“You tell me one thing, Sue tells me another. No one knows the answer.”
Coding for physician services used to have more in common with a cottage industry than a profession. Back in the late 80’s, I was processing paid and denied claims in a Family Practice office. (Stop me if you’ve heard this one….) Medicare was denying claims for B-12 shots, and I didn’t know why. I went next door and talked to the biller at the Internal Medicine practice, and she knew at a glance, and told me, “You’re using the wrong diagnosis. You have to use pernicious anemia in order for B-12 to be paid.” She didn’t say, “Medicare has a policy about B-12 shots, and if a patient doesn’t have a covered indication, it is a non-covered service.” Both statements would have been true, but the second explained the reason, and the coverage and payment implications.
How have most physician coders learned about coding? From the biller or coder in the next office or sitting next to a staff member for a few weeks, whose job they are filling. I admit that back in the 1980’s the BCBS rep came to our office and showed me how to fill out an insurance claim form. Can you imagine? And, there were different claim forms for BCBS, Medicare and Medicaid at the time. She showed me out to complete them all.
Coding is the source of revenue in a physician practice and also the source of compliance risk. Physician practices can’t afford to treat it like a cottage industry anymore, but need to invest time and resources into learning both coding and reimbursement rules.
Some of the answers to medical practice questions are hidden in plain sight. With the internet, it’s easy to log on to a Q&A forum and ask a question. But, before doing that, coders should do some simple research for two reasons: it increases the likelihood of the right answer and the learning is more profound. Let’s take a simple example. I got a call recently from a Endocrinology practice wondering how they could charge to implant a Continuous Glucose Monitor. They had two questions: Is there a separate procedure code for it, and can we charge an office visit on the same day. The answer to these questions can be found –hidden in plain sight—in the CPT book. Looking at the definition of the code of CGM (95250) the definition is: Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording. The placement is considered part of code 95250 and may not be billed separately. As to whether an office visit can be charged on the same day, the answer is found in the definition of modifier 25. A separate and distinct office visit on the same day could be charged. But, if the purpose of the visit was to implant the device, do not charge a separate office visit.
When a coding question arises in the office, start with the CPT book for your answer. Go the source.