# Tdap shot for Medicare



## henimercer

Hello,

I work as a coder/biller for an Internal Medicine practice.
When I bill Medicare for Tdap I get paid for the administration and I get a denial that the patient's is not covered for the drug. Per the EOB the patient is responsible but as I am reading an article we should use the GA modifier to let Medicare know that we got a signed ABN and then bill the patient?

I have never used this modifier before and I just want to know if should...
(We do get the ABN's from the patients.)

If I need to should it look like this:

exp:
99213-25    (401.1)
90471        (V06.1)
90718 - GA (V06.1)

Thank you for the help,


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## Pam Brooks

Use the -GX modifier.  That tells Medicare that you voluntarily obtained an ABN for a service that you know will be categorically denied (such as certain preventive services, which this is).  Here's the MLM article:  http://www.cms.gov/mlnmattersarticles/downloads/MM6563.pdf

The GA is used when you are required to obtain an ABN for services that may be non-covered. Since the Td (as a prophylactic injection) is never covered by CMS, an ABN is not required. Confusing stuff.  

I've never put a -25 on an OV with an injection, but maybe your local carrier wants it? In this case, since the injections are categorically non covered, I don't see why you'd need it.   The -GX is to be appended to all services that are patient liability when an ABN has been obtained, so I'd append it to both the 90471 and the 90718.


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## henimercer

Hello Pam,

Thank you so much for responding. Usually I just read the threads and then I figure things out for myself. 
I just read this article yesterday and I wanted some clarification on it as I have never used the GA or the new GX modifiers before.

When I started working here over a year ago straight out of school (CPC) I was blessed enough to get this position and so lucky to start coding immediately. I was kind of taking over and followed the footsteps of what and how things were done here.

I have been billing every E/M visit with a 25 modifier if I add a procedure with it. I was worried myself because of "unbundling" but I never really questioned her and now that you mentioned it... maybe I was right to question myself...
In an Internal Medicine setting where I work we do a lot of PT/INR, U/A, BMP, Electrolyte, EKG and such and if you don't mind me asking what I understand... I should never use modifier 25 on the E/M just pile up the procedures behind it? I also got a feedback from an consultant company recently that between lab works (CPT 8xxxxx ) U/A, BMP, etc I don't even need to use the 59 modifier if I bill Medicare...

I feel a little bit that my world is shattered because I have been doing otherwise and always got paid. Could it be that I was not supposed to use modifier 25 and 59 and later on they could recoup their payments or we could even flag ourselves for auditing because of this? How can I find out if our local carrier requires it? 

Any input is greatly appreciated...

Thanks,


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## Pam Brooks

Office visits done at the same time as minor procedures are typically bundled. The RVUs for minor procedures includes the pre- and post-procedural work that is similar to an E&M, so you would not bill both, unless the E&M is for a separately identifiable problem, or significant additional work for the same problem outside what is normally done at the same time as the procedure. For example, if your provider schedules and sees a patient specifically for a lesion removal, it would not be appropriate to bill anything other than the removal. Adding an E&M with a -25 modifier is unbundling. But if at the same time the patient reports a new URI, for example, then you'd carve out any documentation relative to the lesion removal and bill the appropriate LOS for the medically necessary components relative to the URI. Significant additional work for the same condition is very difficult to support. And, payer rules vary. All payers have coding guidelines online, so you can typically get the information you need relative to correct coding and medical necessity. 

The -59 is to be reported only when you are doing two or more procedures that normally wouldn't be done at the same session, to identify them as different or separate from the primary procedure. You wouldn't add it to a single procedure with an E&M. Procedures and office labs are not the same thing, and often require differerent modifiers (or none at all). 

You're getting paid because your use of the modifiers is bypassing payer edits. Using the -25 tells the payer, "look, pay me for this additional E&M service, because I affirm that it meets the guidelines for a separately identifiable service". Overuse of modifiers can trigger an audit, but even if you aren't audited and you identified that you've billed inappropriately, you are obligated to return the money. 

It might be worth it for you to do some investigation, first with your local carrier, and then with your commercial payers. There is a lot of regulatory guidance out there...CCI edits, E&M billing guidelines, and MedLearn Matters articles provided so that we all can learn how to code and bill appropriately. I'm not saying that you've billed inappropriately, but I think there's enough question in your mind that you might want to take a closer look. I encourage you to spend a lot of time on your local carrier's website. 

It's hard being in a position where you are expected to do everything "how it's always been done", but as a certified coder, you have the understanding of how to research correct coding processes and the obligation to keep you providers out of hot water.


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## henimercer

Thanks for your input Pam, I really appreciate your trying to guide me!!!

We don't do procedures... they are mostly tests. 
As we were thought in school and also my understanding is that 59 would be appropriate if you do several test or shots. For evey test or shot I use a different ICD-9 at all times, whatever the provider would order it for. I would have used the modifier 59 on my own without being told that is how they have been doing it here. I am quite sure that that is appropriate.

I am more worried about the modifier 25 (unbundling)... I will do a test run I guess... 
I will not use the 25 when I will add test to the claims with the E/M and check back with the claim if it was paid that way. It would make ME feel more comfortable to know that I am not using this modifier as I knew that this could trigger an audit.

These test are not included in the sick visit and separately identifiable as necessary to do for the provider to get a dx. That is the reason I was told to use it at my new position and I thought that was the right way to do. As time went by and I did bill many tests a day that kind of made me curious that other practices would use the 25 as often as I do? Is that completely normal for a practices?  We have CLIA waved tests in the office for quicker diagnosis and accessibility and we do want to get paid and bundling would not be appropriate. We only do it as we as internal medicine wanted to have these tests available to our patients so we could treat them immediately as the results are here quickly. As a coder I am expected to make sure that we would get paid for these test and follow the medical necessity guidelines. Which I do... but none of the *insurance* *websites* would tell you if you need a modifier 25 on your E/M. Or even if I would *call the insurance companies.* They NEVER tell me how it should have been done, they just tell me it was denied for CPT or ICD-9. Sometimes I feel that we as coders are in a maze and there are no maps to find the right way, wherever you want to go... 
You just go by experience (hit and miss) and maybe help from other coders who have maybe using certain codes and they get paid. 

I will admit that I have never used the NCCI edits and even though I was searching for some help online... I wasn't able to even locate it. I guess maybe I will reach out to some help on forums if for some reason I won't be able to get to it myself.
I am resourceful enough to seach online for whatever I need... Most of the time I find guidelines, medical necessity (ICD-9 list). Sometimes I even get help for certain senarios about coding. Unfortunately not always and not for everything.

I was wondering, how did you navigate in the "deep water" when you started coding? Did you have a mentor at work who showed you things? Or researched like myself? 
I wish that our local chapter would be more beneficial to me. We are in a small town here in North Carolina and nobody has a job as a coder... maybe 3 out of 15 who are working as a coder? They don't do the same things we do so I have zero networking opportunity locally. 

I am so sorry... I am just going on and on...
I just wanted to thank you for your input and also just tell you what we do and why I do what I do...

Heni


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## Pam Brooks

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html

Here are the CCI edits. 

We never use the -59 when billing out multiple labs (use -91 for a repeat lab) or multiple vaccinations.  The payers do understand that you're going to do multiple immunizations on the same day (hence the 90472). 

Although we all understand that medicine is a business, we have to be careful to not manipulate our coding/billing just to get paid.  Sometimes services are just not billable, and some are simply not covered, which is patient responsibility.  Learning the difference takes practice and experience, but you're on the right track by identifiying that more information is needed.  

I've found the most information from our local Medicare carrier's website, and also from AAPC coding webinars, workshops and seminars I've attended over the years.  External auditors and consultants can be helpful as well, just make sure that they can back up their recommendations with regulatory guidance. Not every scenario has regulatory guidance, and that's when you depend on ICD-9 and CPT guidelines.  Also, check out the websites for AAFP (American Academy of Family Practitioner) www.aafp.org and American College of Physicians www.acponline.org.  Both have lots of coding information.  


How did I learn?  Trial and error, mistakes, continuing education and blind luck.  I'm fortunate that I work with a team of coders who know what they're doing, and can point out areas of concern and changes that come across.  If you are at all able, get yourself to the national conference in Orlando. Not only are the workshops outstanding, but you can share breakfast and lunch (and after-hours) with other coders who can give you advice and suggestions on how to navigate this ever-changing business.


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## henimercer

Thanks for that Pam... I will check out the CCI Edits as soon as I can. :

I've billed Medicare and Tricare without the 25 and 59 and they both paid. 
I was having a conversation about this with my supervisor today.
I told her that I rather not use the 25 if I don't need to. She said that she would agree with this if the primary dx on the E/M and the test would be the same. 
But she said that when the primary dx is not related to the test(s) we are doing we have to use the 25 to make sure that we let the insurance carrier know that the tests were done and appropriate ICD-9's were given to each tests to prove medical necessity for that particular symptom.
My supervisor was more concerned that in a way if I would not use the 25 in these scenarios the monies could be recouped and that would be more harmful to the practice.
Would you agree with below scenario?                                           

*Problem focused, I didn't use mod 25.
**99213  *           Flank Pain 724.2                 
81003QW        Urinary Frequency 788.41
                      UTI

*Several dx, I used mod 25.   * 
*99214-25   *      HTN 401.1                             
81003QW        Urinary frequency 788.41                   
87880QW        Throat pain 784.1  

I promise I won't bother you with more questions about this... I was just wondering if in the above scenario you would agree with the billing or not. More importantly that you would use the modifier 25 if I have several dx and I would use different ICD-9's for different test?

I am going to look up these websites you suggested and also try to attend more webinars, seminars in the future. I am very invested in my carrier and I enjoy the challenges it brings me...  It is nice to talk to somebody who has gone through the same obsticals and willing to listen and give advise.

Have a great day and I am looking forward hearing from you,

Heni


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## Pam Brooks

I agree with your first example.

For your second example, I still would not append the -25.  In my mind, you're much more likely to have payer issues and recoupments from overuse of the -25 than you are from underuse, so I really do disagree with that line of thought. By reporting separate diags that are medically necessary in relation to the visit and labs ordered, you're indicating the reason for the lab is different than the reason for the OV.  That alone identifies the separation of services, and the -25 is moot.  I double checked with my Medicare billers and although we do not append the -25 on an E&M with office labs,  we get paid.  Perhaps your local carriers have different rules, so I'd encourage you to reach out to your specific provider representative and ask them about their claim edits.


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