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  1. jkyles

    Wiki GXXXX5

    Hi there, Are you reporting the assessment with an annual wellness visit? That's the only time you should append modifier 33. Otherwise it is not a preventive service...
  2. jkyles

    Wiki Phone Visit In-Office

    Hi there, The office/outpatient visit requires a face-to-face encounter or a real-time audio and video connection if you're doing it via telehealth. Assuming the visit meets all of the other requirements (and the doctor documented the time), I could see reporting it as a telephone E/M...
  3. jkyles

    Wiki Interpersonal/Telephone/Internet/Electronic Health Record Consultations and QHP

    Hi there, the LCSWs themselves should know whether they're allowed to report E/M services under their state scope of practice. If they can't report E/M visits, they can't report other E/M services.
  4. jkyles

    Wiki pudenal nerve branch blocks

    Hi there, I highly recommend starting with your payer policies if you plan to bill for this service. It may not be covered at all. For example, Medicare does not consider services performed solely for patient comfort or provider convenience to be medically necessary.
  5. jkyles

    Wiki Shared Visit: Doctor treats new problem & mid-level treats follow-up problem

    I would just add that the PA must be extremely careful to just serve as a scribe. They cannot include any of their clinical impressions in the note. For example: The MD/DO sees the patient, but forgets to review some lab results that would otherwise count toward the visit. The PA (serving as...
  6. jkyles

    Wiki Time vs. MDM-Clarification Please

    Hi there, Unless the auditor can point to a specific payer policy, there's no such thing as matching the MDM to the time for a code (or vice versa). MDM and time are two independent concepts. The CPT editorial group deliberately structured the new coding guidelines to allow providers to...
  7. jkyles

    Wiki Billing G2212 in 2024

    I did see that recently. But until CMS makes the update, that only applies to providers in NGS' jurisdiction. I would also highly recommend that everyone who bills G2212 to NGS save a copy of that page on their computer, just in case. 😁
  8. jkyles

    Wiki G2211- HELP!

    Hi there, I highly recommend the link posted above. Some quick answers: 1. The code can be reported by any provider who can bill office/outpatient E/M visits under their own name/NPI. 2. There's no limit, but the documentation for each visit must meet the requirements for the code. 3. It can...
  9. jkyles

    Wiki In house urine drug test

    Hi there, you do need a CLIA certificate of waiver. Certification of some sort is mandatory for providers that perform lab testing on patients. The type of certificate depends on the complexity of testing performed in the lab. Here's some reading material that may help...
  10. jkyles

    Wiki Billing G2212 in 2024

    Hi there, continue to follow the time guidelines that CMS published in CMS 100-04, Chapter 12, ss 30.6.15.2. The chart sets a minimum of 89 minutes for one unit of G2212 for 99205 and 69 minutes for 99215. CMS disagrees with the AMA/CPT definition for the 9941x codes, which is why it maintains a...
  11. jkyles

    Wiki Telephone only visit for new patient.

    Hi there, everything I've read indicates you cannot report telephone visits for new patients after the PHE. This sounds like an instance where you need to check the carrier for information on how to code when there are technical difficulties like this.
  12. jkyles

    Wiki Telehealth documentation requirements

    Hi there, I agree with you and so does the HHS Office of Inspector General. In a recent audit report the OIG identified failure to report the type of visit (in-person, telehealth or telephone) and reporting telephone visits with an office E/M code as errors. The OIG also identified a failure to...
  13. jkyles

    Wiki Prolonged Modifiers

    Hi there, Please review the full descriptors for codes G0316, G0317, G0318 and G2212. The descriptors include the language "list separately in addition to CPT codes" to indicate they should be reported with the primary E/M service. You'll find more information on prolonged service coding in this...
  14. jkyles

    Wiki Can you charge Critical Care WITHOUT Time Noted?

    Hi there, please review the guidelines in the CPT manual. They clearly state that the provider must document time. Correcting a note might be an option, but the provider will need to follow the carrier's rules or guidelines. Here are the guidelines from Noridian, but check with your own MAC...
  15. jkyles

    Wiki 2024 Split or Shared Visits

    Hi there, it will depend on the carrier. CMS rules are stricter than CPT guidelines. In the 2024 final physician fee schedule Medicare stated that whoever bills the visit must personally perform and document the substantive portion of MDM (problem and risk). I haven't seen any requirements for...
  16. jkyles

    Wiki MAC without sedation

    I recommend starting here to understand the services the anesthesia provider might perform during MAC: www.asahq.org/standards-and-practice-parameters/statement-on-distinguishing-monitored-anesthesia-care-from-moderate-sedation-analgesia
  17. jkyles

    Wiki Your favorite underrated coding tools

    I have two that I think are vital but frequently overlooked: 1. National Correct Coding Initiative - including the edit sets and the manual. 2. Appendix A of the CPT manual. It contains the full descriptors for CPT modifiers.
  18. jkyles

    Wiki inpt charge if not seen

    You cannot.
  19. jkyles

    Wiki G2211 questions

    Hi there - 1. If you don't have a claims history for how you've reported the fingerstick in the past, check the NCCI edits. 2. Short answer: I think so. Longer answer: Remember that according to the descriptor, the care can be related to a serious or complex condition. I haven't seen a list of...
  20. jkyles

    Wiki Telehealth Denials

    Hi there, does Medicaid still require modifier 95? I know that Medicare dropped the modifier in 2024 and now requires a place of service - either 02 (if the patient was not at home during the encounter) or 10 (patient was at home). You should check to see whether Medicaid also switched to place...
  21. jkyles

    Wiki 99459

    Betsy Nicoletti has a helpful summary here: https://codingintel.com/billing-pap-smear/.
  22. jkyles

    Wiki Urine Drug Screen Coding

    The lab code is right but that diagnosis code is incredibly vague and the clarifying term for it is "Encounter for screening for genitourinary disorders". That doesn't make sense for a UDT. The diagnosis code you use must reflect exactly why the provider ordered the test. Ask them what they're...
  23. jkyles

    Wiki Telehealth visits

    Hi there, if MDM is an element of the in-person version of the visit (for example 99202-99215) then you can use it for the telehealth visit.
  24. jkyles

    Wiki Telehealth Place of service

    Hi there, that would be place of service 02 (Telehealth provided other than in patient's home. Patient is not located in their home when receiving health services or health related services through telecommunication technology.)
  25. jkyles

    Wiki ASC BILLING QUESTION FOR NERVE BLOCK CODE 64447

    Hi there, it is in the National Correct Coding Initiative Manual, chapter 2. https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-2.pdf
  26. jkyles

    Wiki Transitional Care Management

    Hi there, this sounds like an office visit. Not every patient who was very ill while in the hospital will need TCM. I recommend comparing the documentation for the visit to the CPT guidelines for the code, including whether the medical decision making for the visit was high. Remember to check...
  27. jkyles

    Wiki Are there moderators for this forum?

    Great comments above. I would add that: 1. Even though this forum doesn't have a rule against ALL CAPS, some people still equate it with shouting and will ignore posts written with the Caps Lock engaged. 2. I can't explain exactly why, but I've become increasingly hesitant to answer a question...
  28. jkyles

    Wiki Telehealth Billing after PHE and changes to place of service causing lower reimbursement

    Yes, I've only looked at that portion of the rule a thousand times. I don't know what I was thinking then. o_O
  29. jkyles

    Wiki Can G2211 be billed by providers other than the patient's Primary Care Provider?

    Hi there, someone asked a similar question during CMS' open door forum last week. According to the CMS official, the answer is yes. Providers at the same practice/specialty can bill for G2211 when they can stand in for one another, assuming the visit and their documentation meets the...
  30. jkyles

    Wiki E/M Utilization Benchmark Tool

    Also: www.codingbooks.com/products/coding-books/e-m/2024-em-bell-curve-sourcebook Products that use Medicare data will (or should) have data that is current to 2022. Medicare data for 2023 will be available at the end of this year.
  31. jkyles

    Wiki Inpatient Consult Split/Shared Services

    Hi there, for Medicare it will depend on whether the physician's documentation shows they performed the substantive portion of the MDM, versus signing off on the PA's MDM. In the final rule CMS indicated the person who actually does (and documents) the work should report the visit. Betsy...
  32. jkyles

    Wiki G2211 Medicare Advantage plans

    Hi there, I agree that this is likely a system update issue and payers just aren't ready to process the code. For Medicare Part B, the implementation date for the code is Feb. 19.
  33. jkyles

    Wiki Anesthesia Diagnosis

    I would just add that depending on the pain procedure and the carrier, you might receive a denial that you'll need to appeal. Medicare and a lot of private payers have adopted policies that treat anesthesia for blocks and RFA of the spine as medically unnecessary unless the documentation...
  34. jkyles

    Wiki Can an MD bill incident to with a DDS?

    Hi there, I recommend members of your practice read your MAC's materials on incident-to services. It looks like NGS has a lot of information, including a webinar in December. Two things to consider now: Every provider must work within their scope of practice. The DDS can't perform services...
  35. jkyles

    G2211 for Home Visits

    Hi there, you can only report G2211 with office/outpatient visit codes (99202-99215). Here is the full descriptor:
  36. jkyles

    Wiki E/M code vs procedure code

    Hi there, every claim must accurately reflect the work the provider performed. Submitting a different code just because it pays more is at the very least an abusive form of billing, which could lead to allegations of fraud, investigations and so on. Medicare has a handy booklet on fraud and...
  37. jkyles

    Wiki Shared Visit: Doctor treats new problem & mid-level treats follow-up problem

    I'm assuming the PA is enrolled with Medicare. In that case you can bill the visit under the PA's name and NPI, but make sure you level the visit based solely on the PA's work. It sounds like your providers are just a bit confused about team-based care. Which is understandable. Some things to...
  38. jkyles

    Wiki SDOH Risk Assessment as an Optional AWV Element

    It's going to depend on the MAC and how their system is set up. You can always send a claim through and see what happens.
  39. jkyles

    Wiki Telehealth Billing after PHE and changes to place of service causing lower reimbursement

    EDIT: Effective Jan 1, 2024 - Medicare Part B pays the facility rate when the patient is not at home (POS 10) and the non-facility rate when the patient is NOT at home (POS 02). Apologies, as two people have noted I got my POS completely backwards here.
  40. jkyles

    Wiki SDOH Risk Assessment as an Optional AWV Element

    Hi there, the implementation date is the date Medicare administrative contractors must be able to enforce a policy, such as process claims for a code or enforce an edit.
  41. jkyles

    Wiki When is it appropriate to use the codes G3002 and G3003 with chronic pain management visits along with E&M codes?

    Hi there, a provider can report an E/M visit and a CPM service on the same day, but there can't be any overlap in the work. From the 2023 final rule: https://www.federalregister.gov/d/2022-23873/p-1180
  42. jkyles

    Wiki G2111 and Telehealth

    Hi there, I assume you're asking about add-on code G2211 (complexity of care). It can be performed with a primary office/outpatient visit that is performed via telehealth and is on Medicare's list of covered telehealth services. I haven't seen anything that says it can be reported with a...
  43. jkyles

    Wiki Stable vs unstable chronic condition

    Hi there, I'm not sure which guidelines you're looking at, but you'll need to know the treatment plan to determine whether the patient is stable. The CPT manual states in part: Chronic pain is an example of a condition that might be stable even though it not completely resolved...
  44. jkyles

    Wiki Neurology clinic codes

    Hi there, greater occipital blocks are reported with 64405. According to CPT Assistant Oct. 2016 the lesser occipital is reported with 64450. I'm assuming you've looked at their latest policy and the services are covered for the diagnosis code(s) you're reporting. Please provide the denial...
  45. jkyles

    Wiki Hospital Shared Visits MDM

    Hi there, I would say that is correct for Medicare based on this statement from the final 2024 physician fee schedule: Also, when CMS first released its new split/shared rules it indicated it wanted to move away from scenarios where the physician performed a drop in visit but got full credit...
  46. jkyles

    Wiki surveys

    Hi there, the AAPC still conducts an annual survey and issues a report. Go to the main website and search for Survey.
  47. jkyles

    Wiki BASE UNITS FOR CPT 00812

    Hi there, the ASA assigns 4 base units, but CMS assigns 3, which is why you've seen two different values.
  48. jkyles

    Wiki E/M AND INJECTION HELP

    Hi there, this isn't a stupid question, but it can't be answered based on the diagnosis codes alone. You need look at the rest of the note for that encounter. For starters, I recommend that anyone who has questions about using a modifier review the complete descriptor, which is in Appendix A of...
  49. jkyles

    Wiki E/M BASED ON TIME. PLEASE HELP ASAP. THANK YOU

    Agreed. While I've yet to see official guidelines from CMS on how to document time beyond that you can use total time or start/stop time, the provider must still follow general guidelines for documenting encounters. You can't just go by the EMR time. In this example, vitals are usually...
  50. jkyles

    Wiki phone call - location of patient

    For Medicare, under the PHE waiver extension that is in place until Dec. 31, 2024, you don't need to justify the use of audio-only services.
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