Level I or Level II?
Coding when a secondary insurer and Medicare disagree.
By G.J. Verhovshek, MA, CPC
Medicare requires providers use HCPCS Level II codes (G codes) to report a number of services for which there may be appropriate HCPCS Level I (CPT®) codes. Often, practices rely on billing software to catch such occurrences.
For instance, Rich Papperman, president of Cape Professional Billing, Inc. in Cape May Court House, N.J. says, “Healthpac software has override tables that allow the software to recognize automatically when a code (or other data) needs to change based on certain conditions, such as the requirement to use a G code for Medicare.” Other billing programs offer similar advantages.
For example, Medicare will not recognize CPT® 97014 Application of a modality to one or more areas; electrical stimulation (unattended), but will recognize HCPCS Level II G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care.
“Our physical and occupational therapists are aware of the G0283 requirement for Medicare, and as a result get paid 100 percent of the time for the correct code. If we bill any insurance other than Medicare, 97014 is used,” Papperman says.
Papperman goes on to note, however, that because of the slight variation in code descriptors, you cannot simply “substitute” a G code for a CPT® code when billing for Medicare. Rather, the service provided must meet the exact G code descriptor requirements.
“The devil is in the details,” he says. “In the case of G0283, Medicare requires the stimulation not be for wound care, and that it occurs as a part of a therapy plan of care. It is rare for PT/OT patients not to have a plan of care, but those requirements aren’t specifically part of the CPT® code.”
As a second example, Level II code G0412 Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral or bilateral for pelvic bone fracture patterns which do not disrupt the pelvic ring includes internal fixation, when performed is similar to CPT® code 27215 Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral, for pelvic bone fracture patterns that do not disrupt the pelvic ring, includes internal fixation, when performed. Whereas 27215 applies to unilateral fracture only, G0412 applies to unilateral or bilateral fracture.
“Good software can prompt you, but the correct coding decision still has to come from the individual evaluating the documentation,” Papperman says. “You have to be careful with anything automatic to be sure you’re not just substituting codes, and ignoring code requirements to get paid.”
Medicare-specific G codes are a minor inconvenience if you’re reporting services to one payer. The situation may get stickier, however, if you’re filing the same claim for Medicare, which requires a G code, and a secondary insurer who requires the CPT® counterpart. In these cases, you may have to report the G code for both payers and, if necessary, file an appeal with the third-party insurer.
“For instance, when the secondary carrier wants 97014 and Medicare as primary wants G0283, it may cause a problem,” confirms Michael Miscoe, JD, CPC, CASCC, CUC, CHCC, CRA, of Practice Masters, Inc., of western Pennsylvania. “Most payers recognize the G0283 code, so they will pay it.” Indeed, a quick Web search of payer policies reveals that several non-Medicare payers (such as OptumHealth Care Solutions and United Healthcare) call for G0283 rather than 97014.
“Some payers recognize both codes (97014 and G0283) and even have different payment allowances for each,” Miscoe continues. “Those payers that don’t recognize the G code will generally reprocess and pay—after an initial denial—when the facts of life are explained on appeal.
“The advice here is the same for any coding issue: Follow the policy for the payer being billed,” Miscoe concludes.
Several third-party payer representatives who spoke “off the record” with Coding Edge noted they are aware of the potential for confusion caused by inconsistent code requirements, but they make an effort to work with providers to ensure claims are processed correctly. Papperman confirms this, noting he sees very few payer problems on this issue. As Miscoe notes, an appeal may be necessary in some cases, but if the claim is legitimate, it will likely be paid with little additional hassle.
As a permanent solution, you might negotiate individually with your third-party payers to have them recognize G codes (as some payers already do), or work with your specialty society to develop statewide guidelines for insurers on how to handle G codes, suggests Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, Tinton Falls, N.J. Although these solutions obviously require a greater effort, they might save time in the long run over having to appeal numerous, individual claims.
Finally, for those providers who are content to handle the “G code vs. CPT® code” dilemma on a claim-by-claim basis, a “wait and see” approach may be best. Over time, CPT® and the Centers for Medicare & Medicaid Services (CMS) requirements tend to converge. For example, CPT® 2009 replaced codes 90918-90925 with new codes 90951-90970 to describe services provided to patients with end-stage renal disease (ESRD). Descriptors for the new codes mirror exactly those for Medicare-specified G codes G0308-G0327. As a result, codes G0308-G0327 were eliminated for 2009, and all payers now accept 90951-90970 for ESRD services.