Primary Care Coding Alert

Question: I have tried using special reports 99080 for a Regence Blue Shield report and for a patient letter describing lab results and treatment recommendations. Both times Regence denied the code, stating that 99080 is not a covered benefit. Even though I had the patient sign a waiver prior to charges, the insurer made 99080 a provider write off" and refused to allow me to bill the patient. Do you have any advice on getting the claim paid?

Washington Subscriber Answer: Unfortunately Regence Blue Shield probably adopted Medicare's policy which designates 99080 (Special reports such as insurance forms more than the information conveyed in the usual medical communications or standard reporting form) as a "bundled" service. That means Medicare considers special reports payment included in the other covered services (such as office visits 99201-99215 Office or other outpatient visit for the evaluation and management of a new or established patient ...) and will not separately pay for 99080. For the same reason Medicare also disallows charging 99080 to Medicare beneficiaries.

To deal with Regence's 99080 stance consider the following twofold advice. First you should check your family physician's Regence contract to ensure that the insurer's 99080 ruling is consistent with the contract. Verify that your practice has to follow Regence's directive to contractually write off the special reports' charge. Second don't assume that other payers follow the same rules. Some insurers may cover 99080 and others that  don't cover it may still allow your family physician to charge the patient.

That said you may want to reconsider whether "a letter describing lab results and treatment recommendations" justifies reporting 99080. As noted this code describes "Special reports such as insurance forms more than the information conveyed in the usual medical communications or standard reporting form." Most coding experts consider lab result and treatment recommendation letters as part of "usual medical communications " rather than something over and above that which is 99080's intent.

For instance CPT considers filling out brief standard reports such as return-to-work forms and hospital discharge summaries not separately reportable. "