HCA
Session II
Preventative Medicine Visits
Procedures
Modifiers
Preventative Medicine Visits
CPT Code 99381-87 (new)
99291-97 (est)
Preventative Medicine Visit Codes include payment for:
 The review of “stable” chronic problems
 Routine Screenings (eg. Pap smear, breast & pelvic, manual
rectal exam)
 Risk Factor Counseling
Billable Separately When Billed on Same Day as Physical are:
 99211-99215 E&M Office Visit codes (for re-management of
existing problems or new problems (need mod 25)
 Injections, Immunizations
 Procedures Performed (exception Medicaid – they will only pay
for procedure)
 Some Screenings
 Labs (Indicate signs/symptoms or diagnosis to support testing)
Preventative Medicine Visits
continued
Dx Codes: V70.0 (well adult) V72.31 (Gyn w/or w/o Pap)
Medicare




Effective 1/1/05 MC will pay physical / new MC enrollee /
within 6 mths G0344
Also: G0366: EKG (global) G0367 (EKG tracking only)
G0368 (EKG Inter & Rep Only)
Medicare does not pay for routine annual physicals (9938187; 99391-97)
Medicare will pay for 99211-99215 services (eg. medically
necessary follow- up or new problems) billed w/physicals.
Mod 25 needs to be affixed to 99211-15 codes.
Preventative Medicine Visits
continued
HMOBlue/HPHC/TUFTS/Medicaid



Will pay for physicals.
They will also pay for 99211-99215 services billed with a
physical.
Affix Mod 25 on 99211-15 codes.
Exception Medicaid– pays for physical Only - No E&M in same day.
Exception Bc/Bs PPO Plans– Physical Coverage is on “age schedule”
Preventative Medicine Visits
Re: Screenings
Medicare will pay for “ Screenings” billed in conjunction with a
Physical Examination. HmoBlue/Tufts/Hphc/Medicaid do not
pay for some screenings (*) billed w/a physical. However, they
will always pay when billed with an E&M code (99211-99215) or
when billed by itself.
*Q0091:
*G0101:
*G0102:
G0107:
79095:
G0104:
G0105:
G0120:
G0202:
Pap Smear Collection (Medicaid X8012)
Breast & Pelvic Screening (7-11 areas of GU system)
Manual Rectal Examination
Blood Occult (Use 82270 only when there are
signs/symptoms)
Bone Density (Heel)
Low Risk Flex Sig
High Risk Flex Sig
Barium Enema
Screening Mammography
Preventative Medicine Visits
Re: Screenings
Q0091: Pap Smear Collection (Annual f/High Risk; every other yr f/ Low
Risk) Not reimburseable when billed w/physical.
X8012: Medicaid pap smear collection code
Diagnosis Code:
V76.47
V72.32
V76.2
V15.89
Special Screening for Malignant Neoplasms; Vagina – No
previous history of any abnormalities.
Abnormal Pap Smear (abn pap 3 mths back, redid pap –
normal; this visit is f/u visit – 3rd visit)
Low Risk of Malignant Neoplasm – History of abnormal paps.
High Risk of Malignant Neoplasm – 7 or more sexual partners in
lifetime, Hx of STD, 3+ abn paps in 7 yrs, colposcopy, CA dx.)
Preventative Medicine Visits
Re: Screenings
G0101: Breast & Pelvic Screening (7 out of the 11 areas in the GU system
must be reviewed and documented.) Not reimburseable when billed
w/a managed care gyn physical. Code G0101 only if “both” the
breast & pelvic exam are performed. Coverage every 2 years.
Diagnosis Codes:
V76.2 (low risk) or V15.89 (high risk)
V76.49 Special screening for malignant neoplasms; other sites (to
indicate low risk for a patient who does not have a uterus or cervix).
Preventative Medicine Visits
Re: Screenings
G0102: Manual Rectal Examination (Not reimburseable when
billed w/managed care physical) Annual Benefit (Age
50 & over)
Diagnosis Codes:
V76.44 Special screening for malignant neoplasms, prostate
Preventative Medicine Visits
Re: Screenings
G0107: Blood Occult (Routine Screening – In absence of
signs/symptoms). Is reimburseable when billed
w/physical.
Annual Benefit
Diagnosis Code: V76.51
Use CPT 82270 when there are signs/symptoms
Preventative Medicine Visits
Re: Screenings
79095:
Bone Density Screening
Every 2 years for those at risk of “losing bone
mass”
Medicare will cover 80% of the cost of one bone mass
measurement every 2 years.
Medicare will also cover follow-up measurements
Preventative Medicine Visits
Re: Screenings
G0104: Low Risk Flex Sig
G0105: High Risk Flex Sig
G0120: Barium Enema
Flexible Sig
- once every 48 mths
- once every 24 mths
- alternative to Flex Sig / Screen
Colonoscopy
– 1 time every 4 yrs.
Colonoscopy – 1 time every 2 yrs if you are at high-risk for
colorectal cancer (e.g. have a family history of the disease or
have had colorectal polyps) or 1 time every 10 years if you are
not at high-risk (but not within 48 months Of a screening flexible
sigmoidoscopy)
Barium enema - this service is not covered if performed in addition
to the other tests
Preventative Medicine Visits
Re: Screenings
G0202 w/76083 : Screening Mammography
Annual Benefit
One screening mammogram a year for women 40 yrs & older.
One baseline mammogram for women 35 to 39 years of age.
No Part B deductible is required for these services.
Procedures
Injections
Administration Codes / Immunizations
Administration Code / Therapeutic or Dx
Administration Code / IV Infusion
Foreign Body Removal
Ear Wax Removal
EKGs
EKG Routine
90471 (1) 94072 (ea. addl)
90782 (eg. Gyn – Depo, B12)
90780 (IM) 18 new codes for
2005
69210 (hearing loss pays;
impacted cerumen does not)
93000 (mod 76 repeat)
Procedures
Lesions
Lesion / Skin Tags
11200 (up to 15)
11201 (ea. addl grp of 10)
Lesions / Common or Plantar Wart
17000 (1) plus
17003 (for ea. addl – indicate)
Example: 6 removed bill
17000 x1 and 17003 x5 = 6
Lesions / Flat Warts, Molluscum /Milia 17110 up to 14
17115 15 or more report code.
Lesion / Vulva
56501
Lesion / Vaginal
57061
Lesion / Penis (cryo)
54056
Procedures
Gyn / Contraceptive Management
Diaphragm or Cervical Cap Fitting
Insertion of IUD
Removal of IUD
Fitting and Insertion of pessary or other
intravaginal support device
Airway Management
Nebulizer Treatment
Nebulizer Treatment (subsequent)
Inhaler Instructions (teaching)
Spirometry
Bronchospasm Evaluation
57170
58300
58301
57160
94640
94640-76
94664-59
94010
94060
Procedures
Incision & Drainage ; Puncture
Incision & Drainage (abcess, cyst)
10060
Incision & Drainage of Pilonidal Cyst
Incision & Removal of Foreign Body, subcut
Incision & Drainage of Hematoma, seroma
or fluid collection
Puncture aspiration of abscess, hematoma,
bulla or cyst
10080
10120
10140
10160
Procedures
Paring/Cutting/Trimming/Excision
Paring/Cutting of benigh hyperkeratotic lesion
(corn or callus) single lesion
Paring/Cutting or benign hyperkeratotic lesion
corn/callus 2-4 lesion
Trimming of non-dystrophic nails, any #
Debridement of 1-5 nails
Debridement of 6-10 nails
Avulsion (toenail plate)
Excision of nail / nail matrix
Wedge Excision of nail fold
11055
11056
11719
11720
11721
11730
11750
11765
Procedures
Epitaxis
Control Nasal Hemorrhage, Anterior
Packing; Simple
Control Nasal Hemorrhage, Posterior
Packing, Initial
Packing, Subsequent
No Modifier is Necessary
Excisions
Excisions Lesion (trunk, arms, legs)
0.6 to 1.0cm
1.1 to 2.0cm
2.1 to 3.0cm
30901
30905
30906
Benign
11401
11402
11403
Malignant
11601
11602
11603
Procedures
Aspiration and/or Injection
20600
20605
20610
“Small Joint” , bursa or ganlion cyst (eg. fingers, toe)
“Intermediate joint”, bursa or ganglion cyst (eg.
temporomandibular, acromioclavicular, wrist, elbow or
ankle (olecranon bursa).
“Major Joint”, bursa or ganglion cyst (eg. shoulder, hip,
knee joint, subaromial bursa).
Procedures
Tendon/Ligament / Ganglion Cyst / Injections / Excisions
There must be an inflammatory process in a given tendon (tendonitis)
or tendon sheath tenosynovitis)
CPT Codes:
20526 Injection of carpal tunnel with local anes or corticosteroid
20550 Injection(s); single tendon sheath, or ligament,plantar fascia)
20551 Injection(s); single tendon origin/insertion
20612 Aspiration and/or injection of ganglion cyst(s) any location
25111 Excision of Ganglion, wrist (dorsal or volar); primary
25112 Excision of Ganglion, wrist (dorsal or valar) recurrent
Procedures
Trigger Point Injections
Use 20552 Injection(s); single or multiple trigger point(s), one or
two muscle(s) – regardless of the # of injections in those muscle
groups
Use 20553 Injection(s); single or multiple trigger point(s), three or
more muscle(s) – regardless of the # of injections within those
muscle groups
Procedures
Wound Repair
Simple Suturing
12001 simple repair scalp, neck,axillae,ext genitalia,trunk and/or
extremities (includes hands/feet) 2.5cm or less.
12011 simple repair of face, ears, eyelids, nose, lips and/or mucous
membrances 2.5cm or less.
Services Billable In Addition to E&M
Tufts, HPHC, NHP pay for the services listed below.
Medicare, Medicaid, Blues DO NOT PAY.
Bill the services below along with a 99211-99215 when applicable:
CPT
99058:
99050:
99052:
99054:
Emergency Services
Services requested after “posted hours”
Services requested between 10:00pm and 8:00am
Services requested on Sundays or Holidays
Modifiers
Modifiers are 2 digit codes which accompany a 5 digit CPT code in
order to further describe a situation to support additional payment
when more then one service is being reported in the same session
on the same day.
Primary Care Modifiers
25, 76, GE, GC
Modifier 25
Modifier –25
Should only be appended to evaluation and management (E/M)
service codes HCPCS codes G0101(Breast & Pelvic Screening)
and Procedures
You do not need a modifier 25 when billing an office visit and
also billing for:
1) Diagnostics (eg. EKG)
2) Immunizations
3) Screenings
Modifier 25 Examples
Modifier 25 Examples
1) When the patient presents for a planned procedure and has
a different problem that requires an E/M service (two different
diagnoses would be used to distinguish the services)
2) the patient presents with a "minor" problem and after
evaluation the decision is made to perform a procedure. In the
second example –25 is used if the procedure is minor in nature,
meaning that the post-operative period is less than 90 days
and the primary diagnosis would be the same for both.
Modifier 76
Modifier 76
Use modifier 76 when you repeat a service already performed
with the same diagnosis code within a 30 day period.
Example: Chest pain order EKG 93000 and did a repeat 2
wks later same diagnosis “ chest pain” – affix modifier 76 on
93000.