaccine counseling described in the deleted immunization administration with vaccine counseling codes (90465-90468). Last year's CPT vaccine administration with counseling codes 90465-90468 limited the counselor role to a physician and, subject to state scope of practice laws, nurse practitioner or physician assistant.

The just-in administration with counseling code extend the counseling opportunity to any "qualified health care professional" practicing within his/her state described scope of practice. An RP, LPN or medical technician could provide the counseling and the practice could still use the vaccine administration along with counseling code.

On a concluding note, you should remember the just-in administration codes - 90460 and 90461 are per vaccine/toxoid component. This means that if your doctor provides counseling and administration for a combination vaccine such as MMR, you will report 90460 for the first component and 90461 for each additional component. In the MMR example, you'd code 90460 once and 90461 twice. You'd report only a single vaccine administration code for a combination vaccine irrespective of the number of components prior to this year.

For more on this and for other medical coding updates, sign up for a one-stop medical coding guide like Supercoder.


Whether it's a powerful code reference tool, a real-time claims auditor to help you reduce denials or step-by-step guidance from CPC certified experts, we've got you covered. Some of our products like Physician Coder's PowerPack, Ambulatory Surgery Coding (ASC) Authority, etc provide you with just the ammunition you need to get instant success.

Which CPT And HCPCS Codes for MOPP?

While coding for your oncology practice, you may sometimes question – which CPT and HCPCS codes are appropriate for MOPP? Answer: Well, the MOPP (also called MVPP) combination chemotherapy regimen includes:

M: Mechlorethamine (Mustargen)
O: Vincristine (Oncovin or Vincasar)
P: Procarbazine (Matulane)
P: Prednisone.

You should code mechlorathemine using J9230 (Injection, mechlorethamine hydrochloride,
[nitrogen mustard], 10 mg). Since it's an antineoplastic, you should report administration using the appropriate chemotherapy administration code(s) (96401-96549).

You should report vincristine using J9370 (Vincristine sulfate, 1 mg). Bear in mind that HCPCS 2011 deleted J9375 (Vincristine sulfate, 2 mg) and J9380 (Vincristine sulfate, 5 mg). Since vincristine also happens to be a chemotherapy drug, you should again use the proper chemotherapy administration code(s) (96401-96549). Do not report these drugs: As part of the MOPP regimen, Procarbazine and prednisone are given orally. HCPCS offers S0182 (Procarbazine hydrochloride, oral, 50 mg) and J7506 (Prednisone, oral, per 5mg), however you shouldn't report supply (HCPCS) or administration (CPT) codes for these drugs on your Part B claims. CMS doesn't cover ‘self-administered' drugs under Part B. (Take a look at Medicare Benefit Policy Manual, chapter 15, section 50.5, www.cms.gov/Manuals/IOM/list.asp.) Exception: The provider may consider it necessary to administer the injectable form of prednisone, such as J1030 (Injection, methylprednisolone acetate, 40 mg). In that rare instance, you may be able to code the drug and administration.

Medicare benefit Policy Manual, chapter 15, section 50.4.3, explains that Medicare does not cover a medication's injectable form if the oral route is standard and medically proper. However the manual indicates there could be an exception if special medical circumstances justify an injection rather than the oral form. If the injectable form is utilized, the provider should briefly document the reason why to help support your code choice.

Note of caution: See to it that you code based on the detailed documentation rather than from a protocol's abbreviation. For instance, the oncologist may change the order based on white blood and platelet counts. For more on this and for other medical coding updates pertaining to CPT and HCPCS codes, sign up for a one-stop medical coding guide like Supercoder.com

CPT 2011 Brings Changes to Flu Vaccines and Counseling Codes, Deletes 90658

This year, your vaccine coding will be action-filled thanks to changes in codes and administration reporting. Two more updates every FP should now involve new Q codes for some Medicare flu vaccines and expanded ages for adolescent vaccine counseling.

Nix 90658 for Medicare Patients this year

CMS has come up with new HCPCS codes (Source "http://www.supercoder.com/hcpcs-codes") and payment allowances to replace 90658. Effective January 1, Medicare will no longer pay for; as such, choose from the new codes instead, based on the specific product: Q2035, Q2036, Q2037, Q2038 and Q2039.

Timing: Codes Q2035-Q2039 went into effect on Oct. 1, last year. When filing claims for dates of service from October 1 to December 31, last year, you had two code choices: To bill Medicare right away with 90658 or hold the claim until January 1, 2011 and file with the proper Q code. For vaccines administered now, post January 2011, you should only report the applicable Q code.

Use 90460, +90461 through age 18

Thanks to CPT, you will be able to use medicine series vaccine administration with counseling codes on older patients and when a nurse provides the counseling.

As counseling for adolescents can involve as much time as counseling on vaccines for younger children, the American Academy of Pediatrics recommended that the age limitation on the vaccine administration with counseling codes be raised. New codes extend vaccine administration with counseling to patients through 18 years of age.

Take advantage of RN/LPN Counseling and still get the payments

Busy practices will be thrilled at being able to use their registered nurses (RN) or licensed practicing nurses (LPN) to capture the higher relative value units (RVU) some private payers associate with the vaccine administration with counseling codes. The just-in vaccine administration with counseling code descriptor expands who can provide the vaccine counseling described in the deleted immunization administration with vaccine counseling codes (90465-90468). Earlier, CPT 2010 vaccine administration with counseling codes 90465-90468 limited the counselor role to a physician and, subject to state scope of practice laws, nurse practitioner or physician assistant.

The just-in vaccine administration with counseling code extend the counseling opportunity to any 'qualified health care professional' practicing within his/her state described scope of practice. An RN, LPN or medical technician could provide the counseling and the practice could still use the vaccine administration with counseling code.

Axe 90658 for Medicare Patients In Favor Of Just-In Q Codes

Medical Coding: Medicare will no longer pay you money for 90658 with effect from January 1, 2011.

The new year brings changes to flu vaccines and counseling codes.

Your vaccine coding in 2011 will be on its toes, thanks to changes in codes and administration reporting. Two more updates every family physician should know involve new Q codes for some Medicare flu vaccines and expanded ages for adolescent vaccine counseling.

Nix 90658 for Medicare patients

CMS has come up with New HCPCS codes and payment allowances to replace 90658. Medicare will no longer pay you money for 90658 with effect from January 1, 2011. As such, select from the new codes instead, based on the specific product: Q2035, Q2036, Q2037, Q2038, Q2039.

Timing: Codes Q2035-Q2039 went into effect on October 1, 2010. When filing claims for DOS from October 1 until December 31, 2010: bill Medicare immediately with 90658, or hold the claim until January 1, 2011 and file with the proper Q code.

Explanation: Medicare pays for influenza vaccine based on 95 percent of the average wholesale price. The products normally classifiable to 90658 have widely varying AWPs. If Medicare continued paying for all of them under a single code, they could be overpaying some and underpaying others, relatively.

Consequence: Medicare assigns different Q codes to each individual product starting January 1, 2011 to account for variances in manufacturing prices. "This should actually ensure that physicians are paid well for products that might have significant differences.

Report 90460, +90461 through age 18

You will be able to use medicine series vaccine administration with counseling codes on older patients and when a nurse provides the counseling, thanks to CPT 2011.

As counseling for adolescents can involve as much as counseling on vaccine for younger children, the American Academy of Pediatrics recommended that the age limitation on the vaccine administration with counseling codes be raised. New codes extend vaccine administration with counseling to patients through 18 years of age.

Benefit from RN/LPN counseling and still get the reimbursements

Busy practices will be excited at being able to use their registered nurses (RN) or licensed practicing nurses (LPN) to capture the higher RVUs some private payers associate with the vaccine administration with counseling codes. The just-in vaccine administation code with counseling code descriptor expands who can provide the vaccine counseling described in the deleted immunization administration with vaccine counseling codes (90465-90468). CPT 2010 vaccine administration with counseling codes 90465-90468 limited the counselor role to a doctor and, subject to state scope of practice laws, nurse practitioner (NP) or physician assistant (PA).

Final say: Remember the just-in administration codes 90460 and 90461 are per vaccine/toxoid component. That means if your doctor provides counseling and administration for a combination, you will report 90460 for the first component and 90461 for each additional component. In the MMR example, you would use 90460 once and 90461 twice. Before 2011, you'd report only a single vaccine administration code for a combination vaccine, irresespective of the number of components in the vaccine.

Cisplatin, Cyclophosphamide, and Vincristine Most Affected

HCPCS 2011 code-set has a number of deletions, streamling your drug coding choices. Most affected are cisplatin, cyclophosphamide, and vincristine.

The just-released HCPCS 2011 code-set has a number of deletions, streamling your drug coding choices. Among the most affected are cisplatin, cyclophosphamide, and vincristine.

The good news is that this change should simplify billing, more so if the system your practice or facility uses like Pyxis or Lynx, limits you to a single code and billable unit for a drug.

Watch out: These HCPCS (http://www.supercoder.com/hcpcs-codes) changes have a positive side, however there are always considerations that'll arise. For instance, if your practice uses different sizes, you'll need to be alert for the different and specific national drug code (NDC) numbers for the agent dispensed to the patient when you send a claim to a payer who needs NDC information.

For cisplatin, stick to J9060

Cisplatin, ordered particularly for patients with metastatic testicular or ovarian neoplasms, or advanced bladder cancers, is one of the many agents impacted by the HCPCS 2011 shake-up.

Revision work: HCPCS 2011 will make a small wording revision to J9060.

2010: J9060 -- Injection, cisplatin, powder or solution, per 10 mg

2011: J9060 -- Injection, cisplatin, powder or solution, 10 mg.

Code J9062 (Cisplatin, 50 mg) will no longer be available for use in the new year. You should go for J9060 to report cisplatin, brand name Platinol, when supplied for 2011 dates of service.

For cyclophosphamide, J9070 comes out on top

At 1 unit per 100 mg, J9070 (Cyclophosphamide, 100 mg) won the role of the single option for coding cyclophosphamide injection supply.

J9080-J9097 go to the chopping block in 2011.

Vincristine Codes J9375 and J9380 feature in deleted list

Oncologists may order vincristine (Vincasar PFS) for patients with leukemia, Hodgkin's disease, non-Hodgkin's lymphoma, soft-tissue tumors, and neuroblastoma, among others. You will be reporting vincristine per milligram in the new year.

Cms Plays Spoiltsport on Your Pay

CMS doesn't make payments for preventive medicine services billed under 99381-99397.

Owing to the flawed Sustainable Growth Rate (SGR) formula to calculate Medicare fees, Medicare payments to doctors are also due to fall, and medical practices will face a perfect storm of payment nightmares.

Practices are not sure what will transpire on January 1, 2011. Some newly-elected Senators and House members will be in place in the new year, and it's not clear whether the present Congress will make changes affecting 2011 pay prior to January or whether they'll leave these issues for the new Congress to solve.

Some specialties will face additional cuts apart from dealing with conversion factor fluctuations.While the most affected practices will be those that specialize in radiology, the cuts will most certainly have a significant impact on specialty practices that are already financially stretched.

The Fee Schedule also incorporates several provisions of the Affordable Care Act of 2010 that was passed last March. Firstly, you will see that coverage has been established for annual wellness visits for Medicare patients. The rule that was issued on November is a major step toward improving the health status of Medicare beneficiaries by providing coverage for an annual wellness visit that will allow a physician and patient to forge closer ties to improve the patient's long term health.

"If you carry out a procedure that meets CMS's description of an annual wellness visit, you shouldn't report a code from CPT's preventive medicine section to your Medicare carrier," indicates the Final Rule.

CMS doesn't make payments for preventive medicine services billed under 99381-99397. Instead, you should report one of the following newly-established HCPCS codes(http://www.supercoder.com/hcpcs-codes/):

G0438 -- Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit

G0439 -- subsequent visit.

Even though most of these wellness examinations are normally carried out by the patient's internist or family physician, occasionally a urologist will carry out this service. If so, think about the above codes and information to help you bill properly and be paid for this service.

CMS has assigned 2.43 physician work RVUs to G0438 and 1.50 RVUs to G0439, and these codes will be effective on January 1, 2011. Beneficiaries who have been enrolled in Part B for a year will be eligible for an initial preventive physical exam, (also known as an IPPE, which is billed with G0402).

Post the first 12 months of Part B coverage on or after January 1, 2011, beneficiaries would be eligible for an initial preventive physical exam. After the first 12 months of Part B coverage on or after January 1, 2011, beneficiaries would be eligible for an annual wellness visit as described by the new G codes, thinking that the patient has had an IPPE within the preceding 12 month period, states the Fee Schedule.

Fee Schedule Establishes Coverage for Annual Wellness Visits for Medicare Patients

The Fee Schedule establishes coverage for annual wellness visits for Medicare patients.

The new Fee Schedule incorporates several provisions of the Affordable Care Act of 2010 that was passed in March.

New coverage: The Fee Schedule(http://www.supercoder.com/coding-tools/fee-schedules) establishes coverage for annual wellness visits for Medicare patients.

The rule that was issued on November 3 is a key step toward improving the health status of Medicare beneficiaries by providing coverage for annual wellness visit that'll allow a physician and patient to develop closer ties to improve the patient's long term health.

Change: If your doctor carries out a procedure that meets CMS's description of an annual wellness visit, don't report a code from CPT's preventive medicine section to your Part B carrier, the Final Rule indicates. CMS doesn't pay for preventive medicine services billed under 99381-99397. Instead, report one of the following newly-established HCPCS codes that'll be effective from January 1, 2011:

G0438 -- Annual wellness visit; includes a personalized prevention plan of service, first visit

G0439 -- Annual wellness visit; includes a personalized prevention plan of service, subsequent visit

CMS has assigned 2.43 physician work RVUs to G0438 and 1.50 work RVUs to G0439. Beneficiaries who have been enrolled in Part B for 12 months will be eligible for an initial preventive physical exam (also known as an IPPE, which is billed with G0402). After the 12 months of Part B coverage on or after January 1, 2011 beneficiaries would be eligible for an annual wellness visit as described by the new G codes, assuming that patient has not had an IPPE within the preceding 12-month period, states the Fee Schedule.