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Three Coding Updates – Provider Beware

Coding

CodingCODING IT RIGHT

We know everyone is busy and there is no way you can read every single article that comes in your inbox or crosses your desk.  So we thought we’d share three bullet items regarding coding that may impact your practice.

  • New Vaccine Codes for 2018

Medicare has announced a coding change.  After January 1, 2018 they will cover the new influenza virus vaccine code 90756 (Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use).

During the interim period of Aug. 1, 2017, through Dec. 31, 2017, Medicare Administrative Contractors (MACs) will use code Q2039 (Influenza virus vaccine, not otherwise specified) to handle bills for this new influenza virus vaccine product (Influenza virus vaccine, quadrivalent (ccIIV4). Q2039 is already an active code.

The new influenza virus vaccine code 90756 will then be implemented for DOS on or after Jan. 1, 2018.

  • Consult Codes not being paid

United Healthcare, has announced that they will stop paying for consult codes effective October 1, 2017.  This may be the wave of the future so make sure your billing service or office manager notifies you if other payers follow suit.

  • Documentation requirements for coding by time

Before you code by time make sure you know the documentation requirements.  The documentation must include the total time of the visit, a summary of the discussion or counseling AND support that over 50% of the visit was spent in counseling or coordination of care.

Is Mod 59 a Magic Bullet?

Coding

Mod 59 codingWe’ve noticed an increase in the usage of modifier 59 (mod 59).  Oh we all want a magic bullet.  The code that will get every charge reimbursed the first time.   Although modifier 59 may get the claims paid it might not be the correct usage of the code.  After all there are no magic bullets.

Mod 59 does have a purpose. We asked a certified professional coder to explain when it should and shouldn’t be used.  Here is an explanation that you may find helpful.

Mod 59 is used on services that are commonly bundled and/or are not normally reported together. However, there are certain circumstances can be reported and paid separately.

WHEN SHOULD I USE MOD 59?

Adding mod 59 indicates that a procedure or service is distinct or independent from other non-E/M services performed on the same day.  You can use modifier 59 when

  1. the procedure is performed in a different session or patient encounter;
  2. there is a different procedure or surgery;
  3. there is a different site or organ system; or
  4. a separate incision/excision and separate lesions or separate injuries not ordinarily encountered or performed on the same day by the same individual.

For billing, bill all services performed in one day on the same claim.  Add mod 59 to the subsequent procedure if the other procedures are not normally reported together and is appropriate for the clinical circumstances.

NO ON MODIFIER 59

If a service is typically included in the performance of the primary procedure then the procedure is bundled and should not be reported with mod 59.  Modifier 59 should never be used when another more appropriate modifier exists to clarify the services performed and when the documentation does not support the separate and distinct status.

The Medicare National Correct Coding Initiative (NCCI) has also addressed the use of mod 59.  One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.  For more detailed information, click here for a copy of the related mod 59 article from the NCCI.

Which Code is the Right Code for 2017 Flu Vaccines?

Coding
by Claire Ariyoshi, CPC

Coding Tips for Flu VaccinesRecent CDC recommendations state that vaccination efforts should begin as soon as the seasonal flu vaccines are available and continue through the flu season.  While administering the flu vaccine may be easy, coding and getting paid for it is not.

Flu vaccines are no longer easy to code due primarily to the vast number of vaccines available.  It puts the onus on the provider to know which code goes with which vaccine.  It seems like every year there are changes on how to code flu vaccines.  This year was no different.

2017 Changes

First, there was the January 1 revision.  This changed many of the influenza CPT code descriptions, removed the age indicator and added dosage.  And, it was recently announced that effective July 1, 2017 the new CPT 90682 will be reimbursed by Medicare.  This is specific to the influenza virus vaccine quadrivalent (RIV4) derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free for intramuscular use.  Medicare carriers have until August 1, 2017 to implement the CPT and pay from service dates starting July 1, 2017.

What Codes for Flu Vaccines?

When a flu vaccine is given, the provider should also enter CPT 90471 for commercial or G0008 for Medicare, for the administration of the vaccine.  The ICD10 DX code is Z23.  Just to confuse the issue even further coding is specific to trade name, how supplied, mercury content and age group.  The Immunization Action Coalition, published a table of flu vaccines by trade name to assist you in selecting the proper CPT code for Commercial and Medicare carriers.

Pricing

The Medicare Part B payment allowance for seasonal flu vaccines are 95% of the average wholesale price.  Patient deductible and coinsurance amounts do not apply for the vaccine.  All providers who administer the vaccine must take assignment on the claim for the vaccine.  The CMS Seasonal Influenza Vaccines Pricing page lists the payment allowances for the 2016-2017 flu season.

Flu Shots Given – Charges Denied

Flu ShotsNew codes for flu shots in 2017!

By:  Claire Ariyoshi, MBA, CPC

The flu season is underway and the Center for Disease Control (CDC) is recommending that people get their flu shots.  According to the CDC, only injectable flu shots are recommended this season.

Health care providers have been providing flu shots to their patients in record numbers.  However, some providers are now left wondering why their charges are being denied by various insurance carriers.  If this is happening to you, it may be because you are using the wrong codes.  Following is a summary of how providers must code in order to be paid.

Effective January 1, 2017, many influenza codes were revised to remove the age indicator and a dosage is now required. The table below illustrates these changes.

REVISED Influenza codes

2016 (age of patient) January 1, 2017 (Dosage)

90655, 90657, 9085,90687

6 – 35 months

0.25 mL dosage

90656, 90658, 90686, 90688 Older than 3 years

0.5 mL dosage

Providers who have followed these coding guidelines are being reimbursed in accordance with the carriers policies.Additionally, a new CPT 90674 has been added for a quadrivalent cell cultured influenza vaccine that is indicated for use in those 4 years of age or older.

Claire Ariyoshi is the Vice President of Finance for Onpoint Medical Solutions.  She has over 30 years experience managing medical billing and patient registration departments for private practices.  In addition to her MBA, she is a certified professional coder and is ICD-10 certified. 

Physical Therapy Coding Changes

Physical Therapy Coding Changes

2017 Coding Changes

Every specialty is impacted by the 2017 coding changes but physical therapy coding changes are drastic.  Over the next few weeks, Onpoint Medical Solutions will highlight some of the changes by specialty.  This week we’ve summarized the coding changes for physical therapy.

There are major changes for the Physical Therapy evaluation and re-evaluation codes for 2017.  The current codes 97001, 97002, 97003, 97004 have been deleted and replaced with 3 new evaluation codes, CPT 97161, 97162, 97163.

You are likely aware that Medicare and most commercial carriers required the switch as of January 1st.   But did you know that workers compensation and auto insurance carriers are not mandated by HIPAA to use the new CPT codes?  This means that you will still have to use the old codes for these carriers while remembering to use the new codes for all other carriers.  For your reference, we have included an easy to read summary of the new physical therapy CPT codes.

For physical therapy, the new evaluation codes will include different components of complexity and severity.  For instance:

  1. Patient history, medical and functional, including relevant comorbidities and personal factors;
  2. Examination AND the use of standardized tests and measures;
  3. Clinical presentation of the patient; and
  4. Clinical decision making including standardized patient assessment instrument and or measurable assessment of functional outcome.

 

Changing what you’ve done and how to do it is always challenging.  Don’t let your practice suffer.  Make sure you capture all services, all codes and enter the correct number of units.  Now is the time to work with your biller to implement edits to catch and correct the coding errors before the claims go out.  This will ensure that your cash flow won’t be negatively impacted.  The physical therapy coding changes don’t have to jeopardize your practice.