You won’t face the same nail-biting payment woes in 2011 as you did this year, thanks to a Senate Finance Committee bill that will freeze Medicare pay at current levels for another 12 months. The House of Representatives passed the Medicare and M...
Get ready to change your flu vaccine product code 90658 to one of four Q codes. For 2010, report 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) to signify that your physici...
Medicare beneficiaries will be thrilled that Medicare will cover annual well checks. The Center for Medicare introduces a new benefit of wellness visits for beneficiaries annually, except during the year of their Welcome to Medicare exam. You’ll use ...
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"
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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,...
When reporting diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity for a Medicare beneficiary in 2011, you’ll use two temporary G codes. Providers were concerned about the different global periods for two t...
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...
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...
All that fine green print on time in your E/M CPT 2011 manual boils down to one thing: you can round to the closest time code. But that advice from CPT contradicts Medicare’s threshold time guideline. CPT Treats Times as Averages CPT 2011 indicates...
Question: A doctor recently told me that appending modifier GY to the refraction code would guarantee payment by a secondary insurer when Medicare denies it. Is this true? Answer: Modifier GY (Item or service statutorily excluded or does not meet the ...
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...
Question: One of our physicians likes to sign everything with just his initials, or sometimes an illegible scrawl. Do we need some type of documentation to support what an auditor might not be able to read? Answer: Yes, you would be wise to keep a sign...
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...