Medicare and Unique Billing Scenarios

I f your practice is like most dermatology practices, Medicare represents a significant portion of your insurance revenues. I personally maintain that Medicare is the easiest carrier to work with for several reasons. For one, their computer software has very few “bugs.” For another, if you file a clean claim, you get paid within 16 to 27 days. Also, if you follow the rules and use the correct modifiers, you will experience very few incorrect denials. Lastly, Medicare’s appeal and review process is well outlined, and it works in a timely and equitable fashion. Although it’s not a perfect system, it works in a far more effective manner than any other commercial or managed care insurer. The key to effective interaction with Medicare, however, is understanding the various nuances of the system. Medicare often uses level two and three codes, versus CPT codes, to reflect services, supplies and procedures. Because of the way this system works your billing staff must always stay current with the latest changes and local medical review policies. To help you keep abreast of some of the new changes that are now in effect, I’ll address a few examples of unique coding variations imposed by Medicare for 2005. New Injection Changes 90782: Therapeutic, prophylactic or diagnostic injection (specify material injected): subcutaneous or intramuscular. This CPT code is used to reflect the administration charge associated with subcutaneous or intramuscular injections. Subcutaneous and intramuscular injections for therapeutic, prophylactic and certain diagnostic medications are billed using a combination of the drug charge (for example, the J code) and the administration charge (for example, 90782). Prior to January 1, 2005 Before January 1st of this year, Medicare allowed payment for CPT code 90782 and the J code only if no evaluation and management (E/M) visit was billed. If an E/M service was billed on the same date of service that an injection was performed, Medicare would only allow payment for the J code and the office visit. After January 1, 2005 Since January 1st of this year, some significant changes occurred. 1. CPT code 90782 was made invalid meaning that it was no longer recognized for payment under Part B benefits. 2. CPT code 90782 was replaced by G0351. The new code, G0351, was defined as “therapeutic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.” 3. After Jan. 1, 2005, providers can now bill G0351, the J code and an office visit, and be paid for all three services. The injection code is no longer bundled into the E/M visit allowance. Medicare has changed the status indicator in its computer edits from a “T” to an “A,” thereby allowing all three services to be paid for the same date of service. Note: CPT code 90782 is still recognized by non-Medicare carriers. G0351 should not be billed to non-Medicare carriers. Numerous other changes regarding injections have also been made, but most of these do not apply to dermatology practices. A summary of the rule changes can be found in the Federal Register dated Nov. 15, 2004, or by logging onto your local Medicare Web site and searching for “2005 Drug Administration Coding Revisions.” Blood Draw Code Change G0001 has been deleted. Level II code G0001 was used by Medicare instead of CPT code 36415 to pay for “collection of venous blood by venipuncture.” Effective Jan. 1, 2005, Medicare will no longer recognize its local G0001 code, but instead will require providers to bill for venipuncture using the CPT code equivalent (36415.) The Medicare payment allowable for 36415 is $3. Physician Performed Microscopy Laboratory Tests Two common in-office lab tests performed by dermatologists are: 1. Wet mounts 2. Potassium hydroxide preparations (KOH). Various CPT codes reflect the above two tests (see CPT codes on page 329 of the 2005 CPT book). Physicians who have a PPM (Physician Performed Microscopy) CLIA certification cannot use the CPT codes to bill Medicare for wet mounts or KOH preps. Instead, Medicare requires providers with PPM certification to replace the appropriate CPT codes with the following “Q” codes: Q0111: Wet mount, including preparation of vaginal, cervical or skin specimens. Q0112: All potassium hydroxide (KOH) preparations. These two “Q” codes replace CPT codes for Medicare claims only and only for providers with PPM CLIA certificates. Physicians with moderate or complex certification should use the appropriate CPT codes. Tapping a Helpful Resource One thing that will always be consistent regarding Medicare is that this agency will always present us with plenty of yearly changes. One way to help your staff keep up with the many changes is to have them log on to either local Medicare Web sites or the agency’s national Web site: www.cms.hhs.gov.