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Transcript
Joslin Diabetes Center
Affiliated Programs
Billing & Coding Discussion
April 22, 2009
Annual Chargemaster Review
• Every Affiliate should have a scheduled annual
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chargemaster and encounter form review on an annual
basis
Your finance area should review your fee schedule to
make sure that fees are set for each code at the highest
level of reimbursement by all payers
Never set your fee at a level lower than any payer’s
reimbursement, as payers will always pay the lesser of
charge or negotiated reimbursement
All hospital and professional encounter forms should be
reviewed on an annual basis by a hospital certified coder
and a professional certified coder
Review with your physicians and nurse practitioners to
determine if there are any injections or other procedures
being done that are not being captured
UseI a chargemaster tool for annual review (attached)
2009 Chargemaster Review Tool
This is a tool that we hope will assist you as you complete your annual ICD9, CPT4
and HCPCS assessment for your 2009 Charge Master review. Below are a series of
questions regarding your current charges and practices. This information will be
helpful in creating hospital you meet with your chargemaster review team for your
annual update.
- Have you had your encounter form reviewed by a hospital coder and a
professional coder?
- Are there any procedures or services on your encounter form that you no longer
perform?
- Are there any procedures or services that you perform that are not on the
encounter form?
- Are there any procedures or services on your encounter form where you know
the CPT4 code is incorrect?
- Are there any drugs or medications that you routinely administer or often use?
If YES, where do you currently get the drugs/medications?
- Do you inject or infuse these drugs or do you give vaccines?
- Please bring with you a list of drugs/medications used in your area.
- Do you administer Hep B, Pneumococcal, or Influenza(Flu) Vaccine(s)?
- Do you inject allergens, toxoids, or venoms for clinical testing?
- Do you perform Skin tests such as PPD for TB, Candida, Mumps, etc.?
- Do you perform any lab tests such as Urinalysis, Occult Blood Stool Guaiac, etc.
- Do you perform Venipuncture?
2009 Chargemaster Review Tool
(continued)
- Do you perform any tests that require a machine such as EKG,
Spirometry, Radiology, etc.?
- Who owns the machine?
- When was it purchased?
- Who interprets the test?
- Are there any supplies, where the cost is more than $25, for which you
currently don’t charge?
- Do you ever write in CPT4 codes/procedures under an “Other”
category on the Encounter Form?
- If a procedure is written in the “Other” field, do you do this more than
one time per month?
- Are you aware of any procedures in your area where the professional
and facility CPT4 varies? (ex, EKG where Interpretation is 93010 and
Tracing is 93005).
- Do you know of any new 2009 ICD-9 codes that should be added to
your encounter form?
- Do you know of any new 2009 CPT4 codes that should be added to
your encounter form?
- Do you know of any new 2009 HCPCS codes that should be added to
your encounter form?
- Medical records review for compliance with hospital standard
(volume, etc.)
- How do you designate whether a visit qualifies for a professional fee if
a resident or other physician extender sees the patient? (i.e., QA check
for MD countersigning note, teaching MD rules, etc?)
- Please bring a sample of a Managed Care referral waiver with you to
the review meeting.
Codes that Should be on your Encounter Form and
Chargemaster
 Codes that should be considered for your Billing Ticket and your Chargemaster
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G0108 - Diabetes outpatient self-management training services, individual, per 30
minutes
G0109 - Diabetes outpatient self-management training services, group session (2
or more), per 30 minutes
97802 – Medical nutrition therapy; initial assessment and intervention, individual,
face-to-face with the patient, each 15 minutes
97803 – Medical nutrition therapy; re-assessment and intervention, individual,
face-to-face with the patient, each 15 minutes
97804 – Medical nutrition therapy, group (2 or more individuals), each 30 minutes
G0270 – Medical nutrition therapy; reassessment and subsequent intervention(s)
following second referral in same year for change in diagnosis, medical condition,
or treatment regimen (including additional hours needed for renal disease),
individual, face-to-face with the patient, each 15 minutes
G0271 – group (2 or more individuals), each 30 minutes
99406 – smoking and tobacco use cessation counseling visit; intermediate, greater
than 3 minutes up to 10 minutes
99407 - smoking and tobacco use cessation counseling visit; intensive, greater
than 10 minutes
98960 – Education and training for patient self-management by a qualified,
nonphysician professional using a standardized curriculum, face-to-face with the
patient (could include caregiver/family) each 30 minutes; individual patient
Codes that Should be on your Encounter Form and
Chargemaster (continued)
 98961 – 2-4 patients, initial or follow-up
 98962 – 5-8 patients, initial or follow-up
 These education and training codes are not covered by Medicare
 A physician must prescribe the education and training
 A qualified healthcare professional must provide the services using a
 standardized curriculum
 (The nonphysician’s qualifications and the program’s contents must be
 consistent with guidelines or standards established or recognized by a
 physician society, nonphysician healthcare professional society or
 association or other appropriate source – (according to the CPT book
 introductory patient self-management education and training notes)
 95250 – Ambulatory continuous glucose monitoring of interstitial tissue fluid via a
subcutaneous sensor for up to 72 hours; sensor placement, hook-up,, calibration of
monitor, patient training, removal of sensor, and printout of recordings
 95251 - Ambulatory continuous glucose monitoring of interstitial tissue fluid via a
subcutaneous sensor for up to 72 hours; physician interpretation and report
 99091 – Collection and interpretation of physiologic data (e.g. ECG, blood pressure,
glucose monitoring) digitally stored and/or transmitted by the patients and/or
caregiver to the physician or other qualified healthcare professional, requiring a
minimum of 30 minutes of time.
Prolonged Service Codes – A Revenue Opportunity
Another notable change in the E/M section is under the prolonged physician service
codes with direct patient contact (99354–99357). The instructions were revised to
clarify that these time-based add-on codes may be reported in addition to the primary
E/M service (at any level), which has a typical or specified time published in the CPT
code book. As a result of this clarification, modifier 21, prolonged evaluation and
management services, was deleted.
 Prolonged Services Definitions
 In the office or other outpatient setting, Medicare will pay for prolonged physician
services (CPT code 99354) (with direct face-to-face patient contact that requires one
hour beyond the usual service), when billed on the same day by the same physician
or qualified NPP as the companion evaluation and management codes. The time for
usual service refers to the typical/average time units associated with the companion
E&M service as noted in the CPT code. You should report each additional 30 minutes
of direct face-to-face patient contact following the first hour of prolonged services
with CPT code 99355.
 In the inpatient setting, Medicare will pay for prolonged physician services (code
99356) (with direct face-to-face patient contact which require one hour beyond the
usual service), when billed on the same day by the same physician or qualified NPP
as the companion evaluation and management codes. You should report each
additional 30 minutes of direct face-to-face patient contact following the first hour of
prolonged services may be reported by CPT code 99357.
 Note: You should not separately report prolonged service of less than 30 minutes
total duration on a given date, because the work involved is included in the total work
of the evaluation & management (E&M) codes.
Prolonged Service Codes – A Revenue Opportunity
(continued)
 You may use code 99355 or 99357 to report each additional 30 minutes beyond the
first hour of prolonged services, based on the place of service. These codes may be
used to report the final 15 - 30 minutes of prolonged service on a given date, if not
otherwise billed. Prolonged service of less than 15 minutes beyond the first hour or
less than 15 minutes beyond the final 30 minutes is not reported separately.
 Required Companion Codes
 Please remember that prolonged services codes 99354 99357 are not paid unless
they are accompanied by the companion codes as described here.
 The companion E&M codes for 99354 are:
 Office or Other Outpatient visit codes (99201 - 99205, 99212 - 99215),
 Office or Other Outpatient Consultation codes (99241 - 99245),
 Domiciliary, Rest Home, or Custodial Care Services codes (99324 - 99328, 99334 99337),
 Home Services codes (99341 - 99345, 99347 - 99350);
 The companion E&M codes for 99355 are 99354 and one of its required E&M codes.
 The companion E&M codes for 99356 are the Initial Hospital Care and Subsequent
Hospital Care codes (99221 - 99223, 99231 - 99233), the Inpatient Consultation codes
(99251 - 99255); Nursing Facility Services codes (99304 -99318).
 The companion codes for 99357 are 99356 and one of its required E&M codes.
Prolonged Service Codes – A Revenue Opportunity
(continued)
 Requirement for Physician Presence
 You may count only the duration of direct face-to-face contact with the patient
(whether the service was continuous or not) beyond the typical/average time of the
visit code billed, to determine whether prolonged services can be billed and to
determine the prolonged services codes that are allowable.
 You cannot bill as prolonged services:
In the office setting, time spent by office staff with the patient, or time the patient
remains unaccompanied in the office; or
 In the hospital setting, time spent reviewing charts or discussing the patient
with house medical staff and not with direct face-to-face contact with the patient
or waiting for test results, for changes in the patient's condition, for end of a
therapy, or for use of facilities.
 Documentation
 Unless you have been selected for medical review, you do not need to send the
medical record documentation with the bill for prolonged services. Documentation,
however, is required to be in the medical record about the duration and content of the
medically necessary evaluation and management service and prolonged services that
you bill.
 You must appropriately and sufficiently document in the medical record that you
personally furnished the direct face-to-face time with the patient specified in the CPT
code definitions. Make sure that you document the start and end times of the visit,
along with the date of service

Prolonged Service Codes – A Revenue Opportunity
(continued)
 Use of the Codes
 You can only bill the prolonged services codes if the total duration of all physician or
qualified NPP direct face-to-face service (including the visit) equals or exceeds the
threshold time for the evaluation and management service the physician or qualified
NPP provided (typical/average time associated with the CPT E/M code plus 30
minutes).
 Threshold Times for Codes 99354 and 99355 (Office or Other Outpatient Setting)
 If the total direct face-to-face time equals or exceeds the threshold time for code
99354, but is less than the threshold time for code 99355, you should bill the E&M
visit code and code 99354. No more than one unit of 99354 is acceptable.
 If the total direct face-to-face time equals or exceeds the threshold time for code
99355 by no more than 29 minutes, you should bill the visit code 99354 and one unit
of code 99355. One additional unit of code 99355 is billed for each additional
increment of 30 minutes extended duration.
 Table 1 displays threshold times that your carriers and A/B MACs use to determine if
the prolonged services codes 99354 and/or 99355 can be billed with the office or
other outpatient settings, including outpatient consultation services and domiciliary,
rest home, or custodial care services and home services codes. The AMA CPT
coding-derived changes are highlighted and noted in bolded italics.