Modifiers on Unlisted Codes. Yes or No?

Question:

Can I use modifiers on an unlisted code? What about global period modifiers such as 58, 78 or 79? It seems reasonable to append those modifiers to the unlisted code.

Answer:

There is not a single right answer to this question. CPT said, in an old CPT Assistant, that generally modifiers are not appended to an unlisted code.

Payors have their own rules. For example, some payors will accept modifier 62 (two surgeons/co-surgery) on an unlisted code such as 64999 while other payors do not.

We would not append modifier 50 (bilateral procedure) to an unlisted code. Your base, or comparison code, should reflect modifier 50 and the associated increase in fee. The same is true for modifier 22.

We also would not append modifier 51 (multiple procedures) to an unlisted code. Let the payor take the discount.

*This response is based on the best information available as of 07/14/22.

Confusion Regarding the 2021 E/M Guidelines

Question:

The guidelines that came out in 2021 for E/M services is for all types of E/M services, right?

Answer:

No. The 2021 E/M guidelines are for office/outpatient visit codes only (99202-99215). You will still need to use the 1995/1997 guidelines for all other E/M services, even consultations in the office.

*This response is based on the best information available as of 06/30/22.

Incident-to Requirements for Medicare

Question:

Thank you so much for all the information you gave out in Chicago at the KZA Convention. We always have great take-a-ways when we leave there. I do have a question for you regarding incident-to billing for Medicare.

One of my physicians is stating that her attorney told her being “under the same roof” of the building counts and you don’t necessarily need to be in the same suite. I am disagreeing stating they have to be in the same suite and even though she is available to run upstairs if needed, by her being on the second floor that goes against the “incident-to” rules. Am I correct?

Answer:

According to CMS In order to qualify as an incident-to service, there must be direct physician supervision of the NPP providing the service. Direct supervision means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. It does not mean that the supervising physician must be present in the room where the procedure is performed. Also the supervising physician must be immediately available (without delay). The supervising physician can be in another room As long as they are not performing a procedure that they cannot stop and go to help with the other patient then they are considered immediately available. CMS also clarifies that immediately available

CMS has clarified the office suite it is limited to the dedicated area or suite designated by records of ownership, rents, or other agreements with the owner.

Sources:https://med.noridianmedicare.com/web/jeb/topics/incident-to-servicesand CMS Medicare Benefit Policy Manual Pub. 100-2, Section 60https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

*This response is based on the best information available as of 06/16/22.

Coding for a Hospital Visit

Question:

I was at your conference this past weekend and I was wondering if you could clarify something for me. When a physician sees a Medicare patient in the hospital, and it is their first time seeing the patient however they are NOT the admitting physician, they can only bill a subsequent visit or consult code depending on what the payor allows and documentation correct? Thank you for your assistance.

Answer:

If the physician is seeing the patient in the hospital for the first time even though he/she is not the admitting physician based on appropriate documentation, an initial hospital visit code (99221-99223) can be billed as long as all three key component requirements are met.  If the minimum requirement for the initial hospital care code is not met a subsequent hospital visit can be reported.  Keep in mind Medicare does not pay for consultations.

*This response is based on the best information available as of 06/02/22.

Billing Additional Pre-op Visit

Question:

Since we have to bring the patients back in for COVID testing and H&P for Joint Commission, can we bill for this visit even though it’s another pre-op visit?

Answer:

Yes, since the original surgery was canceled and is now under consideration for rescheduling due to the pandemic and needs to be seen for a COVID swab prior to surgery, which is an indication for charging a new visit (as a health status change)

*This response is based on the best information available as of 05/019/22.

Vocal Fold Augmentation Injections in the Office

Question:

What code do I use for a vocal fold injection for augmentation in the office? Can I also bill for the injection material?

Answer:

Good questions! The correct code is 31574,Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateralwhen performed via flexible laryngoscopy. If you’re in place of service 11 (physician office), you would NOT separately code for the injection material (J code), to Medicare, because the payment includes the practice expense for the injection material. If you’re in place of service 22 (hospital based clinic), then your payment for 31574 will not include the injection material because the facility (hospital) will have borne the expense for that cost. Finally, if you harvest fat graft via liposuction to be injected into the vocal cord then you may separately report 15773/+15774 depending on the amount of fat injected (not amount of fat harvested).

*This response is based on the best information available as of 05/05/22.