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
Hot Coding Topics

Flu Vaccines: Replace 90658 by new Q codes

Your vaccine coding in 2011 will be anything but dull, thanks to changes in codes and administration reporting. Two more updates every FP should know involve new Q codes for some Medicare flu vaccines and expanded ages for adolescent vaccine counseling.

Nix 90658 in 2011

CMS has created new HCPCS codes and payment allowances to replace 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use). Medicare will no longer pay for 90658 effective Jan. 1, 2011, so choose from the new codes instead, based on the specific product:

  • Q2035 — Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
  • Q2036 — Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
  • Q2037 — Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
  • Q2038 — Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
  • Q2039 — Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified).

Timing: Codes Q2035-Q2039 went into effect Oct. 1, 2010. You have two choices when filing claims for dates of service from Oct. 1, 2010 until Dec. 31, 2010: bill Medicare immediately with 90658, or hold the claim until Jan. 1, 2011 and file with the appropriate Q code. For vaccines administered after Jan. 1, 2011, only report the applicable 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,” says Kent J. Moore, manager of...

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December 15, 2010
Medicare / modifier 76 / modifier 77 / modifier GD / Provider News

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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October 15, 2010
CPT / HCPCS / Hot Coding Topics

Urology Coding: Capture Kegel Exercise Pay With E/M

Don’t assume 90911 is the correct code choice.

Question: Is there a procedure code for billing for Kegel exercise teaching? Can we use code 90911 or possibly 97110?

Answer: There are no specific CPT or HCPCS codes for the performance of or teaching of Kegel exercises. To bill for teaching a patient how to properly perform these exercises, a nurse or medical technician must document a brief history and physical examination as well as the indications for and the expected goals of the Kegel exercises. Under these circumstances, you can then report 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician …) for this encounter.

About the service: Kegel exercises are voluntary contraction and relaxation of the perineal musculature including the urinary sphincter (pelvic diaphragm). These exercises are usually performed outside of the office without medical staff supervision, and are a non-invasive and non-surgical treatment for female and occasionally male stress urinary incontinence.

Pitfall: You should only use 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) for the teaching of biofeedback therapy with face-to-face supervision in office by a trained member of your medical staff.

Additionally, you should use 97110 (Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) only for pelvic floor muscle rehabilitation (PFMR) performed under one-on-one supervision with a physician, physiotherapist, or ancillary office staff member specifically trained in an accredited physiotherapy program.

@ Urology Coding Alert (Editor: Leesa A. Israel, CPC, CUC, CMBS).

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June 8, 2010
Toolkit

Wound Care: Refer to This Handy Chart to Make Graft Coding a Cinch

Careful: Skip over codes for legs and zero in on foot codes.

With the many graft options — including those taken from cadavers, pigs, and newborns — correctly coding a skin graft procedure can leave you guessing. Use this chart to narrow down the grafting field by matching definitions, product names, and treatment applications to CPT codes. Then, you’ll be sure to sail through coding your next graft claim.

Don’t miss: Nothing will get your claim denied faster than using a CPT code not linked to the diagnosis code. Thus, take care to avoid CPT codes for other body areas, such as the legs, which are generally listed above the code for the feet for each type of graft. Below, you will find only CPT codes that you can use to report grafts performed on feet.

Note: Be sure to periodically review the payer’s local coverage determination to ensure your office is in compliance for your state or region.

Remember: Site preparation, lesion excision, and supply (HCPCS) codes may also apply for these services (in addition to the above listed CPT codes). Look in future issues for more on coding skin graft services by subscribing to Podiatry Coding & Billing Alert. Editor: Stacie Borrello.

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May 27, 2010
Provider News / radiology

HCPCS 2010: Make Room for New MRI Contrast Codes A9581, A9583

AdreView gets its own ‘A’ code, too. You can leave confusing “not otherwise classified” codes behind for a few more of the contrast agents that you use. For services on or after Jan. 1, be sure you’re using the product-specific codes detailed below. Not using the proper codes will lead to claim rejection, which means “not receiving [...] Related articles:

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December 17, 2009
Coding Challenge / modifier 77

Pain Management: 2 Providers, 2 Postop Pain Injections

Double 76942 OK for second provider? Question: Two providers from the same physician group performed two separate postoperative pain injections on the same patient, on the same day. Each provider used ultrasonic guidance during the procedure, but I’ve been told to report 76942 only once per day. How should we report both services? Answer: You can bill [...] Related articles:

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December 8, 2009
HCPCS / Pain Management / Provider News

Check New HCPCS Codes to Keep Pain Management Claims on Track

Catch the changes to botulinum toxin and neurostimulator electrode codes. As a pain management coder, you’re facing new CPT codes for posterior intrafacet implants, paravertebral facet joint injections, and sacroplasty. While preparing to implement these additions, don’t overlook HCPCS changes for botulinum toxin injections and implantable neurostimulator electrodes. Pay Attention to Botox Units A new code for botulinum [...] Related articles:

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  3. Pain Management Coding: TPI Do’s and Don’ts for Pay You Can KeepSample ICD-9 codes to support medical necessity for trigger point...

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December 8, 2009
Provider News

HCPCS 2010: CMS Debuts New J Codes

Synvisc, penicillin get new codes — along with injectibles for neurology, bleeding. Hot on the heels of the new CPT codes, CMS follows suit by publishing the 2010 HCPCS code set, posted on the CMS Web site on Nov. 3. You’ll find scores of changes. What follows is a small sampling of what you’ll face in 2010: Synvisc: HCPCS will [...] Related articles:

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  3. 2010 CPT Category II & III Codes You Might Miss Yes, our CPT books are fountains of knowledge, but...

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November 10, 2009