Top 10 Medicare Denials for CPT Codes: What Providers Need to Know

Navigating Medicare’s denial landscape can be challenging for healthcare providers, as denied claims lead to lost revenue and increased administrative costs. Understanding the most frequently denied CPT (Current Procedural Terminology) codes and the reasons behind these denials can help healthcare organizations improve reimbursement rates and avoid costly errors. Here’s an in-depth look at the top 10 Medicare-denied CPT codes, along with best practices for reducing these denials.

1. CPT 99214 - Established Patient Office Visit (Moderate Complexity)

• Common Denial Reasons: Documentation insufficiency, lack of medical necessity, and coding errors.
• Tips to Avoid Denial: Ensure that the complexity level matches the documentation. Include all necessary elements, such as patient history, exam, and medical decision-making, to support the coding level.

2. CPT 99396 - Preventive Medicine Visit (Established Patient, 40-64 Years)

• Common Denial Reasons: Medicare often denies this as “not medically necessary,” as it does not cover preventive services under certain plans.
• Tips to Avoid Denial: Confirm Medicare coverage eligibility and verify if the patient’s plan includes preventive services or if an Advance Beneficiary Notice (ABN) is required.

3. CPT 36415 - Collection of Venous Blood by Venipuncture

• Common Denial Reasons: Service duplication, medical necessity, and bundling issues.
• Tips to Avoid Denial: Confirm that the service is separately payable under the patient’s plan and avoid double-billing when venipuncture is performed with other services.

4. CPT 99203 - New Patient Office Visit (Low Complexity)

• Common Denial Reasons: Incomplete documentation, coding errors, and new patient criteria not met.
• Tips to Avoid Denial: Make sure all required documentation is included, and confirm the patient qualifies as “new” under Medicare guidelines (no professional services provided by the same provider within the last three years).

5. CPT 99308 - Subsequent Nursing Facility Care (Low Complexity)

• Common Denial Reasons: Missing medical necessity and documentation inadequacies.
• Tips to Avoid Denial: Properly document the patient’s condition, services rendered, and reasons for continued nursing facility care to demonstrate medical necessity.

6. CPT 97110 - Therapeutic Exercises (Per 15 Minutes)

• Common Denial Reasons: Lack of documentation to support skilled therapy, exceeding therapy limits, and bundling issues.
• Tips to Avoid Denial: Include detailed notes about therapy goals, progress, and the medical need for ongoing therapy sessions.

7. CPT 99233 - Subsequent Hospital Care (High Complexity)

• Common Denial Reasons: Documentation not supporting complexity, duplication with other codes, and lack of medical necessity.
• Tips to Avoid Denial: Ensure that documentation reflects the high complexity required for this code. Include all elements that substantiate the need for a high-complexity visit.

8. CPT 97010 - Application of a Modality to 1 or More Areas; Hot or Cold Packs

• Common Denial Reasons: Bundling with other services, and Medicare’s non-coverage policy on certain modalities.
• Tips to Avoid Denial: Review Medicare’s bundling policies to determine if the service is covered when provided alongside other therapy services.

9. CPT 80050 - General Health Panel

• Common Denial Reasons: Medicare often does not consider this medically necessary or denies it for exceeding frequency limits.
• Tips to Avoid Denial: Verify if specific components of the panel are covered individually rather than billing the panel as a whole, and confirm the medical necessity before billing.

10. CPT 85025 - Complete Blood Count (CBC) with Automated Differential

• Common Denial Reasons: Medical necessity and frequency limitations.
• Tips to Avoid Denial: Confirm Medicare’s coverage guidelines on frequency and ensure a documented medical reason that justifies ordering the test.

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Key Takeaways for Reducing Medicare Denials

While the reasons for denial vary by code, there are general steps providers can take to minimize the risk:

• Prior Authorization and Coverage Checks: Verify whether the service is covered under the patient’s specific Medicare plan before providing it.
• Proper Documentation: Ensure that medical records comprehensively support the coding level and medical necessity for the service rendered.
• Staff Training: Educate billing and coding staff on Medicare’s policies, including frequent updates to covered services and CPT code guidelines.
• Advance Beneficiary Notices (ABNs): For services with unclear coverage, obtain ABNs from patients to ensure transparency and reduce the likelihood of unexpected denials.

Final Thoughts

By proactively addressing the most commonly denied CPT codes, healthcare providers can reduce administrative burdens, speed up reimbursement, and maintain financial stability. Addressing the underlying causes of denials—whether they involve coding accuracy, documentation, or policy awareness—is essential to a smooth and efficient revenue cycle.

CPT 30075, 30473, 30688 - Panendoscopy

 CPT CODE and Description

30075-16 [977] Biopsy of pancreas

30473-00 [1005] Panendoscopy to duodenum

30688-00 [1949] Endoscopic ultrasound

DOUBLE BALLOON ENTEROSCOPY

Double balloon enteroscopy (DBE) is an endoscopic technique that allows examination of the small intestine beyond the reach of other endoscopes.

** Revision of ACHI Index pathways to eliminate inconsistencies for double balloon enteroscopy (DBE) when performed via retrograde (per rectal) approach.

** Inclusion terms for balloon procedures at Index pathways for panendoscopy blocks [1005] – [1008] have been removed

** Creation of new code 30680-00 Balloon enteroscopy at block [1005] Panendoscopy,

** Assign 30680-00 [1005] Balloon enteroscopy in conjunction with interventions classified to blocks [892], [957], [1006], [1007] and [1008] when performed with double balloon enteroscopy.

30473-00 [1005] Panendoscopy to duodenum

As per WA Coding Rule 0316/09 Double balloon enteroscopy, effective 30 Mar 2016 - 30 Jun 2019, no look up exists at ‘Jejunoscopy’, so the lead term ‘Enteroscopy’ must be used, leading to the assignment of a panendoscopy code.

INSTRUCTION FOR PANENDOSCOPY

General Instructions:

1. If you are Diabetic, please contact the physician that manages your diabetes. They will give you instructions for adjusting your medications for the prep. Let your

physician know you will not be eating/drinking anything after midnight.

2. Take all medications for your heart or blood pressure the morning of the test, with a sip of water. Do NOT take any diuretics (water pills). Examples: Furosemide

(Lasix), Hydrochlorothiazide (HCTZ), Diuril, Aldactone…..

3. If you take blood thinners (Aspirin, Coumadin, Plavix, etc. ), please be sure we are aware of this. We will contact your prescribing doctor for specific instructions.

4. Due to sedation used during the exam, you will not be able to drive or return to work the day of your procedure.

Remember:

1. Eight (8) hours prior to your arrival time: NO solid foods.

 NO milk or milk products. NO red dyes. NO alcoholic beverages or beer. You  can continue the clear liquids for four (4) more hours.

2. Four (4) hours before your arrival time: Stop all clear liquids.

3. Take your medications with a sip of water, at least two hours before your arrival  time.

4. Bring with you: current medication list, photo ID, insurance cards, and the  blue questionnaire.

Clear liquids are allowed up to 4 hours before your arrival time:

Water, clear fruit juices (apple, white grape, white cranberry), bouillon, Jell-O (NO red Jell -O or fruit added), Ginger ale, Fresca, Coke/Pepsi, Gatorade (NO reds), Kool-Aid, SevenUp, Popsicles, or tea (no milk).

Before your Procedure

There are a few things that we ask all patients to do prior to coming in for their endoscopic procedure:

* Please follow all instructions given to you by your physician about eating, drinking and medications before your procedure. FOLLOW OUR INSTRUCTIONS, NOT WHAT COMES IN THE PREP BOX.

* If you are taking any medications, or if you are allergic to any medications, please bring a list of them with you when you come for your procedure.

* If you take any blood thinners and have not been instructed regarding usage prior to your procedure, please contact your physician as soon as possible.

* Notify your physician if there have been any changes in your physical condition since your last appointment was scheduled or since you last saw your physician.

* Please do not arrive prior to 6:45 am

Appointments:

Please be considerate of other patients and your physician by calling our office as soon as possible if you cannot keep your appointment. We understand that circumstances beyond your control may arise, exceptions will be made in the event of inclement weather or real emergencies Every health plan is different. While we make every effort to obtain referrals from primary care physicians and authorizations for outpatient procedures, it is also important for you to be familiar with your health care coverage.

We cannot be held responsible for unpaid services due to lack of referral or prior authorization.

A panendoscopy is the examination of the upper aerodigestive tract (pharynx, larynx, upper trachea and oesophagus). It may also involve the removal or biopsy of any abnormal tissue found.

Patient Information Panendoscopy and Biopsy

What is a panendoscopy and biopsy?

This operation is usually performed when there is suspicion of a cancer within the head and neck. It allows the surgeon to fully assess the oral cavity, larynx (voicebox) and oesophagus (food-pipe) to identify the extent of any growths, and take biopsies (which can include a tonsillectomy) to aid in diagnosis.

What is the operation like?

This is usually a day stay procedure. Before the operation you will see a member of the surgical team and the anaesthetist. The operation is performed with you asleep under a general anaesthetic for approximately 20 minutes.

You will wake up in the recovery room and once the anaesthetic has worn off you will be seen by your surgeon to explain the findings. If there are no significant problems you will then be discharged home with painkillers and an appointment to come back for any biopsy results. You will have a sore throat (especially if tonsillectomy was performed), and this will gradually improve over a week or two.

What can go wrong ?

The surgery is usually safe and uncomplicated however it is important that you are aware of the risks of the procedure.

General complications such as nausea, vomiting, sore throat and drowsiness may occur as a result of the anaesthetic. Serious drug reactions related to the anaesthetic are very rare.

Laparoscopic/arthroscopic/endoscopic surgery.

What is the correct code to assign for a nasendoscopy with views to the larynx** Should the instruction in ACS 0024 Panendoscopy to code to the furthest site viewed be applied to assign a code for laryngoscopy?

Panendoscopy is a generic term for an endoscopy of the upper gastrointestinal tract (ie oesophagus, stomach and duodenum) or aerodigestive tract (ie pharynx, larynx, upper oesophagus). ACS 0024

Panendoscopy states:

The term panendoscopy can also be used to mean endoscopies of the respiratory tract and the urinary system and therefore nongastrointestinal endoscopies should be coded appropriately, to the furthest site viewed

This advice only applies where the term panendoscopy is documented. Where specific types of endoscopes (nasendoscopy, laryngoscopy) are documented these should be coded as such. For example, if documentation indicates a nasendoscopy with views to the larynx has been performed, assign 41764-00 [370] Nasendoscopy. A separate code from block [520] Examination procedures on larynx should be assigned if documentation indicates a laryngoscopy has also been performed.

What is the correct procedure code for biopsy of a lesion using EUS guidance?

Endoscopic ultrasound (EUS) is similar to other endoscopies but with an ultrasound probe attached at the end of the endoscope, which permits both visualisation and tissue sampling of gastrointestinal walls and structures surrounding the gastrointestinal tract. EUS is primarily used for assessing lesions in the gastrointestinal tract, but has increasingly been used for evaluating lesions of adjacent organs such as lung, mediastinum, left kidney, adrenal gland and lymph nodes (intra-thoracic and intra-abdominal).

When biopsy of a lesion is performed under EUS guidance, assign an appropriate code for the type of endoscopy (e.g. gastroscopy, gastroscopy with biopsy) and 30688-00 [1949] Endoscopic ultrasound. For example, EUS guided FNA (fine needle aspiration) biopsy of pancreas, assign:

30075-16 [977] Biopsy of pancreas

30473-00 [1005] Panendoscopy to duodenum

30688-00 [1949] Endoscopic ultrasound

Coding and Billing

At this time, TNE uses the same coding procedures as conventional endoscopy. Diagnostic TNE (43200) and TNE with biopsy(s) (43202).

TNE Versus Conventional Esophagoscopy

Since the introduction of TNE, there have been many studies comparing TNE with the ‘‘gold standard’’ of conventional esophagoscopy (CE), which is performed transorally with sedation. Studies utilizing small-caliber video endoscopes have almost all concluded that TNE image quality and diagnostic capability is equivalent to CE, and that the majority of patients prefer TNE to CE.94–102

A summary review of these and other comparative studies was recently published as a portion of the American Academy of Otolaryngology position paper on TNE.82

TNE is also less expensive than CE. The increased direct costs of CE include longer procedure time, recovery room and recovery time, and the costs associated with medications, monitoring, and nursing.103 The difference in cost has been found to be greater than $2,000 per procedure.104 Indirect costs are also important but

difficult to quantify. This includes loss of work time by both the patient and a driver or caretaker. In contrast, with TNE, most patients are able to return to work or home shortly after the completion of the examination and do not need a caretaker.

Studies have shown a very high patient satisfaction rate, often greater than with CE.81,93 Crossover studies have shown that in patients who had both sedated and

unsedated examinations, the unsedated transnasal endoscopy was better tolerated.97

The Future

We anticipate that the future will bring continued refinements, such as still smaller endoscopes and the development of novel instruments to be used in conjunction with them. In addition, new techniques in imaging have emerged showing promise for enhancement and better visualization of the microvascular patterns of mucosal surfaces. Of particular interest is NBI optical technology, as noted earlier.105,106 NBI employs the filtering of light into three narrow bandwidths. This allows for optimal visualization of surface capillary and mucosa patterns, which the literature has suggested may allow for better evaluation and diagnosis of esophageal lesions. This may very well lead to improvement in the diagnosis of Barrett’s metaplasia, adenocarcinoma, and head and neck squamous cell cancer.

Conclusion

In-office TNE has become an important part of the evaluation and management of patients with dysphagia, extraesophageal/gastroesophageal reflux disease, and head and neck cancer. TNE provides a number of advantages over conventional endoscopy with equivalent clinical results. These advantages are improved safety, decreased overall costs, and patient preference.

MISCELLANEOUS LARYNGEAL PROCEDURES IN THE OFFICE SETTING

Laryngeal Biopsy

The revival of interest in awake laryngeal techniques has led to the development of additional procedures that offer novel value in care of the laryngology patient.

Perhaps the largest and most widely applicable is awake laryngopharyngeal biopsy. Although its roots are over 100 years old, awake laryngeal biopsy has seen a resurgence with the development of new endoscopes, endoscope sheaths, and instrumentation. Until approximately 15 years ago, the primary means for awake

laryngopharyngeal biopsy was similar to the approach used by the fathers of laryngology in the mid 1850s: transoral passage of long curved biopsy forceps with

indirect mirror laryngoscopy guidance. Although visualization is now achieved with rigid or flexible endoscopes with video display of the image rather than laryngeal

mirrors, the technique remains largely unchanged. However, in addition to the peroral biopsy approach, laryngeal biopsy can be done via the working channel of a flexible endoscope.

After adequate laryngopharyngeal anesthesia (as described previously), the patient is positioned sitting upright in the sniffing position. When using a rigid endoscope transorally, the patient holds their tongue protruded. The otolaryngologist holds the rigid endoscope in one hand and the biopsy forceps in the other.

The patient is asked to breathe comfortably through their mouth as the forceps are introduced into the laryngeal introitus. The forceps are directed to the biopsy site  and a representative sample is taken. Today, this still remains a valuable tool for the otolaryngologist, but requires skill and patience on the part of the otolaryngologist and patient.

With the introduction of flexible channeled endoscopes or flexible endoscopes with a channeled sheath (Medtronic ENT, Jacksonville, FL), the procedure has become considerably better tolerated by patients and easier to perform. The patient is anesthetized and positioned similarly to the previous descriptions. The flexible laryngoscope is passed transnasally and held in position viewing the biopsy target. A 2.0-mm flexible cup forceps is introduced by an assistant through the channel of the endoscope or the endosheath until they appear several millimeters beyond the tip of the scope (Fig. 15) (Olympus Biopsy Forceps, SB-34C-1, 1.8 mm diameter, 1050

mm length. Olympus America, Center Valley, PA). The forceps are opened and then the endoscope is advanced onto the target. The assistant closes the forceps and the sample is taken. The specimen can be withdrawn via the forceps, leaving the endoscope in place most of the time, which facilitates a rapid additional biopsy if needed. If the biopsy tissue is very large, then the entire endoscope can be withdrawn, allowing the specimen to be placed in the collection cup without being withdrawn through the working channel.

When combined with transnasal esophagoscopy and bronchoscopy, awake panendoscopy, staging, and biopsy has become a reality. Awake laryngeal biopsy and tumor staging has been demonstrated to be equally as effective as operative staging.83,107 Time from presentation to initiation of treatment is reduced by elimination of the traditional panendoscopy and biopsy under general anesthesia. Patients are spared from additional general anesthesia, physician efficiency is improved, and healthcare costs are reduced. Additional value of awake laryngeal biopsy lies in the evaluation and surveillance of laryngeal lesions that do not warrant operative excision, and culturing of lesions suspicious for bacterial or fungal infection.

CPT code 49082, 49083, 49084 - abdominal paracentesis

Procedure Code Changes and Description

• Deleted Codes

* 49080 - Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); initial

* 49081 - Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); subsequent

• New Codes

* 49082 – Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance

* 49083 - with imaging guidance

* 49084 – Peritoneal lavage, including imaging guidance, when performed

• (Do not report 49083 or 49084 in conjunction with 76942, 77002, 77012, 77021)

Example

Diagnosis: Malignant ascites

Procedure: Therapeutic paracentesis

The patient is explained the risks, benefits, and alternatives of the procedure abdominal paracentesis for treatment of her malignant ascites. She fully understood and wished to proceed. Pre-operative sonographic images of the abdomen show a large volume of ascites with a pocket free of bowel loops with the left lower quadrant, this will be our entry point. The overlying skin was prepped and draped 2% lidocaine was utilized for local anesthetic. A 7- french sheath needle was passed via a left lower quadrant approach into the ascitic fluid. Clear, straw-colored ascitic fluid was noted. A total of 7 liters was removed. The sheath was removed; sampling was not taken to pathology. The patient tolerated the procedure well with no apparent complications.

• Correct CPT code: 49082

CPT® Procedure Code Changes

• Revised Parenthetical notes

* 49418 - Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, contrast injection when performed, and radiological supervision and interpretation, percutaneous

* 49419 - Insertion of tunneled intraperitoneal catheter, with subcutaneous port (i.e., totally implantable)

 (49420 has been deleted. To report open placement of a tunneled intraperitoneal catheter for dialysis, use 49421. To report open or percutaneous peritoneal drainage or lavage, see 49020, 49021, 49040, 49041, 49082-49084, as appropriate. To report percutaneous insertion of a tunneled intraperitoneal catheter without subcutaneous port, use 49418)

Paracentesis

*As stated in the ACR--SIR-SPR Practice Parameter for Specifications and Performance of Image-Guided Percutaneous Drainage/Aspiration of Abscesses and Fluid 

Collections:

Image-guided percutaneous aspiration is defined as evacuation or diagnostic sampling of a fluid collection using either a catheter  or a  needle during a single imaging session, with removal of the catheter or needle immediately after the aspiration.

Image-guided percutaneous drainage is defined as  the placement of a catheter using

image guidance to provide continuous drainage of a fluid collection.

*Codes 49082 and 49083 describe a puncture of the abdominal cavity with insertion of a needle or catheter to remove fluid. The catheter/needle is removed at the end of the procedure.

* Code 49082 describes an  abdominal paracentesis performed without imaging guidance.

* Code 49083 describes an abdominal paracentesis performed with imaging guidance.

* Limited sonography for localization of fluid is bundled. If localization  reveals no fluid,and the paracentesis is not performed assign code 76705.

* For 2018, the NCCI Manual notes the following revised language: “Evaluation of an anatomic region and guidance for a needle placement procedure in that anatomic region by the same radiologic modality on the same date of service may be reported separately if the two procedures are performed in different anatomic regions. For example, a physician may report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in different anatomic regions on the same date of service. Physicians should not avoid these edits based on this principle by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service.” -

Peritoneal Catheter Placements

• 49082 Paracentesis; Dx or Tx, w/o imaging guidance

• 49083 Paracentesis; Dx or Tx, with imaging guidance

• If does paracentesis and leaves catheter in place, use 49406 only.Do not code for the paracentesis.

• If places indwelling catheter, sends to floor for drainage, then pulls catheter on same DOS, use 49083

Paracentesis is the aspiration of fluid from the abdominal cavity. It is most often performed for ascites, which is an abnormal accumulation of peritoneal fluid caused by liver disease, cancer or other conditions. Paracentesis may be performed for diagnostic purposes, in which case only a small amount of fluid is removed. Alternatively, large volume paracentesis (removal of up to 6 liters of fluid) may be performed for therapeutic purposes. Following large volume paracentesis the patient may receive an albumin infusion to prevent electrolyte imbalance.

The following codes are used to report paracentesis:

CPT® Code Description

49082 Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance

49083 . . . with imaging guidance

Remember that aspiration involves removal of the catheter or needle at the conclusion of the procedure. Do not use codes 49082-49083 for drainage procedures in which a catheter is left indwelling.

Correspondence Language Policy/Example Number 14.40000 - Misuse of column two code with column one code

For example, CPT code 49322 describes a surgical laparoscopy with aspiration of single or multiple cavities or cysts (eg, ovarian cyst). CPT code 49082 describes an abdominal paracentesis (diagnostic or therapeutic) without imaging guidance. It is a misuse of CPT code 49082 to report it in addition to CPT code 49322 at the same

patient encounter since the procedure described by CPT code 49322 includes the procedure described by CPT code 49082

Guidelines from UHC insurance 

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. The listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply

CPT Code Description

49082 Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance

CPT 47560, 47561, 47562, 47563, 47564, 47570 and 47579

Procedure code and Description 

47560 Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy

47561 with guided transhepatic cholangiography with biopsy

47562 cholecystectomy

47563 cholecystectomy with cholangiography

47564 cholecystectomy with exploration of common duct

47570 cholecystoenterostomy

47579 Unlisted laparoscopy procedure, biliary tract

47560, 47561 have been deleted. To report laparoscopically guided transhepatic cholangiograpy with biopsy, use 47579

Select Laparoscopic Cholecystectomy with Common Bile Duct Exploration (CBDE) Procedures

Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all-inclusive list. We recommend consulting your relevant manuals for appropriate coding options.

The following codes are thought to be relevant to Laparoscopic Cholecystectomy with Common Bile Duct Exploration (CBDE) procedures and are referenced throughout this guide.

All rates shown are 2020 Medicare national averages; actual rates will vary geographically and/or by individual facility.

Physician Coding and Payment

Code Description Work Total Facility In-Facility

47564 Laparoscopy, surgical; cholecystectomy with exploration of common duct 18.00 32.48 $1,172

Medicare Hospital Inpatient Payment Rates Effective October 1, 2019 - September 30, 2020

Medicare Severity Diagnosis Related Groups (MS-DRGs) assignment is based on a combination of diagnoses and procedure codes reported. While MS-DRGs listed in this guide represent likely assignments, Boston Scientific cannot guarantee assignment to any one specific MS-DRG. MS-DRGs resulting from inpatient laparoscopic cholecystectomy with common bile duct exploration procedures may include (but are not limited to):

A Whipple-type pancreatectomy procedure (CPT codes 48150-48154) includes removal of the gallbladder. A cholecystectomy (e.g., CPT codes 47562-47564, 47600-47620) shall not be reported separately.

Description

This policy addresses coding and coverage when an operative cholangiography is performed to evaluate the biliary tract and help decide whether or not to explore the common bile duct for stones or other abnormalities.

Definitions

Operative cholangiography involves the injection of radiopaque contrast material into the cystic or common bile duct during surgery. This procedure is performed to identify various abnormalities of the biliary ductal system, often secondary to stones (calculi or choledocholithiasis) and occasionally other lesions, such as benign strictures or tumors.

Policy Statement

Frequently during cholecystectomy, an operative cholangiogram is performed to help the surgeon decide whether or not to explore the common bile duct for stones or other pathologic processes.

When one physician reports the cholecystectomy and operative cholangiography with subsequent common bile duct exploration, the services are combined under the procedure codes 47564 (laparoscopic approach) or 47610 (open/excision approach), as appropriate. If additional surgical procedures are performed during the same operative session, then the modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

If, however, a second physician (e.g., a radiologist) provides the formal interpretation of the operative cholangiography, then the service is eligible for coverage under codes 74300-74301 (cholangiography and/or pancreatography).

Documentation Submission

Documentation/operative report must identify and describe the procedures performed. If a denial is appealed, this documentation must be submitted with the appeal.

Coverage

Eligible surgical services will be subject to the Blue Cross fee schedule amount. Denied services will be provider liability.

The following applies to all claim submissions.

All coding and reimbursement is are subject to all terms of the Provider Service Agreement and subject to changes, updates, or other requirements of coding rules and guidelines. All codes are subject to federal HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD), only codes valid for the date of service may be submitted or accepted. Reimbursement for all Health Services is subject to current Blue Cross Medical Policy criteria, policies found in Provider Policy and Procedure Manual sections, Reimbursement Policies and all other provisions of the Provider Service Agreement (Agreement).

In the event that any new codes are developed during the course of Provider's Agreement, such new codes will be reimbursed according to the standard or applicable Blue Cross fee schedule until such time as a new agreement is reached and supersedes the Provider's current Agreement.

All payment for codes based on Relative Value Units (RVU) will include a site of service differential and will be calculated, if appropriate, using the appropriate facility or non-facility components, based on the site of service identified, as submitted by Provider.

Coding

The following codes are included below for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.

CPT / HCPCS Modifier: 59

ICD Diagnosis: N/A

ICD Procedure: N/A

HCPCS: 47564, 47610, 74300, 74301

Revenue Codes: N/A

Deleted Codes: N/A

LAPAROSCOPY

Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320.

EXCISION

47600 Cholecystectomy;

47605 with cholangiography (For laparoscopic approach, see 47562-47564) 

The five-digit numeric codes and descriptions included in the Medical Reimbursement Schedule are obtained from the Physicians’ Current Procedural Terminology, copyright 1999 by the American Medical Association (CPT). CPT is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians and other health care providers.

This publication includes only CPT numeric identifying codes and modifiers for reporting medical services and procedures that were selected by the Louisiana Department of Labor, Office of Workers’ Compensation. Any use of CPT outside the fee schedule should refer to the Physicians’ Current Procedural Terminology, copyright 1999 American Medical Association and any update thereto. These CPT publications contain the complete and most current listing of CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures.

No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of the Physicians’ Current Procedural Terminology, copyright 1999, by the American Medical Association. All rights reserved

Maximum Fee Allowance Schedule Office of Workers' Compensation

CPT Global Maximum

Code Mod Description Days Allowance

47564 Laparo cholecystectomy explr. 90 BR

CPT code 87635, 87426, 87428, 87811

Procedure code and Description

 CPT 87635 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique

CPT 87426 - Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19])

CPT 87428 severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B

CPT 87811 - Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

COVID-19 Billing Guides Updated with CPT Codes 87426 and 86413

Nevada Medicaid has updated the COVID-19 General Billing Guide and COVID-19 Community-Based Testing Billing Guide with the following new Current Procedural Terminology (CPT) codes. These codes have also been added to the Medicaid Management Information System (MMIS) and are active for billing. The Centers for Medicare &

Medicaid Services (CMS) has not established reimbursement rates; therefore, claims will suspend for payment with error code 853 (HCPCS Annual Update – suspend claims) and will be automatically reprocessed once rates have been established by CMS.

Claims for codes 87426 and 86413 that denied with error code 4032 (Procedure code not on file) may be resubmitted back to the dates indicated below.

o Note: Code 87426 is an add-on code under 87301. 87426 became effective by the American Medical Association on June 25, 2020. Claims may only be submitted back to this date.

o Note: 86413 became effective by the American Medical Association on September 8, 2020. Claims may only be submitted back to this date.

Background

Currently, there are two existing CPT codes to report antigen testing using immunoassay technique for influenza type A or B (87400) and SARS-CoV-2 (87426). However, there is no code that describes multiplex immunoassay antigen testing for these three viral targets, ie, SARS-CoV, SARS-CoV-2 [COVID-19], and influenza virus types A and B. A code to report a multiplex viral pathogen panel using an antigen immunoassay technique would facilitate reporting SARS-CoV-2 testing, along with influenza types A and B in the differential diagnosis

The following clinical example and procedural description reflect a typical clinical situation for which this new code would be appropriately reported. Because of the early deployment and utilization of these tests, clinical indications are subject to further refinement as knowledge of the novel coronavirus evolves. The Panel will continue to review and may clarify these indications as more information becomes available.

Clinical Example (87428)

A 50-year-old female presents with fever, cough, and shortness of breath. A nasopharyngeal swab is collected for SARS CoV-2, influenza A, and influenza B antigen testing. 

Description of Procedure (87428)

Place the swab and swirl it in a supplied reagent tube to disrupt and release viral nucleoprotein antigens; transfer an aliquot of that sample to the test cassette sample well; and place it in the analyzer. Report the qualitative results to the ordering health care professional.

COVID-19 Diagnostic Testing Reimbursement

The Centers for Medicare & Medicaid Services (CMS) has established two Healthcare Common Procedure Coding System (HCPCS) codes for coronavirus testing. HCPCS code U0001 is for CDC approved labs to use, and HCPCS code U0002 is for CDC non-approved labs to use when reporting SARS-CoV-2 testing. 

COVID-19 Testing

CMS has established two new HCPCS codes for high throughput technology testing. HCPCS code U0003 and U0004 are to be used when making use of high throughput technologies, as described by CMS2020-01-R. These codes are effective on/ or after 4/14/2020. CMS has established new specimen collections codes for Clinical diagnostic laboratories billing for COVID-19 testing:

** HCPCS G2023- for specimen collection for severe acute respiratory syndrome, any specimen source and

** HCPCS G2024- for specimen collection for severe acute respiratory syndrome, from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source.

Clinical diagnostic laboratories should use these codes to identify specimen collection for COVID-19 testing, effective with item date of service on/or after March 1, 2020. 

The AMA published CPT code 87635 in an effort to help report and track testing services related to SARS-CoV-2 in an effort to assist in reporting and reimbursement.

Medica’s reimbursement rates are based upon rates that were recently announced by the Centers for Medicare and Medicaid Services for COVID-19 testing. Medica will reimburse contracted and noncontracted providers for COVID-19 testing, unless otherwise specified by law. It is not considered medically necessary if a COVID-19 antibody test is to be used as part of ‘return-to-work’ programs, public health surveillance testing or any efforts not associated with disease diagnosis or treatment.

Reimbursement Rates for Coronavirus Diagnostic Testing:

** HCPCS U0001: $35.92

** HCPCS U0002: $51.33

** HCPCS U0003: $75.00 (effective date 4/14/2020)

** HCPCS U0004: $75.00 (effective date 4/14/2020)

** HCPCS U0005: $25.00 (Effective 1/1/2021)

** CPT 87635: $51.33

** HCPCS G2023: $23.46

** HCPCS G2024: $25.46

** HCPCS C9803: $24.67

Diagnosis Codes to be used for confirmed Coronavirus:

** B97.29: Other coronavirus

** B34.2: Coronavirus Infection

** U07.1: 2019 COVID acute respiratory disease

Diagnosis Codes recommended by the CDC for suspected Coronavirus exposure:

** Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out

** Z20.828: Contact with and (suspected) exposure to other viral communicable diseases

** Z11.52: Encounter for screening for COVID-19 (Effective 1/1/21)

** Z20.822: Contact with and (suspected) exposure to CIVUD-19 (Effective 1/1/21)

CPT 99401, 99402, g0446, g0447 and G0473

 CPT CODE and Description

• 99401 – preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 15 minutes

• 99402 – preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 30 minutes

HCPCS codes related to obesity screening and counseling are: 

• G0446 – annual, face-to-face intensive behavioral counseling (IBT) for cardio-vascular disease (CVD), individual, 15 minutes

• G0447 – face-to-face behavioral counseling for obesity, 15 minutes

• G0473 – face-to-face behavioral counseling for obesity, group (2–10), 30 minutes. 

Overview

This policy describes Optum’s requirements for the reimbursement and documentation of “Obesity Screening and Counseling” –CPT codes 99401 and 99402, and HCPCS procedural codes G0446, G0447 and G0473.

The purpose of this policy is to ensure that Optum reimburses for services that are billed and documented, without reimbursing for billing submission or data entry errors or for non-documented services.

Reimbursement Guidelines

For eligible adult health plan members with obesity, defined as Body Mass Index (BMI) equal to or greater than 30 kg/m2 , Optum will align reimbursement with Medicare including:

° One face-to-face visit every week for the first month;

° One face-to-face visit every other week for months 2-6; and

° One face-to-face visit every month for months 7-12 [if the member meets the 3kg (6.6 lbs.) weight loss requirement during the first 6 months.

For adult members who do not achieve a weight loss of at least 3 kg (6.6 pounds) during the first 6 months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period. 

These visits must be provided by a qualified health care provider.

For eligible children and adolescent (6-18 years) health plan members with overweight, defined as having an age/gender-specific BMI at or above the 85th percentile, Optum will align reimbursement with the recommendations of the U.S. Preventive Services

COUNSELING, RISK FACTOR REDUCTION, AND BEHAVIOR CHANGE INTERVENTION CODES

▶ Used to report services provided for the purpose of promoting health and preventing illness or injury.

▶ They are distinct from other E/M services that may be reported separately when performed. However, one exception is you cannot report counseling codes (99401–99404) in addition to preventive medicine service codes (99381–99385 and 99391–99395).

▶ Counseling will vary with age and address such issues as family dynamics, diet and exercise, sexual practices, injury prevention, dental health, and diagnostic or laboratory test results available at the time of the encounter.

▶ Codes are time-based, where the appropriate code is selected according to the approximate time spent providing the service.  Codes may be reported when the midpoint for that time has passed. For example, once 8 minutes are documented, one may report 99401.

▶ Extent of counseling or risk factor reduction intervention must be documented in the patient chart to qualify the service based on time.

▶ Counseling or interventions are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.

▶ Cannot be reported with patients who have symptoms or established illness

Background Information

Obesity screening and counseling is one of a number of distinct preventive services mandated by national and state regulations [US Dept. of Labor]. The USPSTF recommends screening all adults for obesity [Moyer]. The screening of children >6 years old is also recommended in a separate report [USPSTF]. The USPSTF did not find sufficient evidence for screening children younger than age 6 years. Many different types of providers – not limited to but including chiropractors, physical and occupational therapists – can offer screening and counseling for obesity [Frerichs, Ndetan]. Screening for obesity is typically performed by calculating body mass index (BMI). Counseling and behavioral interventions generally consist of problem-solving (assisting by providing specific suggested actions and motivational counseling) and facilitating access to social support services (arranging for services and follow-up) [ChiroCode, MLN].

Medicare covers screening for adult beneficiaries with obesity, defined as Body Mass Index (BMI) equal to or greater than 30 kg/m2

, who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. Those who meet these criteria are eligible for:

• One face-to-face visit every week for the first month;

• One face-to-face visit every other week for months 2-6; and

• One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs.) weight loss requirement during the first 6 months [MLN].

For beneficiaries who do not achieve a weight loss of at least 3 kg (6.6 pounds) during the first 6 months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period. Medicare does not allow the billing of other services provided on the same day as an obesity counseling visit, but private plans have a wide array of policies on such care. They vary with regard to how the visit should be coded, how many visits are allowed in a year, and in reimbursement design [Elliott].

For children and adolescents ages 6-18 years, the USPSTF uses the following terms to define categories of increased BMI:

• Overweight = an age/gender-specific BMI between the 85th and 95th percentiles

• Obesity = an age/gender-specific BMI at or above the 95th percentile.

The USPSTF did not find any evidence describing the appropriate timing of screening intervals. 

Service Procedure Codes Diagnosis Codes

Screening for obesity in adults, children and adolescents Preventive Medicine Individual Counseling:

• 99401 – 99404 (Diagnosis Code Required) Behavioral Counseling or Therapy:

• G0446, G0447, G0473 (Diagnosis Code Not Required) 

• ICD‐10: Z68.41, Z68.42, Z68.43, Z68.44, Z68.45 

Obesity:

• ICD‐10: E66.01, E66.09, E66.1, E66.8, E66.9 

CPT G0104, G0105, G0106, G0120 - Colorectal cancer screening

Procedure code and Description

• CPT 82270 (HCPCS G0107) - Colorectal cancer screening; fecal-occult blood tests, 1-3 simultaneousdeterminations;

• HCPCS G0104 - Colorectal cancer screening; flexible sigmoidoscopy;

• HCPCS G0105 - Colorectal cancer screening; colonoscopy on individual at high risk;

• HCPCS G0106 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0104, screening sigmoidoscopy;

• HCPCS G0120 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0105, screening colonoscopy.

Medicare Billing Guidelines


G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy Screening flexible sigmoidoscopies (HCPCS G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below.

HCPCS G0120 - Colorectal Cancer Screening; Barium Enema; as an Alternative to HCPCS G0105, Screening Colonoscopy Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (HCPCS G0105) examination. The same frequency parameters for screening colonoscopies (see those codes above) apply.

In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (HCPCS G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (HCPCS G0120) as an alternative to a screening colonoscopy (HCPCS G0105) in January 2000.

Start counts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (HCPCS G0120) in January 2002.

The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening colonoscopy, for the same individual. The screening single contrast barium enema also requires a written order from the beneficiary’s attending physician in the same manner as described above for the screening double contrast bariumenema examination.

Screening Barium Enema Examinations (codes G0106 and G0120).--Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy (code G0104) or a screening colonoscopy (code G0105) examination. The same frequency parameters for screening sigmoidoscopies and screening colonoscopies (see §4180.2 B and C) above apply.

In the case of an individual aged 50 or over, payment may be made for a screening barium enema examination (code G0106) performed after at least 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed. For example, the beneficiary received a screening barium enema examination as an alternative to a screening flexible sigmoidoscopy in January 1998. Start your count beginning February 1998. The beneficiary is eligible for another screening barium enema in January 2002.

In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January 1998. Start your count beginning February 1998. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2000.

The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening flexible sigmoidoscopy, or for a screening colonoscopy, as appropriate, for the same individual. The screening single contrast barium enema also requires a written order from the beneficiary’s attending physician in the same manner as described above for the screening double contrast barium enema examination.

Codes G0105 and G0121 (colorectal cancer screening colonoscopies) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic colonoscopy (CPT code 45378). (The same RVUs have been assigned to codes G0105 and G0121 as those assigned to CPT code 45378.) If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate procedure classified as a colonoscopy with biopsy or removal must be billed and paid rather than code G0105 or G0121.


Code G0106 (colorectal cancer screening; barium enema as an alternative to a screening flexible sigmoidoscopy) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic barium enema (CPT code 74280). Code G0120 (colorectal cancer screening; barium enema as an alternative to a screening colonoscopy; high risk individuals) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic barium enema (CPT code 74280).

COLORECTAL CANCER SCREENING TESTS OVERVIEW

The following services are considered colorectal cancer screening services:

• Annual fecal occult blood tests (FOBTs);
• Flexible sigmoidoscopy;
• Screening colonoscopy for persons at average risk for colorectal cancer every 10 years,
• Screening colonoscopy for persons at high risk* for colorectal cancer every 2 years;
• Barium enema every 4 years as an alternative to flexible sigmoidoscopy, or
• Barium enema every 2 years as an alternative to colonoscopy for persons at high risk*;
• CologuardTM - Multitarget Stool DNA (sDNA) Test (effective October 9, 2014)

*Medicare defines high risk of developing colorectal cancer as someone who has one or more of the following risk factors:

• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
• A family history of familial adenomatous polyposis;
• A family history of hereditary nonpolyposis colorectal cancer;
• A personal history of adenomatous polyps;
• A personal history of colorectal cancer; or
• A personal history of inflammatory bowel disease, C rohn’s Disease, and ulcerative colitis

It is not expected that these screening services are performed on patients that present with active gastrointestinal symptomatology.


Remittance Advice Notices.Denial codes

A. If the claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the patient is under 50 years of age, use existing American National Standard Institute (ANSI) X12-835 claim adjustment reason code 6 “the procedure code is inconsistent with the patient’s age,” at the line level along with line level remark code M82 “Service is not covered when beneficiary is under age 50.”

B. If the claim for a screening fecal-occult blood test, a screening colonoscopy, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the time period between the test/procedure has not passed, use existing ANSI X12-835 claim adjustment reason code 119 “Benefit maximum for this time period has been reached” at the line level.

C. If the claim is being denied for a screening colonoscopy (code G0105) or a screening barium enema (G0120) because the beneficiary is not at a high risk, use existing ANSI X12-835 claim adjustment reason code 46 “This procedure is not covered” at the line level along with line level remark code M83 “Service is not covered unless the beneficiary is classified as a high risk.”

D. If the service is being denied because payment has already been made for a similar procedure within the set time frame, use existing ANSI X12-835 claim adjustment reason code 18, “Duplicate claim/service” at the line level along with line level remark code M86 “This service is denied because payment has already been made for a similar procedure within a set timeframe.”

E. If the claim is being denied for a noncovered screening procedure such as G0122, use existing ANSI X12-835 claim adjustment reason code 49, “These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.” 4180.10 Ambulatory Surgical Center Facility Fee.--CPT code 45378, which is used to code a diagnostic colonoscopy, is on the list of procedures approved by Medicare for payment of an ambulatory surgical center (ASC) facility fee under §1833(I) of the Act. CPT code 45378 is currently assigned to ASC payment group 2. Code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) has been added to the ASC list effective for services furnished on or after January 1, 1998. Code G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) was added to the ASC list effective for services furnished on or after July 1, 2001. Codes G0105 and G0121 are assigned to ASC payment group 2. The ASC facility service is the same whether the procedure is a screening or a diagnostic colonoscopy.3

Covered ICD codes

Routine screening examinations:
V76.41 SCREENING FOR MALIGNANT NEOPLASMS OF THE RECTUM
V76.51 SPECIAL SCREENING FOR MALIGNANT NEOPLASMS COLON
Screening examinations for persons at high risk: (HCPCS Codes G0105 and G0120)
Personal or family history of gastrointestinal neoplasia:
211.3 BENIGN NEOPLASM OF COLON
211.4 BENIGN NEOPLASM OF RECTUM AND ANAL CANAL
235.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND
RECTUM
V10.00 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN
GASTROINTESTINAL TRACT
V10.05* PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE
V10.06* PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RECTUM
RECTOSIGMOID JUNCTION AND ANUS
V10.07 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LIVER
V12.72 PERSONAL HISTORY OF COLONIC POLYPS
V12.79 PERSONAL HISTORY OF OTHER SPECIFIED DIGESTIVE SYSTEM DISEASES
V16.0 FAMILY HISTORY OF MALIGNANT NEOPLASM OF GASTROINTESTINAL
TRACT
V18.51 FAMILY HISTORY, COLONIC POLYPS
555.1* REGIONAL ENTERITIS OF LARGE INTESTINE
555.2* REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE
555.9* REGIONAL ENTERITIS OF UNSPECIFIED SITE
556.0* ULCERATIVE (CHRONIC) ENTEROCOLITIS
556.1* ULCERATIVE (CHRONIC) ILEOCOLITIS
556.2* ULCERATIVE (CHRONIC) PROCTITIS
556.3* ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS
556.4 PSEUDOPOLYPOSIS OF COLON
556.5 LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS
556.6 UNIVERSAL ULCERATIVE (CHRONIC) COLITIS
556.8* OTHER ULCERATIVE COLITIS
556.9* ULCERATIVE COLITIS UNSPECIFIED

CPT 99217, 99218, 99219, 99220 - Observation care codes

CPT Code Description

99217 Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])

99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.

99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.

99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity. Typically 70 minutes are spent at the bedside and on the patient's hospital floor or unit.



Initial Observation Care (CPT code range 99218-99220)

• Included in Initial Observation Care:
- Initiation of observation status
- Supervision of the care plan for observation
- Performance of periodic reassessments
• When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218 – 99220, shall be reported by the physician.
• When a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report Initial Observation Care, from CPT code range 99218 – 99220, and CPT observation care discharge CPT code 99217.
• To report services provided to patient who is admitted to the hospital after receiving hospital observation care services on the same date, see initial  hospital carenotes in the American Medical Association (AMA) Current Procedural Terminology (CPT) Publication.
• To report hospital admission on a date subsequent to the date of observation status, use appropriate initial hospital care codes (CPT 99221 – 99223)
• Observation status that is initiated in the course of an encounter in another site of service (eg. hospital emergency department, office, nursing facility) all E/M services provided by the supervising physician or other qualified health care professional in conjunction with initiating “observation status” are considered part of the initial observation care when performed on the same date.
- The level of service reported should include the services related to initiating “observation status” provided in the other sites of service as well as in the observation setting
• On the rare occasion when a patient remains in observation care for 3 days, the physician shall report an initial observation care code (99218-99220) for the first day of observation care, a subsequent observation care code (99224-99226) for the second day of observation care, and an observation care discharge CPT code 99217 for the observation care on the discharge date.
• Admitted and discharges from observation or inpatient status on the same date report CPT codes 99234-99236 as appropriate; do NOT report observation discharge in conjunction with a hospital admission.
• These codes may NOT be utilized for post-operative recovery if the procedure is considered part of the surgical “package.”




REIMBURSEMENT GUIDELINES from Oxford insurance

Initial Observation Care
The physician supervising the care of the patient designated as "observation status" is the only physician who can report an initial Observation Care CPT code (99218-99220). It is not necessary that the patient be located in an observation area designated by the hospital, although in order to report the Observation Care codes the physician must:

** Indicate in the patient's medical record that the patient is designated or admitted as observation status;
** Clearly document the reason for the patient to be admitted to observation status; and
** Initiate the observations status, assess, establish and supervise the care plan for observation and perform periodic reassessments.

The CPT codebook states that "When "observation status" is initiated in the course of an encounter in another site of service (e.g., hospital emergency department, office, nursing facility) all evaluation and management services provided by the supervising physician or other qualified health care professional in conjunction with initiating "observation status" are considered part of the initial Observation Care when performed on the same date. The Observation Care level of service reported by the supervising physician should include the services related to initiating "observation status" provided in the other sites of services as well as in the observation setting."

Oxford follows the Centers for Medicare and Medicaid Services' (CMS) Claims Processing Manual which provides the instructions, "for a physician to bill the initial Observation Care codes [99218-99220], there must be a medical observation record for the patient which contains dated and timed physician's admitting orders regarding the care the patient is to receive while in observation, nursing notes, and progress notes prepared by the physician while the patient was in observation status. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter."

Consistent with CMS guidelines, Oxford requires that an Initial Observation Care CPT code (99218-99220) should be reported for a patient admitted to Observation Care for less than 8 hours on the same calendar date.



Q: Can Observation Care codes 99217 and codes 99218-99220 be reported on the same date of service?
A: No. CPT codes 99234-99236 should be reported for patients who are admitted to and discharged from observation status on the same calendar date for a minimum of 8 hours but less than 24. An initial Observation Care code (99218-99220) should be reported for patients admitted and discharged from observation status for less than 8 hours on the same calendar date. CPT code 99217 can only be reported for a patient discharged on a different calendar date.

Q: Does the patient need to be in an observation unit in order to report the Observation Care codes?
A: It is not necessary that the patient be located in an observation area designated by the hospital as long as the medical record indicates that the patient was admitted as observation status and the reason for Observation Care is documented.




Observation Services limitation

Hospital observation (procedure codes 99217, 99218, 99219, and 99220) are professional services  provided for a period of more than 6 hours but fewer than 24 hours regardless of the hour of the initialcontact, even if the client remains under physician care past midnight. Subsequent observation care, per day (procedure codes 99224, 99225, and 99226) is also a benefit of Texas Medicaid. Inpatient hospital observation services must be submitted using the procedure code 99234, 99235, or 99236.

Observation care discharge day management procedure code 99217 must be billed to report services provided to a client upon discharge from observation status if the discharge is on a date other than the initial date of admission. The following procedure codes are denied if submitted with the same date of service as procedure code 99217:

Procedure Codes

99211 99212 99213 99214 99215 99218 99219 99220

If an E/M service is billed by the same provider with the same date of service as a physician observation visit, the E/M service is denied if provided in any place of service other than inpatient hospital. If a physician observation visit (procedure code 99217, 99218, 99219, 99220, 99234, 99235, or 99236) is billed by the same provider with the same date of service as prolonged services (procedure code 99354, 99355, 99356, or 99357), the prolonged services will be denied as part of another procedure on the same day.

If dialysis treatment and a physician observation visit are billed by the same provider (and same specialty other than an internist or nephrologist) with the same date of service, the dialysis treatment may be reimbursed and the physician observation visit will be denied.

CPT H0031 - Mental health assessment program

Procedure Code and Unit of Service:  

H0031 – Mental Health Assessment by a Non-Mental Health Therapist – per 15 minutes


 Mental Health Assessment  Guidelines from Medicaid

Mental Health Assessment means providers listed below, participating as part of a multi-disciplinary team, assisting in the psychiatric diagnostic evaluation process defined in Chapter 2-2, Psychiatric Diagnostic Evaluation.  Through  face-to-face  contacts  with  the  individual,  the  provider  assists  in  the  psychiatric diagnostic  evaluation  process  by  gathering  psychosocial  information  including  information  on  the individual’s  strengths,  weaknesses  and  needs,  and  historical,  social,  functional,  psychiatric,  or  other information and assisting the individual to identify treatment goals. The provider assists in the psychiatric diagnostic  reassessment/treatment  plan  review  process  specified  in  Chapter  2-2  by  gathering  updated psychosocial information and updated information on treatment goals and assisting the client to identify additional treatment goals. Information also may be collected through in-person or telephonic interviews with family/guardians or other sources as necessary. The information obtained is provided to the individual identified in Chapter 2-2 who will perform the assessment, reassessment or treatment plan review.

Who:   

The following individuals when under the supervision of a licensed mental health therapist identified in Chapter 1-5, A. 1:

1.  licensed social service worker or individual working toward licensure as a social service worker in accordance with state law;

2.  licensed registered nurse;

3.  licensed ASUDC, CASUDC, SUDC, CSUDC or ASUDC-I or SUDC-I;  

4.  licensed practical nurse; or
 
5.  registered nursing student engaged in activities constituting the practice of a regulated occupation or profession while in training in a recognized school approved by DOPL, or an individual enrolled in a qualified substance use disorder education program, exempted from licensure in accordance with state law, and under required supervision. 

  Although these individuals may perform this service and participate as part of a multi-disciplinary team, under state law, qualified providers identified in Chapter 2 -2 are the only providers who may diagnose a behavioral health disorder and prescribe behavioral health services determined to be medically necessary to treat the individual’s behavioral health disorder(s). 

   Limits: 

1.  This service is meant to accompany the psychiatric diagnostic evaluation (see Chapter 2-2).  If a psychiatric diagnostic evaluation (assessment or reassessment) is not conducted after this service is performed, this service may be billed if all of the documentation requirements in the ‘Record’ section are met and the reason for non-completion of the psychiatric diagnostic evaluation is documented.

2.  If the provider conducting the psychiatric diagnostic evaluation defined in Chapter 2-2 obtains all of the psychosocial information directly from the client, only that service is billed.  The provider does not also bill this service. 


Time and Unit calculation

The following time rules apply for converting the duration of the service to the specified number of units:

Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.


CPT code H0031 - Maximum fee - $125.00 per assessment
Description of Service - In-depth assessment, new patient, mental health , In-depth assessment, new patient, mental health—telemedicine.
Limitation -  Medicaid reimburses one in-depth assessment, per recipient, per state fiscal year.* An in-depth assessment is not reimbursable on the same day for the same recipient as a bio-psychosocial evaluation. A bio-psychosocial evaluation is not reimbursable for the same recipient after an in-depth assessment has been completed, unless there is a documented change in the recipient’s status and additional information must be gathered to modify the recipient’s treatment plan.

Tips for usage

HSD/Medicaid will use this code for PSR only. Use modifier U8.
** For multi-disciplinary team, use modifier HT.
** For substance abuse assessment, use modifier HF.
** For substance abuse/mental health assessment, use modifier HH

Eligible Provider

** Bachelor’s degree in human servicesrelated field and a combination of relevant education, training, and experience totaling four years; or
** LADAC; or
** Masters Degree in human servicesrelated field.

NOTE: Completed assessment must be signed and dated by staff completing the assessment and, as appropriate, a masters level supervisor.

CPT code 99050, 99051, 99053, 99056 - After Office hour procedures

Procedure code and Description

99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service

99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service

99056 Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic


Medicaid Guideline for office hour CPT

 After-hours office visit codes cannot be used in a hospital setting, including emergency  department, by private or staff physicians. They cannot be used for standby for surgery, delivery, or other similar circumstances, and they cannot be used when seeing a new patient.  Billing for after-hours service in an established patient requires the service be provided outside  of scheduled staff hours as described in the Medicaid manual.

Policy Name After Hours and Weekend Care

This policy addresses reimbursement of after hours and weekend care services (Current Procedural Terminology (CPT) codes 99050-99060).

The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for CPT codes 99050, 99051, 99053, 99056, 99058 and 99060 to be bundled into payment for other services not specified.These codes have a Status Indicator of “B” in the National Physician Fee Schedule (NPFS).  Consistent with CMS, Medica considers these codes not eligible for reimbursement.

Definitions

Same Physician The same individual rendering health care services reporting the same Federal Tax Identification number.

Status Indicator B

Bundled code. Payment for covered services is always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient).

BCBS payment Guidelines

CPT 99050 is reported when services are provided in the office at times other than regularly scheduled office hours or days when the office is normally closed. The Health Plan refers to this time as “After Hours,” and defines “After Hours” as services rendered between 5:00 p.m. and 8:00 a.m. on weekdays, and anytime on weekends and holidays when the office is usually closed.

CPT code 99050 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:

•It is reported with an office setting place of service;

•It is rendered at a time other than the practice’s regularly scheduled and/or posted office hours; and

•The basic service time is based on arrival time, not actual time services commence.

CPT code 99050 is not eligible for separate reimbursement when it is  reported with a preventive diagnosis and/or a preventive service.CPT code 99051 is reported when services are provided in the office during regularly scheduled evening, weekend, or holiday office hours.

CPT code 99051 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:

•It is reported with an office setting place of service; and

•The basic service time for evening hours is based on arrival time, not actual time the service commenced. E/M services described by the codes 99053, 99056, 99058, and 99060 are not eligible for separate reimbursement


CPT Code 99050

Although CMS considers CPT code 99050 to be bundled into the payment for other services provided on the same day, Oxford will provide additional compensation to participating primary care providers for seeing patients in situations that would otherwise require more costly urgent care or emergency room settings by reimbursing CPT code 99050 in addition to basic service codes.

Oxford will reimburse after hours CPT code 99050 to participating primary care providers when reported with basic services in one of the following CMS non-facility place of service (POS) designations only:

POS Code  Description

03 School
05 Indian health service free-standing facility
07 Tribal
638 free-standing facility
11 Office
49 Independent clinic
50 Federally qualified health center
71 State or local public health clinic
72 Rural health clinic Oxford will reimburse the following participating primary care providers for CPT 99050:

* Adolescent medicine, pediatric-adolescent, pediatrics
*Family nurse practitioner, nurse practitioner, pediatric nurse practitioner, advanced registered nurse practitioner
*Family practice
*General practice
*Geriatric medicine
*Gynecology, obstetrics & gynecology, obstetrics
*Internal medicine
*Certified nurse mid


Questions and Answers

1Q: Why doesn't United Healthcare provide reimbursement for CPT codes 99053, 99056, 99058 or 99060?

A:The After Hours and Weekend Care policy is intended to reimburse participating primary care providers for services that are outside their regular posted business hour as an alternative to more costly emergency room or urgent care center services. Reimbursement for CPT codes 99053, 99056, 99058 or 99060 would not accomplish this purpose and are not reimbursed by CMS.

2Q:  When will United Healthcare provide reimbursement for CPT code 99050?A:  United Healthcare will provide reimbursement for CPT code 99050 during times other than regularly scheduled office hours, or days when the office is normally closed(eg, holidays, Saturday or Sunday), in addition to basic service.

3Q:  When will United Healthcare provide reimbursement for CPT code 99051?

A:  United Healthcare will provide reimbursement for CPT code 99051 during regularly scheduled evening, weekend, or holiday office hours, in addition to acute care services (not preventive medicine services).

CPT code 92540, 92541, 92543, 92545- 92547 - Vesticular Evaluation

Procedure code and Description

92540 Basic vestibular evaluation…

92541 Spontaneous nystagmus including gaze and nystagmus, with recording  test, fixation

92542 Positional nystagmus test, minimum of 4 positions, with recording

92543  Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests), with recording

92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording

92545 Oscillating tracking test, with recording

92546 Sinusoidal vertical axis rotational testing

92547  Use of vertical electrodes (List separately in addition to code for primary procedure)


Reimbursement Guidelines from UHC insurance

UnitedHealthcare Community Plan reimburses for audiologic/vestibular function testing (CPT codes 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, 92547, 92550, 92553, 92555, 92556, 92557, 92561, 92562, 92563, 92564, 92565, 92567, 92568, 92570, 92571, 92572, 92575, 92576, 92577, 92582, 92583, 92584, 92585, 92597, 92620, 92621, 2625) when one of the diagnosis codes are listed on a claim denoting problems associated with either balance or hearing.

UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD9/ICD-10 diagnostic codes being included on the claim accurately reflecting the member’s condition.

Basic Vestibular Evaluation

 The basic vestibular evaluation (92540) is a bundled code, defined as including ƒ 92541,92542, 92544, 92545 .

These procedural components must be included in their entirety, including a minimum of four positional tests. If all four of these procedural components are not
completed on a patient in a single encounter, it is inappropriate to use the bundled 92540 code. Instead, you report the individual codes for the procedures that were performed.

However, since the intent of the basic vestibular evaluation is bundled to include four components, when filing the claim for this evaluation a modifier must be added to indicate the procedure was not completed as intended.

In such a situation in which all four of the procedures of the vestibular evaluation were not completed, a modifier 59 would be added to each of the individual codes that were performed to indicate that they were separate and distinct diagnostic procedures to indicate a distinct procedural service. When using the modifier 59, make sure there is appropriate documentation in the report as to why the full basic vestibular evaluation was not performed. Always remember, it is inappropriate to unbundle the vestibular evaluation code for the sole purpose of higher reimbursement by billing the components separately

Dix-Hallpike

There is no specific CPT code for “Dix-Hallpike.” This maneuver is typically considered a positional component of 92542, positional nystagmus test, minimum of four positions. As noted earlier, CPT code 92542 is also included as part of the basic vestibular evaluation (92540). If performed in isolation, 92542 should be reported with the modifier 59 to indicate a distinct procedural service

Humana insurance billing Guide

CPT code 92540 (basic vestibular evaluation) includes all the services separately included in CPT codes 92541 (spontaneous nystagmus test), 92542 (positional nystagmus test), 92544 (optokinetic nystagmus test), and 92545 (oscillating tracking test). Therefore, none of the component test CPT codes (92541, 92542, 92544, and 92545) may be reported with CPT code 92540. Additionally, if all four component tests are performed, CPT code 92540 should be reported rather than the four separate individual CPT codes. If one, two, or three of the component tests are performed without the others, the individual test codes may be reported separately. However, if two or three component test codes are reported, NCCI-associated modifiers should be utilized


Billing and coding Guidelines

This bundled code is used to bill for codes 92545, 92542, 92544, and 92545 when they are performed on the same patient on the same date of service.

92543 is not included in this bundle and should still be billed separately with the appropriate number of units to reflect the number of irrigations performed.

Spontaneous nystagmus portion of the common ENG/VNG test protocol; if billed with either 92542, 92544 and/or 92545 (two or three of the 92540 codes) add ‐59 modifier.


Positional portion of the common ENG/VNG test protocol, including all positions and the Hallpike maneuver; if billed with either 92541, 92544 and/or 92545 (two or three of the 92540 codes) add ‐59 modifier.

Optokinetic portion of the common ENG/VNG test protocol; if billed with either 92541, 92542 and/or 92545 (two or three of the 92540 codes) add ‐59 modifier.

Tracking portion of the common ENG/VNG test protocol; if billed with either 92541, 92542 and/or 92544 (two or three of the 92540 codes) add ‐59 modifier.

Use 92547 in conjunction with codes 92541‐ 92546

CPT CODE changes in 2019, add on code, deleted code

CPT Updates for 2019

The below CPT updates would give a brief note on 2019 code changes which includes the details on newly added codes, revised codes with descriptors and also the deleted codes. As we all know these codes are to be used for discharges occurring between Jan 1st,2019 through December 31st,2019.

There are no changes in the anesthesia and auditory system under surgery.

The chapters that saw the highest amount of changes are,

1. Category II codes,
2. Surgery – Integumentary,
3. Pathology
4. Medicine section.
A QUICK SNAPSHOT ON THE 2019 - CPT UPDATES
• 168 additions
• 72 deletions
• 49 revisions
With a Glimpse on the 2019 CPT updates related to some specialties which are high level overview of the changes in this newsletter


Add-on codes:


▪ 24 new add-on codes are added throughout the chapters

* Surgery Integumentary
* Surgery Musculoskeletal
* Surgery Cardiovascular
* Radiology
* Medicine
* Category II Code set


Cardiology:

▪ There are 16 CPT codes changes from cardiovascular.

* Loop recorder implantation and removal CPT codes are deleted (CPT 33282 & 33284)

* Leadless pacemaker, Cardiac rhythm monitor, peripherally inserted central venous catheter (PICC) are newly added in cardiovascular section.

* Peripherally inserted central venous catheter (PICC) CPT code are revised with added description of "without imaging guidance"


Musculoskeletal:

▪ There are 6 CPT codes changes from Musculoskeletal section.

* 3 codes added for Allograft (CPT 20932, 20933 & 20934)

* The existing knee arthrography contrast injection code 27370 was deleted and replaced with new CPT code 27369


Integumentary:


▪ There are 19 CPT codes changes from Integumentary.

* Fine needle aspiration, Tangential, Punch & Incisional biopsy codes are newly added in Integumentary section.

* 3 more deleted in skin biopsy & Fine needle aspiration codes from Integumentary.


Evaluation and Management:

▪ There are 10 CPT codes changes from Evaluation and Management.
* Interprofessional telephone/Internet/electronic health record assessment and management service, Remote monitoring of physiologic parameter codes are newly added in Evaluation and Management.

* CPT 99491 added in “Chronic Care Management CCM)’’ in E&M section.

*  The “electronic health record” are revised description in Interprofessional telephone/Internet/electronic health record assessment and management service.



Medicine:

▪ There are 60 CPT codes changes from Medicine section.

* Out of 29 new codes ranging from 1 new flu vaccine code are newly added to Electroretinography services, Developmental testing, Psychological and Neuropsychological testing evaluation services

* Pacemaker programming & Interrogation CPT code are revised with added description of " or leadless pacemaker system in one cardiac chamber"


* Loop recorder programming & Interrogation CPT code are revised with added description of " subcutaneous cardiac rhythm monitor system"

Radiology:


▪ 10 new codes were added as well as 6 deleted codes and 4 codes with revisions
o 76391: Magnetic resonance (e.g. vibration) elastography
o 76978, 76979, 76981, 76982 and 76983 – new ultrasound codes (please note that 76979 and 76983 are new add-on codes)
o 77046, 77047, 77048 and 77049 are all added codes for MRI of the breast



Deleted CPT codes

Deleted CPT Codes effective from 1/1/2019

10022 43760 64550 81213 96103 0189T 0363T 0372T 11100 46762 66220 81214 96111 0190T 0364T 0374T 11101 50395 76001 92275 96118 0195T 0365T 0387T 20005 61332 77058 95974 96119 0196T 0366T 0388T 27370 61480 77059 95975 96120 0337T 0367T 0389T 31595 61610 78270 95978 99090 0346T
0368T 0390T 33282 61612 78271 95979 0001M 0359T 0369T 0391T 33284 63615 78272 96101 0159T 0360T 0370T 0406T 41500 64508 81211 96102 0188T 0361T 0371T 0407T


Highlights of 2019 Changes


Eliminating the requirement to document the medical necessity of a home visit in lieu of an office visit

For E/M office/outpatient visits for new and established patients, allowing physicians to not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary

CMS will not apply the multiple procedure payment reduction policy to office visits and other services done at the same encounter

CMS will pay separately for two newly defined physicians’ services furnished using communication technology: Brief communication technology-based service & Remote evaluation of recorded video and/or images submitted by an established patient

CMS is removing the originating site geographic requirements and adds the home of an individual as a permissible originating site for telehealth services