HCA Session II. Preventative Medicine Visits Procedures Modifiers. Preventative Medicine Visits CPT Code 99381-87 (new) 99291-97 (est). Preventative Medicine Visit Codes include payment for: The review of “stable” chronic problems
Preventative Medicine Visits
Preventative Medicine Visit Codes include payment for:
Billable Separately When Billed on Same Day as Physical are:
Effective 1/1/05 MC will pay physical / new MC enrollee / within 6 mths G0344
Also: G0366: EKG (global) G0367 (EKG tracking only) G0368 (EKG Inter & Rep Only)
Medicare does not pay for routine annual physicals (99381-87; 99391-97)
Medicare will pay for 99211-99215 services (eg. medically necessary follow- up or new problems) billed w/physicals. Mod 25 needs to be affixed to 99211-15 codes.Preventative Medicine Visits continued
Exception Medicaid– pays for physical Only - No E&M in same day.
Exception Bc/Bs PPO Plans– Physical Coverage is on “age schedule”
Medicare will pay for “ Screenings” billed in conjunction with a Physical Examination. HmoBlue/Tufts/Hphc/Medicaid do not pay for some screenings (*) billed w/a physical. However, they will always pay when billed with an E&M code (99211-99215) or when billed by itself.
*Q0091: Pap Smear Collection (Medicaid X8012)
*G0101: Breast & Pelvic Screening (7-11 areas of GU system)
*G0102: Manual Rectal Examination
G0107: Blood Occult (Use 82270 only when there are
79095: Bone Density (Heel)
G0104: Low Risk Flex Sig
G0105: High Risk Flex Sig
G0120: Barium Enema
G0202: Screening Mammography
Q0091: Pap Smear Collection (Annual f/High Risk; every other yr f/ Low
Risk) Not reimburseable when billed w/physical.
X8012: Medicaid pap smear collection code
V76.47 Special Screening for Malignant Neoplasms; Vagina – No
previous history of any abnormalities.
V72.32 Abnormal Pap Smear (abn pap 3 mths back, redid pap –
normal; this visit is f/u visit – 3rd visit)
V76.2 Low Risk of Malignant Neoplasm – History of abnormal paps.
V15.89 High Risk of Malignant Neoplasm – 7 or more sexual partners in
lifetime, Hx of STD, 3+ abn paps in 7 yrs, colposcopy, CA dx.)
G0101: Breast & Pelvic Screening (7 out of the 11 areas in the GU system
must be reviewed and documented.) Not reimburseable when billed
w/a managed care gyn physical. Code G0101 only if “both” the
breast & pelvic exam are performed. Coverage every 2 years.
V76.2 (low risk) or V15.89 (high risk)
V76.49Special screening for malignant neoplasms; other sites (to indicate low risk for a patient who does not have a uterus or cervix).
G0102: Manual Rectal Examination (Not reimburseable when billed w/managed care physical) Annual Benefit (Age
50 & over)
V76.44 Special screening for malignant neoplasms, prostate
G0107: Blood Occult (Routine Screening – In absence of signs/symptoms). Is reimburseable when billed
Diagnosis Code: V76.51
Use CPT 82270 when there are signs/symptoms
79095: Bone Density Screening
Every 2 years for those at risk of “losing bone
Medicare will cover 80% of the cost of one bone mass
measurement every 2 years.
Medicare will also cover follow-up measurements
G0104: Low Risk Flex Sig - once every 48 mths
G0105: High Risk Flex Sig - once every 24 mths
G0120: Barium Enema - alternative to Flex Sig / Screen
Flexible Sig – 1 time every 4 yrs.
Colonoscopy – 1 time every 2 yrs if you are at high-risk for colorectal cancer (e.g. have a family history of the disease or have had colorectal polyps) or 1 time every 10 years if you are not at high-risk (but not within 48 months Of a screening flexible sigmoidoscopy)
Barium enema - this service is not covered if performed in addition to the other tests
G0202 w/76083 : Screening Mammography
One screening mammogram a year for women 40 yrs & older.
One baseline mammogram for women 35 to 39 years of age.
No Part B deductible is required for these services.
Administration Codes / Immunizations 90471 (1) 94072 (ea. addl)
Administration Code / Therapeutic or Dx 90782 (eg. Gyn – Depo, B12)
Administration Code / IV Infusion 90780 (IM) 18 new codes for 2005
Foreign Body Removal
Ear Wax Removal 69210 (hearing loss pays;
impacted cerumen does not)
EKG Routine 93000 (mod 76 repeat)
Lesion / Skin Tags 11200 (up to 15)
11201 (ea. addl grp of 10)
Lesions / Common or Plantar Wart 17000 (1) plus
17003 (for ea. addl – indicate)
Example: 6 removed bill 17000 x1 and 17003 x5 = 6
Lesions / Flat Warts, Molluscum /Milia 17110 up to 14
17115 15 or more report code.
Lesion / Vulva 56501
Lesion / Vaginal 57061
Lesion / Penis (cryo) 54056
Gyn / Contraceptive Management
Diaphragm or Cervical Cap Fitting 57170
Insertion of IUD 58300
Removal of IUD 58301
Fitting and Insertion of pessary or other
intravaginal support device 57160
Nebulizer Treatment 94640
Nebulizer Treatment (subsequent) 94640-76
Inhaler Instructions (teaching) 94664-59
Bronchospasm Evaluation 94060
Incision & Drainage ; Puncture
Incision & Drainage (abcess, cyst)10060
Incision & Drainage of Pilonidal Cyst 10080
Incision & Removal of Foreign Body, subcut 10120
Incision & Drainage of Hematoma, seroma
or fluid collection 10140
Puncture aspiration of abscess, hematoma,
bulla or cyst 10160
Paring/Cutting of benigh hyperkeratotic lesion
(corn or callus) single lesion 11055
Paring/Cutting or benign hyperkeratotic lesion
corn/callus 2-4 lesion 11056
Trimming of non-dystrophic nails, any # 11719
Debridement of 1-5 nails 11720
Debridement of 6-10 nails 11721
Avulsion (toenail plate) 11730
Excision of nail / nail matrix 11750
Wedge Excision of nail fold 11765
Control Nasal Hemorrhage, Anterior
Packing; Simple 30901
Control Nasal Hemorrhage, Posterior
Packing, Initial 30905
Packing, Subsequent 30906
No Modifier is Necessary
Excisions Lesion (trunk, arms, legs) BenignMalignant
0.6 to 1.0cm 11401 11601
1.1 to 2.0cm 11402 11602
2.1 to 3.0cm 11403 11603
Aspiration and/or Injection
20600 “Small Joint” , bursa or ganlion cyst (eg. fingers, toe)
20605 “Intermediate joint”, bursa or ganglion cyst (eg.
temporomandibular, acromioclavicular, wrist, elbow or
ankle (olecranon bursa).
20610“Major Joint”, bursa or ganglion cyst (eg. shoulder, hip,
knee joint, subaromial bursa).
Tendon/Ligament / Ganglion Cyst / Injections / Excisions
There must be an inflammatory process in a given tendon (tendonitis)
or tendon sheath tenosynovitis)
20526 Injection of carpal tunnel with local anes or corticosteroid
20550 Injection(s); single tendon sheath, or ligament,plantar fascia)
20551 Injection(s); singletendon origin/insertion
20612 Aspiration and/or injection of ganglion cyst(s) any location
25111 Excision of Ganglion, wrist (dorsal or volar); primary
25112 Excision of Ganglion, wrist (dorsal or valar) recurrent
Trigger Point Injections
Use 20552 Injection(s); single or multiple trigger point(s), one or two muscle(s) – regardless of the # of injections in those muscle groups
Use 20553 Injection(s); single or multiple trigger point(s), three or more muscle(s) – regardless of the # of injections within those muscle groups
12001 simple repair scalp, neck,axillae,ext genitalia,trunk and/or
extremities (includes hands/feet) 2.5cm or less.
12011 simple repair of face, ears, eyelids, nose, lips and/or mucous
membrances 2.5cm or less.
Tufts, HPHC, NHP pay for the services listed below.
Medicare, Medicaid, Blues DO NOT PAY.
Bill the services below along with a 99211-99215 when applicable:
99058: Emergency Services
99050: Services requested after “posted hours”
99052: Services requested between 10:00pm and 8:00am
99054: Services requested on Sundays or Holidays
Modifiers are 2 digit codes which accompany a 5 digit CPT code in
order to further describe a situation to support additional payment
when more then one service is being reported in the same session
on the same day.
Primary Care Modifiers
25, 76, GE, GC
Should only be appended to evaluation and management (E/M)
service codes HCPCS codes G0101(Breast & Pelvic Screening)
You do not need a modifier 25 when billing an office visit and
also billing for:
1) Diagnostics (eg. EKG)
Modifier 25 Examples
1) When the patient presents for a planned procedure and has a different problem that requires an E/M service (two different diagnoses would be used to distinguish the services)
2) the patient presents with a "minor" problem and after evaluation the decision is made to perform a procedure. In the second example –25 is used if the procedure is minor in nature, meaning that the post-operative period is less than 90 days and the primary diagnosis would be the same for both.
Use modifier 76 when you repeat a service already performed
with the same diagnosis code within a 30 day period.
Example: Chest pain order EKG 93000 and did a repeat 2
wks later same diagnosis “ chest pain” – affix modifier 76 on