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CPT 2011: New Modifier GU and Revisions to 76, 77, and 78 Change Your Reporting

2011 adds a new modifier to your coding arsenal and updates the descriptors for several others you might often use.
Get ready for modifier GU (Waiver of liability statement issued as required by payer policy, routine notice). You might have times when …

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Medicare Medically Unlikely Edits MythBuster Stops Practice Pay Losses

Medically unlikely edits ignorance could be causing you medical coding claim  denials.

Ensure you’re not letting medically unlikely edits (MUEs) wreak havoc on your urology practice’s coding and reimbursement by uncovering the truth about four aspects of these edits.

Myth 1: MUE Edits Don’t Affect Your Practice

Some practices feel that they don’t need to worry about MUEs.

Reality: “They limit the frequency a CPT code can be used,” says Chandra L. Hines, business office manager at Capital Urological Associates in Raleigh, N.C. “With our specialty of urology, we need to become aware of the denials and not let every denial go because the insurance company said it was an MUE. We should all be aware of MUEs as they occur, and we cannot always control whether or not we will receive payment.”

The MUE list includes specific CPT or HCPCS codes, followed by the number of units that CMS will pay. CMS developed the MUEs to reduce paid claims error rates in the Medicare Program. The first edits were implemented in January 2007, although some of the edits themselves became public in October 2008.

Some MUEs deal with anatomical impossibilities while others edit automatically the number of units of service you can bill for a service in any 24-hour period. Still others limit codes according to CMS policy. For example, excision of a hydrocele, bilateral (55041) has a bilateral indicator of “2,” so you should never bill two or more units of this code. Additional edits focus on the nature of the equipment for testing, the study or procedure, or pathology specimen.

Anatomical example: The MUEs edit out and deny an erroneously coded claim for a circumcision (54161, Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age) for a patient…

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96110 Modifier Requirements Change Again

BC/BS UHC, tell coder to halt 96110-59 denials with 96110-79.

If you’re ready to bill 96110 and 96110-59, think again.

One office was billing 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) with modifier 59 (Distinct procedural service). BlueCross/BlueShield (BC/BS), UnitedHealthcare (UHC), and other insurers were denying the 96110-59s. “I called BC/BS on 8-19-2010 and was told that we should be using a 76 (Repeat procedure or service by the same physician) modifier instead,” reports Bonnie Palmer, with Lawrenceville Pediatrics in Georgia. “I also called UHC and was told the same thing.”

96110 x 2 or 96110-59 Is Technically Correct

Modifier 59 rather than 76 more appropriately describes two distinct 96110s. When you’re reporting two 96110s, you’re doing so to represent two different tests, not a repeat second test as modifier 76 represents. That being said, the American Academy of Pediatrics prefers that you report multiple 96110s using units rather than any modifier.

Two 96110s indicate that the second developmental test is a separate test. Staff administered — or the parent completed — two different tests, such as the Ages and Stages Questionnaire (ASQ) and the Modified Checklist for Autism in Toddlers (MCHAT) — and that the physician interpreted and documented the tests’ interpretation.

Before Using Repeat Method, Obtain Proof

Modifier 76 instead indicates that the second test was repeated. The modifier appropriately describes cases in which staff has to readminister the same test and the physician has to reinterpret the results.

In practice, the old adage is best to follow: Get the policy in writing. If you obtain a modifier directive from an insurer to use modifier 76 for multiple 96110s – either from the payer’s Web site or an email confirmation, save the documentation – and then adhere…

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Put Your Rehab Coding and Billing Knowledge to the Test

This quick quiz will show you where you fall.

Want to stay polished on your coding and billing skills to ensure stellar reimbursement and compliance? Give this quiz a whirl, and then turn to page 21 for the answers —…

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Breathe New Life Into Your Asthma Coding Claims

Focus on form and drug to pinpoint the correct asthma supply code.

Are you clear on how to report asthma procedures and inhalers? Follow this advice, and you’ll breathe easy when it comes to asthma related claims.

Propellant-Driven Inhaler Falls

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