Providers

• An example of an appropriate diagnosis code may be for a member who is confined to the bed, dependent on a respirator/ventilator or have a need for continuous supervision.

Place of service codes are used to identify where a procedure or service is furnished to a patient. Services within Independent lab settings (POS 81) should only be billed once per day as it would be extremely rare to need two different labs for the same tests on the same date of service, for the same patient.

• In addition, claims from a physician/provider within the office setting are incorrectly coded when a claim from any outpatient facility (e.g. ambulatory surgical center, outpatient hospital) exists for the same date of service and for the same procedure or service.

• According to the AMA CPT Manual, modifiers 52 and 53 are used by a physician or other qualified health care professionals to report a service or procedure that has been partially reduced or discontinued.

• Modifiers 73 and 74 are used by an outpatient facility to report a surgical or diagnostic procedure that has been discontinued, either before or after anesthesia has been administered.

• There should be consistency between the professional claim and the outpatient facility claim when these reduced or discontinued services are reported. 

• Transthoracic echocardiography codes represent a complete ultrasound study of the heart. When an initial, complete study is performed, and another study is performed within six months for the same diagnosis, this latter study should represent a follow-up study given the fact that the complete study has already been done recently for the same condition.

• According to CMS policy, Evaluation and Management (E/M) services are not separately payable when performed on the same date of service as implantable cardiac device monitoring services, cardiac device evaluation services or noninvasive physiologic studies.

• CMS also states it would not be necessary to perform a mobile cardiovascular telemetry (MCT) procedure or external patient activated single or multiple event recording with pre-symptom memory loop test more frequently than once in a six-month period.

• According to the American Heart Association and the National Institute of Health and Care Excellence, evaluation of cardiovascular function with tilt table testing should only be performed for suspected neurocardiogenic syncope.
  
  -Furthermore, it is not appropriate to perform evaluation of cardiovascular function with tilt table testing for syncope and collapse if significant arrhythmia is not first ruled out by electrocardiographic monitoring.

• According to CMS Policy, services, such as these, which are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered. A lower limb medical event would be an amputation of the leg (at the hip joint, below the knee or above the knee), or foot (including ankle or ankle disarticulation).
  
  
• Once a patient has had a lower extremity amputation, certain lower limb services cannot be performed on the same leg since the required anatomical structures for the procedure or service are no longer present

• Scenarios where a patient has multiple initial hospital care services billed within three days of a prior initial hospital care service for the same diagnosis will be changed to a subsequent hospital care service, because the services rendered for the same diagnosis represent a continuation of the same episode of care.

• According to the AMA CPT Manual, inpatient neonatal and pediatric critical care services may be reported by only one physician and only once per day, per patient. Initial pediatric critical care codes are to be reported on the day of admission only, therefore, if initial critical care codes are billed following the date of admission, they will be changed to a subsequent care code. 

Medicare accepts any National Uniform Billing Committee (NUBC) approved revenue codes. The Medicare Claims Processing Manual and the UB-04 Data Specifications Manual outlines requirements for billing outpatient claims including that (HCPCS) codes are required on outpatient claims (UB-04) with related Revenue codes.

• FL 42 – Revenue Code Required. The provider enters the appropriate revenue codes  to identify specific accommodation and/or ancillary charges

• FL 44 – HCPCS/Rates/HIPPS Rate Codes Required. When coding HCPCS for outpatient services, the provider enters the HCPCS code describing the procedure. 

• According to the American Academy of Otolaryngology Head and Neck Surgery and the American Academy of Pediatrics, imaging of the sinuses or a sinus CT scan is considered unnecessary to establish a diagnosis of allergic rhinitis for a patient two years of age or older. They further state that a routine follow-up CT scan of the sinuses is not necessary for uncomplicated chronic sinusitis.

• According to the CPT Manual, a diagnostic ultrasound (specifically CPT code 76816) describes an examination to reassess fetal size, interval growth, or to re-evaluate one or more anatomic abnormalities of a fetus previously demonstrated on ultrasound.
  
  
• Therefore, this follow-up ultrasound should be used if an initial study has already been performed, and another study is needed within the same pregnancy. A repeat detailed ultrasound when billed with a high-risk diagnosis is allowed.

• General ophthalmoscopy (direct or indirect) is a routine procedure and is a standard component of an eye exam; therefore, it is included in eye exam codes.

• Extended ophthalmoscopy exams are a much more detailed exam of the fundus and not performed routinely unless evidence of fundal disease is found during routine ophthalmoscopy.  In cases of fundus photography, it’s recommended an exam is required no more than two times per 12 months.
  
  
• SCODI is used as a diagnostic tool for further, more detailed evaluation of patients who already have a detected abnormality found on exam. It is also an effective tool in treatment planning as changes to the structures can be measured over time. However, it is not commonly used to screen for a potential disease or to obtain baseline documentation of a healthy eye. According to CMS policy, it would rarely be necessary to perform scanning computerized ophthalmic diagnostic imaging (SCODI), of the retina more than once per month for patients whose primary ophthalmological condition is related to retina disease or more than twice per year for patients with damage related to glaucoma.

• Casts, Strapping and Splints were also created. Since it would be unusual to bill for more than three casts, strapping and splints within 90 days, three separate billings will be allowed which will cover the initial placement and two replacements within the global period. 

• Policies for injections involving tendons, ligaments and ganglion cysts are also being added as injections into tendon sheaths, ligaments, tendon origins or insertions, or ganglion cysts may be indicated to relieve pain or dysfunction resulting from inflammation or other pathological changes.
  
  -According to CMS policy, there are numerous diagnoses that are appropriate indications for these types of therapeutic injections including, but not limited to bursitis, carpal tunnel syndrome, hallux valgus, Morton's neuroma, and Depuytren's contracture. These injection codes are not considered to be billable services unless an appropriate diagnosis is reported.

Abdominal aortography and iliofemoral runoff

• When a physician performs an angiogram of the abdominal aorta and lower extremities, one code is used to report the procedure.  This technique is known as a "single" study because the catheter is placed at the bifurcation, and contrast is injected into the aorta as well as the extremities (single injection of contrast).