99153 Medicare denial

LissaBridget

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Lake In The Hills, IL
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We are getting denials for CPT 99153 for Medicare. When I called CMS, they state 99153 has an PCTC indicator of 3 which indicates that this is only billable by the facility and not billable by a provider (technical component only). I have sat in on multiple webinars and this was never mentioned - is this true?
 

Ginger417

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My 99153s are being denied for CO-109 (claim not covered by this payer/contractor) I don't understand why they will pay for 99152 but not 99153 either.
 

thomas7331

True Blue
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That information is correct - 99153 was designated as a 'PE-only code' under the PFS 2017 final rule, which means that the payment for that code will only include reimbursement for practice expense. No physician work is paid for 99153, so you will only receive payment for that code under Part B if the services were performed in the office. The explanation given was that the value for the conscious sedation RVU value that was previously included in the surgical procedure codes was taken out from those codes and re-assigned to 99152. So for the physician work portion, the entire value of the conscious sedation service is paid in full by 99152, regardless of the amount of time spent.
 

jasonrme

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Medicare denials

We received several denials from Medicare that denied as duplicates. We billed 99153 on separate lines five times. Should we have billed 99153 with a quantity of 5 instead?
 

willnat2

Networker
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Port Charlotte, FL
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My 99153's are from our own cath lab, not in a hospital. The place of service for our cath lab is 11. Medicare has paid 99152 and one 99153 but not the other three. Do I need to use a modifier?
Thank you
 
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Clarification for Moderate sedation 99153 denials

I've been waiting for clarification on why denials for add-on code 99153 occur. I was told by MedAxiom that 99153 can only be billed by facility. Today a member posted their Medicare carriers clarification:
Home » KY & OH Part B » News & Publications » News » 2017 » 03 » Clarification of CPT Code 99153
March 16, 2017

Clarification of CPT Code 99153
Code Descriptor: Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; each additional 15 minutes intraservice time (list separately in addition to code for primary service)

Billing for moderate sedation services (CPT Codes 99151 or 99152) represents the first 15 minutes of service. All physician work occurs during that first 15 minutes. Usually thereafter, the physician is engaged in performing the procedure, and a nurse will monitor the patient.

The CPT code 99153 represents additional time performed by the nurse (or other personnel). Since the nurse is employed by the facility, incident to billing is not appropriate. Therefore, CPT code 99153 is not payable to the physician since that nurse does not work for him/her, hence the PC/TC indicator 3. There is no physician work involved since he/she is engaged in performing the procedure and the nurse is not employed by the physician. Therefore, the physician cannot bill for the nurse’s services. In an office setting where the nurse is employed by the physician, the code will be billable and the practice will get the value of the facility side of the payment (ie. Practice expense and malpractice expense)

CMS has categorized the code with the PC/TC indicator 3 because it essentially behaves like a technical component only code, since there is no physician work.
 
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