CMS COVID-19 Response Updated on April 4

CMS COVID-19 Response Updated on April 4

This is an update of the blog Expansion of Telehealth for Medicare Patients during the COVID-19 Emergency – Key Points

With telehealth widely accepted as the gold standard for care to fight COVID-19, the government and payers are adapting their guidelines and policies to meet the new and complex needs of patients and providers. Staying up-to-date with regulatory changes made during the current Public Health Emergency (PHE), as every medical billing company knows, is critical for accurate telehealth billing and coding. In fact, on April 4, 2020, Medicare changed its guidance for billing for professional telehealth distant site services issued on March 31, 2020. Here are the key updates:

Medicare defines telehealth as two-way telecommunications using interactive audio and video that permit real time communication between medical providers and patients. CMS rules for billing professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the PHE are as follows:

    • Place of Service (POS) and Modifier 95

  • Bill with Place of Service (POS) same as what it would have been if the service been furnished in-person.
  • The place of service code would be the location the patient encounter would have occurred, except for the outbreak.
  • If the visit had been in the clinic, POS 11 should be used.
  • If the visit had taken place in an outpatient hospital, POS 19 (Off-Campus Outpatient Hospital) or 22 (On-Campus Outpatient Hospital) should be used as appropriate.
  • A house call doctor that typically sees the patient at their home should bill with POS 12 and use the house visit codes.
  • A physician’s home has to be enrolled when the physician performs telehealth from a home office. The same place of service should be used that the physician would be using should be used if it weren’t for the COVID-19 crisis, i.e., 11 for office can be used as this is where the physician would have before the pandemic.
  • Modifier 95 should be appended, indicating that the service was rendered via a synchronous or real-time audiovisual interaction between a patient and a provider, in which the provider at a distant site provides healthcare services for a patient at a different location.
  • POS 02 should not be used in telehealth. If any service is reported with POS 02 (“Telehealth”) it will be paid at the facility rate under the Medicare physician fee schedule, which is likely to be lower than the corresponding non-facility rate.
    • Medicare Part B – Documentation of E&M Visits via Telehealth

There are new rules for documenting Medicare Part B patient visits done via telehealth:

  • When choosing the code for a telehealth encounter, the level of service will be determined either based on medical decision making (MDM) or time, though the category of EM code (new patient, established patient, subsequent hospital care, etc.) remains unchanged.
  • “Time” is defined as all the time associated with the E/M on the day of the encounter. The current typical times associated with office/outpatient E/M codes in CPT are what should be met for the purposes of level selection (www.aafp.org).
  • Time can be used even if counselling takes place.
  • CMS has retained the current definition of MDM.
  • Neither history nor exam will impact code assignment. All requirements have been removed regarding documentation of history and/or physical exam in the medical record for office/outpatient E/M visit (CPT codes 99201-99215) furnished via Medicare telehealth.
  • Telephone Calls

    CMS allows telephone calls and has finalized payment for telephone codes 99441 to 994443 for physicians, and 98966 to 98968 for nonphysicians during the COVID-19 pandemic. Though the code description states that apply only to established patients, CMS is permitting the use of telephone codes for new patients as well.

  • CS Modifier on Claims relating to COVID-19 Testing Services

    Through the PHE, physicians, other providers, and suppliers that bill Medicare for Part B service should use the CS modifier on claims for COVID-19 testing-related services. Using the CS modifier will identify the service as subject to the cost-sharing wavier for COVID-19 lab tests.

  • Additional Regulatory Relief for Family Physicians:

    • For Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), the services included in Virtual Communication Services (code G0071) have been expanded to cover the services reflected in CPT codes 99421-99423 (Online digital E/M services).
    • Physicians will not be subject to sanctions for routinely reducing or waiving cost sharing for a broad category of non-face-to-face services such as telehealth visits, virtual check-in services, e-visits, monthly remote care management, and monthly remote patient monitoring.

    While the above updates are for Medicare services, private health insurance companies may have their own rules with regards to place of service and modifiers. Additional CMS actions in response to COVID-19 can be expected in the coming days. US based medical billing and coding companies keep track of the updates of government and private payers so that they can help providers submit accurate claims for reimbursement.

Learn the ICD-10 Codes to Document Atherosclerosis

Atherosclerosis is a condition wherein the arteries become clogged with fatty substances called plaque, or atheroma. The condition occurs when the blood vessels that carry oxygen and essential nutrients from your heart to the rest of your body (arteries) become thick and stiff thereby restricting blood flow to your organs and tissues. The condition doesn’t cause any visible symptoms at first. However, many people may not be aware that they suffer from this condition which can lead to severe life-threatening complications such as heart attack and stroke if left untreated. The condition is largely preventable with a healthy lifestyle, and timely treatment. Billing and coding for atherosclerosis can be challenging. Cardiology health practices as well as medical billing and coding companies should stay up-to-date with the latest billing and coding changes along with the associated medical codes and report the right diagnoses codes on their medical claims.

Considered as a slow, progressive disease, atherosclerosis may often begin in childhood and progress with age. Even though the exact cause is unknown, the condition may start with damage or injury to the inner layer of an artery. The damage to the artery may be caused by – high blood pressure, high cholesterol, insulin resistance, obesity or diabetes, high triglycerides, a type of fat (lipid) in your blood, smoking and other sources of tobacco and inflammation from diseases, such as arthritis, lupus or infections.

Unlock the Symptoms

Most symptoms of this condition arise when a blockage occurs. The signs and symptoms of moderate to severe atherosclerosis depend on which arteries are affected. Common symptoms include –

  • Chest pain or angina
  • Weakness or numbness in the face or limbs
  • Vision problems
  • Trouble speaking
  • Shortness of breath
  • Pain in your leg, arm, and anywhere else that has a blocked artery
  • Muscle weakness in your legs from lack of circulation
  • Loss of balance
  • Fatigue
  • Confusion, which occurs if the blockage affects circulation to your brain

Factors that can place people at risk for atherosclerosis include – family history, high blood pressure, diabetes, lack of physical exercise and smoking.

How Is Atherosclerosis Diagnosed and Treated?

Initial diagnosis of this condition will generally consist of medical history evaluation, physical examination and diagnostic test evaluation. Physicians will conduct a detailed physical examination wherein they will check for signs of narrowed, enlarged or hardened arteries, including – weakened pulse, decreased blood pressure in an affected limb, an aneurysm, (abnormal bulging or widening of an artery due to weakness of the arterial wall) and slow wound healing (indicating a restricted blood flow).

Physicians will also conduct blood tests to detect levels of cholesterol and blood sugar that may potentially increase the risk of the condition. A stress test, (also called an exercise stress test), will be performed which monitors your heart rate and blood pressure while you exercise on a treadmill or stationary bicycle. In addition, several diagnostic imaging tests such as – Electrocardiogram (ECG), Doppler ultrasound, Ankle-brachial index, Cardiac catheterization and angiogram, Computerized tomography (CT) scan, Magnetic resonance angiography (MRA) will be conducted to check for any areas of decreased blood flow.

Incorporating positive lifestyle changes such as eating a healthy diet and doing regular physical exercise are considered the most appropriate treatments for atherosclerosis. Sometimes, medication or surgical procedure may be recommended as well. Medications include angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, anti-platelet medications, Beta blocker medications and cholesterol medications. If symptoms are especially severe, or if muscle or skin tissue are endangered surgical procedures may be opted which include – Angioplasty and stent placement, Endarterectomy, Fibrinolytic therapy and Bypass surgery.

Cardiology medical coding involves using the specific ICD-10 codes to show accurate diagnosis of atherosclerosis on your medical claims.

ICD-10 Codes To Use

I70 – Atherosclerosis
I70.0 – Atherosclerosis of aorta
I70.1 – Atherosclerosis of renal artery
I70.2 – Atherosclerosis of native arteries of the extremities

  • I70.20 – Unspecified atherosclerosis of native arteries of extremities
  • I70.21 – Atherosclerosis of native arteries of extremities with intermittent claudication
  • I70.22 – Atherosclerosis of native arteries of extremities with rest pain
  • I70.23 – Atherosclerosis of native arteries of right leg with ulceration
  • I70.24 – Atherosclerosis of native arteries of left leg with ulceration
  • I70.25 – Atherosclerosis of native arteries of other extremities with ulceration
  • I70.26 – Atherosclerosis of native arteries of extremities with gangrene
  • I70.29 – Other atherosclerosis of native arteries of extremities

I70.3 – Atherosclerosis of unspecified type of bypass graft(s) of the extremities

  • I70.30 – Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities
  • I70.31 – Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication
  • I70.32 – Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain
  • I70.33 – Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration
  • I70.34 – Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration
  • I70.35 – Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration
  • I70.36 – Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene
  • I70.39 – Other atherosclerosis of unspecified type of bypass graft(s) of the extremities

I70.4 – Atherosclerosis of autologous vein bypass graft(s) of the extremities

  • I70.40 – Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities
  • I70.41 – Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication
  • I70.42 – Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain
  • I70.43 – Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration
  • I70.44 – Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration
  • I70.45 – Atherosclerosis of autologous vein bypass graft(s) of other extremity with ulceration
  • I70.46 – Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene
  • I70.49 – Other atherosclerosis of autologous vein bypass graft(s) of the extremities

I70.5 – Atherosclerosis of nonautologous biological bypass graft(s) of the extremities

  • I70.50 – Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities
  • I70.51 – Atherosclerosis of nonautologous biological bypass graft(s) of the extremities intermittent claudication
  • I70.52 – Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain
  • I70.53 – Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration
  • I70.54 – Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration
  • I70.55 – Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with ulceration
  • I70.56 – Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene
  • I70.59 – Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities

I70.6 – Atherosclerosis of nonbiological bypass graft(s) of the extremities

  • I70.60 – Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities
  • I70.61 – Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication
  • I70.62 – Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain
  • I70.63 – Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration
  • I70.64 – Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration
  • I70.65 – Atherosclerosis of nonbiological bypass graft(s) of other extremity with ulceration
  • I70.66 – Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene
  • I70.69 – Other atherosclerosis of nonbiological bypass graft(s) of the extremities

I70.7 – Atherosclerosis of other type of bypass graft(s) of the extremities

  • I70.70 – Unspecified atherosclerosis of other type of bypass graft(s) of the extremities
  • I70.71 – Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication
  • I70.72 – Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain
  • I70.73 – Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration
  • I70.74 – Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration
  • I70.75 – Atherosclerosis of other type of bypass graft(s) of other extremity with ulceration
  • I70.76 – Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene
  • I70.79 – Other atherosclerosis of other type of bypass graft(s) of the extremities

I70.8 – Atherosclerosis of other arteries
I70.9 – Other and unspecified atherosclerosis

Incorporating key lifestyle changes can help prevent or slow the progression of atherosclerosis in the long run. Several new steps can be included to limit the risk of plaque buildup which include – regular body exercise, quitting the habit of smoking, maintaining a healthy body weight, eating a healthy diet (that is low in saturated fat and cholesterol), managing stress and treating conditions associated with atherosclerosis, such as hypertension, high cholesterol, and diabetes.

Medical billing and coding for various cardiology conditions and procedures can be complex and requires knowledge regarding appropriate coding, modifiers and payer-specific medical billing. For correct and well-timed medical billing and claims submissions, healthcare practices can outsource their billing and coding tasks to a reliable and professional medical billing company that provides the services of AAPC-certified coding specialists.

Billing and Coding Endoscopic Ultrasound in 2018

Introduced in 1980, endoscopic ultrasound or endoscopic ultrasonography (EUS) is a minimally invasive endoscopic technique. With its expanding diagnostic and therapeutic uses, this unique interventional modality is built into everyday practice in the field of gastroenterology. Payer policies vary and need to be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. Partnering with an experienced gastroenterology medical billing company is a practical option to submit accurate and appropriate claims for the use of EUS.

EUS was initially used to get detailed images of remote organs, such as the pancreas and abdominal lymph nodes. With the advent of fine needle aspiration, the indications for EUS expanded to include tissue sampling for diagnostic purposes. Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNA) is used for obtaining a definite tissue diagnosis from lesions outlined by endosonography. Though not easy to master, EUS-FNA is now a routine therapeutic procedure.

EUS supplements the information obtained with CT or MRI imaging. It is a minimally invasive alternative to various surgical interventions. For instance, using EUS to take needle biopsies from abnormal areas of the pancreas avoids the need for exploratory surgery. This ultrasound technique is used evaluate the following:

  • esophageal and stomach linings
  • upper gastrointestinal tract comprising the esophagus, stomach and duodenum
  • lower gastrointestinal tract including the colon and rectum
  • other organs near the gastrointestinal tract, including the lungs, liver, gall bladder and pancreas

Performed on an outpatient basis, EUS is well-tolerated by most people and may ultimately help in lowering healthcare costs and complications in patients.

While EUS had been primarily limited to identification of pancreatic malignancies, its diagnostic and therapeutic scope has evolved over the years to cover a variety of diseases and indications. According to Mayo Clinic, EUS may help in the assessment of the following conditions:

  • Cancer of the colon, esophagus, lung, pancreas or stomach, and ampullary and rectal cancers
  • Lymphoma
  • Barrett’s esophagus
  • Neuroendocrine tumors
  • Pancreatitis and pancreatic cysts
  • Bile duct stones
  • Sarcoidosis

EUS can be used to:

  • Assess the extent to which a tumor has penetrated the abdominal wall in esophageal, gastric, rectal, pancreatic and lung cancers
  • Establish the stage of cancer
  • Determine if cancer has metastasized to the lymph nodes or other organs
  • Provide precise information to guide treatment of non-small cell lung cancer cells
  • Evaluate abnormal findings from imaging tests (e.g., cysts of the pancreas)
  • Guide drainage of pseudocysts and other abnormal accumulation of fluid in the abdomen
  • Allow precise delivery of medication directly into the pancreas, liver and other organs

2018 CPT Codes for EUS Services

The American Society for Gastrointestinal Endoscopy (ASGE) has developed CPT codes for EUS-related procedures, tests and visits. The work for GI EUS such as supervision and interpretation and guidance for needle placement, supervision and interpretation is bundled into the EUS codes themselves. The EUS CPT codes for 2018 are as follows:

  • 43231 Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination
  • 43232 Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine-needle aspiration/biopsy(s)
  • 43237 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures
  • 43238 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine-needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures)
  • 43240 Esophagogastroduodenoscopy, flexible, transoral; with transmural drainage of pseudocyst (includes placement of transmural drainage catheter[s]/stent[s], when performed, and endoscopic ultrasound, when performed)
  • 43242 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine-needle aspiration/biopsy(s), (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
  • 43253 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s) (eg, anesthetic, neurolytic agent) or fiducial marker(s) (includes endoscopic ultrasound examination limited to the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
  • 43259 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis
  • 44406 Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures
  • 44407 Colonoscopy through stoma with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures
  • 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination
  • 45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine-needle aspiration/biopsy(s)
  • 45391 Colonoscopy, flexible; with endoscopic ultrasound examination, limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures
  • 45392 Colonoscopy, flexible; with transendoscopic ultrasound-guided intramural or transmural fine-needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures)

The ASGE’s code sheet also provides the following summary of upper GI EUS Code distinctions

Visual Endoscopy Extent EUS Extent Code to report EUS/FNA Extent Code to report
Esophagus Esophagus 43231 Esophagus 43232
Esophagus, stomach, duodenum/jejunum Esophagus, stomach, OR duodenum/jejunum 43237 Esophagus, stomach, OR duodenum/jejunum 43238
Esophagus, stomach, duodenum/jejunum Esophagus, stomach, AND duodenum/jejunum 43259 Esophagus, stomach, AND duodenum/jejunum 43242

Moderate Sedation and Anesthesia Codes

Starting January 1, 2017, moderate sedation was removed from the relative value units (RVUs) for gastrointestinal endoscopy services. If moderate (conscious) sedation is provided when performing GI procedures, moderate sedation should be billed separately using appropriate moderate sedation HCPCS code(s): 99151, 99152, +99153, 99155, 99156, +99157 and G0500. Failure to do so will result in loss of reimbursement for these services.

In 2018, five codes were added for anesthesia for gastro-endoscopic procedures and three low-volume codes (01180, 01190, and 01682)were deleted. The five new CPT codes are:

  • 00731 – Anesthesia Upper GI Endoscopy (EGD, EUS, Enteroscopy, Secretin Stimulation Test)
  • 00732 – Anesthesia Upper GI Endoscopy (ERCP)
  • 00811 – Anesthesia Lower GI Endoscopy (Colonoscopy, Ileoscopy)
  • 00812 – Anesthesia Lower GI Endoscopy (screening colonoscopy)
  • 00813 – Anesthesia for combined upper and lower GI Endoscopic procedures.
  • 00813 – Anesthesia for combined upper and lower GI Endoscopic procedures

Actual reimbursement for gastroenterology procedures will vary for each provider/institution based on factors such as geographic differences in labor and non-labor costs, hospital teaching status, and/or proportion of low-income patients. Experienced medical billing and coding company help practices can ensure fair and reasonable reimbursement by reporting EUS with the appropriate codes and in accordance with individual payer policies.

Reporting Psoriasis Diagnosis and Management

Dermatology is a more complex specialty than many others when it comes to reporting diagnosis and management, and many providers rely on medical coding and billing outsourcing companies to do so. According to the National Psoriasis Foundation, psoriasis is the most prevalent autoimmune disease in the U.S. and affects about 7.5 million Americans. Phototherapy is considered one the safest and most cost-effective treatments for psoriasis and many other skin conditions. Proper documentation and complete and compliant coding is critical to quality reporting and provider reimbursement.

About Psoriasis

A chronic skin disease, psoriasis affects multiple body systems, and mainly the skin and the joints. It causes rapid buildup of skin cells which result in scaling on the surface of the skin. Common symptoms include inflammation and redness around the scales. Psoriatic scales may progress into thick, red patches and in some cases, the patches will crack and bleed. Psoriasis can affect the hands, feet, face and/or genital regions. The severity of psoriasis depends how much body surface area and which body parts are affected. Severe skin disease can make daily living difficult and impact quality of life.

Psoriasis presents in different ways, with psoriasis vulgaris being the most common form. Other subtypes of this disease include flexural psoriasis, guttate psoriasis, erythrodermic psoriasis, generalized pustular psoriasis, palmoplantar psoriasis, and psoriasis that affects specific body sites such as the scalp and nails.

Treating Psoriasis

Several conventional treatment modalities are used to treat psoriasis such as:

  • topical application of steroids or other drugs
  • ultraviolet light (actinotherapy)
  • coal tar alone or in combination with ultraviolet Blight (Goeckerman treatment)
  • Vitamin D analogues (e.g., calcipotriol and calcitriol), tazarotene, and anthralin.

A newer treatment is psoralen derivative drug in combination with ultraviolet light or PUVA therapy. The American Academy of Dermatology does not support phototherapy for patients with mild localized psoriasis whose disease can be controlled with topical medications.

ICD-10 Coding for Psoriasis

Compared to ICD-9, the ICD-10 codes for psoriasis are driven by increased specificity. While 696.1 was only code in ICD-9, there are multiple ICD-10 codes for psoriasis and its numerous subtypes under the category L40, that is:

Primary category: L (0-99, for diseases of the skin and subcutaneous tissue)
2-digit category: 40 (Psoriasis)

  • L40.0 Psoriasis vulgaris
  • L40.1 Generalized pustular psoriasis
  • L40.2 Acrodermatitis continua
  • L40.3 Pustulosispalmariserplantaris
  • L40.4 Guttate psoriasis
  • L40.5 Psoriasis, other
  • L40.50 Arthropathic psoriasis, unspecified
  • L40.51 Distal interphalangeal psoriatic arthropathy
  • L40.52 Psoriatic arthritis mutilans
  • L40.53 Psoriatic spondylitis
  • L40.54 Psoriatic juvenile arthropathy
  • L40.59 Other psoriatic arthropathy
  • L40.8 Other psoriasis
  • L40.9 Psoriasis, unspecified
  • L41 Parapsoriasis
  • L41.0 Pityriasislichenoidesetvarioliformisacuta
  • L41.1 Pityriasislichenoideschronica
  • L41.3 Small plaque parapsoriasis
  • L41.4 Large plaque parapsoriasis
  • L41.5 Retiformparapsoriasis
  • L41.8 Otherparapsoriasis
  • L41.9 Parapsoriasis, unspecified

CPT Codes for Phototherapy

According to an article published in MDedge in July 2017, phototherapy is one of the safest and most cost-effective treatments for psoriasis and other dermatoses. Both UVA and UVB light could help in reducing symptoms of mild to moderate psoriasis. Insurers may provide coverage for PUVA used to treat intractable, disabling psoriasis, on the condition that the psoriasis has not responded to more conventional treatment. Providers who offer phototherapy services for psoriasis should know payer policies and the relevant CPT codes. The MDedge report lists the CPT codes for reporting phototherapy services as follows:

  • 96900 Actinotherapy (UV light treatment)
  • 96910 Photochemotherapy, tar, and UVB (Goeckerman treatment) or petrolatum and UVB
  • 96912 Photochemotherapy and PUVA
  • 96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsivedermatoses requiring at least 4 to 8 hours of care under direct supervision of the physician

Points to Note when Reporting Phototherapy Services for Psoriasis

  • The MDedge article highlights that actinotherapy (96900) defines the basic service of treating a patient with a UV light unit, and does not involve application of topical medications while the patient is in the office.
  • On the other hand, as a www.daavlin.com report points out, photochemotherapy (96910) and photochemotherapy and PUVA (96912) mean that the light treatments are given in conjunction with mineral oil, tar or the photosensitizing drug, Psoralen. According to the MDedge report, if the application of topical photo enhancing products occurs outside the office, the requirements of photochemotherapy are not met, and 96900 should be reported.
  • When billing 96910, the documentation should include a contemporaneous note stating that mineral oil was applied with the direct involvement of a clinical staff member. The staff member should be identified in the note. “Contemporaneous” means that the provider should document this each and every time a treatment is given.
  • Code 96913 code defines prolonged phototherapy service with intensive topical therapy requirements and multiple phototherapy sessions per day.
  • Providers have specific coverage rules. For instance, Blue Cross Blue Shield BCBS) of North Carolina may consider PUVA as medically necessary for the treatment of Severe, disabling psoriasis, which is not responsive to other forms of conservative therapy (e.g., topical corticosteroids, coal/tar preparations, and ultraviolet light). BCBS of North Carolina also states that they may consider targeted phototherapy as medically necessary for the treatment of the following conditions:
    • Moderate to severe psoriasis (comprising less than 20% body area) for which NB-UVBor PUVA are indicated
    • Mild to moderate localized psoriasis that is unresponsive to conservative treatment
      BCBS of North Carolina considers targeted phototherapy as investigational for conditions not addressed as medically necessary, for e.g., first-line treatment of mild psoriasis and generalized psoriasis or psoriatic arthritis.
  • For Medicare Plan members, providers should reference the Applicable National Coverage Determinations(NCD) and Local Coverage Determinations (LCD) and ensure where applicable.

Private insurer as well as Medicare audits of medical records for phototherapy services has increased. Detailed and accurate documentation is necessary to avoid scrutiny. Partnering with an experienced dermatology medical billing and coding company can help ensure error-free reporting of phototherapy services for psoriasis for optimal reimbursement.

Key Considerations in Billing and Coding Spine Procedures

Mastering medical language is a must when it comes to medical coding and billing. As physicians use precise medical terminology to communicate their observations and prescriptions, medical coders and billing staff should be knowledgeable about these terms to be able to report diagnoses and procedures performed to third-party payers for accurate reimbursement. Coding spine surgeries is a challenging process, but professional coders in medical billing and coding companies can assign the appropriate codes to describe services delivered as they have a proper understanding of the spinal anatomy and terminology.

To assign the correct codes for spinal procedures, expert coders will examine the documentation to ensure that it supports the following items:

  • Location: cervical, thoracic, lumbar or sacral (the 33 vertebrae are classified as 7 cervical: C1-C7; 12 thoracic: T1-T12; 5 lumbar: L1-L5; 5 Sacral, and 4 Coccygeal vertebrae
  • Approach: anterior, posterior or lateral extracavity, or percutaneous
  • Pathology: what was done and medical indication (decompression, disc-ectomy, corpectomy, arthrodesis)
  • Bone grafting: allograft or autograft
  • Instrumentation: rods, screws or cages
  • Implants used

Here are some important considerations when reporting spinal procedures:

  • Code assignment requires knowledge of spine anatomy: Correct CPT and ICD coding would depend on identifying which portion of the spine the physician is working to determine the approach used and level assignment for a particular procedure, according to a Beckers ASC Review report.
    For example, take spinal fusion (arthrodesis). The location reflects the level of the vertebrae (cervical, thoracic, lumbar and/or sacral) and the number of vertebral joints fused. While ICD-10 codes can reflect the complexity of the procedures performed, correct ICD coding depends on knowing:

    • The information required to accurately assign the characters of a spinal fusion procedure code.
    • The procedures that are considered integral to the fusion and assigned separate codes and those are not integral to the fusion and not assigned additional codes.
    • The number of fusion codes to assign (this depends on how many levels were fused).

    A recent AAPC blog explains how to code the spinal fusion procedure. As fusion is the merging of adjacent parts, the standalone CPT code for the fusion (synonymous with “arthrodesis,” or the joining of two or more vertebrae) should be assigned. For a single fusion segment that involves adjacent vertebral segments L4 and L5, the appropriate CPT code is:
    22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed
    If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that used a different device and/or qualifier. For e.g.:

    • Fusion of lumbar vertebral joint, posterior approach, anterior column
    • Fusion of lumbar vertebral joint, posterior approach, posterior column

    Therefore, to assign the appropriate CPT and ICD-10 codes, the medical coding service provider should obtain proper and accurate information from the surgeon.

    Point to note: Code 22551 should be used for the 1st level of fusion and discectomy performed and add-on code 22552 for subsequent levels. The following codes are valid when only individual procedures are performed and not combined:

    22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2) with the separate anterior cervical discectomy/decompression code

    63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace).

  • Use standalone codes to describe decompression surgery/discectomy: Spinal decompression surgery can be performed anywhere along the spine from the neck. It involves the removal of the spinal disc, bone, or tissue causing pressure and pain. This may be the only procedure performed. Examples:

    Laminectomy to decompress spinal canal and/or nerve roots: CPT codes 63001-63017, 63045-+63048
    Discectomy to decompress spinal canal and/or nerve roots: 63020-+63035, 63040-+63044, 63055-+63057
    Corpectomy: 63081-+63091 (To use these codes, the documentation also should reflect removal of at least 50 percent of the cervical vertebral body, or 33 percent of the thoracic and lumbar vertebral bodies)

    Fracture repair: 22325-+22328The coder should examine the operative report to:

    • Identify the presenting diagnosis
    • Identify which decompression/discectomy activity was performed
    • Identify whether the approach was posterior or anterior
    • Assign the appropriate standalone code and any associated add-on codes

    Point to note: The presenting diagnosis will determine the code when both lumbar discectomy and decompression are performed on the patient. Beckers ASC Review recommends coding a discectomy if the presenting diagnosis is disc herniation, and a decompression if the presenting diagnosis is spinal stenosis.

  • Code for all levels of spinal decompression: The Beckers ASC Review report recommends careful review of the operative report to understand how many nerve roots or levels were decompressed in order to code for all appropriate levels.
  • Include the appropriate add-on bone graft code with fusion: The work of placing the bone graft is included in the arthrodesis/fusion codes and a bone graft code should be included when a fusion is performed. The coder has to examine the operative report to determine:
    • whether the bone graft was an allograft or an autograft, and
    • whether it was a morselized (bits or pieces) or structural (wedge or chunk) bone

    Bone graft codes commonly-used add-on in spine surgery include:

    • Allograft (donor bone): +20930 (morselized), 20931 (structural)
    • Autograft (patient’s bone): +20936, +20937 (morselized), +20938 (structural)
  • Determine if hardware or instrumentation was used: The operative note should mention whether instrumentation was used in the fusion or not; if yes, where the instrument was used, and whether it was non-segmental, segmental, or intervertebral. Knowledge about the following is necessary to code instrumentation code correctly:
    • If the spacer is made from titanium, PEEK or bone
    • If the surgeon used a standalone cage (includes built-in hardware to anchor the device)
    • Whether the implant has a separate plate and screws (these require additional CPT codes)
    • Whether it is a first-time implant, removal or revision surgery.

    The relevant CPT codes in this context are:

    Non-segmental instrumentation (+22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure))
    Segmental instrumentation (+22842-+22844) as “fixation at each end of the construct and at least one additional interposed bony attachment,” meaning at least three points of attachment on the spine
    Anterior instrumentation codes (+22845-+22847) are based on the number of vertebral segments the hardware (typically, a plate) spans
    Intervertebral instrumentation (+22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)) is any synthetic device, not considered a bone graft. +22851 is reported per interspace, or per vertebral defect, not by the number of devices placed in the interspace

    Point to note: AAPC cautions that as instrumentation codes are add-on codes, they should not be reported with modifier 62.

For proper CPT code assignment for spinal procedures, the operative note has to support the CPT code selection as well as postoperative diagnosis. The operative note should also support medical necessity for a given procedure or service. Partnering with a medical coding company with a team of experienced AAPC-certified coders who stay updated on the latest billing and coding guidelines, as well as changes in payers’ rules can drive accurate and timely submission of claims and optimal reimbursement.

Billing and Coding Laboratory Panels and Their Components

Health insurance companies reimburse clinical laboratories and hospital laboratories for microbiological, serological, chemical, hematological, biophysical, radiobioassay, cytological, immunohematological, immunological, pathological, or other examinations that provide information for evaluating a medical condition or for the diagnosis, prevention, or treatment of any disease. Laboratory panels or chemistry panels are groups of tests that are ordered together for a specified member on a specified day. Experienced coders in medical coding companies are well-versed about the billing guidelines and codes for laboratory panel procedures as well as individual component procedures.

Common Chemistry Panels

  • Basic Metabolic Panel (BMP) – tests that measure blood sugar (glucose) levels, electrolyte and fluid balance, and provide information about kidney function, respiratory function and liver function.
  • Comprehensive Metabolic Panel (CMP) – provides the same information as the BMP as well as the status of the liver and key blood proteins.
  • Electrolyte Panel – for detecting a problem with the body’s fluid and electrolyte balance.
  • Lipid Profile – to assess the risk of developing cardiovascular disease.
  • Hepatic Function Panel or Liver Panel – to screen for, detect, evaluate, and monitor acute and chronic liver inflammation (hepatitis), liver disease and/or damage.
  • Renal Panel or Kidney Function Panel – includes tests to evaluate kidney function, such as albumin, creatinine, BUN, eGFR.
  • Thyroid Function Panel – to assess thyroid gland function and help diagnose thyroid disorders.

Reporting Clinical Laboratory Panels – Points to Note

According to CPT, “…panels were developed for coding purposes only and should not be interpreted as clinical parameters. The test are listed with each panel identify the defined components of the panel. These panel components are not intended to limit the performance of other test. If one performs tests in addition to those specifically indicated for a particular panel, those tests should be reported separately in addition to the panel code”.

  •  Lab panel tests are the group of tests designated as a panel by the latest CPT version of the American Medical Association (AMA).
  • Providers may bill either a panel code or an individual code.
  • Each panel code comprises multiple tests.
  • The panel code should be reported when all individual components in the panel have been performed.
  • The code or codes to describe the individual tests performed should be reported if any test defined as part of the panel is not performed.
  • Two or more panel codes that include any of the same constituent tests performed from the same patient collection should not be reported.
  • If a group of tests overlaps two or more panels, the panel that incorporates the greater number of tests to fulfill the code definition should be reported and the remaining tests should be reported using individual test codes.
  • Each test billed under the panel must be reasonable and necessary.

Reimbursement would depend on the number of tests billed on the same day, by the same provider, for the same beneficiary.

Laboratories should document the verbal communication from physician or other qualified practitioner regarding the treating physician or practitioner intent for the test. The date the service was performed should be stated in the patient’s record. Labs should also maintain all patient medical records supporting test as reasonable and necessary.

2017 Laboratory Panel CPT Codes

Here are the CPT codes for laboratory panels and their components:

80047 Basic metabolic panel (Calcium, ionized). Components: Calcium, ionized (82330); Carbon dioxide (bicarbonate) (82374); Chloride (82435); Creatinine (82565); Glucose (82947); Potassium (84132); Sodium (84295), and Urea Nitrogen (BUN) (84520).

80048 Basic metabolic panel (Calcium total): This panel includes the following components: Calcium; total (82310), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), Sodium (84295), and Urea nitrogen (BUN) (84520).

80050 General health panel: The components of this panel include the following: Comprehensive metabolic panel (80053); Thyroid stimulating hormone (TSH) (84443); Plus one of the following CBC or combination of CBC components: 85025 Blood count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count, 85027 + 85004 Blood count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count and Blood count; automated differential WBC count; 85027 + 85007 Blood count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count and Blood count; blood smear, microscopic examination with manual differential WBC count; 85027 + 85009: Blood count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count, and Blood count; manual differential WBC count, buffy coat.

80051 Electrolyte panel: This panel must include the following: Carbon dioxide (bicarbonate) (82374) Chloride (82435) Potassium (84132) Sodium (84295).

80053 Comprehensive metabolic panel: This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520).

80069 Renal function panel: This panel must include the following: Albumin (82040) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus inorganic (phosphate) (84100) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520).

80074 Acute hepatitis panel: This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsAg) (87340) Hepatitis C antibody (86803).

80076 Hepatic function panel: This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT).

80081 Obstetric panel(includes HIV testing) Components: Hepatitis B surface antigen (HbsAg) (87340); HIV-1 antigen(s) with HIV-1 & HIV-2 antibodies, single result (87389) Antibody, rubella (86762); Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPE, ART) (86592); Antibody screen, RBC, each serum technique (86850); Blood typing ABO (86900); Blood typing, Rh (D) (86901) Plus one of the following CBC or combination of CBC components: Blood count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count (85025); Blood count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count and Blood count; automated differential WBC count (85027 + 85004); Blood count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count and Blood count; blood smear, microscopic examination with manual differential WBC count (85027 + 85007); Blood count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count and Blood count; manual differential WBC count, buffy coat (85027 + 85009).

Laboratory Modifiers

90 Reference lab; used to indicate a lab test was sent to a referral (outside) lab

91 Repeat clinical diagnostic laboratory test; used to report laboratory tests performed more than once on the same date to obtain subsequent, multiple test results. This modifier is not to be used when test is repeated due to specimen mishandling, insufficient sampling or re-confirmation.

92 Alternative laboratory platform testing; When lab testing is performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code.

26 Professional component; used with CMS identified codes with separate professional and technical components.

TC Technical component; used with CMS identified codes with separate professional and technical components.

QP Panel test Documentation on file showing laboratory test(s) was ordered individually or ordered as a CPT recognized panel other than automated profile codes 80002-80019, G0058, G0059, and G0060.

Medical billing and coding companies are up to date on the guidelines pertaining to reporting screening diagnosis codes as well as choosing the codes to bill lab tests. Moreover, they will contact insurance carriers and employer groups to get clear and concise information when billing and coding for screening blood tests. Their support can be invaluable to ensure proper reimbursement for laboratory panel procedures and individual component procedures.