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Rearranging Codes by Cost; Time-based Codes; Multiple Payment Reductions


Coding questions? We've got the answers

Editor's Note: This article was updated on Jan. 25, 2012 to correct information in the "Time-based codes" section referring a new paragraph and counseling time. A previous version of the text referred to the counseling time as "five minutes;" it now is correct in stating "25 minutes."

Rearranging Codes by Cost

Q: We always rearrange the codes to make sure the pediatric vaccines we give are listed in order of cost. Is this really necessary?

A: It shouldn’t be necessary - these are supplies and not normally subject to multiple procedure payment reduction formulas.

Time-based Codes

Q: I hear there is a major change in the way time is counted in terms of counseling and coordination of care, but I can’t find it in the CPT manual?

A: What you are likely referring to is a new paragraph added to the CPT 2011 Professional Edition, Page XII, that covers time-based codes. This is a little odd because there is already a section of the E&M guidelines that details time-based codes. The placement of the text in the introduction indicates its terms apply to all time-based codes - regardless of where they appear in the rest of the manual.

Much of this section of the introduction echoes time concepts we have heard before, midpoints and the like. But there is one sentence here that could have considerable impact on primary care when applied to E&M codes in certain circumstances.

The sentence reads: “When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used.”
The two areas of the CPT manual which meet this criterion (they include significant numbers of codes ranked in sequential times) are the E&M codes section and the psychotherapy codes section. The E&M code descriptions - at least for the standard office, inpatient, and consult codes - use the term “typical times.” The psychotherapy codes do not.

The new text in the introduction seems to say that if the actual time of a visit is, say 35 minutes, and you spent 25 minutes of this time counseling (let’s use the example of established outpatient visit codes), then the correct code is 99215.

The “typical time” for a 99214 is 25 minutes. The “typical time” for a 99215 is 40 minutes. So based on the new text, if the actual time is 35 minutes, and the counseling by time criteria is met for that (more than half the time would be 18 minutes), then you have a 99215 based on counseling with a 35-minute total visit.

Cutting this closer, you could qualify for a 99215 at 33 minutes, with 17 minutes of that time spent counseling.

Not many people think this precisely about time, but in some cases it is a smart move. The traditional approach, or really the only one we’ve had to date based on the rules as written, stated that if the total encounter time was not 40 minutes, you weren’t in 99215 country even if you spent all 35 minutes counseling. That visit would default to the lesser 99214 time of 25 minutes.

This new sentence changes all of that. Think about it.

Multiple Payment Reductions

Q: I read your article about the correct use of modifier 59 and have a question about payments. If the modifier is used correctly and documentation supports it, is the payment subject to a multiple-procedure payment reduction? I have a provider who is insisting since he performed the same procedure on multiple digits, he should be paid at 100 percent of the Medicare fee schedule (which is how we base our payments), and he says he should not be subject to a cascading payment allowance. I know this could be a carrier policy, but can you identify any documentation that Medicare may have on this regarding how it pays?

A: The intent of modifier 59 is to prevent the multiple payment reduction and allow each distinct procedure to be paid at 100 percent.

Look in the Medicare Physician Fee Schedule and find the procedure code that you perform in multiples. On the far right side there is a column that indicates whether or not Medicare accepts modifier 59 for this procedure. You also need to look your code up in the NCCI tables to see what other codes (including this code) are included or excluded and what modifiers can be used. That's where the code specific answers are located.

Transfer of Care

Q: I have a post-operative management coding question. CMS and Blue Cross have some documentation about a written transfer of care between physicians and the billing of a modifier 55. According to a coder I spoke with at another office, CMS and Blue Cross told her they always bill an office visit instead of the surgical codes with modifier 55, even if there is a transfer of care because the office visit will always be paid.

Should we proceed with the other office’s advice, or go with modifier 55? If we have an actual transfer of care from the other physician, aren’t we beholden to file the surgical codes with a modifier 55?

A: Although I know of no authority on this specific issue, it would seem that if you have a transfer of care documented, then you need to bill the 55. But I can't imagine if “office A” is transferring care automatically and sends the transfer, that “office B” is obligated to use modifier 55 if it is comfortable with its own (“office B’s”) delivery and documentation of the E&M service as a standalone E&M. “Office A” shouldn't ask for the transfer of care or expect that “Office B” will use the 55 because that is “office A’s” protocol. “Office B” needs to agree to it!

Depending on the surgery, there could be significant revenue differences, as you know. The modifier 55 pretty much averages out to about 20 percent of the allowable in the Medicare fee schedule, and if you are doing this work, I can’t see why you wouldn’t want to capture its associated value.

Technically modifier 55 seems the proper coding way to go, but when you are dealing with payers that don't pay this one or that one - you need to find out how they want it done. The real answer is that the coder/biller probably has options based on insurance company payment policy.

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 billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the January 2012 issue of Physicians Practice.

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