Medical Coding Rights

Clinical Examples - Critical care services An 85-year-old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator-dependent. A 66-year-old female patient is 4 days status post mitral valve repair. She develops petechiae, hypotension, and hypoxia requiring respiratory and circulatory support. A 72-year-old male admitted for right lower lobe pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive 2 days after admission. A 58-year-old admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy Clinical Examples - Non Covered Critical care services The Patients admitted to a critical care unit because no other hospital beds were available. The Patients admitted to a critical care unit for c

The New HCPCS Lab Codes are released which is Effective from July 1, 2021. These new codes are contractor-priced (where applicable) until they are nationally priced and undergo the CLFS annual payment determination process.  The MACs will only price PLA codes for laboratories within their jurisdiction. and Type of Service (TOS) for all the codes should be "5". 0248U - Oncology (brain), spheroid cell culture in a 3D microenvironment, 12 drug panel, tumor-response prediction for each drug. 0249U - Oncology (breast), semiquantitative analysis of 32 phosphoproteins and protein analytes, includes laser capture microdissection, with algorithmic analysis and interpretative report. 0250U - Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden. 0251U

Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.  Critical care services include the treatment of vital organ failure or prevention of further life-threatening conditions.  Delivering medical care in a moment of crisis and in time of emergency is not the only requirement for providing Critical Care services. Examples of vital organ system failure include, but are not limited to, Central nervous system failure,  Circulatory failure,  Shock,  Renal, hepatic, metabolic, and/or respiratory failure.  Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient's condition continues to require the le

The CPT Codes 99495 and 99496 are used to report transitional care management services (TCM). These services are covered for a new patient or established patient and the code selection will be considered based on the MDM and the problems require either " Moderate Complexity or High Complexity". The TCM service is eligible who discharged from as mentioned below locations, Inpatient hospital setting (including acute hospital, a rehabilitation hospital, long-term acute care hospital). Partial hospital,  Observation status in a hospital,  Skilled nursing facility Nursing facility to the patient's community setting  H ome,  Domiciliary,  Rest home,  Assisted living.  Guidelines TCM is included in one face-to-face visit within the specified timeframes, in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional. Only one individual may report these services and only once per patient within 30 days of discharge

Guidelines Online digital evaluation and management (E/M) services (99421, 99422, 99423) are patient-initiated services with physicians or other qualified health care professionals (QHPs).  It requires a physician or other QHP's evaluation, assessment, and management of the patient.  These services are not for the nonevaluative electronic communication of test results, scheduling of appointments, or other communication that does not include E/M.  While the patient's problem may be new to the physician or other QHP, the patient is an established patient.  Patients initiate these services through Health Insurance Portability and Accountability Act (HIPAA)-compliant secure platforms, such as electronic health record (EHR) portals, secure email, or other digital applications, which allow digital communication with the physician or other QHP. Online digital E/M services are reported once for the physician's or other QHP's cumulative time devoted to the service during a se

The FDA is recommended to use "Pfizer-BioNTech" COVID-19 vaccine for adolescents aged 12-15 years.   On May 12, 2021, the Advisory Committee on Immunization Practices (ACIP) recommended the use of the "Pfizer-BioNTech" COVID-19 vaccine in adolescents aged 12-15 years, and CDC Director Rochelle Walensky adopted this ACIP recommendation. All COVID-19 vaccination providers are directed and required to make available and administer COVID-19 vaccine to all persons eligible to receive the COVID-19 vaccine consistent with the applicable Emergency Use Authorizations for such products.     The COVID-19 vaccines themselves are free to everyone 12 years and older in the United States, but providers incur costs associated with administering them, training staff, and storing the vaccine.  If these services are not covered by a patient’s health plan or only partially covered, providers are not allowed to balance bill the patients. Claims for reimbursement will be priced as desc

Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition. Do not report cognitive assessment and care plan services if any of the required elements are not performed or are  deemed unnecessary for the patient’s condition A single physician or other qualified health care professional should not report 99483 more than once every 180 days. CPT code 99483 provides reimbursement to physicians and other eligible billing practitioners for a comprehensive clinical visit that results in a written care plan Eligible Provider Any provider is eligible to report E/M services can provide this service. Eligible providers include physicians MD and DO, nurse practitioners, clinical nurse specialists, and physician assistants .  Eligible practitioners must provide documentation that supports a m

The CMS to conduct provider outreach and education for the Medicare-covered Cognitive Assessment & Care Plan Services for CPT code 99483 to increase awareness of this service and its eligibility requirements. The CMC sending education document, including a direct mailing, from the Medicare Administrative Contractors (MACs) to eligible clinicians.  For about Medicare-covered Cognitive Assessment & Care Plan Services. The education and mailing will raise general awareness of the benefit and provide information on eligibility and billing. Eligible Providers Physicians,  Nurse practitioners,  Clinical nurse specialists,  Certified nurse-midwives Physician assistants Eligible Patients All beneficiaries who are cognitively impaired are eligible to receive the services under the code.  This includes those who have been diagnosed with Alzheimer’s, other dementias, or mild cognitive impairment . But, it also includes those individuals without a clinical diagnosis who, in the judgment of

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test performed.  To ensure that Medicare & Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver. The listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA.  The Current Procedural Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test.  However, the below-mentioned tests did not require a QW modifier to be recognized as a waived test. Example (i.e., CPT codes: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651)  81002 - Dipstick or tablet reagent urinalysis – non-automated for bilirubin, glucose, hemoglobin, ketone, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen. 81025 - Urine pregnancy tests by visual color comparison. 82270

The E/M codes are categorized based on the service rendered in the setting and or location.  Examples, Office or other outpatient setting  Emergency department (ED)  Hospital inpatient  Nursing facility (NF) Patient Type  For the billing purpose and the code selection will be depending on the service performed with the same physician either new patients or established patients.  New Patient An individual who did not receive any professional services from the physician and or other qualified healthcare professional or non-physician practitioner (NPP) or another physician of the same specialty and or sub specialty  who belongs to the same group practice within the previous 3 years Established Patient An individual who receives professional services from the physician or other qualified healthcare professional or non-physician practitioner (NPP) or another physician of the same specialty and or sub specialty who belongs to the same group practice within the previous 3 years. Key Component

Effective January 1, 2021, the RHC payment limit per visit for Calendar Year (CY) 2021 is $87.52. This payment limit applies to independent RHCs and RHCs that are provider-based to a hospital with 50 or more beds. Beginning April 1, 2021, the RHCs will begin to receive an increase in their payment limit per visit over an 8-year period, with a prescribed amount for each year from 2021, through 2028.  Then, in subsequent years, the limit is updated by the percentage increase in MEI applicable to primary care services furnished as of the first day of that year. The RHC payment limit per visit over an 8-year period is as follows, In 2021, after March 31, at $100 per visit In 2022, at $113 per visit In 2023, at $126 per visit In 2024, at $139 per visit In 2025, at $152 per visit In 2026, at $165 per visit In 2027, at $178 per visit In 2028, at $190 per visit

The Biden-Harris Administration is providing free access to COVID-19 vaccines for every adult living in the United States.  Accordingly, the Health Resources and Services Administration’s (HRSA) COVID-19 Coverage Assistance Fund (CAF) will cover the costs of administering COVID-19 vaccines to patients whose health insurance doesn’t cover vaccine administration fees, or does but typically has patient cost-sharing.  While patients cannot be billed directly for the COVID-19 vaccine fees, costs to health care providers on the front lines for administering COVID-19 vaccines to underinsured patients will now be fully covered through CAF, subject to available funding.  As vaccination efforts accelerate, patients will increasingly gain access to COVID-19 vaccines at locations near where they live with providers they trust. Providers are eligible for claims reimbursement if they have administered Food and Drug Administration (FDA) authorized COVID-19 vaccines under an Emergency Use Authorizatio

The chronic care management additional 20 minutes add-on CPT code G2058 was deleted from Jan 1, 2021, and the new code chronic care management CPT 99439 was introduced for the same. G2058 - Chronic care management services, each additional 20 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 the primary procedure - 99490) 99439 - Chronic care management services with the following required elements: multiple (two or more) chronic conditions; each additional 20 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 the primary procedure) Use 99439 in conjunction with 99490 and Chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately Do not report 99439 more than twice per calendar month Do not report 99439, 99490 in

The following codes are used to report evaluation and management services provided in the office and or outpatient setting. The  office and or outpatient setting codes CPT 99202  to 99215, the time guidelines had been changed effective from Jan 1. 2021.  There are few changes with exiting guidelines, The  Counseling and/or coordination of care with other physicians, other qualified health care professionals has been removed and included following guidelines.  In 2021, The time guidelines explain about that for 99202-99205 and 99212-99215, The total time spends on the encounter for the date, includes both face-to-face and non-face-to-face time spent by the provider. Physician/other qualified health care professional time includes the following activities when performed, Preparing to see the patient (eg, review of tests) Obtaining and/or reviewing the separately obtained history Performing a medically appropriate examination and/or evaluation Counseling and educating the patient/family/c