CPT CODE and description

99080 - Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form - average fee amount - $0.00

99090 - Analysis of clinical data stored in computers (eg, ECGs, blood pressures, hematologic data

99091 - Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time


Use Current Procedural Terminology (CPT®) code 99080 for additional diagnoses

 BlueCross BlueShield of Western New York encourages claim submissions containing the maximum number of diagnosis codes along with CPT code 99080, which allows multiple ICD-9/ICD-10 diagnosis codes.

• Code 99080 can be used with Evaluation and Management (E/M) codes when a patient has multiple medical conditions, but only one procedure was performed in your office on the date of service.

• If you already use 99080 for other reasons, such as medical records or workers’ compensation, your practice management system should be updated to use this code for reporting additional diagnoses also.

• Some EMRs require every diagnosis code to point to a CPT code, while other EMRs do not; therefore, there will be occasional discrepancies between the number of diagnosis codes providers believe they are sending and what we actually receive.

• Some practice management systems limit the number of diagnosis codes that can be submitted with a claim. Provider offices experiencing system limitations are encouraged to contact their software vendor for assistance.

• The examples provided show how to best use  this code.

MEDENT Users Only: Use EXTDX or 99080 ANSI 5010 guidelines specify a maximum of 12 diagnosis codes can be sent at the claim level; however, charges can only have a total of 4 diagnosis pointers in MEDENT software.

To allow additional diagnosis codes to be sent on claims, MEDENT programmed a special house code – EXTDX – that can be entered at charge entry for the additional diagnosis codes.


How does this work?

MEDENT looks for any EXTDX code with a matching doctor, location, and date of service for the charge being billed.

The diagnosis codes listed on the charge activity of the matching EXTDX charge will be added to the claim. Up to 12 diagnosis codes can be sent.

Diagnosis codes beyond the maximum allowed per claim will not be sent.

MEDENT will not send duplicate diagnosis codes  on the same claim. The EXTDX feature will automatically work with any electronic or printed insurance claim.



Development of an updated treatment plan will be billed using Current Procedural Terminology (CPT) code 99080, “Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form.”



ValueOptions - TRICARE South ABA Benefits


Approved Codes

S5108 (Functional Behavioral Assessment, Initial Treatment Plan, and ABA rendered by authorized provider)

S5108 (Initial Functional Behavioral Assessment, Initial Treatment Plan, and ABA reinforcement rendered jointly by Supervisor and Tutor)

Pilot Assessment (OPBH 53)

1181F (Initial assessment by BCBA) with G8539 (Initial assessment & TP per 15 min units); G9165  (patient status code); AND G9166 (initial ABA TP goal); OR if no deficiencies found use G8542 with 1181F

99080 (Treatment plan updates) H2019 (ABA reinforcement rendered directly by Tutor) 96110 & 96111 (psychometric testing)

90887 (Progress meetings w/family) 99080 (Development of progress report and updated BP) Pilot ABA & Reinforcement (OPBH 52)

90887 (Quarterly progress meetings with bene’s caregivers)

S5108 (ABA reinforcement rendered jointly by Supervisor and BCaBA/Tutor)

H2019 (ABA reinforcement rendered directly by BCaBA/Tutor)

S5110 (Family/caregiver training by BCBA)

S5115 (Beneficiary ABA by BCBA)

1450F (Reassessment & TP update by BCBA) with G8539 (repeat assessment & TP per 15 min units); G9165 (patient status code); AND G9166 (ABA TP goal update); OR if discharge is indicated, use G8542 (continued ABA not indicated); and G9167 (discharge from ABA) with 1140F ValueOptions - TRICARE South ABA Benefits Criteria to receive ABA Enrolled in ECHO. Eligibility and registration are prerequisites to ECHO benefits being authorized

CPT CODE and description

90686 - Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use -

90715 - Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular us


Tdap Tetanus -Diphtheria -Pertussis Boostrix SKB Pedi: 1 dose at 11-12 years; Catch-up vaccination < 19 yrs; during each pregnancy 0.5 mL IM 90715 115 Free Adacel PMC Adult: 1 dose for unvaccinated adults >19 years ; vaccinate pregnant5 women during each pregnancy; Varicella Chickenpox Varivax MSD Pedi & Adult: 1 st dose at 12-15 months; catch-up vaccination
children and adults 19- 26 years 0.5 mL SC 90716 21 Free


DT  & Tdap/Td Administration of influenza virus vaccine Varicella virus vaccine (VAR), live, for subcutaneous use (Varivax) Influenza Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use Tetanus, diphtheria toxoids and acellular pertussis (Tdap), when administered to individuals 7 years or older, for intramuscular use


Background

This recurring update notification provides the payment allowances for the following seasonal infl uenza virus vaccines, when payment is based on 95 percent of the Average Wholesale Price (AWP).

The Medicare Part B payment allowances for the following Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes below apply for the effective dates of August 1, 2015­ July 31, 2016:

• CPT 90655 Payment allowance is pending;

• CPT 90656 Payment allowance is pending;

• CPT 90657 Payment allowance is pending;

• CPT 90661 Payment allowance is pending;

• CPT 90685 Payment allowance is pending;

• CPT 90686 Payment allowance is pending;

• CPT 90687 Payment allowance is pending;

• CPT 90688 Payment allowance is pending;

• HCPCS Q2035 Payment allowance is pending;

• HCPCS Q2036 Payment allowance is pending;

• HCPCS Q2037 Payment allowance is pending; and

• HCPCS Q2038 Payment allowance is pending.


Submit claims for shingles or tetanus vaccinations to Medicare Part D

Providers who have administered a shingles (90736; regardless of any diagnosis) or tetanus vaccine (90714, 90715, 90718 & 90723; regardless of any diagnosis) to our individual and group-sponsored Medicare Advantage plan members with pharmacy benefits should bill the Medicare Part D Benefit. Providers will encounter a denial if these claims are billed to the Medical benefit because the claim is covered under Medicare Part D only. This applies to the vaccine and the administration charges. Please note you can refer your patients to their local pharmacy for administration as well.
For Medicare Part B benefit of tetanus vaccine (90703; diagnosis range 800.00 to 897.99), this may be submitted as a medical claim for processing.



A given service or procedure billed to the Medicare program may not be linked to a National Coverage Determination (NCD) or Local Coverage Determination (LCD). Assuming all other requirements of the program are met and absent specific coverage criteria outlined in a LCD or NCD, all procedures or services must meet the medically reasonable and necessary threshold for coverage as demonstrated by the performing provider or attending physician in the official medical record. The Noncovered Services LCD compiles services or procedures that have been addressed by the Medical Policy department as to the medically reasonable and necessary threshold for coverage. Certain services or procedures will not have specific level I or level II HCPCS coding. Such services or procedures would be coded as the appropriate unclassified code. Occasionally services or procedures will be identified by a specific level I (Category I or Category III CPT code) or level II HCPCS code. It is the expectation that physicians and allied providers code to specificity. Payment of a claim is not a coverage statement especially if payable codes were used to bypass the medical review of more specific Level I/Category I unlisted codes or Level I/Category III codes or level II HCPCS codes.

In determining if a service or procedure reaches the threshold for coverage, this contractor addresses the quality of the evidence per the program integrity manual in making its recommendation to non-cover a service, pending new information in the public domain. This recommendation is taken through the LCD development process (draft recommendation of noncoverage, 45-day comment period, CAC advisory meeting, open public meeting, finalization, and 45-day notice period). Any interested stakeholder can request a reconsideration of an LCD after the notice period. In the case of the Noncovered Services LCD the stakeholder will receive a list of the articles and related information in the public domain that were addressed by the Medical Policy department in making the noncoverage decision. If the stakeholder has new information based on the evaluation of the list, a LCD reconsideration can be initiated. It is the responsibility of the interested stakeholder to request the evidentiary list from the contractor and to submit the additional articles, data, and related information in support of their request for coverage. The request must meet the LCD reconsideration requirements outlined on the web site.

It is not unusual that there will be a paucity of information for an emerging technology or service, and the Medial Policy department may noncover a service as noted in this LCD awaiting information in the public domain on safety and efficacy based on the quality of evidence. Also this contractor may be silent in terms of LCD in regard to a service or procedure (such a procedure or service is not listed in the Noncovered Services LCD or has been removed from the Noncovered Services LCD). A service or procedure not addressed in the Noncovered Services LCD is not a positive coverage statement. Claims for such services assuming all other requirements of the program are met would always need to meet the medically reasonable and necessary threshold for coverage in a prepayment or post payment audit of the official medical record.

 Patient Is a Member of a Medicare Advantage (MA) Organization for Only a Portion of the Billing Period

Where a patient either enrolls or disenrolls in an MA organization (See Pub. 100-01, the General Information, Eligibility, and Entitlement Manual, Chapter 5, §80 for definition) during a period of services, two factors determine whether the MA organization is liable for the payment.

• Whether the provider is included in inpatient hospital or home health PPS, and

• The date of enrollment.



Hospital Services

If the provider is an inpatient acute care hospital, inpatient rehabilitation facility or a long term care hospital, and the patient changes MA status during an inpatient stay for an inpatient institution, the patient’s status at admission or start of care determines liability.

If the hospital inpatient was not an MA enrollee upon admission but enrolls before discharge, the MA organization is not responsible for payment.

For hospitals exempt from PPS (children’s hospitals, cancer hospitals, and psychiatric hospitals/units) and Maryland waiver hospitals, if the MA organization has processing jurisdiction for the MA involved portion of the bill, it will direct the provider to split the bill and send the appropriate portions to the appropriate FI or MA organization. When forwarding a bill to an MA organization, the provider must also submit the necessary supporting documents.

If the provider is not a PPS provider, the MA organization is responsible for payment for services on and after the day of enrollment up through the day that disenrollment is effective.


Home Health

If the patient was enrolled in the MA organization before start of care, the MA organization is liable until disenrollment. Upon disenrollment, an episode must be opened under home heath PPS for billing to the FI.

If the beneficiary was not an MA enrollee upon admission but enrolls before discharge, the home health PPS episode will end as of the day before the MA enrollment. The episode will be proportionately paid according to its shortened length (i.e., paid a partial episode payment [PEP] adjustment). The MA organization is responsible for payment as of the MA enrollment date.

CPT Code and description

99381 - Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)

99382 - Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years)


99383 - Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) - Average fee amount $110 - $130

99384 - Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Average fee amount $120 - $140

99385 - Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years  -  Average fee amount - $120 - $ 150


State Exceptions

Arizona Per Arizona State Regulations, effective 4/1/14 claims for EPSDT services must be submitted on a CMS (formerly HCFA) 1500 form for members up to age 21. Providers must bill for preventative EPSDT services using the preventative service, office or other outpatient services and preventive medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier.

EPSDT visits are paid at a global rate for the services specified and no additional reimbursement is allowed. Providers must use an EP modifier to designate all services related to the EPSDT well child check-ups, including  routine vision and hearing screenings.

* A list of preventative, office or other outpatient services that are considered included in the global payment of the preventive medicine CPT code is attached to this policy

*  Ocular photoscreening with interpretation and report, bilateral (CPT code 99174) is allowed for members under age 19.

Arizona EPSDT Bundled

Codes List

A list of preventative, office or other outpatient services that are considered included in the global payment for the preventive medicine CPT codes (99381 – 99385, 99391 – 99395).


DC EPSDT Well-Child Visit Billing Reference Guide

When conducting a well-child visit (WCV), a primary care provider (PCP) must perform all components required in a visit and all age-appropriate screenings and/or assessments as required in the DC Medicaid HealthCheck Periodicity Schedule. Covered screening services are medical, developmental/mental health, vision, hearing and dental. The components of medical screening include:

* Comprehensive health and developmental history that assesses for both physical and mental health as well as for substance use disorders

* Comprehensive, unclothed physical examination

* Appropriate immunizations (as established by ACIP)

* Laboratory testing (including blood lead screening appropriate for age and risk factors)

* Health education and anticipatory guidance for both the child and the caregiver.i

To bill for a well-child visit:

* Use the age-based CPT code (99381-99385; 99391-99395). See Table 1.

o Use the following ICD-9 diagnosis codes listed in Table 1 in conjunction with the CPT Code

* Bill for each separate assessment/screening performed using the applicable CPT code from Table 2.

* If a screening or assessment is positive and requires follow-up or a referral, please use modifier TS with the applicable screening code that had a positive result.

DO NOT USE THE E&M OUTPATIENT VISIT CODES (99201-99205; 99213-99215) TO BILL FOR A WELLCHILD VISIT.


Table1: Age Based Preventive Visit CPT Codes Table 2: Screening/Assessment CPT Codes

Patient’s Age                CPT Code           Dx Code

< 1 year  99381/91  new/established  V20.31,  20.32,  V20.2

1 – 4 years 99382/92 V20.2

5 – 11 years 99383/93 V20.2

12 – 17 years 99384/94 V20.2

18 – 21 years 99385/95 V70.0

cpt code and description

J7040 - Infusion, normal saline solution, sterile (500 ml=1 unit)


J7050 - Infusion, normal saline solution , 250 cc

J2405 - Injection, ondansetron hydrochloride, per 1 mg


J2930 - Injection, methylprednisolone sodium succinate, up to 125 mg


 Background:

Effective April 1, 2002, CWF edits were implemented to identify HCPCS codes for ambulance services that are either subject to or excluded from Skilled Nursing Facility (SNF) consolidated billing (CB). This coding change added SNF CB edits to CWF to deny payment of some separately billed ambulance services for beneficiaries in a SNF Part A covered stay. Effective July 1, 2003, CWF added an edit to allow claims submitted with specialty type “59” and CPCS codes J7030 or J7050 (Saline Solution Injection) to process and pay correctly for modifiers other than “NN” when a beneficiary is in a Part A stay, and for claims submitted with an “NN” modifier when the beneficiary is not in a Part A stay. Since the implementation of this update, CMS has identified additional HCPCS codes for drugs and CPT codes for electrocardiogram (EKG) testing that may be separately payable when provided during a SNF ambulance transport that is not subject to SNF CB. HCPCS J-codes (J0000-J9999) not included in previous updates, Q-codes for anti-emetic drugs (Q0163 through Q0181), and CPT codes for EKG testing (93005 and 93041) will be added to the CWF SNF CB bypass for ambulance specialty type “59” carrier claims during the October 2004 SNF CB quarterly update.


Intravenous administration includes all methods, such as gravity infusion, injections, and timed pushes. The ‘VAR’ posting denotes various routes of administration and is used for drugs that are commonly administered into joints, cavities, tissues, or topical applications, in addition to other parenteral administrations. Listings posted with ‘OTH’ indicate other administration methods, such as suppositories or catheter injections.

Saline solution, sterile 500 ml = 1 unit IV, OTH J7040


Services Incorrectly Coded and Unbundling

Billed HCPCS J7050, and CPT 85025 and 36591.

HCPCS J7050 -  Billing for J7050- Normal saline solution 250cc, (3) units = 750cc. Documentation supports 150cc for medication use and would allow 250cc for a maintenance line. Change units of service from (3) to (2) = 500cc.

Billing for 85025- blood count; complete (CBC), automated (HGB, HCT, RBC, WBC and platelet count) and automated differential WBC count. Physician's order is for a CBC, no differential was ordered. Resulted is a CBC with differential. Change code from 85025 to 85027- Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet.
Per the physician's fees schedule, billed code 36591(Draw blood off venous device) is listed as T statusonly paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made. Payment is made for E/M services as well as infusion therapy. Unbundling.


Drug

Medicare Administrative Contractors (MACs), many private payers, and most Medicaid agencies require healthcare providers to use Healthcare Common Procedure Coding System (HCPCS) codes to identify infused drugs on claim forms. HCPCS codes have a 5-character alphanumeric format and are used to bill for supplies and services not described by the Current Procedural Terminology (CPT), 4th Edition, coding system. The following HCPCS code may be used to describe REMICADE® (infliximab) on claim forms submitted from the hospital outpatient setting:

• J1745 Infliximab 10 mg

Although the National Drug Code (NDC) is usually reserved for billing by pharmacies, some private payers and the majority of Medicaid fee-for-service programs require an NDC for billing instead of, or in addition to, an HCPCS code, for physicians and other service providers as well. Although the FDA uses a 10-digit format when registering NDCs, payers usually recognize and often require an 11-digit NDC format on claim forms for billing purposes. It is important to confirm with your payer which NDC format they require. Guidelines for reporting the NDC in the appropriate format, quantity, and unit of measure vary by state and by payer, and should be reviewed prior to submitting a claim. The 10-digit NDC and 11-digit alternative NDC formats used for REMICADE® 100 mg are:

• 10-Digit NDC format: 57894-030-01

• 11-Digit NDC format (used by most payers): 57894-0030-01

Payers’ policies regarding separate payment for saline used to administer IV drugs vary. Hospitals may need to record costs on claims even though saline is not separately reimbursed (ie, it is bundled into the APC payment for infusion services). If billed on the claim form, the following HCPCS code describes saline used to administer REMICADE®:

• J7050 Infusion, normal saline solution, 250 mL


Billing Examples

1.) Patient receives 4 mg Zofran IV in the physician’s office.

• NDC package display: 00173-0442-02

• Descriptor: Zofran 2 mg/ml in solution form

• 2 ml per vial


Report:

• J2405 (ondansetron hydrochloride, per 1 mg)

o 4 HCPCS units

• 001730442025 (NDC Number)

o ML2 (2 millimeters NDC units)



2.) Patient receives 1gram of Rocephin IM in the physician/s office.

• NDC for the product used: 00004-1963-02

• Descriptor: Rocephin 500 mg vial in powder form, reconstituted prior to injection.


Report:

• J0696 (ceftriaxone sodium, per 250 mg)

o 4 HCPCS units

• 00004196302 (NDC number)

o UN2 (NDC units as 2, also called 2 each)



3.) If the patient in the first example above (Example 1) received a partial vial, only 2 mg of Zofran, use the same NDC which is for Zofran 2 mg/ml in a 2 ml vial:

Report:

• J2405 (ondansetron hydrochloride, per 1 mg)

o 2 HCPCS units

• 00173044202 (NDC Number)

o ML1 (1 millimeter NDC units)

 CPT code and description


80050 - General health panel


This panel must include the following: Comprehensive metabolic panel (80053), Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004), OR, Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009), Thyroid stimulating hormone (TSH) (84443)

82435 - Chloride; blood

86910 - Blood typing, for paternity testing, per individual; ABO, Rh and MN

86911 - Blood typing, for paternity testing, per individual; each additional antigen system

P2031 - HAIR ANALYSIS (EXCLUDING ARSENIC)


80053 - Comprehensive metabolic panel  - Average fee amount $17- $25

This panel must include the following:

Albumin (82040)
Bilirubin, total (82247)
Calcium, total (82310)
Carbon dioxide (bicarbonate) (82374)
Chloride (82435)
Creatinine (82565)
Glucose (82947)
Phosphatase, alkaline (84075)
Potassium (84132)
Protein, total (84155)
Sodium (84295)
Transferase, alanine amino (ALT) (SGPT) (84460)
Transferase, aspartate amino (AST) (SGOT) (84450)
Urea nitrogen (BUN) (84520)

Medicare payment Guidelines.

80050 General health panel - Not payable by Medicare 310, 330, 400

In general, Medicare pays for items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body part.The statutory provisions for Medicare coverage found in section 1862 (a)(1)(A) of the Social Security Act, exclude from Medicare coverage “items and services that are not reasonable and necessary for the diagnosis of illness or injury or to improve the functioning of a malformed body member.”

"Not medically necessary" charges are those charges for services that the Medicare FI or carrier decides were not necessary or reasonable for the patient’s condition.

Concurrent hospital care during hospice (condition code 07), will be denied when the hospice diagnosis is:


Debility, ICD-9 code 799.3

Adult failure to thrive, ICD-9 code 783.7

Other general symptoms, ICD-9code 780.9


"Non-covered services" are services and procedures billed to the patient, not covered by Medicare, and are always denied either because:

A national decision to noncover the service/procedure exists, or

The service/procedure is included on the list of services determined by the contractor to be excluded from coverage

These non-covered services are charges that:

The beneficiary already knows are noncovered because they are included in the information given in the Medicare handbook (e.g., oral medications, screening mammograms in less than the designated waiting period, etc.)

They are considered either experimental or investigational in nature

They are routine physical examinations, for which Medicare does not pay under any circumstances because of statutory exclusions.

Medicare law places general and categorical limitations on services furnished by certain health care practitioners, such as dentists, chiropractors and podiatrists. The law specifically excludes from coverage such services as:

cosmetic surgery

personal comfort items

custodial care

routine physical checkups

services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury

Unless written notice of non-coverage is issued to the beneficiary prior to rendering a specific non-covered service, in some instances the provider may be held financially liable.

Providers are made aware of these non-covered items and services through updates to the Medicare Coverage Issues Manual, Medicare Carriers Manual, Medicare Hospital Manual, and other sources.

It is important to note that the fact that a new service or procedure has been issued a CPT code or is FDA approved does not, in itself, make the procedure "medically reasonable and necessary." It is our policy that new services, procedures, drugs, or technology must be evaluated and approved either nationally or by our local medical review policy process before they are considered Medicare covered services. Furthermore, national non-covered services may not be covered by local contractors.

This policy is initiated to list medical services and procedures that are never covered by the Medicare program.

Indications and Limitations

A service or procedure on the "national non-coverage list" may be non-covered based on a specific exclusion contained in the Medicare law; for example, acupuncture; it may be viewed as not yet proven safe and effective and, therefore, not medically reasonable and necessary; or it may be a procedure that is always considered cosmetic in nature and is denied on that basis. The precise basis for a national decision to noncover a procedure may be found in references cited in this policy.

A service or procedure on the "local" list is always denied on the basis that Riverbend GBA does not believe it is ever "medically reasonable and necessary". Our list of local medical review policy exclusions contains procedures that, for example, are:

experimental

not yet proven safe and effective

not yet approved by the FDA


Reasons for Denial

An advance notice of Medicare’s denial of payment must be provided to the patient when the provider does not want to accept financial responsibility for a service that is considered investigational/experimental, or is not approved by the FDA, or because there is a lack of scientific and clinical evidence to support the procedure’s safety and efficacy.

The service does not follow the guidelines of this policy.

The service is considered:

Investigational

Cosmetic

Routine screening

Dental

Program exclusion

Otherwise not covered

Never medically necessary



Commercial insurance Guidelines

In addition, Moda Health covers a limited list of additional tests when billed with a routine, preventive, or screening diagnosis code. These tests are not on the PPACA list of mandated preventive services and so are not eligible for the 100%, no-cost-share Affordable Care Act preventive benefit. The tests will be covered but are subject to the member’s usual costsharing and deductible requirements.

The following additional CPT codes will be covered as noted above with a routine/preventive/screening diagnosis:

* 80048 (Basic metabolic panel)

* 80050 (General health panel)

* 80051(Electrolyte panel)

* 80053 (Comprehensive metabolic panel)

* 80061 (Lipid panel)

* 81001 (Urinalysis, by dip stick or tablet reagent; automated, with microscopy)

* 82310 (Calcium; total)

* 83036 (Hemoglobin; glycosylated (A1C))

* 83655 (Lead)

* 84443 (Thyroid stimulating hormone (TSH))

* 85025 (Blood count; complete (CBC), automated)

* Chlamydia screening for males (87110, 87270, 87370, 87490, 87491, 87492, 87810)


CLIA update

CPT 80053  requied CLIA certificate.

CLIA regulations require a facility to be appropriately certified for each test they perform. Laboratory claims are edited at the CLIA certificate level in order to
ensure the Centers for Medicare & Medicaid Services (CMS) pay only for  laboratory tests categorized as waived complexity under CLIA by facilities with a CLIA certificate of waiver.

The chart below identifies the newly added waived tests and their effective dates. The Current Procedural Terminology (CPT) codes for these tests must have the
QW modifier to be recognized as a waived test.

80053QW January 16, 2008 Abaxis Piccolo Blood Chemistry Analyzer (Comprehensive Metabolic Reagent Disc){Whole Blood}

80053QW January 16, 2008 Abaxis Piccolo xpress Chemistry Analyzer (Comprehensive Metabolic Reagent Disc){Whole Blood}


Comprehensive Metabolic Panel, 80053 

There are 3 configurations for a Comprehensive Metabolic Panel, CPT code 80053: 1. A submission that includes 10 or more of the following laboratory Component Codes by the Same Individual Physician or Other Health Care Professional for the same patient on the same date of service is a reimbursable service as a Comprehensive Metabolic Panel,

CPT code 80053


1 .Must contain 10 or more of the following Component Codes for the same patient on the same date of service:

82040 Albumin; serum, plasma or whole blood
82247 Bilirubin; total
82310 Calcium; total
82374 Carbon dioxide (bicarbonate)
82435 Chloride; blood
82565 Creatinine; blood
82947 Glucose quantitative, blood (except reagent strip)
84075 Phosphatase, alkaline
84132 Potassium; serum, plasma or whole blood
84155 Protein, total, except by refractometry; serum, plasma or whole blood
84295 Sodium; serum, plasma or whole blood
84450 Transferase, aspartate amino (AST) (SGOT)
84460 Transferase, alanine amino (ALT) (SGPT)
84520 Urea Nitrogen (BUN)

2. A submission that includes a Basic Metabolic Panel (Calcium, total), CPT code 80048, and 2 or more of the following laboratory Component Codes by the Same Individual Physician or Other Health Care Professional for the same patient on the same date of service is a reimbursable service as a Comprehensive Metabolic Panel, CPT code 80053.



80053 Comprehensive Metabolic Panel

Includes the following panel:
80048 Basic Metabolic Panel (Calcium, total)
Plus 2 or more of the following Component Codes for the same patient on
the same date of service:
82040 Albumin; serum, plasma or whole blood
82247 Bilirubin; total
84075 Phosphatase, alkaline
84155 Protein, total
84450 Transferase, aspartate amino (AST) (SGOT)
84460 Transferase; alanine amino (ALT) (SGPT)


3. A submission that includes an Electrolyte Panel, CPT code 80051, and 6 or more of the following laboratory Component Codes by the Same Individual Physician or Other Health Care Professional for the same patient on the same date of service is a reimbursable service as a Comprehensive Metabolic Panel,

80053 Comprehensive Metabolic Panel

Includes the following panel:

80051 Electrolyte Panel
Plus 6 or more of the following Component Codes for the same patient on the same date of service:

82040 Albumin; serum, plasma or whole blood
82247 Bilirubin; total
82310 Calcium; total
82565 Creatinine; blood
82947 Glucose; quantitative, blood (except reagent strip)
84075 Phosphatase, alkaline
84155 Protein, total, except by refractometry; serum, plasma or whole blood
84450 Transferase, aspartate amino (AST) (SGOT)
84460 Transferase; alanine amino (ALT) (SGPT)
84520 Urea nitrogen (BUN)
When the Same Individual Physician or Other Health Care Professional reports CPT 80053 with CPT
80048 or CPT 80076 for the same patient on the same date of service, neither CPT 80048 nor CPT
80076 will be reimbursed separately.


CPT Panel Code 80053 includes all of the components of CPT Panel Code 80048 and all the components of CPT Panel Code 80076, except for CPT 82248 (bilirubin, direct). Therefore, when performed with all of the components of CPT 80053, report CPT 82248 separately.


The Organ or Disease-Oriented Panels as defined in the CPT book are codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, and 80076. According to the CPT book, these panels were developed for coding purposes only and are not to be interpreted as clinical parameters.

UnitedHealthcare Community Plan uses CPT coding guidelines to define the components of each panel. UnitedHealthcare Community Plan also considers an individual component code included in the more comprehensive Panel Code when reported on the same date of service by the Same Individual Physician  or Other Health Care Professional. The Professional Edition of the CPT ® book, Organ or DiseaseOriented Panel section states: "Do not report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes."

For reimbursement purposes, UnitedHealthcare Community Plan differs from the CPT book's inclusion of the specific number of Component Codes within an Organ or Disease-Oriented Panel. UnitedHealthcare Community Plan will deny the individual Component Codes and require the provider to submit the more comprehensive Panel Code. as set forth more fully in the tables below. The tables for CPT codes 80047, 80048, 80050, 80051, 80053, 80061, 80069, 80074 and 80076 identify the Component Codes that UnitedHealthcare Community Plan will require the submission of the specific panel.

cpt code and description

84443 - Thyroid stimulating hormone (TSH)  - average fee amount  - $30  - $40

Providers retain records in all categories as applicable:

A. Billing Material

Provider copies of Form CMS-1450 and any other supporting documents, e.g., charge slips, daily patient census records, and other business and accounting records referring to specific claims.


B. Cost Report Material

All data necessary to support the accuracy of the entries on the annual cost reports, including original invoices, cancelled checks, and provider copies of material used in preparing them. Also include other similar cost reports, schedules, and related worksheets and contracts or records of dealings with outside sources of medical supplies and services or with related organizations.


C. Medical Record Material

For hospitals, utilization review committee reports and discharge summaries. For hospitals and home health agencies, physicians’ certifications, and recertifications, and clinical and other medical records relating to health insurance claims.


D. Provider Physician Materials

Provider physician agreements upon which Part A and Part B allocations are based.

After payment of the bill, the provider should not retain administrative and billing work records if the material does not represent critical detail in support of summaries related to these records. These include punch cards, adding machine tapes, or other similar material not required for record retention.

Retention Period

The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The provider must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

The provider (hospital, skilled nursing facility, and home health agency) must retain medical records in their original or legally reproduced form for a period of at least five years after it files with its FI the cost report to which the records apply, unless State law stipulates a longer period of time.

After payment of the bill, the provider need not retain administrative and billing work records provided that, and only to the extent that, such material does not represent critical detail in support of summaries related to the records outlined in §110.2. These records include punch cards, adding machine tapes, internal controls, or other similar material not required for record retention.


Providers must retain clinical records as follows:

• The period of time required by State law;

• Five years from the date of discharge when there is no requirement in State law; or

• For a minor, three years after a resident reaches legal age under State law.



 Destruction of Records

The provider may destroy material that no longer needs to be retained for title XVIII purposes, unless State law stipulates a longer period of retention.

To insure the confidentiality of the records, they must be destroyed by shredding, mutilation or other protective measures. The method of final disposition of the records may provide for their sale as salvage. The provider must report monies received as an adjustment to expense in the cost report for the year sold.

97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training) direct (one-on-one) patient contact by the provider, each 15 minutes

* Compensatory training is provided to make up for a deficiency or loss of cognitive skills resulting from brain injury or psychiatric disorders.

* Cognitive impairments addressed by this code include attentional impairments (loss of focused, sustained, alternating and divided attention), memory impairments, and problem solving impairments (inability to initiate a behavioral response, to organize parts or concepts or thoughts into a whole, and to sequence thoughts so as to modify behavior). (CPT Assistant, Vol. 11, Issue 12, December 2001)

* This procedure is not medically reasonable and necessary when the patient's cognitive skills are not expected to improve.

* This therapy may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate therapeutic procedures to effect continued improvement.


97533 Sensory integrative techniques to enhance sensory processing and promote adaptive response to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

* These treatments are performed when a deficit in processing input from one of the sensory systems decreases the patient’s ability to make adaptive sensory, motor, and behavioral responses to environmental demands.

* These patients may demonstrate sensory defensiveness, over-reactivity to environmental stimuli, attention difficulties, and behavioral problems. (CPT Assistant, Vol.11, Issue 12, December 2001)

* Sensory integrative interventions enhance sensory processing by persons with deficits in sensory systems (e. g., vestibular, proprioceptive, tactile) by increasing their ability to make adaptive sensory, motor, and behavioral responses to environmental demand.

* Sensory integrative treatments are almost exclusively provided to a pediatric population for responses to environmental demand and are almost exclusively provided for conditions such as autism, developmental disorders, attention deficit hyperactivity disorder, cerebral palsy, and motor apraxia. Similar techniques used in treatment for adults should be coded with 97112.

* This procedure is not medically reasonable and necessary when the patient's sensory processing and adaptive responses are not expected to improve.

* This therapy may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate therapeutic procedures to effect continued improvement.


97535 Self care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one on one contact by provider, each 15 minutes:

* This procedure is medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific outcome.
* The patient must have the capacity to learn from instructions.
* Medical treatment may generally require up to 12 visits in 4 weeks. Coverage beyond 12 visits in 4 weeks may require documentation supporting the medical necessity of continued treatment.
* Documentation must relate the training to expected functional goals that are attainable by the patient.
* The medical record should document the distinct goals and service rendered when self-care/home management training is done during the same visit as gait training (97116), orthotics fitting and training (97504) or prosthetic training (97520).

97537 Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one on one contact by provider, each 15 minutes:

* This training may be medically necessary when performed in conjunction with a patient’s individual treatment plan aimed at improving or restoring specific functions which were impaired by an identified illness or injury and when expected outcomes that are attainable by the patient are specified in the plan.

* This training is medically necessary only when it requires the professional skills of a provider. Generally speaking, the professional skills of a provider are not required to effect improvement or restoration of function where a patient suffers a temporary loss or reduction of function which could reasonably be expected to improve as the patient gradually resumes normal activities. General activity programs and all activities which are primarily social or diversional in nature will be denied because the professional skills of a provider are not required.

* Services which are related solely to specific employment opportunities, work skills or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1) of the Social Security Act (Medicare Benefit Policy Manual, Pub. 100-2, Chapter 15, Section 220.2, formerly Ref. MCM 2217.B).

* The CPT code 97537 was modified in 2004. This code is expanded to complement the 97755 assessment code. The modification is intended to allow the post-assessment patient fitting and training for use of the advanced technology device/adaptive equipment.
* The patient must have the capacity to learn from instructions.
* Medical treatment may generally require up to 12 visits in 4 weeks.
* Documentation must relate the training to expected functional goals that are attainable by the patient.


97520 Prosthetic training, upper and/or lower extremities, each 15 minutes:

* The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training (97116), orthotics fitting and training (97504) or self care/home management training (97535).
* Periodic revisits beyond the third month may require supportive documentation of medical necessity if requested.
* In some cases, prosthetic training may require more than 30 minutes on a given date and when this occurs the medical record must document the medical necessity of the additional time.
* Note: The following items are included in the Durable Medical Equipment Regional Contractor (DMERC) reimbursement for a prosthesis within 90 days of delivery of the prosthesis and, therefore, are not separately billable to Medicare:
a. Evaluation of the residual limb and/or gait
b. Fitting of the prosthesis
c. Cost of base component parts and labor contained in HCPCS base codes
d. Repairs due to normal wear or tear
e. Adjustments of the prosthesis or the prosthetic component made when fitting the prosthesis or component when the adjustments are not necessitated by changes in the residual limb or the patient’s functional abilities.

97750 Physical Performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes:

* This testing may be medically necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific treatment plan, or to determine a patient's capacity.
* The patient's medical record must document the problem requiring tests, the specific tests performed, and measurement report.
* Documentation of the need for more than 30 minutes of time should be submitted upon request.
* Requires direct one-on-one patient contact

97755 Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact by provider, with written report, each 15 minutes

* This procedure is medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific outcome.
* The patient must have the capacity to learn from instructions.
* Documentation must relate the training to expected functional goals that are attainable by the patient.
* Requires direct one-on-one patient contact.

97597 Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters

97598 total wound(s) surface area greater than 20 square centimeters

* Though more than one wound may have been debrided, either code 97597 or 97598 may be billed only once per session.

* Consistent with reasonable and necessary guidelines, providers may bill CPT 11000-11044 codes. However, the providers should not bill 11000-11044 codes and the 97597 or 97598 together. But note that the 11000-11044 codes may be billed only by physicians (MDs and DOs) and qualified nonphysician practitioners (PA, NP, CNS), as defined by CMS and as allowed by individual State scope of practice.

* Billing for 97597 and 97598 entails all of the elements of these codes; i.e., debridement, wound assessment, and instructions for ongoing care.

* The simple removal and replacement of a dressing of any kind is “non-selective” debridement and is always bundled into another service.

* Per 2005 CPT, do not report 97597-97598 in conjunction with 11040-11044.

* If whirlpool is used for the same wound prior to selective debridement, it is bundled into the new code (97597 or 97598). However, if whirlpool is used for a different body part or body area on the same date of service than the area being debrided, it could be billed.

97799 Unlisted physical medicine/rehabilitation service or procedure:

For all claims submitted for unlisted services or procedures, the following documentation must be submitted:

* A description of the service or procedure; and,

* A treatment plan including information indicating the medical necessity of the service or procedure

* Microamperage E-stimulation (MENS) has not been proven effective and will be denied as such. If MENS therapy is billed to Medicare for a denial, such as in cases of supplemental coverage, providers should bill using procedure code 97799, placing “MENS therapy” in Item 19 on the CMS 1500 form or equivalent electronic field. An Advance Beneficiary Notice (ABN) should be obtained when MENS is utilized.

* Vertebral Axial Decompression (VAX-D®)

As noted in Medicare National Coverage Determination Manual, Pub. 100-3, Section 160.11 (formerly Coverage Issues Manual (CIM) 35-97), Vertebral Axial Decompression (VAX-D®) is not covered by Medicare. Medicare notes that there is insufficient scientific data to support a finding of significant benefits of this technique. If billing for a denial for the provision of this service, you must use procedure code 97799, Unlisted physical medicine/rehabilitation service or procedure, and enter "VAX-D®" in Item 19 on the CMS 1500 claim form, or electronic equivalent. An Advance Beneficiary Notice (ABN) should be obtained when VAX-D® is utilized. DO NOT bill using 64722, decompression, unspecified nerves, or 97012, application of modality.

* MedX or SPINEX® or DRX9000™

NAS, based on the advice of Physical Therapy consultants, considers MedX or SPINEX® or DRX9000™ treatments to also be non-covered, and such services will be denied as not proven effective. Use procedure code 97799, Unlisted physical medicine/rehabilitation service or procedure, and enter "MedX" or “SPINEX®” or “DRX90000™” in Item 19 on the CMS 1500 claim form, or electronic equivalent. An Advance Beneficiary Notice (ABN) should be obtained when MedX or SPINEX® are utilized.

NAS will deny VAX-D®, MedX, SPINEX® and other similar devices as not proven effective. Providers may not bill the beneficiary unless the provider has previously informed the beneficiary that this service will be denied by Medicare and has obtained his/her signature on a valid Advan.


97150 Therapeutic procedure(s), group (2 or more individuals):

* Since many group procedures do not require the professional skills of a provider, the need for skilled intervention must be documented and submitted upon request.

* Documentation must be maintained in the medical record identifying the specific treatment technique(s) used in the group, how the treatment technique will restore function, the frequency and duration of the particular group setting, and the treatment goal in the individualized plan. The number of persons in the group must also be furnished. The medical record must be made available upon request.

* Group therapy is defined as payment for physical therapy services (which includes speech-language pathology services) and occupational therapy services provided simultaneously to two or more individuals by a practitioner. The individuals can be, but need not be, performing the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required.

97504 Orthotics fitting and training, upper extremity(ies), lower extremity(ies), and/or trunk, each 15 minutes:

* The medical record should document the distinct treatments rendered when orthotic training for a lower extremity is done during the same visit as gait training (97116), prosthetic training (97520), or self care/home management training (97535).

* It is unusual to require more than 30 minutes of static orthotic training. In some cases, dynamic training may require more additional time and when this occurs the medical record must document the medical necessity of additional time.

* Note: The following items are included in the Durable Medical Equipment Regional Contractor (DMERC) reimbursement for an orthosis within 90 days of delivery of the orthosis and, therefore, are not separately billable to Medicare:

a. Evaluation of the orthosis and/or gait
b. Fitting of the orthosis
c. Cost of base component parts and labor contained in HCPCS base codes
d. Repairs due to normal wear or tear
e. Adjustments of the orthosis or the orthotic component made when fitting the orthotic or component when the adjustments are not necessitated by changes in the patient’s functional abilities.

Institutional providers may submit a taxonomy code on claims they submit to Medicare. Medicare does not use the taxonomy code for matching a provider’s NPI to the appropriate legacy identifier. Medicare uses other claims data for this purpose. Medicare does not use the taxonomy code for any other claims processing purpose. Payers other than Medicare may have requirements for taxonomy codes. Medicare will pass any taxonomy code submitted on a Medicare claim to our trading partners on crossover claims, to allow for the possibility that those payers may use it.


If an institutional provider chooses to submit taxonomy codes, the following table supplies the crosswalk from Medicare’s legacy identifier (the OSCAR number) to the appropriate taxonomy code based on the provider’s facility type:


OSCAR Provider Type     SCAR Coding   Taxonomy Code

Short-term (General and Specialty) Hospitals    0001-0879 *Positions 3-6  282N00000X
Critical Access Hospitals   1300-1399 *  282NC0060X
Long-Term Care Hospitals2000-2299 *  282E00000X
Hospital Based Renal Dialysis Facilities  2300-2499*  261QE0700X
Independent Renal Dialysis Facilities  2500-2899*             261QE0700X
Rehabilitation Hospitals   3025-3099 *    283X00000X
Children’s Hospitals       3300-3399 *   282NC2000X
Psychiatric Hospitals4000-4499 *  283Q00000X
Organ Procurement Organization (OPO)P in third Position  335U00000X
Psychiatric UnitM or S in third Position  273R00000X
Rehabilitation UnitR or T in third Position  273Y00000X

Hospital Based Satellite Renal Dialysis Facilities 3500-3699
Type of Bill code 72X + 261QE0700X + different zip code than any renal dialysis facility issued an OSCAR that is located on that hospital’s campus

Swing-Bed Unit   U, W, Y, or Z in third Position
Type of Bill Code X8X (swing bed) with one of the following taxonomy codes to define the type of facility in which the swing bed is located
275N00000X if unit in a short-term hospital (U),
282E00000X if unit in a long-term care hospital (W), 283X00000X if unit in a rehab facility (Y),
282NC0060X if unit in a critical access hospital (Z)

Implementation of New Influenza Virus Vaccine Code 

Implementation Date: January 3, 2017 


Change Request (CR) 9793 which informs MACs about the changes to  instructions for  payment and edits for the Common Working File  (CWF) to include influenza virus vaccine code 90674 (Influenza virus vaccine, quadrivalent (ccIIV4), derived  from cell cultures,  subunit, preservative and antibiotic free, 0.5 mL  dosage, for intramuscular use) as payable  for claims with dates of service on or after August 1, 2016, processed on or after January 3,  2017. Make sure that your billing st
affs are aware of these changes.

CR9793 provides instructions for payment and edits  to include influenza virus vaccine code  90674. Medicare waives coinsurance and deductibles for code 90674. Medicare will pay for  code 90674 based on reasonable cost when submitted by:

Hospitals on Type of Bill (TOB) 12X and 13X

Skilled Nursing Facilities on TOB 22X and 23X

Home Health Agencies on TOB 34X

Hospital-Based Renal Dialysis facilities on 72X, and

Critical Access Hospitals (CAHs) on TOB 85X


MACs will pay for influenza virus vaccine code 90674 based on the lower of the actual  charge or 95 percent of the Average Wholesale Price (AWP) to:


Indian Health Services (IHS) hospitals submitting claims on TOB 12X and 13X

IHS CAHs submitting claims on TOB 85X

Comprehensive Outpatient Rehabilitation Facilities using TOB 75X, and

Independent Renal Dialysis Facilities using TOB 72X

It is important to note that MACs will hold institutional claims with  code 90674 with dates  of service on or after January 1, 2017, through February 20, 2017, until the Fiscal Intermediary Shared System (FISS) changes are implemented on February 20, 2017. Medicare will issue further instructions on how to handle claims for code 90674 with dates of service from August 1, 2017, through December 31, 2016

procedure code and description

99221 - Initial hospital care - average fee payment - $100 - $120

When we can bill procedure code 99221


When a patient is admitted to inpatient hospital care for less than 8 hours on the same calendar date, the physician shall report Initial Hospital Care using a code from procedure  code range 99221 – 99223. The Hospital Discharge Day Management Service, procedure  code 99238 or 99239, shall not be reported for this scenario.

When a patient is admitted for inpatient hospital care and discharged on a different calendar date, the physician shall report Initial Hospital Care using a code from procedure  code range 99221 – 99223 and procedure  code 99238 or 99239 for a Hospital Discharge Day Management Service.

When a patient is admitted to inpatient hospital care for a minimum of 8 hours, but less than 24 hours and discharged on the same calendar date, the physician shall report the Observation or Inpatient Hospital Care Services (Including Admission and Discharge Service Same Day) using a code from procedure  code range 99234 – 99236, and no additional discharge service.

Physician documentation shall meet the evaluation and management (E/M) documentation requirements for history, examination and medical decision making. In addition, the physician shall identify he/she was physically present and that he personally performed the initial hospital care service. The physician shall personally document the admission and discharge notes and include the number of hours the patient remained in inpatient hospital care status.


Billing Guide and Policy: 

Effective January 1, 2010, procedure  consultation codes were no longer recognized for Medicare Part B payment. As explained in CR 6740, Transmittal 1875, Revisions to Consultation Services Payment Policy, issued on December 14, 2009, physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. CMS instructed providers billing under the PFS to use other applicable E/M codes to report the services that could be described by procedure  consultation codes. CMS also provided that, in the inpatient hospital setting, physicians (and qualified nonphysicians where permitted) who perform an initial E/M service may bill the initial hospital care codes (99221 – 99223).

CMS is aware of concerns pertaining to reporting initial hospital care codes for services that previously could have been reported with procedure  consultation codes and for which the minimum key component work and/or medical necessity requirements for procedure  codes 99221 through 99223 are not documented. Providers may report procedure  code 99221 for an E/M service if the requirements for billing that code, which are greater than procedure  consultation codes 99251 and 99252, are met by the service furnished to the patient.

In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care procedure  codes (99231 and 99232) could potentially meet requirements to be reported for an E/M service that could be described by procedure  consultation code 99251 or99252. Contractors shall expect changes to physician billing practices accordingly. Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay .



A. Hospital Visit and Critical Care on Same Day

When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (procedure  codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital
emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.

During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with procedure  Subsequent Hospital Care using a code from procedure  code range 99231 – 99233. Both Initial Hospital Care (procedure  codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians  of the same specialty from the same group practice.



C. Initial Hospital Care and Discharge on Same Day

When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from procedure  code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, procedure  codes 99238 or 99239, shall not be reported for this scenario.

When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report an Initial Hospital Care from procedure  code range 99221 – 99223 and a Hospital Discharge Day Management service, procedure  code 99238 or 99239.

When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from procedure  code range 99234 – 99236, shall be reported.




F. Initial Hospital Care Service History and Physical That Is Less Than Comprehensive

When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Contractors pay the office visit as billed and the Level 1 initial hospital care code.

Physicians who provide an initial visit to a patient during inpatient hospital care that meets the minimum key component work and/or medical necessity requirements shall report an initial hospital care code (99221-99223). The principal physician of record shall append modifier “-AI” (Principal Physician of Record) to the claim for the initial hospital care code. This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.

Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with procedure  consultation codes (99241 – 99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements. Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report procedure  code 99221, which are greater than the requirements for consultation codes 99251 and 99252.

Subsequent hospital care procedure  codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by procedure  consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care procedure  code for services that were reported as procedure  consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.

Reporting procedure  code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service.
Reporting procedure  code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these
circumstances to be unusual.


G. Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same Admission

In the inpatient hospital setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304 – 99306). Contractors consider only one M.D. or D.O. to be the principal physician of record (sometimes referred to as the admitting physician.)

The principal physician of record is identified in Medicare as the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. Only the principal physician of record shall append modifier “-AI” (Principal Physician of Record) in addition to the E/M code. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits.

Consultation code as admit code

Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management visit with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysicians where permitted) who perform an initial evaluation and management may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304-99306). As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day.

Modifier “-AI,” defined as “Principal Physician of Record,” shall be used by the admitting or attending physician who oversees the patient’s care, as distinct from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “-AI” in addition to the initial visit code. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level performed. NOTE: The primary purpose of this modifier is to identify the principal physician of record on the initial hospital and nursing home visit codes. It is not necessary to reject claims that include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes). Follow-up visits in the facility setting may be billed as subsequent hospital care visits and subsequent nursing facility care visits as is the current policy. In all cases, physicians shall bill the available code that most appropriately describes the level of the services provided.

Initial Hospital Care From Emergency Room

Contractors pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

B. Initial Hospital Care on Day Following Visit

Contractors pay both visits if a patient is seen in the office on one date and admitted to the hospital on the next date, even if fewer than 24 hours has elapsed between the visit and the admission.

C. Initial Hospital Care and Discharge on Same Day

When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from procedure  code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, procedure  codes 99238 or 99239, shall not be reported for this scenario.

When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report an Initial Hospital Care from procedure  code range 99221 – 99223 and a Hospital Discharge Day Management service, procedure  code 99238 or 99239. When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from procedure  code range 99234 – 99236, shall be reported.

procedure code and description

99241 - Office consultation level 1

99245 - Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family. Average payment - $210 - $250

Office or Other Outpatient Consultations: Office or other outpatient consultations are reported with procedure  codes 99241-99245 with no distinction between new and established patients. Consultation is appropriate in any outpatient setting including the office, emergency department, home, or domiciliary setting.

A. Initial Consultation

1. In the hospital and nursing facility setting, the consulting physician or other qualified health care professional shall use the appropriate inpatient consultation procedure ? codes 99251-99255 for the initial consultation service. The initial inpatient consultation may be reported only once per consultant per patient per facility admission.

2. In the office or outpatient setting, the consultant should use the appropriate office or outpatient consultation procedure ? codes 99241-99245 for the initial consultation service.

3. A consulting physician or other qualified health care professional may initiate diagnostic services and treatment at the initial consultation service or may even take over the patient’s care after the initial consultation.

Follow-up Services

1. Ongoing management, following the initial consultation service by the consulting physician or other qualified health care professional should not be reported with consultation service codes. These services need to be reported as subsequent visits with the appropriate place of service and level of service.

2. In the hospital setting, following the initial consultation service, the subsequent hospital care procedure ? codes 99231-99233 should be reported for additional follow-up visits. In the nursing facility setting, following the initial consultation service, the subsequent nursing facility care procedure ?codes 99307-99310 should be reported for additional follow-up visits.

3. In the outpatient setting, following the initial consultation service, the office or outpatient established patient procedure ? codes 99212-99215 should be reported for additional follow-up visits.

4. If an additional request for an opinion regarding the same or new problem with the same patient is received from the same or another physician or other appropriate source and documented in the medical record, the office or outpatient consultation  procedure ? codes 99241- 99245 may be used again.  

Inpatient Claim Diagnosis Reporting

On inpatient claims providers must report the principal diagnosis. The principal diagnosis is the condition established after study to be chiefly responsible for the admission. Even though another diagnosis may be more severe than the principal diagnosis, the principal diagnosis, as defined above, is entered. Entering any other diagnosis may result in incorrect assignment of a Medicare Severity - Diagnosis Related Group (MS-DRG) and an incorrect payment to a hospital under PPS

Other diagnoses codes are required on inpatient claims and are used in determining the appropriate MS-DRG. The provider reports the full codes for up to twenty four additional conditions if they coexisted at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay.

The principal diagnosis should not under any circumstances be duplicated as an additional or secondary diagnosis. If the provider reports duplicate diagnoses they are eliminated in Medicare Code Editor (MCE) before GROUPER.

The Admitting Diagnosis Code is required for inpatient hospital claims subject to A/B MAC (A) review. The admitting diagnosis is the condition identified by the physician at the time of the patient’s admission requiring hospitalization. For outpatient bills, the field defined as Patient’s Reason for Visit is not required by Medicare but may be used by providers for nonscheduled visits for outpatient bills.


Outpatient Claim Diagnosis Reporting


For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be chiefly responsible for the outpatient services. For instance, if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported. If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported. If the patient arrives at the hospital for examination or testing without a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital reports the encounter code that most accurately reflects the reason for the encounter.

Examples include:
• Z00.00 Encounter for general adult medical examination without abnormal findings
• Z00.01 Encounter for general adult medical examination with abnormal findings
• Z01.10 Encounter for examination of ears and hearing without abnormal findings
• Z01.118 Encounter for examination of ears and hearing with other abnormal findings

For outpatient claims, providers report the full diagnosis codes for up to 24 other diagnoses that coexisted in addition to the diagnosis reported as the principal diagnosis. For instance, if the patient is referred to a hospital for evaluation of hypertension and the medical record also documents diabetes, diabetes is reported as another diagnosis.

Diagnosis codes must be reported based on the date of service (including, when applicable, the date of discharge) on the claim and not the date the claim is prepared or received. A/B MACs (A), (B), (HHH), and DME MACs are required to edit claims on this basis, including providing for annual updates each October.

Shared systems must maintain date parameters for diagnosis editing. Use of actual effective and end dates is required when new diagnosis codes are issued or current codes become obsolete with the annual updates.


The Health Insurance Portability and Accountability Act (HIPAA) requires that medical code sets must be date-of-service compliant. Since ICD diagnosis codes are a medical code set, effective for dates of service on and after October 1, 2004, CMS does not provide any grace period for providers to use in billing discontinued diagnosis codes on Medicare claims. The updated codes are published in the Federal Register each year as part of the Proposed Changes to the Hospital Inpatient Prospective Payment Systems in table 6 and effective each October 1.

All MACs will return claims containing a discontinued diagnosis code as unprocessable. For dates of service beginning October 1, 2004, physicians, practitioners, and suppliers must use the current and valid diagnosis code that is then in effect for the date of service. After the updated codes are published in the Federal Register, CMS places the new, revised and discontinued codes on the ICD-9 or ICD-10 Web site as applicable.

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html
or http://www.cms.gov/Medicare/Coding/ICD10/index.html.

The CMS sends the updated codes to All MACs on an annual basis via a recurring update notification instruction. This is normally released to MACs each June, and contains the new, revised, and discontinued diagnosis codes which are effective for dates of service on and after October 1st.

The HCPCS has been selected as the approved coding set for entities covered under the Health Insurance Portability and Accountability Act (HIPAA), for reporting outpatient procedures.


The HCPCS is based upon the American Medical Association’s (AMA) “Physicians’ Current Procedural Terminology, Fourth Edition” (CPT-4). It includes three levels of codes and modifiers. Level I contains only the AMA’s CPT-4 codes. This level consists of all numeric codes. Level II contains alpha-numeric codes primarily for items and nonphysician services not included in CPT-4, e.g., ambulance, DME, orthotics, and prosthetics. These are alpha-numeric codes maintained jointly by CMS, the Blue Cross and Blue Shield Association (BCBSA), and the Health Insurance Association of America (HIAA).

Normally Level I and Level II codes are updated annually, issued in October for January implementation. However, Level II codes also may be issued quarterly to provide for new or changed Medicare coverage policy for physicians’ services as well as services normally described in Level II. These codes may be temporary and be replaced by a Level I or Level II code in the related CPT or HCPCS code section, or may remain for a considerable time as “temporary” codes. Designation as temporary does not affect the coverage status of the service identified by the code. New temporary codes that have been approved will be issued in a Recurring Update Notification instruction quarterly.

New K or Q codes may be identified from time to time and, when they are, they will be announced in a Recurring Change Request issued on a quarterly basis.
The CMS monitors the system to ensure uniformity.


Use and Maintenance of CPT-4 in HCPCS


There are over 7,000 service codes, plus titles and modifiers, in the CPT-4 section of HCPCS, which is copyrighted by the AMA. The AMA and CMS have entered into an agreement that permits the use of HCPCS codes and describes the manner in which they may be used. See §20.7 below.

• The AMA permits CMS, its agents, and other entities participating in programs administered by CMS to use CPT-4 codes/modifiers and terminology as part of HCPCS;

• CMS shall adopt and use CPT-4 in connection with HCPCS for the purpose of reporting services under Medicare and Medicaid;

• CMS agrees to include a statement in HCPCS that participants are authorized to use the copies of CPT-4 material in HCPCS only for purposes directly related to participating in CMS programs, and that permission for any other use must be obtained from the AMA;

• HCPCS shall be prepared in format(s) approved in writing by the AMA, which include(s) appropriate notice(s) to indicate that CPT-4 is copyrighted material of the AMA;

• Both the AMA and CMS will encourage health insurance organizations to adopt CPT-4 for the reporting of physicians’ services in order to achieve the widest possible acceptance of the system and the uniformity of services reporting;

• The AMA recognizes that CMS and other users of CPT-4 may not provide payment under their programs for certain procedures identified in CPT-4. Accordingly, CMS and other health insurance organizations may independently establish policies and procedures governing the manner in which the codes are used within their operations; and
• The AMA’s CPT-4 Editorial Panel has the sole responsibility to revise, update, or modify CPT-4 codes.

The AMA updates and republishes CPT-4 annually and provides CMS with the updated data. The CMS updates the alpha-numeric (Level II) portion of HCPCS and incorporates the updated AMA material to create the HCPCS code file. The CMS provides the file to A/B MACs (A), (B), (HHH), and DME MACs and Medicaid State agencies annually.
It is the MAC’s responsibility to develop payment screens and limits within Federal guidelines and to implement CMS’ issuances. The coding system is merely one of the tools used to achieve national consistency in claims processing.

MACs may edit and abridge CPT-4 terminology within their claims processing area. However, MACs are not allowed to publish, edit, or abridge versions of CPT-4 for distribution outside of the claims processing structure. This would violate copyright laws. MACs may furnish providers/suppliers AMA and CMS Internet addresses, and may issue newsletters with codes and approved narrative descriptions that instruct physicians, suppliers and providers on the use of certain codes/modifiers when reporting services on claims forms, e.g., need for documentation of services, handling of unusual circumstances. The CMS acknowledges that CPT is a trademark of the AMA, and the newsletter must show the following statement in close proximity to listed codes and descriptors:

CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

If only a small portion of the terminology is used, MACs do not need to show the copyright legend. MACs may also print the code and approved narrative description in development requests relating to individual cases.

The CMS provides MACs an annual update file of HCPCS codes and instructions to retrieve the update via CMS mainframe telecommunication system.

procedure code and description


90832 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 30 minutes with the patient and/or family member (time range 16-37 minutes)

90833 - Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 30 minutes with the patient and/or family member (time range 16-37 minutes), when performed with an evaluation and management service.  - average fee payment - $60 - $70


90837 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 60 minutes with the patient and/or family member (time range 53 minutes or more)

90838 - Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 60 minutes with the patient and/or family member (time range 53 minutes or more), when performed with an evaluation and management service.

90785 - Use the add-on code with 90832, +90833, 90834, +90836, 90837 and

90838 for interactive psychotherapy using play equipment, physical devices, language interpreter, or other mechanisms of communication

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

    Indications of Coverage and/or Medical Necessity:

    This part of the policy has been divided into seven (7) sections addressing the following services:

    I. Psychiatric Diagnostic Evaluation and Psychiatric Diagnostic Evaluation with Medical Services
    II. Psychotherapy
    III. Group Psychotherapy
    IV. Family Psychotherapy
    V. Psychoanalysis
    VI. Interactive Complexity Services
    VII. Psychotherapy for Crisis

 

    Section II: Psychotherapy (procedure Codes 90832-90838)

    Psychotherapy is the treatment of mental illness and behavior disturbances, in which the provider establishes a professional contact with the patient and through therapeutic communication and techniques, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, facilitate coping mechanisms and/or encourage personality growth and development.

    Insight oriented, behavior modifying, and/or supportive psychotherapy refers to the development of insight or affective understanding, the use of behavior modification techniques, the use of supportive interactions, and the use of cognitive discussion of reality, or any combination of the above to provide therapeutic change.

    Psychotherapy will be considered medically necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning. Psychotherapy services must be performed by a person licensed by the state where practicing, and whose training and scope of practice allow that person to perform such services.

    Psychotherapy must be provided as an integral part of an active treatment plan for which it is directly related to the patient’s identified condition/diagnoses. Some patients receive psychotherapy alone, and others receive psychotherapy along with medical evaluation and management services. These services involve a variety of responsibilities unique to the medical management of psychiatric patients such as medical diagnostic evaluation (i.e. evaluation of co-morbid medical conditions, drug interactions, and physical examinations), drug management when indicated, physician orders, interpretation of laboratory or other diagnostic studies and observations. The patient should be amenable to allowing insight-oriented therapy such as behavioral modification techniques, interpersonal psychotherapy techniques, supportive therapy, and cognitive/behavioral techniques to be effective.

    Psychotherapy services are not considered to be medically reasonable and necessary when they are rendered to a patient who has a medical/neurological condition such as dementia, delirium or other psychiatric conditions, which have produced a severe enough cognitive deficit to prevent effective communication with interaction of sufficient quality to allow insight oriented therapy (i.e. behavioral modification techniques, interpersonal psychotherapy techniques, supportive therapy or cognitive/behavioral techniques). In these cases, evaluation and management or pharmacological codes should be used.

    Psychotherapy services are not considered to be medically reasonable and necessary when they primarily include the teaching of grooming skills, monitoring activities of daily living, recreational therapy (dance, art play), or social interaction.

    Psychotherapy times are for face-to-face services with the patient and/or family member. The patient must be present for all or some of the service. In reporting, choose the code closest to the actual time (i.e., 16-37 minutes for 90832 and 90833, 38-52 minutes for 90834 and 90836, and 53 or more minutes for 90837 and 90838). Do not report psychotherapy of less than 16 minutes duration.
    Some psychiatric patients receive a medical evaluation and management service on the same day as a psychotherapy service by the same physician or other qualified health care professional. These services to be medically necessary should be significantly different and separately identifiable.

   Section III: Group Psychotherapy (procedure Code 90853)

    Group Psychotherapy is a form of treatment administered in a group setting with a trained group leader in charge of several patients. Since it involves psychotherapy it must be led by a person, authorized by state statute to perform this service. This will usually mean a psychiatrist, clinical psychologist, licensed clinical social worker, certified nurse practitioner, or clinical nurse specialist. The group is a carefully selected group of patients meeting for a prescribed period of time during which common issues are presented and generally relate to and evolve towards a therapeutic goal. Personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional outpouring, instruction, and support. Medical diagnostic evaluation and pharmacological management may continue by a physician when indicated. The group size should be of a size that can be considered therapeutically successful (i.e., maximum 12 people).

    Group therapy will be considered medically necessary when the patient has a psychiatric illness and /or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior patterns or maladaptive functioning in personal or social settings. The issues presented and explored in the group setting should evolve towards a theme or a therapeutic goal. Group psychotherapy must be ordered by a provider as an integral part of an active treatment plan for which it is directly related to the patient’s identified condition/diagnosis. This treatment plan must be adhered to and should be endorsed and monitored by the treating physician or physician of record. The specialized skills of a mental health care professional must be required.

    Group psychotherapy services are not considered to be medically reasonable and necessary when they are rendered to a patient who has a medical/neurological condition such as dementia, delirium, or other psychiatric conditions, which have produced a severe enough cognitive deficit to prevent effective communication including interaction of sufficient quality with the therapist and members of the group. Other services such as music therapy, socialization, recreational activities/recreational therapy, art classes/art therapy, excursions, sensory stimulation, eating together, cognitive stimulation, or motion therapy are not considered to be medically reasonable and necessary.

    Section IV: Family Psychotherapy (procedure Codes 90846, 90847)

    Family Psychotherapy is a specialized therapeutic technique for treating the identified patients’ mental illness by intervening in a family system in such a way as to modify the family structure, dynamics, and interactions which exert influence on the patient’s emotions and behaviors.

    Family psychotherapy sessions may occur with or without the patient present. The process of family psychotherapy helps reveal a family’s repetitious communication patterns that are sustaining and reflecting the identified patient’s behavior. For the purposes of this policy, a family member is any individual who spends a significant amount of the time with the patient and provides psychological support to the patient, which may include but is not limited to a caregiver or significant other.

    Family psychotherapy will be considered medically reasonable and necessary only in clinically appropriate circumstances and when the primary purpose of such psychotherapy is the treatment/management of the patient’s condition. Examples are as follows:

    •when there is a need to observe and correct, through psychotherapeutic techniques, the patient’s interaction with family members; and/or

    •where there is a need to assess the conflicts or impediments within the family, and assist, through psychotherapeutic techniques, the family members in the management of the patient.

    Family psychotherapy must be ordered by a provider as an integral part of an active treatment plan for which it is directly related to the patient’s identified condition/diagnosis.

    Family psychotherapy must be conducted face to face by physicians (MD/DO), psychologists, or other mental health professionals licensed or authorized by state statutes and considered eligible for reimbursement.

    Family psychotherapy is considered to be medically reasonable and necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning.

    In certain types of medical conditions, such as the unconscious or comatose patient, family psychotherapy would not be medically reasonable or necessary. Also, procedure code 90849 (Multiple family group psychotherapy) would not be considered treatment directly related to the patient’s care and therefore would not be considered medically necessary.

    A family psychotherapy session generally lasts for at least 45-50 minutes.

    Section V: Psychoanalysis (procedure Code 90845)

    Psychoanalysis is a treatment modality that uses psychoanalytic theories as the frame for formulation and understanding of the therapy process. These theories provide a focus on increasing self-understanding and deepening insight into emotional issues and conflicts which underlie presenting emotional difficulties. Typically therapists make use of exploration of unconscious thoughts and feelings which may relate to underlying emotional conflicts, interpretation of defensive processes which obstruct emotional awareness, and consideration of issues related to sense of self-esteem.

    Psychoanalysis uses a special technique to gain insight into a patient's unconscious motivations and conflicts using the development and resolution of a therapeutic transference to achieve therapeutic effect. It is a different therapeutic modality than psychotherapy.

    The medical record must document the indications for psychoanalysis, description of the transference, and that psychoanalytic techniques were used. The physician using this technique must be trained and credentialed in its use. Clinical nurse specialists (CNS) and nurse practitioners (NP) are not eligible for payment for psychoanalysis. It is not a time-related code, but the service is usually 45 to 50 minutes in duration. The code may be billed once for each daily session regardless of the time involved. Psychoanalysis is generally considered unsuitable for psychoses.

    Section VI: Interactive Complexity Services (procedure Code 90785)

    Interactive complexity refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients.

    The interactive complexity techniques are utilized primarily to evaluate children and/or adults who do not have the ability to interact through ordinary verbal communication. In the aforementioned instances, it involves the use of physical aids and nonverbal communication to overcome barriers to the therapeutic interaction between the clinician and the patient who has not yet developed or has lost either the expressive language communication skills to explain his/her symptoms and response to treatment or the receptive communication skills to understand the clinician if he/she were to use ordinary adult language for communication. An interactive technique may include the use of inanimate objects such as toys and dolls for a child, physical aids, and non-verbal communication to overcome barriers to therapeutic interaction, or an interpreter for a person who is deaf or in situations where the patient does not speak the same language as the provider of care.

    If a patient is unable to communicate by any means, the interactive complexity codes should not be billed. This service is used in conjunction with codes for diagnostic psychiatric evaluation (90791, 90792), psychotherapy (90832, 90834, 90837), psychotherapy when performed with an evaluation and management service (90833, 90836, 90838, 99201-99255, 99304-99337, 99341-99350), and group psychotherapy (90853).

    Interactive complexity may be reported with psychotherapy when at least one of the following communication factors is present during the visit:

    • The need to manage maladaptive communication among participants (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) that complicates delivery of care.
    • Caregiver emotions or behaviors that interfere with implementation of the treatment plan.
    • Evidence or disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants.
    • Use of play equipment, physical devices, interpreter, or translator to overcome barriers to diagnostic or therapeutic interaction with a patient who is not fluent in the same language or who has not developed or has lost expressive or receptive language skills to use or understand typical language.

    Section VII: Psychotherapy for Crisis (procedure Codes 90839-90840)

    Psychotherapy for crisis is an urgent assessment and history of a crisis state, a mental status exam, and a disposition. The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma. The presenting problem is typically life threatening or complex and requires immediate attention to a patient with high distress. The crisis codes are used to report the total duration of time face-to-face with the patient and/or family spent by the physician or other qualified health care professional providing psychotherapy for crisis, even if the time spent on that date is not continuous. For any given period of time spent providing psychotherapy for crisis state, the physician or other qualified health care professional must devote his or her full attention to the patient and, therefore, cannot provide service to any other patient during the same time period. The patient must be present for all or some of the service.


procedure/HCPCS Codes
 
    90785Psytx complex interactive
    90791Psych diagnostic evaluation
    90792Psych diag eval w/med srvcs
    90832Psytx pt&/family 30 minutes
    90833Psytx pt&/fam w/e&m 30 min
    90834Psytx pt&/family 45 minutes
    90836Psytx pt&/fam w/e&m 45 min
    90837Psytx pt&/family 60 minutes
    90838Psytx pt&/fam w/e&m 60 min
    90839Psytx crisis initial 60 min
    90840Psytx crisis ea addl 30 min
    90845Psychoanalysis
    90846Family psytx w/o patient
    90847Family psytx w/patient
    90853Group psychotherapy


Billing and Coding Guidelines

The main error that CERT has identified with the revised psychiatry and psychotherapy codes is not clearly documenting the amount of time spent only on psychotherapy services.

The correct E&M code selection must be based on the elements of the history and exam and medical decision making required by the complexity/intensity of the patient’s condition.

The psychotherapy code is chosen on the basis of the time spent providing psychotherapy.

When a beneficiary receives an Evaluation and Management Service (E&M) service with a psychotherapeutic service on the same day, by the same provider, both services are payable if they are significant and separately identifiable and billed using the correct codes. New add-on codes (in the bulleted list below) designate psychotherapeutic services performed with E&M codes. An add-on code (often designated with a “+” in codebooks) describes a service performed with another primary service. An add-on code is eligible for payment only if reported with an appropriate primary service performed on the same date of service.

Time spent for the E&M service is separate from the time spent providing psychotherapy and time spent providing psychotherapy cannot be used to meet criteria for the E&M service. Because time is indicated in the code descriptor for the psychotherapy procedure codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.

For psychotherapy services provided with an E&M service:

• Code + 90833: Psychotherapy, 30 minutes with patient and/or family member when performed with an E&M service (list separately in addition to the code for primary procedure)

• Code + 90836: Psychotherapy, 45 minutes with patient and/or family member when performed with an E&M service (list separately in addition to the code for primary procedure)

• Code + 90838: Psychotherapy, 60 minutes with patient and/or family member when performed with an E&M service (list separately in addition to the code for primary procedure)


For psychotherapy services provided without an E&M service, the correct code depends on the time spent with the beneficiary.

• Code 90832: Psychotherapy, 30 minutes with patient and/or family member• Code 90834: Psychotherapy, 45 minutes with patient and/or family member

• Code 90837: Psychotherapy, 60 minutes with patient and/or family member In general, providers should select the code that most closely matches the actual time spent performing psychotherapy. procedure® provides flexibility by identifying time ranges that may be associated with each of the three codes:

• Code 90832 (or + 90833): 16 to 37 minutes,

• Code 90834 (or + 90836): 38 to 52 minutes, or

• Code 90837 (or + 90838): 53 minutes or longer

Do not bill psychotherapy codes for sessions lasting less than 16 minutes.

Psychotherapy codes are no longer dependent on the service location (i.e., office, hospital, residential setting, or other location is not a factor). However, effective January 1, 2014, when E&M services are paid under Medicare’s Partial Hospitalization Program (PHP) and not in the physician office setting, the procedure outpatient visit codes 99201-99215 have been replaced with one Level II HCPCS code - G0463. Further information about this code can be found in the CY 2014 OPPS/ASC final rule that was published in the Federal Register on December 10, 2013.

Example: A geriatric psychiatrist (physician) billed for a level 3 E&M service (99213) and 45 minutes of psychotherapy (90836). The medical record contained one entry for the date of service and, at the top, a notation: “45 minutes”. It did not indicate whether the 45 minutes was spent providing the psychotherapy services or both services. An overpayment for the psychotherapy service and a billing error occur when there is no separate entry for the amount of time spent performing psychotherapy services.


Psychotherapy 90832-90834, 90836-90838

* Time conventions are consistent with procedure  convention (more than 50 percent of stated time must be spent in order to report the code).

* Psychotherapy time may include face-to-face time with family members as long as the patient is present for part of the session.

add-on codes 90833, 90836, 90838.

o To report both an E/M code and a psychotherapy add on code, the two services must be significant and separately identifiable.

o The type and level of E/M service is selected first based upon the key components of history, examination, and medical decision making.

o Time may not be used as the basis of the E/M code selection
ICD-10 Codes that Support Medical Necessity

    F01.51Vascular dementia with behavioral disturbance
    F02.80Dementia in other diseases classified elsewhere without behavioral disturbance
    F02.81Dementia in other diseases classified elsewhere with behavioral disturbance
    F03.90Unspecified dementia without behavioral disturbance
    F03.91Unspecified dementia with behavioral disturbance
    F04Amnestic disorder due to known physiological condition
    F05Delirium due to known physiological condition
    F06.0Psychotic disorder with hallucinations due to known physiological condition
    F06.1Catatonic disorder due to known physiological condition
    F06.30Mood disorder due to known physiological condition, unspecified
    F06.31Mood disorder due to known physiological condition with depressive features
    F06.32Mood disorder due to known physiological condition with major depressive-like episode
    F06.33Mood disorder due to known physiological condition with manic features
    F06.34Mood disorder due to known physiological condition with mixed features
    F06.4Anxiety disorder due to known physiological condition
    F06.8Other specified mental disorders due to known physiological condition
    F07.0Personality change due to known physiological condition
    F07.81Postconcussional syndrome
    F07.89Other personality and behavioral disorders due to known physiological condition
    F07.9Unspecified personality and behavioral disorder due to known physiological condition
    F09Unspecified mental disorder due to known physiological condition
    F10.10Alcohol abuse, uncomplicated
    F10.120Alcohol abuse with intoxication, uncomplicated
    F10.121Alcohol abuse with intoxication delirium
    F10.129Alcohol abuse with intoxication, unspecified
    F10.14Alcohol abuse with alcohol-induced mood disorder
    F10.150Alcohol abuse with alcohol-induced psychotic disorder with delusions
    F10.151Alcohol abuse with alcohol-induced psychotic disorder with hallucinations
    F10.159Alcohol abuse with alcohol-induced psychotic disorder, unspecified
    F10.180Alcohol abuse with alcohol-induced anxiety disorder
    F10.181Alcohol abuse with alcohol-induced sexual dysfunction
    F10.182Alcohol abuse with alcohol-induced sleep disorder
    F10.188Alcohol abuse with other alcohol-induced disorder
    F10.19Alcohol abuse with unspecified alcohol-induced disorder
    F10.20Alcohol dependence, uncomplicated
    F10.21Alcohol dependence, in remission
    F10.220Alcohol dependence with intoxication, uncomplicated
    F10.221Alcohol dependence with intoxication delirium
    F10.229Alcohol dependence with intoxication, unspecified
    F11.10Opioid abuse, uncomplicated
    F11.120Opioid abuse with intoxication, uncomplicated
    F11.129Opioid abuse with intoxication, unspecified
    F11.20Opioid dependence, uncomplicated
    F11.21Opioid dependence, in remission
    F11.220Opioid dependence with intoxication, uncomplicated
    F11.221Opioid dependence with intoxication delirium
    F11.222Opioid dependence with intoxication with perceptual disturbance
    F11.229Opioid dependence with intoxication, unspecified
    F11.23Opioid dependence with withdrawal
    F11.24Opioid dependence with opioid-induced mood disorder
    F11.250Opioid dependence with opioid-induced psychotic disorder with delusions
    F11.251Opioid dependence with opioid-induced psychotic disorder with hallucinations
    F11.259Opioid dependence with opioid-induced psychotic disorder, unspecified
    F11.281Opioid dependence with opioid-induced sexual dysfunction
    F11.282Opioid dependence with opioid-induced sleep disorder
    F11.288Opioid dependence with other opioid-induced disorder
    F11.29Opioid dependence with unspecified opioid-induced disorder
    F11.90Opioid use, unspecified, uncomplicated
    F12.10Cannabis abuse, uncomplicated
    F12.20Cannabis dependence, uncomplicated
    F12.21Cannabis dependence, in remission
    F12.220Cannabis dependence with intoxication, uncomplicated
    F12.221Cannabis dependence with intoxication delirium
    F12.222Cannabis dependence with intoxication with perceptual disturbance
    F12.229Cannabis dependence with intoxication, unspecified
    F12.250Cannabis dependence with psychotic disorder with delusions
    F12.251Cannabis dependence with psychotic disorder with hallucinations
    F12.259Cannabis dependence with psychotic disorder, unspecified
    F12.280Cannabis dependence with cannabis-induced anxiety disorder
    F12.288Cannabis dependence with other cannabis-induced disorder
    F12.29Cannabis dependence with unspecified cannabis-induced disorder
    F12.90Cannabis use, unspecified, uncomplicated
    F13.10Sedative, hypnotic or anxiolytic abuse, uncomplicated
    F13.120Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated
    F13.20Sedative, hypnotic or anxiolytic dependence, uncomplicated
    F13.21Sedative, hypnotic or anxiolytic dependence, in remission
    F13.220Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated
    F13.221Sedative, hypnotic or anxiolytic dependence with intoxication delirium
    F13.229Sedative, hypnotic or anxiolytic dependence with intoxication, unspecified
    F13.230Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated
    F13.231Sedative, hypnotic or anxiolytic dependence with withdrawal delirium
    F13.232Sedative, hypnotic or anxiolytic dependence with withdrawal with perceptual disturbance
    F13.239Sedative, hypnotic or anxiolytic dependence with withdrawal, unspecified
    F13.24Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced mood disorder
    F13.250Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions
    F13.251Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations
    F13.259Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified
    F13.26Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder
    F13.27Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia
    F13.280Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety disorder
    F13.281Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sexual dysfunction
    F13.282Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
    F13.288Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorder
    F13.29Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic or anxiolytic-induced disorder
    F13.90Sedative, hypnotic, or anxiolytic use, unspecified, uncomplicated
    F14.10Cocaine abuse, uncomplicated
    F14.120Cocaine abuse with intoxication, uncomplicated
    F14.20Cocaine dependence, uncomplicated
    F14.21Cocaine dependence, in remission
    F14.220Cocaine dependence with intoxication, uncomplicated
    F14.221Cocaine dependence with intoxication delirium
    F14.222Cocaine dependence with intoxication with perceptual disturbance
    F14.229Cocaine dependence with intoxication, unspecified
    F14.23Cocaine dependence with withdrawal
    F14.24Cocaine dependence with cocaine-induced mood disorder
    F14.250Cocaine dependence with cocaine-induced psychotic disorder with delusions
    F14.251Cocaine dependence with cocaine-induced psychotic disorder with hallucinations
    F14.259Cocaine dependence with cocaine-induced psychotic disorder, unspecified
    F14.280Cocaine dependence with cocaine-induced anxiety disorder
    F14.281Cocaine dependence with cocaine-induced sexual dysfunction
    F14.282Cocaine dependence with cocaine-induced sleep disorder
    F14.288Cocaine dependence with other cocaine-induced disorder
    F14.29Cocaine dependence with unspecified cocaine-induced disorder
    F14.90Cocaine use, unspecified, uncomplicated
    F15.10Other stimulant abuse, uncomplicated
    F15.120Other stimulant abuse with intoxication, uncomplicated
    F15.20Other stimulant dependence, uncomplicated
    F15.21Other stimulant dependence, in remission
    F15.220Other stimulant dependence with intoxication, uncomplicated
    F15.221Other stimulant dependence with intoxication delirium
    F15.222Other stimulant dependence with intoxication with perceptual disturbance