Medical Billing and Coding Online

Arteriovenous (AV) Fistula/Shunt/Graft:36147 vs 36148,75791

<div dir="ltr" style="text-align: justify;" trbidi="on">Learn the difference between CPT Code 36147 vs 36148, 75791 for correct coding of Arteriovenous (AV) Fistula/Shunt/Graft.<br />
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An arteriovenous fistula is an abnormal connection or passageway between an artery and a vein. It may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial aneurysm. <br />
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While if we take a look at Arteriovenous (AV) Shunt definition according to CPT guidelines: <br />
<blockquote>For diagnostic studies, the arteriovenous (AV) dialysis shunt (AV shunt) is defined as beginning with the arterial anastomosis [opening between two normally separate structures] and extending to the right atrium.</blockquote>This definition includes all upper and lower extremity AV Shunts, Arteriovenous Fistulae (AVF) and Arteriovenous Grafts(AVG).<br />
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<div style="text-align:center;"><a href="http://www.medicalbillingcodings.org/2014/10/av-arteriovenous-fistula-shunt-graft36147vs36148-75791.html"><img alt="Arteriovenous (AV) Fistula/Shunt/Graft:36147 vs 36148,75791" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgak-NIil5uyEzahqcMN6F_lbwPSRuNjoolAwwjnYx3ndDQJDaye5bwtq_kGPa9_8K9Cr2irc3TUvWEUXtkc8NdAvVqACCodq8BgrCQjnebU7Dm93g9FwVvHFQxF9cw7DICpQxlOgdG7XAn/s1600/Arteriovenous-AV-Fistula-Shunt-Graft-36147-vs-36148-75791.jpg" /></a></div><br />
An AVF for dialysis is surgically created by cutting an opening in an artery and an opening in a nearby vein and then joining the openings together so that blood can communicate between the artery and the vein. An AVG also involves creating openings in an artery and a vein, but uses an artificial vessel to link the two openings<br />
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<h2>Arteriovenous (AV) Fistula, Shunt, Graft: 36147 vs 36148 vs 75791</h2>Medical Coders typically use CPT 36147 for patients with end-stage renal disease (ESRD), having trouble with his AV shunt for dialysis and requires an evaluation.<br />
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CPT can pack a lot into one little code. Let's take a closer look at Arteriovenous (AV) Fistula/ Shunt/ Graft coding with using CPT codes 36147, 36148 and/or 75791:<br />
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<h3>36147 Access AV Dial Grft for Eval</h3><b>CPT Code 36147 Description</b><br />
Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava).<br />
<b>When CPT Code 36147 is Used</b><br />
CPT Code 36147 is reported when the physician performs a fistulagram to evaluate a dialysis arteriovenous fistula or graft. This code includes all components of the fistulagram, including the work of the initial puncture into the graft or fistula and all of the necessary imaging from the arterial anastomosis through the entire venous outflow – including the central veins and superior or inferior vena cava. This code also includes all of the catheter manipulation to perform the diagnostic examination, including advancement of the catheter to the cava if necessary to fully visualize the central veins. <br />
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<h3>36148 Access AV Dial Grft for Proc</h3><b>CPT Code 36148 Description</b><br />
Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention (list separately in addition to code for primary procedure).<br />
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<b>When CPT Code 36148 is Used</b><br />
CPT Code 36148 was established to describe the placement of a second (additional) access that may be necessary to perform a therapeutic procedure (e.g., percutaneous transluminal angioplasty, thrombolysis). Please note that code 36148 is an add-on code that is reported only in conjunction with code 36147. <br />
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<h3>75791 AV Dialysis Shunt Imaging</h3><b>CPT Code 75791 Description</b><br />
Angiography, arteriovenous shunt (eg, dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological supervision and interpretation.<br />
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<b>When CPT Code 75791 is Billed</b><br />
CPT Code 75791 is reported to describe the imaging of the arteriovenous dialysis fistula or graft performed through an existing access (e.g., patient presents from the dialysis suite with needles placed into the graft or fistula, or from a remote access such as the femoral artery that is not a direct puncture to the graft, or images from an operative angiogram that are submitted for interpretation only). The imaging includes the entire length of the graft or fistula and all of the outflow veins through the central veins, including the vena cava. <br />
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When procedure codes 36147 and 75791 are used to report the services described in this LCD (appropriate evaluation of the patency of an established hemodialysis fistula and the percutaneous interventions needed to enhance or re-establish patency of that hemodialysis fistula), the following diagnosis codes will be considered by Medicare to support medical necessity:<br />
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<table cellspacing=1 cellpadding=2 border=1 bordercolor='silver' style='border-collapse:collapse;'><tbody><tr><th>Code</th><th>ICD code description</th></tr><tr><td>440.31</td><td>ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES</td></tr><tr><td>440.32</td><td>ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES</td></tr><tr><td>442.0</td><td>ANEURYSM OF ARTERY OF UPPER EXTREMITY</td></tr><tr><td>442.3</td><td>ANEURYSM OF ARTERY OF LOWER EXTREMITY</td></tr><tr><td>444.21</td><td>ARTERIAL EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY</td></tr><tr><td>444.22</td><td>ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY</td></tr><tr><td>447.0</td><td>ARTERIOVENOUS FISTULA ACQUIRED</td></tr><tr><td>447.1</td><td>STRICTURE OF ARTERY</td></tr><tr><td>451.82</td><td>PHLEBITIS AND THROMBOPHLEBOTIS OF SUPERFICIAL VEINS OF UPPER EXTREMITIES</td></tr><tr><td>453.40</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY</td></tr><tr><td>453.41</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF PROXIMAL LOWER EXTREMITY</td></tr><tr><td>453.42</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY</td></tr><tr><td>453.50</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY</td></tr><tr><td>453.51</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF PROXIMAL LOWER EXTREMITY</td></tr><tr><td>453.52</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY</td></tr><tr><td>453.6</td><td>VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITY</td></tr><tr><td>453.71</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VEINS OF UPPER EXTREMITY</td></tr><tr><td>453.72</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VEINS OF UPPER EXTREMITY</td></tr><tr><td>453.73</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY, UNSPECIFIED</td></tr><tr><td>453.74</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF AXILLARY VEINS</td></tr><tr><td>453.75</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS</td></tr><tr><td>453.76</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF INTERNAL JUGULAR VEINS</td></tr><tr><td>453.77</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF OTHER THORACIC VEINS</td></tr><tr><td>453.79</td><td>CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS</td></tr><tr><td>453.81</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VEINS OF UPPER EXTREMITY</td></tr><tr><td>453.82</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VEINS OF UPPER EXTREMITY</td></tr><tr><td>453.83</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY, UNSPECIFIED</td></tr><tr><td>453.84</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF AXILLARY VEINS</td></tr><tr><td>453.85</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS</td></tr><tr><td>453.86</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF INTERNAL JUGULAR VEINS</td></tr><tr><td>453.87</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER THORACIC VEINS</td></tr><tr><td>453.89</td><td>ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS</td></tr><tr><td>459.2</td><td>COMPRESSION OF VEIN</td></tr><tr><td>996.1</td><td>MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT</td></tr><tr><td>996.62</td><td>INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT</td></tr><tr><td>996.73</td><td>OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE IMPLANT AND GRAFT</td></tr><tr><td>996.74</td><td>OTHER COMPLICATIONS DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT</td></tr></tbody></table><br />
A medical coder should report 36148 (additional access for therapeutic intervention [List separately in addition to code for primary procedure]) in addition to 36147 if the initial evaluation (36147) prompts a therapeutic intervention requiring a second shunt catheterization.<br />
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CPT Code 36148 is not used to identify a second diagnostic injection procedure from a second access point. Use 36148 when an interventional procedure is provided from that second access point.<br />
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If percutaneous access had already been established prior to the service, 36147 would not be appropriate. You should instead report 75791 (Angiography, arteriovenous shunt [e.g. dialysis patient fistula/graft], complete evaluation of dialysis access, including fluoroscopy, image documentation and report [includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava], radiological supervision and interpretation).<br />
</div>

Arteriovenous (AV) Fistula/Shunt/Graft:36147 vs 36148,75791

Learn the difference between CPT Code 36147 vs 36148, 75791 for correct coding of Arteriovenous (AV) Fistula/Shunt/Graft. An arteriovenous...

XE,XS,XP,XU with CPT Modifier 59 for Medicare Reimbursement

<div dir="ltr" style="text-align: justify;" trbidi="on">As we has already posted that Modifier 59 has been split between XE, XS, XP, XU sub codes for Medicare reimbursement. These <a href="http://www.medicalbillingcodings.org/2014/09/CPT29Modifier-59changes2015-distinctProceduralService.html">CPT Modifier 59 Changes</a> takes effect from Januaray 2015, under Distinct Procedural Service.<br />
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The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent un-bundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing.<br />
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<h3>XE,XS,XP,XU with CPT Modifier 59 for Medicare Reimbursement</h3>CR8863 discusses changes to HCPCS modifier -59, a modifier which is used to define a “Distinct Procedural Service.” Modifier -59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.<br />
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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.<br />
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<div style="text-align:center;"><a href=""><img alt="XE, XS, XP, XU with CPT Modifier 59 for Medicare Reimbursement" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3eiZGwZVQr3sYh9-pju8q9f2_ercA2EQLGEspEYlY02ydy0mgP8QqePB43CIDrQWv5HP30VFEQi33bQ42HmrCpaN4s-2ZK8LMtcxd3SJ9iuthAue-dQ_F-7BQnqO_a_RutvHPM6Y7Jp_F/s1600/Medical-Billing-Coding-Updates-Changes-News2014.jpg" /></a></div><br />
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:<br />
<ul><li>Different encounters.</li>
<li>Different anatomic sites.</li>
<li>Distinct services.</li>
</ul>The -59 modifier is:<br />
<ol><li>Infrequently (and usually correctly) used to identify a separate encounter.</li>
<li>Less commonly (and less correctly) used to define a separate anatomic site.</li>
<li>More commonly (and frequently incorrectly) used to define a distinct service.</li>
</ol>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.<br />
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CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59<br />
modifier:<br />
<ul><li>XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter.</li>
<li>XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure.</li>
<li>XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner.</li>
<li>XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct  Because It Does Not Overlap Usual Components Of The Main Service.</li>
</ul>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. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of<br />
the -59 modifier so it would be incorrect to include both modifiers on the same line.<br />
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The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.<br />
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However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier, when necessitated by local program integrity and compliance needs.</div>

XE,XS,XP,XU with CPT Modifier 59 for Medicare Reimbursement

As we has already posted that Modifier 59 has been split between XE, XS, XP, XU sub codes for Medicare reimbursement. These CPT Modifier 59 ...

J3490 CPT Code Medicare Reimbursement for Unclassified NDC numbers drugs

<div dir="ltr" style="text-align: justify;" trbidi="on">Learn CPT Code J3490 medicare reimbursement guidelines for drugs with unclassified NDC numbers. <br />
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<b>J3490</b> is a HCPCS Code. The Healthcare Common Prodecure Coding System (HCPCS) is a collection of codes that represent procedures, supplies, products and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs.<br />
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For new FDA approved drugs, biologicals and radio pharmaceuticals with no specific HCPCS code assigned yet, HCPCS code C9399 should be billed. <b>C-Codes</b> are for new drugs and biologicals and are generally replaced or expire after a year. If a drug or biological does not have an established or valid HCPCS code it should be billed with a not otherwise classified (NOC) code. NOC codes are for '<i>unclassified drugs</i>' or '<i>not otherwise classified</i>' drugs (J3490) and biologics (J3590).<br />
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HCPCS Code J3490 is used for non-coded drugs unlisted NDC number. J3490 is a non-specific code that should be used only when another <b>J-Code</b> does not describe the drug being administered (CMS has not assigned a specific 'J' code to the drug used). The appropriate J-Code should be used if one has been assigned to the drug. <br />
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<h2>J3490 Unclassified Drugs & Injections</h2>For the drug with no assigned 'J' code, the name, strength of the drug (if applicable) and the actual dosage administered must be indicated on the CMS-1500 form in Block 19 or Block 24 (listed with the procedure code). <br />
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<h3>J3490 Medicare Reimbursement and Coverage</h3>CMS Medicare offers two codes for unlisted drugs: J9999 Unclassified Chemotherapy Drugs and <b>J3490 Unclassified drugs</b> for others. The more commonly used unlisted drug code is J3490. With an unlisted drug code, it is needed to document the importance of trying this new drug and record it in the chart notes. If the physician tried listed drugs and they didn't work, you need to make sure the claim includes that information. <br />
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<div style="text-align:center;"><a href="http://www.medicalbillingcodings.org/2014/09/HCPCSCodeJ3490MedicareReimbursement-BillingGuidelines.html"><img alt="HCPCS Code J3490 Medicare Reimbursement Billing Guidelines" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbA7gMyBykI_Z2rQPNbkpv6wTAeVrLBjtifM7hI_H_vS_93vBi2gbAuOmRGDZEW2AV-vvgm6tx14qq0LamVf9vrLrEMnaXuT_jaBz8bJTLwWyb1Tqq8cx-pjKtY_SLeW7a5bLUzP7cB2Y/s1600/eRx+Prescription.gif" /></a></div><br />
The main drugs that now require unlisted codes are Neulasta and Faslodex, both of which are non-chemotherapy drugs and therefore require J3490. The two main chemotherapy drugs that require J9999 are Velcade and Oxaliplatin. <br />
<p><ins class="adsbygoogle" style="background:transparent;display:block" data-ad-client="ca-pub-3317414412439023" data-ad-slot="2329304590" data-ad-format="auto"></ins><br />
<script defer>(adsbygoogle = window.adsbygoogle || []).push({});</script></p>If the drug is compounded, the invoice/acquisition cost must be included with the description. This would ensure proper adjudication of your claim for J3490. In order for Medicare to correctly reimburse NOC J3490, providers must indicate the following in the electronic narrative, line level 2400 loop NTE segment, or Item 19 of the CMS 1500 form:<br />
<ul><li>The name of the drug</li>
<li>The total dosage (plus strength of dosage, if appropriate)</li>
<li>The method of administration</li>
<li>List the units of service as one in 2400/SV1-04 data element of the ANSI X12 4010A1 or in item 24G of the CMS 1500 form.</li>
</ul><h3>J3490 CPT Code use for Drugs without NDC number listed</h3>If the name, strength and dosage administered of the drug are not all listed, the claim will be denied for lack of information necessary to process the claim. At present, Railroad Medicare cannot identify a drug by only the NDC number.<br />
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For billing of compounded drugs administered via implanted pump, submit a single combined line item for all drugs with HCPCS Code J3490 and bill the combined charges for all drugs.<br />
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Pricing for <b>NOC J-codes</b> is determined by the Average Sales Price (ASP) NOC pricing file. If the ASP NOC file lists the strength for a drug on the file, this indicates that the drug comes in different strengths. Depending on the strength, Medicare payment varies.<br />
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<b>For Electronic Claims</b> <br />
Indicate the name(s) and dose(s) of each drug being submitted in the documentation record.<br />
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<b>For Paper Claims</b><br />
<ul><li>Indicate Compounded drugs, invoice attached in Item 19 of the CMS-1500 Claim Form</li>
<li>Abbreviations are acceptable, but must use industry acceptable abbreviations (e.g., 'MS' for morphine sulphate)</li>
<li>Billed amount must be the invoice price for the compounded drug(s). To indicate this, we suggest using 'INV' next to the price (e.g INV $250.00)</li>
</ul>Inappropriately using C9399 when a NOC code (J3490 or J3590) should be used is a billing error and may result in a claims payment error or overpayment. CMS has tasked all A/B MACs, including CGS, to assist with reducing the national claims payment error rate.<br />
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The following are examples of drugs inappropriately billed using C9399 that should have been billed using J3490, J3590 or the specific assigned 'J' HCPCS codes:<br />
<ul><li>Morphine Sulfate (J2270) – up to 10mg</li>
<li>Diltiazem HCL (J3490) – unclassified drugs</li>
<li>Propofol (J3490) – unclassified drugs</li>
</ul></div>

J3490 CPT Code Medicare Reimbursement for Unclassified NDC numbers drugs

Learn CPT Code J3490 medicare reimbursement guidelines for drugs with unclassified NDC numbers. J3490 is a HCPCS Code. The Healthcare Com...

CPT Modifier 59 changes 2015 under Distinct Procedural Service

<div dir="ltr" style="text-align: justify;" trbidi="on">Learn about changes related to CPT Modifier 59 reimbursement and use guidelines under Distinct Procedural Service, effective from January 2015.<br />
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Important CPT Modifier 59 changes are coming one of the frequently used and misused modifier for Medicare reimbursement of CPT Codes in Acupuncture, Breast Biopsies, Physical Therapy, Radiology, Surgery and other medical practices. <br />
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On August 15, 2014 CMS released the final ruling for the appropriate Modifier 59 use and the changes that will take effect on January 1, 2015. It is critical that all coders and providers be made aware of the changes to the utilization of Modifier 59 (Distinct Procedural Service) that will go into effect starting from 2015. <br />
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Transmittal 1422, CR8863 details new modifiers to be used in place of modifier 59. The new modifiers will impact NCCI (National Correct Coding Initiative) edits utilized by CMS MAC Carriers. <br />
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<div style="text-align:center;"><a href="http://www.medicalbillingcodings.org/2014/09/CPT29Modifier-59changes2015-distinctProceduralService.html"><img alt="CPT Modifier 59 changes 2015 under Distinct Procedural Service" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3eiZGwZVQr3sYh9-pju8q9f2_ercA2EQLGEspEYlY02ydy0mgP8QqePB43CIDrQWv5HP30VFEQi33bQ42HmrCpaN4s-2ZK8LMtcxd3SJ9iuthAue-dQ_F-7BQnqO_a_RutvHPM6Y7Jp_F/s1600/Medical-Billing-Coding-Updates-Changes-News2014.jpg" /></a></div><br />
Studies have shown that the modifier 59 is both commonly used and commonly abused. According to the 2013 CERT report $2.4 billion was paid on claims containing modifier 59 with a projected error rate of $450 million USD. The error rate is not exclusively attributed to modifier 59, but if only 10% of those found to be in error were due to the modifier 59, that would represent a $45 million damage.<br />
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<h3>CPT Modifier 59 changes 2015 under Distinct Procedural Service</h3>CMS has established new HCPCS modifiers to define subsets of modifier 59 which was previously used to define a "Distinct Procedural Service" CMS will continue to recognize modifier 59.<br />
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However due to the over utilization of Modifier 59, it should not be used beyond December 31, 2014. As a default, at this time CMS will initially accept either a -59 modifier or a more selective – X{EPSU} modifier as correct coding. Although the rapid migration of providers to the more selective modifiers is encouraged. <br />
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These modifiers are valid modifiers even before national edits are in place, so contractors are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.<br />
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<h3>CPT Modifier 59 Replacement Use</h3>Therefore, our recommendation for all providers, coders and medical billing companies is to prepare to replace utilization of Modifier 59 with the distinctive descriptors as follows:<br />
<ul><li><strong>XE Separate Encounter:</strong> Service That Is Distinct Because It Occurred During A Separate Encounter</li>
<li><strong>XS Separate Structure:</strong> Service That Is Distinct Because It Was Performed On A Separate Organ/Structure</li>
<li><strong>XP Separate Practitioner:</strong> Service That Is Distinct Because It Was Performed By A Different Practitioner</li>
<li><strong>XU Unusual Non-Overlapping Svc:</strong> Use Of A Service That Is Distinct Because It Does Not Overlap usual components of the main service</li>
</ul>These modifiers, are referred to as -X{EPSU} modifiers, and define specific subsets of the -59 modifier. CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. <br />
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<h3>CPT Modifier 59 Reimbursement Guidelines</h3>To prepare and work well with CPT Modifier 59 changes 2015 under Distinct Procedural Service, we recommend the following steps to be taken:<br />
<ol><li>Always use the subset more descriptive Modifier EPSU’s. CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific –X{EPSU} modifier for billing certain codes at high risk for incorrect billing.<br />
<br />
</li>
<li>All Medical Billing Practices should monitor the use of modifier 59 to ensure that it is currently being utilized appropriately. <br />
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</li>
<li>All Medical Billing Practice Managers should check with their medical coder or medical billers to insure they are prepared for this modifier 59 alteration.  <br />
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</li>
<li>All Medical Billing and Coding Specialist should inform their providers. Make sure that there are no defaults set up in their Practice Management Software System, that automatically default modifier 59.  <br />
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</li>
<li>Ensure the proper documentation of any distinct service.</li>
</ol><br />
Happy Coding! and keep visiting us to stay on top of all the continuing Medical Billing and Coding updates and changes. <br />
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CPT Modifier 59 changes 2015 under Distinct Procedural Service

Learn about changes related to CPT Modifier 59 reimbursement and use guidelines under Distinct Procedural Service, effective from January 20...

Medical Billing and Coding Updates, Changes & News

<div dir="ltr" style="text-align: justify;" trbidi="on">Analysis of <b>Medical Billing and Coding updates</b>, changes & news from year 2014 to date.<br />
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Medical Billers and Medical Coders are healthcare trained experts that document all the information related to patients visits, their medical charts and everything about treatment in the form of medical codes for the reference of the patients and provider and particularly insurance payers. Medical coding jobs are in high demand and Medical Billing is an excellent career. <br />
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<h2>Medical Billing and Coding Updates</h2>However, since this is a dynamic field which requires being regularly updated. Let's, look at the most important Medical Billing and Coding Updates, Changes & News of year:<br />
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<h3>CPT Code Changes and Updates</h3>The American Medical Association's current procedural terminology code set will experience a massive overhaul at the start of next year. In September, 353 changes were announced, many of which pertain to technology improvements. As Ardis Dee Hoven, M.D, President AMA said:<br />
<blockquote>The CPT code set is the foundation upon which every element of the medical community; doctors, hospitals, allied health professionals, laboratories and payers; can efficiently share accurate information about medical services. The latest annual changes to the CPT code set reflect new technological and scientific advancements available to mainstream clinical practice and ensures the code set can fulfill its vital role as the health system's common language for reporting contemporary medical procedures.</blockquote>This is considered to be the largest CPT code modification in years. The CPT codes and descriptors can be purchased and imported directly into existing claims and billing software using this downloadable <a href="https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod2420015&navAction=push" target="_blank" rel="nofollow">CPT Data File</a>.<br />
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<h3>Revised CMS 1500 Form</h3>The Centers for Medicare and Medicaid have released a <a target="_blank" href="http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdf">revised claims form</a> that will be distributed for use on January 6 and become mandatory by April 1. The new form has been created to accommodate ICD-10 come October. Check with your payers for their projected effective dates.<br />
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<div style="text-align:center;"><a href="http://www.medicalbillingcodings.org/2014/09/Medical-Billing-Coding-Updates-Changes-News.html"><img alt="Medical Billing and Coding Updates, Changes & News" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3eiZGwZVQr3sYh9-pju8q9f2_ercA2EQLGEspEYlY02ydy0mgP8QqePB43CIDrQWv5HP30VFEQi33bQ42HmrCpaN4s-2ZK8LMtcxd3SJ9iuthAue-dQ_F-7BQnqO_a_RutvHPM6Y7Jp_F/s1600/Medical-Billing-Coding-Updates-Changes-News2014.jpg" /></a></div><br />
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The biggest change on the <a href="http://www.medicalbillingcodings.org/2014/02/new-hcfa-form-2014-version-0212-of-cms.html">new claim form</a> is the inclusion of eight additional areas for healthcare providers to list diagnosis codes associated with the claim. The current version only allows four spaces per claim to list related diagnosis codes. Other fields have been removed or changed as well. For example, the new claim form will no longer ask for marital status, employment status or the insured’s employer/school name.<br />
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<h3>Healthcare Exchanges (HIX)</h3>How HIXs will set payment rates is still an uncertainty, but some states are already aligning with Medicaid prices, resulting in lower reimbursement rates for doctors. Couple lower payments with an influx of thousands of new patients and practices are facing some serious jumps in costs.<br />
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Mitigate underwhelming reimbursements by implementing new technologies like an EHR/EMR and comprehensive practice management solutions that streamline your workflow and help move patients through your practice faster, a quality that will be vital as you look to take in more patients to cancel out decreases in revenue.<br />
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<h3>Quality Reporting</h3>The quality reporting program managed by the Centers for Medicare & Medicaid Services will be able to levy penalties for noncompliance. Providers are required to complete checklists that review the quality standards of routine procedures and surgery for patients who are enrolled in Medicare or Medicaid.<br />
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Quality reporting. Penalties for noncompliance with CMS' quality reporting program will commence next year. The use of G-codes on Medicare claims for five types of adverse events started Oct. 1, 2012, and has grown over the last year to include safe surgery checklist use and volumes of certain procedures. Any ASCs that did not successfully report G-codes on at least 50 percent of Medicare claims between Oct. 1, 2012, and Dec. 31, 2012, will experience a 2 percent reduction in payments beginning in 2014.<br />
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Ambulatory surgery centers that failed to comply with G-code reporting standards between October and December 2012 will receive a 2 percent reduction in the reimbursement amount for Medicare claims. This penalty will also be applied to ASCs that fail to comply in the future, so it is essential for providers to be proactive about compliance.<br />
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The reimbursement reduction will be continual. Billing staff members must keep complying with the quality reporting measures to avoid penalties in 2015 and 2016. <br />
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<h3>Post ICD-10 Billing</h3>The long-anticipated, new International Classification of Diseases code finally effective from October 1, 2015. The major fear factor. The insurances are lenient so far. But the provider and practice in the healthcare industry are still expected to have issues off and on. It will still take another year before ICD-9 Codes and their references become history.<br />
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ICD-9 codes have been used in the United States for more than 30 years. There are only about 13,000 codes for the entire gamut of medical services that can be provided. ICD-10 replaces the outdated terminology and requires more specific documentation as well as more details about the service that was provided. The requirements for greater documentation are expected to increase the quality of care. Experts say the type of documentation providers will be required to submit for billing purposes is the type of documentation they should already be using if they are providing proper medical services.<br />
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<h3>Medical Billing Software based on HIT</h3>Changes in patient volume will force medical offices to move to digital <a href="http://www.medicalbillingcodings.org/search/label/Medical%20Billing%20and%20Coding%20Softwares">Medical Billing Softwares</a>. While most offices have already switched to digital medical coding and billing, approximately 20 percent of hospitals and nearly half of physicians still need to make the change.<br />
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Expanded access to insurance is sure to increase patient volume significantly. Medical offices that struggle to manage paperwork will not be able to keep up with the change in volume without the help of computer programs. Outsourcing medical coding and billing is one way to benefit from digital processing without the need to purchase a software package or take the time to train administrative professionals on the changes in medical coding and billing.<br />
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Medical coding and billing changes in this year bring unique challenges for providers and their medical billing staff. Ultimately, physicians have to prepare for these billing changes if they want to keep receiving the appropriate reimbursements for services rendered. Make sure your billing department is updated in compliance with regulations put into place under the Affordable Care Act.</div>

Medical Billing and Coding Updates, Changes & News

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