Question: Our therapist recently saw a patient for whom she performed an Epley maneuver for the treatment of benign paroxysmal positional vertigo (BPPV). In researching how to code for this, I came across a 2010 article in AAPC’s Coding Edge stating that Medicare will not pay for the procedure. Is this true?
Answer: In 2009, CPT® added 95992 Canalith repositioning procedure(s) (e.g. Epley maneuver, Semont maneuver), per day for canalith repositioning, which involves therapeutic maneuvering of the patient’s body and head to redeposit calcium crystal debris in the semicircular canal system, for treatment of BPPV.
The Centers for Medicare & Medicaid Services (CMS) initially assigned a “B” (bundled) status indicator to 95992, such that no separate Medicare payment was available for the service (payment was bundled to any E/M service provided on the same date). This was especially problematic for therapists, who are not allowed to bill E/M codes. CMS later issued guidance allowing therapists to report 97112 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities for the service (maximum one unit per day, per patient).
Since that time, CMS has revised its guidance once again. Beginning with the 2011 National Physician Fee Scheduled Relative Value File, CMS has assigned an “A” (active) status to 95992, which means Medicare now recognizes the code for payment. Physical therapists may now submit 95992 for payment for canalith repositioning.
December 2nd, 2013
You must always match preventive medicine codes with a V code, even for Medicare patients.
A preventive medicine service is not a problem-oriented visit. Instead of signs and symptoms or other “problem” diagnoses, use an ICD-9 code that supports the services provided (e.g., V70.0 Routine general medical examination at a health care facility for adults; V72.31 Routine gynecological examination for gynecologic exams; or V20.2 Routine infant or child health check for well-child care). You may apply additional special screening codes (V73.0-V82.9), as appropriate.
The American Medical Association (AMA) released, Nov. 11, errata and technical corrections updates for CPT® 2013 and 2014. To ensure accurate medical coding, you will need to update your codebooks with these changes.
CPT® 2013 Errata
There are a handful of corrections and revisions for CPT® 2013, which are effective Jan. 1, 2013. Among them are medium description revisions for Arterial Ligation code 37618 and Stereotactic Biopsy code 61751. There are also technical corrections for a parenthetical note following Cardiac Catheterization code 93463, guidelines preceding Chemodenervation code 64642, and transplantation and post-transplantation cellular infusion guidelines.
Click here to view the errata and technical corrections update for CPT® 2013.
CPT® 2014 Errata
There are several changes you’ll want to make note of in your CPT® 2014 codebook.
For starters, you’ll need to make technical corrections to guidelines preceding Chemodenervation code 64642, and revise the transplantation and post-transplantation cellular infusion guidelines preceding code 38241, which is also revised to add “transplantation.”
Further, AMA has clarified instructions for use of the CPT® codebook to say, “In selected instances, specific instructions may define a service as limited to professionals or limited to other entities (eg. Hospital or home health agency).” If no such specific instruction exists, “the use of terms such as “physician,” “qualified health care professional,” or “individual” is not intended to indicate that other entities may not report the service.
Also effective Jan. 1, 2014, code 43238 is revised to remove the term “esophagus;” and revisions have been made to the medium descriptors for codes 43238-43270, 64645, 64605, and 96119.
Parenthetical notes for Category III codes 0256T, 0257T, 0259T, and 0003T have been deleted; the exclusionary parenthetical note following 93656 has been revised to fix a transposed code; and the parenthetical note preceding 93000 has been revised to remove the reference to code 93799, replacing it with Category III codes 0178T-0180T.
Lastly, Category II code 1040F has been revised to reflect DSM-“5.”
Click here for complete details of the recent entries added to AMA’s Errata and Technical Corrections – CPT® 2014 document.
Working within a group practice can alleviate many of the financial headaches encountered in a private practice, but it also can create new challenges—such as keeping track of new versus established patients.
A “new patient” is one who hasn’t received any professional services, such as an evaluation and management (E/M) or other face-to-face service, from a physician or physician group practice of the same specialty within the previous three years.
For example: A physician in a radiology group practice provides an E/M service for a patient. The group practice provided diagnostic imaging one year prior, but no E/M or other face-to-face services have been provided to this patient with the past three years. This patient would be considered a new patient.
Per the Medicare Claims Processing Manual, chapter 12, section 30.6.5: “An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient, does not affect the designation of a new patient.” A beneficiary seeing a physician of a different specialty within the same group practice within a three-year period also would not affect his or her “new patient” status.
Many practices will soon find out just how costly a mistake it can be to claim a new patient E/M visit for an established patient. Effective Oct. 1, 2013, Medicare payers implemented a new edit for checking claims to make sure they aren’t paying for two new patient CPT® codes within a three-year period.
The new patient CPT® codes they will be checking in these edits include 99201-99205, 99324-99328, 99341-99345, 99381-99387, and 92004. The edits will also check to ensure that a claim with one of these new patient CPT® codes is not paid subsequent to payment of a claim with an established patient CPT® code (92012, 92014, 99211-99215, 99334-99337, 99347-99350, 99391-99397).
Payers will be treating such claims as improper payments and will take usual steps to recoup payment. If you haven’t received any such notices of repayment, don’t breath a sigh of relief just yet. Due to the government shutdown in September, payers are back-peddling a bit.
In an E/M general article published Oct. 22 on its website, Palmetto GBA, Part B Medicare administrative contractor for jurisdiction 11, advises providers to follow the usual protocol for appealing claims believed to be incorrectly adjudicated.
Source: MLN Matters® MM8165 Revised
If two surgeons act as co-surgeons, they must likewise coordinate their documentation and billing to ensure that each receives proper reimbursement.
When two surgeons work together to perform distinct portions of a procedure identified by a single CPT® code, each surgeon will report the appropriate code with modifier 62 Two surgeons appended. Each surgeon must serve as the primary surgeon during some portion of the procedure. For example, per CPT® Assistant (February 2002), “In some cases, one surgeon may perform the approach procedure for anterior spine surgery, including making the incision and exposing the area requiring surgery, while another surgeon then performs the definitive procedure on the spine. Following completion of the definitive procedure, the first physician returns to perform the closure of the operative site. Therefore, two surgeons have performed the work included in one total procedure, reportable with a single code.”
Medicare (and many other payers) will recognize modifier 62 only with certain codes, as identified in the “CO-SURG” column of the National Physician Fee Scheduled Relative Value File.
- If the CO-SURG column includes a “1” indicator: You may append modifier 62, but documentation must show which special circumstances or skills required two surgeons to share responsibility.
- If the CO-SURG column includes a “2” indicator: You may append modifier 62 as long as each of the operating surgeons is of a different specialty.
- If the CO-SURG column includes a “0” or “9” indicator: Medicare does not allow modifier 62 with that code.
When submitting claims with modifier 62, each physician must document his or her own operative notes, detailing what portion of the procedure he or she performed, how much work was involved, how long the procedure took, etc. Each physician should identify the other as a co-surgeon; both surgeons should link the same diagnosis to the common procedure code; and each will submit his or her own claim.
Medicare and many other payers pay for codes appropriately submitted with modifier 62 at 125 percent of the usual fee schedule amount. The payer divides this between the two surgeons reporting the procedure, so each surgeon receives 62.5 percent of the regular fee. If the operating surgeons fail to coordinate their claims, however, one or both surgeons may not receive the earned reimbursement. For instance, if surgeon A sends his claim without a modifier appended, and his claim is the first to reach the payer, surgeon B (who acted as a co-surgeon) may have his or her claim rejected as a duplicate.
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