Remote patient monitoring may be catching on with health systems across the country, but its path to Medicare reimbursement is still a work in progress. The Centers for Medicare &…
The Medicare Physician Fee Schedule (MPFS) includes special pricing for four colonoscopy codes when you append modifier 53 (Discontinued procedure). Here’s what you need to know about appending modifier 53…
CMS clearly is honing-in on reducing administrative burden as changes go into effect. On Friday, Nov. 1, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee…
The Centers for Medicare & Medicaid Services (CMS) Transmittal 1058, Change Request (CR) 7767 confirms a zero percent update for payments under the Medicare Physician Fee Schedule (MPFS) through year’s end.
Effective April 1, your practice’s bottom line is going to be hit, especially if your provider uses chemodenervation to treat patients. Reason: Medicare Physician Fee Schedule is all set to introduce a bunch of changes. So here’s the big news.
Bilateral Indicator Shifts to ‘2’
Neurologists and pain management specialists sometimes use chemodenervation to help relieve symptoms of spasmodic torticollis (333.83), cerebral palsy (such as 343.x), or other conditions. The codes you rely on for these procedures include:
Previous versions of the physician fee schedule listed a bilateral status indicator of “1” for 64613 and 64614. That meant you could append modifier 50 (Bilateral procedure) and receive additional payment if your provider injected botulinum toxin into bilateral anatomic sites, such as the right and left upper extremities.
Medicare is changing the bilateral status indicator for 64613 and 64614 to “2,” effective April 1, 2011. You’ll no longer be able to report the service bilaterally, even if your provider chooses that treatment option.
“Medicare now considers that the RVUs (relative value units) are already based on the procedure being performed as a bilateral procedure,” explains Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co.
Pay cut: Submitting a claim with modifier 50 means the payer will reimburse at 100 percent for the first procedure and at 50 percent for the second contralateral procedure. Based on the national conversion factor of $33.9764, Medicare pays $145.42 for code 64613 in a facility setting and $164.11 in a non-facility setting. Medicare pays $151.87 for code 64614 in a facility setting and $174.98 in a nonfacility setting. Once the...
Despite adjusted rate of 33.9764, overall change is zero. The President locked in a zero percent adjustment to your Medicare Part B payments but that doesn’t mean you’ve got the same rate. The Medicare and Medicaid Extenders Act of 2010, wh...
Medicare Physician Fee Schedule rate won’t be cut 23 percent. Although the government appeared poised to take a big bite out of your next Medicare Part B payments, you now have another month before you need to worry about losing pay. That’s because...
Pediatricians who were thrilled with CPT 2011’s move to paying vaccines per component got a setback from Medicare’s rejection of the recommended RVUs for new vaccine administration codes 90460 and 90461.
The Relative Update Committe recommended that the 2011 Medicare Physician Fee Schedule and Resource Based Relative Value Scale assign 0.20 practice expense (PE) RVUs to 90460 and 0.16 PE RVUs to 90461. But CMS disagreed with the proposal. “We disagree with the recommendations and will maintain 0.17 RVUs for code 90460 and 0.15 RVUs for code 90461 since these codes would be billed on a per toxoid basis,” said Kenneth Simon, MD, MBA, Senior Medical Officer, Center for Medicare and AMA CPT Editorial Panel Member, in “Medicare Physician Payment Schedule 2011 Changes and Beyond” at the CPT® and RBRVS 2011 Annual Symposium on Nov. 10, 2010.
The increased PEs represent an increase in RVUs from the 2010 values for comparable codes 90465/90467 and 90466/90468. The RUC requested the increase in value due to increased time for patient education. Since the new codes are valued per component, CMS felt no increase was warranted.
CMS assigned RVUs to 90460 and 90461 by crosswalking them with the values of the noncounseling vaccine administration codes 90471 and 90472. This means that new code 90460 has the same RVUs as 90471, and each unit of 90461 has the same RVUs as 90472.
The work and total RVUs for the codes include:
| Code | PE RVU RUC Proposed | PE RVU MPFS Accepted | Total RVUs |
| 90460 | 0.20 | 0.17 | 0.59 |
| 90461 | 0.16 | 0.15 | 0.3 |
| 90465 | <td width="203"
...
Physicians could feel a little looser on their spending thanks to a hold on the 2011 Medicare Physician Fee Schedule cut. On Nov. 18, the U.S. Senate unanimously consented to halt the Medicare planned conversion factor cut for a 31-day period. The U.S...
Question: Sometimes I cannot find my two-code pair in the CCI edits. How do I know which code would be considered a column 1 code and which would be considered a column 2 code, so that I could put my modifier on the correct code?
Answer: If the codes are not listed, the codes are not bundled per the Correct Coding Initiative (CCI). You would not need a CCI modifier, such as 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), 57 (Decision for surgery), or 59 (Distinct procedural service), to override the edit when appropriate.
A private payer could have a black box edit. You would need to check with a rep for a recommendation.
Watch out: Just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. While you won’t need a CCI modifier to override the edit, you might need apayment modifier.
You can find Medicare’s other allowed modifiers for any given CPT code in the Medicare Physician Fee Schedule (MPFS). Columns Y-AC indicate if modifier 51 (Multiple procedure), 50 (Bilateral procedure), etc. apply.
To determine which code receives modifier 51, you need to know the code’s relative value units, which are also listed in the MPFS. Private payers may not adjust claim items in descending order as Medicare’s Outpatient Code Editor software does. If you append modifier 51 to a higher valued item, the private payer may apply the adjustment based on your coding, costing you payment. You should instead list the items in descending relative value order from highest to lowest. Append modifier 51 to the lower priced procedure as necessary. The insurer will then apply the typical 50 percent,...
Medicare still won’t reimburse audiologist-billed Epley. After two years of battles with CMS over canalith repositioning procedure (CRP) coding, physicians will finally get paid for these specific codes. CPT® 2009 excited ENT coders with new CPT cod...
Forget about digging through the latest Medicare Physician Fee Schedule and calculating the conversion factor when it comes to determining your Part B reimbursement rate for flu shots. CMS has come out with a handy MLN Matters article explaining this i...
Get ready for another year of nail-biting to find out if your Medicare payments will be slashed. “The calendar year 2011 Physician Fee Schedule conversion factor is $25.5217,” notes the 2011 Medicare Physician Fee Schedule Final Rule, printed in th...
You can sit back and enjoy the fall foliage spectacle — SuperCoder.com’s got your ICD-9-CM 2011, National Correct Coding Initiative 16.3, and October Medicare Physician Fee Schedule medical coding updates covered. Go ahead and search for th...
We’ve got the links you need to keep up with these bottom-line changers from HHS, CMS. While most of us were celebrating the last few days the Old Year and preparing to welcome the New Year, the federal regulators had one last, little rulemaking frenzy for 2009. The result is a 555-page proposed rule implementing the [...] Related articles:
And what it means for pediatric practices. A report from AMA in Chicago. Although CPT clarifies the transfer of care definition, the fix came too late for Medicare, meaning your private payers may follow suit. Continued Errors Result in E/M Boon The Office of Inspector General found a high error rate on consultation codes. Different opinions on when [...] Related articles: