Family Planning Modifier
Q: We get denials when we use the 96372 code for the administration of Depo-Provera. Can we just use a 99211 instead?
A: You could be getting denials on these because you are not using the family planning modifier, which is required by some payers. The provider manual for one payer states that "CPT procedure code 96372 (therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular) was a new code effective with date of service January 1, 2009. The FP (family planning) modifier is allowed with this code. However, some claims have been denied with a denial code that states 'Claim includes family planning diagnosis and no family planning procedure.' Please resubmit with family planning procedure/modifier or correct the diagnosis." Watch those Level II HCPCS modifiers.
Q: If a NPP sees a new problem on one Medicare patient and bills under the NPP's own ID, then continues management on the next visit following the physician's plan outlined in the previous visit, would the billing be incident-to in the second visit but not the first visit? Is it OK to go back and forth depending on the situation on the same day?
A: Yes. Although the regulatory side would not express it that way, (that it's OK to go back and forth on the same day), that is what the regulations come down to if you have the requisite oversight in the incident-to version.
For a new problem, use the NPP NPI and direct bill. For an established problem with oversight, use the MD NPI and bill in the physician's name. Good distinction!
There has been discussion among carriers and regulators that once a NPP is using his own number, they should not have to pay for the incident-to version, but as long as the incident-to policy is in effect, what you describe is allowed.
Coding for Multiple Services
Q: When I bill an E&M visit along with an AWV, I have been getting some patient complaints about the two charges — even though Medicare patients don't pay anything on the AWV. Complaints worsen when I bill a regular 99395 or 99396 to a commercial insurer in addition to an E&M office visit. I thought this was allowed. What am I missing here? I'm really getting some upset patients.
A: If you are billing two codes because you are performing two distinct services then you are doing this correctly. But don't forget to include the patient in the discussion.
It is really most efficient to combine an AWV for a Medicare patient with a scheduled chronic disease follow-up visit. In fact, some Medicare patients seem disturbed when they show up for an AWV and discover that there is no exam component. Patients like to have someone "kick all the tires" every once in a while.
But to avoid any confusion, be sure to state upfront what the nature of the visit is. State that two services are being provided. Tell the patient, "You are here today for the AWV and management/assessment of X."
You will of course document the history, exam, and decision making associated with the problem and outline the elements addressed for the AWV.
If you communicate this well during the encounter you will have fewer problems later. Some practices design work flows so that office or nursing staff participates in "prepping" the patient for the "what we are doing today" conversation. But in the end, the provider really should confirm or restate the services that will be provided.
This can be more difficult for commercial plans when using the 99381-99397 preventive codes along with an E&M. Not all plans cover both codes on the same day and this will surely get a rise out of patients.
In this case, it is more important to check the patient's coverage when the visit seems likely to be one in which multiple services will be provided. But again, the key to avoiding the phone calls and upsets is communicating along the way what you are doing.
The trickiest visit of this sort is when it starts as a well visit only, and a finding is made either on examination or as a result of the ROS which then requires significant problem management. In this case, a problem crops up unexpectedly and no one — neither you nor the patient — was expecting two types of codes.
Once more, the best course is likely to communicate with the patient that you need to account for the tests ordered and work done and that there will be a problem-management component to this visit.
A best practice is to post a policy or guide to combination visits somewhere in the office where patients can see it. No surprises is the goal.
Modifiers and Bundled Codes
Q: I recently started working at an orthopedic practice and I am working on denied claims. I have come across several claims that have been billed with CPT codes 29881 and 29877-59. Different payers are denying the claims stating the payment for 29877 is included with the primary code, even though modifier 59 was used. Is this correct?
A: The first place you should refer to is to CCI. You'll see that 29887 is a Column II component of 29881. The modifier indicator is "0" — which tells you that no modifier will break the edit.
The modifier you would likely have used is 59, but even that won't work here. Modifier 59 will break bundling edits in some cases, when indicated by the CCI tables, but it isn't fairy dust!
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at [email protected] or [email protected].
This article originally appeared in the April 2012 issue of Physicians Practice.