Secondary Payor Doesn’t Recognize Consultations

Question:

We have a patient with 2 commercial payers (BCBS and Cigna). A consultation code was submitted to BCBS, and they paid according to our contract. However, Cigna is refusing to process the claim since they no longer pay for consult codes. Am I allowed to change the CPT code and rebill Cigna? Or would I need to change the CPT, refile to the primary as a corrected claim, then send the balance on to Cigna?

Answer:

We suggest calling CIGNA and ask how they want this handled according to their policies. WithMedicareyou have two options: (1) bill the appropriate category and level of service documented (e.g., for outpatient consults [99202-99215] or inpatient consults [99221-99223]) or (2) bill the consultation code, which will result in a denial of payment from Medicare and appeal on paper explaining the situation.

E&M Coding Based on Time

Question:

Our physicians default to time for almost every office encounter. We are working with them on documentation and what work contributes to total time and what does not. They perform their own independent interpretation of X-Rays (we bill globally), perform injections, and reduce fractures in the office. They are counting the total time spent with the patient, including these activities and we do not believe that is correct. Can you help?

Answer:

Thank you for your inquiry. We will not address the default to time for almost every encounter other than to say medical necessity must be present for time spent.

With that said, the activities you identify, because they are billable services represented by other CPT codes (aka are separately reported), do not contribute to the total time spent; this time must be deducted from the total time, assuming the E&M service is reportable.

SI Joint Injection

Question:

What CPT code do we use when our physician performs an SI joint injection using ultrasound guidance? CPT code 27096 states with fluoroscopy or CT guidance.

Answer:

CPT instructs to report CPT code 20552 for unilateral or bilateral SI joint injections if CT or Fluoroscopic imaging is not used. CPT code 76942, for the ultrasound guidance, may be reported if the documentation requirements are met.

source: CPT Assistant April 2022

E&M Coding Based on Time

Question:

When choosing the level of E&M we are confused about the History and Exam. If we choose a level of E&M based on time, does this time count toward total time, or is it only time spent on MDM?

Answer:

When choosing a level of E&M based on time, CPT identifies the following activities as those that may contribute to total time on the date of service. As displayed below in bold font, obtaining the history and performing the exam contribute to the total time for code selection. These activities occur on the same day as the actual encounter to contribute to the level of service.

Physician/other qualified health care professional time includes the following activities when performed:

• preparing to see the patient (eg, review of tests);
• obtaining and/or reviewing separately obtained history;
• performing a medically appropriate examination and/or evaluation;
• counseling and educating the patient/family/ caregiver;
• ordering medications, tests, or procedures;
• referring and communicating with other health care professionals (when not separately reported);
• documenting clinical information in the electronic or other health record;
• independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver; and
• care coordination (when not separately reported).

These guidelines currently apply only to E/M codes 99202-99215 that are used in the office/outpatient setting.
source: CPT Assistant April 2022

Counting Laminectomy Levels

Question:

I am confused and hoping you can clarify a coding question I have. I thought I understood how to report laminectomy levels, however, after recently reading an article in the AHA Coding Clinic HCPCS Volume 22, Number 2 Second Quarter 2022 publication, I doubt myself. The surgeon performs and documents a L2, L3, L4 laminectomy with decompression (lateral recess). I have always coded this as 63047, and one unit of 63048. The coding publication I was reading states to report 63047 and 2 units of 63048. Have I been coding incorrectly by only reporting one unit of 63048?

Answer:

Thank you for contacting KZA for clarification. We understand your concern when reading various publications and seeing articles that are not consistent with what you thought you knew.

Without seeing an actual operative note, we agree with how you have coded this type of case in the past. Let’s take a look why.

CPT code 63047 is defined as “Laminectomy, facetectomy and foraminotomy (unilateral or bilateral) with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)),single vertebral segment; lumbar”

A “vertebral segment” means per motion segment. The decompression of the existing nerve root is performed in the interspace between the two lamina.

L2, L3, L4 when looked at closely defines two motion segments:

L2-3 =63047

L3-4= 63048 x 1 unit.

To report a third unit of 63048, the surgeon would either have had to go “up a level” to L1-L2, or “down a level” to L4-5.

We appreciate your verifying your coding practices.

2021 Evaluation and Management Codes: Is a History and Exam Required?

Question:

After a recent audit and review with my physicians, they are telling me that they do not need to document a history and/or exam any more for the new and established patients. That is not my understanding.

Answer:

You are wise to ask because that’s not exactly true; we hear it not infrequently. It is correct that the History or Exam will no longer be used to select a new patient (9920x) or established patient (9921x) visit code. However, it is expected that the physician/provider will document a “medically appropriate” (per CPT™) history and exam for each encounter.

In Orthopaedics, we find the History section to provide important information that assists with the Data Element sections in the MDM table. Items such as the location, duration of the problem, past treatments such as injections, documentation that external X-Rays were brought with the patient are helpful in determining the level of risk in addition to the remainder of the note.