Neuropsychological Testing

On November 5th, 2010, posted in: Industry News by

Although codes 96118 through 98125 are bundled into many E/M codes, the current CCI edits allow you to bypass the edit with a modifier if you have sufficient documentation for performing the test on the same day as the E/M. If you determine during your visit that the testing needs to be performed in order for you to make a clear clinical diagnosis, adjust meds, etc. don’t hesitate to report it –just remember to document the reasoning and your diagnosis.

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Earlier editions of CPT included vaccine administration codes 90465-90468 for children younger than 8 years of age when the physician counseled the patient/family. The 2011 version of CPT introduces two administration codes that expand the concept to include adolescent and teens and eliminates the distinction based on route of administration:

90460 immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoids component
90761 ……each additional vaccine/toxoids component – listed separately in addition to code for primary procedures.

Many of the new codes are based on the number of components in the vaccine.

Example, MMR:
In 2010 you are reporting: 90465 – administration – younger than 8……single or combination toxoids, per day. In 2011 you will report the same administration code, 90465 along with 90460- 1 unit and 90461 – 2 units because MMR has three components (measles, mumps, rubella).

Other examples of multiple vaccines include:
90696 – DTaP-IVP – ages 4 to 6 – IM
90698 – DTaP-Hib-IPV –
90710 – MMRV
90723 – DTaP-HepB-IPV
90748 – HepB-HIB

If you are treating infants and toddlers, there is a new vaccine product 90644 – meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B vaccine, tetanus toxoids conjugate (Hib-MenCY-TT), 4 dose schedule, when administered to children 2-15 months of age, IM use.

There are four (4) new influenza codes to add to your charge sheet:
90664 Influenza virus vaccine, pandemic formulation, live, for intranasal use
90666 Influenza virus vaccine, pandemic formulation, split virus, preservative free, IM use
90667 Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for IM use
90668 Influenza virus vaccine, pandemic formulation, split virus, for IM use

Also remember to add: (if you haven’t already)
90470 H1N1 immunization administration (IM, intranasal) including counseling when performed.

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I am attaching Special Bulletin, October 2, 2010 to this luv note. Effective February 1, 2011 Highmark has revised the list of codes needing prior authorization. Please see bulletin attached.

Additionally, 103 codes will be deleted, effective December 1, 2010. Please read the bulletin in its entirety and access the web site for details.

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Effective December 6, 2010 Blue Shield will deny transforaminal epidural blocks that exceed two levels (bilaterally) on the same day as not medically necessary. They will deny repeat injections at the same level, in the absence of a prior response demonstrating greater than 50 % relief of pain lasting at least 6 weeks as not medically necessary.

Blue Shield will automatically review transforaminal epidural injections in excess of four injections per side, per region per year, each, on an individual consideration basis.

If Blue Shield denies the services as not medically necessary, a provider may not bill the member for the denied service unless she/he has provided written notification informing the member that the service may be deemed not medically necessary and has included an estimate of the cost. The member must agree in writing to assume financial responsibility prior to the service and the agreement should be maintained in the provider record.

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Effective December 6, 2010, Highmark Blue Shield will pay for manipulation under anesthesia when it is used to treat significant arthrofibrosis of the knee resulting from trauma or surgery and for capsulitis of the shoulder. Blue Shield will deny MUA of the shoulder or knee as not medically necessary if it is reported for any other condition.

Also, MUA is limited to a single session. If either code 27570 or 23700 is reported two or three consecutive days in succession, Blue Shield will only pay for the first session and deny the others as medically not necessary.

Blue Shield will deny MUA of the following joints as medically not necessary:
Ankle 27860
Elbow 24300
Finger 26340
Hip 27275
Pelvic Ring 27194
Spine 22505 and
Wrist 25259

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Recently Medicare has determined, after a wide spread audit, that new patient codes 99204 and 99205 were reported incorrectly 73% of the time. As a result, expect pre and post payment reviews of these services. The majority of the errors were due to documentation not meeting a comprehensive history or exam. Attached you will find the comprehensive exam requirements. The exam portion of your documentation has been problematic for some of you for quite some time according to our audits and your report cards. It’s time to pay attention to the detail.

When reviewing the records, Medicare looks for the following in your documentation:

  • Chief Complaint
  • History
  • Exam
  • Medical Decision making

To support 99205, documentation must include:

  • A comprehensive history
  • A comprehensive exam and
  • Medical decision making of high complexity

99204 documentation must include:

  • A comprehensive history
  • A comprehensive exam and
  • Medical decision making of moderate complexity

Medicare requires that the medical record entries for services provided/ordered by authenticated by the author. The method shall be handwritten or electronic signature. Patient identification, date of service and provider of service should be clearly identified.

If they question the legibility of authentication of your signature, they will request an attestation form along with the documentation sent. I suggest each of you have this form available in your office.

In regards to NPP (mid-level providers) remember, in order to bill for these services provided by an NPP under incident to, there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the NPP is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. If services are rendered to a new patient, there is no course of treatment already initiated by the physician, therefore, the service provided by the NPP may not be billed incident to under the physician’s provider number.

Know that we dislike the amount of paper work, rules and regulations just as much as you do. It is our job to communicate what’s happening and why. And hopefully, working together we can achieve compliance and pass any audit that comes about.

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On November 5th, 2010, posted in: Industry News by

After the first of the year, we are going to slowly start preparing each and every one of you for ICD-10. As a reminder, the current diagnosing system contains about 14,000 ICD-9 codes. ICD-10 (effective 10/1/2013) contains over 69,000 diagnosis codes.

What will change for you? Well, first and foremost, your documentation. The additional codes require that you are more detailed and specific about the diagnosis codes you are reporting and that my friends leads to essential detailed documentation.

In order to get ready, start by improving your documentation and code choices now. Try not to report unspecified or non-specific diagnoses. The higher the quality of your documentation now, the easier the transition will be.

PMA will slowly begin performing diagnosis auditing in your documentation which will lead to training you in the new codes. Precise and specific code selection will be necessary and only possible if you improve your ability to paint a clear meticulous picture of the patient’s clinical conditions.

Payers also will more than likely take this opportunity to have more specific medical necessity requirements along with potentially linking diagnosis coding to reimbursement.

PMA is continually working of the new 5010 format which is required for claim submission which required a lot of training and testing. We will test with carriers as they set the testing schedules.

We will try our best to make the ICD-10 training specific to your practice. It will take time, but I can guarantee that we will have you prepared by October 1, 2013. Please check with your EMR vendor – ask if the updates are included or if you are going to have to pay a fee. Also ask where they are in the preparation process.

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RADIOLOGY Accreditation required by CMS

On November 5th, 2010, posted in: Industry News by

If you are providing the technical component for advance imaging services such as MRI, CT and PET scans, federal law requires all providers to be accredited by 2012.

“Since we expect it can take up to six month from the time you initiate the accreditation process to completion, we urge you to begin the accreditation process for advanced diagnostic imaging services as soon as possible,” says CMS in transmittal 755.

NOTE: the accreditation EXCLUDES X-ray, ultrasound and fluoroscopy procedures. Diagnostic and screening mammography is excluded because they fall under the Food and Drug Administration oversight.

You eventually will have to submit information about your accreditation to CMS. CMS is in the process of developing instructions for that process. Failure to obtain accreditation will result in zero reimbursement beginning January 1, 2012.

Do some homework. Look at the following links or contact either the American College of Radiology or the Joint Commission who can accredit all imaging providers.

Transmittal 775:

American College of Radiology:
Intersocietal Accreditation Commission:
The Joint Commission:

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NaviNet reminder

On November 5th, 2010, posted in: Industry News by

Per IBC, all provider groups will be required to have all sites enabled by December 31, 2010. To register for NaviNet, go to: and select “Sign Up” from the top right.

Also remember for those radiology services requiring preauthorization, requests need to be submitted to American Imaging Management (AIM).

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(per Partners and Health Update, October, 2010)

POS members, like HMO members, must choose a primary care physician. However, POS members have the option of seeing a specialist who is either in or out of network. When POS members seek specialty services, they must receive a referral from their PCP to receive maximum benefit levels. If they choose to ‘self-refer’, the patient will be responsible for additional out-of-pocket expenses. This applies both to in and out of network providers.

POS member may also need preauthorization for some services. When you request preauthorization through NaviNet, you will be asked “has the member been referred by the PCP for treatment?” PER IBC, It is very important to answer YES, IF your office has a referral on file for the member to receive the highest benefit. Please check the members chart for a referral or verify that an electronic referral is ‘on file’ through NaviNet.

If you incorrectly answer NO, the system will automatically process the claim as self-referred and the member may be responsible for erroneous out of pocket expenses. In addition, you may receive the following message due to the difference in preauthorization requirements:

“This member’s benefits program does not require pre-authorization for the procedure(s) requested based upon the information provide.” Claims will be denied for lack of preauthorization!

POS members seeking services from OB/GYN providers are not required to have a referral. For correct payment, answer the above mentioned question “YES”. This will ensure the member’s benefits are managed correctly.

If you have further questions, regarding POS preauthorization, per IBC, please contact your Network Provider.

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