, please help to check the billing/coding rules

January 13, 2010

Dear ,Thank you for your strong support to help to get my IMP off the groud. I am getting ready to submit claims.Could you please confirm that the following is correct:1. when bill EM office visit with a physical, use -25 with 99214, not with the physical code for the age of pt2. when bill 99354 (prolonged visit) in addition to 99214, no modifier is needed3. in house labs strep, UA, glucose, EKG done during OV don't need modifier (one other biller told em taht I do need -25 for glucose finger stick check, which one is correct?).4. These done during OV need -25 : anoscopic exam, cerumen removal, trigger point injection, peak flow, skin lesion removal procedures5. These done during ov don't need -25: vaccine 9Which box on the form 1500 do I put in vaccine code and where to put in the administration of vac code?6 B12 shot- no modifier when done without OV, yes to use -125 if done with OV.7. When and how to use -59?8. How to client bill the labs with and without OV?Thank you very much in deed for your kind help.HelenTo: From: karen.oaktree@...Date: Tue, 12 Jan 2010 16:56:10 -0800Subject: RE: Re: PQRI

Here is what we code (Internal Medicine

office), for anyone who’s interested:

e-RX: (2% bonus from CMS this year and

next, 1% penalty starting in 2011)

G8443 – rx electronically submitted (note that this means that you sent

the rx electronically, not just generated from your EMR)

G8445 – no rx’s generated

G8446 – rx prescribed, but not electronically submitted

EMR: (this is what will eventually partially qualify

you for being eligible for stimulus package money)

G8447 – Encounter done on CCHIT Certified HER

G8448 – Encounter done on non-CCHIT Certified EHR

For PQRI, Steve is reporting on LDL, BP, and A1C’s for

diabetics, antiplatelet therapy for CAD and the measure for osteoporosis.

For all measures, if the patient is “not eligible” (I’m not

sure what that exactly means – it’s his note to himself), then you

use a modifier 8P. There are many other options, you need to review them

on the CMS website and decide for yourself which ones are the easiest for you

to submit. The codes are:

DM – reported once per year per patient:

3044F

– A1C <7

3045F

– A1C 7-9

3046F

– A1C >9

DM – reported once per year per patient:

3048F

– LDL <100

3049F

– LDL 100-129

3049F

– LDL 130+

DM – BP (reported every time)

3074F

– sbp <130

3075F

– sbp 130-139

3076F

– sbp 140+

3078F

– dbp <80

3079F

– dbp 80-89

3080F

– dbp 90+

2000F-8P

– BP not done

CAD (aspirin, Plavix, or depyridamole) – Note that other

providers might freak out when they see 4011F-1P because it may print out on

the note as “oral antiplatelet prescribed”, when the modifier -1P

is stating that it wasn’t prescribed

4011F –

oral antiplatelet prescribed

Mod -1P –

Not done for medical reason

Mod -2P

– Not done for patient reason

Mod -3P

– not done for system reason

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Pratt

Sent: Tuesday, January 12, 2010

4:43 PM

To:

Subject: RE:

Re: PQRI

Let me find it….I posted it to the list earlier (or maybe I

just sent it to someone).

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From:

[mailto: ]

On Behalf Of Myria

Sent: Tuesday, January 12, 2010

4:22 PM

To:

Subject: Re:

Re: PQRI

Can I get

copy of the cheat sheet?

From: Pratt <karen.oaktreecomcast (DOT) net>

To:

Sent: Tue, January 12, 2010

2:01:29 PM

Subject: RE:

Re: PQRI

I would recommend claims-based reporting for 2010, since

we’re at the beginning of the year. It takes very little time to

add the codes to your outbound claims and is FREE. Steve has a cheat

sheet on his desk with about 20 or 30 codes on it; he simply adds the code at

the end of the visit and it goes out on the claim for that visit.

I’d estimate it takes him less than 30 seconds per patient to do

this. That’s a maximum amount of time spent of 15 minutes per 30

patients.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.

info

From: Practiceimprovement 1yahoogroups (DOT) com [mailto:

Practiceimprovement 1yahoogroups (DOT) com ] On

Behalf Of Will Conner

Sent: Tuesday, January 12, 2010

6:56 AM

To: Practiceimprovement

1yahoogroups (DOT) com

Subject: RE: [Practiceimprovemen

t1] Re: PQRI

Can we do this without paying a fee when we use the AAFP or AFM

web-site?

J. Conner,

M.D.

211 West s St

s, N.C.

28105

Note: Privileged/confiden tial information may be contained in this

message and may be subject to legal privilege. Access to this e-mail by anyone other

than the intended is unauthorised. If you are not the intended recipient (or

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take any action in reliance on it. In such case, you should destroy this

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please notify us immediately by e-mail or telephone and delete the e-mail from

any computer.

From: Practiceimprovement 1yahoogroups (DOT) com [mailto:

Practiceimp rovement1@ yahoogroups. com ] On

Behalf Of

Sent: Tuesday, January 12, 2010

8:55 AM

To: Practiceimprovement

1yahoogroups (DOT) com

Subject: Re: [Practiceimprovemen

t1] Re: PQRI

thanks

I am working my way up to this . I remember Gordon tried to

introduce the first IMPs to doc Site. Does doc site provide Valium?

Will you need extra visits with RAmona when I complain? AH this could

be good for Ramona if I do PQRI!

Jean

On Tue, Jan 12,

2010 at 8:50 AM, Haughton MD, MS <jhaughtondocsite (DOT) com>

wrote:

is right – it appears that PQRI (and its ability to report

structured clinical data – either directly or as numerator / denominator

info is a key part of health reform / payment reform – paying based on

quality, cost [ risk adjusted expected vs observed gainsharing on top of fee

for service? ] and patient satisfaction – which should put the IMP

practices in good stead (vs current system of paying fully for volume of

service).

Regarding my offer for PQRI @ $250 a user and trust and is it

worth it:

1) Ramona

Seidel is my physician

2) I’ve

been working with Gordon and others for about a dozen years, trying to

make scalable quality healthcare a reality

3) Some

IMPs have used docSite’s old system – its registry (which is a

core, core part of our current and ongoing offering that can augment an EMR/

EHR or act as an EMR/EHR for meaningful use payments)

Regarding is PQRI worth it – If you don’t have about

$50,000 of medicare billing, it really may not be worth the hassle. BUT,

whether through AAFP (for Diabetes) or DocSite (for prevention or diabetes or

other) or another program (there are about 70 options out there this year) ---

it should take about 2 or 3 hours to accomplish the activities associated with

collecting, and submitting data on 30 consecutive patients. In

2008, we had many primary care physicians who received as much as a few

thousand $. Many received $800-$1500. Some surgeons received

as much as $15K or $20K.

In short if you are doing Diabetes – use the AAFP site. If

you are doing prevention and want to use a system run by a physician who cares

about quality, feel free to use the discount code I put in the last e-mail

ThankYou08 to make the cost $250 instead of $350.

Thanks –

Haughton MD, MS

Chair / CMO

office:

mobile:

fax:

Raleigh | polis

www.docsite. com

Don’t miss the opportunity to earn

a bonus payment of up to 2% of your total allowed Medicare charges from 2009!

DocSite PQRI makes it simple – click here to learn more.

--

PATIENTS,please remember email may not be entirely secure and that Email is

part of the medical record and is placed into the chart ( be careful what

you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the

matter is more urgent .

MD

115 Mt

Blue Circle

Farmington

ME 04938

ph fax

impcenter.org

Hotmail: Trusted email with Microsoft’s powerful SPAM protection. Sign up now.

January 13, 2010

Helen, See responses below:

Beth

Sullivan, DO

Ridgeway

Family Practice

Commerce,

GA 30529

From:

[mailto: ] On Behalf Of Helen Yang

Sent: Tuesday, January 12, 2010 11:19 PM

To: practiceimprovement1

Subject: , please help to check the billing/coding

rules

Dear ,

Thank you for your strong support to help to get my IMP off the groud. I am

getting ready to submit claims.

Could you please confirm that the following is correct:

1. when bill EM office visit with a physical, use -25 with 99214, not with the

physical code for the age of pt

[beth Sullivan, DO] The E & M billed

with an preventative visit code would get a -25 modifier. The level of the

E & M code would be based on the additional services needed to document the

separately identifiable part of the total exam. Most coders agree that in

order to meet the separately identifiable E & M service a separate note or at

least a clearly separate area on the consolidated progress note is needed.

This clearly demarcates the separate service.

2. when bill 99354 (prolonged visit) in addition to 99214, no modifier is

needed

[beth Sullivan, DO] This is correct.

Make sure the time needed for face to face contact with the patient as well as

a clear indication of what the patient was counseled on during the additional

time in order to be able to bill the extended visit code.

3. in house labs strep, UA, glucose, EKG done during OV don't need

modifier (one other biller told em taht I do need -25 for glucose finger

stick check, which one is correct?).

[beth Sullivan, DO] Most in house labs do

not need a 25 modifier. Some payers including Medicare in particular require a

25 modifier on the E & M when billing for an EKG. If your practice is located

in a PSA or a HPSA the professional and technical component of the EKG service

must be unbundled and billed separately. In other words, normally an EKG is

billed with code 93000 but in HPSA or PSA MUA then when you bill Medicare or

Medicare Advantage plans for the EKG service it has to be billed as 93005 &

93010 on separate lines to fully describe the service provided.

4. These done during OV need -25 : anoscopic exam, cerumen removal, trigger

point injection, peak flow, skin lesion removal procedures

[beth Sullivan, DO] Peak Flows are not

separately reimbursable and neither are pulse oximetry readings when billed

with an office visit. If more than one additional procedure is done on the same

day as an office E & M than the lower priced additional procedure would get a

59 modifier. Cerumen removal must be a manual hands on procedure performed by

the physician. Simply flushing cerumen is not a separately billable procedure

and is bundled in to the E & M code. However if a manual disimpaction is

performed with a ear scoop or other instrument and a separate note detailing

the procedure is written then a separate cerumen impaction removal code can be

billed. A 25 modifier would be needed in this case. Medicare does not

recognize a cerumen impaction removal done on the same date of service as a

office E & M and will bundle the procedure with whatever E & M is billed.

I generally schedule a separate visit following the E & M where the cerumen

impaction is identified, to remove the impaction manually and that is the only

service billed.

5. These done during ov don't need -25: vaccine 9Which box on the form

1500 do I put in vaccine code and where to put in the administration of vac

code?

[beth Sullivan, DO] The vaccine code is

billed on one line of the 1500 with the appropriate V code for the vaccine

administered. The administration code is billed on another line of the 1500

with the same diagnosis as the associated vaccine. If more than 2 pediatric

vaccines are given to patients under age 8 than each additional admin code will

need a 59 modifier to delineate that it is separate from the other ones billed

for other vaccines given that day. For adults the same is true if 2 or more

vaccines are given on the same day. A 25 modifier will be needed if vaccines

are given on a day where another E & M service is provided whether it is a

preventative visit or a regular office visit.

6 B12 shot- no modifier when done without OV, yes to use -125 if done with OV.

[beth Sullivan, DO] Any injection done in

conjunction with an E & M service will require a 25 modifier on the E & M

service. Watch out for medications on the self Injectable list as these are

ones that Medicare and other insurers consider to be self Injectable and will

not be paid for when given at the office, If more than 1 injection is provided

on a given DOS the 59 modifier rule explained above in terms of multiple

vaccine administration codes is applicable.

7. When and how to use -59?

[beth Sullivan, DO] See above and also

review the documents attached to this email for more detailed information on

the use of the 59 modifier and other important modifiers needed when billing

for services in the office.

Labs repeated on the same DOS are coded

with different modifiers than other procedures and I attached a handout about

this as well. In addition to the already covered modifiers don’t forget

the QW for Clia waived tests. I can send you the latest list of waived tests if

this would help or you can download it from the CMS website.

[beth Sullivan, DO] 59

8. How to client bill the labs with and without OV?

[beth Sullivan, DO] Not sure what you

mean by client bill the labs

Thank you very much in deed for your kind help.

Helen

[beth Sullivan, DO] If you have any other

questions feel free to ask. I also have several other coding handouts I have acquired

over the years since I took my first CPT coding class while studying to get my

CPC certification. If you want I can send some of these to you as well.

To:

From: karen.oaktree@...

Date: Tue, 12 Jan 2010 16:56:10 -0800

Subject: RE: Re: PQRI

Here is what we code (Internal Medicine office), for anyone

who’s interested:

e-RX: (2% bonus from CMS this year and

next, 1% penalty starting in 2011)

G8443 – rx electronically submitted (note that this means that you sent

the rx electronically, not just generated from your EMR)

G8445 – no rx’s generated

G8446 – rx prescribed, but not electronically submitted

EMR: (this is what will eventually partially

qualify you for being eligible for stimulus package money)

G8447 – Encounter done on CCHIT Certified HER

G8448 – Encounter done on non-CCHIT Certified EHR

For PQRI, Steve

is reporting on LDL, BP, and A1C’s for diabetics, antiplatelet therapy

for CAD and the measure for osteoporosis. For all measures, if the

patient is “not eligible” (I’m not sure what that exactly

means – it’s his note to himself), then you use a modifier 8P.

There are many other options, you need to review them on the CMS website

and decide for yourself which ones are the easiest for you to submit. The codes

are:

DM –

reported once per year per patient:

3044F

– A1C <7

3045F

– A1C 7-9

3046F

– A1C >9

DM –

reported once per year per patient:

3048F

– LDL <100

3049F

– LDL 100-129

3049F

– LDL 130+

DM – BP

(reported every time)

3074F

– sbp <130

3075F

– sbp 130-139

3076F

– sbp 140+

3078F

– dbp <80

3079F

– dbp 80-89

3080F

– dbp 90+

2000F-8P

– BP not done

CAD (aspirin,

Plavix, or depyridamole) – Note that other providers might freak out when

they see 4011F-1P because it may print out on the note as “oral

antiplatelet prescribed”, when the modifier -1P is stating that it

wasn’t prescribed

4011F –

oral antiplatelet prescribed

Mod -1P –

Not done for medical reason

Mod -2P

– Not done for patient reason

Mod -3P

– not done for system reason

Pratt

Office Manager

Oak Tree

Internal Medicine P.C

www.prattmd.info

From:

[mailto: ] On Behalf Of Pratt

Sent: Tuesday, January 12, 2010 4:43 PM

To:

Subject: RE: Re: PQRI

Let me find it….I posted it to the list earlier (or maybe I

just sent it to someone).

Pratt

Office Manager

Oak Tree

Internal Medicine P.C

www.prattmd.info

From:

[mailto: ] On Behalf Of Myria

Sent: Tuesday, January 12, 2010 4:22 PM

To:

Subject: Re: Re: PQRI

Can I get copy of the cheat sheet?

From: Pratt

To:

Sent: Tue, January 12, 2010 2:01:29 PM

Subject: RE: Re: PQRI

I would recommend claims-based reporting for 2010, since

we’re at the beginning of the year. It takes very little time to

add the codes to your outbound claims and is FREE. Steve has a cheat

sheet on his desk with about 20 or 30 codes on it; he simply adds the code at

the end of the visit and it goes out on the claim for that visit.

I’d estimate it takes him less than 30 seconds per patient to do

this. That’s a maximum amount of time spent of 15 minutes per 30

patients.

Pratt

Office Manager

Oak Tree

Internal Medicine P.C

www.prattmd. info

From: Practiceimprovement

1yahoogroups (DOT) com [mailto: Practiceimprovement 1yahoogroups (DOT) com ] On

Behalf Of Will Conner

Sent: Tuesday, January 12, 2010 6:56 AM

To: Practiceimprovement 1yahoogroups (DOT) com

Subject: RE: [Practiceimprovemen t1] Re: PQRI

Can we do this without paying a fee when we use the AAFP or AFM

web-site?

J. Conner, M.D.

211 West s St

s, N.C. 28105

Note:

Privileged/confiden tial information may be contained in this message and may

be subject to legal privilege. Access to this e-mail by anyone other than the

intended is unauthorised. If you are not the intended recipient (or responsible

for delivery of the message to such person), you may not use, copy, distribute

or deliver to anyone this message (or any part of its contents ) or take any

action in reliance on it. In such case, you should destroy this message, and

notify us immediately. If you have received this e-mail in error, please notify

us immediately by e-mail or telephone and delete the e-mail from any computer.

From: Practiceimprovement

1yahoogroups (DOT) com [mailto: Practiceimp rovement1@ yahoogroups. com ] On

Behalf Of

Sent: Tuesday, January 12, 2010 8:55 AM

To: Practiceimprovement 1yahoogroups (DOT) com

Subject: Re: [Practiceimprovemen t1] Re: PQRI

thanks I am working my way up to this . I

remember Gordon tried to introduce the first IMPs to doc Site. Does doc site

provide Valium? Will you need extra visits with RAmona when I

complain? AH this could be good for Ramona if I do PQRI!

Jean

On Tue, Jan 12, 2010 at 8:50 AM, Haughton MD, MS

wrote:

is right – it appears that PQRI (and its

ability to report structured clinical data – either directly or as

numerator / denominator info is a key part of health reform / payment reform

– paying based on quality, cost [ risk adjusted expected vs observed

gainsharing on top of fee for service? ] and patient satisfaction –

which should put the IMP practices in good stead (vs current system of paying

fully for volume of service).

Regarding my offer for PQRI @ $250 a user and trust

and is it worth it:

1) Ramona

Seidel is my physician

2) I’ve

been working with Gordon and others for about a dozen years, trying to

make scalable quality healthcare a reality

3) Some

IMPs have used docSite’s old system – its registry (which is a

core, core part of our current and ongoing offering that can augment an EMR/

EHR or act as an EMR/EHR for meaningful use payments)

Regarding is PQRI worth it – If you don’t

have about $50,000 of medicare billing, it really may not be worth the

hassle. BUT, whether through AAFP (for Diabetes) or DocSite (for

prevention or diabetes or other) or another program (there are about 70 options

out there this year) --- it should take about 2 or 3 hours to accomplish the

activities associated with collecting, and submitting data on 30 consecutive

patients. In 2008, we had many primary care physicians who received

as much as a few thousand $. Many received $800-$1500. Some

surgeons received as much as $15K or $20K.

In short if you are doing Diabetes – use the AAFP

site. If you are doing prevention and want to use a system run by a

physician who cares about quality, feel free to use the discount code I put in

the last e-mail ThankYou08 to make the cost $250 instead of $350.

Thanks –

Haughton MD, MS

Chair / CMO

office:

mobile:

fax:

Raleigh | polis

www.docsite. com

Don’t

miss the opportunity to earn a bonus payment of up to 2% of your total allowed

Medicare charges from 2009!

DocSite PQRI

makes it simple – click here to learn more.

--

PATIENTS,please remember email may not be entirely secure and that Email is

part of the medical record and is placed into the chart ( be careful what

you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the

matter is more urgent .

MD

ph fax

impcenter.org

Hotmail: Trusted email with Microsoft’s powerful SPAM

protection. Sign up now.

6 of 6 File(s)

E&M minor surg proc. coding.pdf

M odifiers-Using Wisely.pdf

modifier59.pdf

59 decision tree.doc

Modifier_25_51_59_04-22-05.pdf

Modifiers.pdf

January 13, 2010

Helen just watch out for cerumen removalCerumen removal coding is extra points on t he billing trivia examIF THEY HAVE MEDICARE it is a no n ono to do cerumen removal and anythign else at the same time( and b epaid) Heaven knows who invented that one

It is after all MUCH better for elderly frail folks with hearing aids and accumulated wax to call their daughteranother time and come out again and buy more gas and the daughter h as to take more time off work or gather up her babies and fire up the stroller and diaper bag and crackers and other take the baby out parapharnalia and find parking etc etc to bring mom in agian becasue when mom came in last week for her physical which of course medicare does not allow but mom wants and or anything else, one can look but not touch the cerumen

Got tha?t Cerumen and medicare--separete visits NO modifiers allowedCerumen and nonmedicare- sure -25.Now please compare and contrast par , non par, and opted out. YOu have 3 lines and 15minutes(No cheating off MEgan)

SIghjean

Dear ,Thank you for your strong support to help to get my IMP off the groud. I am getting ready to submit claims.Could you please confirm that the following is correct:1. when bill EM office visit with a physical, use -25 with 99214, not with the physical code for the age of pt

2. when bill 99354 (prolonged visit) in addition to 99214, no modifier is needed3. in house labs strep, UA, glucose, EKG done during OV don't need modifier (one other biller told em taht I do need -25 for glucose finger stick check, which one is correct?).

4. These done during OV need -25 : anoscopic exam, cerumen removal, trigger point injection, peak flow, skin lesion removal procedures5. These done during ov don't need -25: vaccine 9Which box on the form 1500 do I put in vaccine code and where to put in the administration of vac code?

6 B12 shot- no modifier when done without OV, yes to use -125 if done with OV.7. When and how to use -59?8. How to client bill the labs with and without OV?Thank you very much in deed for your kind help.

HelenTo: From: karen.oaktree@...

Date: Tue, 12 Jan 2010 16:56:10 -0800Subject: RE: Re: PQRI