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    Wiki MA Performing Physical Exam via Telehealth

    I think it's valid concern and an important question you're asking here, but I don't think you are going to find much in the way of written guidance in the addressing this in the coding and billing areas. It's understood for telehealth services that the provider is going to have to rely on the...
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    Wiki Patient on phone, representative in office

    As a general rule, you will code the claim based on the location of the individual who is receiving the services. If the patient is the one being evaluated and treated by the physician, then code and bill based on the patient's location. The location of the representative is not relevant if...
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    Wiki Medicare Private Contract

    I'm not an attorney so can't give legal advice, but it's been my understanding the laws would apply to all Medicare beneficiaries, so you would need to have the contract for any patient who is eligible for Medicare, whether or not they are enrolled in an Advantage plan.
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    Wiki T10-11 fracture

    OK, I see what you're saying. But those codes aren't for reporting two fractures - it just happens to be the case that in those other cases the two different vertebrae are reported with the same code. In your case, you have a T10 and a T11 fracture, which are reported with different codes...
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    Wiki Initial or Subsequent Code?

    To start with, your question is rather confusing because it sounds like you're talking about new vs. established, not initial vs. subsequent? Initial and subsequent terminology only applies to hospital visit codes during a given admission. If you're asking if the clinic visit should be new...
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    Wiki T10-11 fracture

    I agree, if there are two fractured bones, you'd use two separate diagnosis codes. Not sure what code range your looking at, but each vertebra has its own codes for traumatic fractures.
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    Wiki Cardiology

    These are two different conditions - neither one is more or less specific than the other. If the documentation indicates that the patient has both, then I would code both.
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    Wiki Hyperlipedemia

    Z13.220 is a screening code, for use with a test done for early detection of disease in a patient without symptoms or a known condition. If the patient is getting the test because they already have a diagnosis of hyperlipidemia, it would not be appropriate to use the screening code.
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    Wiki Internal Med vs Family practice

    These are definitely two different specialties. On the Medicare enrollment forms, the provider would identify one or the other as their primary specialty. Other payers may follow different rules, of course, for example if both providers are fulfilling the role of a primary care physician. But...
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    Wiki ultrasound codes for OB

    The Z3A codes are for additional information, so they would never be used as the primary code since they do not indicate a reason for an encounter. You can list them anywhere else - the order is not important beyond the first diagnosis code which needs to be your condition that is 'chiefly...
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    Wiki Adding new therapist issues

    I would agree, if the therapist is acting independently at that location and it's not under the management of your organization, then it's not a part of your practice and shouldn't be credentialed as one of your locations with your payers.
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    Wiki SELF PAY CT

    Is your provider contracted or not? If yes, then, they cannot do this. If no, then, I believe that it would be OK as long as you get something in writing from the patient in advance. But I’d caution that you are asking a compliance question here that could have legal ramifications for your...
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    Wiki Non DRG inpatient labor and delivery billing

    I think that this is a question that your hospital is going to have to answer for you. Most facilities would charge their drugs separately, but it’s possible that some would already figure the service charge to be including them. Regarding the revenue codes and units you should also follow your...
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    Wiki SELF PAY CT

    It really depends on what insurance the patient has and also whether or not the provider has a contract with that insurance. For example, if the patient has Medicare, the provider can only do this if they have opted out of Medicare and make a contractual agreement with the patient. On the other...
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    Wiki Anesthesia Billing

    No, nerve blocks are only subject to multiple procedure reductions when performed on the same date as another surgical procedure done by the same provider. Anesthesia is not considered a surgical procedure for purposes of calculating reductions.
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    Wiki HPV denials for adults

    Z23 is correct unless the vaccine is being given to treat an existing illness or known exposure. What reason are they giving you for the denial? Many denials have nothing to do with the way you are coding and billing. It’s possible that the patient just doesn’t have this benefit from their plan.
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    Wiki ultrasound codes for OB

    I'd refer you here to section IV.G of the ICD-10 guidelines: List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any...
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    Wiki HLA-B27 positive

    You cannot assign a code from a laboratory test result, you would need to have the treating physician document their interpretation of what this result means for the patient and use that wording to assign the diagnosis code. I would not use R76.8 unless the provider has specifically documented...
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    Wiki Date of death prior to completion of 90 day monitoring

    This same question was asked a few months ago here on the forum. I don't think that there is any way to bill this that will bypass the Medicare edits. Your only option, as I see it, is to file a written appeal explaining the situation and see if that might work. My suspicion is that the...
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    Wiki Assistant Surgeon Billing for NPs

    I believe this must be an error in the AAPC article. I've only ever coded, or seen coded, non-physician assistant-at-surgery claims with just the AS modifier, not with both modifiers. I've never worked with a practice that used both modifiers AS and 80 together on the same claim, and never...
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    Wiki Is there a non-3M way to group APR-DRGs?

    I believe that the APR-DRG methodology is copyrighted by 3M so you would not (legally) be able to use it without some kind of license arrangement with the owner. However, it shouldn't be necessary to purchase the entire 3M encoder to get access to just the APR-DRG grouper. 3M offers other...
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    Wiki Coding for Self Pay patients

    There are no 'PCS coding charges'. The PCS are just codes that identify on the claim form what procedures were performed during an inpatient stay. They have nothing to do with charges. The presence of a PCS code might change the DRG (which in turn might change the reimbursement), but it...
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    Wiki Inpatient E&M question - Subsequent visit with 25 modifier on day of scope??

    You're welcome. I appreciate the difficulty and have been in that situation. It's always hard when one coder has been generous in allowing physician to bill something and then another coder has to come in an explain why it's being taken away. No fun. Hopefully you will have some support from...
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    Wiki Inpatient E&M question - Subsequent visit with 25 modifier on day of scope??

    Well, as you correctly state, the E/M with the modifier is only appropriate if the documentation supports it. I have not coded as many of this particular kind of chart as yo have, and don't know how your particular providers are documenting anyway. Without seeing the charts you're looking at...
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    Wiki Surgical Pathology/Modifier 52

    I don't think that modifier is appropriate since that is to report a service that was partially performed but reduced at the physician's discretion. In the situation you are describing, the pathology service was not performed at all because the tissue was not able to be prepared for the...
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    Wiki Inpatient Setting- Billing Professional and Technical Component

    I agree with @CBLENNIE 's post above, though I would say it a little more emphatically: not that you 'might' run into issues, but that you certainly will, and that they payers and not just 'likely' to deny the technical component, but almost always will. The costs of technical components of...
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    Wiki Including Co-Payment on Claim forms

    Your process is correct but I'd stress again that what you report on the claim form is not going to change what the payer does with the claim. If you happen to report an incorrect amount that isn't what your provider actually collected, the payer is still going to make their own determination...
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    Wiki Flu shot Medicare

    Medicare requires G0008 for the administration, but for the vaccine itself the code will depend on what type of vaccine was administered - you'll need to review the various descriptions to find the most appropriate code. Here's a link with guidance that may help...
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    Wiki Botox Injection

    L74.519 would be the correct diagnosis for hyperhidrosis of the scalp. If that diagnosis appears to be excluded from your LCD, then my recommendation would be to obtain an ABN from the patient prior to performing the service to protect your provider. There's no way of knowing what really...
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    Wiki E/M initial visit

    Codes that have 'new' or 'established' in the descriptors are assigned based on whether or not the patient has been seen by a provider in the same practice and same specialty withing the last three years. Codes that have 'initial' or 'subsequent' in the descriptors are assigned based on whether...
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    Wiki Determining how much to set your fee schedule

    You should make sure that your fees are equal to or greater than your highest paying contract, otherwise you will be billing less that some of your contracts allow, and you'll be leaving money on the table. So, for example, if 140% Medicare is the most this practice gets under any contract...
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    Wiki Medicare and ER consults

    Medicare does accept emergency E/M codes. See section 30.6.11 - Emergency Department Visits - in chapter 12 of the Medicare Claims Processing Manual, linked here: https://www.cms.gov/sites/default/files/2020-05/clm104c12_0.pdf Any physician seeing a patient registered in the emergency...
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    Wiki Myocutaneous flap placement

    I believe that is correct, but I think it's something you might want to discuss with your physician. I know that UnitedHealthcare in particular has recently been strict about this (and may even have a written policy) and in the past would retract payment for a myocutaneous flap code if the...
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    Wiki E/M initial visit

    Are you asking about 'initial' visits for hospital E/M services, or 'new patient' visits in the office? These are two different things and are handled differently. Take a look at the CPT guidelines for both of these. You have to consider both 'group' AND 'specialty' for new patient coding...
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    Wiki 99214 with 99233

    If the two providers are of different specialties, then it is fine to bill both. If they are of the same specialty, then you will have to combine the services and only bill one.
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    Wiki Z91 Noncompliant Diagnosis Code and Z59 Homelessness Dx Code

    If that is all you have in the documentation, then that's what you'd have to use. There's no coding guideline saying this code can't be primary, although there's no guarantee that some payers won't deny it for this. I would recommend reviewing the documentation though - if the patient is...
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    Wiki EKG / ECG Dx Coding

    'Prolonged QT', per the ICD-10 alphabetic index, is classified to R94.31. I would code 'long QT' the same way as I don't see any substantial difference in the two. But I45.81 is for 'long QT syndrome' which is a different thing so in the absence of a documented diagnosis of the 'syndrome', I...
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    Wiki Remote physiological monitoring 99457 during global period

    Modifier 24 is for use with evaluation and management codes. My guess is that the payer is not classifying 99457 as an E/M service and because of this is identifying the modifier as invalid for the code. If they are considering this a diagnostic test code, that would not be part of global...
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    Wiki Coding for Self Pay patients

    For inpatient facility claims, coding and charges are two separate things - it's not like physician coding where every code has a specific charge. On a hospital claim, the charges are based on facility resource utilization - all of the items you mention above, plus things like drugs, supplies...
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    Wiki Reimbursement of Pentamidine Non-DME

    How is it being administered then?
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    Wiki claims regarding the provider specialty

    This strikes me as being clearly an error on United's part. It seems to me that one of 3 things is going on here: 1) they're giving you the incorrect denial reason when the claim is actually denied for something else that has nothing to do with specialty (for example a missing or invalid CLIA...
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    Wiki Cosmetic on blind eye

    Without seeing the medical records and without knowing the patient's insurance plan's benefits and reimbursement policies are, it's really impossible to answer either of these questions.
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    Wiki Orthopedics - DM - Corticosteroids

    In this example, the diabetes should be coded. Per the ICD-10 guidelines, section IV.J. you should code "all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management." It certainly meets the criteria in this case as...
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    Wiki Signing off

    Either way is correct - it's really up to the provider. But I agree with the post above that if the patient delays or doesn't end up getting the labs done, then the provider has to be holding notes open for results that may or may not come in and if doing this for multiple patients, it could...
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    Wiki Canadian to US coding crosswalk?

    The patient should be able to obtain copies of itemized statements and medical records from which the necessary codes could be derived. Claims for services received outside of the US are usually submitted by the patient themselves with this documentation attached for the insurance companies to...
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    Wiki lidocaine jelly 2%

    There most likely is not a HCPCS code for this, and so in order to bill it you would need to use an unlisted code. I expected most payers' reimbursement policies would consider it inclusive to the procedure and decline to pay for it, and even those that might pay for it will likely only...
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    Wiki New Patient Billing

    There's nothing to understand - it cannot be billed. It's a coding error on the provider's part. Only one E/M service per day may be billed, and 99225 would only be reported if the patient was in observation status in a hospital.
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    Wiki Storage of many pages of reports?

    You mentioned EMR systems in your initial post, so I was assuming you had electronic charts. Really, it's best to move away from paper charts in this day and age. But either way, as I said, I'm not aware there are any requirements that you keep these. They are not your own physician's...
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    Wiki Billing for Physician Assistant service under Supervising Dr

    OK, for ALL professional services performed in the hospital, you bill each service under the provider who performed that service. So the physician acting as the surgeon will bill the surgery under their own credentials and the PA who assisted will bill their services, with the AS modifier...
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    Wiki Patients documents

    Healthcare insurance companies are covered entities under the HIPAA laws, so it's permitted to share any patient information that is necessary and relevant for purposes of 'treatment, payment and healthcare operations'.
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