Common Claims Conundrums

….and what to do about them



Click to jump to a section:

  • Medicare Screening: How to code screening for depression, alcohol, and Advance Care Planning

  • Labs: are you including a lab in your claim? Here's what to do












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).




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Which AWV? Annual Well Visit Codes

  • Appointments for patients who are eligible for an AWV will have an alert on their PracticeMate record, and/or it may appear as part of the “Reason for Visit.”

  • Patients are eligible for one AWV every year.


There are  three types of AWVs:

  • IPPE (Initial Preventive Physical Examination, or "Welcome to Medicare")

    • code: G0402

    • Must be done within 12 months of Medicare enrollment otherwise use G048, initial AWV

  • Initial AWV

    • code: G0438

    • May be done a year after IPPE, or after patient has had Medicare >1 year

  • Subsequent AWV

    • Code G0439

    • May be done anytime after a year following a 1st AWV. and every year thereafter


Charting Requirements for AWVs:


  • Charting Requirements --  See this document for more on documentation requirement

  • List of current healthcare providers

  • Current medications and supplements

  • Family history

  • History related to alcohol, tobacco, illicit drugs

  • Diet and physical activities

  • Risk for depression and mood disorders

  • Use a screening instrument to assess potential for depression (eg, PHQ-9) (this is included in the IPPE but billed separately for the other two

  • Review functional ability and level of safety

  • Hearing, ADLs, fall risk and home safety Examination

  • Height, weight, body mass index, and blood pressure

  • Visual acuity screen; and Other factors deemed appropriate based on the beneficiary’s medical and social history and current clinical standards.

  • End of life planning (optional and separately billed)

  • Education, counseling and necessary referrals


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Medicare Screening Codes

  • G0442:Alcohol screening may be done and 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.

  • 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.

  • For both screenings, use the screening tool and then attach it to the AWV encounter.

  • This service is provided to patients with no deductible or co-pay as long as it's done along with an AWV.

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Advance Care Planning

  • 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. 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 99497 is chosen from the superbill.

  • 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,

  • This service is provided to patients with no deductible or co-pay as long as it's done along with an AWV.

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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. Please also complete the following. And don't forget the 25 on the E/M if you've done that as well.

  1. Choose the Billing Options tab in the visit

  2. Scroll down to the Miscellaneous section near the bottom of the claim and insert our CLIA number: 21D2068655 for "Prior authorization, box 23" I know that doesn't sound right, but it is!

  3. Click here to see an example of a visit with the correct Billing Options provided. Click Billing Options to see the CLIA entered, the Billing Info tab to see the modifiers 25 and QW.

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Vaccine/Immunotherapy Tips

  • If you are providing ONE allergy injection, bill 95115.

  • When providing 2 or more allergy injections, bill 95117 ONLY.  see example

  •  Do not bill both 95115 and 95117

  • When providing one vaccine, use 90471. When providing more than one, you can use 90471 and 90472 see example

  • 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:

    • United Health Community Plan

    • Maryland Physicians Care

    • Better Health AETNA MD

    • Priority Partners

  • 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.

  • 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)

  • 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)


These codes indicate the patient was seen for a Hospital Followup. 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. From there, the two codes differ in the amount of time between the discharge date and seeing the patient in person:

  • 99495: Covers communication with the patient or caregiver within two days of discharge, and an in-person visit within 14 days.

  • 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 seven days of discharge.

  • 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.

  • You may not bill a transitional code for ER visits unless, of course the patient is admitted




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Ear Wax Removal


69209: Ear wax removal requiring irrigation only

69210 Ear wax removal requiring instrumentation


In either case, Medicare will not pay unless:

  • There is impaction documented

  • Wax is extremely hard and irritative

  • Ear(s) have foul odor, infection, etc

  • Cerumen impairs examination of ear

For Medicare ONLY, do not use mod 50 to indicate removal from both ears.

Use mod 50 for bilateral procedure for commercial insurers.

Use mod 25 if an E/M code is used in addition

For non-impacted cerumen, use E/M code only



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How to use mod 25

  •  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.

  • The separate service might be a lab, an immunization, or an Annual Well Visit.

  • Click here to see an example

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COVID Vaccines

Only the Medicaids are requiring you use the CPT for the Moderna Vaccine in (91301) addition to the admin code (0011A, 0012A, or 0013A.Please do not use any other Vaccine code or Admin code. 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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Foot problems

It’s difficult to get paid for foot issues such as corn/toenail removal, fungus, etc. However, here are some things to try:

Be sure to use a primary dx of whatever condition the foot issue could be linked to (ie diabetes)

Use a modifier to indicate which toe was effected: