INJURY AND POISONING [800-999]

[800-829] Fractures.
[800-804] Fracture of skull.
[805-809] Fracture of neck and trunk.
[810-819] Fracture of upper limb.
[820-829] Fracture of lower limb.
[830-839] Dislocation.

[840-848] Sprains and strains of joints and adjacent muscles.
[850-854] Intracranial injury, excluding those with skull fracture.
[860-869] Internal injury of thorax, abdomen, and pelvis.
[870-897] Open wound o.
[900-904] Injury to blood vessels.
[905-909] Late effects of injuries, poisonings, toxic effects, and other external causes.
[910-919] Superficial injury.
[920-924] Contusion with intact skin surface.
[925-929] Crushing injury.
[930-939] Effects of foreign body entering through orifice.
[940-949] Burns.

The Benefits of Outsourcing - Process of Medical Billing outsource

Are you a doctor who has a successful medical practice? Have you often heard friends suggesting you to switch outsourced medical billing if you are planning to expand your business further? If the answer to those two questions is “Yes!” you do not have to look any further. We are here to demystify the benefits of outsourcing for you.

First let’s understand what exactly outsourced medical billing is. Outsourcing your medical billing to a company that provides a more efficient solution to organize and arrange your medical billing records. These experienced firms bring their latest and trusted methods to manage your accounts after doing an in-depth analysis of your business. They may have one basic process but they fine-tune in to meet the needs of each client. So before you decide if you want to adopt this model for your business, let’s have a look at some of the benefits of outsourcing.

When you opt for an outsourcing firm to handle your medical billing, you can go back to doing what you do best. You can continue to be the friendly doctor you always dreamt to become, instead of constantly worrying about the financial aspects of the business. Healthcare billing has become quite complex in the last few years. Also the rules of insurance companies and other regulatory agencies change so frequently that it has become almost impossible to keep a tab on all of that. But when you pick a partner to handle your outsourced medical billing, they will resolve all your tensions. After all you have left the task of worrying to the experts.

DX code 630.00 - 759.99

COMPLICATIONS OF PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM [630-677]

[630-633] Ectopic and molar pregnancy.

[634-639] Other pregnancy with abortive outcome.

[640-648] Complications mainly related to pregnancy.

[650-659] Normal delivery, and other indications for care in pregnancy, labor, and delivery.

[660-669] Complications occuring mainly in the course of labor and delivery.

[670-677] Complications of the puerperium.

DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE [680-709]

[680-686] Infections of skin and subcutanious tissue.

[690-698] Other inflammatory conditions of skin and subcutaneous tissue.

[700-709] Other diseases of skin and subcutaneous tissue.

DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE [710-739]

[710-719] Arthropathies and related disorders.

[720-724] Dorsopathies.

[725-729] Rheumatism, excluding the back.

[730-739] Osteopathies, chondropathies, and acquired musculoskeletal deformities.

Anesthesia Modifiers - P1 - P6 modifier

Anesthesia Modifiers Including Physical Status Modifiers:

All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-01999) plus the addition of a physical status modifier. The use of other optional modifiers may be appropriate.

Physical Status Modifiers

Physical Status modifiers are represented by the initial letter 'P' followed by a single digit from 1 to 6

defined below:

P1 - A normal healthy patient.

P2 - A patient with mild systemic disease.

P3 - A patient with severe systemic disease.

P4 - A patient with severe systemic disease that is a constant threat to life.

P5 - A moribund patient who is not expected to survive without the operation.

P6 - A declared brain-dead patient whose organs are being removed for donor purposes.

The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of

complexity of the anesthesia service provided.

Example: 00100-P1

Other Modifiers (Optional)

Under certain circumstances, medical services and procedures may need to be further modified. Other

modifiers commonly used in Anesthesia are included below. A complete list of modifiers and their

respective codes are listed in Appendix A.

-22 Unusual Procedural Services: When the service(s) provided is greater than that usually

required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure

number or by use of the separate five digit modifier code 09922. A report may also be appropriate.

-23 Unusual Anesthesia: Occasionally, a procedure which usually requires either no anesthesia or

local anesthesia, because of unusual circumstances must be done under general anesthesia. This

circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service

or by use of the separate five digit modifier code 09923. Note: Modifier '-47', Anesthesia by

Surgeon, (see modifier section) would not be used as a modifier for the anesthesia procedures 00100-

01999.

-32 Mandated Services: Services related to mandated consultation and/or related services (eg,

PRO, 3rd party payer) may be identified by adding the modifier '-32' to the basic procedure, or the

service may be reported by use of the five digit modifier 09932.

Anesthesia billing services - BCBS

Anesthesia Payment & Billing Information - BCBS

Time and Points Eligible Anesthesia Procedures Defined

HMO Blue Texas and Blue Cross and Blue Shield of Texas have determined that certain anesthesia procedures will be reimbursed on time and points methodology.

Procedures that are not included on the Anesthesia Time & Points Eligible List will not be reimbursed using time and points methodology. If a procedure is not on this list, and it is submitted using anesthesia indicators for Time & Points such as:

using an anesthesia modifier, or

using time on the claim, or

 if submitted on a non-HIPAA claim format, (Type of Service = 7) then the provider may receive a denial message for that procedure noting that the service is not eligible for time and points payment methodology.

Anesthesia Services

Services involving administration of anesthesia should be reported by the use of the Current Procedural Terminology (CPT) anesthesia five-digit procedure codes, American Society of Anesthesiologists (ASA) or CPT surgical codes plus a modifier. HMO Blue Texas and Blue Cross and Blue Shield of Texas will require that the appropriate anesthesia modifier be filed on anesthesia

services.

An anesthesiologist or a CRNA can provide anesthesia services. The anesthesiologist and the CRNA can bill separately for anesthesia services personally performed. When an anesthesiologist provides medical direction to a CRNA, both the anesthesiologist and the CRNA should bill for the

appropriate component of the procedure performed. Each provider should use the appropriate anesthesia modifier.

In keeping with the American Medical Association Current Procedural Terminology (CPT) Book, services involving administration of anesthesia include the usual pre-operative and post-operative visits, the anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services (e.g., ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry). Intra-arterial, central venous, and Swan-Ganz catheter insertion are allowed separately.

Modifier Information Billed by an Anesthesiologist 

AA Anesthesia services personally performed by the anesthesiologist

AD Supervision, more than four procedures

QK Medical Direction of two, three or four concurrent anesthesia procedures

QY Medical Direction of one CRNA by an anesthesiologist

Modifier Information Billed by a CRNA

QX Anesthesia, CRNA medically directed

QZ Anesthesia, CRNA not medically directed

BCBS - Anesthesia Modifier reimbursement

Anesthesia Payment & Billing Information - BCBS

Anesthesia Modifier Reimbursement :

Effective for dates of service on or after May 19, 2004, the HMO Blue Texas and Blue Cross and Blue Shield of Texas maximum allowable fees for services billed as MD supervision of a CRNA are as follows:

QY MD supervision of a CRNA $325.52

QK MD supervision of a CRNA $310.01

AD MD supervision of a CRNA $162.76

OB Time and Points Maximum Allowable Points : 

The following are the current HMO Blue Texas and Blue Cross and Blue Shield of Texas total maximum allowable points for Vaginal or Cesarean deliveries:

Obstetrical Vaginal delivery: 23 total maximum allowable points

Obstetrical Cesarean delivery: 32 total maximum allowable points

If general anesthesia is used in the performance of any obstetrical Vaginal or Cesarean delivery, the maximum allowable points are applicable. In the event that total actual points are less than the total maximum allowable points, you will be reimbursed based on total actual points.

Reimbursement of OB Anesthesia Add-On Codes 01968 and 01969 :

When a primary OB delivery anesthesia procedure (01967) is billed with either 01968 and/or 01969, HMO Blue Texas and Blue Cross and Blue Shield of Texas allows a combined maximum of 32 points.

Aneshthesia Time-Based Units

During the first 4 hours of service, 15 minutes equals 1 unit. If services are provided for longer than 4 hours in one occurrence, each 10-minute period after the initial 4 hours equals 1 unit. A period less than a unit should be rounded up to the next unit.

Example A: 5 hours or 300 minutes equals 22 units – 16 units for the first 4 hours (1 unit per each 15 minutes) and 6 units for the last hour

(1 unit per each 10 minutes).

Example B: 128 minutes is billed as 9 units (8 units for the first 120 minutes and 1 additional unit for the remaining 8 minutes).

Completing the Claim Form

The following instructions are specific to anesthesia services and must be used in conjunction with the complete CMS-1500 Claim Form Instructions provided on First Health Services’ website (select “Billing Information” from the “Providers” menu).

· Field 19: When billing a time-based code, enter the total minutes of reportable anesthesia time in Field 19.

· Field 24D: On the bottom, white half of the claim line, enter one CPT code and one physical status modifier (P1-P6). List additional modifiers when appropriate.

· Field 24G:

o When using a time-based code, enter the number of reportable anesthesia time units; do not add base units or modifier units to the time units.

o When using an occurrence-based code, enter a “1” for each occurrence. The following codes are paid per occurrence: 01953, 01967, 01968, 01969, 01996, 99100, 99116, 99135 and 99140.

Anethesia billing - Introduction

Anesthesia care conventionally includes all services associated with the administration of analgesia/anesthesia, provided by an anesthesiologist and/or certified registered nurse anesthetist (CRNA)1 to a patient undergoing a surgical or other invasive procedure so that intervention can be undertaken. This may involve local, regional, epidural, general anesthesia or monitored anesthesia care (MAC), and usually involves administration of anxiolytics or amnesia-inducing medications. 

Additionally, anesthesia care includes preoperatively evaluating the patient with a sufficient history and physical examination so that the risk of adverse reactions can be minimized, planning alternative approaches to accomplishing anesthesia and answering all questions regarding the anesthesia procedure asked by the patient.

The anesthesiologist assumes responsibility for the post anesthesia recovery period which is included in the anesthesia care package. It encompasses all care until the patient is released to the surgeon or another physician; this point of release generally occurs at the time of release from the post anesthesia recovery area.

Medicine CPT code List

Immunization Injections 90700 - 90749
Therapeutic/ Diagnostic Infusions ( excludes chemo) 90780 - 90781
Therapeutic or Diagnostic Injections 90782 - 90799
Psychiatry 90801 - 90899
Biofeedback 90901 - 90911
Dialysis 90918 - 90999
Gastroenterology 91000 - 91299
Ophthalmology 92002 - 92499
Special Otorhinolaryngologic Services 92502 - 92599
Cardiovascular 92950 - 93799
Non-Invasive Vascular Diagnostic Studies 93875 - 93990
Pulmonary 94010 - 94799
Allergy and Clinical Immunology 95004 - 95199
Endocrinology 95250
Neurology and Neuromuscular Procedures 95805 - 96004
Central Nervous System Assessments/Tests 96100 - 96117
Health and Behavior Assessment/Intervention 96150 - 96155
Chemotherapy Administration 96400 - 96549
Photodynamic Therapy 96567 - 96571
Special Dermatological Procedures 96900 - 96999
Physical Medicine and Rehabilitation 97001 - 97799
Medical Nutrition Therapy 97802 - 97804
Osteopathic Manipulative Treatment 98925 - 98929
Chiropractic Manipulative Treatment 98940 - 98943
Special Services Procedures and Reports 99000 - 99091
Qualifying Circumstances for Anesthesia 99100 - 99140
Sedation With or Without Analgesia 99141 - 99142
Other Services and procedures 99170 - 99199
Home Health Procedures/Services 99500 - 99539
Home Infusion Procedures 99551 - 99569.

Medical billing basic - What is CPT

What is CPT? 

CPT was developed by the American Medical Association (AMA) in 1966. The AMA revises and publishes CPT each year to keep pace with changes in medical practice. They delete obsolete procedures, modify existing procedures, and add newly developed procedures. Your physicians’ office should make it a policy to order the current book from the AMA each year. Begin using the new CPT codes on January 1. 

•  listing of descriptive terms and five-digit, numeric codes for reporting medical services and procedures performed by physicians. 

• provides a uniform language to accurately designate medical, surgical and diagnostic services. 

•     serves as an effective means of reliable nationwide communication between physicians, patients and third-party payers. 

Each time you submit a claim, identify the service provided by using one of these five-digit CPT codes, plus a two-digit modifier when appropriate. 

HCPCS Levels of Codes

HCPCS is the acronym for the Healthcare Common Procedure Coding System. This system is a uniform method for health care providers and medical suppliers to report professional services, procedures, and supplies. 

There are three levels of codes within the HCPCS system: 

Level I. Level I is the largest component, made up of five-digit numeric CPT codes and two-digit modifiers. Both CPT codes and modifiers have descriptive terms for reporting services performed by health care providers. The first edition of CPT was published by the American Medical Association (AMA) in 1966 and it continues to release updates each year. 

Example: 10060 * Incision and drainage of abscess 

Level II. These national codes, created by The Centers for Medicare and Medicaid Services (CMS), were developed to cover services not specifically reported in CPT. Level II HCPCS codes consist of one alpha character (A through V), followed by four numbers. Level II HCPCS modifiers are two-digit codes which can be used with any level of codes. Level II codes are grouped by the type of service or supply they represent and are updated annually by CMS with input from private insurance companies. 

Example: A4580 Cast supplies 

Level III. Level III codes are used to report services and supplies that may be covered but not listed in the other two levels of HCPCS. These codes begin with a letter (W - Z) followed by four numeric digits. Wellmark has eliminated all Level III codes in accordance with HIPPA (Health Insurance Portability and Accountability Act of 1996) requirements. 

Remember: 

• CPT* provides a uniform language to accurately designate medical, surgical and diagnos-tic services. 

• CPT and HCPCS are updated annually to reflect medical practice changes. 

•  The AMA is responsible for revising CPT and CMS updates HCPCS Level II codes. 

• CPT is used to report the medical services and procedures performed by physicians to insurance carriers. 

• To assure that correct CPT codes are used for all procedures, a new CPT book should be purchased annually. 

• Choose a procedure code that accurately identifies the service performed. Do not choose an approximate code (use an unlisted code if none exists to accurately describe it). 

what is CPT Coding System

CPT Coding System

Current Procedural Terminology (CPT), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and
third parties

The American Medical Association (AMA) first developed and published CPT in 1966. The first edition helped encourage the use of standard terms and descriptors to document procedures in the medical record; helped communicate accurate information on procedures and services to agencies concerned with insurance claims; provided the basis for a computer-oriented system to evaluate operative procedures; and contributed basic information for actuarial and statistical purposes.The first edition of the CPT code book contained primarily surgical procedures, with limited sections on medicine, radiology, and laboratory procedures.

The second edition was published in 1970, and presented an expanded work of terms and codes to designate diagnostic and therapeutic procedures in surgery , medicine, and the specialties. At that time, five-digit coding was introduced, replacing the former four-digit classification. Another significant change was a listing of procedures relating to internal medicine.

In the mid- to late 1970s, the third and fourth editions of the CPT code were introduced. The fourth edition, published in 1977, represented significant updates in medical technology, and a procedure of periodic updating was introduced to keep pace with the rapidly changing medical environment. In 1983, the CPT code was adopted as part of the HealthCare Common Procedure Coding System (HCPCS) (Formerly called as HealthCare Financing Administration's (HCFA) Common Procedure Coding System) . 

With this adoption, HCFA mandated the use of HCPCS to report services for Part B of the Medicare Program. In October 1986, CMS also required State Medicaid agencies to use HCPCS in the Medicaid Management Information System. In July 1987, as part of the Omnibus Budget Reconciliation Act, HCFA mandated the use of CPT for reporting outpatient hospital surgical procedures. Today, in addition to use in federal programs (Medicare and Medicaid), CPT is used extensively throughout the United States as the preferred work of coding and describing health care services 

Medical Billing Code Changes - Keep up with updation.

Medical billing coding is used to claim from insurance companies, and change frequently, usually on an annual basis. When billing codes become obsolete, insurance companies do not accept them, and as a consequence, claims are rejected.

There are a few methods which one can employ to stay in touch with changes and maintain a current medical billing code. The Code Books like CPT give a definition for each billing code, and list each billing code alphanumerically, making it easy to follow. Billing codes recorded in the CPT Code Books are revised with each issue on annual basis. Within each book is an appendix of changes, which show how a service has been modified from the current procedural terminology while maintain the same definition. By following the changes in the CPT Code Book every year, one is able to maintain an up to date database of billing code changes.

Another possible method to handle billing code changes involves using the International Classification of Diseases (ICD9). This system is used primarily as a means of reporting statistical data, and works by grouping the procedures of the related diseases. Similar to the CPT Code Books, ICD9 Books sort their diseases and diagnoses alphanumerically, and are updated annually.

Having to cross-reference billing codes with two referencing systems can be very time consuming, and there can be an element of human error involved. Using Medical Billing Software is a worthwhile alternative for referencing code books, which is likely to be updated frequently. Another advantage is that one does not require cross-referencing or the need to refer a range of billing code books when coding any medical procedure. Electronic software completely removes this problem, and more importantly, online referencing features are available that cannot be matched by using code reference books.

RESPIRATORY, DIGESTIVE SYSTEM, GENITOURINARY SYSTEM - DX CODE

DISEASES OF THE RESPIRATORY SYSTEM [460-519]

[460-466] Acute respiratory infections.

[470-478] Other diseases of the upper respiratory tract.

[480-487] Pneumonia and influenza.

[490-496] Chronic obstructive pulmonary disease and allied conditions.

[500-508] Pneumoconioses and other lung diseases due to external agents.

[510-519] Other diseases of respiratory system.

DISEASES OF THE DIGESTIVE SYSTEM [520-579]

[520-529] Diseases of oral cavity, salivary glands. and jaws.

[530-537] Diseases of esophagus, stomach, and duodenum.

[540-543] Appendicitis.

[550-553] Hernia of abdominal cavity.

[555-558] Noninfectious enteritis and colitis.

[560-569] Other diseases of intestines and peritoneum.

[570-579] Other diseases of digestive system.

How costly is Medical Billing Mistakes and Fraud?

Even though working from the comfort of home as a medical billing professional may seem like the near-perfect career, offering benefits and advantages that within a doctor’s office or healthcare center are unavailable, the ramifications of possible mistakes can be very costly. 

An example of how things can go wrong can be shown by MSO Washington, Inc. MSO is a medical practice management and billing service company that had to agree a settlement against claims of healthcare fraud, to the value of $565,000. The Dept. of Justice alleges that the company made claims to Medicare and Medicaid for settlement which failed to include the proper records and claims for procedures that were deemed medically unnecessary. The Department found that in some cases the procedures claimed for were never completed, or they were executed but charged for at rates above the industry standard.

It seems as though the healthcare providers were allegedly not aware of the questionable billing practices, and consequently, they were not a part of the investigation. The system that was under investigation was a home visitation program, in which doctors and medical professionals visited homes to inspect the residence itself. 

ICD 9 - DX code Mandatory Fiftt digit

Mandatory Fifth Digit

A 3-digit code is the primary classification for an illness or injury, a 4-digit code is a secondary classification of the same illness or injury, and a 5-digit code is a classification of the same illness or injury.

Notes are also used to list the fifth-digit sub classifications for subcategories – such as entries “Tuberculosis” or Diabetes mellitus.” Only the four-digit code is given for the individual entry, and you must refer to the note following the main term to locate the appropriate fifth-digit sub classification.

Not all ICD codes are valid for use on insurance claim forms. Carriers require the greatest specificity possible when using the codes. The idea is never to use a 3-digit code that has been sub-classified into 4-digit codes, and never use a 4- digit code that has been sub-classified as a 5-digit code.

Not all codes have fourth and fifth digits, but when a fourth or fifth digit is available, it must be used. It is a good idea to highlight codes with which a fifth digit is listed. This will serve as a reminder to you to always use that fifth digit. The following is a list of fifth digits that are used to identify location.

Pathology and Laboratory CPT code list

• CPT Divided into fourteen subsections:

Organ or Disease Oriented Panels 80048* - 80076

Drug Testing 80100 - 80103

Therapeutic Drug Assays 80150 - 80299

Evocative/Suppression Testing 80400 - 80440

Consultations (Clinical Pathology) 80500 - 80502

Urinalysis 81000 - 81099

Chemistry 82000 - 84999

Hematology and Coagulation 85002 - 85999

Immunology 86000 - 86849

Transfusion Medicine 86850 - 86999

Microbiology 87001 - 87999

Anatomic Pathology 88000 - 88099

Cytopathology 88104 - 88199

Cytogenetic Studies 88230 - 88299

Surgical Pathology 88300 - 88399

Transcutaneous Procedures 88400

Other Procedures 89050 - 89399

Laboratory and pathology cpt code 80500, 80502, 88300,88309, 88342

Laboratory and pathology codes during colonoscopy episode

Description CPT/HCPCs

Consultations (Clinical pathology)

Clinical Pathology Consultation, Limited, Without Review Of Patient's History And Medical Records : 80500

Clinical Pathology Consultation, Comprehensive, For A Complex 

Diagnostic Problem, With Review Of Records : 80502

Surgical Pathology

Level I - Surgical Pathology, Gross Examination Only : 88300

Level III - Surgical Pathology, Gross And Microscopic (Abscess, Colon, Colsotomy, Hematoma, Soft Tissue Debridement) : 88304

Level IV - Surgical Pathology, Gross And Microscopic (Colon Biopsy, Lymph Node Biopsy, Colorectal Polyp) : 88305

Level V - Surgical Pathology, Gross And Microscopic (Colon, Segmental Resection, Other Than For Tumor, Liver Biopsy Or Partial Resection) : 88307

Level VI - Surgical Pathology, Gross And Micoscopic (Colon, 

Resection For Tumor, Total Colon Resection) : 88309

Special Stains, Histochemical With Frozen Section : 88314

Consultation And Report On Referred Slides Prepared Elsewhere : 8321 

Consultation And Report On Referred Material Requiring Preparation Of Slides : 88323

Consultation, Comprehensive, With Review Of Records And Specimens : 88325

Immunohistochemistry (including tissue immunoperoxidase), each antibody : 88342

Pathology service under ASC setup - Would insurance reimburse

Non-ASC Facility Services

Non-ASC facility services include a number of items and services furnished in an ASC that can be reimbursed under other Florida Workers’ Compensation Manuals which are not reimbursable to an ASC facility.

The following are examples of non-ASC facility services that must be billed and reimbursed to those providers under other Florida Workers’ Compensation Reimbursement Manual policies and guidelines:

• Physician and other recognized health care practitioner services;

• Sale, lease, or rental of durable medical equipment for ASC patients to use at home;

• Services furnished by an independent laboratory; and

• Hospital-based Ambulance services.

Pathology/Laboratory Services

Preadmission pathology or laboratory services, when required by the physician and performed by the ASC on a date other than the date of surgery, shall be reimbursed in accordance with the Fee Schedule established for health care providers in the Florida Workers Compensation Health Care Provider Reimbursement Manual, Rule 69L-7.020, F.A.C.

Pathology or laboratory services provided by an Independent Clinical Laboratory shall be billed and reimbursed directly to the laboratory service provider according to the fee schedule in rule 69L-7.020, F.A.C. However, the ASC shall be reimbursed for procedure code 36415 for the collection of a blood specimen that must be conveyed to an independent laboratory.

Lab CPT codes list which can be performed by CLIA certified providers. Providers with a CLIA certificate may conduct the following laboratory tests in their offices:

Description Codes Description Codes

Urinalysis 81000- 81003

Crystal Identification 89060

Glucose 82947- 82948

ESR 85651, 85652

Prothrombin time 85610

BM Aspiration 85097

Tuberculosis Intra-Dermal Skin Test 86580

Platelet 85007

Urine Pregnancy Test 81025

Bilirubin Direct 82248

Tissue Exam (KOH) Prep 87220

Bilirubin Total 82247

Wet Mounts 87177, 87210

Hemoglobin Glycated 83036

FOBT (Hemocult) 82270

Blood Smear 85060

Strep Test Group A 87070, 87880

Molecular Cytogenetics Chromosomal 88273

CBC 85025- 85048

Molecular Cytogenetics Interphase 88274

BUN, Creatinine 82565

Special Stains Group I 88312

Potassium 84132

Special Stains Group II 88313

Hemoglobin 85018

Clinical Pathology Consultation Limited 80500

Semen Analysis 89300 - 89320

Clinical Pathology Consultation Comprehensive 80502

Sperm Evaluation 89329

Lead Testing 83655

Cervical Mucus Penetration Test 89330

Rapid Flu Test 87804

Anesthesia Billing Guideline CPT 99200, 99000,99070

Time Reporting:

Time for anesthesia procedures may be reported as is customary in the local area. Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision.

Physicians Services:

Physician's services rendered in the office, home, or hospital, consultation and other medical services are listed in the "Codes" section entitled Evaluation and Management Services (99200 series). "Special Services and Reporting" (99000 series) are presented in the Medicine section.

Materials Supplied by Physician:

Supplies and materials provided by the physician (eg, sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately. List drugs, tray supplies, and materials provided. Identify as 99070.

CPT CODE 99200, 99000,99070 Guide

CPT code and description

99000 - Handling and/or conveyance of specimen for transfer from the office to a laboratory -average fee amount-$0.00

99070 - Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)

Handling fees, CPT codes 99000 and 99001

CPT codes 99000 and 99001 are designated as status B codes (bundled and never separately reimbursed) on the Physician Fee Schedule RBRVU file. Moda Health clinical edits will deny CPT 99000 or 99001 with explanation code WGO (Service/supply is considered incidental and no separate payment can be made. Payment is always bundled into a related service), whether 99000

or 99001 is billed with another code or as the sole service for that date. This edit is not eligible for a modifier bypass

Laboratory Handling

Laboratory handling and conveyance CPT codes 99000 and 99001 and HCPCS code H0048 are included in the overall management of a patient and are not separately reimbursed when submitted with another code, or when submitted as the only code on a claim for the same date of service.

Submitting CPT 99000 with Modifier 59

Blue Cross and Blue Shield of Texas (BCBSTX) regularly evaluates the coding practices of physicians and other providers who submit claims for services. This includes issues such as bundling and use of CPT modifiers.

BCBSTX recently studied the use of Modifier 59 (distinct procedural service) with the submission of CPT 99000 (handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory).

Because CPT 99000 is purely an administrative service and not a procedure, BCBSTX considers use of Modifier 59 for this code to be inappropriate.

This inappropriate use of Modifier 59 results in an override of a claim system edit that considers CPT 99000 incidental to any other service performed on that date of service, including CPT 36415 for routine collection of venous blood, and results in overpayment. Please do not submit claims for CPT 99000 with Modifier 59.

Payment policy

10/16/06 “Specimen Handling and/or Conveyance or Implementation of Orders for Devices” to “Specimen Handling and/or Conveyance.” and clarified reimbursement policy for 99000.

Combined statements related to Therapeutic, prophylactic or diagnostic injection(Allergen Immunotherapy)and statements related Office Visit(s). Removed “Routine office visits provided in addition to preventive health office visits are considered mutually exclusive to the preventive health office visit.”

11/05/07 In the Pathologist section added code 85060 to the list of codes eligible for clinical interpretation. Changed the wording from “Pathology interpretation of all other codes in the 80002-87999 range is considered an integral service.” to “Pathology interpretation of all other codes in the 80002-87999 range is considered an integral to the laboratory test.” Changed the words “mutually exclusive” to “incidental” in the Cardiac Stress Test section. 

Removed code 93000 and 93040 because the incidental logic no longer applies to 99291 and 99292 in the Critical Care section. Code 93798 removed from the Electrocardiograms section. Removed code 82800, 82805, 82810, 93000, 93040 and 94640 because the incidental logic no longer applies to codes 99296, 99294, 99295, 99296 and 99298 in the Neonatal Intensive Care Services. 

Changed the word from “incidental” to “mutually exclusive” in the Transvaginal Ultrasound section. Removed the Maldistribution of Inspired Gas, hlamydia Testing by Direct or Amplified Probe Technique, Fluoroscopic Guidance and Voiding Pressure Studies section. Removed any deleted codes. Policy reviewed 10/26/07 by Senior Medical Director of Provider Partnerships, Medical and Reimbursement Policy.

6/7/2011 Further defined “When a lumbar laminectomy, facetectomy or foraminotomy is performed in conjunction with a lumbar spinal fusion procedure, the lumbar laminectomy, facetectomy or for aminotomy will be considered incidental to the lumbar spinal fusion.” Notification 3/15/2011 with an Effective date of 6/19/2011. (dpe)

Policy implementation information from 3/30/2006-05/05/2008 restored. Added information regarding After Hours Care and Specimen Handling. “After Hours Care - Reimbursement is not provided for CPT codes 99050 and 99051 for a facility credentialed and contracted as an urgent care center” and “CPT codes 99000 and 99001, the handling and/or conveyance of specimen, are eligible for payment to the provider’s office when the laboratory service is not performed in the provider’s office and the independent laboratory bills BCBSNC directly for the test. 

The independent laboratory/reference laboratory will not be reimbursed for 99000 and 99001.” Removed the following information from Topics of Frequent Interest Related to Blue Care, Blue Choice, Blue Options, and Classic Blue Products as not longer applicable : “Visual Acuity Screening - Visual acuity screening (99173) is considered incidental to routine office visits and preventive health visits.  separate reimbursement is not allowed for incidental services.” Notification given 6/7/2011 for effective date of 9/1/2011.

MATERIALS AND SUPPLIES – CPT CODE 99070

Anthem’s reimbursement for materials and supplies provided by the physician is included in the global reimbursement of the primary service being provided. Materials and supplies are not separately payable. Therefore, CPT code 99070 is not separately payable. If a provider bills with CPT code 99070 for a material or supply that is not usually part of the primary service, and CPT code 99070 is denied, the provider may call the Customer Service number listed on the member’s card or Provider Inquiry for a manual review of  the claim.

Anthem's reimbursement, if any, is reduced by any applicable deductibles, copayments and/or coinsurance as defined in the member’s contract for benefits and coverage. 99070 for Reporting Supplies, Materials, Supplements, Remedies, etc.

For HCFA1500 claims with dates of service 04/01/2015 and following, Moda Health will deny CPT code 99070 to provider write-off with an explanation code mapped to Claim Adjustment Reason Code 189 (Not otherwise classified or "unlisted" procedure code Page 3 of 10 (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.). There is always a procedure code more specific than 99070 available to be used.

Correct coding guidelines require that the most specific, comprehensive code available be selected to report services or items billed. 

Moda Health accepts HCPCS codes for processing. Therefore, 99070 is never the most specific code available to use to report a supply, drug, tray, or material provided over and above those usually included in a service rendered.

Any HCPCS Level II code in the HCPCS book is more specific than 99070. The HCPCS book also includes a wide variety of more specific unlisted codes that should be used in  place of 99070 when the billing office cannot identify a listed HCPCS code to describe the supply or material being billed. The use of more specific HCPCS Level II procedure codes helps to ensure more accurate determination of benefits and processing of the claim.

It is important to note that not all HCPCS codes will be eligible for covered benefits under the member’s contract, and if covered, not all HCPCS codes will be eligible for separate reimbursement.

For reimbursement of covered medical and surgical supplies, an appropriate Level II HCPCS code must be submitted. The non-specific CPT code 99070 (supplies and materials, except spectacles, provided by the physician or other health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) is not reimbursable in any setting

Supply Code L8680

Effective May 1, 2016 HCPCS code L8680 is no longer separately billable, with CPT code 63650, for Medicare because payment for electrode cost has been incorporated in CPT code 63650.