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Issue #2 - October 3, 2012

Coding/Billing Tips and Resources


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Know Your Payer to Make the Most of
Modifier 24

Successful coding often means knowing what a payer wants.

The CPT® codebook instructs you to append modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period for an unrelated evaluation and management (E/M) service during the global period of a previous procedure. CPT® and the Centers for Medicare & Medicaid Services (CMS) agree the global surgical package includes routine, related postoperative care. But CMS and CPT® differ on what they include in the global surgical package.

To cut through the confusion, determine if your payer follows CMS or American Medical Association (AMA) guidelines (get the reply in writing, if possible). Then, apply the following rules.

Under CMS policy, modifier 24 applies for a:

  • Visit for a new problem unrelated to surgery (must be supported by a different ICD-9-CM code)
  • Visit for treatment of the underlying condition (not wound care, pain management, or a repeat procedure) that is not part of normal recovery from surgery.

Under AMA guidelines, modifier 24 applies for a:

  • Visit for a new problem unrelated to surgery — supported by a different ICD-9-CM code;
  • Visit for treatment of the underlying condition; and
  • Visit for treatment of complications, exacerbations, or recurrence.

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Medicare Screening Pap Often Calls
for Q0091

Reporting physician services for collection of a Papanicolaou (Pap) smear is complicated due to varying payer guidelines, and depends on whether the test is for screening or diagnostic purposes.

When coding for Medicare patients, collection only of a screening Pap smear is reported using Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory. Medicare will pay for one screening every two years for low risk beneficiaries, or once per year for beneficiaries at high risk for cervical or vaginal cancer, or for woman who are of childbearing age and have had an abnormal Pap test in the past 36 months.

Complete instructions (including the full definition of “high risk” and applicable diagnosis codes) may be found in the Medicare Claims Processing Manual, chapter 18, sections 30.2-30.9.

A few private (non-Medicare) payers will accept Q0091 for collection only of a screening Pap smear. If the payer does request Q0091, ask for the policy in writing.

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CPT 2013 Errata Posted by AMA

CPT® 2013 codebooks are already shipping out of warehouses, and the American Medical Association (AMA) has moved quickly to post its annual corrections document. The corrections document is a vital part of coding CPT® correctly for the coming year. It includes code and guideline updates that were approved too late to be included in the book, additional clarifications, and simple corrections to typographical errors. New material is added to the document throughout the year.

Changes so far include clarifying edits in guidelines and parenthetical comments, with two changes directly affecting coding. Under codes 20930-20937 is the addition of codes 22633-22634 in place of codes 0195T-0196T, with which they can be reported in conjunction. And new rules for endoscopy of the trachea and bronchi above code 31615 are "For endoscopy procedures, code appropriate endoscopy of each anatomic site examined. Surgical bronchoscopy always includes diagnostic bronchoscopy when performed by the same physician. Codes 31622-31651, 31660, 31661 include fluoroscopic guidance when performed."

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In This Issue
Know Your Payer
Medicare Screening Pap
CPT 2013 Errata



Optum Ingenix





BC Advantage

Gateway EDI



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