Tag Archives: AMA

Healthcare Fraud Shield’s Latest Article: 2023 Hernia Repair Code Changes

25 Oct

What is Hernia?

Hernia is when an organ or fatty tissue squeezes through a weak spot in a surrounding muscle or connective tissue called fascia. There are several types of hernia including inguinal (inner groin), incisional (resulting from an incision), femoral (outer groin), umbilical (belly button), and hiatal (upper stomach). [1]

How is it Billed?

There are different Current Procedural Terminology Codes (CPT) based on the type of hernia and the surgical approach. However, 2023 brought many change to this section of codes to address reporting of “hybrid” abdominal hernia repair procedures where the procedure is performed via open approach and laparoscopically or with the use of a robot.  The following codes were deleted from CPT 2023:

  • 49560-Repair initial incisional or ventral hernia; reducible
  • 49561-Repair initial incisional or ventral hernia; incarcerated or strangulated
  • 49565-Repair recurrent incisional or ventral hernia; reducible
  • 49566-Repair recurrent incisional or ventral hernia; incarcerated or strangulated
  • 49570-Repair epigastric hernia (e.g., preperitoneal fat); reducible (separate procedure)
  • 49572-Repair epigastric hernia (e.g., preperitoneal fat); incarcerated or strangulated
  • 49580-Repair umbilical hernia, younger than age 5 years; reducible
  • 49582-Repair umbilical hernia, younger than age 5 years; incarcerated or strangulated
  • 49585-Repair umbilical hernia, age 5 years or older; reducible
  • 49590-Repair spigelian hernia

The new codes combine some of the various types of hernia into one set of codes creating 15[2] new CPT codes. The codes bundle epigastric, incisional, ventral, umbilical, and spigelian hernia repair, whether open or laparoscopic, into one category, anterior abdominal hernia. In 2023, you report one code based on initial or recurrent, reducible or incarcerated/strangulated, and repair size, as follows:

  • 49591-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible
  • 49592-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, incarcerated or strangulated
  • 49593-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible
  • 49594-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, incarcerated or strangulated
  • 49595-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible
  • 49596-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, incarcerated or strangulated
  • 49613-Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible
  • 49614-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, incarcerated or strangulated
  • 49615-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible
  • 49616-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, incarcerated or strangulated
  • 49617-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible
  • 49618-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, incarcerated or strangulated
  • 49621-Repair of parastomal hernia, any approach (i.e., open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; reducible
  • 49622-Repair of parastomal hernia, any approach (i.e., open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; incarcerated or strangulated
  • +49623-Removal of total or near total non-infected mesh or other prosthesis at the time of initial or recurrent anterior abdominal hernia repair or parastomal hernia repair, any approach (i.e., open, laparoscopic, robotic) (List separately in addition to code for primary procedure)

Providers will also have a choice of new codes for repair of parastomal hernias reducible (49621) or incarcerated/strangulated (49622).

In 2023 as shown above, providers will also have a choice of new codes for repair of parastomal hernias reducible (49621) or incarcerated/strangulated (49622) and a new add-on code (+49623) for removal of mesh or other prosthesis.

What to look for?

  1. Upcoding the size of the repair
  2. Coding initial when performing recurrent
  3. Medically unnecessary surgeries (check the appropriate medical policies and guidelines)

[1] https://www.webmd.com/digestive-disorders/understanding-hernia-basics

[2] https://www.ama-assn.org/press-center/press-releases/ama-new-2023-cpt-code-set-includes-burden-reducing-revisions

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Healthcare Fraud Shield’s Latest Article: Understanding Wheelchair Management

19 May

Most people need a little tutorial on how to use new equipment. This also applies to patients who need new wheelchairs. Enter the service of wheelchair management. In this service, the provider assesses a patient’s need for a wheelchair and/or teaches a patient wheelchair maneuvering skills. CPT code 97542 is the correct procedure code for wheelchair management. The units measure one unit per 15-minute increment1


According to CMS2:This service trains the patient, family and/or caregiver in functional activities that promote safe wheelchair mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications. Consider the following points when providing wheelchair management services.


Practice makes perfect! Most wheelchair users will need to practice a bit, but typically no more than a few days of training is enough. Regardless of whether the training took one day or four, the service needs to be documented.3 The medical record should include the following: 

  • the recent event that prompted the need for a skilled wheelchair assessment;
  • any previous wheelchair assessments have been completed, such as during a Part A SNF stay;
  • most recent prior functional level;
  • if applicable, any previous interventions that have been tried by nursing staff, caregivers or the patient that may have failed, prompting the initiation of skilled therapy intervention;
  • functional deficits due to poor seating or positioning;
  • objective assessments of applicable impairments such as range of motion (ROM), strength, sitting balance, skin integrity, sensation and tone;
  • the response of the patient or caregiver to the fitting and training.

Since it is a timed code, the practitioner should record the time for the visit from start to finish in the notes.  As of April 2021, the Medically Unlikely Edits (MUE)4 show the maximum number of units per day is 8 (2 hours of time). Additionally, only a Practitioner or Facility Outpatient Services can bill for this service, not DME Supplier Services.


What to look for?
When assessing this service for any potential fraud, waste and abuse (FWA), you should look for the following:

  • Excessive units in a given day/compared to other providers;
  • More than 8 units in a day;
  • Patients who don’t have any other wheelchair related claims;
  • Excessive number of dates of service per patient/compared to other providers;
  • Look for services unbundled from CPT 97542 (Per CMS CCI – 36591, 36592, 96523)5

If you have any questions or comments, please reach out to SIU@hcfraudshield.com. 

REFERENCES

1,5 https://www.aapc.com/codes/cpt-codes/97542

2, 3 Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)

4 https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE

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Healthcare Fraud Shield’s Latest Article: Changes to Prolonged Services

20 Oct

 

Healthcare Fraud Shield wrote an article in 2013 explaining the use of prolonged service codes. Well, back in 2013 we said time is money and in 2020, the times have changed.  Just a refresher – what are Prolonged Services? Prolonged Service codes are used when the healthcare professional performs “beyond the usual service.”1 Providers are able to bill for three types of prolonged service codes:

 

1.   Prolonged service with direct patient contact,

2.   Prolonged services without direct patient contact,

3.   Providers providing direct supervision of clinical staff delivering a prolonged service    Providers billing these codes typically receive added reimbursement in addition to payment for the base evaluation and management code. As a result, these services may be prone to fraudulent and/or abusive billing.

So what’s new in 2021 for Prolonged Services?

 Effective January 1, 2021, there is a new Current Procedural Terminology (CPT) code, 99417.2 Per the AMA, CPT 99417 is defined as a: Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services).

In addition to the new code, changes were made to existing prolonged services. For example:

CPT 99354 and 99355 underwent some changes as well:

·     Both codes are described now as prolonged services as opposed to “prolonged evaluation and management or psychotherapy service(s)”

·     Office was removed or other outpatient was removed from the description and now it’s just outpatient setting

·     The codes can no longer be reported with new patient or established patient evaluation and management (e/m) codes (99202-99215)

·     99354 is to be used in conjunction with 90837, 90847, 99241-99245, 99324-99337, 99341- 99350, 99483 only

The American Academy of Family Physicians3 provided an example of the use of 99417:

“the multiple current codes will become a single CPT code, 99417, which you can bill in 15-minute increments when total time exceeds a level 5 visit. So, a visit of 55-69 minutes with an established patient would require 99215 plus a single 99417 prolonged services code. A visit of 70-84 minutes with an established patient would take a 99215 plus two 99417 prolonged services codes, and so on”

What to look for?

·     Any outlier billing patterns related to prolonged services by specialty, diagnoses, line of business and more

·     What percentage of a provider’s overall claims contain these codes?

·     Check policies and verify with your respective plans how time is to be calculated.4

 If you have any questions, feel free to email us at info@hcfraudshield.com.

REFERENCES:

1,2 AMA CPT Book

3 AAFP

4 CMS – Prolonged Services

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Healthcare Fraud Shield’s Latest Article: Are you ready for the 2020 Code Updates?

6 Jan
Every year around September, the AMA releases their annual code set changes for the following year. There are 394 code changes effective January 1, 2020 which includes 248 new codes, 75 revisions and 71 deletions.
It’s important to familiarize yourself with the new code set changes. Let’s take a look at some of the changes and the potential schemes they bring with them.

Online Digital Evaluations or E-visits
Six new codes for reporting online digital evaluation services, or e-visits will be introduced in 2020. These codes cover patient-initiated digital communications with a physician or other qualified healthcare professional (99421, 99422, 99423) or a non-physician healthcare professional (98970, 98971, 98972).
Potential Scheme:
Schemes could occur with upcoding the level of service or the type of healthcare professional rendering the services.

Vaccines
Two new vaccine codes have been established, 90694 for reporting Influenza virus vaccine for intramuscular use, quadrivalent (allV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, and code 90619 for reporting meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier for intramuscular use.
 
Potential Scheme:
CPT 90694 carries the   symbol advising that this vaccine is pending FDA approval. Health plans may not reimburse for codes with this symbol until they are approved by the FDA. Be sure to check the FDA status of this code semiannually (July 1st and January 1st) at the AMA CPT website:  www.ama-assn.org/go/cpt-vaccine under the CPT Category I vaccine codes.

Biofeedback
Two new codes (90912-90913) have been added for reporting biofeedback training, perineal muscles, including EMG and/or manometry when performed.
 
Potential Scheme:
CPT 90912 is used for the first 15 minutes of one-on-one physician or other qualified healthcare professional contact with the patient for biofeedback training. CPT code 90913 is an add-on code used for each additional 15-minute increment. Since these codes represent personal contact with the patient, look for providers treating more than one patient at a time or excessive units of service.
 
Self-Measured Blood Pressure Monitoring
The 2020 code updates include the addition of CPT codes:
99473-patient education and calibration of home BP device); and
99474-separate self-measurements of two readings one minute apart, twice daily over 30-day period.

Potential Scheme:
Look for providers inappropriately billing CPT code 99473 more than once per device/patient, and CPT code 99474 being reported more than once per calendar month.

Health and Behavioral Assessments and Intervention Services
In order to more accurately reflect current clinical practice that increasingly emphasizes interdisciplinary care coordination and teamwork with physicians in primary care and specialty settings the AMA is incorporating new codes for health and behavior assessment and intervention services (96156, 96158, 96164, 96167, 96170 and add-on codes 96159, 96165, 96168, 96171) to replace 6 older codes.
 
Potential Scheme:
Health behavioral Assessments are conducted through health-focused clinical interviews, observation and clinical decision making. Health Behavioral Interventions emphasize active patient/family engagement and involvement. Look for the same provider billing evaluation and management codes including counseling risk factor reduction and behavior change intervention (99401-99421) on the same day as health behavior assessment and intervention codes, 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170 and 96171 as this is generally considered inappropriate.

Long term electroencephalographic (EEG) Monitoring services
According to the AMA, one of the major changes coming in 2020 involves a significant enhancement to the codes for reporting long term electroencephalographic (EEG) monitoring services (95700-95726).
  • Deletion of CPT Codes 95950, 95951, 95953, 95956
  • Creation of 10 Professional Component Codes(for physician work only)
 
  • Creation of 13 Technical Component Codes (no physician work included)
    • Unmonitored – or more than 13 patients monitored concurrently
    • Intermittent monitoring – between five and 12 patients concurrently
    • Continuous monitoring – four or fewer patients concurrently
    • 95701 – Set up code (includes take down)
Potential Scheme:
 
Review claims and medical records for indications the provider is billing set up/take down code 95700 more than one time per recording. Patient placed electrode sets should be reported with code 95999. Confirm through the medical records that the correct code is being used for professional versus technical services, EEG with or without video, the monitoring and duration of testing.
In addition to the changes mentioned, additions, revisions and deletions are also being introduced in several other areas including:
  • Evaluation and Management
  • Surgery
  • Radiology
  • Pathology and lab
  • Medicine
  • Category II and III
Look for more code changes for 2020 in our upcoming Articles in 2020.
If you have any questions or comments, please contact SIU@hcfraudshield.com.

 

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Healthcare Fraud Shield’s Latest Article: The Stimulating Billing of P-Stim devices!

3 Dec

 

We all want to be pain free right? What if I told you that you could experience relief of chronic pain using a minimally invasive technique with virtually no side effects? You would probably say sign me up, right? At least that’s what the makers of P-Stim devices like ANSiStim and Stivax are advertising.

What is P-Stim?

Point-Stimulation Therapy or P-Stim is a non-narcotic approach to pain management. P-Stim is a miniaturized electro-acupuncture device worn by the patient that administers continuous pulses of a low-level electrical current at the ear over several days. Electrical pulses are emitted through three selectively positioned acupuncture needles.

Some examples of the devices include:

  1. AcuStim (S.H.P. International)
  2. P-Stim™ System (NeuroScience Therapy)
  3. E-pulse® (AMM Marketing)
  4. Electro Auricular Device – EAD (Key Electronics)
  5. P-Stim (Biegler Gmbh)
  6. ANSiStim® (DyAnsys)
  7. Stivax System (Biegler Gmbh)

Who should use a P-Stim?

Makers of the PStim devices advise that using P-Stim can be highly effective in relieving chronic pain for conditions such as:1

  • Peripheral Vascular Disease
  • Neuropathy
  • Post-amputation Pain
  • Herpetic Neuralgia
  • Trigeminal Neuralgia
  • Reflex Sympathetic Dystrophy (RSD)
  • Migraines
  • Occipital Neuralgia
  • Peripheral Artery Disease (PAD)
  • Back and Neck Pain
  • Post-Surgical Pain
  • Complex Regional Pain Syndrome (CRPS)
  • Diabetic Peripheral Neuropathy
  • Lateral Femoral Cutaneous Neuropathy
  • Traumatic Nerve Injuries

Can anyone place a P-Stim device?

Check your respective state guidelines and internal policies, but typically only licensed medical providers may apply this device.

How is it billed?

S8930-Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the patient.

The Potential Scheme

Medicare does not reimburse for acupuncture or for acupuncture devices such as P-Stim, nor does Medicare reimburse for P-Stim as a neurostimulator or as implantation of neurostimulator electrodes. Medicare considers Electrical stimulation of auricular acupuncture not medically necessary and not covered for all indications, including but not limited to chronic and acute pain.2

P-Stim is sometimes incorrectly billed as a surgically implanted neurostimulator (HCPCS code L8679). The American Medical Association defines code L8679 as an “Implantable Neurostimulator, Pulse Generator.”  P-stims are applied as devices employing acupuncture needles attached to electrodes that are being applied to a patient’s ear through simple bandages and therefore does not qualify as “implantable”.

Implantation of a Percutaneous Neurostimulator Pulse Generator is typically performed in an outpatient or Ambulatory Surgical Center (ASC) setting while P-stims can generally be performed in an office environment.

Auditors and investigators should:

1)      Review claims to determine the place of service and if an implantable neurostimulator is being billed without an accompanying surgical code as this might imply the provider is incorrectly reporting P-Stim.

2)      Look for excessive billing of L8679

3)      Look for S8930 with a place of service for ASC.

If you have any questions or comments, please contact SIU@hcfraudshield.com.
REFERENCES

[1,]P-Stim

[2]Medicare/DOJ

If you would like to learn more about Healthcare Fraud Shield’s PostShield Shared Analytics, contact us at info@hcfraudshield.com.  

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Healthcare Fraud Shield’s Latest Article: All You Wanted To Know About Fluoride Varnish, But Were Afraid To Ask!

10 Sep
Healthy gums and teeth are important, to overall health. Oral health is a predictor of overall health and wellness. The Surgeon General reports: “Dental decay is the most common chronic disease of childhood and affects a disproportionate number of low-income and minority children.” [1] According to the Centers for Disease Control and Prevention (CDC), Healthy People 2010 Final Review: [2] “Approximately 42% of children ages 2 to 11 years have dental caries in their primary teeth.”

What is Fluoride Varnish?
Fluoride varnish is a topical dental treatment, simple to apply that can help prevent tooth decay. It can slow it down or stop it from getting worse. Fluoride varnish is made with fluoride, a mineral that is proven to strengthen tooth enamel (strong outer coating on teeth).  

Once a child starts to get teeth it is recommended that preventative care including fluoride varnish are used to assist with oral health preservation. Baby teeth begin to come in about six months of age and permanent teeth at six years of age, continuing until early adulthood.

When should Fluoride Varnish be used?
The Bright Futures/American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care Periodicity Schedule, [3] recommends the following schedule: “Age 6 months to Age 5 years.”

The American Dental Association (ADA)[4] recommends: “Varnishes must be reapplied at regular intervals with at least 2 applications per year needed for sustained benefit.”

Who can apply Fluoride Varnish?
Fluoride Varnish can be applied by trained health care providers like dentists, and primary care providers. It only takes a few minutes to apply and can be done during routine preventive health visits.

How is it billed?
Dental providers should be using dental code CDT code D1206 (Topical application of fluoride varnish).
Primary Care providers should be using CPT code 99188 (Application of topical fluoride varnish by a physician or other qualified health professional).

Most payors will have guidelines around the frequency of billing that may vary from 2-4 times per year. Make sure to be familiar with your carrier’s policies.

What to look for?
Dental claims and medical claims usually don’t run in the same claim platform.  Look for cross over billing.  i.e. dentists billing medical platform.  Additionally, watch for Dental providers who are billing D1206 (Topical application of fluoride varnish) and reporting D1208 (Topical application of fluoride).  Both codes can be used but should not be reported more than four times per year in total no matter the combination.

Primary care providers should not be reporting D1206 (Topical application of fluoride varnish) D1208 (Topical application of fluoride) as these are dental codes.

Finally, there should be an indication of high risk of caries (cavities) reported with any fluoride service code by either dentists or primary care providers. Most payors will have guidelines around the frequency of billing that may vary from 2-4 times per year.  Make sure to be familiar with your carrier’s policies.

If you have any questions or comments, please contact SIU@hcfraudshield.com.

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ABC, 123, I mean A1C?

14 Aug
How many of us look at our lab results and know what all the letters and numbers mean?  It can be overwhelming to know what all of the different tests are for and why we need them. One test we hear a lot about as consumers is A1C.   A1C also goes by several other names such as hemoglobin A1C, HbA1c, glycated hemoglobin, or glycohemoglobin test.1 

So what is A1C?
A1C is a blood test that is used to manage diabetes, in particular Type II diabetes as well as prediabetes.  The A1C test measures the average blood sugar or blood glucose levels over the last 2-3 months.

How are the results reported?
If you are looking at your lab test results, you will see a percentage recorded for your A1C level. The higher the percentage, the higher your levels of blood sugar or glucose.   Below 5.7% is considered a normal test result, between 5.7% and 6.4% indicates a likelihood of developing diabetes and anyone with 6.5% would most likely be diagnosed with diabetes.
 
How is the test billed?
The A1C test is billed using Current Procedural Terminology Code 83036, Hemoglobin; glycosylated (A1C).  Since the test is looking at the average levels over the last 2-3 months, it would not be common to see this test billed daily, weekly or even monthly.  
 
What to look for?
Keep in mind that every patient has a different medical history which should be reviewed in context of any analysis.  It is always recommended to check your internal policies and procedures first. However, some areas of concern could be:
  • Look for providers billing this upwards of 6 or more times per year
  • Look for diagnoses that don’t correspond to diabetes related symptoms
  • Look for excessive units per date of service
  • Review medical records to determine if tests are repeated after normal results
If you have any questions or comments, please contact SIU@hcfraudshield.com.

REFERENCES

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Healthcare Fraud Shield’s Latest Article: Let’s Talk About Modifier JW!

26 Jun

Let’s refresh our memories on what modifiers are and what they do.  Modifiers are extra characters that may be letters, numbers or both that are appended to either a CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) Code.  Modifiers provide additional information about equipment, service, procedure, and/or condition of a patient.  Some modifiers may also have an impact on reimbursement. 

What is Modifier JW?
Modifier JW is defined as Drug amount discarded/not administered to any patient. Effective January 1, 2017, CMS required providers to submit Modifier JW on Part B claims for the discarded material for drugs and biologicals.[1]
How is it billed?

According to CMS, This modifier should not be used for[2]:

  • drugs or biologicals administered in a Rural Health Clinic (RHC) or a Federally Qualified Health Center (FQHC).
  • claims for hospital inpatient admissions that are billed under the Inpatient Prospective Payment System
  • drugs or biologicals from multi-dose or multi-use packages
Modifier JW should only be used for drugs in single dose or single use packaging.[2] If a provider administers 30 units of a 50 unit single use file and discards the 20, then the provider should bill the appropriate code with 30 units on one line with no modifier and the same code on a separate claim line with 20 units and modifier JW.   
Modifier JW should not be used when the dosage administered plus the discarded amount would be less than or equal to the billing unit.  For example, if 1 unit equals 10 mg and the provider only administers 5 mg and discards 5 mg, then the provider would submit the appropriate code with 1 unit and no modifier.
Another example provided by UnitedHealthcare in their policy is as follows:
“Example of vial size selection, the CPT/HCPCS code for Drug A indicates 1 unit = 30 mg. Drug A is available from the manufacturer in 60mg and 90mg vials. The amount prescribed for the patient is 48 mg. If the provider uses a 90 mg vial to administer the dose, the provider may only submit 2 units (rather than 3 units) as the doses available from the manufacturer allow the prescribed amount to be administered with a 60 mg vial”.[3]
What to look for?

It is important to check your respective plan policies and guidelines.  However, it is recommended to look for providers billing for this modifier excessively and for the average number of units higher per patient than other providers.  Keep in mind, many dosage amounts for drugs or biologicals are based on various guidelines including the patient’s weight and diagnosis.    The dosage amount used and the amount discard should be documented in the medical record (compounding record).  Therefore, if the dosage amount is based on a patient’s weight one could calculate the appropriate drug amount based on the information in the medical records. This information would include the physician’s order, patient’s weight and medically necessity of the treatment.

Another area of review would be to look for providers appending a modifier JW for drugs or biologicals that come in a multi-use dose or package. Crosswalk the J code to the drug’s NDC number which would provide the specific package size.
When requesting records, make sure this request includes the following components of the records:  compounding records, nurse’s infusion records, physician’s orders, progress notes and drug invoices.
If you have any questions or comments, please contact SIU@hcfraudshield.com.
REFERENCES

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Healthcare Fraud Shield Latest Article: Are You Seeing an Increase in Digital Medicine Billing?

19 Mar
In 2019, the American Medical Association (AMA) introduced two new codes related to the review and assessment of a patient’s heath record.   The AMA refers to these codes as digital medicine[1].   Several new codes were introduced relating to Remote Patient Monitoring (RPM) and Interprofessional Consultation codes. Today’s article will focus on the new Interprofessional Consultation Current Procedural Terminology (CPT) codes which are as follows:

CPT 99451 – Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time
CPT 99452 – Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes

What’s the difference?
 
There were several codes introduced in 2014 that also relate to non-contact services. The table below shows the difference between the old and new codes[2]:
CPT 99451 is written only and reported by the consultant and CPT 99452 is reported by the treating/requesting physician.

What to look for?
  • Both codes are time-based so look for excessive time billed in a day
  • Look for frequency of codes billed per patient, per provider
  • Look for services billed separately that would be considered included. For example, according to Medicare CCI, CPT 99358 and 99359 (prolonged services without face to face contact) would not be allowed with 99451.
If you have any questions or comments, please contact SIU@hcfraudshield.com.
REFERENCES

[1]  AMA
If you would like to learn more about Healthcare Fraud Shield’s analytics solution, contact us at info@hcfraudshield.com.  

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Healthcare Fraud Shield’s Latest Article: Developmental Testing Code Changes

5 Jan

Happy New Year! With a New Year comes new codes, coding changes and of course coding challenges.   This article will focus specifically on the changes made to developmental testing.  In February 2018, Healthcare Fraud Shield wrote an article about the differences between Current Procedural Terminology Code (CPT) 96110 and 96111[1]. CPT 96111 was deleted; however, CPT 96110 remains.

2018 Codes and Descriptions

96110: Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96111: Developmental testing, (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments) with interpretation and report.

2019 Codes and Descriptions

As mentioned above, CPT 96110 remains an active code for 2019.   Additionally, two new codes were added:

96112: Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour

+96113: Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure)

What is Developmental Testing?

It used to diagnosis developmental problems among children.   For example, according to the AAP (American Academy of Pediatrics), CPT 96111 including tests such as the Bayley Scales of Infant Development (Third Edition).[2] This test is used to “identify possible developmental delay, inform professionals about specific areas of strength or weakness when planning a comprehensive intervention, and provide a method of monitoring a child’s developmental progress.”[3]

What to look for?

  • Since the new codes are time based, look for providers billing excessive time per patient, per day across all patients, and/or excessive units of the add-on code (96113).
  • Look for bundled services. Evaluation and management codes can be billed along with developmental testing codes as long as the services are separate and distinct.

If you have general SIU questions or comments, please contact us at  SIU@hcfraudshield.com.

REFERENCES

  1. HCFS Article
  2. AAP Fact Sheet
  3. Bayley Scales of Infant Development (Third Edition)

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