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Encounter Form Education
May 2006
Medicare Physicals
Documentation Requirements
Procedures
Home Health Certification
Preventative Medicine Visits
CPT Code 99381-87 (new) 99291-97 (est)
Preventative Medicine Visit Codes include payment for:
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The review of “stable” chronic problems
Routine Screenings (eg. Pap smear, breast & pelvic, manual rectal exam)
Risk Factor Counseling
Billable Separately When Billed on Same Day as Physical are:
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99211-99215 E&M Office Visit codes (for re-management of existing problems or new
problems (need mod 25)
Do not bill 2 new E&M’s in same day
Injections, Immunizations
Procedures Performed (exception Medicaid – they will only pay for procedure)
Some Screenings
Labs (Indicate signs/symptoms or diagnosis to support testing)
Physicals - Medicare
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MC does not pay for physicals (99381-87; 99391-97) other then new mc beneficiaries
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They will pay for 99211-99215 services (eg. medically necessary follow-up or new
problems addressed during a physical.
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They will pay for problems addressed during a physical when a modifier 25 is affixed.
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MC will pay for screenings performed during a physical if the service is performed
during a covered period. (eg. paps covered every 2 yrs).
(next slide)
Physicals
Medicare “New MC Beneficiary”
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G0344: Effective 1/1/05 MC will pay physical / new MC enrollee / within 6 mths
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G0366: EKG (global)
G0367 (EKG tracking only)
G0368 (EKG Inter & Rep Only)
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Medicare does not pay for routine annual physicals (99381-87; 99391-97)
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Medicare will pay for 99211-99215 services (eg. medically necessary follow- up or
new problems) billed w/physicals. Mod 25 needs to be affixed to 99211-15 codes.
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Medicare – “New MC Beneficiary”
Required Documentation
Initial Exam includes review of:
HPI
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Attention to risk factors for disease detection
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Past medical, Social & Surgical history
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Experiences w/illnesses
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Hospital stays
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Operations
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Allergies
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Injuries & treatments
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Current medication & supplements
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FH (hereditary or place the individual at risk) History of alcohol, tobacco,
illicit drug use
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Diet
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Physical activities
Psych Eval - Depression
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Individual’s potential (risk factors) for depression including current or past
experiences w/depression or other mood disorders.
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Refer to appropriate screening instrument for persons without a current diagnosis of
depression recognized by a National Professional Medical Organizations.
Medicare – “New MC Beneficiary”
Required Documentation
EKG
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Performance and interpretation of an EKG.
Functional Abilities / Level of Safety
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Mininum review must include assessment of:
Hearing impairment
Activities of daily living
Falls risk
Home safety
Examination
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Measurement of individual’s height, weight, blood pressure
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Visual acuity screen
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Other age-appropriate factors as deemed appropriate by the provider based on the
individual’s med/social history and current clinical standards.
Medicare – “New MC Beneficiary”
Required Documentation
Risk Factor Counseling
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Education, counseling and referral as deemed appropriate by the provider based on results of
the review
Provide Brief Written Plan
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A checklist or alternative provided to the individual for obtaining the appropriate screening and
other preventive services which are covered separately under Medicare Part B.
11 points checklist:
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Immunizations (pneumococcal, Influenza, Hep B and their administration.
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Mammography screening
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Pap smear & pelvic examination screening
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Prostate cancer screening tests
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Colorectal cancer screening tests
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Diabetes outpatient self-mgmt training services
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Bone mass measurements
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Glaucoma screening
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Medical nutrition therapy for individuals with diabetes or renal disease
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Cardiovascular screening blood tests
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Diabetes screening tests
Injection – Administration Codes
Bill Administration along w/”J” Supply Code when appropriate
Identify Type of Injection
Immunization
90471; 90472
Immunization – Pedi Codes
90465-90468
Infusion “hydrate” up to 1 hr
90760
ea additional
90761
Infusion “therapeutic/diagnostic”
Initial Infusion up to 1hr
90765
ea additional up to 8 hrs
90766
Addl sequential infusion
up to 1 hr
90767
concurrent infusion
90768
Injection, single/initial; IM or SQ (eg. Depo; B12) 90772
Injection, intra-arterial
90773
IV push, initial/single drug
90774
each additional new drug
90775
Injection – Administration Codes
Immunizations - Pedi
The new pediatric administration codes were developed to recognize “physician time”
spent counseling parents on the risks (e.g., reactions) and benefits of vaccination for
children under 8 yrs. of age. Note: Discussions and/or counseling performed by a nurse
with the parents does not qualify for use of 90465-68. Instead the nurse would use the
old codes 90471-72.
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90465 - admin under 8 years of age (includes percutaneous, intradermal, subcutaneous, or
intramuscular injections) when the physician counsels the patient/family; first injection (single or
combination vaccine/toxoid), per day
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90466 - ea addl injection (single or combination vaccine/toxoid), per day
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90467 - admin under age 8 years (includes intranasal or oral routes of administration) when the
physician counsels the patient/family; first administration (single or combination vaccine/toxoid),
per day
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90468 - ea addl admin (single or combination vaccine/toxoid), per day
Telephone Calls (99371-99373)
Telephone Calls (CPT Codes 99371-99373): Simple, intermediate or complex phone
calls made by a physician to the patient or other health care allied professional that are
*medically necessary to manage and coordinate patient care.
Documentation Required:
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Date of call
Reason for call
Treatment given
Involved parties named (other then pt)
Follow-up instructions
Telephone Calls
What Supports Medical Necessity?
AMA Examples of Reimbursable Telephone Services:
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Services that involve a new diagnosis or require a new treatment plan (eg. acute
respiratory illness) when the equivalent service performed in person would have led
to a service charge itself.
Patient maintenance services, such as management of insulin-dependent diabetics
with multiple blood-sugar checks and insulin changes.
Treating relapses of a previous condition when this can be adequately assessed by
phone, but a significant investment of physician time and judgment are involved
(eg. irritable bowel; asthma; congestive heart failure; flare-up of gout)
Reporting laboratory results (for laboratory work not done in conjunction with an
office visit) that require a significant change in medication or further diagnostic tests
(eg. adjustment of warfarin after a prothrombin time is done; addition of a second
drug when treating hyperlipidemia; or ordering gallbladder studies when liver
functions are abnormal on routine studies).
Telephone Calls - continued
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Extended personal counseling by telephone when the specific situation of an urgent
nature, where a physical exam is not essential or necessary to perform the service,
and where failure to perform the service could lead to patient harm.
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An established patient with acute exacerbation of a severe anxiety disorder or
depression, commonly involving discussion of medications or recommended
psychotherapy needs, mental status and mood assessment, and recommendations
for further immediate care.
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A test result entails a referral for a significantly complex procedure, with the
potential for morbidity, complex preparation, and/or hospitalization; however, the
discussion, consent and instructions do not require a face-to-face encounter (eg.
breast lump found on mammogram; positive treadmill entails a cardiology referral
and possible angiogram; patient refusal of a test or treatment previously discussed
in detail necessitates further discussion and counseling).
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Nursing or rest home calls when the patient has a significant change in condition,
such as a change in vital signs, respiratory infection, or fall.
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Extended counseling with family when done by telephone (eg. cases in which there
are significant intrafamily conflicts or deficits in understanding related to a patient
under direct care).
Home Health Aide
Certification – Form 485
G0180: Physician certification services:
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Patient is NOT present
Certification covers 60 days
Completed by the ordering provider
You can bill both a G0180 and a G0181 within a 30 day period.
Provider Note includes review & supportive documentation on:
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Initial and subsequent reports on patient’s status
patient’s responses to the oasis assessment
adequate contact with the home health
agency to follow-up on initial/subsequent management plan(s) .
G0179: Physician "recertification" srvs - Patient is NOT present documentation ncludes
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patient’s status
patient’s responses to the oasis assessment
adequate contact with the home health
Procedures
Foreign Body Removal
Ear Wax Removal
EKGs
EKG Routine
69210 (hearing loss pays;
impacted cerumen does not)
Hearing Loss (389.90) pays
Otalgia (388.70) pays
93000 (mod 76 repeat)
Procedures
Lesions
Lesion / Skin Tags
Lesions / Common or Plantar Wart
Lesions / Flat Warts, Molluscum /Milia
Lesion / Vulva
Lesion / Vaginal
Lesion / Penis (cryo)
11200 (up to 15)
11201 (ea. addl grp of 10)
17000 (1) plus
17003 (for ea. addl – indicate)
Example: 6 removed bill
17000 x1 and 17003 x5 = 6
17110 up to 14
17115 15 or more report code.
56501
57061
54056
Procedures
Gyn / Contraceptive Management
Diaphragm or Cervical Cap Fitting
Insertion of IUD
Removal of IUD
Fitting and Insertion of pessary or other
intravaginal support device
Airway Management
Nebulizer Treatment
Nebulizer Treatment (subsequent)
Inhaler Instructions (teaching)
Spirometry
Bronchospasm Evaluation
57170
58300
58301
57160
94640
94640-76
94664-59
94010
94060
Procedures
Incision & Drainage ; Puncture
Incision & Drainage (abcess, cyst)
Incision & Drainage of Pilonidal Cyst
Incision & Removal of Foreign Body, subcut
Incision & Drainage of Hematoma, seroma
or fluid collection
Puncture aspiration of abscess, hematoma,
bulla or cyst
10060
10080
10120
10140
10160
Procedures
Paring/Cutting/Trimming/Excision
Paring/Cutting of benigh hyperkeratotic lesion
(corn or callus) single lesion
Paring/Cutting or benign hyperkeratotic lesion
corn/callus 2-4 lesion
Trimming of non-dystrophic nails, any #
Debridement of 1-5 nails
Debridement of 6-10 nails
Avulsion (toenail plate)
Excision of nail / nail matrix
Wedge Excision of nail fold
11055
11056
11719
11720
11721
11730
11750
11765
Procedures
Epitaxis
Control Nasal Hemorrhage, Anterior
Packing; Simple
Control Nasal Hemorrhage, Posterior
Packing, Initial
Packing, Subsequent
No Modifier is Necessary
Excisions
Excisions Lesion (trunk, arms, legs)
0.6 to 1.0cm
1.1 to 2.0cm
2.1 to 3.0cm
30901
30905
30906
Benign
11401
11402
11403
Malignant
11601
11602
11603
Procedures
Aspiration and/or Injection
20600
20605
20610
“Small Joint” , bursa or ganlion cyst (eg. fingers, toe)
“Intermediate joint”, bursa or ganglion cyst (eg.
temporomandibular, acromioclavicular, wrist, elbow or
ankle (olecranon bursa).
“Major Joint”, bursa or ganglion cyst (eg. shoulder, hip,
knee joint, subaromial bursa).
Procedures
Tendon/Ligament / Ganglion Cyst / Injections / Excisions
There must be an inflammatory process in a given tendon (tendonitis)
or tendon sheath tenosynovitis)
CPT Codes:
20526 Injection of carpal tunnel with local anes or corticosteroid
20550 Injection(s); single tendon sheath, or ligament,plantar fascia)
20551 Injection(s); single tendon origin/insertion
20612 Aspiration and/or injection of ganglion cyst(s) any location
25111 Excision of Ganglion, wrist (dorsal or volar); primary
25112 Excision of Ganglion, wrist (dorsal or valar) recurrent
Procedures
Trigger Point Injections
Use 20552 Injection(s); single or multiple trigger point(s), one or two muscle(s) –
regardless of the # of injections in those muscle groups
Use 20553 Injection(s); single or multiple trigger point(s), three or more muscle(s) –
regardless of the # of injections within those muscle groups
Procedures
EXCISION CPT Codes (size, location needed)
11400-11471 (benign) 11600-11646 (malignant)
Excision codes are used to reflect “full-thickness” (through dermis) removal of a lesion
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Select a cpt code based on lesion diameter plus the most narrow margins
required which equals the excised diameter.
Codes are also based on body area /location (eg. trunk/arms/ legs is 1 body area)
Use Modifier 59 when multiple lesions are removed in a single body area
(eg. reflect different lesions, different site, different methods in same body area)
Use Modifier 58 – for all re-excisions (eg. didn’t get all margins – pt. comes back)
Select a CPT code after the path report has returned as malignant lesions require
different coding and reimburse at a much higher rate.
Simple Suturing codes ( less then 0.5 cm) - (12001-12021) are bundled into excision codes.
You can code additionally for simple (greater then .05cm) intermediate or complex
repairs
Code only the most complex procedure when multiple procedures are performed on
same lesion/same day.
Example: If a physician removes a self-contained cyst and not an “area” of skin code as
excision vs. debridement. (eg. Sebaceous Cyst)
Procedures
SHAVING CPT Codes
11300-11313
(Shaving of Epidermal or Dermal Lesions)
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Shaving = sharp removal of epidermal and dermal lesions without
a full thickness dermal excision.
Code Partial thickness removal (not through dermis) as shaving.
Shaving codes are used when lesions are completely removed w/scalpel,
scissors.
Typically shaving does not require sutures.
Procedures
DEBRIDEMENT CPT Codes
11000-11044
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Surgical excision of dead, devitalized, or contaminated tissue and
removal of foreign matter from a wound.
Procedures
BIOPSY CPT Codes
11100 – 11101
Biopsies remove a “portion” of a lesion for diagnostic purposes.
Excisional biopsies removes “all”.
Multiple biopsies on the same lesion may only be coded as a “single lesion”
You cannot code a biopsy and removal in the same day. Different days yes.
Modifier 59 needed when you biopsy “one” lesion & “excise” another on the same
day.
Note: modifier 59 should be affixed to biopsy code.
No modifier is necessary if the biopsy and excision are performed on separate days.
You can code an E&M office visit (99211-15) with a biopsy if the patient presents
with
If
Procedures
Wound Repair
Simple Suturing
12001 simple repair scalp, neck,axillae,ext genitalia,trunk and/or
extremities (includes hands/feet) 2.5cm or less.
12011 simple repair of face, ears, eyelids, nose, lips and/or mucous
membrances 2.5cm or less.