HCAEncounter Form Education

May 2006

Medicare PhysicalsDocumentation RequirementsProceduresHome Health Certification

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:

99211-99215 E&M Office Visit codes (for re-management of existing problems or new problems (need mod 25)

Do not bill 2 new E&M’s in same day Injections, Immunizations Procedures Performed (exception Medicaid – they will only pay for

procedure) Some Screenings Labs (Indicate signs/symptoms or diagnosis to support testing)

Physicals - Medicare

MC does not pay for physicals (99381-87; 99391-97) other then new mc beneficiaries (next slide)

They will pay for 99211-99215 services (eg. medically necessary follow-up or new problems addressed during a physical.

They will pay for problems addressed during a physical when a modifier 25 is affixed.

MC will pay for screenings performed during a physical if the service is performed during a covered period. (eg. paps covered every 2 yrs).

Physicals Medicare “New MC Beneficiary”

G0344: Effective 1/1/05 MC will pay physical / new MC enrollee / within 6 mths

G0366: EKG (global) G0367 (EKG tracking only) G0368 (EKG Inter & Rep Only)

Medicare does not pay for routine annual physicals (99381-87; 99391-97)

Medicare will pay for 99211-99215 services (eg. medically necessary follow- up or new problems) billed w/physicals. Mod 25 needs to be affixed to 99211-15 codes.

Medicare – “New MC Beneficiary” Required DocumentationInitial Exam includes review of:

HPI Attention to risk factors for disease detection Past medical, Social & Surgical history Experiences w/illnesses Hospital stays Operations Allergies Injuries & treatments Current medication & supplements FH (hereditary or place the individual at risk) History of alcohol, tobacco,

illicit drug use Diet Physical activities

Psych Eval - Depression Individual’s potential (risk factors) for depression including current or past

experiences w/depression or other mood disorders. Refer to appropriate screening instrument for persons without a current diagnosis of

depression recognized by a National Professional Medical Organizations.

Medicare – “New MC Beneficiary” Required Documentation

EKG Performance and interpretation of an EKG.

Functional Abilities / Level of Safety Mininum review must include assessment of: Hearing impairment Activities of daily living Falls risk Home safety

Examination Measurement of individual’s height, weight, blood pressure Visual acuity screen Other age-appropriate factors as deemed appropriate by the provider

based on the individual’s med/social history and current clinical standards.

Medicare – “New MC Beneficiary” Required Documentation

Risk Factor Counseling Education, counseling and referral as deemed appropriate by the provider based on

results of the review

Provide Brief Written Plan A checklist or alternative provided to the individual for obtaining the appropriate

screening and other preventive services which are covered separately under Medicare Part B.

11 points checklist: Immunizations (pneumococcal, Influenza, Hep B and their administration. Mammography screening Pap smear & pelvic examination screening Prostate cancer screening tests Colorectal cancer screening tests Diabetes outpatient self-mgmt training services Bone mass measurements Glaucoma screening Medical nutrition therapy for individuals with diabetes or renal disease Cardiovascular screening blood tests Diabetes screening tests

Injection – Administration CodesBill Administration along w/”J” Supply Code when appropriate

Identify Type of Injection

Immunization 90471; 90472Immunization – Pedi Codes 90465-90468Infusion “hydrate” up to 1 hr 90760 ea additional 90761Infusion “therapeutic/diagnostic” Initial Infusion up to 1hr 90765

ea additional up to 8 hrs 90766 Addl sequential infusion up to 1 hr 90767 concurrent infusion 90768Injection, single/initial; IM or SQ (eg. Depo; B12) 90772Injection, intra-arterial 90773IV push, initial/single drug 90774

each additional new drug 90775

Injection – Administration CodesImmunizations - Pedi

The new pediatric administration codes were developed to recognize “physician time”

spent counseling parents on the risks (e.g., reactions) and benefits of vaccination for children under 8 yrs. of age. Note: Discussions and/or counseling performed by a

nurse with the parents does not qualify for use of 90465-68. Instead the nurse would use

theold codes 90471-72.  90465 - admin under 8 years of age (includes percutaneous, intradermal, subcutaneous, or

intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day

  90466 - ea addl injection (single or combination vaccine/toxoid), per day   90467 - admin under age 8 years (includes intranasal or oral routes of administration) when

the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day

  90468 - ea addl admin (single or combination vaccine/toxoid), per day

Telephone Calls (99371-99373)

Telephone Calls (CPT Codes 99371-99373): Simple, intermediate or complex phone

calls made by a physician to the patient or other health care allied professional that are

*medically necessary to manage and coordinate patient care.

Documentation Required:

Date of call Reason for call Treatment given Involved parties named (other then pt) Follow-up instructions

Telephone Calls

What Supports Medical Necessity?AMA Examples of Reimbursable Telephone Services:

Services that involve a new diagnosis or require a new treatment plan (eg. acute respiratory illness) when the equivalent service performed in person would have led to a service charge itself.

Patient maintenance services, such as management of insulin-dependent diabetics with multiple blood-sugar checks and insulin changes.

Treating relapses of a previous condition when this can be adequately assessed by phone, but a significant investment of physician time and judgment are involved (eg. irritable bowel; asthma; congestive heart failure; flare-up of gout)

Reporting laboratory results (for laboratory work not done in conjunction with an office visit) that require a significant change in medication or further diagnostic tests (eg. adjustment of warfarin after a prothrombin time is done; addition of a second drug when treating hyperlipidemia; or ordering gallbladder studies when liver functions are abnormal on routine studies).

Telephone Calls - continued Extended personal counseling by telephone when the specific situation of an urgent

nature, where a physical exam is not essential or necessary to perform the service, and where failure to perform the service could lead to patient harm.

An established patient with acute exacerbation of a severe anxiety disorder or depression, commonly involving discussion of medications or recommended psychotherapy needs, mental status and mood assessment, and recommendations for further immediate care.

A test result entails a referral for a significantly complex procedure, with the potential for morbidity, complex preparation, and/or hospitalization; however, the discussion, consent and instructions do not require a face-to-face encounter (eg. breast lump found on mammogram; positive treadmill entails a cardiology referral and possible angiogram; patient refusal of a test or treatment previously discussed in detail necessitates further discussion and counseling).

Nursing or rest home calls when the patient has a significant change in condition, such as a change in vital signs, respiratory infection, or fall.

Extended counseling with family when done by telephone (eg. cases in which there are significant intrafamily conflicts or deficits in understanding related to a patient under direct care).

Home Health AideCertification – Form 485

G0180: Physician certification services:

Patient is NOT present Certification covers 60 days Completed by the ordering provider You can bill both a G0180 and a G0181 within a 30 day period.

Provider Note includes review & supportive documentation on:

Initial and subsequent reports on patient’s status patient’s responses to the oasis assessment adequate contact with the home health agency to follow-up on initial/subsequent management plan(s) .

G0179: Physician "recertification" srvs - Patient is NOT present documentation ncludes

patient’s status patient’s responses to the oasis assessment adequate contact with the home health

Procedures

Foreign Body RemovalEar Wax Removal 69210 (hearing loss pays;

impacted cerumen does not)Hearing Loss (389.90) paysOtalgia (388.70) pays

EKGsEKG Routine 93000 (mod 76 repeat)

Procedures

LesionsLesion / Skin Tags 11200 (up to 15)

11201 (ea. addl grp of 10)Lesions / Common or Plantar Wart 17000 (1) plus

17003 (for ea. addl – indicate)Example: 6 removed bill

17000 x1 and 17003 x5 = 6

Lesions / Flat Warts, Molluscum /Milia 17110 up to 1417115 15 or more report code.

Lesion / Vulva 56501Lesion / Vaginal 57061Lesion / Penis (cryo) 54056

Procedures

Gyn / Contraceptive ManagementDiaphragm or Cervical Cap Fitting 57170Insertion of IUD 58300Removal of IUD 58301Fitting and Insertion of pessary or other intravaginal support device 57160

Airway ManagementNebulizer Treatment 94640Nebulizer Treatment (subsequent)

94640-76Inhaler Instructions (teaching) 94664-59 Spirometry 94010Bronchospasm Evaluation 94060

Procedures

Incision & Drainage ; Puncture

Incision & Drainage (abcess, cyst) 10060Incision & Drainage of Pilonidal Cyst 10080Incision & Removal of Foreign Body, subcut 10120Incision & Drainage of Hematoma, seroma or fluid collection 10140Puncture aspiration of abscess, hematoma, bulla or cyst 10160

Procedures

Paring/Cutting/Trimming/ExcisionParing/Cutting of benigh hyperkeratotic lesion

(corn or callus) single lesion 11055Paring/Cutting or benign hyperkeratotic lesion

corn/callus 2-4 lesion 11056Trimming of non-dystrophic nails, any # 11719Debridement of 1-5 nails 11720Debridement of 6-10 nails 11721Avulsion (toenail plate) 11730Excision of nail / nail matrix 11750Wedge Excision of nail fold 11765

Procedures

EpitaxisControl Nasal Hemorrhage, Anterior Packing; Simple 30901Control Nasal Hemorrhage, Posterior

Packing, Initial 30905Packing, Subsequent 30906No Modifier is Necessary

ExcisionsExcisions Lesion (trunk, arms, legs) Benign Malignant

0.6 to 1.0cm 11401 116011.1 to 2.0cm 11402 116022.1 to 3.0cm 11403 11603

Procedures

Aspiration and/or Injection

20600 “Small Joint” , bursa or ganlion cyst (eg. fingers, toe)  20605 “Intermediate joint”, bursa or ganglion cyst (eg.

temporomandibular, acromioclavicular, wrist, elbow or ankle (olecranon bursa).  20610 “Major Joint”, bursa or ganglion cyst (eg. shoulder, hip, knee joint, subaromial bursa).   

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

Procedures

Trigger Point Injections

  Use 20552 Injection(s); single or multiple trigger point(s), one or two muscle(s)

– regardless of the # of injections in those muscle groups

Use 20553 Injection(s); single or multiple trigger point(s), three or more muscle(s) – regardless of the # of injections within those muscle groups

 

Procedures EXCISION CPT Codes (size, location needed)

11400-11471 (benign) 11600-11646 (malignant)

Excision codes are used to reflect “full-thickness” (through dermis) removal of a lesion

Select a cpt code based on lesion diameter plus the most narrow margins required which equals the excised diameter.

Codes are also based on body area /location (eg. trunk/arms/ legs is 1 body area) Use Modifier 59 when multiple lesions are removed in a single body area (eg. reflect different lesions, different site, different methods in same body area) Use Modifier 58 – for all re-excisions (eg. didn’t get all margins – pt. comes back) Select a CPT code after the path report has returned as malignant lesions require different coding and reimburse at a much higher rate. Simple Suturing codes ( less then 0.5 cm) - (12001-12021) are bundled into excision

codes. You can code additionally for simple (greater then .05cm) intermediate or complex

repairs Code only the most complex procedure when multiple procedures are performed on

same lesion/same day. Example: If a physician removes a self-contained cyst and not an “area” of skin code

as excision vs. debridement. (eg. Sebaceous Cyst)

ProceduresSHAVING CPT Codes11300-11313

(Shaving of Epidermal or Dermal Lesions)  Shaving = sharp removal of epidermal and dermal lesions

without a full thickness dermal excision. Code Partial thickness removal (not through dermis) as shaving. Shaving codes are used when lesions are completely removed

w/scalpel, scissors. Typically shaving does not require sutures.

ProceduresDEBRIDEMENT CPT Codes11000-11044

Surgical excision of dead, devitalized, or contaminated tissue andremoval of foreign matter from a wound.

ProceduresBIOPSY CPT Codes11100 – 11101

Biopsies remove a “portion” of a lesion for diagnostic purposes.

Excisional biopsies removes “all”.

Multiple biopsies on the same lesion may only be coded as a “single lesion”

You cannot code a biopsy and removal in the same day. Different days yes. Modifier 59 needed when you biopsy “one” lesion & “excise” another on the same

day. Note: modifier 59 should be affixed to biopsy code.

No modifier is necessary if the biopsy and excision are performed on separate days. You can code an E&M office visit (99211-15) with a biopsy if the patient presents

with If

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.