Common Claims Conundrums
….and what to do about them
Click to jump to a section:
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Tick Bites and All other injuries: The order of the dx matters!
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Here's your best bet for getting tetanus shots covered. Use the dx codes found here.
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Which AWV? Choosing the correct Annual Well Visit for your Medicare Patients.
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How to use mod 25 to bill for a separate service. ALWAYS PUT IT ON THE E/M! but here's more
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Medicare Screening: How to code screening for depression, alcohol, and Advance Care Planning
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Labs: are you including a lab in your claim? Here's what to do
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Vaccine Admin Codes (but see COVID section if you're dealing with the COVID vax)
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Transitional Care (Hospital Followup)
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Ear Wax Removal
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COVID Tests: Only certain diagnoses get paid, see which ones!
Tick Bites and other injuries
We need at least two dx codes:
1. The 1st dx should be WHERE on the body the injury is (usually an “S” code)
2. The 2nd dx should be WHAT the injury is (insect bite, cause, etc)
3. Any other codes should be after these
Note: Injuries usually require a dx that indicates initial or subsequent encounter: ex S00.01XA indicates first encounter for superficial injury to the scalp; S00.01XD indicates subsequent encounter. S00.01XS indicates a continuing condition beyond the second encounter
See this visit example (look under the Billing Info tab).
You can look up diagnosis codes at this free website.
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Which AWV? Annual Well Visit Codes
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It's important to check the appointment "Reason For Visit" and/or alert on patient's PracticeMate record to see which AWV the patient is eligible for. If you're not sure, it's best to ask Bibi or Mary before entering charges.
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Patients are eligible for one AWV every year.
There are three types of AWVs:
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IPPE (Initial Preventive Physical Examination, or "Welcome to Medicare")
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code: G0402
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Must be done within 12 months of Medicare enrollment otherwise use G048, initial AWV
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Initial AWV
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code: G0438
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May be done a year after IPPE, or after patient has had Medicare >1 year
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Subsequent AWV
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Code G0439
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May be done anytime after a year following a 1st AWV. and every year thereafter
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Which screenings can be billed with which AWV?
Medicare Screening Codes
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G0442: Alcohol screening may be done and be billed separately with both the Initial AWV (G0438) and subsequent AWV (G0439) but NOT the IPPE (G0402). The modifier 59 is inserted when you select the screening CPT.
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G0444 Depression screening may also be done and billed separately with both AWVs. Modifier 59 is inserted indicating procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.
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These services are provided to patients with no deductible or co-pay as long as it's done along with an AWV.
Here's an example of a G0438 (first AWV) that's also included screening, Advance Care Planning, and an E/M. -
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Advance Care Planning
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ACP offers patients the chance to specify what kinds of potentially life-saving procedures they would/would not want, in the situation where they cannot speak for themselves. 99497 is the CPT for ACP when you spend less than 30 minutes discussing with the patient. BE SURE TO DOCUMENT HOW MUCH TIME YOU SPENT DISCUSSING
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It may be billed as a separate service with G0438 and G0439 (but not G0402). Modifier 33, used to identify certain screening and preventive services, is appended automatically when either is chosen from the superbill.
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After completing the MOLST with the patient, attach to the AWV encounter. You must also document how long you spent discussing the ACP with the patient
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This service is provided to patients with no deductible or co-pay as long as it's done along with an AWV.
Click to view an example claim.
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Labs
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Urine, Flu, Strep and other labs need modifier QW. The modifier should be inserted when you choose it from the Superbill.
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Many insurers, including Medicare, require a "Referring Physician." When you're putting in charges for a claim that involves a lab, put in your charges as usual, but before closing, choose the Billing Options tab. You'll see three choices: Referring, Supervising, and Ordering. From the Referring Physician, click the three dots, and type "Hahn" to search for Dr Hahn. Choose him, and it populates that field. ALSO, scroll down to the "Miscellaneous" section and in the Prior Authorization field, type our CLIA number: 21D2068655 (I know, shouldn't it go in the "CLIA" field? You'd think!. Now you can close it.
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Don't forget the 25 on the E/M (this includes Well Child Visits)
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Vaccine/Immunotherapy Tips
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If you are providing ONE allergy injection, bill 95115. See example
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When providing 2 or more allergy injections, bill 95117 ONLY. see example
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Do not bill both 95115 and 95117
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You may bill for an E/M office visit as well by using modifier 25 on the E/M.
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When providing one vaccine, use 90471. When providing more than one, you can use 90471 and 90472 see example. Note the mod 25 on the E/M.
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Use the Maryland Medicaid section of the superbill when billing for vaccines given to those patients. Choosing those will insert the necessary extra codes. Maryland Medicaid incudes the following MCOS:
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United Health Community Plan
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Maryland Physicians Care
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Better Health AETNA MD
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Priority Partners
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Most vaccines already have the National Drug Codes (NDC) inserted automatically. If you find one that does not, please let Bibi know so she can update the superbill.
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When providing an immunization in addition to another separate service (usually an E/M service) use modifier 25 on the E/M code. Click here to see an example of a flu shot for a Medicare patient + an E/M (click the Billing Options tab to seee codes)
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Be sure you're using the Medicare admin codes for flu vaccine (G0008) or pneumococcal vaccine (G0009) for any Medicare-eligible patient
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Transitional Care (Hospital Followup)
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You must document that the patient or caregiver has been contacted within two business days of discharge. This can be done by phone, e-mail, or in person.
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From there, the two codes differ in the amount of time between the discharge date and seeing the patient in person:
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99495: Covers communication with the patient or caregiver within two days of discharge, and an in-person visit within 14 days.
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99496: covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It involves medical decision making of high complexity and a face-to-face visit within 7 days of discharge.
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If patient is readmitted during the 30 days, the claim will need to be changed to a regular E/M visit. Then once the patient was discharged, you may bill the TC.
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You may not bill a transitional code for ER visits unless, of course the patient is admitted
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Ear Wax Removal
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69209: Ear wax removal requiring irrigation only
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69210 Ear wax removal requiring instrumentation
In either case, Medicare will not pay unless:
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There is impaction documented
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Wax is extremely hard and irritative
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Ear(s) have foul odor, infection, etc
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Cerumen impairs examination of ear
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For Medicare ONLY, do not use mod 50 to indicate removal from both ears.
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Use mod 50 for bilateral procedure for commercial insurers.
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Use mod 25 if an E/M code is used in addition
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For non-impacted cerumen, use E/M code only
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It may be a good idea to get the patient to sign an Advance Beneficiary Notice of Noncoverage (ABN) in case it's not covered. Click the link and print.
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Pap smears, when to bill:
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If using CPT® preventive medicine services, and also performing a screening pap smear report a code in 99381-99397 series and Q0091.
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If using E/M codes for a symptom or condition and practitioner also obtains a pap smear report only the E/M service. Do not report Q0091 because it is for obtaining a screening test.
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Use G0101 and Q0091 for Medicare patients receiving a screening pelvic and breast exam and having a screening pap smear. There are frequency limits for this service.
How to use mod 25
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Modifier 25 is used to report an Evaluation and Management (E/M) service on a day when an additional, separate service was provided to the patient by the same physician or other qualified health care professional. For example, you might provide a child wellvisit along with immunizations. Therefore, the 25 should be used on the Well Child exam CPT
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The 25 ALWAYS goes on the E/M. Not the AWV. Not the immunization, or the Advance Care Plan. ON THE E/M! Don't forget to use with Well Child (99391-99394) and any new patient (99202-99205).
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The separate service might be a lab, an immunization, or an Annual Well Visit.
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COVID Vaccines
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Only the Medicaids are requiring you use the CPT for the actual vaccine in addition to the admin code. All three are on the superbill.
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Please create a separate visit for vaccines if the patient is being seen for other concerns. If you see your charges are more than $50, you've probably chosen the wrong vaccine code.
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Diagnosis codes
If a diagnosis isn't specific enough, it gets rejected. I have updated the diagnosis list in Practice Mate for the most commonly rejected codes. When you start typing one of these (coughs, back pain, breast lump are some of these), you should see a pop-up with suggestions to make it more specific. Please be sure to choose from this list, or look one up at this website.
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Diagnoses to use for COVID TESTING
I'm not going to list them all here. Go to this page for a list - you'll need to scroll down a little!
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Foot problems
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It’s difficult to get paid for foot issues such as corn/toenail removal, fungus, etc. However, here are some things to try:
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Be sure to use a primary dx of whatever condition the foot issue could be linked to (ie diabetes)
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Use a modifier to indicate which toe was effected:
