HCA Session II Preventative Medicine Visits Procedures Modifiers

HCASession II

Preventative Medicine VisitsProceduresModifiers

Preventative Medicine Visits CPT Code 99381-87 (new) 99291-97 (est)

Preventative Medicine Visit Codes include payment for: The review of “stable” chronic problems Routine Screenings (eg. Pap smear, breast & pelvic, manual

rectal exam) Risk Factor Counseling

Billable Separately When Billed on Same Day as Physical are: 99211-99215 E&M Office Visit codes (for re-management of

existing problems or new problems (need mod 25) Injections, Immunizations Procedures Performed (exception Medicaid – they will only pay

for procedure) Some Screenings Labs (Indicate signs/symptoms or diagnosis to support testing)

Preventative Medicine Visits continued

Dx Codes: V70.0 (well adult) V72.31 (Gyn w/or w/o Pap)

Medicare

Effective 1/1/05 MC will pay physical / new MC enrollee / within 6 mths G0344

Also: G0366: EKG (global) G0367 (EKG tracking only) G0368 (EKG Inter & Rep Only)

Medicare does not pay for routine annual physicals (99381-87; 99391-97)

Medicare will pay for 99211-99215 services (eg. medically necessary follow- up or new problems) billed w/physicals. Mod 25 needs to be affixed to 99211-15 codes.

Preventative Medicine Visits continued

HMOBlue/HPHC/TUFTS/Medicaid Will pay for physicals. They will also pay for 99211-99215 services billed with a

physical. Affix Mod 25 on 99211-15 codes.

Exception Medicaid– pays for physical Only - No E&M in same day.Exception Bc/Bs PPO Plans– Physical Coverage is on “age schedule”

Preventative Medicine Visits Re: Screenings

Medicare will pay for “ Screenings” billed in conjunction with a Physical Examination. HmoBlue/Tufts/Hphc/Medicaid do not pay for some screenings (*) billed w/a physical. However, they will always pay when billed with an E&M code (99211-99215) or when billed by itself.

*Q0091: Pap Smear Collection (Medicaid X8012)*G0101: Breast & Pelvic Screening (7-11 areas of GU system)*G0102: Manual Rectal Examination G0107: Blood Occult (Use 82270 only when there are signs/symptoms) 79095: Bone Density (Heel) G0104: Low Risk Flex Sig G0105: High Risk Flex Sig G0120: Barium Enema G0202: Screening Mammography


Q0091: Pap Smear Collection (Annual f/High Risk; every other yr f/ Low Risk) Not reimburseable when billed w/physical. X8012: Medicaid pap smear collection code

Diagnosis Code:

V76.47 Special Screening for Malignant Neoplasms; Vagina – No previous history of any abnormalities.V72.32 Abnormal Pap Smear (abn pap 3 mths back, redid pap – normal; this visit is f/u visit – 3rd visit)V76.2 Low Risk of Malignant Neoplasm – History of abnormal paps.V15.89 High Risk of Malignant Neoplasm – 7 or more sexual partners in lifetime, Hx of STD, 3+ abn paps in 7 yrs, colposcopy, CA dx.)


G0101: Breast & Pelvic Screening (7 out of the 11 areas in the GU system must be reviewed and documented.) Not reimburseable when billed w/a managed care gyn physical. Code G0101 only if “both” the breast & pelvic exam are performed. Coverage every 2 years. Diagnosis Codes:

V76.2 (low risk) or V15.89 (high risk) V76.49 Special screening for malignant neoplasms; other sites (to

indicate low risk for a patient who does not have a uterus or cervix).


G0102: Manual Rectal Examination (Not reimburseable when billed w/managed care physical) Annual Benefit (Age

50 & over)

Diagnosis Codes:

V76.44 Special screening for malignant neoplasms, prostate


G0107: Blood Occult (Routine Screening – In absence of signs/symptoms). Is reimburseable when billed

w/physical. Annual Benefit

Diagnosis Code: V76.51

Use CPT 82270 when there are signs/symptoms


79095: Bone Density Screening Every 2 years for those at risk of “losing bone mass”

Medicare will cover 80% of the cost of one bone mass measurement every 2 years.

Medicare will also cover follow-up measurements


G0104: Low Risk Flex Sig - once every 48 mthsG0105: High Risk Flex Sig - once every 24 mthsG0120: Barium Enema - alternative to Flex Sig / Screen

ColonoscopyFlexible Sig – 1 time every 4 yrs.

Colonoscopy – 1 time every 2 yrs if you are at high-risk for colorectal cancer (e.g. have a family history of the disease or have had colorectal polyps) or 1 time every 10 years if you are not at high-risk (but not within 48 months Of a screening flexible sigmoidoscopy)

Barium enema - this service is not covered if performed in addition to the other tests


G0202 w/76083 : Screening Mammography Annual Benefit

One screening mammogram a year for women 40 yrs & older. One baseline mammogram for women 35 to 39 years of age.

No Part B deductible is required for these services.

Procedures

Injections

Administration Codes / Immunizations 90471 (1) 94072 (ea. addl)Administration Code / Therapeutic or Dx 90782 (eg. Gyn – Depo, B12)Administration Code / IV Infusion 90780 (IM) 18 new codes for

2005Foreign Body RemovalEar Wax Removal 69210 (hearing loss pays;

impacted cerumen does not)EKGsEKG Routine 93000 (mod 76 repeat)

Procedures

Lesions

Lesion / Skin Tags 11200 (up to 15)

11201 (ea. addl grp of 10)

Lesions / Common or Plantar Wart 17000 (1) plus

17003 (for ea. addl – indicate)

Example: 6 removed bill 17000 x1 and 17003 x5 = 6

Lesions / Flat Warts, Molluscum /Milia 17110 up to 14

17115 15 or more report code.

Lesion / Vulva 56501

Lesion / Vaginal 57061

Lesion / Penis (cryo) 54056

Procedures

Gyn / Contraceptive ManagementDiaphragm or Cervical Cap Fitting 57170Insertion of IUD 58300Removal of IUD 58301Fitting and Insertion of pessary or other intravaginal support device 57160

Airway ManagementNebulizer Treatment 94640Nebulizer Treatment (subsequent)

94640-76Inhaler Instructions (teaching) 94664-59 Spirometry 94010Bronchospasm Evaluation 94060

Procedures

Incision & Drainage ; Puncture

Incision & Drainage (abcess, cyst) 10060

Incision & Drainage of Pilonidal Cyst 10080Incision & Removal of Foreign Body, subcut 10120Incision & Drainage of Hematoma, seroma or fluid collection 10140Puncture aspiration of abscess, hematoma, bulla or cyst 10160

Procedures

Paring/Cutting/Trimming/ExcisionParing/Cutting of benigh hyperkeratotic lesion

(corn or callus) single lesion 11055Paring/Cutting or benign hyperkeratotic lesion

corn/callus 2-4 lesion 11056Trimming of non-dystrophic nails, any # 11719Debridement of 1-5 nails 11720Debridement of 6-10 nails 11721Avulsion (toenail plate) 11730Excision of nail / nail matrix 11750Wedge Excision of nail fold 11765

Procedures

EpitaxisControl Nasal Hemorrhage, Anterior Packing; Simple 30901Control Nasal Hemorrhage, Posterior

Packing, Initial 30905Packing, Subsequent 30906No Modifier is Necessary

ExcisionsExcisions Lesion (trunk, arms, legs) Benign Malignant

0.6 to 1.0cm 11401 116011.1 to 2.0cm 11402 116022.1 to 3.0cm 11403 11603

Procedures

Aspiration and/or Injection

20600 “Small Joint” , bursa or ganlion cyst (eg. fingers, toe) 20605 “Intermediate joint”, bursa or ganglion cyst (eg.

temporomandibular, acromioclavicular, wrist, elbow or

ankle (olecranon bursa). 20610 “Major Joint”, bursa or ganglion cyst (eg. shoulder, hip, knee joint, subaromial bursa).

Procedures

Tendon/Ligament / Ganglion Cyst / Injections / Excisions There must be an inflammatory process in a given tendon (tendonitis) or tendon sheath tenosynovitis) CPT Codes: 20526 Injection of carpal tunnel with local anes or corticosteroid 20550 Injection(s); single tendon sheath, or ligament,plantar fascia) 20551 Injection(s); single tendon origin/insertion 20612 Aspiration and/or injection of ganglion cyst(s) any location 25111 Excision of Ganglion, wrist (dorsal or volar); primary 25112 Excision of Ganglion, wrist (dorsal or valar) recurrent

Procedures

Trigger Point Injections

Use 20552 Injection(s); single or multiple trigger point(s), one or two

muscle(s) – regardless of the # of injections in those muscle groups

Use 20553 Injection(s); single or multiple trigger point(s), three or more muscle(s) – regardless of the # of injections within those muscle groups

Procedures

Wound Repair

Simple Suturing

12001 simple repair scalp, neck,axillae,ext genitalia,trunk and/or extremities (includes hands/feet) 2.5cm or less.

12011 simple repair of face, ears, eyelids, nose, lips and/or mucous

membrances 2.5cm or less.

Services Billable In Addition to E&M

Tufts, HPHC, NHP pay for the services listed below.Medicare, Medicaid, Blues DO NOT PAY.Bill the services below along with a 99211-99215 when applicable:

CPT99058: Emergency Services99050: Services requested after “posted hours”99052: Services requested between 10:00pm and 8:00am99054: Services requested on Sundays or Holidays

Modifiers

Modifiers are 2 digit codes which accompany a 5 digit CPT code in order to further describe a situation to support additional payment when more then one service is being reported in the same session on the same day.

Primary Care Modifiers

25, 76, GE, GC

Modifier 25

Modifier –25

Should only be appended to evaluation and management (E/M) service codes HCPCS codes G0101(Breast & Pelvic Screening) and Procedures

You do not need a modifier 25 when billing an office visit and also billing for:

1) Diagnostics (eg. EKG) 2) Immunizations 3) Screenings

Modifier 25 Examples

Modifier 25 Examples

1) When the patient presents for a planned procedure and has a different problem that requires an E/M service (two different diagnoses would be used to distinguish the services)

2) the patient presents with a "minor" problem and after evaluation the decision is made to perform a procedure. In the second example –25 is used if the procedure is minor in nature, meaning that the post-operative period is less than 90 days and the primary diagnosis would be the same for both.

Modifier 76

Modifier 76

Use modifier 76 when you repeat a service already performed with the same diagnosis code within a 30 day period. Example: Chest pain order EKG 93000 and did a repeat 2 wks later same diagnosis “ chest pain” – affix modifier 76 on 93000.

Documents

HCA Session II Preventative Medicine Visits Procedures Modifiers