AACE Socioeconomic and Member Advocacy
Frequently Asked Coding Question
Consultations vs. Transfer of Care
In section 15506 of Medicare Carrier Manual it states:
"Medicare will pay for an initial consult and treatment if all criteria is satisfied – UNLESS a transfer of care occurs."
Definition of Transfer of Care
A transfer of care occurs when a referring physician transfers the responsibility of a patient’s complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance.
Words play a vital role in consultation vs. transfer of care:
Examples:
- "Thanks for allowing me to participate in the care of/letting me see…"
- "Thanks for referring…. (try to avoid referring - you would be accepting the transfer of care).
- When a consultation has been requested, there should be a confirmed note in the medical record.
- Example: "I saw Mrs. _______ today at the request of Dr. ________ for consultation on her _______."
Remember the (3) R’s for Consultation Services
Consultation
Suspected problem- Opinion or advice sought
- Request is recorded
- Written opinion is sent back to referring MD
- Patient advised to follow-up with attending
Visit
- Known problem
- Known course of treatment
- Appt made for purpose of providing treatment
- No further communication with referring MD
Can a consultation initiate treatment?
- Physicians may initiate diagnostic and/or therapeutic services at initial or subsequent visits. Subsequent visits should be reported as established visits.
Q: How do I bill Medicare and other insurers for the cost of Reclast® and its administration?
A: You may bill the following:
90765- Intravenous infusion for therapy, up to 1 hour.
J3488- Injection, zoledronic acid (Reclast®), 1mg. Physician needs to specify 5 units for approved 5mg dosing of Reclast®
For more information regarding Reclast® reimbursement, please see the following CMS Transmittal Medicare Part B Competitive Acquisition Program (CAP) 2008 Drug List or you may contact the Patient Assistance Program at 1-800-833-0166 or the product information line at 1-866- Reclast® (1-866-732-5278)
Please see the below information regarding Exubera. Please note: if this information does not accurately reflect your procedure and/or service, please feel free to contact the AACE office or refer to your CPT, ICD-9-CM and HCPCS books for further direction. Thank you.
The long awaited inhaled insulin drug Exubera will be available in US pharmacies beginning September 2006, and with it comes additional screening procedures. Exubera is indicated for the treatment of adult patients with diabetes mellitus for the control of hyperglycemia but is contraindicated in patients with unstable or poorly controlled lung disease. In two years of clinical trials, patients treated with EXUBERA demonstrated a greater decline in pulmonary function, specifically the forced expiratory volume in one second (FEV1) and the carbon monoxide diffusing capacity (DLCO), than comparator-treated patients. Because of the effect of Exubera on pulmonary function, all patients should have spirometry (FEV1) assessed prior to initiating therapy, after the first 6 months of therapy, and annually thereafter, even in the absence of pulmonary symptoms. The CPT and ICD-9 Codes recommended for billing for these services are listed below:
Procedure:
Initial Screening
94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation
Possible DX Codes:
If you are doing a special screening for other and unspecified respiratory conditions, then you may use:
V81.4 Special screening for other and unspecified respiratory conditions
If you are using this as a baseline instead of a screening, then you may use:
V72.85, other specified examination, the underlying condition being treated would be listed as an additional diagnosis
Subsequent Screening
94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation
V58.83 Encounter for therapeutic drug monitoring
and
V58.67 Long term (current) use of insulin
For additional information we highly recommend that healthcare professionals visit www.exubera.com as it contains a variety of information for both patients and healthcare professionals, including the full package insert and patients medication guide.
A TDM2 patient returns to their endocrinologist with a feeling of a lump in their throat when swallowing. The physician documents a detailed history and examination. The physician then performs a diagnostic ultrasound of the patient’s thyroid and finds two suspicious nodules. As a result, the physician decides to perform a biopsy using a fine needle on each nodule and uses ultrasound for guidance. Once the physician has the aspirate, it is stained and put under a microscope to ensure that there is an adequate amount for the pathologist to view. The physician further documents that the patient’s blood sugar level is great. These were all done on the same date of service in the physician’s office.
99214-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.
76536-59 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation
10022 Fine needle aspiration; with imaging guidance
10022-59 Fine needle aspiration; with imaging guidance
76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation
88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s)
36416 Collection of capillary blood specimen (eg, finger, heel, ear stick)
82948 Glucose, blood, reagent strip
Fine needle aspiration (FNA) (CPT codes 10021, 10022) should not be reported with another biopsy procedure code for the same lesion unless one specimen is inadequate for diagnosis.
For example, an FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another biopsy (eg, needle, open) is subsequently performed at the same patient encounter, the other biopsy procedure code may also be reported with modifier 76.
The ability to getting reimbursed for multiple FNA's, during the same session on the same date of service, lies within the proper use of modifiers. Claiming multiple FNA's, using the units column, does not provide for the use of modifiers to paint an accurate picture on a claim. Modifiers 59, 76, LT and RT are needed in order to accurately claim multiple FNA's.
Proper use of Modifier 59
Distinct Procedural Service
Under certain circumstances, a it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.
Documentation must support:
A different
- Session,
- Procedure or surgery,
- Site or organ system.
- incision or excision,
- lesion, or
- injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25
Other examples:
99213-25
10021 – FNA without ultrasound guidance
10021 – 59 different lesion
This could be billed multiple times with different lesions if appropriate. For more information on the proper use of Modifier 59, please visit http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0715.pdf.
Q: What is the appropriate code to use when using an ultrasound to examine the thyroid?
A: You may bill the following:
76536 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), B-scan and/or real time with image documentation
Q: How do I bill Medicare and other insurers for the cost of Cortrosyn and its administration?
A: You may bill the following:
90772 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
J0835: Cosyntropin per 0.25 mg (bill in multiple units if the dosage exceeds .25mg, i.e. .75 mg would be J0835 x 3 units
Q: Could you please clarify CPT code 76970 and when it is appropriate to bill this code.
A: 76970 Ultrasound study follow-up (specify)
It is appropriate to use this code when a physician follows up on the original ultrasound study. The tissues studied and methods used are the same in scope to the original procedure (CPT code 76536), and the medical necessity for the follow-up must be specified in the documentation for the procedure.
Q: What is the correct code for glucometer blood glucose testing?
A: You may bill the following:
82962 Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use
82948 Glucose; blood, reagent strip
Q: What is the correct code for thyroid ultrasound guidance thyroid FNA biopsy in the office and viewing specimen for adequacy under the microscope?
A: You may bill the following:
10022 Fine needle aspiration; with imaging guidance
76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation
88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s)
Q: How do I bill Medicare and other insurers for the cost of Thyrogen and its administration?
A: You may bill the following:
90772 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
J3240 Injection, thyrotropin alpha, 0.9mg, provided in 1.1 mg vial
For information about pricing, in your area, and available discounts, please contact your individual Thyrogen Distributor. For reimbursement information and support, please contact the ThyrogenOne Service Center at 1-888-497-6436 or you may visit http://www.thyrogen.com/healthcare/ordering_reimbursement/p_hc_order.asp for further details.
Modifier -25 is to be used with a Significant, Separately Identifiable Evaluation and Management (E/M) Service by the Same Physician on the Same Day of the Procedure or Other Service.
Medicare payments for medical procedures include payments for certain evaluation and management (E/M) services that are necessary prior to the performance of a procedure. The Centers for Medicare & Medicaid Services (CMS) does not normally allow additional payments for separate E/M services performed by a provider on the same day as a procedure. Physicians and qualified Nonphysician practitioners (NPP) should use CPT modifier -25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure. Modifier 25 may be attached to the claim to allow additional payment for the separate E/M service. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified NPP in the patient’s medical record to support the need for Modifier -25 on the claim for these services, even though the documentation is not required to be submitted with the claim.
To obtain a clear understanding of modifier -25, and any limitations that your insurance carrier may have, it is important to contact each carrier directly for further information. For more information, from the OIG, on Modifier -25, please see the below scenario or visit http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
******************************************************************************MODIFIER -25 BILLING SCENARIO
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A patient’s primary-care physician refers her to your endocrinologist to evaluate a lump the patient discovered on the right side of her neck. The endocrinologist spent 60 minutes of face-to-face time with the patient performing a comprehensive history, a comprehensive exam and determined the medical decision making to be of moderate complexity before deciding to perform an in-office FNA with imaging guidance.
With adequate documentation, you might report 99244 (Office consultation) with a modifier -25 for the consultation. In addition to 10022 and 76942, the primary ICD-9 code might be 241.0 (Nontoxic uninodular goiter), depending on documentation.