November 10, 2014

Colon Cancer Screening Medicare Coverage Guidelines and Codes

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Medicare does cover Colon Cancer also referred as Colorectal Cancer, Rectal Cancer or Bowel cancer. Which is the development of cancer in the colon or rectum in the lower part of the large intestine. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body.

Colon Cancer Symptoms and Signs include blood in the stool, a change in bowel movements, weight loss, and feeling tired all the time.

Colon Cancer Screening

Colon Cancer Screening can be done by obtaining a sample of the colon during a sigmoidoscopy or colonoscopy. This is then followed by medical imaging to determine disease spread, colon cancer staging and prognosis.

In US, Colon Cancer Screening is found effective to decrease colon cancer related deaths. Colon Cancer Screening is recommended starting at the age of 50 and continuing until the age of 75 in United States.

Colon Cancer Screening Medicare Coverage Guidelines and Codes

You can checkout the Colorectal Cancer Screening ICD 9 and CPT Codes under which Medicare does cover colorectal (colon) cancer screenings.

Colon Cancer Screening Medicare Coverage Guidelines and Codes

Medicare Colon Cancer Screening Coverage Guidelines

With Medicare, a patient must be 50 age or older to be eligible for Medicare Colon Cancer Screening Coverage for most of the colon cancer types.

However, there is an exception to this. For colonoscopy procedure (which can also diagnose colon cancer) there is no minimum age requirement.

Below are the medicare colon cancer screening coverage eligibility guidelines:
  • Fecal occult blood test - once a year (every 12 months) for persons age 50 or older.

  • Flexible sigmoidoscopy - once every four years (48 months) for persons at high risk and less frequently for other persons.

  • Colonoscopy - once every two years (24 months) if you are at high risk for colorectal cancer (Have a family history of the disease or have had colorectal polyps or colorectal cancer, or have had inflammatory bowel disease).

  • Medicare covers colonoscopies every 10 years (but not within 48 months of a screening flexible sigmoidoscopy) if you are not at high-risk.

  • Barium enema – once every two years for persons at high risk and once every four year for others (but not within 48 months of a screening flexible sigmoidoscopy).
From 2011, if you have original Medicare, no coinsurance or deductible applies to the fecal occult blood test, flexible sigmiodoscopy or colonoscopy if you see doctors who take assignment. Doctors and other health care providers who take assignment cannot charge you more than the Medicare approved amount.

From 2012, Medicare Advantage Plans will cover all preventive services the same as Original Medicare. This means Medicare Advantage (MA) plans will not be allowed to charge cost-sharing fees (coinsurances, copays or deductibles) for preventive services that Original Medicare does not charge for as long as you see in-network providers. If you see providers that are not in your plan’s network, charges will typically apply. Therefore, if you are in a Medicare Advantage plan, contact your plan to find out what rules and costs apply.

For Barium Enema, patient will pay 80 percent of the Medicare approved amount if the doctor takes assignment. The Medicare Part-B deductible does not apply.

For Diagnostic Colon Cancer Screening, if a patient undergoes colonoscopy and the provider finds and removes a polyp, the costs will apply. Patient would have to pay the coinsurance for the colonoscopy and the polyp removal because the Colon Cancer Screening became diagnostic. However, no deductible will apply.

November 3, 2014

AR Analyst Role in Medical Billing Claims Review Process

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Account Receivables (AR) in Medical Billing and Coding are defined as amounts due and expected to be collected by Medical billing / provider office for the services provided to individuals.

In Medical Billing Business receivables are handled by Account Receivables (AR) Department. Thus, Account Receivables (AR) Analyst's role is crucial in identifying and resolving issues which helps to reduce or clear receivables.

AR Analyst Role in Medical Billing Claims Review Process

AR Analyst Role in Medical Billing Claims Review Process

AR Analyst Role and Responsibilities in Medical Billing Claims review process are based on ensuring timely, accurate and final settlement of medical insurance claims and patient bills by insurers or patients as appropriate.

The purpose of Medical Billing Claim Analysis is to identify and resolve medical claims billing and reimbursement issues aimed at maximizing collections and minimizing accounts receivables.

The scope of AR Claim Analysis is applicable to all health insurance claims and patient bills that have not been fully and finally settled by liable party or parties comprising health insurers, patients and others. It is the responsibility of the Accounts Receivables Analyst to ensure that AR is under control and acceptable by industry standards.

What is AR Department Role in Medical Billing?

An AR analyst as a part of Account Receivables (AR) Department has to ensure steady inflow of money from the medical insurances to the provider and in turn medical billing company.

The main motive of this department is to collect money for all the treatments taken by the patients in a timely fashion. Usually the turn around period for the payment by the medical insurance companies is 30 to 45 days. Once the limit is exceeded AR department has to make an inquiry for the delay. There could be various reasons for the delay like:
  1. Correct details may not have been provided to the insurance companies.

  2. Claims were sent correctly but Insurance Company may not have received the claims.

  3. The checks issued might have been sent to the wrong address.

  4. The insurance company may delay the payments if they have a backlog and they would inform us by a letter that they have received the claims and would be making the payments shortly.

AR Analyst and Medical Billing Softwares

In a medical billing business, AR department acts as a hub around which other departments revolve. This department can gather and update lot of billing information which is required to settle a claim. Account analyst uses various reports available in billing software to identify claims which have not been settled.

Medical Billing Softwares are capable of running reports that pull out claims that are unpaid for greater than 30 days. These are called aging reports and these reports show pending payments in slots such as 0–30 days, 31-60 days and 61-90 days.

Medical billing Claims filed within the last 30 days will find themselves in the first slot (0-30days). Claims that are more than 30 days but less than 60 days old will be found in the 31-60 days slot.

A glance at this report will show the AR personnel the claims that need to be followed up on with the insurance company.

AR Follow up in Medical Billing

In Medical Billing, AR analyst follow up the claims over the telephone, email or by written correspondence. It's his duty to find out why the claims are yet to be paid and what needs to be done to have these claims paid.

The delay and denials in claim reimbursement will be corrected by the billing office in coordination with the physician’s office and the insurance carriers.

The same applies when patient billing statements are sent out. The patient is given 3-4 weeks to pay the bill and if the payment is not received with in that time, the billing office will follow up with the patient.

October 27, 2014

ENT CPT Codes Changes 2015 for Billing by AMA RUC

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As the medical community has come to expect, part of the annual rulemaking process conducted by the Centers for Medicare and Medicaid Services (CMS) includes the annual issuance of new and modified CPT codes, developed by the American Medical Association’s (AMA) Current Procedural Terminology (CPT) Editorial Panel, for the coming year.

In addition, CMS includes new or updated values, also known as relative value units (RVUs), for medical services which have undergone review by the American Medical Association’s Relative Update Committee (AMA RUC).

CMS has the discretion to accept the RUC's RVU recommendations for physician work, as well as recommendations for direct practice expense inputs, or it may exercise its administrative authority and elect to assign a different value, or practice expense inputs, for medical procedures paid for by Medicare.

The final value, as determined by CMS, is then publicly released in the final Medicare Physician Fee Schedule (MPFS) rule for the following calendar year.

ENT CPT Codes Changes 2015 for Billing by AMA RUC

The Academy is an active participant in both the AMA RUC valuation of otolaryngology-head and neck services, and the CMS annual rulemaking processes. As part of those efforts, we want to ensure members are informed and prepared for key changes to CPT codes and valuations related to otolaryngology-head and neck surgery serviced for CY 2015.

The following outlines a list of coding changes, including new and revised CPT codes, as well as codes which were reviewed by the AMA RUC and could have modified Medicare reimbursement values for 2015:

ENT CPT Codes Changes 2015 for Otolaryngology Billing

InCY 2015, a new CPT code and/or deleted CPT codes will be announced, including:
  1. 1 New ENT CPT Code (43180) to report Endoscopic Zenker's Diverticulum
  2. 3 Deleted ENT CPT Codes (69400, 69401, and 69405) for Eustachian Tube
  3. An unlisted CPT code (69799) is recommended to report the work of 69400 or 69405
  4. For CPT Code 69401, the appropriate Evaluation and Management (E&M) office visit code is recommended.

ENT CPT Codes Reviewed by AMA RUC in CY 2014

In addition to the creation of several new CPT codes for 2015, a number of existing CPT codes relating to Otolaryngology were reviewed by the AMA RUC and their RUC approved values were submitted to CMS for final determination for the CY 2015 final rule.

Members should be prepared for modified relative value units for some, or all, of these procedures in CY 2015. It is critical to note that once the final MPFS is issued by CMS, typically on or about November 1 of each year. Upon receipt, Academy health policy staff will summarize the final rule and alert members to any critical changes in reimbursement for any of the following medical procedures. Services which were reviewed include:
  1. 92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording
  2. 92542 Positional nystagmus test, minimum of 4 positions, with recording
  3. 92543 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests), with recording
  4. 92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording
  5. 92545 Oscillating tracking test, with recording
For the following ENT CPT codes , only practice expense inputs are reviewed by the RUC in 2014, physician work was not surveyed or discussed for these codes.
  1. 10021 Fine needle aspiration; without imaging guidance
  2. 30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method
  3. 30905 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial
  4. 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa
  5. 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation)
  6. 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation)
  7. 41530 Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session
  8. 30300 Removal foreign body, intranasal; office type procedure
  9. 30906 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; subsequent
  10. 40804 Removal of embedded foreign body, vestibule of mouth; simple
  11. 42809 Removal of foreign body from pharynx
  12. 69200 Removal foreign body from external auditory canal; without general anesthesia
  13. 69220 Debridement, mastoidectomy cavity, simple (eg, routine cleaning)
  14. 92511 Nasopharyngoscopy with endoscope (separate procedure)

October 20, 2014

Colorectal Cancer Screening ICD 9 and CPT Codes

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Colorectal Cancer is one of the leading causes of cancer deaths in the United States. Approximately 56,290 people died from colorectal cancer, and 145,290 people were newly diagnosed with the disease in 2005. Colorectal cancer is usually found in people ages 50 and older. Therefore, screening for colorectal cancer for people ages 50 and older is strongly recommended.

Fortunately, Colorectal cancers are some of the most preventable cancers because screening tests can detect growths before they become cancerous. Most colorectal cancers develop from polyps (growths on the lining of the colon). Polyps are usually noncancerous when they first appear. But they can turn into cancerous polyps (adenoma). Removal of these polyps can reduce risk of colon cancer by more than 80 percent.

Colon cancer most commonly occurs in the lower part of the colon. Cancer in the rectum is called rectal cancer. Together, they are referred to as colorectal cancer.

Colorectal Cancer Screening ICD 9 and CPT Codes

Colon cancer happens when cells that are not normal grow in your colon. These cells grow together and form tumors. Colonoscopy is the only colorectal screening test that examines the entire colon and can remove any polyps found during the test. There are other colorectal cancer screening tools, but colonoscopy is the gold standard.

Colorectal Cancer Screening ICD 9 for Colonoscopy

Colonoscopy is a widely used endoscopic technique used to screen individuals for colorectal cancer. It is very sensitive in detecting colorectal cancers. Colonoscopy is an endoscopic procedure in which a thin tube with a camera at the tip is introduced through the anus till the start of the colon.

Colorectal Cancer Screening ICD-9-CM diagnosis code for an average risk patient presenting for colonoscopy is:

V76.51 Special Screening for Malignant Neoplasm, Colon
Code V76.51 should be the first listed diagnosis code if the reason for the visit is specifically for the screening exam. For high risk patients, the appropriate family or personal history V code identifying the risk should also be assigned. As with screening for malignant neoplasm of the breast, if a condition is discovered during the screening then the code for the condition may also be assigned as an additional diagnosis.

If the colonoscopy is performed because the patient has a sign or symptom, the sign or symptom code is used to explain the reason for the test, not the screening code. However, if positive findings are discovered during the diagnostic colonoscopy assign the code for these findings instead.

Colorectal cancer screening tests and procedures can be used alone or in various combinations and include fecal blood test, barium enema, flexible sigmoidoscopy and colonoscopy. Colonoscopy screening procedures are discussed here.

Colonoscopy CPT Codes for Colon Cancer Screening

After the patient's bowel has been prepped, the physician inserts the colonoscope-a long, thin, flexible lighted tube-through the anus and advances the scope through the colon past the splenic flexure. The lumen of the colon and rectum is visualized. Most polyps and some cancers can be removed during this procedure. The colonoscope is then withdrawn.

HCPCS Level ll codes G0105 and G0121 should be reported for Medicare outpatients requiring screening colonoscopy for colorectal cancer:
  • G0121 Colorectal cancer screening, colonoscopy on individual not meeting criteria for high risk
  • G0105 Colorectal cancer screening, colonoscopy on individual at high risk
According to Medicare, a patient is considered to be at high risk if he or she has any of the following risk factors:
  1. Close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp
  2. Family history of familial adenomatous polyposis
  3. Family history of hereditary nonpolyposis colorectal cancer
  4. Personal history of adenomatous polyps
  5. Personal history of colorectal cancer
  6. Inflammatory bowel disease, including Crohn's disease and ulcerative colitis
Screening colonoscopy for non-Medicare patients is coded with 45378, Colonoscopy, flexible, proximal to splenic flexure, diagnostic.

If an abnormality is found during a screening colonoscopy and results in a therapeutic procedure, then the appropriate diagnostic colonoscopy CPT code (45379-45392) is used instead of codes G0105, G0121 or 45378. Therapeutic procedures include biopsy, polypectomy, etc.

Review the CCS Prep column titled, "Understanding How to Code Colonoscopies" for instructions on coding therapeutic procedures.
Example: A patient is seen in the outpatient clinic for screening colonoscopy due to family history of colon cancer. The colonoscopy revealed a colonic polyp that was removed by snare technique. Assign CPT code 45385.

For Medicare OPPS coding, when a screening colonoscopy is attempted but due to extenuating circumstances cannot be completed, code G0105 or G0121 should be reported with either modifier -73 or -74 as appropriate.

October 13, 2014

Breast Cancer Screening ICD 9 and CPT Codes

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Breast Cancer is the most common type of cancer in women in the United States. However, there are screening procedures available to diagnose breast cancers in the early stage.

We are listing the Breast Cancer Screening ICD and CPT Codes invloved in the diagnoses and procedures coding for screening malignant neoplasm of the breast.

Breast Cancer Screening ICD 9 and CPT Codes

Screening is the testing for diseases in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease. If testing is performed because the patient has a sign or symptom, the sign or symptom code is used to explain the reason for the test, not the screening code.

A screening code may be the first listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an encounter for other health problems. If a condition is discovered during the screening, the code for the condition may be assigned as an additional diagnosis.

Breast Cancer Screening ICD 9 and CPT Codes

The following ICD 9 V Code categories are reported to indicate that a screening exam is planned. A procedure code is also required to confirm that the screening was performed. ICD 9 V73-V82 Special screening examinations are used for the purpose.

When the reason for performing a test is because the patient has had contact with, or exposure to, a communicable disease, the appropriate code from category V01, Contact with or exposure to communicable diseases, should be assigned, not a screening code.

ICD 9 Codes for Breast Cancer Screening Mammograms

Every woman is at risk for developing breast cancer, and the risk increases with age. According to the Center of Disease Control and Prevention (CDC), approximately 94 percent of breast cancers are diagnosed in women older than age 40. Mammography is the best available way to detect breast cancer early, when it is most curable. Timely screening can reduce breast cancer mortality in women 40 and older by 17 percent to 30 percent.

The National Cancer Institute (NCI) guidelines for screening mammography recommend that asymptomatic women 40 years or older be screened every 1 to 2 years and women aged 50 or older be screened every 1 to 2 years. NCI further recommends that younger women who are at higher risk for developing breast cancer consult with their physician regarding screening mammography and the frequency of such screenings.

Diagnostic mammograms differ from screening mammograms. Screening mammograms are for patients without documented problems. Diagnostic mammograms are performed when there is a problem such as a breast mass, pain, discharge, etc. Code any positive findings found on the diagnostic mammogram as the first listed diagnoses. If there are no reported findings, assign the reason for the test. The ICD 9 diagnoses codes for encounters for screening mammogram are:
  • V76.11 and V76.12 Special screening for malignant neoplasm, other screening mammography.
  • V76.11, Special screening for malignant neoplasm, screening mammogram for high-risk patients.
Example: A healthy 40-year-old woman presents to the radiology department for a screening mammogram. The patient has no symptoms or known risks for breast cancer. Assign code V76.12.
The following ICD 9 codes may be assigned with code V76.11 to identify why the patient is considered to be at high-risk:
  • V10.3, Personal history of malignant neoplasm, breast
  • V16.3, Family history of malignant neoplasm, breast
  • V15.89, Other specified personal history presenting hazards to health, other
Example: A woman with no symptoms is referred to the hospital for screening mammogram. The patient is considered high risk for breast cancer secondary to family history of breast malignancy in the mother and sister. Assign code V76.11 followed by code V16.3.
If a condition is found during the screening, then the code for the condition may be used as an additional diagnosis. The rationale for this is that even though a condition is found during the mammography, the visit is still considered a screening.

For Medicare services, diagnosis codes V76.11 and V76.12 must be the first listed diagnosis on all encounters for screening mammography services. However, effective Oct. 1, 2006, this requirement will change to allow the reporting of any applicable diagnosis code as a primary diagnosis on claims containing other services in addition to a screening mammography. Continue reporting diagnosis codes V76.11 and V76.12 as the first listed diagnosis codes on claims that contain only screening mammography services.

Breast Cancer Mammography CPT Codes

A mammogram is a low-dose X-ray of the breast that can find lumps that are too small to be felt during a breast examination. The breast is compressed firmly between two planes and pictures are taken. This spreads the tissue and allows for a lower X-ray dose. A screening mammogram is used to detect breast changes in women who have no signs of breast cancer. When the patient has signs or symptoms of a suspected disease then a diagnostic mammogram is performed and coded instead.

A screening mammogram is inherently bilateral and is reported with Breast Cancer Screening CPT Codes 76092 and G0202 given below:
  • 76092, Screening mammography, bilateral (two view film study of each breast)
  • G0202, Screening mammography, producing direct digital image, bilateral, all views
Code 76083, Computer aided detection (CAD); screening mammography, may be assigned as an additional procedure code when it is performed in addition to the primary procedure. The additional CAD code indicates that a laser beam was used to scan the mammography film and then the image was converted to digital data for computer analysis.

As mentioned earlier, if a condition is discovered during the screening, then the code for the condition may be used as an additional diagnosis. In this instance, if the radiologist performing the mammogram orders additional films based on the condition discovered during the screening mammogram, both may be coded.

When a screening mammogram is converted to a diagnostic mammogram on the same day append modifier GG, Performance and payment of a screening mammography and diagnostic mammography on same patient same day, to the diagnostic mammography code. Modifier GG indicates that the test changed from a screening test to a diagnostic test. If not performed on both breasts, it is also important to append the appropriate anatomic modifier, RT or LT, to indicate which side the diagnostic mammogram was performed on.

October 6, 2014

Radiation Oncology CPT Codes and Billing Coding Guidelines

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Learn all about Radiation Oncology CPT Codes and Billing Coding Guidelines. Radiation Oncology is a specialty that involves treatment of various forms of Cancer through radiation. This forms of therapy use carefully selected targeted and regulated doses for the process of killing cancer cells.

The cancer cells normally die as a result of destruction of chromosomes and DNA, preventing them from further growing, thus preventing a tumor from growing.

Radiation Oncology CPT Codes and Billing Coding Guidelines

For proper reimbursement from insurance companies, Medical Billing staff working for a Radiologist, Oncologist or Radiology Practice need to document proper disease and diagnosis coding through the use of ICD and CPT codes.

Radiation Oncology CPT Codes and Billing Coding Guidelines

Radiology CPT codes comprise of 70,000 series of codes that are normally organized depending on the type of radiology and the purpose of the service. Radiation oncology CPT code are normally classified as shown below:
  • Diagnostic Radiology CPT Codes 70000 - 76499
  • Diagnostic Ultrasound CPT Codes 76500 - 76999
  • Radiologic Guidance CPT Codes 77001 - 77032
  • Breast, Mammography CPT Codes 77051 - 77059
  • Bone/Joint Studies CPT Codes 77071 - 77084
  • Radiation Oncology CPT Codes 77261 - 77999
  • Nuclear Medicine CPT/HCPCS Codes 78000 – 79999
Two CPT codes are primarily used for reporting Intensity Modulated Radiation Therapy (IMRT). CPT Code 77301 for Radiotherapy dose planning, and CPT Code 77418 for Radiotherapy treatment delivery.

Radiation CPT code 77301 is commonly utilized as an intensity modulated radiotherapy plan that includes dose volume histograms for target and critical structure partial tolerance specifications.

Radiation CPT code 77418 is one the other hand normally used as a delivery single or multiple fields/arcs via narrow spatially and temporary modulated beams. CPT code 77418 is a technical-component only code which can be used by physicians when services are performed in a non-facility setting such as the office.

Billing Radiation Oncology Services

Radiological service can be billed for the physician's work as well as the use of equipment or supplies. The technical component (TC) includes facility charges, equipment, supplies, pre/post injection services, staff and so on. The professional component (PC) involves studying and making inferences about the radiological test and submitting a written report with the findings.

Radiation Oncology CPT Code Modifiers

Modifiers are used to signify the technical and professional components in a radiological service. They are 2-digit numbers that are used to explain a procedure in more detail. They can indicate repeat or multiple procedures, such as radiography performed bilaterally. When billing for the technical component only, the modifier 52 has to be used; when billing only for the professional component, the modifier 26 is to be used. In the latter case, a written report by the physician providing the services is required to avoid claim denial.

Some of the main challenges that radiologists face include understatement of procedures carried that many at times result in insufficient reimbursement. On the other hand overstatement might result in risk of abuse repayments and fines.

Radiologists can resolve all these issues by going in for the services of professional medical coding companies. That's why Radiology Practices need professional Medical Billers skilled to document correct ICD and CPT coders to do the job.

You can also checkout Echocardiogram CPT Codes, CPT codes for MRI of Brain, Breast, Lumbar Spine and Shoulder, Cardiology CPT Changes and other Medical Billing and Coding Updates 2014 to learn further.

Effective reimbursement of Radiation Oncology services, in-depth knowledge of the medical billing coding systems, application of coding principles, and thorough understanding of documentation is required. That's why most of the professional companies utilize Best Medical Billing Softwares to guarantee efficiency and accuracy in billing and coding, for checking local coverage determination and so on to ensure that all claims are reimbursed.