Hot Coding Topics / MAC / Provider News

New AWV Codes: Here’s What the MACs Are Saying

Stop worrying if your claims were denied, you still hold a chance as many carriers are reprocessing.

Almost a year ago, practices were told that Medicare will cover an annual wellness visit (AWV) for Part B beneficiaries effective Jan. 1 and last month, CMS announced the new codes for the AWVs. Everything seemed to look perfect until came the time for claims submissions and came the denials along with it.

The MACs may have hit a few speedbumps while processing the first of the AWV claims, but are attempting to get their systems rolling smoothly as January closes out for codes G0438 (Annual wellness visit, initial) and G0439 (Annual wellness visit, subsequent). We give you answers to several questions — straight from the MACs themselves — which may help you ensure that your claims go through smoothly.

Which Diagnosis Code Should You Use?

Several subscribers have told the Insider that they submitted their AWV claims using ICD-9 code V70.0 (Routine general medical examination at a health care facility), but faced immediate denials due to MACs claiming that this is the wrong diagnosis code.

It appears that those denials were the result of a computer glitch that made the AWV codes non-payable when billed with V70.0, but some payers have already fixed this problem.

National Government Services, a Part B payer in four states, sent out a notification on Jan. 25 stating that they “omitted the editing for diagnosis code V70.0 that is allowable with HCPCS codes G0438 and G0439, and claims that were initially denied are being reprocessed.

Pinnacle Business Solutions, a Part B MAC in two states, ran a notification on its Web site on Jan. 21 stating that a system error in the claims processing system incorrectly denied claims for G0438-G0439 between Jan. 1 and Jan 20. “A...

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February 3, 2011
Coder's Cranium

Steer Clear of MUE Denials With These Tips

If you’re receiving denials from Medicare, one possibility is that you’re running up against medically unlikely edits (MUEs). The edits, which are designed to prevent overpayments caused by gross billing errors, usually a result of clerical or billing systems’ mistakes, often confuse even veteran coders.

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

While you shouldn’t stress too much, any practice filing a claim with Medicare should know what MUEs are and how they work.

“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, says Jillian Harrington, MHA, CPC, CPC-P, CPCI, CCS-P, president of ComplyCode in Binghamton, New York. “The first edits were implemented in January 2007, although the edits themselves became public in October 2008,” she adds.

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...

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December 20, 2010
Coding Challenge / Hot Coding Topics / modifier 25

Is 99211 + 95115 OK?

Question: If a nurse has to check vitals to make sure an allergy injection is the correct quantity or if she has to educate the patient about the administration or side effects of the injections, we’ve been billing 99211 with 95115 or 95117. There is...

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December 6, 2010
Toolkit

JCAAI 99211+95115: Appealing E/M With Allergy Injection Denials

March 21, 2007

Dear JCAAI Member:

We recently surveyed JCAAI members regarding reimbursement for an E&M service on the same day as a skin test or on the same day as an injection (95115 – 95117). Well over 80% are paid for an E&M service on the same day as a skin test. Far fewer are paid for an E&M service on the same day as an injection. In particular, the majority of allergists reported that they were not paid for an injection on the same day they billed a minimal office visit (99211).

Under Medicare policy, neither the injections codes nor the skin testing codes have global periods. Codes that have global periods (typically procedure codes) usually cannot be billed with an office visit because the E & M service is considered bundled into the procedure. Codes that do not have global periods do not include any bundling of E & M services; thus, coding policy generally permits them to be billed on the same day as an E & M without the use of modifier-25. However, as our survey results indicate, not all payers are aware of or are following this policy. This may be because, until January 1, 2006, the injection codes were classified as global period codes (which meant that they could not be billed with an E & M service without the use of modifier-25). JCAAI was successful in getting Medicare to change this so that you are allowed to bill an E & M service (including 99211) with allergy injection codes without meeting the requirements for modifier-25. The primary reason for this change was to allow a physician to bill 99211 when dealing with clinical issues surrounding allergy injection administration (e.g., directing a nurse giving injections as to what the nurse should do if...

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November 23, 2010
CPT / Hot Coding Topics / ICD-9

CrossRef, 100% Lay Terms, Illustrations Are Coming Soon

Denials for mismatched CPT and ICD-9 codes cost practices thousands of dollars every year. SuperCoder.com will soon help you ensure your links are correct helping you further reduce your denials rate. Plus, more code details and pictures will improve y...

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October 21, 2010
modifier 59 / modifier 76 / Provider News

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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October 11, 2010
Hot Coding Topics

ICD-9 2011: Avoid H1N1, Fecal Incontinence Denials With 5th Digit Savvy

488.1x Cheat sheet makes fast work of snagging correct code.

Don’t let rumors of few ICD-9 changes in prep for ICD-10 blindside you to top diagnosis changes for 2011. Without the scoop on expansion to the 488, 784, and 787 categories, denials for invalid codes will derail your claims delaying your payments.

In ICD-9 2011, “Codes continue to become more and more specific necessitating a provider to document clearly and thoroughly to allow for selection of the most specific and accurate code,” says Jennifer Swindle, RHIT, CCS-P, CEMC, CFPC, CCP-P, PCS, Director Coding & Compliance Division, PivotHealth, LLC.

Good news: Updating your ICD-9 coding by the Oct. 1, 2010, effective date doesn’t have to be a chore. Start using your new choices in no time flat following these guidelines.

Look at Manifestation When Assigning “Swine Flu” Dx

This fall, when a patient has H1N1 (“swine flu”) pay attention to two details. The medical record will have to identify the correct influenza and you will have to capture the appropriate manifestation to select the codes to the degree of specificity now required, Swindle points out.

With the change “category 488 (Influenza due to certain identified influenza viruses) would mirror the structure of category 487 (Influenza),” according to the Summary of March 2010 ICD-9-CM Coordination and Maintenance Committee Meeting. The current 488.x sub-category didn’t provide the level of detail that category 487 (Influenza) does.

Change: There will be “tremendous expansion of the H1N1 category,” Swindle explains. ICD-9 2011 deletes 488.0 and 488.1 and adds six new five-digit codes. New codes 488.0x (Influenza due to identified avian influenza virus) and 488.1x (Influenza due to identified novel H1N1 influenza virus) allow you “to uniquely capture pneumonia, other respiratory manifestations, and other manifestations occurring with these types of influenza,” states the summary.

Starting Oct....

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August 26, 2010
CMS / Hot Coding Topics / ICD-10

Watch for Denials If You Take Shortcuts on Form 5010

Say goodbye to form 4010A1 for ICD codes as well, starting in 2012.

Dig into your claim forms now to ensure that the beneficiary’s information is accurate to the letter, or you’ll face scores of denied claims on the new HIPAA 5010 forms.

Why it matters: CMS will deny claims on which the beneficiary’s name doesn’t perfectly match how it’s listed on his Medicare I.D. card when you begin using HIPAA 5010 form — the new Medicare universal claim form starting in 2012.

Include Jr. or Sr. Suffixes

“Whenever there is a name suffix, such as ‘Jr.’ or ‘Sr.’ abbreviations, etc., it must be included with the last name,” said Veronica Harshman of CMS’s Division of Medicare Billing Procedures during an April 28 Open Door Forum regarding the eligibility component of the HIPAA 5010 form.

You can include the suffix either with the patient’s last name or in the suffix field, specified CMS’s Chris Stahlecker during the call.

“The date of birth must also match exactly to what the Social Security Administration has on file,” Harshman said. CMS will use several new error codes on claims once the 5010 form goes into effect. “If you communicate with CMS through a third-party vendor (clearinghouse), it is strongly recommended that you discuss with them how these errors will be communicated to you and how these changes will impact you and your business,” Harshman advised.

Look for Production Systems Next Year

According to the HIPAA 5010 Final Rule, CMS will have a production 5010 system available as of Jan. 1, 2011, Harshman said.

The last day CMS will accept a 4010A1 form will be Dec. 31, 2011. As of Jan. 1, 2012, if you aren’t using the 5010 form, you’ll “lose the ability to receive eligibility data from Medicare,” Harshman said. In...

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August 12, 2010
CCI / NCCI / Provider News

Avoid Denials With This Lowdown on Newborn CCI Bundles

These edits took effect April 1, so start observing them yesterday.

The latest version of the Correct Coding Initiative (CCI) has an edit that family practice coders should note – especially if the practice treats newborn patients.

Get to know the new CCI 16.1 edit and get ready to observe it with this expert breakdown. Check Column 1 on These Hospital E/Ms According to CCI 16.1, these codes are in column 1 of the mutually exclusive edits:

  • 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …)
  • 99232 (… an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity …)
  • 99233 (… a detailed interval history; a detailed examination; medical decision making of high complexity …).

Column 2 of these edits includes these codes:

  • 99460 (Initial hospital or birthing center care, per day,for evaluation and management of normal newborn infant)
  • 99461 (Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center)
  • 99462 (Subsequent hospital care, per day. for evaluation and management of normal newborn).

Translation: An FP may not report both normal newborn care and subsequent hospital care for a newborn on the same date of service. If the FP performs normal newborn services (99460-99462) on the same date that the newborn later becomes ill and receives subsequent hospital care (99231-99233), you should only report a code from the 99231-99233 code set, explains Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

The...

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May 20, 2010
CCI / Hot Coding Topics

CCI 16.1: This Electrophysiology Edit Deletion Is Official

If you’ve been holding study claims, the time to send them in is here.

Correct Coding Initiative (CCI) version 16.1 has the news you’ve been waiting for.

The latest version, effective April 1, deletes 142 edit pairs, Frank D. Cohen,...

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April 22, 2010
Coding Challenge / ICD-10 / ICD-9

Coding Generalized Bronchitis? Prepare for Denials

Relying on the physician’s encounter form could be a big mistake.

Question: I used 491.9 to report a patient’s bronchitis, but the payer denied my claim and requested additional information. What was wrong?

Vermont Subscriber

Answer: Your claim may have...

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March 23, 2010
CMS / E/M / Medicare / modifier 25 / Oig / Toolkit

Use This Sample Appeal Letter As Ammo in Your Fight Against Modifier 25 Denials

Attach your procedure notes and the OIG’s report to pack extra punch.

Even if you follow all of CMS’s rules in reporting modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the…

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March 12, 2010
CCI / CMS / Hot Coding Topics

Red Alert, Cardiology Coders: Expect EP Study + Ablation Denials Until April 1

CMS won’t fix CCI blunder until version 16.1, to be released in the spring. If your heart skipped a beat when you saw that January’s Correct Coding Initiative (CCI) edits bundled catheter ablations with electrophysiology (EP) studies, you weren’t alone. Good news: CMS has decided to delete the edits retroactively because their addition was a mistake, according [...] Related articles:

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February 23, 2010