by k3llyadm1n | Nov 27, 2019 | Coding Updates
2015 Modifier 59 -sub coding updates
The –59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the “modifier to use to bypass (NCCI).” This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.
The -59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.
The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:
vDifferent encounters;
vDifferent anatomic sites;
vDistinct services.
The -59 modifier is
- Infrequently (and usually correctly) used to identify a separate encounter;
- Less commonly (and less correctly) used to define a separate anatomic site;
- More commonly (and frequently incorrectly) used to define a distinct service.
CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:
XE- Separate Encounter, a service that is distinct because it occurred during a separate encounter.
XS –Separate Structure, a service that is distinct because it was performed on a separate Organ/Structure.
XP –Separate Practitioner, a service that is distinct because it was performed by a different practitioner.
XU- Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.
CMS will continue to recognize the -59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific – X{EPSU} modifier for billing certain codes at high risk for incorrect billing.
As always, my staff will be available to assist you with any questions are concerns you may have.
by k3llyadm1n | Nov 27, 2019 | Coding Updates
2015 Arthrocentesis Injection coding updates
Starting January 1, 2015 all providers will need to properly report Arthrocentesis procedures dependent if the procedure was performed with or without ultrasound guidance.
Without Ultrasound Guidance:
Starting January 1, 2015, CPT codes 20600, 20605, or 20610 have been revised to describe Arthrocentesis procedures performed without ultrasound guidance.
v20600: Arthrocentesis, aspiration and /or injection, small joint or bursa (eg, fingers; toes); without ultrasound guidance, with permanent recording and reporting.
v20605: Arthrocentesis, aspiration and /or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, writs, elbow or ankle, olecranon bursa;); without ultrasound guidance, with permanent recording and reporting.
v20610: Arthrocentesis, aspiration and /or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance, with permanent recording and reporting.
With Ultrasound Guidance:
Starting January 1, 2015, CPT 20604, 20606, or 20611 have been created to report Arthrocentesis procedures perform with ultrasound guidance.
v20604: Arthrocentesis, aspiration and /or injection, small joint or bursa (eg, fingers; toes); with ultrasound guidance, with permanent recording and reporting.
v20606: Arthrocentesis, aspiration and /or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, writs, elbow or ankle, olecranon bursa;); with ultrasound guidance, with permanent recording and reporting.
v20611: Arthrocentesis, aspiration and /or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting
Steps for proper coding:
vDetermine the size of the joint.
vReview the description to determine if imaging is used.
vReport 20604, 20606, or 20611 if performed with ultrasound guidance
vIf fluoroscopic, CT, or MRI guidance is used report 20600, 20605, 20610 for the surgical procedure and see 77002, 77012, and 77021 to report imagining guidance separately.
As always, my staff will be available to assist you with any questions are concerns you may have.
by k3llyadm1n | Nov 27, 2019 | Coding Updates
Physical Therapy Evaluation (97001) and Physical Therapy Re-evaluation (97002) codes have been deleted for 2017 and replaced with four new codes.
The new evaluation codes 97161-97163 describe services that range in complexity from low to high and have a code descriptor that has specific required components. I have cited some of these requirements below from the new AMA 2017 CPT codebook however I do recommend that you review it as well.
#•97161 Physical therapy evaluation: low complexity, requiring these components:
• A history with no personal factors and/or comorbidities that impact the plan of care;
• An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
• A clinical presentation with stable and/or uncomplicated characteristics; and
• Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face-to-face with the patient and/or family.
#•97162 Physical therapy evaluation: moderate complexity, requiring these components:
• A history of present problems with 1-2 personal factors and/or comorbidities that impact the plan of care;
• An examination of body system(s) using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
• An evolving clinical presentation with changing characteristics; and
• Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 30 minutes are spent face-to-face with he patient and/or family.
#•97163 Physical therapy evaluation: high complexity, requiring these components:
• A history of present problems with 3 or more personal factors and/or comorbidities that impact the plan of care;
• An examination of body system(s) using standardized tests and measures in addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
• An clinical presentation with unstable and unpredictable characteristics; and
• Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 45 minutes are spent face-to-face with the patient and/or family.
For re-evaluation of physical therapy established plans of care, you would now utilize CPT 97164.
#•97164 Re-evaluation of physical therapy established plan of care, requiring these components:
• An examination including a review of history and use of standardized tests and measures is required; and
• Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face-to-face with the patient and/or family.
