The Rheumatologist
COVID-19 News
  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed
  • Home
  • Conditions
    • Rheumatoid Arthritis
    • SLE (Lupus)
    • Crystal Arthritis
      • Gout Resource Center
    • Spondyloarthritis
    • Osteoarthritis
    • Soft Tissue Pain
    • Scleroderma
    • Vasculitis
    • Systemic Inflammatory Syndromes
    • Guidelines
  • Resource Centers
    • Ankylosing Spondylitis Resource Center
    • Gout Resource Center
    • Rheumatoid Arthritis Resource Center
    • Systemic Lupus Erythematosus Resource Center
  • Drug Updates
    • Biologics & Biosimilars
    • DMARDs & Immunosuppressives
    • Topical Drugs
    • Analgesics
    • Safety
    • Pharma Co. News
  • Professional Topics
    • Ethics
    • Legal
    • Legislation & Advocacy
    • Career Development
      • Certification
      • Education & Training
    • Awards
    • Profiles
    • President’s Perspective
    • Rheuminations
  • Practice Management
    • Billing/Coding
    • Quality Assurance/Improvement
    • Workforce
    • Facility
    • Patient Perspective
    • Electronic Health Records
    • Apps
    • Information Technology
    • From the College
    • Multimedia
      • Audio
      • Video
  • Resources
    • Issue Archives
    • ACR Convergence
      • Systemic Lupus Erythematosus Resource Center
      • Rheumatoid Arthritis Resource Center
      • Gout Resource Center
      • Abstracts
      • Meeting Reports
      • ACR Convergence Home
    • American College of Rheumatology
    • ACR ExamRheum
    • Research Reviews
    • ACR Journals
      • Arthritis & Rheumatology
      • Arthritis Care & Research
      • ACR Open Rheumatology
    • Rheumatology Image Library
    • Treatment Guidelines
    • Rheumatology Research Foundation
    • Events
  • About Us
    • Mission/Vision
    • Meet the Authors
    • Meet the Editors
    • Contribute to The Rheumatologist
    • Subscription
    • Contact
  • Advertise
  • Search
You are here: Home / Articles / Coding Corner Answers: Navigating Medicare’s Online Resources

Coding Corner Answers: Navigating Medicare’s Online Resources

November 17, 2019 • By From the College

  • Tweet
  • Email
Print-Friendly Version / Save PDF

Take the challenge.

You Might Also Like
  • Coding Corner Questions: Navigating Medicare’s Online Resources
  • Rheumatology Coding Corner Answers: 2017 End-of-Year Quiz
  • Coding Corner Answers: Billing for Joint Injection within a Series
Explore This Issue
November 2019
Also By This Author
  • Email & Text in the World of HIPAA

1. A—Internet-only manuals

ad goes here:advert-1
ADVERTISEMENT
SCROLL TO CONTINUE

Before appealing the request for an overpayment or appealing a denial, providers and staff should first verify the claim was coded and billed correctly. Second, staff should review the internet-only manuals website, which includes operating instructions, policies and procedures that cover CMS policies based on statutes, regulations, guidelines, models and directives. For example, the request for overpayment occurred because an evaluation and management (E/M) visit was billed on the same day as the biologic infusion procedure. According to coding guidelines, unless there is a separate and identifiable reason to bill for an E/M service, then it is not reimbursable. To appeal this, the documentation will need to prove the medical necessity for these two services to be billed together. You can find this rules here, under section 30.6.7.

2. B—Not allowed

ad goes here:advert-2
ADVERTISEMENT
SCROLL TO CONTINUE

The Medicare National Correct Coding Initiative (NCCI), also known as CCI, was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. The NCCI Procedure-to-Procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.

Coding Corner answers

Accurate coding and reporting of services are critical aspects of proper billing. Service denied on the basis of PTP code pair edits or Medically Unlikely Edits may not be billed to Medicare beneficiaries; a provider cannot utilize an Advance Beneficiary Notice of Noncoverage (ABN) to seek payment from a Medicare beneficiary. The NCCI tools found on the CMS website (including the NCCI Policy Manual for Medicare Services) help providers avoid coding and billing errors and subsequent payment denials.

ad goes here:advert-3
ADVERTISEMENT
SCROLL TO CONTINUE

For example, the PTP table lists CPT code 20604 (arthrocentesis, aspiration and/or injection, small joint or bursa [e.g., fingers, toes] with ultrasound guidance), with permanent recording and reporting, and 76942 with an edit modifier “1.” Upon review of the coding columns of the PTP table row for 20604 and 76942, it states that CPT Manual or CMS manual coding instructions indicate CPT code 20604 is inclusive of the guidance—“Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection localization device), imaging supervision and interpretation.”

The PTP table can be found here.

3. B—When the table has it listed as “1”

You should not need to do this in all cases, but sometimes it is needed. This can occur when the provider is injecting two joints of the same size, but the injections are not bilateral. For example, the patient needs a joint injection in the right knee and right shoulder; both joints are large but not bilateral. The carrier may reject the claim as a duplicate, but a modifier -59 can be used to bypass this issue.

4. D—All of the above

It is impossible to remove more than one gallbladder on a patient, or to perform a hysterectomy on a male patient. Also, it is against CPT and CMS guidelines to bill 99211-nursing visit with drug administration codes 96360–96415, because the nursing service is built into the relative value unit (RVU) for the drug administration services. The services would be mutually exclusive of one another. RVUs are a measure of value used in the Medicare reimbursement formula for physician services and part of the resource-based relative value scale. The RVU/fee-for-service information can be found here.

5. A—True

All of the medical polices and articles are available on the CMS website and can be filtered by individual states. The list of policies can be found on the CMS website. Once the state is selected, the Local Coverage Determination can be viewed in alphabetical order.

For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at mtillman@rheumatology.org or call 404-633-3777 x820.

Filed Under: Billing/Coding, From the College Tagged With: Centers for Medicaid & Medicare Services (CMS)Issue: November 2019

You Might Also Like:
  • Coding Corner Questions: Navigating Medicare’s Online Resources
  • Rheumatology Coding Corner Answers: 2017 End-of-Year Quiz
  • Coding Corner Answers: Billing for Joint Injection within a Series
  • Coding Corner Answers: July

American College of Rheumatology

Visit the official website for the American College of Rheumatology.

Visit the ACR »

Meeting Abstracts

Browse and search abstracts from the ACR Convergence and ACR/ARP Annual Meetings going back to 2012.

Visit the Abstracts site »

Rheumatology Research Foundation

The Foundation is the largest private funding source for rheumatology research and training in the U.S.

Learn more »

The Rheumatologist newsmagazine reports on issues and trends in the management and treatment of rheumatic diseases. The Rheumatologist reaches 11,500 rheumatologists, internists, orthopedic surgeons, nurse practitioners, physician assistants, nurses, and other healthcare professionals who practice, research, or teach in the field of rheumatology.

About Us / Contact Us / Advertise / Privacy Policy / Terms of Use

  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed

Copyright © 2006–2021 American College of Rheumatology. All rights reserved.

ISSN 1931-3268 (print)
ISSN 1931-3209 (online)

loading Cancel
Post was not sent - check your email addresses!
Email check failed, please try again
Sorry, your blog cannot share posts by email.
This site uses cookies: Find out more.