Fam Pract Manag. 2003 Jan;10(1):17-18.
- 1995 or 1997 guidelines?
- HIV counseling
- Pure tone testing: 92551 or 92552?
- Transfer with discharge and admission
- Home visit codes for homebound patients
- Using modifiers -GZ and -GY
- Postpartum care
- Ambulatory blood-pressure monitoring
- Injection code 20550
1995 or 1997 guidelines?
I understand that Medicare is allowing physicians to use either the 1995 or 1997 documentation guidelines for evaluation and management (E/M) services, so I have been using the 1997 version because I am more familiar with it. However, I was recently told that Medicare now expects physicians to use the 1995 guidelines. Is this true?
No. The Centers for Medicare & Medicaid Services (CMS) has instructed Medicare carriers to use both the 1995 and 1997 documentation guidelines when reviewing records. Also, CMS has stated that physicians can use whichever set of guidelines is most advantageous to them. Both sets of guidelines are available on the CMS Web site at cms.hhs.gov/medlearn/emdoc.asp.
We’re using ICD–9 code V25.09, “Encounter for contraceptive management; General counseling and advice; Other,” for HIV pretest counseling, and we’re receiving denials from Medicaid. Do you know of another code that we should be using for this?
You may want to try V65.44, “Other persons seeking consultation without complaint or sickness; Other counseling, not elsewhere classified; Human immunodeficiency virus [HIV] counseling.” Other possibilities, depending on the situation, might include V01.7, “Contact with or exposure to communicable diseases; Other viral diseases,” or V08, “Asymptomatic human immunodeficiency virus [HIV] infection status.” You may also want to contact Medicaid to be sure this is a covered service. If it is, request guidance on how the claims should be submitted.
Pure tone testing: 92551 or 92552?
I am confused by the difference between 92551, “Screening test, pure tone, air only” and 92552, “Pure tone audiometry (threshold); air only.” It seems to be the same test. Should 92552 only be used when a pure tone test is done because of hearing loss or some diagnosis that supports the test? Code 92551 is not a Medicare-covered service as far as I can tell.
You are essentially correct. As the descriptor states, 92551 is a screening test. It typically involves the use of a device that produces a series of tones. If the patient does not hear a certain number of tones, depending on the standard used by the office, he or she fails the test. At that point, the patient may be scheduled for further tests or referred to another source (e.g., an audiologist) to determine the exact nature of the problem. You should typically report diagnosis code V72.1, “Special investigations and examinations; examination of ears and hearing,” with 92551.
By comparison, 92552 is a diagnostic test. It typically involves presenting the patient with a series of tones at varying intensity to identify the softest level at which the patient can hear (i.e., the “threshold” referenced in the descriptor). The diagnosis code used with 92552 should reflect the definitive diagnosis derived from the test, if available (e.g., 388.12, “Noise-induced hearing loss”), or the symptom(s) that prompted the test (e.g., 389.9, “Unspecified hearing loss”).
Note that both 92551 and 92552 refer to testing both ears. If you only test one ear, you need to add modifier –52, “Reduced services,” to the code. Also, as you mentioned, Medicare does not cover 92551, because it is a screening test for which the law does not provide Medicare coverage. However, some commercial insurers may pay for this service; you will need to check with the health plans with which you interact most often regarding their policies related to this service.
Transfer with discharge and admission
What code(s) should I submit when I transfer a patient from the hospital to a nursing facility, since I’ll be doing a discharge from the hospital and an admission to the nursing facility?
According to CPT and the Medicare Carriers Manual, you should submit codes for both services – 99238 or 99239 for the hospital discharge (assuming the patient was admitted to the hospital on a prior date) and 99303 (“Evaluation and management of a new or established patient involving a nursing facility assessment at the time of initial admission or readmission to the facility …”) for the nursing facility admission even when the work of the nursing-home admission is done in the hospital during the course of a hospital discharge. In the guidelines preceding the comprehensive nursing facility assessment codes, CPT states that “comprehensive assessments may be performed at one or more sites in the assessment process: the hospital, observation unit, office, nursing facility, domiciliary/non-nursing facility or patient’s home.” Of course, the physician still needs to perform the key components of the nursing facility admission (i.e., comprehensive history, comprehensive exam and medical decision making of moderate to high complexity), even if the service is done in the hospital.
Home visit codes for homebound patients
Does the use of CPT’s home services codes (99341–99350) require that the patient meet the Medicare criteria for a homebound patient?
No. The Medicare criteria for a homebound patient apply only to Medicare coverage of home health agency services. Patients do not have to be homebound to qualify for codes 99341–99350, either for CPT or Medicare purposes. However, for Medicare patients, the Medicare Carriers Manual states, “The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit.”
Using modifiers -GZ and -GY
How should we code a claim for a service we expect Medicare will deny as not reasonable and necessary and for which we don’t have an advance beneficiary notice (ABN) on file?
The Centers for Medicare & Medicaid Services (CMS) last year created two new modifiers, -GZ and -GY, that allow you to further distinguish between services that are statutorily not covered or otherwise not a Medicare benefit and services that are not covered because Medicare does not consider them “reasonable and necessary.” The -GX modifier, which simply indicated “Service not covered by Medicare,” has been discontinued.
Appending the -GZ modifier to the CPT code will enable you to make it clear that you know what you’re billing for is probably not covered, you didn’t get an ABN, and you’re not trying to abuse the Medicare program. Using the -GY modifier will identify an “item or service statutorily excluded or [that] does not meet the definition of any Medicare benefit” (e.g., when a beneficiary receives an annual preventive medicine service and wants to get a Medicare denial for secondary payer purposes). Since Medicare carriers may “autodeny” claims with the -GY modifier, the claim may be processed faster than it would without it. If the claim is denied, as expected, the beneficiary is liable for all charges, either personally or through other insurance.
Does postpartum care include hospital and office visits?
Yes. According to CPT, postpartum care includes “hospital and office visits following vaginal or cesarean section delivery.” These are visits with the mother related to the delivery. Visits with the newborn or visits with the mother unrelated to the delivery are not included in postpartum care.
Ambulatory blood-pressure monitoring
Are there codes for 24-hour ambulatory blood-pressure monitoring?
Yes. Codes 93784 through 93790 describe this service. Code 93784, “Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report,” represents the global service. Codes 93786 (recording only), 93788 (scanning analysis with report) and 93790 (physician review with interpretation and report) allow you to report the various technical and professional components of the service when you do not provide the global service.
Injection code 20550
When I submit CPT code 20550, “Injections; tendon sheath, ligament” for different sites injected on the same date, should I attach modifier -51, “Multiple procedures,” so that a multiple procedure rate reduction may apply to the second, third or any additional sites injected?
Yes. According to CPT, 20550 is not exempt from modifier -51. Likewise, the Medicare Fee Schedule database indicates that this code is subject to the standard payment adjustment rules for multiple procedures. To make it clear that injections were done at different sites, submit 20550 for the first site injected and 20550 with modifier -59 (to show that a different site was injected) and modifier -51 (to indicate multiple procedures were performed) for subsequent injection sites. Linking appropriate diagnosis codes to each instance of 20550 may also make it clear that the injections were done at different sites.
Editor’s note: While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. You should refer to the current CPT and ICD–9 manuals and the “Documentation Guidelines for Evaluation and Management Services” for the most detailed and up-to-date information.
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