Friday, August 19, 2016

Policy guideline for CPT CODE G0372 & 99360


Power Mobility Devices (PMDs)


Section 302(a)(2)(E)(iv) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) sets forth revised conditions for Medicare payment of Power Mobility Devices (PMDs). This section of the MMA states that payment for motorized or power wheelchairs may not be made unless a physician (as defined in §1861(r)(1) of the Act), a physician assistant, nurse practitioner, or a clinical nurse specialist (as those terms are defined in §1861(aa)(5)) has conducted a face-to-face examination of the beneficiary and written a prescription for the PMD.


Payment for the history and physical examination will be made through the appropriate evaluation and management (E&M) code corresponding to the history and physical examination of the patient. Due to the MMA requirement that the physician or treating practitioner create a written prescription and a regulatory requirement that the physician or treating practitioner prepare pertinent parts of the medical record for submission to the durable medical equipment supplier, code G0372 (physician service required to establish and document the need for a power mobility device) has been established to recognize additional physician services and resources required to establish and document the need for the PMD.


The G code indicates that all of the information necessary to document the PMD prescription is included in the medical record, and the prescription and supporting documentation is delivered to the PMD supplier within 30 days after the face-to-face examination.


Effective October 25, 2005, G0372 will be used to recognize additional physician services and resources required to establish and document the need for the PMD and will be added to the Medicare physician fee schedule.

Physician Standby Service (Code 99360)

Standby services are not payable to physicians. Physicians may not bill Medicare or beneficiaries for standby services. Payment for standby services is included in the Part A payment to the facility. Such services are a part of hospital costs to provide quality care. If hospitals pay physicians for standby services, such services are part of hospital costs to provide quality care.

Wednesday, August 17, 2016

Example of billable and non billable prolonged service - CPT CODE 99358 & 99359

Examples of Billable Prolonged Services

EXAMPLE 1

A physician performed a visit that met the definition of an office visit code 99213 and the total duration of the direct face-to-face services (including the visit) was 65 minutes. The physician bills code 99213 and one unit of code 99354.


EXAMPLE 2

A physician performed a visit that met the definition of a domiciliary, rest home care visit code 99327 and the total duration of the direct face-to-face contact (including the visit) was 140 minutes. The physician bills codes 99327, 99354, and one unit of code 99355.


EXAMPLE 3

A physician performed an office visit to an established patient that was predominantly counseling, spending 75 minutes (direct face-to-face) with the patient. The physician should report CPT code 99215 and one unit of code 99354.



J. Examples of Nonbillable Prolonged Services

EXAMPLE 1

A physician performed a visit that met the definition of visit code 99212 and the total duration of the direct face-to-face contact (including the visit) was 35 minutes. The physician cannot bill prolonged services because the total duration of direct face-to-face service did not meet the threshold time for billing prolonged services.


EXAMPLE 2

A physician performed a visit that met the definition of code 99213 and, while the patient was in the office receiving treatment for 4 hours, the total duration of the direct face-to-face service of the physician was 40 minutes. The physician cannot bill prolonged services because the total duration of direct face-to-face service did not meet the threshold time for billing prolonged services.


EXAMPLE 3

A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (face-to-face) with the patient. The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215 which has 40 minutes typical/average time units associated with it). The additional time spent beyond this code is 20 minutes and does not meet the threshold time for billing prolonged services.

Prolonged Services Without Direct Face-to-Face Patient Contact Service (Codes 99358 - 99359)

Contractors may not pay prolonged services codes 99358 and 99359, which do not require any direct patient face-to-face contact (e.g., telephone calls). Payment for these services is included in the payment for direct face-to-face services that physicians bill. The physician cannot bill the patient for these services since they are Medicare covered services and payment is included in the payment for other billable services.

ICD 10 code for osteopenia

Provider Action Needed

The Centers for Medicare & Medicaid Services (CMS) will implement Change Request (CR) 9252 on January 4, 2016, effective October 1, 2015. (See related MLN Matters® article MM9252.) This CR establishes the list of covered conditions and corresponding ICD-10-CM diagnosis codes approved for Bone Mass Measurement studies according to the requirements set forth in National Coverage Determination (NCD) 150.3. CR9252 and accompanying spreadsheet inadvertently omitted the condition of osteopenia and the ICD- 10-CM codes that describe it which are classified to subcategory M85.8- Other specified disorders of bone density and structure. The codes and conditions identified within this subcategory are considered covered indications for bone mass measurement under NCD 150.3 and providers should report these appropriately according to medical documentation.


Additional guidance and education as to the updated complete list of covered indications will be forthcoming as CMS continues to review this issue and the systems updates required. Under ICD-9-CM, the term “Osteopenia” was indexed to ICD-9-CM diagnosis code 733.90 (Disorder of bone and cartilage). This code was listed as a covered condition under the Business requirement 5521.1.1 for CR 5521/NCD 150.3, dated May 11, 2007, when reported with CPT code 77080. (See related MLN Matters article MM552


Under ICD-10-CM, the term “Osteopenia” is indexed to ICD-10-CM subcategory M85.8- Other specified disorders of bone density and structure, within the ICD-10-CM Alphabetic Index. The codes within this subcategory were inadvertently omitted from the CMS spreadsheet that accompanied CR 9252 containing the list of covered conditions and corresponding diagnosis codes. These are considered covered for NCD 150.3 indications.

Below is the list of ICD-10-CM diagnosis codes within subcategory M85.8- that providers may report as covered indications in addition to the current list provided in CR 9252 and its accompanying CMS spreadsheet.

** M85.811 Other specified disorders of bone density and structure, right shoulder

** M85.812 Other specified disorders of bone density and structure, left shoulder

** M85.821 Other specified disorders of bone density and structure, right upper arm

** M85.822 Other specified disorders of bone density and structure, left upper arm

** M85.831 Other specified disorders of bone density and structure, right forearm

** M85.832 Other specified disorders of bone density and structure, left forearm

** M85.841 Other specified disorders of bone density and structure, right hand


** M85.842 Other specified disorders of bone density and structure, left hand

** M85.851 Other specified disorders of bone density and structure, right thigh

** M85.852 Other specified disorders of bone density and structure, left thigh

** M85.861 Other specified disorders of bone density and structure, right lower leg

** M85.862 Other specified disorders of bone density and structure, left lower leg

** M85.871 Other specified disorders of bone density and structure, right ankle and  foot

** M85.872 Other specified disorders of bone density and structure, left ankle and foot

** M85.88 Other specified disorders of bone density and structure, other site

** M85.89 Other specified disorders of bone density and structure, multiple sites



Question 1 When will the LCD be updated to either remove Osteopenia as an indication or include the ICD-10 diagnosis codes for Osteopenia? 

Answer

• The ICD-10 codes that crosswalk with Osteopenia are under subcategory M85.8 and do not refer to Osteopenia. They are a group of very nonspecific disorders of bone density which do NOT justify or qualify for Vitamin D testing. • The specificity of the ICD-10 testing has refined what disorders qualify for coverage of Oncology Cytogenetics and have allowed us to cull out diagnoses that were previously covered but should not have been. We feel at present the appropriate diagnoses are covered and do not plan on developing a LCD that will expand on the covered ICD-10 codes that CMS has established in NCD 190.3


The following two studies are not covered by Medicare:

 78350: Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry
 78351: Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry

ICD-10-CM code Z90.721 or Z90.722 should be reported for women s/p oophorectomy.

ICD-10-CM code Z79.51 or Z79.52 should be reported for an individual on glucocorticoid therapy.

ICD-10-CM code Z79.83 should be reported for DXA testing while taking medicines for osteoporosis/osteopenia.

ICD-10-CM Z09 should be reported for an individual who has COMPLETED drug therapy for osteoporosis and is being monitored for response to the therapy.

Medicare covers a bone mass measurement for a beneficiary once every two years (if at least 23 months have passed since the month the last bone measurement was performed). The criteria for bone mass measurement every two years are listed below:

 It is performed with a bone densitometer, other than dual photon absorptiometry (DPA) or a bone sonometer (e.g., ultrasound) device that has been approved or cleared for marketing by the Food and Drug Administration (FDA).

 It is performed on a qualified individual for the purpose of identifying bone mass, detecting bone loss or determining bone quality. The term “qualified individual” means an individual who meets the medical indications  for at least one of the criteria listed below:

o A woman who has been determined by the physician or qualified non-physician treating her to be estrogendeficient and at clinical risk for osteoporosis, based on her medical history and other indicators

o An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture

o An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5 mg of Prednisone, or greater, per day for more than 3 months

o An individual with primary hyperparathyroidism

o An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy. This service must be performed using dual energy x-ray absorptiometry system (axial skeleton) – CPT code 77080 and 77085


Monday, August 15, 2016

MO HealthNet contact information for provider enrollment

PROVIDER COMMUNICATIONS
573-751-2896

MO HealthNet providers can contact the Provider Communications Unit with inquiries, concerns or questions regarding proper claim filing, claims resolution and disposition, and participant eligibility questions and verification. The IVR (Interactive Voice Response) system is accessed by calling the 573-751-2896 number. The IVR system can address participant eligibility, last two check amounts and claim status inquiries. At anytime during the IVR options, providers may select "0" to speak with the next available specialist. Calls are put into a queue and will be answered in the order received. Providers must use a touchtone phone to access the
IVR.

Providers may send and receive secure E-mail inquiries to MO HealthNet Provider Communications and Technical Help Desk Staff. This application is available through the MO HealthNet Web portal at www.emomed.com. Once logged in and on the eProvider page, click on the ‘Provider Communications Management’ icon, this opens the ‘Manage Provider Communications’ page. From here, click on ‘New Request’ to open the ‘Create New Request’ form to enter and submit an inquiry. Providers are limited to one inquiry per E-mail. The user submitting the E-mail inquiry will be notified  via E-mail when they have a response available to their inquiry.
The Provider Communications Unit also responds to written inquiries. Written inquiries should be sent to:

Provider Communications Unit
PO Box 5500
Jefferson City, Missouri 65102

WIPRO INFOCROSSING HEALTHCARE SERVICES, INC. HELP DESK
573-635-3559

Call this number for assistance in establishing the required electronic claims and remittance advice formats, network communication, HIPAA trading partner agreements and assistance with the Wipro Infocrossing Internet billing service.


PROVIDER ENROLLMENT

Providers are required to notify Missouri Medicaid Audit Compliance, Provider Enrollment Section regarding changes to their Provider Master File. Changes include, but are not limited to, physical address, tax identification, ownership, individual's name or practice name, or NPI number. Changes may be reported via E-mail at mmac.providerenrollment@dss.mo.gov or by mail to:

Missouri Medicaid Audit and Compliance
Provider Enrollment Section
PO Box 6500
Jefferson City, Missouri 65102



THIRD PARTY LIABILITY
573-751-2005

Call the Third Party Liability Unit to report injuries sustained by MO HealthNet participants, problems obtaining a response from an insurance carrier, or unusual situations concerning third party insurance coverage for a MO HealthNet participant.


PROVIDER EDUCATION
573-751-6683

Provider Education Unit staff are available to educate providers and other groups on0 proper billing methods and procedures for MO HealthNet claims. Contact the unit for training information and scheduling. Providers may also send E-mails to the unit at
mhd.provtrain@dss.mo.gov.


PARTICIPANT SERVICES
800-392-2161 or 573-751-6527

The Participant Services Unit assists participants regarding access to providers, eligibility, covered and non-covered services and unpaid medical bills.


MO HEALTHNET PHARMACY AND CALL CENTER
800-392-8030

Providers can call this toll free number to:

• Request pre-certification for specific DME items;

• Initiate an emergency request for an essential medical service or an item of equipment that would not normally be covered under the MO HealthNet program;

Providers are encouraged to sign up for the MO HealthNet Web tool – CyberAccessSM – which automates the pre-certification process. To become a CyberAccessSM user, contact the Xerox Care and Quality help desk at 888-581-9797 or 573-632-9797 or
send an E-mail to CyberAccessHelpdesk@xerox.com. The CyberAccessSM tool allows each pre-certification to automatically reference the individual participant's claim history, including ICD-9 diagnosis codes and procedure codes.

• Request information on Medicare Part D,

• Request a drug prior authorization; or,

• Request medical pre-certification for a CT scan or MRI.

Saturday, August 13, 2016

Medicare Coverage Related to Investigational Device Exemption (IDE)

Requesting Coverage

Interested parties with Food and Drug Administration (FDA) approval letters dated January 1, 2015 or later for IDE Category A or Category B studies that are seeking Medicare coverage for Category A or B IDE studies must submit a request packet to CMS that includes the following information:

A. A request letter that describes the scope and nature of the IDE study. For your convenience we created a checklist and sample crosswalk to assist submitters in submitting a complete package. We encourage you to submit this crosswalk along with the request packet to facilitate CMS' review. The letter should focus on how the IDE study meets each of the regulatory Medicare coverage IDE study criteria, which are:

1. The principal purpose of the study is to test whether the device improves health outcomes of appropriately selected patients.
2. The rationale for the study is well supported by available scientific and medical information, or it is intended to clarify or establish the health outcomes of interventions already in common clinical use.
3. The study results are not anticipated to unjustifiably duplicate existing knowledge.
4. The study design is methodologically appropriate and the anticipated number of enrolled subjects is adequate to confidently answer the research question(s) being asked in the study.
5. The study is sponsored by an organization or individual capable of successfully completing the study.
6. The study is in compliance with all applicable Federal regulations concerning the protection of human subjects found at 21 CFR parts 50, 56, and 812, and 45 CFR part 46.
7. Where appropriate, the study is not designed to exclusively test toxicity or disease pathophysiology in healthy individuals.  Studies of all medical technologies measuring therapeutic outcomes as one of the objectives may be exempt from this criterion only if the disease or condition being studied is life threatening and the patient has no other viable treatment options.
8. The study is registered with the National Institutes of Health (NIH) National Library of Medicine’s (NLM) ClinicalTrials.gov.
9. The study protocol describes the method and timing of release of results on all pre-specified outcomes, including release of negative outcomes and that the release should be hastened if the study is terminated early.
10. The study protocol must describe how Medicare beneficiaries may be affected by the device under investigation, and how the study results are or are not expected to be generalizable to the Medicare beneficiary population. Generalizability to populations eligible for Medicare due to age, disability, or other eligibility status must be explicitly described.
B. FDA approval letter of the Category A or Category B IDE. (CMS will review a submission with a conditional FDA approval letter; however, please submit the final FDA approval letter to CMS at clinicalstudynotification@cms.hhs.gov.)
C. IDE study protocol.
D. Institutional Review Board (IRB) approval letter (only submit one IRB approval letter per request).
E. National Clinical Trial (NCT) number (e.g., NCT00000123)
F. Supporting materials, as appropriate.

Claims Submission Related to IDE Studies



Medicare claims for routine care items and services related to Category A or B IDE studies and Category B IDE devices should be submitted to MACs that will identify routine costs for which Medicare payment is made for each related claim.

Wednesday, August 10, 2016

Chemotherapy Administration and Evaluation and Management Services Furnished on the Same Day


For services furnished on or after January 1, 2004, do not allow payment for CPT code 99211, with or without modifier 25, if it is billed with a nonchemotherapy drug infusion code or a chemotherapy administration code. Apply this policy to code 99211 when it is billed with a diagnostic or therapeutic injection code on or after January 1, 2005.

Physicians providing a chemotherapy administration service or a nonchemotherapy drug infusion service and evaluation and management services, other than CPT code 99211, on the same day must bill in accordance with §30.6.6 using modifier 25. The carriers pay for evaluation and management services provided on the same day as the chemotherapy administration services or a nonchemotherapy injection or infusion service if the evaluation and management service meets the requirements of section §30.6.6 even though the underlying codes do not have global periods. If a chemotherapy service and a significant separately identifiable evaluation and management service are provided on the same day, a different diagnosis is not required.

In 2005, the Medicare physician fee schedule status database indicators for therapeutic and diagnostic injections were changed from T to A. Thus, beginning in 2005, the policy on evaluation and management services, other than 99211, that is applicable to a chemotherapy or a nonchemotherapy injection or infusion service applies equally to these codes.

Monday, August 8, 2016

gynaecologist CPT code list

HCPCS Description Place of Service 

36415 Routine venipuncture for collection of specimen(s) 11 – Office, 12 – Home
36416 Collection of capillary blood specimen 11 – Office, 12 – Home
59400 Vaginal delivery w/7 or more antepartum & postpartum 11 – Office, 12 – Home
59409 Vaginal delivery only 11 – Office, 12 – Home
59410 Vaginal delivery; including postpartum care 11 – Office, 12 – Home
59425 Antepartum care only; 4-6 visits 11 – Office, 12 – Home
59426 Antepartum care only; 7 or more visits 11 – Office, 12 – Home
59430 Post-partum care only 11 – Office, 12 – Home
59610 Routine OB care including antepartum, vaginal delivery & postpartum; after previous cesarean 11 – Office, 12 – Home
59612 Vaginal delivery only, after previous cesarean 11 – Office, 12 – Home
59614 Vaginal delivery only after cesarean, including postpartum 11 – Office, 12 – Home
59899 Unlisted maternity procedure (use for labor management in the event of transfer intrapartum) 11 – Office, 12 – Home
90471 Immunization administration, first vaccine. Single or combination vaccine/toxoid (use for injection of vaccination/rhogam injection) 11 – Office, 12 – Home
96360 Intravenous infusion, hydration 11 – Office, 12 – Home
96361 Each additional hour (list separately in addition to code for primary procedure) 11 – Office, 12 – Home
96365 IV for therapy, prophylaxis, or diagnosis (specify substance or drug); initial one (1) hour 11 – Office, 12 – Home
96366 Each additional hour (list separately in addition to code for primary procedure) 11 – Office, 12 – Home
99001 Handling and/or conveyance of specimen for transfer 11 – Office, 12 –
Home EVALUATION AND MANAGEMENT VISITS (99201 – 99348) can be used for initial patient visit
99201 New patient office visit problem focused 11 – Office, 12 – Home
99202 New patient office visit expanded problem 11 – Office, 12 – Home
99203 OV or OP evaluation new patient detailed 30 minutes 11 – Office, 12 – Home
99211 Established patient office visit problem focused 11 – Office, 12 – Home
99212 Established patient office visit expanded problem 11 – Office, 12 – Home
99213 OV or OP evaluation established patient detailed 30 minutes 11 – Office, 12 – Home
99341 Home visit new pt/a problem (low severity) 12 – Home
99342 Home visit new pt/expanded (moderate severity) 12 – Home
99347 Home visit for e/m of established patient; problem focused 12 – Home
99348 Home visit for e/m of established patients; expanded problem focused 12 – Home
99460 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant 11 – Office
99461 Initial care, per day, for evaluation & management of normal newborn other than hospital or birthing center 12 – Home
99463 Initial hospital or birthing center per day for evaluation & management of normal newborn admit/discharge same day 11 – Office, 12 – Home
99465 Delivery/birthing room resuscitation: provision of positive pressure ventilation and/or chest compressions in presence of acute inadequate ventilation 11 – Office, 12 – Home  A4217 Sterile water/saline, 500 ml 11 – Office, 12 – Home
J0171 Injection, adrenalin, epinephrine, 0.1 mg 11 – Office, 12 – Home
J0290 Injection, ampicillin, up to 500 mg 11 – Office, 12 – Home
J0561 Injection, penicillin g benzathine, per 100,000 units 11 – Office, 12 – Home
J0690 Injection, cefazolin sodium, ancef, kefzol, up to 500 mg 11 – Office, 12 – Home
J2590 Injection, oxytocin, up to 10 units 11 – Office, 12 – Home
J2790 Rho d immune globulin injection 300 mcg 11 – Office, 12 – Home
J3430 Injection, vitamin K, per 1 mg 11 – Office, 12 – Home
J3490 UNCLASSIFIED DRUGS (use for erythromycin ointment, or for lidocaine injection and attach a copy of the invoice to the claim) 11 – Office, 12 – Home
J7040 Infusion, normal saline solution, (500 ml=1 unit) 11 – Office, 12 – Home
J7050 Infusion, normal saline solution, 250 cc 11 – Office, 12 – Home
J7120 Ringers lactate infusion up to 1000 cc 11 – Office, 12 – Home
S0077 Injection, clindamycin phosphate, 300 mg 11 – Office, 12 – Home
S3620 Newborn metabolic screening, includes test kit, postage & lab tests specified
11 – Office, 12 – Home S5011 5% dextrose in lactated ringer’s, 1000 ml 11 – Office, 12 – Home

Friday, August 5, 2016

Coding Rules for Chemotherapy Administration and Nonchemotherapy Injections and Infusion Services - 96523 CODE

Instruct physicians to follow the CPT coding instructions to report chemotherapy administration and nonchemotherapy injections and infusion services with the exception listed in subsection C for CPT code 90772. The physician should be aware of the following specific rules.

When administering multiple infusions, injections or combinations, the physician should report only one “initial” service code unless protocol requires that two separate IV sites must be used. The initial code is the code that best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code should be reported. For example, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code.

If more than one “initial” service code is billed per day, the carrier shall deny the second initial service code unless the patient has to come back for a separately identifiable service on the same day or has two IV lines per protocol. For these separately identifiable services, instruct the physician to report with modifier 59.
The CPT includes a code for a concurrent infusion in addition to an intravenous infusion for therapy, prophylaxis or diagnosis. Allow only one concurrent infusion per patient per encounter. Do not allow payment for the concurrent infusion billed with modifier 59 unless it is provided during a second encounter on the same day with the patient and is documented in the medical record.

For chemotherapy administration and therapeutic, prophylactic and diagnostic injections and infusions, an intravenous or intra-arterial push is defined as: 1.) an injection in which the healthcare professional is continuously present to administer the substance/drug and observe the patient; or 2.) an infusion of 15 minutes or less.
The physician may report the infusion code for “each additional hour” only if the infusion interval is greater than 30 minutes beyond the 1 hour increment. For example if the patient receives an infusion of a single drug that lasts 1 hour and 45 minutes, the physician would report the “initial” code up to 1 hour and the add-on code for the additional 45 minutes.

Several chemotherapy administration and nonchemotherapy injection and infusion service codes have the following parenthetical descriptor included as a part of the CPT code, “List separately in addition to code for primary procedure.” Each of these codes has a physician fee schedule indicator of “ZZZ” meaning this service is allowed if billed with another chemotherapy administration or nonchemotherapy injection and infusion service code.

Do not interpret this parenthetical descriptor to mean that the add-on code can be billed only if it is listed with another drug administration primary code. For example, code 90761 will be ordinarily billed with code 90760. However, there may be instances when only the add-on code, 90761, is billed because an “initial” code from another section in the drug administration codes, instead of 90760, is billed as the primary code.

Pay for code 96523, “Irrigation of implanted venous access device for drug delivery systems,” if it is the only service provided that day. If there is a visit or other chemotherapy administration or nonchemotherapy injection or infusion service provided on the same day, payment for 96523 is included in the payment for the other service.

Thursday, August 4, 2016

Threshold Times for Codes 99356 and 99357



(Inpatient Setting) If the total direct face-to-face time equals or exceeds the threshold time for code 99356, but is less than the threshold time for code 99357, the physician should bill the visit and code 99356. Contractors do not accept more than one unit of code 99356. If the total direct face-to-face time equals or exceeds the threshold time for code 99356 by no more than 29 minutes, the physician bills the visit code 99356 and one unit of code 99357. One additional unit of code 99357 is billed for each additional increment of 30 minutes extended duration.


Code    Typical Time for Code   Threshold Time to Bill Code 99356  Threshold Time to Bill Codes 99356 and 99357

99221  30  60  105
99222  50  80  125
99223  70  100  145
99231  15  45  90
99232  25  55  100

Add 30 minutes to the threshold time for billing codes 99356 and 99357 to get the threshold time for billing code 99356 and two units of 99357.


Prolonged Services Associated With Evaluation and Management Services Based on Counseling and/or Coordination of Care (Time-Based)

When an evaluation and management service is dominated by counseling and/or coordination of care (the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a face-to-face encounter between the physician or qualified NPP and the patient in the office/clinic or the floor time (in the scenario of an inpatient service), then the evaluation and management code is selected based on the typical/average time associated with the code levels. The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the evaluation and management code) and should not be “rounded” to the next higher level.

In those evaluation and management services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code.

Wednesday, August 3, 2016

Admin CPT code policy - Therapeutic, prophylactic, and diagnostic injections and infusions


A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable.

If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable:

1. Use of local anesthesia;
2. IV start;
3. Access to indwelling IV, subcutaneous catheter or port;
4. Flush at conclusion of infusion; and
5. Standard tubing, syringes and supplies.

Payment for the above is included in the payment for the chemotherapy administration or nonchemotherapy injection and infusion service.

If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to the chemotherapy administration or nonchemotherapy injection and infusion service. For an evaluation and management service provided on the same day, a different diagnosis is not required.

The CPT 2006 includes a parenthetical remark immediately following CPT code 90772 (Therapeutic, prophylactic or diagnostic injection; (specify substance or drug); subcutaneous or intramuscular.) It states, “Do not report 90772 for injections given without direct supervision. To report, use 99211.”


This coding guideline does not apply to Medicare patients. If the RN, LPN or other auxiliary
personnel furnishes the injection in the office and the physician is not present in the office to meet the supervision requirement, which is one of the requirements for coverage of an incident to service, then the injection is not covered. The physician would also not report 99211 as this would not be covered as an incident to service.

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