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DME Billing Inquiry
With Medicare, some of our patients come in on a different day other than the office visit to pick up their DME. Do we use the date they pick up the DME item or the date of the office visit for billing?
Question:
With Medicare, some of our patients come in on a different day other than the office visit to pick up their DME. Do we use the date they pick up the DME item or the date of the office visit for billing?
Answer:
The date of service for billing in this instance would be the date the DME is picked up (date of delivery to the patient).
*This response is based on the best information available as of 2/29/24.
Tongue Lesion Excision
My physician always bills a glossectomy CPT code 41120 when removing a lesion from the tongue. Is this correct?
Question:
My physician always bills a glossectomy CPT code 41120 when removing a lesion from the tongue. Is this correct?
Answer:
No this is not correct. The glossectomy codes require the removal of a portion or all of the tongue. When a lesion is removed report a code from CPT 41112-41114.
*This response is based on the best information available as of 2/29/24.
Repairs following Mohs Surgery
Our Mohs surgeons will sometimes perform an adjacent tissue transfer or a flap after Mohs surgery. They want to bill an E/M service with Modifier 57 since they decided to do the flap after Mohs. I don’t think this is correct. Can you help clarify?
Question:
Our Mohs surgeons will sometimes perform an adjacent tissue transfer or a flap after Mohs surgery. They want to bill an E/M service with Modifier 57 since they decided to do the flap after Mohs. I don’t think this is correct. Can you help clarify?
Answer:
The E/M service should not be reported after Mohs surgery when a decision is made for a repair, flap, or graft. Even though a flap has a 90-day global period, the surgical decision was made to perform Mohs, the primary procedure. The intent of the E/M with Modifier 57 for a procedure with a 90 global period is when the initial decision is made to perform the primary procedure. The repair is secondary; therefore, billing an E/M service is inappropriate. The discussion and recommendation for the repair is part of the pre-service work for the repair.
*This response is based on the best information available as of 2/29/24.
Denials for Initial Hospital Care and Observation E/M Codes: 2024
We are experiencing denials when we bill 99221-99223 and the place of service is observation (outpatient hospital). Are we doing something wrong?
Question:
We are experiencing denials when we bill 99221-99223 and the place of service is observation (outpatient hospital). Are we doing something wrong?
Answer:
You are billing correctly based on CPT 2023 guidelines for E/M that merged inpatient hospital encounters/codes with observation encounters/codes. Unfortunately, some payor claims processing systems may not yet recognize these changes as they apply to billing. You will have to appeal these denied claims, with CPT references showing the current guidelines for E/M reporting.
*This response is based on the best information available as of 2/29/24.
Modifiers with Unlisted Codes
Can I use modifiers on an unlisted code?
Question:
Can I use modifiers on an unlisted code?
Answer:
In some circumstances, a modifier may be appropriately appended to an unlisted code.
For example,
CPT says, while uncommon, if multiple separately reportable unlisted codes are performed on the same patient on the same date by the same physician, multiple unlisted codes may be reported. If the two procedures are performed in the same anatomic region, then multiple units of the unlisted code may be reported with a modifier 59
Modifier 62 (two surgeons/co-surgery) may also be appended to an unlisted code such as 64999 if co-surgery is documented.
Modifier 58 for staged or more extensive procedures may also be appended to alert the payor to a second surgery during the global period,
During the global period, it may also be appropriate (and recommended) to append global period modifiers such as 78 or 79 to an unlisted code to fully describe the surgical scenario to a payor.
Do not append modifier 50 (bilateral procedure), modifier 51 or modifier 52 or 53 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.
*This response is based on the best information available as of 2/29/24.
DME Billing Inquiry
Do you have any tips on how to handle Medicare Replacement/Part C/Advantage patients for possible non-coverage?
Question:
Do you have any tips on how to handle Medicare Replacement/Part C/Advantage patients for possible non-coverage?
Answer:
Medicare Advantage Plans are required to cover what Medicare covers at a minimum. You should reach out to the individual plan and inform them of this. You can also attach the Medicare coverage policy when you appeal the claim.
*This response is based on the best information available as of 2/15/24.