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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

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HCA Session II

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Hca session ii

HCASession II

Preventative Medicine Visits



Preventative medicine visits cpt code 99381 87 new 99291 97 est

Preventative Medicine Visits CPT Code 99381-87 (new) 99291-97 (est)

Preventative Medicine Visit Codes include payment for:

  • The review of “stable” chronic problems

  • Routine Screenings (eg. Pap smear, breast & pelvic, manual rectal exam)

  • Risk Factor Counseling

    Billable Separately When Billed on Same Day as Physical are:

  • 99211-99215 E&M Office Visit codes (for re-management of existing problems or new problems (need mod 25)

  • Injections, Immunizations

  • Procedures Performed (exception Medicaid – they will only pay for procedure)

  • Some Screenings

  • Labs (Indicate signs/symptoms or diagnosis to support testing)

Preventative medicine visits continued

Dx Codes: V70.0 (well adult) V72.31 (Gyn w/or w/o Pap)


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

Preventative medicine visits continued1

Preventative Medicine Visits continued


  • Will pay for physicals.

  • They will also pay for 99211-99215 services billed with a physical.

  • Affix Mod 25 on 99211-15 codes.

    Exception Medicaid– pays for physical Only - No E&M in same day.

    Exception Bc/Bs PPO Plans– Physical Coverage is on “age schedule”

Preventative medicine visits re screenings

Preventative Medicine Visits Re: Screenings

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

Preventative medicine visits re screenings1

Preventative Medicine Visits Re: Screenings

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

Diagnosis 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.)

Preventative medicine visits re screenings2

Preventative Medicine Visits Re: Screenings

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.

Diagnosis Codes:

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).

Preventative medicine visits re screenings3

Preventative Medicine Visits Re: Screenings

G0102: Manual Rectal Examination (Not reimburseable when billed w/managed care physical) Annual Benefit (Age

50 & over)

Diagnosis Codes:

V76.44 Special screening for malignant neoplasms, prostate

Preventative medicine visits re screenings4

Preventative Medicine Visits Re: Screenings

G0107: Blood Occult (Routine Screening – In absence of signs/symptoms). Is reimburseable when billed


Annual Benefit

Diagnosis Code: V76.51

Use CPT 82270 when there are signs/symptoms

Preventative medicine visits re screenings5

Preventative Medicine Visits Re: Screenings

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

Preventative medicine visits re screenings6

Preventative Medicine Visits Re: Screenings

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

Preventative medicine visits re screenings7

Preventative Medicine Visits Re: Screenings

G0202 w/76083 : Screening Mammography

Annual Benefit

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 / Immunizations90471 (1) 94072 (ea. addl)

Administration Code / Therapeutic or Dx90782 (eg. Gyn – Depo, B12)

Administration Code / IV Infusion90780 (IM) 18 new codes for 2005

Foreign Body Removal

Ear Wax Removal69210 (hearing loss pays;

impacted cerumen does not)


EKG Routine93000 (mod 76 repeat)




Lesion / Skin Tags11200 (up to 15)

11201 (ea. addl grp of 10)

Lesions / Common or Plantar Wart17000 (1) plus

17003 (for ea. addl – indicate)

Example: 6 removed bill 17000 x1 and 17003 x5 = 6

Lesions / Flat Warts, Molluscum /Milia17110 up to 14

17115 15 or more report code.

Lesion / Vulva56501

Lesion / Vaginal57061

Lesion / Penis (cryo)54056



Gyn / Contraceptive Management

Diaphragm or Cervical Cap Fitting57170

Insertion of IUD58300

Removal of IUD58301

Fitting and Insertion of pessary or other

intravaginal support device57160

Airway Management

Nebulizer Treatment94640

Nebulizer Treatment (subsequent)94640-76

Inhaler Instructions (teaching)94664-59


Bronchospasm Evaluation94060



Incision & Drainage ; Puncture

Incision & Drainage (abcess, cyst)10060

Incision & Drainage of Pilonidal Cyst10080

Incision & Removal of Foreign Body, subcut10120

Incision & Drainage of Hematoma, seroma

or fluid collection10140

Puncture aspiration of abscess, hematoma,

bulla or cyst10160




Paring/Cutting of benigh hyperkeratotic lesion

(corn or callus) single lesion11055

Paring/Cutting or benign hyperkeratotic lesion

corn/callus 2-4 lesion11056

Trimming of non-dystrophic nails, any #11719

Debridement of 1-5 nails11720

Debridement of 6-10 nails11721

Avulsion (toenail plate)11730

Excision of nail / nail matrix11750

Wedge Excision of nail fold11765




Control Nasal Hemorrhage, Anterior

Packing; Simple30901

Control Nasal Hemorrhage, Posterior

Packing, Initial30905

Packing, Subsequent30906

No Modifier is Necessary


Excisions Lesion (trunk, arms, legs)BenignMalignant

0.6 to 1.0cm1140111601

1.1 to 2.0cm1140211602

2.1 to 3.0cm1140311603



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)

CPT Codes:

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



Wound Repair

Simple Suturing

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.

Services billable in addition to e m

Services Billable In Addition to E&M

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

Modifier 25

Modifier 25

Modifier –25

Should only be appended to evaluation and management (E/M)

service codes HCPCS codes G0101(Breast & Pelvic Screening)

and Procedures

You do not need a modifier 25 when billing an office visit and

also billing for:

1) Diagnostics (eg. EKG)

2) Immunizations

3) Screenings

Modifier 25 examples

Modifier 25 Examples

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.

Modifier 76

Modifier 76

Modifier 76

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


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