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