Code Treatment Standard Uses Indicator Concern Actions 7xxxx Diagnostic services and procedures, general. Provided early and often in treatment

Transcription

1 7xxxx Diagnostic services and procedures, general Provided early and often in treatment Radiologic examination, spine, cervical; complete, including oblique and flexion and/or extension studies Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient X-rays, MRIs, etc, are used to make a diagnosis, rule out a condition, or to monitor treatment progress. This is the Davis Series of x-rays, including seven views/images of the spine. For use when interpreting data takes significantly longer than accounted for in the normal CPT code for the service Biofeedback training by any modality May be used to reduce chronic pain Conducted on several dates rather than a single visit Fewer than seven images or reports in the file Lots of hours billed Little detail in report Performed on all of a doctor s patients Billed as attended by the doctor but someone else performs it Aggressive imaging may be to generate revenue rather than diagnose or to monitor progress. Billable amount is greater for multiple visits. Seven views may be excessive. Not all views were taken. Provider may be upcoding or billing for services not rendered. If performed, is likely medically unnecessary most of the time. May not be performed. Billing is at the higher physician s rate. documentation to verify the services were performed. Check billing documentation for justification for the separate dates. rate allowed. Check diagnosis to justify taking all views. for Ask patient how many x- rays were taken. Check billing documentation for justification of the extra time. Refer to supervisor or SIU. documentation to find a rationale for the treatment in the particular patient. Link the treatment to the diagnosis code. Check the treatment worksheets to verify who performed the service. CPT Reference Guide Version 10/22/10 Page 2

2 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk Testing a particular extremity to determine impairment Billed for each muscle tested rather than once for each extremity or body part in descriptor Billing for each muscle is unbundling. for If a pattern exists in multiple visits or across patents, refer to Range of motion measurements and report (separate procedure) hand, with or without comparison with normal side Testing a particular extremity to determine impairment E&M, eg Billed for each muscle tested rather than once for each extremity or body part in descriptor E&M, eg Range of motion testing and muscle testing should be included in E&M. Billing for each muscle is unbundling. Range of motion testing and muscle testing should be included in E&M. supervisor or SIU. for If a pattern exists in multiple visits or across patents, refer to supervisor or SIU. for If a pattern exists in multiple visits or across patents, refer to supervisor or SIU. If a pattern exists in multiple visits or across patents, refer to supervisor or SIU. CPT Reference Guide Version 10/22/10 Page 3

3 Testing a particular extremity to determine impairment E&M, eg Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) Range of motion measurements and report (separate procedure) hand, with or without comparison with normal side Testing a particular extremity to determine impairment TMJ injury , which includes ROM testing Frequent (3-4 times) range of motion testing E&M, eg Range of motion testing and muscle testing should be included in E&M. Range of motion testing and muscle testing should be included in E&M. Billing for both is unbundling. May constitute services not rendered. Range of motion testing and muscle testing should be included in E&M for If a pattern exists in multiple visits or across patents, refer to supervisor or SIU. for If a pattern exists in multiple visits or across patents, refer to supervisor or SIU. for If a pattern exists in multiple visits or across patents, refer to supervisor or SIU. Verify testing w/ patient. Check others who may be in the same claim file to see if they are also being billed for frequent ROM testing. for If a pattern exists in multiple visits or across patents, refer to supervisor or SIU. CPT Reference Guide Version 10/22/10 Page 4

4 95860 Needle electromyography; 1 extremity with or without related paraspinal areas Needle electromyography; four extremities, with or without related paraspinal areas Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study Nerve conduction, amplitude and latency/velocity study, each nerve; motor, with F-wave study An electromyogram (EMG) is a an electrical test of muscles and nerve activity to find or exclude a problem, for example a pinched nerve or nerve disease An electromyogram (EMG) is a an electrical test of muscles and nerve activity to find or exclude a problem, for example a pinched nerve or nerve disease For diagnosing nerve damage by stimulating a nerve and recording the activity in the associated muscle For diagnosing nerve damage by stimulating a nerve and recording the activity in the associated muscle Performed on more than one extremity per date of visit Identical test results across patients Separate charges for supplies for the EMG test Billed multiple times for the same nerve Billed multiple times for the same nerve Identical test results when compared across patients May indicate unbundling; other codes provide for testing of 2,3, or 4 extremities. Performing the procedure on all four extremities is not usually necessary. No two people should have the same results. Supplies should be bundled into the charge for the test. Should be charged only one time when multiple sites on the same nerve are stimulated or recorded. Should be charged only one time when multiple sites on the same nerve are stimulated or recorded. No two people should have the same results. for Check reports for the number of needle insertions. Ask the patient which extremities were tested. Refer to supervisor or SIU. for for Refer to supervisor or SIU. CPT Reference Guide Version 10/22/10 Page 5

5 95904 Nerve conduction, amplitude and latency/velocity study, each nerve; sensory For diagnosing nerve damage by stimulating a nerve and recording the activity in the associated sensory nerves Multiple charges for the stimulation of the same nerve Should be charged only one time when multiple sites on the same nerve are stimulated or recorded Digital analysis of electroencephalogram (EEG) Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional hour of physician attendance (List separately in addition to code for primary procedure) Used when significant additional time is required, not simply when the EEG is recorded digitally rather than analog To display and analyze electrophysiological brain data To display and analyze electrophysiological brain data Identical test results when compared across patients No two people should have the same results. May be unbundling with other EEG services. May be considered investigational for post-concussion or mild/moderate brain injuries. May be considered investigational for post-concussion or mild/moderate brain injuries. for Refer to supervisor or SIU. documentation to verify or question the necessity of the additional time. Check company policy. Check diagnosis codes for the injury requiring the service. Consider an IME or peer review. Check company policy. Check diagnosis codes for the injury requiring the service. Consider an IME or peer review. CPT Reference Guide Version 10/22/10 Page 6

6 In P&C medical claims, usually to assess psychological trauma resulting from auto or WC accidents Testing is administered by a person other than the psychologist A receptionist may administer the test, but the time is billed as a psychologist s Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report 97xxx Physical therapy procedures For rehabilitation; uses exercise and other modalities to restore movement and functionality Interpretation time (90887) is billed along with 96101, along with evaluation of medial records (90885), and/or interpretation of test results (90887) Billing for numerous instances of psychological testing Reports provide no detail Doctor bills for initial exam and This is unbundling. This may be possible unnecessary testing or testing not performed. The tests might not have been performed. The doctor s billing rate is higher than a PT s. Ask claimant who administered the tests. for Verify testing with patient. Check documentation for test results, especially boilerplate or cursory reports. Verify testing with patient. Check documentation to verify patient s visit on testing dates. Check signature and provider s ID on bill. Check SOAP notes to see who performed the services. CPT Reference Guide Version 10/22/10 Page 7

7 97010 Application of a modality to 1 or more Presence of 51 areas; hot or cold packs modifier Application of a modality to 1 or more areas; traction, mechanical Electrical stimulation (unattended but supervised); in physical medicine and rehabilitation Application of a modality to 1 or more areas; infrared Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes (constant attendance) To relieve pain and swelling in soft tissue injuries A procedure that allows separation of joint surfaces in the spine to relieve low back pain; can be computerized To restore muscle function through electrical stimulation of nerves Cold laser or infrared, modified to be a service provided greater than that usually required for the listed procedure To restore muscle function through electrical stimulation of nerves Presence of charge Modifier 50 Signs that treatment may have been unattended Modifier indicates multiple procedures, but procedure already includes 1 or more areas. Some providers will bill P&C companies for this procedure but not bill health insurance companies As modified, providers can charge whatever they want. Reimbursement rates for infrared treatment are low; provider may be trying to improve reimbursement May be used when (unattended) should be used. documentation for areas, time treated. Check your company s policy regarding reimbursement of this procedure. Compare the treatment to the diagnosis; does it make sense? documentation to verify the type of treatment and its appropriateness for the injury. Verify treatment with patient. CPT Reference Guide Version 10/22/10 Page 8

8 97039 Unlisted modality (specify type and time if constant attendance) Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, flexibility Neuromuscular reeducation, 15- minute increment Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and or standing activities; Physical medicine services not adequately described by other CPT codes Physical therapy, eg exercises for strength and flexibility Physical therapy for movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting or standing activities; typically used in cases of stroke, broken bones, or damage to nerves and muscles; time sensitive Used to bill Aqua-Med or Aqua-Bed treatments Presence of 51 modifier (multiple procedures) Is billed for a soft-tissue sprain Patient account does not match treatment Billed by a massage therapist No diagnosis of nerve damage Providers may use an unlisted modality for cold laser treatment, permitting higher billing. Water massage beds or chairs may be considered unproven treatments. Treatment is a multiple procedure by definition, so it is not appropriate to use modifier 51 (which indicates multiple treatments) Neuromuscular education is not legitimately used in cases of soft-tissue sprain or strain. The billed services were not rendered. This treatment is generally not permitted by a massage therapist. Nerve damage must be present to justify this documentation to verify the type of See if a more appropriate code exists. Check company policy. Verify the diagnosis and diagnosis code. Verify the provider s credentials. Verify the diagnosis and diagnosis code. CPT Reference Guide Version 10/22/10 Page 9

9 97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion); direct patient contact Massage to increase circulation or promote muscle relaxation Not performed by a physical therapist The provider may try to increase revenue by allowing an untrained masseuse to do the massage. documentation to see who provided the service. Verify credentials of provider Unlisted therapeutic procedure (specify); direct patient contact Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes [direct patient contact] Physical medicine services not adequately described by other CPT codes Hands-on physical therapy, for example moving joints to increase pain-free range of motion or , modifier 59 Providers may use an unlisted modality to permit higher billing. A patient might not be able to tolerate more than a few minutes, but a minimum of 8 minutes is required to bill one unit. May be billed instead of 97110, physical therapy; includes the services in 97110, Allows billing of both treatments to the same area. documentation to verify the type of See if a more appropriate code exists. Ask patient how long the treatment was. Ask patient about the treatments. billing documentation. billing documentation. CPT Reference Guide Version 10/22/10 Page 10

10 97112 The use of both codes is generally not justified Therapeutic activities, direct (one-onone) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes Unlisted physical medicine/ rehabilitation service or procedure Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient Therapeutic activities for balance, strength, and range of motion. Movements involving flexibility, strength and coordination to allow recovery of everyday functionality. Patient education for activities of dialing living or in-home, selfadministered training. Patient training/education for injury recovery Used when no existing CPT code accurately describes the service or procedure provided; sometimes used to represent new or emerging technologies For relieving pain associated with musculo-skeletal injuries from accidents Billed by a massage therapist Billed repeatedly Billed repeatedly Billed numerous times per visit This is intended to be performed by trained PT or OT. This instruction should be one-time, except where a patient has difficulty with the instructions/ training. This instruction should be one-time, except where a patient has difficulty with the instructions/ training May be used to receive reimbursement for an otherwise unreimbursable service or to increase reimbursement for a low-paying service. This charge is for the initial 15 minutes; additional time is billed using Verify treatment with patient. Verify treatment on supporting documentation. Verify provider with patient. Verify provider on supporting documentation. Verify service with patient. Verify service on supporting documentation. Verify service with patient. Verify service on supporting documentation to see if there is a more appropriate CPT code. Verify the medical necessity of the service/procedure. Ask for explanation of CPT Reference Guide Version 10/22/10 Page 11

11 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) For relieving pain associated with musculo-skeletal injuries from accidents Used more than twice after a preceding 97810, acupuncture without electrical stimulation, first 15 minutes 45 minutes or more of this treatment is unusually long duration. Check SOAP notes for verify the number of minutes billed. Verify with patient the length of Verify with patient whether the provider was present the entire Acupuncture with Electrical Stimulation - 15 Minutes Similar, with multiple needles More than 3-4 codes per body part on one date of serviced Billed numerous times per visit More than 3-4 codes per body part on one date of serviced Service might not have been rendered. This charge is for the initial 15 minutes; additional time is billed using The service might not have been rendered. time. Check company policy on acupuncture reimbursement. Refer to supervisor or SIU. Ask for explanation of Check company policy on acupuncture reimbursement. Refer to supervisor or SIU. CPT Reference Guide Version 10/22/10 Page 12

12 97814 Acupuncture with Electrical Stimulation - Additional 15 Minutes Similar, with multiple needles Used more than twice after a preceding 97813, acupuncture without electrical stimulation, first 15 minutes 45 minutes or more of this treatment is unusually long duration. Check SOAP notes for verify the number of minutes billed. Verify with patient the length of Verify with patient whether the provider was present the entire Chiropractic manipulation treatment (CMT); spinal, one to two regions Hand manipulation of the spine to correct chiropractic problems More than 3-4 codes per body part on one date of serviced Billing this service in an office visit or E&M codes May be service not rendered. Manipulative treatment includes a pre-manipulation assessment; a separate E&M charge is not warranted. time. Check company policy on acupuncture reimbursement. Refer to supervisor or SIU Chiropractic manipulation treatment (CMT); spinal, three to four regions Chiropractic manipulation treatment (CMT); spinal, three to four regions Hand manipulation of the spine to correct chiropractic problems Hand manipulation of the spine to correct chiropractic problems Billed with -59 modifier and in on the same area an office visit or E&M codes an office visit or E&M codes The modifier allows both treatments to be billed; it is similar to unbundling. Manipulative treatment includes a pre-manipulation assessment; a separate E&M charge is not warranted. Manipulative treatment includes a pre-manipulation assessment; a separate E&M charge is not warranted. CPT Reference Guide Version 10/22/10 Page 13

13 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions Hand manipulation of the spine to correct chiropractic problems an office visit or E&M codes Manipulative treatment includes a pre-manipulation assessment; a separate E&M charge is not warranted Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: a problem-focused medical history; a problem-focused examination; straightforward medical decision-making. Usually, the presenting problems are self-limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: an expanded problemfocused history; an expanded problem-focused examination; straightforward medical decisionmaking. Usually, the presenting problems are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. For E&M of new patient, minor problems For E&M of new patient, low/moderate problems Billed multiple times in one visit Billed every visit by chiropractor Billed every visit by chiropractor Should be used only one time per visit, regardless of the number of manipulations performed. In general, a patient is new only for one visit. In addition, this E/M code should not be billed when all that is provided is adjustment. This E/M code should not be billed when all that is provided is adjustment. CPT Reference Guide Version 10/22/10 Page 14

14 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: a detailed medical history; a detailed examination; medical decision-making of low complexity. Usually, the presenting problems are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. For E&M of new patient, moderate problems Billed every visit by chiropractor This E/M code should not be billed when all that is provided is adjustment Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: a comprehensive medical history; a comprehensive examination; medical decision-making of moderate complexity. Usually, the presenting problems are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: a comprehensive medical history; a comprehensive examination; medical decision-making of high complexity. Usually, the presenting problems are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. For E&M of new patient, moderate/severe problems For E&M of new patient, severe problems Used for relatively minor injuries Used for visits subsequent to the first when adjustment is all that is provided Used for relatively minor injuries Used for visits subsequent to the first when adjustment is all that is provided This is upcoding, seeking reimbursement for more services than actually provided. This E/M code should not be billed when all that is provided is adjustment. This is upcoding, seeking reimbursement for more services than actually provided. This E/M code should not be billed when all that is provided is adjustment. CPT Reference Guide Version 10/22/10 Page 15

15 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: an expanded, problem-focused history; an expanded, problemfocused examination; medical decision-making of low complexity. Usually, the presenting problems are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. For E&M of established patient, problems of low/moderate severity Used to bill manipulations rather than using the manipulation code, eg This E/M code should not be billed when all that is provided is adjustment Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed medical history; a detailed examination; medical decision-making of moderate complexity. Usually, the presenting problems are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive medical history; a comprehensive examination; medical decision-making of high complexity. Usually, the presenting problems are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. For E&M of established patient, problems of moderate/high severity For E&M of established patient, problems of high severity Used for relatively minor injuries Visits are billed at this code until release Used for relatively minor injuries Visits are billed at this code until release This is upcoding, seeking reimbursement for more services than actually provided. Billing at the same code implies no improvement in the patient s condition. This is upcoding, seeking reimbursement for more services than actually provided. Billing at the same code implies no improvement in the patient s condition. documentation for condition, treatments. Consider referring to supervisor, SIU. CPT Reference Guide Version 10/22/10 Page 16

16 99241 to Office consultations for a new or established patient Frequent consultations There may be kickbacks involved to the referring provider Prolonged evaluation and management service before and/or after direct (face-to-face) patient care; first hour Referral to another provider to help evaluate or manage a patient s condition Review of records or diagnostic testing results in non-face-toface time, minutes of time beyond the time built into other codes for the services provided Billed by nonphysician, eg an acupuncturist Billing for a consultation for the provider s own patient, eg, a patient not referred by another provider for consultation An appropriate acupuncture code would include treatment, setup, and evaluation. This is not permitted. Provider may be attempting to bill more time than actually spent. Look for connections with other providers. Refer claim to SIU. Use supporting documentation to verify provider. Look for patterns across patients. Look for patterns across patients. documentation for the necessity of the documentation for evidence of the results of the additional E&M time. CPT Reference Guide Version 10/22/10 Page 17

17 Cross-Reference Term See this CPT code Acupuncture 97810, 97811, 97812, Biofeedback training Brain testing 95957, 95961, Chiropractic manipulation 98940, 98941, 98942, Community/work reintegration training Consultations 99241, 99242, 99243, 99244, Davis series Diagnostic services 7xxxx EEG interpretation Electromyography 95860, Epidural steroid injection (ESI) 62310, 62311, , Evaluation and management (E&M) 99201, 99202, 99203, 99204, 99205, 99213, 99214, 99215, Exercises, physical therapy Heat treatment Hot or cold packs Manipulation under anesthesia (MUA) Manipulation, chiropractic 98940, 98941, 98942, Manual therapy (physical therapy) Massage Muscle testing Nerve testing 95860, 95864, 95900, 95903, Neuromuscular re-education Patient education Percutaneous disk decompression (PDD) Physical therapy 97xxx Psychiatric services Psychological services Range of motion testing 95832, 95851, Self-care/home management training Stimulation, electrical 97014, Therapeutic activities (physical therapy) Traction Unlisted modality Unlisted physical medicine Unlisted therapeutic procedure (physical medicine) X-rays CPT Reference Guide Version 10/22/10 Page 18