Medical Coding Rights

Modifier QW The Medicare and Medicaid only pay for laboratory tests performed in certified facilities, each claim for a HCPCS code that is considered a CLIA laboratory test is currently edited at the CLIA certificate level.  To be recognized as a test that can be performed in a facility having a CLIA certificate of waiver for listed below CPT codes and the modifier QW must be added . The CMS released updates for adding modifier QW for COVID-19 lab codes with effective date of service. The Medicare contractor shall permit the use of code 87636 QW for claims submitted by facilities with a valid, current CLIA certificate of waiver with dates of service on or after October 6, 2020 and effective from July 1, 2021 The Medicare contractor shall permit the use of code  87428 QW   for claims submitted by facilities with a valid, current CLIA certificate of waiver with   dates of service on or after November 10, 2020. The Medicare contractor shall permit the use of code  87811 QW  for claims s

CPT Codes 99487 - Complex chronic care management services can be billed with following criteria are met Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline Establishment or substantial revision of a comprehensive care plan Moderate or high complexity medical decision making Complex chronic care management services of less than 60 minutes duration, in a calendar month, are not reported separately 99489 - Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).  Report 99489 in conjunction with 99487.  Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex CCM services during a calendar month. Guideli

The Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions from 2015 Guidelines Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline Comprehensive care plan established, implemented, revised, or monitored Only one practitioner may be paid for CCM services for a given calendar month. This practitioner must only report either complex or non-complex CCM for a given patient for the month (not both). CCM may be billed most frequently by primary care practitioners, although in certain circumstances specialty practitioners may provide and bill for CCM. The CCM service is not within the scope of practice of limited-license physicians and practitioners such as clinical psychologists, podiatrists, or dentists

Definition of Burn The burn is tissue damage with the  partial or complete destruction of the skin caused by heat, chemicals, electricity, sunlight, or nuclear radiation.  Scalds from hot liquids and steam, building fires, and flammable liquids and gases are the most common causes of burns. Inhalation injury, another type of burn, results from breathing smoke. Burn Types Thermal burns are caused by an external heat source such as fire or hot liquids in direct contact with the skin, causing tissue cell death or charring. Electrical burns happen when the body makes contact with an electric current. Electrical burns can be more extensive than what is seen externally, often affecting internal tissues and muscles. Radiation dermatitis is a type of dermatitis resulting from exposure of the skin, eyes, or internal organs to types of radiatio n. Causes include exposure from sources such as Cobalt therapy, fluoroscopy, welding arcs, sun exposure, and tanning bed lights. Corrosion's are

Risk The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk.  Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.  Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities).  For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization.  The risk of patien

Data and Analyzed The process of using the data as part of the MDM. The data element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment.  Tests ordered are presumed to be analyzed when the results are reported . Therefore, when  they are ordered during an encounter, they are counted in that encounter.  Tests that are  ordered outside of an encounter may be counted  in the encounter in which they are analyzed.  In the case of a  recurring order ,  each new result  may be counted in the encounter in which it is analyzed.  For example, an encounter that includes an order for monthly prothrombin times would count for one prothrombin time ordered and reviewed.  Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter.  Any service for which the professional component is s eparately reported  by the physician or other qualified he

Number and Complexity of Problems Addressed at the Encounter   One element used in selecting the level of office or other outpatient services is the number and complexity of the problems that are addressed at an encounter.  Multiple new or established conditions may be addressed at the same time and may affect MDM. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition.  The Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.  The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.  Therefore, presenting

Number and Complexity of Problems Addressed at the Encounter   One element used in selecting the level of office or other outpatient services is the number and complexity of the problems that are addressed at an encounter.  Multiple new or established conditions may be addressed at the same time and may affect MDM. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition.  The Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.  The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.  Therefore, presenting

E/M Guidelines for Office/Outpatient History and Exam The 2021 E&M Guidelines for Office or Other Outpatient E/M Services will help you understand the revised E/M codes. The History and/or Examination portion of these E/M guidelines explains that office and other outpatient E/M services include “a medically appropriate history and/or physical examination, when performed.” The “ Medically appropriate” means that the physician or other qualified healthcare professional reporting the E/M determines the nature and extent of any history or exam for a particular service. Remember that c ode selection does not depend on the level of history or exam . The history and exam guidelines for office and outpatient E/M visits also specify that the “care team” may collect information, and the patient (or caregiver) may provide information, such as by portal or questionnaire. The reporting provider must then review that information. MEDICAL DECESION ON MAKING GUIDELINES The code selection will be

Sequencing of modifiers  How can that be if the modifiers used were accurate?  There is an order to reporting modifiers and there are three categories that modifier usage fall under:  1. Pricing  Pricing modifiers are always sequenced “before” payment modifiers and/or location modifiers.   The only exception to this rule is when a global surgery package is involved.  For example, you would code modifier 58 first and modifier 82 second in a global surgery.  A few examples of pricing modifiers are: 22, 26, 50, 52, 53, 62, 80, and P1-P6.   2. Payment   Payment modifiers alert the insurance carrier that there is a special situation within the claim  Some examples of payment modifiers would be: 24, 25, 51, 57, 58, 59, 76, and 78.  3. Location  Examples of location modifiers are: E1-E4, FA, F1-F9, LC, LD, LT, RT, RC, TA, and T1-T9.  The general order of sequencing modifiers is ( 1) pricing (2) payment (3) location. Location modifiers, in all coding situations, are coded “last”.  If you code

Modifier 78  “Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period  Modifier 79 “Unrelated procedure or service by the same physician during a post-operative  Example - Modifier 78  The Dual chamber Pacemaker (CPT 33208) was implanted on Dec 26th and during the post-operative periods, the patients feel uncomfortable due to pain, hence the provider examined and confirmed the Atrial lead and or Ventricular lead is dislodged, hence provider performed “Repositioning of right atrial or right ventricular lead” on Jan 10th.   For mentioned above scenarios, the claim must be submitted with modifier 78, since this procedure performed within 90 days. CPT 33215 – 78  Example - Modifier 79  The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.   Provider performs right toe amputation on May 24,

Modifier 24  An Unrelated evaluation and management service performed by the same physician or other qualified health care professional during a post-operative period use modifier 24 for E/M Services. (Never to a procedure)  Modifier 24 is applied to two code sets,  E/M (Evaluation and management) services (99201-99499).  General ophthalmological services (92002-92014), which are eye examination codes.  Appropriate Use of Modifier 24  An unrelated E/M service is performed beginning the day after the procedure, by the same physician, during the 10 or 90-day post-operative period.   Documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care. Unrelated critical care performed by the same physician during the post-operative period.  Inappropriate Use  Do not use Modifier 24 when,  The E/M is for a surgical complication or infection. This treatment is part of the surgery package.  The service is removal  of sutures or othe