1. B—No. CPT 99358, prolonged evaluation and management service can be billed before or after direct patient care, first hour or 99539 —each additional 30 minutes (list separately in addition to code for prolonged service). This code cannot be used to bill a higher level E/M visit code. According to 2017 CPT: This service is to be reported in relation to other physician or other qualified healthcare professional services, including evaluation and management services at any level.
2. D—None of the above. Currently there is no ICD-10 code available to report multiple joint pain. Keep in mind, M25.50 is for pain in an unspecified joint and the unspecified ICD-10 codes should not be billed. Unfortunately, the coder must list all the joints that are affected.
3. B—96372. Even though denosumab is a monoclonal antibody, it does not meet the requirements to qualify for the higher chemotherapy injection code 96401.
4. B—No. Unless there is documentation that shows a separate and/or identifiable reason for the E/M visit, it cannot be billed. The work done to examine the patient to receive the infusion is included in the administration code. If a follow-up visit is medically necessary for the visit, the provider must include specific documentation showing there is a separate or identifiable reason above and beyond the infusion service.
5. A—When a ZPIC audit letter is received the physician must be notified immediately. ZPIC audits are very different from other audits, in that it means a suspicion of fraud exists. This will need to be addressed by the provider as soon as possible. Medicare defines fraud as, “Any unlawful act which results in the inappropriate billing of Medicare for services by a health care provider (e.g., physicians, hospitals and affiliated providers).” Below are key areas to be aware of:
i. Make sure all items that are requested in the audit are delivered.
ii. Make sure to keep a copy everything that is sent to Medicare.
iii. Depending on the scope of the audit, the practice may want to seek outside counsel.
iv. The ACR coders and audit specialists are available to review the ZPIC letter and can assist with the requests.
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 by phone at 404-633-3777 x820.