Surgical Modifiers: How Do They Impact Reimbursement?

September 15, 2016 Question: What reimbursement should we expect when using the global period modifiers 58, 79 and 78? Answer: Surgical modifiers are used to indicate that a subsequent procedure was performed during the global period of a prior surgery. Modifiers tell the payer the rationale for allowing payment for this subsequent procedure. The modifiers…


Medicare X Modifiers: Use or not Use?

September 1, 2016 Question: What’s new with the X modifiers established by Medicare? Should we be using them now? Answer: As of today, July 7, 2016, Medicare has yet to finalize a formal policy for the use of the X modifiers as a replacement to the 59 modifier. The X modifiers are shown below. XE:…


Reimbursement: Assistant Surgeon

August 18, 2016 Question: What is the reimbursement for an assistant surgeon using modifier 80? Is the payment different for the primary and the assistant? Answer: Assistant surgeon is described as one surgeon, of the same or a different specialty, providing assistance during a surgical procedure or CPT code. Modifier 80 (modifier 82 for an…


Reimbursement: Co-surgery

August 4, 2016 Question: What is the reimbursement for co-surgery using modifier 62? Is it different for the primary and co-surgeon? Answer: For Medicare, co-surgery requires two different specialties performing separate parts of a single CPT code. For both surgeons, modifier 62 is appended to the appropriate CPT code(s). Medicare multiplies the allowable by 125%…


Signing NPP Notes

July 21, 2016 Question: Do I have to sign each of my NP’s notes that are reported incident to? Answer: The guidelines for reviewing and signing NPP documentation are set by each state in its scope of practice regulations. Each practice must research those requirements individually. But as an employer, you are responsible for the…


Degenerative Disc Disease (DDD)

July 7, 2016 Question: What diagnosis would you report for a patient with chronic low back pain due to degenerative disc disease (DDD) of the lumbar spine with radiculopathy. Answer: The ICD-10-CM guidelines state that if the cause of the pain is known, assign a code for the underlying diagnosis, not the pain code. However,…


Radiofrequency Destruction

June 23, 2016 Question: Our physician performs Radiofrequency destruction of L2, L3 and L4 paravertebral facet joint nerves using fluoroscopy for pain management. What CPT code should I use? Answer: Report CPT code 63635 (Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint) and…


Spinal Injections

June 9, 2016 Question: As a pain management physician, I perform spinal injections for pain management. What information should be documented in my procedure notes? Answer: When reporting spinal injections, documentation for each procedure should include (1) the approach (epidural, transforaminal, facet); (2) what is injected (anesthetic, steroid, contrast, neurolytic agent); (3) regions treated (cervical,…


Sacral Nerve Destruction

May 26, 2016 Question: My physician performed sacral nerve destruction of the S1, S2, S3 and S4 peripheral nerves.  How do I code this? Answer: Each individual peripheral neurolytic block would be reported with code 64640, Destruction by neurolytic agent, peripheral nerve or branch; coding would be 64640 x 4 units. *This response is based…


Incident-to Hospital Billing

May 12, 2016 Question: If the physician practice is owned by the hospital, and the midlevel practitioners are employed by the hospital, can the physicians bill incident-to service and/or split shared visit in the hospital? Answer: Click here for the video answer. *This response is based on the best information available as of 05/12/16.


Coding Sphenopalatine

April 28, 2016 Question: One of our physicians treats patients using Sphenopalatine however; he is not preforming this as an injection but as a topical anesthetic. What procedure code should I use? I have found a 64505 code, is this correct? Please advise. Answer: According to CPT Advisors, it would not be appropriate to report…


New vs. Established Patient

April 14, 2016 Question: If I see a new patient and during that visit I identify the need for surgery the same day, can I append a Modifier 57 to the E/M service and get paid? Answer: You determine during the evaluation that the patient would need surgery the same or next day for a…


Source for a Consult

March 31, 2016 Question: What is an appropriate “source” for a consult? I asked at a recent workshop and the instructors did not have an answer. Answer: The guidelines for a consultation (inpatient or outpatient) must be requested by a physician, or qualified non-physician practitioner. Guidelines are not clear regarding individuals who may be considered…


Acute Care Coding

March 17, 2016 Question: I discharged a patient from an acute care hospital today and admitted them to inpatient rehab on the same date.  Can I report the initial hospital care code for the admission to acute care? Answer: No.  If you are discharging a patient from the acute care hospital, report 99238 or 99239…


Reporting Physical Therapy

March 3, 2016 Question: We have added physical therapy to our office practice and have hired two physical therapists.  When the physician sees the patient to evaluate whether PT would be beneficial can he/she report 97001 for the physical therapy evaluation? Answer: The physician should not report 97001 but instead report an Evaluation and Management…


How to Use CPT Codes 64461, 64462 and 64463

February 18, 2016 Question: There are three new CPT codes our physicians want to use: 64461, 64462 and 64463.  What are these codes used for and what are the rules for reporting them? Answer: CPT codes 64461-64462 are new codes in 2016 to report a paravertebral (PVB) block and are used to treat chronic pain…


Joint Injection with Trigger Point Injection

February 2, 2016 Question: If I am performing a joint injection with a trigger point injection in two different anatomic areas, can I get paid for both? Answer: Yes, you should get paid for both if in different anatomic areas.  Modifier 59 should be used (on the lower valued CPT code) with either a modifier…


Joint Injections with Ultrasound Guidance

January 14, 2016 Question: We do a lot of joint injections (20604, 20606 and 20611) and sometimes use ultrasound guidance. Is this bundled with the CPT code or can we get separate reimbursement for the 76942? My doctors think we can get paid for ultrasound separately. Answer: CPT 20604, 20606, and 20611 include ultrasound guidance….