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  1. R

    Wiki CPT code 99417 for UHC

    UHC has been following Medicare guidelines. Check the Prolonged Services policy with UHC, but I think they accept G2212 instead.
  2. R

    Wiki G2211 with PHQ2 and TCM

    Has to be an O/O E/M visit and 25 modifier cannot be appended. It's in the MLN article and the 2024 Physician Fee Schedule Final Rule.
  3. R

    Wiki Infusion start/stop times

    Start and stop times that are actually performed. Dr could order 2 hours but an adverse reaction occurs and there's additional time, or they stop the infusion, etc. You code what was actually done.
  4. R

    Wiki Immunotherapy Injection with Ultrasound

    Definitely going to be an unlisted code. I was looking at intralesional injections last week. I'd have to look at my books at work, but I'd consider unlisted chemotherapy (as chemotherapy also includes complex drug and highly complex biological agents).
  5. R

    Wiki G2211- HELP!

    Throwing this one out there too: https://society.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/2024-01-Visit-Complexity-AddOn-Code.pdf
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    Wiki IV infusion

    No admin code for the hydration. It's at the same time.
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    Wiki Cancer as illness posing a threat to life

    CPT Manual definition states "poses a threat to life or bodily function in the near term without treatment".
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    Wiki Prior Authorization

    Check policies on the payer website. Get names, dates, and times if no reference number is available. I used to get the run around from benefits/eligibility. I didn't both with them, because in the end I'd need to check with PA department anyway. I had one tell me no auth was needed, but...
  9. R

    Wiki Denials of high dollar drugs with JW for wastage

    If this is a commercial member and not a Medicare Part B member, you can't look at the NCD for Medicare. You have to go to BCBS Michigan's clinical policy for the drug. If you go to the clinical policy for BCBS Michigan, it shows non-small cell lung cancer, small cell lung cancer, biliary...
  10. R

    Wiki Z08

    I understand why you feel that way. However, there was an update to the guidelines for 2024. "Codes Z08, Encounter for follow-up examination after completed treatment for malignant neoplasm, and Z09, Encounter for follow up examination after completed treatment for conditions other than...
  11. R

    Wiki RTM coding

    No.
  12. R

    Wiki Prostate cancer with cancer symptoms

    C61 for Prostate cancer with z19.2 for castration resistant hormone status
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    Wiki Prostate cancer with cancer symptoms

  14. R

    Wiki prolonged cpt code

    Nope, they need to be documenting actual total time, not just "in excess of". Also 60 minutes won't cut it for Medicare with the way they apply the prolonged service time. Most Medicare Advantage plans use the G codes for prolonged services. It's payer choice as to which set of codes they take...
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    Wiki 99212 denial

    It's not just commercial plans. Medicare, as shown in previous payment rules, can choose to accept AMA guidelines (CPT coding) or make their own. Take prolonged services for example. They didn't like how the time period was applied so they made their own code. Commercial plans can choose to...
  16. R

    Wiki Pharmacy Claim/Billing

    Usually if the payer is requiring the dispensing from the pharmacy, it's usually as part of the pharmaceutical benefits - not medical. Is this a specialty med that is subject to site of care or specialty pharmacy restrictions? If so, then yes the bill would be under the pharmacy benefit. The...
  17. R

    Wiki Hospital Shared Visit Language Template

    Ugh, I expect pushback on that again. I'll be interested to see what comes out in the proposed rule. There was significant pushback on this last year, hence the delay on the final rule.
  18. R

    Wiki FY 2024 ICD-10-PCS Code Files

    They've posted the ICD-10-CM files too!
  19. R

    Wiki 2024 update - cachexia

    Can someone explain to me why cancerous cachexia points to R64 Cachexia, but now this code has an excludes1 for cachexia due to underlying condition (E88.A)? Wouldn't the cancerous cachexia be due to an underlying condition? UPDATE: CMS update fixed this issue.
  20. R

    Wiki 99490 Chronic Care Management

    It is my understanding that the time spent should be coordinating care for the chronic conditions. Also consent is required, I've posted some resources that better explain it. The following is a great resource for these services - and includes a bit about the consent required...
  21. R

    Wiki Horizon BCBS denying 76942

    Check into NCCI PTP edits. There's an edit between the 76882 and 76942. Has nothing to do with Horizon medical policies but they do utilize NCCI edits as part of their claims reimbursement edits. Anytime you have a bundled denial, NCCI edits should be the first place you look.
  22. R

    Wiki Does the assessment count as the reason for the visit?

    If the patient is only there for the botox injection, there has to be something over and above for the provider to bill for an e/m. Otherwise, you can only bill for the injection. That presenting problem has been an issue with providers not understanding that "here for treatment" is not a...
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    Wiki Revision to Modifier 25 Policy for CIGNA

    More like delay...again. Here are the details regarding its announced delay: Cigna is currently reevaluating this reimbursement policy update, which will delay implementation. Cigna will look to implement this policy later, when it can optimize the provider experience and perform additional...
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    Wiki Medicare Not Accepting Corrected Claims

    Novitas requires a claims correction through their portal or the provider line. They do not not accept electronic claims corrections with a resubmission code. Not sure which MAC you're referring to, but other MACs may be similar.
  25. R

    Wiki modifier 25 reduction

    Looks like you received info above that applies. However I'd also like to point out that there are a number of payers that have reductions for modifier 25 usage according to their payer policy. Payers do not have to follow CMS guidelines.
  26. R

    Wiki CT and MRI Contrast Waste

    Drug waste modifiers apply to single-dose vials of separately payable drugs. It would depend on the contrast and its payment indicator as to whether the modifier applies. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf
  27. R

    Wiki J84.10 and pulmonary nodules

    Pulmonary nodules are not necessarily fibrosis. Unless there is a specific diagnosis, multiple pulmonary nodules falls under R91.8.
  28. R

    Wiki Drug waste and MUEs

    MUE includes total billed units, but some MUEs can be appealed (which doesn't always mean that they will be paid, but that the MUE edit can be overriden in some situations). It depends on the CPT and the edit indicator.
  29. R

    Wiki Multiple Modifiers for ESA Drugs

    Do you have a source for this that I can refer to?
  30. R

    Wiki Using 99358 and 99359 for Chemotherapy Plans

    Not with Medicare. Those codes are non-payable by Medicare effective 2023.
  31. R

    Wiki Practice Management Professional Orgs

    I work in oncology and just came across a few states with Oncology Manager/Management societies. I can only find less than a handful though. Does anyone know of which states have societies, associations, or groups for Oncology Managers?
  32. R

    Wiki New Facebook group

    There's now Facebook groups for our oncology coders and billers. Feel free to join us over on the book to discuss all things oncology coding and billing. Medical Oncology: https://www.facebook.com/groups/561194622452788/ Radiation Oncology: https://www.facebook.com/groups/radiationoncologycoders/
  33. R

    Wiki Billing for Category III code

    Category III codes aren't always reimbursable. It's a case by case basis and by payer. Basically these codes have been created to establish usage so that in the future a category I code might be created. Reach out to the payer to see if they reimburse the code.
  34. R

    Wiki Cancer and Hepatitis Dx in patients with liver transplant.

    If the primary cancer of the liver has been excised and is no longer receiving treatment for that, then it's a history of code. I would query the physician about the hepatitis and whether this is considered active or not. The physician would need to state the current status of the hepatitis.
  35. R

    Wiki Radiation Oncology Diagnosis

    I've had to do this and explain to the doctor why it wouldn't be coded as a neoplastic code. If the documentation doesn't show a definitive cancer diagnosis, they will have issues getting an authorization for the services and/or recoupment should they be audited due to medical necessity.
  36. R

    Wiki 2023 Home/Domiciliary vists and POS

    POS isn't changing. Just descriptors. See the inpatient/obs discussions on the board. Call the payer and tell them that CPT codes have changed and ask if their policy has been updated accordingly. Also appeal based on CPT coding guidelines.
  37. R

    Wiki 2023 observation cpt codes

    They're not changing the requirement to report the admitting modifier or their 8-to-24 hour rule. They are adopting the coding changes for inpatient and observation care though per the CMS PFS Final Rule such as descriptor times, code level selection on mdm/time. The descriptor has been updated...
  38. R

    Wiki Revised CPT E/M MDM Grid

    It's in the CPT book, and AAPC has a free E/M tool for the 2023 guidelines like they did for the 2021 changes.
  39. R

    Wiki CPT 77336 AND 77370 (POS)

    Aetna was giving me those denials, and I even appealed. Was told it was a no go because Aetna's policy doesn't allow for the guidance with certain modalities. I don't have access to the denial anymore, but if you found a way to counter these I'd be interested in hearing about it.
  40. R

    Wiki XGEVA dx question

    Yes, bone mets as primary as this is the primary indication for the drug.
  41. R

    Wiki MUE and drug waste

    MUE includes all units billed. When the "powers that be" evaluate codes for MUE, they typically take into account the usual and customary use of whatever is being billed. I've seen some of the drug MUEs, and usually they're pretty high or at what is considered FDA approved. I would double...
  42. R

    Wiki 'DR' Modifier

    I found a resource (https://www.cms.gov/files/document/se20011.pdf), and thought maybe this would apply. However not really sure of your situation, so I did include the link for the Medicare resource. "Allows extended neoplastic disease care hospitals to exclude inpatient stays where the...
  43. R

    Wiki Need CEU's for CHONC ASAP....

    Try Himagine
  44. R

    Wiki Ceftriaxone/Rocephin dosage documentation

    Dosage must be documented, but it doesn't have to reach 1000mg. It can read the 1 gram.
  45. R

    Wiki 2023 observation cpt codes

    Yes, the CPT code definitions have been revised for 2023 to read hospital observation and inpatient services.
  46. R

    Wiki Immunization Clinic

    I would be cautious as it depends on the immunization on whether Medicare will even cover under Part B, regardless of the physician's specialty. The majority of immunizations are only covered by Part D. Second question would be the same as the above - is it within the scope of practice?
  47. R

    Wiki CMS Procedural Time list

    It's usually an addendum file to the PFS Final Rule. Look for Physician Time.
  48. R

    Wiki Medicare new LCD/NCD advice

    https://practice.asco.org/sites/default/files/drupalfiles/2022-07/Medicare-Coverage-Documents-NCD-LCD.pdf https://med.noridianmedicare.com/web/jfa/policies/lcd/new It's a process, and it may be determined that a policy isn't warranted for whatever reason.
  49. R

    Wiki Help determining risk level

    I would say it depends on if the provider explained the reasoning for not going with the surgery.
  50. R

    Wiki MIPS AMD APM'S

    Some APM's are adopted by other payers as well. It may be beneficial to check the APM information on the Medicare website for details.
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