I'm going to make Asian Medicine more popular but...

[Guest guest]

It's a great skill to have. Wish I had it!

 

Warm regards,

 

Attilio D'Alberto

Doctor of (Beijing, China)

B.Sc. (Hons) T.C.M. M.A.T.C.M.

Editor

Times

07786 198900

enquiries

<http://www.chinesemedicinetimes.com/> www.chinesemedicinetimes.com

 

 

Chinese Medicine

Chinese Medicine On Behalf Of mike

Bowser

25 February 2006 15:47

Chinese Medicine

Re: Re: I'm going to make Asian Medicine more popular but...

 

 

 

My chiro program has us taking business courses from the beginning and these

 

involve public speaking.

 

Mike W. Bowser, L Ac

 

 

 

 

 

>KarateStan

>Chinese Medicine

>Chinese Medicine

>Re: Re: I'm going to make Asian Medicine more popular but...

>Thu, 23 Feb 2006 10:56:33 EST

>

>

>In a message dated 2/23/2006 10:42:08 A.M. Eastern Standard Time,

>ra6151 writes:

>

>I agree with you, Mike. We had 2 different business courses at my

>school,

>and still the business side is a challenge.

>

>

>Many colleges offer MD's a night course for a MBA.

>Medicine is a business.

>

>

>

[Guest guest]

Forgot to add that the example is using Medicaid. This form can be used for

all insurance not just this govt program.

 

Mike W. Bowser, L Ac

 

 

 

 

 

> " mike Bowser " <naturaldoc1

>Chinese Medicine

>Chinese Medicine

>Re: Re: I'm going to make Asian Medicine more popular but...

>Sat, 25 Feb 2006 15:05:37 +0000

>

>Here is a state link that shows how to fill out the new CMA-1500 form.

>

>http://www.dhs.state.mn.us/main/groups/business_partners/documents/pub/dhs_id_0\

10115.hcsp

>

>If you want an electronically fillable form that you can print out instead

>of having to write-in, check out www.cigna.com and look for forms. They

>have updated with the newer form.

>

>Hope this helps.

>

>Mike W. Bowser, L Ac

>

>

>

>

>

> >petetheisen <petetheisen

> >Chinese Medicine

> >Chinese Medicine

> >Re: Re: I'm going to make Asian Medicine more popular

>but...

> >Sat, 25 Feb 2006 04:16:14 -0500

> >

> >mike Bowser wrote:

> > > Unless one wants to do this as a hobby, it is important to be aware of

> >the

> > > business side of things. I am familiar with too many graduates who

> >never

> > > take on full-time practice. It is very problematic and a bad sign

>that

> > > maybe something is wrong with the non-TCM side of their education.

>This

> >is

> > > an aside but I feel that we need to better prepare graduates with more

> > > business ideas and info on how to start and run a practice. I am

>blown

> >away

> > > when I read that graduates do not know billing codes or how to fill

>out

> >the

> > > insurance form.

> >

> >Hi Mike!

> >

> >I have been looking for instructions on how to fill out the insurance

> >form. To begin with, I haven't seen two alike . . .

> >

> >Regards,

> >

> >Pete

>

>

>

>

[Guest guest]

mike Bowser wrote:

> Forgot to add that the example is using Medicaid. This form can be used for

> all insurance not just this govt program.

 

Hi Mike!

 

So I just make up my own form using that information?

 

Regards,

 

Pete

[Guest guest]

I accepted that you already have a copy of the billing form. If not use the

link below to get a fillable form, must have Adobe Reader to use. Can only

print out on a Mac (not fillable) unless you have virtual PC.

 

http://www.cigna.com/health/consumer/service/forms/forms_medical_claim_form.pdf

 

The previous instructions were given to share with another member how to

fill the form out. Hope this helps.

 

Mike W. Bowser, L Ac

 

 

 

 

 

>petetheisen <petetheisen

>Chinese Medicine

>Chinese Medicine

>Re: Re: I'm going to make Asian Medicine more popular but...

>Sat, 25 Feb 2006 13:37:57 -0500

>

>mike Bowser wrote:

> > Forgot to add that the example is using Medicaid. This form can be used

>for

> > all insurance not just this govt program.

>

>Hi Mike!

>

>So I just make up my own form using that information?

>

>Regards,

>

>Pete

[Guest guest]

In a message dated 2/25/2006 4:22:53 A.M. Eastern Standard Time,

petetheisen writes:

 

I have been looking for instructions on how to fill out the insurance

form.

 

 

Pet,

The State Worker Comp web site as the instructions.

 

 

 

[Guest guest]

mike Bowser wrote:

> I accepted that you already have a copy of the billing form. If not use the

> link below to get a fillable form, must have Adobe Reader to use. Can only

> print out on a Mac (not fillable) unless you have virtual PC.

>

>

http://www.cigna.com/health/consumer/service/forms/forms_medical_claim_form.pdf

>

> The previous instructions were given to share with another member how to

> fill the form out. Hope this helps.

 

Hi Mike!

 

So I just use the cigna form with any company?

 

Regards,

 

Pete

[Guest guest]

Just go to staples and buy the forms.

 

Kelvin

 

 

Chinese Medicine , petetheisen

<petetheisen wrote:

>

> mike Bowser wrote:

> > I accepted that you already have a copy of the billing form. If

not use the

> > link below to get a fillable form, must have Adobe Reader to use.

Can only

> > print out on a Mac (not fillable) unless you have virtual PC.

> >

> >

http://www.cigna.com/health/consumer/service/forms/forms_medical_claim_form.pdf

> >

> > The previous instructions were given to share with another member

how to

> > fill the form out. Hope this helps.

>

> Hi Mike!

>

> So I just use the cigna form with any company?

>

> Regards,

>

> Pete

>

[Guest guest]

I have never had any problem doing that, even though the cigna name appears

in the upper right corner. Think of it as an advertisement. The form is a

standard, all else should be the same. If you find a better one, please

post it for everyone's benefit. I found another one yesterday but it had

the insr name and their address largely displayed accross the top. I opted

not to post that link feeling that this one is much more discrete and

professional. You should like that you can type in the info and print it

out in a nice professional format.

 

By the way, instructions for filling it out are included. Hope this helps.

 

Mike W. Bowser, L Ac

 

 

 

 

 

>petetheisen <petetheisen

>Chinese Medicine

>Chinese Medicine

>Re: Re: I'm going to make Asian Medicine more popular but...

>Sun, 26 Feb 2006 00:25:13 -0500

>

>mike Bowser wrote:

> > I accepted that you already have a copy of the billing form. If not use

>the

> > link below to get a fillable form, must have Adobe Reader to use. Can

>only

> > print out on a Mac (not fillable) unless you have virtual PC.

> >

> >

>http://www.cigna.com/health/consumer/service/forms/forms_medical_claim_form.pdf

> >

> > The previous instructions were given to share with another member how to

> > fill the form out. Hope this helps.

>

>Hi Mike!

>

>So I just use the cigna form with any company?

>

>Regards,

>

>Pete

[Guest guest]

acupuncturebeverlyhills wrote:

> Just go to staples and buy the forms.

>

> Kelvin

 

Hi Kelvin!

 

Whoa, bingo!

 

Ran over to Staples and there they were! Thanks for the tip!

 

Regards,

 

Pete

[Guest guest]

mike Bowser wrote:

<snip>

> blown away when I read that graduates do not know billing codes or

> how to fill out the insurance form. We should be expert in all areas

> of our profession.

 

Hi Mike!

 

Struggling with codes, have the forms now.

 

http://www.acupuncturetoday.com/archives2006/mar/03collins.html

 

Talks about " E & M " . Acronyms are confusing, what is E & M? Of course,

not a *word* of this in three years of TCM school.

 

Is there a list of all the codes we would use somewhere on the web? Is

this different from state to state?

 

Regards,

 

Pete

[Guest guest]

petetheisen wrote:

 

Hi Everybody!

 

This is pretty good:

 

<www.aaom.info/cptcodes.pdf>

 

Regards,

 

Pete

 

> mike Bowser wrote: <snip>

>

>> blown away when I read that graduates do not know billing codes or

>> how to fill out the insurance form. We should be expert in all

>> areas of our profession.

>

>

> Hi Mike!

>

> Struggling with codes, have the forms now.

[Guest guest]

Don't forget to check out ABC codes.

You don;t HAVE to use CPT (owned by AMA).

_http://www.alternativelink.com/ali/intro_altlink.html_

(http://www.alternativelink.com/ali/intro_altlink.html)

 

Richard

 

 

Pete,

 

Sorry to hear that and more common than most of us think. The CPT codes are

universal and do not vary. Payments for services, however, are another

story and this depends upon the insurance co and patient plan. Best

suggestion is to attend a seminar and/or purchase a copy of the AMA CPT

manual. Hope this helps.

 

 

Mike W. Bowser, L Ac

 

 

 

 

 

 

[Guest guest]

Hello there!

So how do we file for Evaluation & Management (EM)

How do we use modifier 25? Which column will that go to?

Thanks.

amy

 

 

 

[Guest guest]

In a message dated 2/27/2006 11:30:45 A.M. Eastern Standard Time,

Amyc144 writes:

 

How do we use modifier 25? Which column will that go to?

Thanks.

 

 

 

 

MODIFIER -25: GENERAL USAGE GUIDELINES

To properly use the Modifier -25 code, follow these four general guidelines.

1. Same day as procedure. Modifier -25 can only be used to bill a

significant, separately identifiable E/M service which occurs on the same day

as a

primary procedure or service by the same provider. If the significant

separately identifiable E/M service occurs during a post-procedure global

coverage

period, but not on the same day of the procedure, use modifier -24. The

physician may claim both the evaluation and management service and the

procedure

by appending a modifier -25 to the evaluation and management service code.

(Modifier -25 should be used with E/M codes only and not with surgery /global

codes).

2. Significant, separately identifiable E/M service. The patient’s medical

record documentation is expected to clearly evidence that the evaluation and

management service performed and billed was “above and beyond†the usual

pre-operative and post-operative care associated with the procedure performed

on that same day. The need to perform an independent evaluation and

management service may be prompted by a complaint, symptom, condition, problem,

or

circumstance which may or may not be related to the procedure (or other

service) provided. As such, different diagnoses from those related to the

procedure are not required for reporting of a significant, separately

identifiable

E/M service performed on the same date. However, the record should document an

important, notable, distinct correlation with signs and symptoms to make a

diagnostic classification or demonstrate a distinct problem. The following

case histories provide guidance in classifying a significant, separable E/M

service.

3. Adequate documentation as an E/M service. E/M services for established

visits require two of three key components: history, exam, and

decision-making. Documenting only the evaluation of a separate problem without

documenting

the management component (what was done about the problem) is incomplete and

would be denied as an E/M service, with or without the modifier

-25.Appropriate level of E/M service.

4. An E/M service with the modifier -25 must be coded at the appropriate

level (99211-99215) for the E/M service without the modifier -25. The E/M

service should include at least the evaluation of the significant, separately

identifiable finding and management (two of the three key components of an E/M

service). Just identifying the finding without decision making does not meet

the E/M criteria. The level of service should only include that significant,

separately identifiable finding and management, and not include the usual pre-

and post-operative/procedural evaluation (this remember, is included in a

global surgery/procedure).

SPECIAL USAGE GUIDELINES

New patient E/M. A new patient E/M service, as defined by CPT, is, by its

very nature, considered to be a significant, separately identifiable

evaluation and management service when documentation guidelines for the E/M

service

are met. A new patient E/M service does not need to have a modifier -25

appended when a minor procedure/surgery (global period: 000 [same day only] or

010 [10 days]) is performed on the same date. Therefore when billing any global

procedures/surgeries, including foot care codes (CMS dropped the CCI edit),

modifier -25 does not need to be appended to the new patient E/M service

code.

Procedure as a follow-up service. When a procedure (e.g., minor surgery)

is performed as a follow-up service, or is scheduled in advance to be the

primary or major service performed during a patient encounter, billing an E/M

service is only warranted when there is documentation that a significant,

separately identifiable new problem or condition exists. An example of this

is if

a patient with actinic keratoses is scheduled to return in two weeks for

treatment (destruction) of the lesions. Unless there is a new and unrelated

problem/condition presented for evaluation and management; or there is a

significant change in her current problem treatment plan, the primary purpose

or

major service performed on that scheduled return encounter would be procedural,

and not an independent significant, separately identifiable evaluation or

management service.

E/M on day before a minor procedure (000). Modifier -25 is not needed if

an E/M patient encounter occurred the day before the performance of a minor

surgery, since the global period for minor procedures does not include the day

prior to the surgery.

Services of another physician. The global surgery policy does not apply to

services of another physician who may be rendering services during the pre-

and post-operative period unless the physician is a member of the same group

and is of the same specialty as the operating physician.

EXCEPTIONS

Documentation justification. Medical records must clearly document

information evidencing extra work beyond a procedure’s usual and customary

pre-operative service when billing an E/M service with modifier -25. That

supportive

documentation must be available upon request with the following exceptions

for inpatient dialysis services and critical care visits:

Inpatient dialysis service. Inpatient dialysis service(s) (90935, 90937,

90945, and 90947): All E/M services provided on the same day as inpatient

dialysis services are denied without review. However, the codes 99221-99223,

99251-99255 and 99238-99239 billed with –25 may be allowed when the

respective

service was unrelated to the treatment of ESRD and was not and could not have

been furnished during the dialysis treatment. Documentation supporting the

need of the respective service unrelated to the treatment of end stage renal

disease (ESRD), must be submitted with the claim.

Critical care visits. When used in conjunction with critical care visits

(99291 and 99292) performed during the global period, reimbursement can be made

when the following conditions exist:

The patient is critically ill and requires the constant attention of the

physician and

The critical care is unrelated to the specific anatomic injury or general

procedure performed.

In lieu of documenting these conditions, ICD-9-CM codes in ranges

800.00-929.9 and 940-959.9 are acceptable (i.e., coded to the highest level of

specificity).

******************************************************************************

 

MODIFIER -25 BILLING SCENARIOS

******************************************************************************

 

Scenario 1: A patient’s primary care physician writes orders for Dr.

Smith, a podiatrist, to see a newly admitted skilled nursing facility (SNF)

patient for foot problems. The podiatrist’s documentation reads as follows:

SUBJECTIVE: Pain both great toenails. The patient is reporting pain on those

two toes with any pressure – shoes, socks, even the bed sheets. The patient

is also reporting constant itching on the bottom of both feet.

OBJECTIVE: This pleasant, elderly patient is complaining of pain in the

great toenails. The patient states that those nails have been tender for

several

weeks, steadily increasing in discomfort. No treatment has previously been

performed. DERM: All nails are discolored and long. The hallux nails are

thick, brittle, and severely dystrophic. There is mild redness surrounding

the

great toenails. No drainage is noted. The patient’s skin is generally

thin and shiny. There is no hair present on the lower extremities. There is

general dryness with scaly reddened skin present along the bottom of both feet.

VASCULAR: the pedal pulses are noted as right dorsalis pedis: trace palpable;

right PT pulse: 1/4 palpable; left dorsalis pedis: 1/4 palpable; left PT

trace palpable. The patient has mild non-pitting swelling around both ankles.

NEURO: normal sharp/dull sensation with no apparent loss of protective

sensation. Vibratory sensation: deferred. DTR: deferred.

ASSESSMENT: Painful onychomycosis dystrophic hallux nails bilateral with

onychia; peripheral vascular disease bilateral; 1-10 nails; dystrophic hallux

toenails; onychia hallux bilateral; peripheral vascular disease both feet;

chronic tinea pedis bilateral.

Admission diagnosis: UTI, Hx of CVA.

PLAN: 1) evaluate the patient; 2) debride hallux nails, bilateral 3) trim

remaining 8 nails; 4) Rx Loprox cream BID application to bottom of both feet,

5) re-evaluate patient prn.

_

The billing was submitted as follows:

01/01/03 Subsequent nursing facility care E/M code with modifier -25

01/01/03 CPT 11721 (debridement of nails 6-10)

Review of the above medical record indicates the following:

· Performance of a nursing facility E/M service was reasonable and

necessary.

· Debridement of painful mycotic dystrophic of the hallux nails

meets Medicare mycotic nail coverage guidelines.

· Since the podiatrist is seeing the patient on a first time basis

(as a new patient), and a new patient or initial nursing care facility E/M

cannot be used, the podiatrist should bill:

CPT coding should have been: Subsequent nursing facility care E/M code

with modifier -25 is correct.

CPT 11720 – only the great toenails are debrided.

ICD-9-CM coding should have been: ICD-9-CM 110.1 (onychomycosis);

ICD-9-CM 681.11 (onychia);

ICD-9-CM 110.4 (tinea pedis);

******************************************************************************

 

Scenario 2: Ms. Jones has returned for re-evaluation of her heel pain, and

possible follow-up cortisone injection. Ten days prior, the doctor told her

that she might require a series of three cortisone injections 10 days apart

in order to resolve her symptoms. Ms. Jones was given her first injection at

that time. During this return visit, she reported that, at first, the right

heel hurt, but over the past 4 or 5 days, the pain level had reduced by 60%.

The patient pointed to the area of the right heel that was still tender.

The site was palpated to isolate the area of maximum pain, and a 2nd

injection (3 mg) of Celestone Soluspan was administered to the area near the

ins

ertion of the plantar fascia. The patient was advised to continue her

stretching

exercises, and keep her weightbearing activities to a minimum. Impression:

plantar fasciitis right heel. Return to office: 2 weeks for possible 3rd

injection.

_

The billing was submitted as follows:

02/01/04 E/M code with modifier 25

02/01/04 CPT 20551 (injection tendon origin/insertion)

Review of the above scenario indicates the following:

· There was no evidence of a separate, significantly identifiable

E/M service since:

· The diagnosis/condition remained with same

· The treatment was “pre-scheduled†– it was the primary service

performed on a patient scheduled to return to the office for follow-up care.

· There was no significant interval history or examination change,

and the follow-up treatment remained unchanged.

CPT coding should have been:

CPT 20550-RT (the appropriate code for injection plantar fascia)

 

J0702 (betamethasone acetate and betamethasone sodium phosphate, 3 mg)

ICD-9-CM coding should have been: ICD-9-CM 728.71 (plantar fasciitis);

 

ICD-9-CM 729.5 (pain in limb)

******************************************************************************

 

Scenario 3: A new patient was referred to an orthopedic surgeon for a

consultation. The patient was complaining of left shoulder pain of one month

duration. The pain was increasing in intensity and limiting according to the

patient. The physician’s documentation indicated that the left and right

shoulders were examined, including the performance of a brief range of motion

test.

A complete x-ray study of the left should was taken and read as normal.

The orthopedist determined that the patient had a joint inflammation, and

administered a cortisone injection. The documentation information included

additional history of present illness, a medical history, a review of systems

check-off list which was left blank, his impression and plan (documentation

only

indicates that “injection givenâ€).

_

The billing was submitted as follows:

11/01/03 Consultation E/M code with modifier 25

11/01/03 CPT 73030

11/01/03 CPT 20610 (injection, shoulder)

Review of the above scenario indicates the following:

· The consultation E/M service code with a modifier -25 was

appropriately billed because consultation series E/M codes do not distinguish

whether

the patient is new or established, only if the encounter is an initial

consultation or and established consultation.

· It is expected that the medical record documentation will include

the specific type and dosage of steroid that is injected into the joint.

CPT coding should have been:

Initial consultation E/M with modifier -25

CPT 73030-LT - however this was assessed an overpayment due to lack of

documentation of site.

CPT 20610-LT – however this was assessed an overpayment due to lack of

documentation of dosage administered.

· In this scenario, had the provider’s medical documentation

included the name, dosage, & site of the cortisone injected, the cortisone

injection

would have been approved as well.

******************************************************************************

 

Scenario 4. An established patient who has not been seen for two years

comes into the office complaining of a 1 year history of bleeding hemorrhoids

with pain and prolapsed bowel. The symptoms have been increasing in the last

2 months. The documentation indicates no significant medical problems other

than hemorrhoids. No significant relief of symptoms with medications,

suppositories, or sitz baths is reported. The patient denies constipation,

abdominal pain or other gastrointestinal problems. She does relate that she

had

a cardiac catheterization last year, but no symptoms of CAD; no HTN or lung

problems. The patient’s medications included Vioxx 25 mg/day; Premarin 0.025

mg/day; Provera 2-5 mg/day; Dicole bid, Fosamax 20 mg/week; and Anusol DC

suppositories prn. The history and physical examination only gave positive

and negative findings regarding the visual rectum and skin surrounding the

anus. The remaining physical exam of other systems only has check-offs in the

‘

WNL’ column with no positive or negative written findings. No digital rectal

examination is documented.

The provider performed an anoscopy, and documents the findings of:

hemorrhoids – 3 internal @ 3:00 o’clock; two @ 9:00 o’clock & 12:00

o’clock with

thrombosis and bleeding; one fissure at 10:00 o’clock position with moderate

degree of rectal prolapse. Perianal erythema with excoriation; stool –

positive for occult blood.

The provider scheduled and performed the next morning a fissurectomy,

sphincterotomy, and hemorrhoidectomy of the three-thrombosed internal

hemorrhoids @

the 3:00, 9:00 & 12:00 o’clock position. The patient is given the

instruction for the prep. The operative note dated 01/02/03, confirms this

surgery was

performed.

 

 

 

[Guest guest]

Crystal!

Thanks, Stan.

 

amy

 

 

 

[Guest guest]

Pete,

 

Sorry to hear that and more common than most of us think. The CPT codes are

universal and do not vary. Payments for services, however, are another

story and this depends upon the insurance co and patient plan. Best

suggestion is to attend a seminar and/or purchase a copy of the AMA CPT

manual. Hope this helps.

 

 

Mike W. Bowser, L Ac

 

 

 

 

 

>petetheisen <petetheisen

>Chinese Medicine

>Chinese Medicine

>Re: Re: I'm going to make Asian Medicine more popular but...

>Mon, 27 Feb 2006 03:27:46 -0500

>

>mike Bowser wrote:

><snip>

> > blown away when I read that graduates do not know billing codes or

> > how to fill out the insurance form. We should be expert in all areas

> > of our profession.

>

>Hi Mike!

>

>Struggling with codes, have the forms now.

>

>http://www.acupuncturetoday.com/archives2006/mar/03collins.html

>

>Talks about " E & M " . Acronyms are confusing, what is E & M? Of course,

>not a *word* of this in three years of TCM school.

>

>Is there a list of all the codes we would use somewhere on the web? Is

>this different from state to state?

>

>Regards,

>

>Pete

[Guest guest]

I think you do if you want CA work comp payments.

 

Mike W. Bowser, L Ac

 

 

 

 

 

>acudoc11

>Chinese Medicine

>Chinese Medicine

>Re: Re: I'm going to make Asian Medicine more popular but...

>Mon, 27 Feb 2006 10:33:49 EST

>

>

>Don't forget to check out ABC codes.

>You don;t HAVE to use CPT (owned by AMA).

>_http://www.alternativelink.com/ali/intro_altlink.html_

>(http://www.alternativelink.com/ali/intro_altlink.html)

>

>Richard

>

>

>Pete,

>

>Sorry to hear that and more common than most of us think. The CPT codes

>are

>universal and do not vary. Payments for services, however, are another

>story and this depends upon the insurance co and patient plan. Best

>suggestion is to attend a seminar and/or purchase a copy of the AMA CPT

>manual. Hope this helps.

>

>

>Mike W. Bowser, L Ac

>

>

>

>

>

>

[Guest guest]

Be careful, I think that this refers to a procedure like an xray, which has

two distinct parts (technical and professional).

 

Mike W. Bowser, L Ac

 

 

 

 

 

>KarateStan

>Chinese Medicine

>Chinese Medicine

>Re: Re: I'm going to make Asian Medicine more popular but...

>Mon, 27 Feb 2006 12:23:23 EST

>

>

>In a message dated 2/27/2006 11:30:45 A.M. Eastern Standard Time,

>Amyc144 writes:

>

>How do we use modifier 25? Which column will that go to?

>Thanks.

>

>

>

>

>MODIFIER -25: GENERAL USAGE GUIDELINES

>To properly use the Modifier -25 code, follow these four general

>guidelines.

>1. Same day as procedure. Modifier -25 can only be used to bill a

>significant, separately identifiable E/M service which occurs on the same

>day as a

>primary procedure or service by the same provider. If the significant

>separately identifiable E/M service occurs during a post-procedure global

>coverage

>period, but not on the same day of the procedure, use modifier -24. The

>physician may claim both the evaluation and management service and the

>procedure

>by appending a modifier -25 to the evaluation and management service code.

>(Modifier -25 should be used with E/M codes only and not with surgery

>/global

>codes).

>2. Significant, separately identifiable E/M service. The patient’s

>medical

> record documentation is expected to clearly evidence that the evaluation

>and

> management service performed and billed was “above and beyond†the

>usual

>pre-operative and post-operative care associated with the procedure

>performed

>on that same day. The need to perform an independent evaluation and

>management service may be prompted by a complaint, symptom, condition,

>problem, or

>circumstance which may or may not be related to the procedure (or other

>service) provided. As such, different diagnoses from those related to the

>procedure are not required for reporting of a significant, separately

>identifiable

>E/M service performed on the same date. However, the record should

>document an

>important, notable, distinct correlation with signs and symptoms to make a

>diagnostic classification or demonstrate a distinct problem. The following

>case histories provide guidance in classifying a significant, separable

>E/M

>service.

>3. Adequate documentation as an E/M service. E/M services for

>established

>visits require two of three key components: history, exam, and

>decision-making. Documenting only the evaluation of a separate problem

>without documenting

>the management component (what was done about the problem) is incomplete

>and

>would be denied as an E/M service, with or without the modifier

>-25.Appropriate level of E/M service.

>4. An E/M service with the modifier -25 must be coded at the appropriate

>level (99211-99215) for the E/M service without the modifier -25. The E/M

>service should include at least the evaluation of the significant,

>separately

>identifiable finding and management (two of the three key components of an

>E/M

>service). Just identifying the finding without decision making does not

>meet

>the E/M criteria. The level of service should only include that

>significant,

>separately identifiable finding and management, and not include the usual

>pre-

>and post-operative/procedural evaluation (this remember, is included in a

>global surgery/procedure).

>SPECIAL USAGE GUIDELINES

>New patient E/M. A new patient E/M service, as defined by CPT, is, by

>its

>very nature, considered to be a significant, separately identifiable

>evaluation and management service when documentation guidelines for the

>E/M service

>are met. A new patient E/M service does not need to have a modifier -25

>appended when a minor procedure/surgery (global period: 000 [same day

>only] or

>010 [10 days]) is performed on the same date. Therefore when billing any

>global

> procedures/surgeries, including foot care codes (CMS dropped the CCI

>edit),

>modifier -25 does not need to be appended to the new patient E/M service

>code.

>Procedure as a follow-up service. When a procedure (e.g., minor surgery)

>is performed as a follow-up service, or is scheduled in advance to be the

>primary or major service performed during a patient encounter, billing an

>E/M

>service is only warranted when there is documentation that a significant,

>separately identifiable new problem or condition exists. An example of

>this is if

>a patient with actinic keratoses is scheduled to return in two weeks for

>treatment (destruction) of the lesions. Unless there is a new and

>unrelated

>problem/condition presented for evaluation and management; or there is a

>significant change in her current problem treatment plan, the primary

>purpose or

>major service performed on that scheduled return encounter would be

>procedural,

>and not an independent significant, separately identifiable evaluation or

>management service.

>E/M on day before a minor procedure (000). Modifier -25 is not needed if

>an E/M patient encounter occurred the day before the performance of a

>minor

>surgery, since the global period for minor procedures does not include the

>day

>prior to the surgery.

>Services of another physician. The global surgery policy does not apply

>to

>services of another physician who may be rendering services during the

>pre-

>and post-operative period unless the physician is a member of the same

>group

>and is of the same specialty as the operating physician.

>EXCEPTIONS

>Documentation justification. Medical records must clearly document

>information evidencing extra work beyond a procedure’s usual and

>customary

>pre-operative service when billing an E/M service with modifier -25. That

> supportive

>documentation must be available upon request with the following exceptions

>for inpatient dialysis services and critical care visits:

>Inpatient dialysis service. Inpatient dialysis service(s) (90935, 90937,

>90945, and 90947): All E/M services provided on the same day as inpatient

>dialysis services are denied without review. However, the codes

>99221-99223,

>99251-99255 and 99238-99239 billed with –25 may be allowed when the

>respective

>service was unrelated to the treatment of ESRD and was not and could not

>have

>been furnished during the dialysis treatment. Documentation supporting the

>need of the respective service unrelated to the treatment of end stage

>renal

>disease (ESRD), must be submitted with the claim.

>Critical care visits. When used in conjunction with critical care visits

>(99291 and 99292) performed during the global period, reimbursement can be

>made

>when the following conditions exist:

>The patient is critically ill and requires the constant attention of the

>physician and

>The critical care is unrelated to the specific anatomic injury or general

>procedure performed.

>In lieu of documenting these conditions, ICD-9-CM codes in ranges

>800.00-929.9 and 940-959.9 are acceptable (i.e., coded to the highest

>level of

>specificity).

>******************************************************************************

>

>MODIFIER -25 BILLING SCENARIOS

>******************************************************************************

>

>Scenario 1: A patient’s primary care physician writes orders for Dr.

>Smith, a podiatrist, to see a newly admitted skilled nursing facility

>(SNF)

>patient for foot problems. The podiatrist’s documentation reads as

>follows:

>SUBJECTIVE: Pain both great toenails. The patient is reporting pain on

>those

>two toes with any pressure – shoes, socks, even the bed sheets. The

>patient

>is also reporting constant itching on the bottom of both feet.

>OBJECTIVE: This pleasant, elderly patient is complaining of pain in the

>great toenails. The patient states that those nails have been tender for

>several

>weeks, steadily increasing in discomfort. No treatment has previously

>been

>performed. DERM: All nails are discolored and long. The hallux nails are

>thick, brittle, and severely dystrophic. There is mild redness

>surrounding the

>great toenails. No drainage is noted. The patient’s skin is generally

>thin and shiny. There is no hair present on the lower extremities. There

>is

>general dryness with scaly reddened skin present along the bottom of both

>feet.

>VASCULAR: the pedal pulses are noted as right dorsalis pedis: trace

>palpable;

>right PT pulse: 1/4 palpable; left dorsalis pedis: 1/4 palpable; left PT

>trace palpable. The patient has mild non-pitting swelling around both

>ankles.

>NEURO: normal sharp/dull sensation with no apparent loss of protective

>sensation. Vibratory sensation: deferred. DTR: deferred.

>ASSESSMENT: Painful onychomycosis dystrophic hallux nails bilateral with

>onychia; peripheral vascular disease bilateral; 1-10 nails; dystrophic

>hallux

>toenails; onychia hallux bilateral; peripheral vascular disease both feet;

>chronic tinea pedis bilateral.

>Admission diagnosis: UTI, Hx of CVA.

>PLAN: 1) evaluate the patient; 2) debride hallux nails, bilateral 3) trim

>remaining 8 nails; 4) Rx Loprox cream BID application to bottom of both

>feet,

>5) re-evaluate patient prn.

>_

>The billing was submitted as follows:

>01/01/03 Subsequent nursing facility care E/M code with modifier -25

>01/01/03 CPT 11721 (debridement of nails 6-10)

>Review of the above medical record indicates the following:

>· Performance of a nursing facility E/M service was reasonable

>and

>necessary.

>· Debridement of painful mycotic dystrophic of the hallux nails

>meets Medicare mycotic nail coverage guidelines.

>· Since the podiatrist is seeing the patient on a first time

>basis

>(as a new patient), and a new patient or initial nursing care facility E/M

>cannot be used, the podiatrist should bill:

>CPT coding should have been: Subsequent nursing facility care E/M code

>with modifier -25 is correct.

>CPT 11720 – only the great toenails are debrided.

>ICD-9-CM coding should have been: ICD-9-CM 110.1 (onychomycosis);

>ICD-9-CM 681.11 (onychia);

>ICD-9-CM 110.4 (tinea pedis);

>******************************************************************************

>

>Scenario 2: Ms. Jones has returned for re-evaluation of her heel pain,

>and

>possible follow-up cortisone injection. Ten days prior, the doctor told

>her

>that she might require a series of three cortisone injections 10 days

>apart

>in order to resolve her symptoms. Ms. Jones was given her first

>injection at

>that time. During this return visit, she reported that, at first, the

>right

>heel hurt, but over the past 4 or 5 days, the pain level had reduced by

>60%.

> The patient pointed to the area of the right heel that was still

>tender.

>The site was palpated to isolate the area of maximum pain, and a 2nd

>injection (3 mg) of Celestone Soluspan was administered to the area near

>the ins

>ertion of the plantar fascia. The patient was advised to continue her

>stretching

>exercises, and keep her weightbearing activities to a minimum. Impression:

>plantar fasciitis right heel. Return to office: 2 weeks for possible 3rd

>injection.

>_

>The billing was submitted as follows:

>02/01/04 E/M code with modifier 25

>02/01/04 CPT 20551 (injection tendon origin/insertion)

>Review of the above scenario indicates the following:

>· There was no evidence of a separate, significantly identifiable

>E/M service since:

>· The diagnosis/condition remained with same

>· The treatment was “pre-scheduled†– it was the primary

>service

>performed on a patient scheduled to return to the office for follow-up

>care.

>· There was no significant interval history or examination

>change,

>and the follow-up treatment remained unchanged.

>CPT coding should have been:

>CPT 20550-RT (the appropriate code for injection plantar fascia)

>

>J0702 (betamethasone acetate and betamethasone sodium phosphate, 3 mg)

>ICD-9-CM coding should have been: ICD-9-CM 728.71 (plantar

>fasciitis);

>

>ICD-9-CM 729.5 (pain in limb)

>******************************************************************************

>

>Scenario 3: A new patient was referred to an orthopedic surgeon for a

>consultation. The patient was complaining of left shoulder pain of one

>month

>duration. The pain was increasing in intensity and limiting according to

>the

>patient. The physician’s documentation indicated that the left and right

>shoulders were examined, including the performance of a brief range of

>motion test.

> A complete x-ray study of the left should was taken and read as normal.

>The orthopedist determined that the patient had a joint inflammation, and

>administered a cortisone injection. The documentation information

>included

>additional history of present illness, a medical history, a review of

>systems

>check-off list which was left blank, his impression and plan

>(documentation only

>indicates that “injection givenâ€).

>_

>The billing was submitted as follows:

>11/01/03 Consultation E/M code with modifier 25

>11/01/03 CPT 73030

>11/01/03 CPT 20610 (injection, shoulder)

>Review of the above scenario indicates the following:

>· The consultation E/M service code with a modifier -25 was

>appropriately billed because consultation series E/M codes do not

>distinguish whether

>the patient is new or established, only if the encounter is an initial

>consultation or and established consultation.

>· It is expected that the medical record documentation will

>include

>the specific type and dosage of steroid that is injected into the joint.

>CPT coding should have been:

>Initial consultation E/M with modifier -25

>CPT 73030-LT - however this was assessed an overpayment due to lack of

>documentation of site.

>CPT 20610-LT – however this was assessed an overpayment due to lack of

>documentation of dosage administered.

>· In this scenario, had the provider’s medical documentation

>included the name, dosage, & site of the cortisone injected, the cortisone

>injection

>would have been approved as well.

>******************************************************************************

>

>Scenario 4. An established patient who has not been seen for two years

>comes into the office complaining of a 1 year history of bleeding

>hemorrhoids

>with pain and prolapsed bowel. The symptoms have been increasing in the

>last

>2 months. The documentation indicates no significant medical problems

>other

>than hemorrhoids. No significant relief of symptoms with medications,

>suppositories, or sitz baths is reported. The patient denies

>constipation,

>abdominal pain or other gastrointestinal problems. She does relate that

>she had

>a cardiac catheterization last year, but no symptoms of CAD; no HTN or lung

>problems. The patient’s medications included Vioxx 25 mg/day; Premarin

>0.025

>mg/day; Provera 2-5 mg/day; Dicole bid, Fosamax 20 mg/week; and Anusol DC

>suppositories prn. The history and physical examination only gave

>positive

>and negative findings regarding the visual rectum and skin surrounding the

>anus. The remaining physical exam of other systems only has check-offs in

> the ‘

>WNL’ column with no positive or negative written findings. No digital

>rectal

>examination is documented.

>The provider performed an anoscopy, and documents the findings of:

>hemorrhoids – 3 internal @ 3:00 o’clock; two @ 9:00 o’clock & 12:00

> o’clock with

>thrombosis and bleeding; one fissure at 10:00 o’clock position with

>moderate

>degree of rectal prolapse. Perianal erythema with excoriation; stool –

>positive for occult blood.

>The provider scheduled and performed the next morning a fissurectomy,

>sphincterotomy, and hemorrhoidectomy of the three-thrombosed internal

>hemorrhoids @

>the 3:00, 9:00 & 12:00 o’clock position. The patient is given the

>instruction for the prep. The operative note dated 01/02/03, confirms this

>surgery was

>performed.

>

>

>

[Guest guest]

Amy,

To become better at all of this and gain the knowledge and confidence you

seek, I would recommend a seminar and ask lots of questions. I am not sure

that we should be using modifier 25 for anything we do. As for E and M

codes, they would also need to part of your established fee schedule and

part of everyone's bill. You cannot charge insr differently then cash but

you can give a discount for same day payment. This all gets kind of sticky

and you would best check out a seminar. Email offlist for a recommendation

of one.

 

Mike W. Bowser, L Ac

 

 

 

 

 

>Amyc144

>Chinese Medicine

>Chinese Medicine

>Re: Re: I'm going to make Asian Medicine more popular but...

>Mon, 27 Feb 2006 11:30:04 EST

>

>Hello there!

>So how do we file for Evaluation & Management (EM)

>How do we use modifier 25? Which column will that go to?

>Thanks.

> amy

>

>

>

[Guest guest]

Mike:

 

Why don't you let us all know about such seminars.

 

Anne

 

mike Bowser wrote:

 

> Amy,

> To become better at all of this and gain the knowledge and confidence you

> seek, I would recommend a seminar and ask lots of questions. I am not

> sure

> that we should be using modifier 25 for anything we do. As for E and M

> codes, they would also need to part of your established fee schedule and

> part of everyone's bill. You cannot charge insr differently then cash

> but

> you can give a discount for same day payment. This all gets kind of

> sticky

> and you would best check out a seminar. Email offlist for a

> recommendation

> of one.

>

> Mike W. Bowser, L Ac

>

>

>

>

>

> >Amyc144

> >Chinese Medicine

> >Chinese Medicine

> >Re: Re: I'm going to make Asian Medicine more popular

> but...

> >Mon, 27 Feb 2006 11:30:04 EST

> >

> >Hello there!

> >So how do we file for Evaluation & Management (EM)

> >How do we use modifier 25? Which column will that go to?

> >Thanks.

> >

> amy

> >

> >

> >

[Guest guest]

Anne,

This is an international group and this type of discussion is not encouraged

by our other collegues. Check the printed version of Acupuncturetoday for a

listing of various seminars. Please let me know if you need or want more

info.

 

Mike W. Bowser, L Ac

 

 

 

 

 

>Anne Crowley <blazing.valley

>Chinese Medicine

>Chinese Medicine

>Re: Re: I'm going to make Asian Medicine more popular but...

>Tue, 28 Feb 2006 09:26:51 -0500

>

>Mike:

>

>Why don't you let us all know about such seminars.

>

>Anne

>

>mike Bowser wrote:

>

> > Amy,

> > To become better at all of this and gain the knowledge and confidence

>you

> > seek, I would recommend a seminar and ask lots of questions. I am not

> > sure

> > that we should be using modifier 25 for anything we do. As for E and M

> > codes, they would also need to part of your established fee schedule and

> > part of everyone's bill. You cannot charge insr differently then cash

> > but

> > you can give a discount for same day payment. This all gets kind of

> > sticky

> > and you would best check out a seminar. Email offlist for a

> > recommendation

> > of one.

> >

> > Mike W. Bowser, L Ac

> >

> >

> >

> >

> >

> > >Amyc144

> > >Chinese Medicine

> > >Chinese Medicine

> > >Re: Re: I'm going to make Asian Medicine more popular

> > but...

> > >Mon, 27 Feb 2006 11:30:04 EST

> > >

> > >Hello there!

> > >So how do we file for Evaluation & Management (EM)

> > >How do we use modifier 25? Which column will that go to?

> > >Thanks.

> > >

> > amy

> > >

> > >

> > >