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Wiki sequencing of CPT coding
- Thread starter ciwil123
- Start date
RebeccaWoodward*
True Blue
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Page 108-
C. Carrier Claims Processing System Requirements
10. Rank the surgeries subject to the multiple surgery rules (indicator “2”) in descending order by the Medicare fee schedule amount;
11. Base payment for each ranked procedure (indicator “2”) on the lower of the billed amount:
• 100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure; and
• 50 percent of the fee schedule amount for the second through the fifth highest valued procedures; or
12. If more than five procedures with an indicator of “2” are billed, pay for the first five according to the rules listed in 9, 10, and 11 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, “by report.” Payment determined on a “by report” basis for these codes should never be lower than 50 percent of the full payment amount. Pay by the unit for services that are already reduced (e.g., 17003). Pay for 17340 only once per session, regardless of how many lesions were destroyed;
NOTE: For dates of service prior to January 1, 1995, the multiple surgery indicator of “2” indicated that special dermatology rules applied. The payment rules for these codes have not changed. The rules were expanded, however, to all codes that previously had a multiple surgery indicator of “1.” For dates of service prior to January 1, 1995, if a dermatological procedure with an indicator of “2” was billed with the “-51” modifier with other procedures that are not dermatological procedures (procedures with an indicator of “1” in Field 21), the standard multiple surgery rules applied. Pay no less than 50 percent for the dermatological procedures with an indicator of “2.” See §§40.6.C.6-8 for required actions.
13. If Field 21 contains an indicator of “3,” and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. Access Field 31A of the MFSDB to determine the base endoscopy.
http://www.cms.gov/manuals/downloads/clm104c12.pdf
Page 108-
C. Carrier Claims Processing System Requirements
10. Rank the surgeries subject to the multiple surgery rules (indicator “2”) in descending order by the Medicare fee schedule amount;
11. Base payment for each ranked procedure (indicator “2”) on the lower of the billed amount:
• 100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure; and
• 50 percent of the fee schedule amount for the second through the fifth highest valued procedures; or
12. If more than five procedures with an indicator of “2” are billed, pay for the first five according to the rules listed in 9, 10, and 11 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, “by report.” Payment determined on a “by report” basis for these codes should never be lower than 50 percent of the full payment amount. Pay by the unit for services that are already reduced (e.g., 17003). Pay for 17340 only once per session, regardless of how many lesions were destroyed;
NOTE: For dates of service prior to January 1, 1995, the multiple surgery indicator of “2” indicated that special dermatology rules applied. The payment rules for these codes have not changed. The rules were expanded, however, to all codes that previously had a multiple surgery indicator of “1.” For dates of service prior to January 1, 1995, if a dermatological procedure with an indicator of “2” was billed with the “-51” modifier with other procedures that are not dermatological procedures (procedures with an indicator of “1” in Field 21), the standard multiple surgery rules applied. Pay no less than 50 percent for the dermatological procedures with an indicator of “2.” See §§40.6.C.6-8 for required actions.
13. If Field 21 contains an indicator of “3,” and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. Access Field 31A of the MFSDB to determine the base endoscopy.
http://www.cms.gov/manuals/downloads/clm104c12.pdf
Thanks for the resource
Thank you for the answer to some of my question, here is a example:
Sequence
1-14-11 46824
1-14-11 99232-25
1-15-11 99232
Or post
99232-25 E/M First
46824
99232
The way you enter the charges on your CMS-1500 does it really matter to remibursement? or do the Medicare/insurance companies pay any charges they wish at 100% of the higest RVU. for the first DOS.
Another example
office visit 99 code, with labs 8000 codes, and x-ray 70000. What is the proper way of sequencing? E/M first then highest RVU? or E/M first then all 8000 codes, then 70000 codes. I need some clairfication, please advise!
Thank you,
But, Getting Better!
Thank you for the answer to some of my question, here is a example:
Sequence
1-14-11 46824
1-14-11 99232-25
1-15-11 99232
Or post
99232-25 E/M First
46824
99232
The way you enter the charges on your CMS-1500 does it really matter to remibursement? or do the Medicare/insurance companies pay any charges they wish at 100% of the higest RVU. for the first DOS.
Another example
office visit 99 code, with labs 8000 codes, and x-ray 70000. What is the proper way of sequencing? E/M first then highest RVU? or E/M first then all 8000 codes, then 70000 codes. I need some clairfication, please advise!
Thank you,
But, Getting Better!