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Issue #3 - November 7, 2012

Coding/Billing Tips and Resources


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The "Eyes" Have it: Routine vs. Medical Eye Exams
By Nancy Clark, CPC, CPMA, CPC-I

Understanding the difference between routine and medical eye examinations will guide you to properly code these services and prevent your patient from receiving an unexpected bill. Coding eye examinations is different than coding physical examinations, which have separate CPT® codes for routine and medical visits.

CPT® codes 92002-92014 indicate new and established eye exams, and are used for both routine and medical visits. The primary diagnosis code makes the distinction.


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Include Gastric Band Adjustments in E/M Service

Tightening the gastric band requires particular care when reporting. It can lead to a denial if done wrong.

When billing for gastric band adjustments outside of the global period of 43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty or 43659 Unlisted laparoscopy procedure, stomach for Medicare part B patients in California, Nevada, and Hawaii, you should report only a medically-necessary evaluation and management (E/M) service at the level of 99213 Office or other outpatient visit for the evaluation and management of an established patient…. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

Per instructions from Palmetto GBA, Medicare Part B carrier for Jurisdiction 1 (Calif., Nev. Hawaii.), "Prior to making an adjustment, Medicare expects a medically necessary evaluation and management service to be performed. The adjustment is included in the E/M service provided on the date of service for the E/M code billed. Ordinarily this would be at the level of CPT® code 99213."

The number and frequency of adjustments to the band depends on individual considerations. Most patients have between five and eight adjustments within the first year after surgery. There is no specific HCPCS code that describes these adjustments. You should not report an unlisted procedure code for these adjustments, according to Palmetto, or the claim will be rejected for incorrect coding.

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POS Coding Must Match Setting Where Service Was Provided

Putting a place of service (POS) that disagrees with the site of care can derail the revenue train. Here are some tips to help assure you are recognizing the correct place where your patient received care.

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Start Using Cat. III Codes for TAVR Services

Since this past May, you've been able to report—and be paid for—transcatheter aortic valve replacement (TAVR) for Medicare patients. The Centers for Medicare & Medicaid Services (CMS) recently release instructions for how to meet specific requirements for this new national coverage determination (NCD).

When submitting claims for these services, providers should use the following temporary Category III CPT® codes, per MLN Matters® MM7897:

  • 0256T Implantation of catheter-delivered prosthetic aortic heart valve; endovascular approach
  • 0257T Implantation of catheter-delivered prosthetic aortic heart valve; open thoracic approach (eg, transapical, transventricular)
  • 0258T Transthoracic cardiac exposure (eg, sternotomy, thoracotomy, subxiphoid) for catheter-delivered aortic valve replacement; without cardiopulmonary bypass
  • 0259T Transthoracic cardiac exposure (eg, sternotomy, thoracotomy, subxiphoid) for catheter-delivered aortic valve replacement; with cardiopulmonary bypass

Beginning Jan. 1, 2013, permanent CPT® Category I codes 33361-33369 will replace these temporary codes.

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In This Issue
Eye Exams
Gastric Band Adjustments
POS Coding
Cat. III Codes



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