Q: My question is related to the new coding changes that affect the use of the 17000 to 17004 CPT codes as well as the 17110 and 17111 CPT codes. Because CPT now states that benign lesions are to be billed using CPT codes 17110 and 17111, does this mean I can no longer use CPT codes 11300 to 11313?
I’m already upset about the financial losses my practice has incurred due to the lumping of all benign lesions into two codes versus individual billing, and it would a double whammy if I also lost the revenue for the shave codes.
A: Remember, the definition of destruction is the “ablation of lesions by any method, with or without curettement, including local anesthesia, and not usually requiring closure. Any method includes electrosurgery, cryosurgery, laser and chemical treatment.”
On the same page of the book it states, “For shaving of epidermal or dermal lesions, see 11300 to 11313). So keep billing shaves if you do them. Remember, your documentation should state “shave removal” when using these codes. Avoid terms such as “shave excision”, “excisional biopsy”, or “shave biopsy”.
Q: An insurance carrier that I frequently bill recently has denied office visits when I have done a surgery on the same date of service. The insurer’s reasoning has been that the CPT book states that an E/M visit billed on the day before or the day that a procedure is performed is included in the procedure and cannot be billed separately — even if modifier 25 is appended. I clearly documented the medical record to show that a significant, separately identifiable service was performed. In most cases I have even used a diagnosis code that is different from that billed for the procedure. If the diagnosis code was the same, then my documentation usually included an examination of at least six body parts and an appropriate history update for the level of care billed.
Is this some change in the CPT book that I missed?
A: There was a change in the 2006 CPT book within the descriptor for modifier 25. The following sentence was added: “A significant, separate E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.”
CPT 2007 made no changes to the E/M definition. The important part of the modifier 25 definition is the portion that states, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service.
Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. For this, see modifier 57.”
Another portion of the CPT book that the carrier might be misusing to justify their denials is the section at the beginning of the surgery section, on page 45 titled, “Surgery Guidelines.”
In the section titled, “CPT Surgical Package Definition,” bullet number two states, “Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical” is included in the surgical package.
What’s important for you to understand is the word, “subsequent”. It does not mean you cannot bill for a visit if you haven’t already evaluated the patient and made the decision to do surgery. What this definition states is that if you decide to schedule an excision in 1 week because the patient has a skin cancer, you can’t bill a visit again next week.
However, if today you are examining the patient, taking the appropriate history and based on the history and exam feel that surgery is necessary, you are allowed to bill an E/M visit as long as the documentation supports the visit billed. Most carriers do not recognize modifier 57, so modifier 25 is used.
If the carrier stated that according to CPT guidelines, you couldn’t bill a visit, I would set up a meeting with the provider representative to show them the errors of their ways or just drop the contract. You would lose way too much money if you keep with the plan under these circumstances.
Q: With the use of the new destruction code changes, will I need a modifier if I bill both CPT codes 17110/17111 and either CPT code 17000 or 17004 on the same date of service? Are these bundled?
A: According to the most recent version of Medicare’s Correct Coding Initiative (CCI), there are some combinations of the four codes that are bundled, requiring the use of modifier 59. They are very inconsistent bundles and make no sense, so be sure to carefully check the CCI tables before submitting your claims.
Also, if other surgical procedures are billed on the same date of service, the CCI tables must be checked as well. Keep in mind that the CCI tables change every 90 days; therefore, it is important to have a current copy in your billing department at all times.
Q: I was told by another practice that Medicare covers 90736, which is an injection code for zoster vaccine. Is this true? By using this code, will I be paid to use the new zoster vaccine Zostavax?
A: Zostavax, which is from Merck Pharmaceuticals, was approved on May 25, 2006, in individuals 60 years of age and older. Zostavax is given as a single dose by subcutaneous injection.
Presently, no HCPCS code is available for this medication, so I know of no way to get paid for the drug itself. However, according to our sources, Medicare will pay for the injection of this vaccine using CPT code 90736. Although you won’t find reimbursement for CPT code 90736 in the 2007 fee schedule, payment for the injection may be made by carriers if the carrier deems the charge reasonable.
Q: My question is related to the new coding changes that affect the use of the 17000 to 17004 CPT codes as well as the 17110 and 17111 CPT codes. Because CPT now states that benign lesions are to be billed using CPT codes 17110 and 17111, does this mean I can no longer use CPT codes 11300 to 11313?
I’m already upset about the financial losses my practice has incurred due to the lumping of all benign lesions into two codes versus individual billing, and it would a double whammy if I also lost the revenue for the shave codes.
A: Remember, the definition of destruction is the “ablation of lesions by any method, with or without curettement, including local anesthesia, and not usually requiring closure. Any method includes electrosurgery, cryosurgery, laser and chemical treatment.”
On the same page of the book it states, “For shaving of epidermal or dermal lesions, see 11300 to 11313). So keep billing shaves if you do them. Remember, your documentation should state “shave removal” when using these codes. Avoid terms such as “shave excision”, “excisional biopsy”, or “shave biopsy”.
Q: An insurance carrier that I frequently bill recently has denied office visits when I have done a surgery on the same date of service. The insurer’s reasoning has been that the CPT book states that an E/M visit billed on the day before or the day that a procedure is performed is included in the procedure and cannot be billed separately — even if modifier 25 is appended. I clearly documented the medical record to show that a significant, separately identifiable service was performed. In most cases I have even used a diagnosis code that is different from that billed for the procedure. If the diagnosis code was the same, then my documentation usually included an examination of at least six body parts and an appropriate history update for the level of care billed.
Is this some change in the CPT book that I missed?
A: There was a change in the 2006 CPT book within the descriptor for modifier 25. The following sentence was added: “A significant, separate E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.”
CPT 2007 made no changes to the E/M definition. The important part of the modifier 25 definition is the portion that states, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service.
Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. For this, see modifier 57.”
Another portion of the CPT book that the carrier might be misusing to justify their denials is the section at the beginning of the surgery section, on page 45 titled, “Surgery Guidelines.”
In the section titled, “CPT Surgical Package Definition,” bullet number two states, “Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical” is included in the surgical package.
What’s important for you to understand is the word, “subsequent”. It does not mean you cannot bill for a visit if you haven’t already evaluated the patient and made the decision to do surgery. What this definition states is that if you decide to schedule an excision in 1 week because the patient has a skin cancer, you can’t bill a visit again next week.
However, if today you are examining the patient, taking the appropriate history and based on the history and exam feel that surgery is necessary, you are allowed to bill an E/M visit as long as the documentation supports the visit billed. Most carriers do not recognize modifier 57, so modifier 25 is used.
If the carrier stated that according to CPT guidelines, you couldn’t bill a visit, I would set up a meeting with the provider representative to show them the errors of their ways or just drop the contract. You would lose way too much money if you keep with the plan under these circumstances.
Q: With the use of the new destruction code changes, will I need a modifier if I bill both CPT codes 17110/17111 and either CPT code 17000 or 17004 on the same date of service? Are these bundled?
A: According to the most recent version of Medicare’s Correct Coding Initiative (CCI), there are some combinations of the four codes that are bundled, requiring the use of modifier 59. They are very inconsistent bundles and make no sense, so be sure to carefully check the CCI tables before submitting your claims.
Also, if other surgical procedures are billed on the same date of service, the CCI tables must be checked as well. Keep in mind that the CCI tables change every 90 days; therefore, it is important to have a current copy in your billing department at all times.
Q: I was told by another practice that Medicare covers 90736, which is an injection code for zoster vaccine. Is this true? By using this code, will I be paid to use the new zoster vaccine Zostavax?
A: Zostavax, which is from Merck Pharmaceuticals, was approved on May 25, 2006, in individuals 60 years of age and older. Zostavax is given as a single dose by subcutaneous injection.
Presently, no HCPCS code is available for this medication, so I know of no way to get paid for the drug itself. However, according to our sources, Medicare will pay for the injection of this vaccine using CPT code 90736. Although you won’t find reimbursement for CPT code 90736 in the 2007 fee schedule, payment for the injection may be made by carriers if the carrier deems the charge reasonable.
Q: My question is related to the new coding changes that affect the use of the 17000 to 17004 CPT codes as well as the 17110 and 17111 CPT codes. Because CPT now states that benign lesions are to be billed using CPT codes 17110 and 17111, does this mean I can no longer use CPT codes 11300 to 11313?
I’m already upset about the financial losses my practice has incurred due to the lumping of all benign lesions into two codes versus individual billing, and it would a double whammy if I also lost the revenue for the shave codes.
A: Remember, the definition of destruction is the “ablation of lesions by any method, with or without curettement, including local anesthesia, and not usually requiring closure. Any method includes electrosurgery, cryosurgery, laser and chemical treatment.”
On the same page of the book it states, “For shaving of epidermal or dermal lesions, see 11300 to 11313). So keep billing shaves if you do them. Remember, your documentation should state “shave removal” when using these codes. Avoid terms such as “shave excision”, “excisional biopsy”, or “shave biopsy”.
Q: An insurance carrier that I frequently bill recently has denied office visits when I have done a surgery on the same date of service. The insurer’s reasoning has been that the CPT book states that an E/M visit billed on the day before or the day that a procedure is performed is included in the procedure and cannot be billed separately — even if modifier 25 is appended. I clearly documented the medical record to show that a significant, separately identifiable service was performed. In most cases I have even used a diagnosis code that is different from that billed for the procedure. If the diagnosis code was the same, then my documentation usually included an examination of at least six body parts and an appropriate history update for the level of care billed.
Is this some change in the CPT book that I missed?
A: There was a change in the 2006 CPT book within the descriptor for modifier 25. The following sentence was added: “A significant, separate E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.”
CPT 2007 made no changes to the E/M definition. The important part of the modifier 25 definition is the portion that states, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service.
Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. For this, see modifier 57.”
Another portion of the CPT book that the carrier might be misusing to justify their denials is the section at the beginning of the surgery section, on page 45 titled, “Surgery Guidelines.”
In the section titled, “CPT Surgical Package Definition,” bullet number two states, “Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical” is included in the surgical package.
What’s important for you to understand is the word, “subsequent”. It does not mean you cannot bill for a visit if you haven’t already evaluated the patient and made the decision to do surgery. What this definition states is that if you decide to schedule an excision in 1 week because the patient has a skin cancer, you can’t bill a visit again next week.
However, if today you are examining the patient, taking the appropriate history and based on the history and exam feel that surgery is necessary, you are allowed to bill an E/M visit as long as the documentation supports the visit billed. Most carriers do not recognize modifier 57, so modifier 25 is used.
If the carrier stated that according to CPT guidelines, you couldn’t bill a visit, I would set up a meeting with the provider representative to show them the errors of their ways or just drop the contract. You would lose way too much money if you keep with the plan under these circumstances.
Q: With the use of the new destruction code changes, will I need a modifier if I bill both CPT codes 17110/17111 and either CPT code 17000 or 17004 on the same date of service? Are these bundled?
A: According to the most recent version of Medicare’s Correct Coding Initiative (CCI), there are some combinations of the four codes that are bundled, requiring the use of modifier 59. They are very inconsistent bundles and make no sense, so be sure to carefully check the CCI tables before submitting your claims.
Also, if other surgical procedures are billed on the same date of service, the CCI tables must be checked as well. Keep in mind that the CCI tables change every 90 days; therefore, it is important to have a current copy in your billing department at all times.
Q: I was told by another practice that Medicare covers 90736, which is an injection code for zoster vaccine. Is this true? By using this code, will I be paid to use the new zoster vaccine Zostavax?
A: Zostavax, which is from Merck Pharmaceuticals, was approved on May 25, 2006, in individuals 60 years of age and older. Zostavax is given as a single dose by subcutaneous injection.
Presently, no HCPCS code is available for this medication, so I know of no way to get paid for the drug itself. However, according to our sources, Medicare will pay for the injection of this vaccine using CPT code 90736. Although you won’t find reimbursement for CPT code 90736 in the 2007 fee schedule, payment for the injection may be made by carriers if the carrier deems the charge reasonable.
