Office Visits Primarily for the Purpose of HbA1c Testing
The following evaluation and management code may be billed in addition to 83036 or 83036QW for A1c testing under certain circumstances.
99211 Office or outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician.
Physician interpretation of test results is considered to be part of the evaluation and management services provided to a patient during an office visit and is not separately billable. However, if a patient sees a nurse or other non-physician health care professional for the purpose of A1c testing (for example, to monitor insulin therapy) and the nurse takes vital signs, compares the results of the A1c test to predetermined guidelines, and advises the patient accordingly, 99211 may be billed.
Patients with abnormal results or other indications not covered by established guidelines should always be referred to a physician. The level of office visit then reported would depend on the evaluation and management services provided by the physician. When a Metrika A1cNow test is provided to a patient by a physician for home testing at a later date, the test may be submitted for payment when the patient notifies the physician of the result and it is entered in the medical record.
The date of service would be the date the test is performed, not the date the test materials are provided to the patient. If the patient fails to perform the test, the physician may bill the patient for the cost of the test materials; however, the test itself can not be billed to Medicare or the patient since it was not performed.
Medicare payment for lab cpt code 83036 - important points to consider
Medicare Payment for Clinical Laboratory Services
Before Medicare pays for any test or diagnostic service, two basic criteria must be met:
(1) the service must be covered by Medicare (e.g., certain procedures such as routine screening tests are not covered) and
(2) the service must be medically necessary or indicated.
Once these two criteria are met, Medicare pays for most clinical laboratory tests based on the Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and adjusts payment levels annually on January 1st based on Congressional budget recommendation.
Medicare payment for clinical laboratory tests is always the lesser of the fee schedule amount or the actual amount billed. The provider must accept the Medicare reimbursement as payment in full for a laboratory test. Medicare patients may NOT be billed for any additional amounts. Tests must be billed directly to Medicare by the laboratory or physician performing the test. If an outside laboratory performs a test on a referral from a physician, only the reference laboratory may legally bill Medicare for the procedure.
Procedure (CPT) Codes and Modifiers
The CPT codes for Glycated Hemogobin (A1c) determinations are:
83036 Hemoglobin; glycated (A1c)
83036QW Hemoglobin; glycated (A1c) using CLIA waived method
Medicare reimbursement for CPT codes 83036 and 83036QW is $13.42 in all states except:
Idaho: $9.66 Maryland: $12.66 Oklahoma: $11.95
Rhode Island: $12.09 South Dakota: $12.86 Wyoming: $10.49
Diagnosis (ICD-9) Codes
An appropriate diagnosis (ICD-9) code (or narrative description) must be indicated for each service or supply billed under Medicare Part B. ICD-9-CM is an acronym for International
Classification of Diseases, 9th Revision, Clinical Modification.
When a patient presents with an undiagnosed illness, the ICD-9 code is determined by the "signs and symptoms" present. Symptoms are defined as what the patient tells the physician. Signs are what the physician observes as part of his examination of the patient. Definitive ICD-9 codes should only be assigned and recorded in the medical record after a diagnosis is clearly determined. Terms such as "rule out", "probable", and "suspected" should NOT be used since they can not be coded as such and may be interpreted as a firm diagnosis by a third party payer.
Medicare payment for lab cpt code 83036 - important points to consider
Medicare Payment for Clinical Laboratory Services
Before Medicare pays for any test or diagnostic service, two basic criteria must be met:
(1) the service must be covered by Medicare (e.g., certain procedures such as routine screening tests are not covered) and
(2) the service must be medically necessary or indicated.
Once these two criteria are met, Medicare pays for most clinical laboratory tests based on the Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and adjusts payment levels annually on January 1st based on Congressional budget recommendation.
Medicare payment for clinical laboratory tests is always the lesser of the fee schedule amount or the actual amount billed. The provider must accept the Medicare reimbursement as payment in full for a laboratory test. Medicare patients may NOT be billed for any additional amounts. Tests must be billed directly to Medicare by the laboratory or physician performing the test. If an outside laboratory performs a test on a referral from a physician, only the reference laboratory may legally bill Medicare for the procedure.
Procedure (CPT) Codes and Modifiers
The CPT codes for Glycated Hemogobin (A1c) determinations are:
83036 Hemoglobin; glycated (A1c)
83036QW Hemoglobin; glycated (A1c) using CLIA waived method
Medicare reimbursement for CPT codes 83036 and 83036QW is $13.42 in all states except:
Idaho: $9.66 Maryland: $12.66 Oklahoma: $11.95
Rhode Island: $12.09 South Dakota: $12.86 Wyoming: $10.49
Diagnosis (ICD-9) Codes
An appropriate diagnosis (ICD-9) code (or narrative description) must be indicated for each service or supply billed under Medicare Part B. ICD-9-CM is an acronym for International
Classification of Diseases, 9th Revision, Clinical Modification.
When a patient presents with an undiagnosed illness, the ICD-9 code is determined by the "signs and symptoms" present. Symptoms are defined as what the patient tells the physician. Signs are what the physician observes as part of his examination of the patient. Definitive ICD-9 codes should only be assigned and recorded in the medical record after a diagnosis is clearly determined. Terms such as "rule out", "probable", and "suspected" should NOT be used since they can not be coded as such and may be interpreted as a firm diagnosis by a third party payer.
CPT code 99211 - definition and how to use.
CPT code 99211© is used to report a low-level Evaluation and Management (E/M) service. The CPT book defines code 99211 as:
“Office or other outpatient visits for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.”
Code 99211 requires a face-to-face patient encounter; however, when billed as an “incident to” service, the physician’s service may be performed by ancillary staff and billed as if the physician personally performed the service. For such instances, all billing and payment requirements for “incident to” services must be met.
As with all services billed to Medicare, code 99211 services must be reasonable and necessary for the diagnosis or treatment of an illness or injury. Unlike the other E/M CPT codes, the CPT book does not specify completion of particular levels of work for code 99211 in terms of key components or contributory factors. Also, unlike the other E/M codes, CMS did not provide documentation requirements for code 99211 in the “E/M Documentation Guidelines.”
CPT code 99211 describes a service that is a face-to-face encounter with a patient consisting of elements of both evaluation and management. The evaluation portion of code 99211 is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information (historical information and/or physical data) between the provider and the patient.
The management portion of code 99211 is substantiated when the record demonstrates influence by the service of patient care (medical decision-making, provision of patient education, etc.). Documentation of all code 99211 services must be legible and include the identity and credentials of the individual who provided the service.
For code 99211, services performed by ancillary staff and billed by the physician as an “incident to” service, the documentation should also demonstrate the “link” between the non-physician service and the precedent physician service to which the non-physician service is incidental.
Therefore, documentation of code 99211 services provided “incident to” should include the identity and credentials of both the individual who provided the service and the supervising physician. Documentation of a code 99211 service provided “incident to” should also indicate the supervising physician’s involvement with the patient care as demonstrated by one of the following:
• Notation of the nature of involvement by the physician (the degree of which must be consistent with clinical circumstances of the care).
• Documentation from other dates of service that establishes the link between the services of the two providers.
• Medicare has reviewed numerous claims on which 99211 was reported inappropriately. All 99211 services for which supporting documentation does not demonstrate that an E/M service was performed and was necessary as outlined in this document will be denied upon review.
For code 99211, the office or outpatient visit for the evaluation and management of an established patient may not require the presence of a physician or other ualified health care professional.
Here’s a tip for billing code 99211: the presenting problem or problems should be minimal. Typically, five minutes are spent performing or supervising services such as blood pressure checks.
No comments:
Post a Comment