Re: (unknown)

January 21, 2009

Have her come in for PPD placement, but don't charge copay for that.

Come another time for the skin biopsy.

I often may have pt come back for immunization later, like a flu shot I wouldn't charge the copay just for that.

Matt in Western PA

(unknown)

Dear all,

I have an established patient coming in for a skin lesion removal in a few wks. She called stating that she needs a ppd placed for Tb testing and wanted to get both, the skin procedure and ppd placement done at same visit to avoid 2 copays. This is my first ppd placement in my new practice and I was wondering..

Do insurance companies pay for 2 different CPT on same date of visit? (insurance company in this case is United UHC)

Also, should one collect a copay for ppd visit & /or when patient comes back for reading? What is the right way to do this...is the ppd visit considered an office visit..99211 or 99212?

I appreciate your help on this one!

Nita

January 21, 2009

Nita:

May I suggest you place PPD on one day and have her return 48 hours later for

reading and the skin procedure? I would actually have her pay the co-pay

both times…but that is just me. Some insurance requires the co-pay

every time a patient is seen; it is part of the patient’s contract…(and

yours if you are in network)

On the other hand, I do not ever charge

for the reading of a PPD as long as it is negative.

I think if you do both on one day there is

that always present risk that the insurance will cover the “lesser”

of the two fees, especially if they do not honor a 25 modifier. Depending

on your willingness to take that risk, you will want to use the modifier for “separate

and identifiable service” on same day.

Finally, if PPD is being placed for

employment purposes only, some insurers will also deny coverage for that

purpose. (non medically necessary)

Ramona

Ramona G. Seidel, MD

www.baycrossingfamilymedicine.com

Your Bridge to Health

NOTE NEW ADDRESS AND PHONE NUMBER:

269 Peninsula Farm Road

Suite F

Arnold, MD 21012

410 518-9808

From: [mailto: ] On Behalf Of Dr Levin

Sent: Tuesday, January 20, 2009

10:17 PM

To:

Subject: Re:

(unknown)

Have her come in for PPD placement, but don't charge copay

for that.

Come another time for the skin biopsy.

I often may have pt come back for immunization later, like a

flu shot I wouldn't charge the copay just for that.

Matt in Western PA

(unknown)

Dear all,

I have an established patient coming in for a skin lesion removal in a

few wks. She called stating that she needs a ppd placed for Tb testing and

wanted to get both, the skin procedure and ppd placement done at same visit to

avoid 2 copays. This is my first ppd placement in my new practice and I was

wondering..

Do insurance companies pay for 2 different CPT on same date of visit?

(insurance company in this case is United UHC)

Also, should one collect a copay for ppd visit & /or when patient

comes back for reading? What is the right way to do this...is the ppd visit

considered an office visit..99211 or 99212?

I appreciate your help on this one!

Nita

January 21, 2009

>

> Have her come in for PPD placement, but don't charge copay for that.

>

> Come another time for the skin biopsy.

>

> I often may have pt come back for immunization later, like a flu shot I

wouldn't charge the

copay just for that.

For example, BCBSIL will pay the entire amt for a depo shot, so the patient does

not have to

pay a copay.

January 21, 2009

Thanks for your input.

So should I call the insurance company to see if they will cover the cpt for ppd and if the pt owes a copay? Doing the two procedures on separate days makes sense. Just a hassle for the patient though.

Are we expected to routinely prior authorize derm lesion excision/biopsy with the insurance company prior to services?

Nita

To: Sent: Tuesday, January 20, 2009 10:25:56 PMSubject: RE: (unknown)

Nita: May I suggest you place PPD on one day and have her return 48 hours later for reading and the skin procedure? I would actually have her pay the co-pay both times…but that is just me. Some insurance requires the co-pay every time a patient is seen; it is part of the patient’s contract…(and yours if you are in network)

On the other hand, I do not ever charge for the reading of a PPD as long as it is negative.

I think if you do both on one day there is that always present risk that the insurance will cover the “lesser” of the two fees, especially if they do not honor a 25 modifier. Depending on your willingness to take that risk, you will want to use the modifier for “separate and identifiable service” on same day.

Finally, if PPD is being placed for employment purposes only, some insurers will also deny coverage for that purpose. (non medically necessary)

Ramona

Ramona G. Seidel, MD

www.baycrossingfami lymedicine. com

Your Bridge to Health

NOTE NEW ADDRESS AND PHONE NUMBER:

269 Peninsula Farm RoadSuite F

Arnold, MD 21012

410 518-9808

From: Practiceimprovement 1yahoogroups (DOT) com [mailto: Practiceimprovement 1yahoogroups (DOT) com ] On Behalf Of Dr LevinSent: Tuesday, January 20, 2009 10:17 PMTo: Practiceimprovement 1yahoogroups (DOT) comSubject: Re: [Practiceimprovemen t1] (unknown)

Have her come in for PPD placement, but don't charge copay for that.

Come another time for the skin biopsy.

I often may have pt come back for immunization later, like a flu shot I wouldn't charge the copay just for that.

Matt in Western PA

[Practiceimprovemen t1] (unknown)

Dear all,

I have an established patient coming in for a skin lesion removal in a few wks.. She called stating that she needs a ppd placed for Tb testing and wanted to get both, the skin procedure and ppd placement done at same visit to avoid 2 copays. This is my first ppd placement in my new practice and I was wondering..

Do insurance companies pay for 2 different CPT on same date of visit? (insurance company in this case is United UHC)

Also, should one collect a copay for ppd visit & /or when patient comes back for reading? What is the right way to do this...is the ppd visit considered an office visit..99211 or 99212?

I appreciate your help on this one!

Nita

January 21, 2009

I have yet another answer. Usually, the problem with

getting paid for two CPT codes on one day is getting paid for and E & M

code plus another CPT so doing a HTN visit with the skin bx. Then you use

the -25 modifier which I don’t think United HC pays yet, as it takes them

2 years to make changes in their computer system.

SO I would go ahead a place it using the code for the PPD and

doing the skin bx. They usually do not pay an E & M code for placing

a PPD, just the PPD code anyway. When she comes back, you are entitled to

a 99211 for the reading if you actually have to read it and sign off on it

being negative. You collect a co-pay for that. I do not know if “procedures”

other than an E & M code require co-pays (like skin bx day) but I would

collect and at worse, you credit or give it back. I would not collect 2

co-pays on skin bx/PPD day. That is usually only done with a E & M

code on same day as a Preventive Health Maintenance exam.

You will probably get as many answers as people who

answer. The rules change state to state too.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of RGMS

Sent: Tuesday, January 20, 2009 10:26 PM

To:

Subject: RE: (unknown)

Nita:

May I suggest you place PPD on one day and have her return 48 hours later for

reading and the skin procedure? I would actually have her pay the co-pay

both times…but that is just me. Some insurance requires the co-pay

every time a patient is seen; it is part of the patient’s

contract…(and yours if you are in network)

On the

other hand, I do not ever charge for the reading of a PPD as long as it is

negative.

I think if

you do both on one day there is that always present risk that the insurance

will cover the “lesser” of the two fees, especially if they do not

honor a 25 modifier. Depending on your willingness to take that risk, you

will want to use the modifier for “separate and identifiable

service” on same day.

Finally,

if PPD is being placed for employment purposes only, some insurers will also

deny coverage for that purpose. (non medically necessary)

Ramona

Ramona G.

Seidel, MD

www.baycrossingfamilymedicine.com

Your

Bridge to Health

NOTE NEW

ADDRESS AND PHONE NUMBER:

269

Peninsula Farm Road

Suite F

Arnold,

MD 21012

410

518-9808

From:

[mailto: ] On Behalf Of Dr Levin

Sent: Tuesday, January 20, 2009 10:17 PM

To:

Subject: Re: (unknown)

Have her come in for

PPD placement, but don't charge copay for that.

Come another time for

the skin biopsy.

I often may have pt

come back for immunization later, like a flu shot I wouldn't charge the copay

just for that.

Matt in Western PA

----- Original

Message -----

From: Nivedita Bijoor

To:

Sent: Tuesday, January 20,

2009 8:49 PM

Subject:

(unknown)

Dear

all,

I

have an established patient coming in for a skin lesion removal in a few wks.

She called stating that she needs a ppd placed for Tb testing and wanted to get

both, the skin procedure and ppd placement done at same visit to avoid 2

copays. This is my first ppd placement in my new practice and I was wondering..

Do

insurance companies pay for 2 different CPT on same date of visit? (insurance

company in this case is United UHC)

Also,

should one collect a copay for ppd visit & /or when patient comes back for

reading? What is the right way to do this...is the ppd visit considered an

office visit..99211 or 99212?

I

appreciate your help on this one!

Nita

January 21, 2009

nivedita there is never a charge for reading the ppd .the code 86580 is for placing and reading it There are never two separete cahrgesPPD stuff is really quick and cheap She does need to come in twice but If it was me I would do both the same day charge one c opay and then she bops by for a 2min reading that you write down for her

IF teh ppd is postive that becomes a visit with copay becasue you need to do work explaing ordering w/u of course.ONe issue here is HOW the insurance and billing owrk Which others on this list serv know better than I

But th eother issue is how you serve the patietn YOu make mor eloyality among patients when you sevre their agenda firs.t If she wants the skin procedure to be done -do it for herOther caveats PPD is only good for 30 days after you use it once Good chance you will have ot toss it and buy more before you need it agian MAke sure your cost covers the whole vial.

ALso When patietns enter your office is the best time to tell them that if insurance does not cover a procedure and I always state the likley time for that is with cosmetic procedures ,and then when they are requesteing something that is obvioulsy cosmetcitic, I warn t hem again a nd I tell them my cost

I cann't recommedn the hassle and likley lies you get when calling insurance That is not your responsibility it is the patietnsWhen we are allied with patietns they can take on these tasks When we are seen to be here to serve not to figure out how many copays to get, we keep them and serve them better, and our practices grow

2 cents. minus 12 agian I have hot water thooght(new yesterday)Jean

Thanks for your input.

So should I call the insurance company to see if they will cover the cpt for ppd and if the pt owes a copay? Doing the two procedures on separate days makes sense. Just a hassle for the patient though.

Are we expected to routinely prior authorize derm lesion excision/biopsy with the insurance company prior to services?

Nita

To:

Sent: Tuesday, January 20, 2009 10:25:56 PMSubject: RE: (unknown)

Nita: May I suggest you place PPD on one day and have her return 48 hours later for reading and the skin procedure? I would actually have her pay the co-pay both times…but that is just me. Some insurance requires the co-pay every time a patient is seen; it is part of the patient's contract…(and yours if you are in network)

On the other hand, I do not ever charge for the reading of a PPD as long as it is negative.

I think if you do both on one day there is that always present risk that the insurance will cover the "lesser" of the two fees, especially if they do not honor a 25 modifier. Depending on your willingness to take that risk, you will want to use the modifier for "separate and identifiable service" on same day.

Finally, if PPD is being placed for employment purposes only, some insurers will also deny coverage for that purpose. (non medically necessary)

Ramona

Ramona G. Seidel, MD

www.baycrossingfami lymedicine. com

Your Bridge to Health

NOTE NEW ADDRESS AND PHONE NUMBER:

269 Peninsula Farm Road

Suite F

Arnold, MD 21012

410 518-9808

From: Practiceimprovement 1yahoogroups (DOT) com [mailto: Practiceimprovement 1yahoogroups (DOT) com ] On Behalf Of Dr Levin

Sent: Tuesday, January 20, 2009 10:17 PMTo: Practiceimprovement 1yahoogroups (DOT) comSubject: Re: [Practiceimprovemen t1] (unknown)

Have her come in for PPD placement, but don't charge copay for that.

Come another time for the skin biopsy.

I often may have pt come back for immunization later, like a flu shot I wouldn't charge the copay just for that.

Matt in Western PA

[Practiceimprovemen t1] (unknown)

Dear all,

I have an established patient coming in for a skin lesion removal in a few wks.. She called stating that she needs a ppd placed for Tb testing and wanted to get both, the skin procedure and ppd placement done at same visit to avoid 2 copays. This is my first ppd placement in my new practice and I was wondering..

Do insurance companies pay for 2 different CPT on same date of visit? (insurance company in this case is United UHC)

Also, should one collect a copay for ppd visit & /or when patient comes back for reading? What is the right way to do this...is the ppd visit considered an office visit..99211 or 99212?

I appreciate your help on this one!

Nita

-- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD

ph fax

January 21, 2009

<<you are entitled to

a 99211 for the reading if you actually have to read it and sign off on it

being negative.>>It should not be 99211If a doctor even looks at patient---ie anything more than a nurse and nurse only visit-- can be 99212+of course you can do non-nurse workwhy would I want to not code as good as possible?

When I am reading PPD, I am investing my time and I am using a skill that took time, effort and certain qualification to acquireI should be paid for that.I would code PPD reading as 99212History- did you have any trouble, does it itch, did it change red in color, did you apply any cosmetic/medication/chemical on it

exam- reading PPda/p- straight complexityor simply-- 5 of 10 minutes spent on c/c at this visit--- this is unlikely to be truthful so I would avoid it***************************once I had my garbage disposal choked and I had no idea

plumber came and push the reset button and voila .......... it started workingso he charges me 75$ PLUS sales tax PLUS gas surcharge (gas rates were up in those days)WHY DO WE DOCTORS UNDERSELL OURSELVES?

what is wrong with getting paid for our effort?If we are not being paid well, we are creating a situation which discourages future students to come to medical profession.who will take care of me when I am old?

January 21, 2009

OK, my

turn

The cost of a ppd

in my office is less than the cost of most co-pays, so then things can get

confusing through insurance. For example, if her copay

is $20 and UHC allowable is $12.50, then you owe the patient back $7.50. As you

can see, things get complex fast. I would place the ppd

on the same day I did the skin biopsy with the separate code gave, collect

one co-pay, follow up the patient in 48 hours for free reading, and then accept

whatever pittance UHC threw in my direction. Losing a patient over $10 is not

worth it.

Re:

[Practiceimprovemen t1] (unknown)

Have her come in for PPD placement,

but don't charge copay for that.

Come another time for the skin

biopsy.

I often may have pt come back for

immunization later, like a flu shot I wouldn't charge the copay just for that.

Matt in Western PA

[Practiceimprovemen t1] (unknown)

Dear all,

I have an established patient coming in for a skin

lesion removal in a few wks.. She called stating that she needs a ppd placed

for Tb testing and wanted to get both, the skin procedure and ppd placement

done at same visit to avoid 2 copays. This is my first ppd placement in my new

practice and I was wondering..

Do insurance companies pay for 2 different CPT on same

date of visit? (insurance company in this case is United UHC)

Also, should one collect a copay for ppd visit & /or

when patient comes back for reading? What is the right way to do this...is the

ppd visit considered an office visit..99211 or 99212?

I appreciate your help on this one!

Nita

--

If you are a patient please allow up to 24 hours for a reply by email/

please note the new email address.

Remember that e-mail may not be entirely secure/

MD

ph fax

January 21, 2009

ok I did not know about 86580Can I do this;If it is likely to be covered by insurance-- do an E/M visit and place PPD..... E/M is needed b/c I need to evaluate if py has had previous TB, or exposure, pt's nationality, travel, where he lived.......... etc

then reading also requires some brain activity.if it is not covered by insurance--- I will go with 86580

January 21, 2009

There have been a lot of discussion on this on the AAFP

listservs. Official answer:

Q What is

the correct ICD-9 code for the purified protein derivative (PPD) skin test, CPT

code 86580?

A ICD-9 code V74.1 represents a special screening

examination for pulmonary tuberculosis, including diagnostic skin testing for

the disease. Often code V70.5, " Health examination of defined

subpopulations, " may be a secondary diagnosis to indicate the test is

performed as part of a pre-employment or occupational health examination.

Additional ICD-9 codes may be reported to indicate the patient's risk for

tuberculosis. For example, report V01.1 for " Contact with or exposure to

tuberculosis, " 042 for HIV infection or 793.1 for " Nonspecific

abnormal findings of radiological and other examination of the lung

field. "

Remember that when a patient returns for the PPD reading, even when the

reading is done by a nurse working incident to your services, you may report

code 99211 for this evaluation and management (E/M) service.

In the

past. I did not bill for the reading, I assumed it was part of the 86580

code. But when I learned I am entitled and expected to bill for the

reading, I started doing it. It is a 99211. You could make it a

99215 if you want to but you don’t need to. None of those questions

matter (did it itch, change color, etc). The only thing that matters is

how it “feels” (not even looks) at 48-72 hours. Of course if

it is positive or questionable then it turns into more than a 1 minute. “Looks

good here is your form” and you code appropriately. I bill a 99211

for anything the nurse would do if I had a nurse.

I also think

it’s important to bill for the reading as the reimbursement for the 86580

does not cover the cost of the vial. I think you have to do 5 PPDs to

recoup the cost of the vial and I rarely get that many requests in a 30 day

period. I believe I got lucky 10-11 and had a bunch of PPDs and actually

will recoup the cost. So the reading charge is actually important at

least break even and possibly make a little money on the procedure. It’s

not charity. Does the supermarket ever throw in a can of soup? Does

the gas station give you a can of oil with your fill-up? Or even a 12 pack of

coke. No. Yet, all the time, we are expected and we do, just throw

something in for poorly paid work to start with. I have

spoken J

In the end, we

all do what we think is right and we all do it differently.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Pawan Kumar

Sent: Wednesday, January 21, 2009 8:08 AM

To:

Subject: Re: (unknown)

<<you are entitled to a

99211 for the reading if you actually have to read it and sign off on it being

negative.>>

It should not be 99211

If a doctor even looks at patient---ie anything more than a nurse and nurse

only visit-- can be 99212+

of course you can do non-nurse work

why would I want to not code as good as possible?

When I am reading PPD, I am investing my time and I am using a skill that took

time, effort and certain qualification to acquire

I should be paid for that.

I would code PPD reading as 99212

History- did you have any trouble, does it itch, did it change red in color,

did you apply any cosmetic/medication/chemical on it

exam- reading PPd

a/p- straight complexity

or simply-- 5 of 10 minutes spent on c/c at this visit--- this is unlikely to

be truthful so I would avoid it

***************************

once I had my garbage disposal choked and I had no idea

plumber came and push the reset button and voila .......... it started working

so he charges me 75$ PLUS sales tax PLUS gas surcharge (gas rates were up in

those days)

WHY DO WE DOCTORS UNDERSELL OURSELVES?

what is wrong with getting paid for our effort?

If we are not being paid well, we are creating a situation which discourages

future students to come to medical profession.

who will take care of me when I am old?

January 21, 2009

Ok, confession time…I never really

knew you were supposed to discard the vial after 30 days…oops! (I just

tossed it when it expired). Does everyone else really toss them after 30 d? A vial

costs me $31 and I get $5-$10 from insurance per test. I do maybe 1/month. What

do you all do?

Gretchen Reis

Circleville, OH

From:

[mailto: ] On

Behalf Of Kathy Saradarian

Sent: Wednesday, January 21, 2009

8:29 AM

To:

Subject: RE:

(unknown)

There have been a lot of discussion on this on the AAFP

listservs. Official answer:

Q What is the correct

ICD-9 code for the purified protein derivative (PPD) skin test, CPT code 86580?

A ICD-9 code

V74.1 represents a special screening examination for pulmonary tuberculosis,

including diagnostic skin testing for the disease. Often code V70.5,

" Health examination of defined subpopulations, " may be a secondary

diagnosis to indicate the test is performed as part of a pre-employment or

occupational health examination. Additional ICD-9 codes may be reported to

indicate the patient's risk for tuberculosis. For example, report V01.1 for

" Contact with or exposure to tuberculosis, " 042 for HIV infection or

793.1 for " Nonspecific abnormal findings of radiological and other

examination of the lung field. "

Remember that

when a patient returns for the PPD reading, even when the reading is done by a

nurse working incident to your services, you may report code 99211 for this

evaluation and management (E/M) service.

In the

past. I did not bill for the reading, I assumed it was part of the 86580

code. But when I learned I am entitled and expected to bill for the

reading, I started doing it. It is a 99211. You could make it a

99215 if you want to but you don’t need to. None of those questions

matter (did it itch, change color, etc). The only thing that matters is

how it “feels” (not even looks) at 48-72 hours. Of course if

it is positive or questionable then it turns into more than a 1 minute.

“Looks good here is your form” and you code appropriately. I

bill a 99211 for anything the nurse would do if I had a nurse.

I also think

it’s important to bill for the reading as the reimbursement for the 86580

does not cover the cost of the vial. I think you have to do 5 PPDs to

recoup the cost of the vial and I rarely get that many requests in a 30 day

period. I believe I got lucky 10-11 and had a bunch of PPDs and actually

will recoup the cost. So the reading charge is actually important at

least break even and possibly make a little money on the procedure.

It’s not charity. Does the supermarket ever throw in a can of

soup? Does the gas station give you a can of oil with your fill-up? Or even

a 12 pack of coke. No. Yet, all the time, we are expected and we

do, just throw something in for poorly paid work to start with. I have

spoken J

In the end,

we all do what we think is right and we all do it differently.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Pawan Kumar

Sent: Wednesday, January 21, 2009

8:08 AM

To:

Subject: Re:

(unknown)

<<you are

entitled to a 99211 for the reading if you actually have to read it and sign

off on it being negative.>>

It should not be 99211

If a doctor even looks at patient---ie anything more than a nurse and nurse

only visit-- can be 99212+

of course you can do non-nurse work

why would I want to not code as good as possible?

When I am reading PPD, I am investing my time and I am using a skill that took

time, effort and certain qualification to acquire

I should be paid for that.

I would code PPD reading as 99212

History- did you have any trouble, does it itch, did it change red in color,

did you apply any cosmetic/medication/chemical on it

exam- reading PPd

a/p- straight complexity

or simply-- 5 of 10 minutes spent on c/c at this visit--- this is unlikely to

be truthful so I would avoid it

***************************

once I had my garbage disposal choked and I had no idea

plumber came and push the reset button and voila .......... it started working

so he charges me 75$ PLUS sales tax PLUS gas surcharge (gas rates were up in

those days)

WHY DO WE DOCTORS UNDERSELL OURSELVES?

what is wrong with getting paid for our effort?

If we are not being paid well, we are creating a situation which discourages

future students to come to medical profession.

who will take care of me when I am old?

January 21, 2009

Yeah, bummer. Right. I really discard the vial in

30ish days. I will sometimes stretch to 32.

I try not to do them and then try to find a reason to do many of

them once a vial is open. But mostly, we lose money. Just another

thing we lose money on.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Gretchen Reis

MD

Sent: Wednesday, January 21, 2009 11:59 AM

To:

Subject: RE: (unknown)

Ok,

confession time…I never really knew you were supposed to discard the vial

after 30 days…oops! (I just tossed it when it expired). Does everyone

else really toss them after 30 d? A vial costs me $31 and I get $5-$10 from

insurance per test. I do maybe 1/month. What do you all do?

Gretchen Reis

Circleville, OH

From:

[mailto: ] On Behalf Of Kathy Saradarian

Sent: Wednesday, January 21, 2009 8:29 AM

To:

Subject: RE: (unknown)

There have been a lot of discussion on

this on the AAFP listservs. Official answer:

Q What is the correct ICD-9

code for the purified protein derivative (PPD) skin test, CPT code 86580?

A

ICD-9 code V74.1 represents a special screening examination for pulmonary

tuberculosis, including diagnostic skin testing for the disease. Often code

V70.5, " Health examination of defined subpopulations, " may be a

secondary diagnosis to indicate the test is performed as part of a

pre-employment or occupational health examination. Additional ICD-9 codes may

be reported to indicate the patient's risk for tuberculosis. For example,

report V01.1 for " Contact with or exposure to tuberculosis, " 042 for

HIV infection or 793.1 for " Nonspecific abnormal findings of radiological

and other examination of the lung field. "