Can a provider within a group refer their patients to a specialist within the same group of providers and bill a consult?

Healthcare Fraud Shield Reader Question:  Can a provider within a group refer their patients to a specialist within the same group of providers and bill a consult?  The group consists of four internal medicine doctors, one family practice MD and one board certified endocrinologist.

Healthcare Fraud Shield Answer:  Consultation codes are an area of frequent billing errors, as they have specific documentation requirements that must be met for the codes to be used appropriately, no matter the practice setting.

First, the CPT code range for in-office or other outpatient consultations is 99241-99245.  The same code range is used for patients that are new to the specialist and for established patients who have seen the specialist previously, as a long a new request for consultation is made for each new or established consultation visit. 

Per CPT/AAPC Coder, there are three required components that must be met in order for a consultation code to be used:

1. There must be a request for an opinion or advice, made by a provider (or other appropriate source) to the specialist/consulting physician. The request can be verbal or in writing, but must be documented in the patient’s record in order to be considered a valid consultation request. 

The consultation request is for the specialist’s advice or opinion only.  In the case of your multi-specialty office, the record must be very clear that the first provider is seeking the specialist’s advice or opinion about the patient’s specific condition.  If the record states something like “the patient is referred to Dr. X…”, this first requirement is not met and a consultation code cannot be used.

2. The consulting specialist must come to an opinion or treatment recommendation about the patient’s specific problem or condition for which the consultation was requested. This finding must be documented in the consultant’s patient record.
3. The consultant must prepare a written report of their finding(s) and recommendation(s), which must be provided to the requesting physician (or other appropriate source). This cannot be a “thanks for the referral” note, and it cannot be a copy of the history and physical.  The report must include information to assist the requesting physician in their treatment of the patient, and in specific response to the consultation request.

The transmission of the written report from the consultant to the requesting physician can be difficult to track within a group’s electronic medical record system.  You will need to verify the report was created by the consultant, and reviewed by the requesting physician.  As noted above, if the H&P is the only document sent from the consultant, the “written report” criteria is not met.

How many units of CPT 88321 can a provider bill?

Question to Healthcare Fraud Shield

How many units of CPT 88321 (Consultation and report on referred slides prepared elsewhere)[1] can a provider bill and how multiple units can be billed? I have some providers billing per specimen and some per date collected.

Dear Healthcare Fraud Shield Reader:

Great question.  According to the AAPC Coding Tool-AAPC Coder[2], a qualified provider, typically a pathologist, receives a consultation request and prepared slides from another location that he/she reviews as part of a consultation. A consultation request can come from another pathologist, surgeon, or other clinician. The consulting provider may review multiple slide types, such as cytology or tissue slides, from different body areas that count as one surgical pathology case. After a thorough examination of the slides, he prepares a report detailing his evaluation and opinion.

In other words,  the report can be on one (1) or multiple slide types, and from one or more body areas — but the bottom line the billing is “1”, as in one (1) surgical pathology case.  There should also be a detailed report of the findings.  So to answer your question, one (1) report/ DOS.  Unlike most other surgical pathology codes, the specimen is not the unit of service for 88321 to 88325. The surgical case is the unit of service.

**Be sure to check payer policies before reporting this code. Some payers may limit you to reporting 88321 once per patient per day even when the provider consults on more than one surgical case.

[1,2] coder.aapc.com

Questions or comments?  Please feel free to contact Healthcare Fraud Shield’s Subject Matter Experts at SIU@hcfraudshield.com for more information.

Can a provider can bill multiple units of CPT 75898?

Question to Healthcare Fraud Shield

Can a provider can bill multiple units of CPT 75898 (Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis)[1]?

Dear Healthcare Fraud Shield Reader:

Answer:

The MUE limit on CPT 75898 is 1. To be able to bill multiple units, the provider would need to perform separate follow up studies. In addition, I would also expect you would see the -76 modifier attached.

[1] coder.aapc.com

Questions or comments?  Please feel free to contact Healthcare Fraud Shield’s Subject Matter Experts at SIU@hcfraudshield.com for more information.

How should one bill for TB (Tuberculin) Testing?

Question to Healthcare Fraud Shield

I am reviewing a case in which the provider is billing CPT codes 90471, 85680, 99211 and diagnosis Code V03.2.  I have denied the 90471 as 86580 is not considered a vaccine, it is considered a lab.  My question is am I also able to deny the 99211 because the patient was only in the office for this TB test?

Dear Healthcare Fraud Shield Reader:

Thank you for your question! Healthcare Fraud Shield believes you are correct in your thinking. If the patient was only in for the TB test, it is not appropriate to bill a 99211. I copied and pasted below information found on AAPC Coder regarding this. Also, note that 99211 can be billed when the patient returns to have the test read.

“TIPS” from AAPC Coder:

“The provider may order 86580 as a TB skin test, TB delayed hypersensitivity testing DHT or DHR, Mantoux test, tuberculin skin test, or purified protein derivative test PPD.

No E/M service takes place when administering a PPD test, so don’t report an E M code for the actual screening. When administering the PPD test, use codes V74.1 Special screening examination for bacterial and spirochetal diseases; pulmonary tuberculosis along with 86580 or report V01.1, Contact with or exposure to tuberculosis, when the patient has known exposure to tuberculosis. However, you can report an appropriate EM code, such as 99211 along with 86580 if the provider performs an E/M service in conjunction with the tuberculosis skin test administration. PPD testing results are read 48 to 72 hours after administering the skin test. This will require another office visit and evaluation of the results to determine whether it is negative or positive. As 86580 does not cover any follow up care, when a provider does the reading, the provider may choose to report the service using an E M code. Therefore, if the patient returns to the office to have the provider evaluate the test’s results, you may then report 99211, Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician.”

Thanks again for your question and for reading Healthcare Fraud Shield’s newsletter.

Sphenopalatine Ganglion Block Coding

Question to Healthcare Fraud Shield:

What is the proper procedure code for Sphenopalatine ganglion block?  It is not an injection, therefore 64505 is not the correct code.  It is a minimally invasive procedure, whereby an anesthetic or a neurolytic is introduced intranasally for topical administration to sphenopalatine ganglion.

Dear Healthcare Fraud Shield Reader:

Great question!  According to some advice found on justcoding.com

Our pain management physician also performs sphenopalantine nerve blocks using a lidocaine soaked Q-tip. I submitted this coding scenario to the AMA through knowledgebase (KB#5436) and the AMA replied:

“According to our CPT Advisors and from a CPT coding perspective, it would not be appropriate to report code 64505, Injection, anesthetic agent; sphenopalatine ganglion, as this code represents a procedure requiring the performance of an “injection”. Therefore, the insertion of the Lidocaine soaked Q-tip in the nostril is not reported separately by any specific CPT code, and would be considered inclusive of an appropriate level E/M, as appropriate. Alternatively, if performed in the absence of an accompanying E/M service, the unlisted code 30999, Unlisted procedure, nose, or 64999, Unlisted procedure, nervous system, should be reported. Respectfully, CPT Education and Information Services.”

If you have an AMA Knowledgebase account set up, you can search the knowledgebase for KB#5436 and find the above question and response.

Thank you!

-Healthcare Fraud Shield

 

Place of Service – A doctor’s office billing POS 22?

Question to Healthcare Fraud Shield:

I have a question about place of service coding.  I have a doctor’s office and a hospital billing for an E/M with POS 22.  The service was performed in the doctor’s office, which is not on the hospitals campus.  However I am being told by the billing company for the doctor that the building is owned by the hospital system. Also I have been advised that the employees are employed by the hospital system however the doctor is not.

So is it appropriate for the POS to be 22 and for the hospital to also bill for their facility fee?

Dear Healthcare Fraud Shield Reader:

Based on the scenario you presented, the appropriateness for a physician billing a POS 22 and the hospital billing a facility fee would mainly depend on the Medicare Claims Processing Manual (particularly for plans such as yours that have members with Medicare lines of business),  your organizational policies and any organizational  contractual arrangement with the provider and/or the hospital system.

Strictly from a billing prospective, a professional service billed with the 22 POS would typically account for a rate reduction based on the POS to account for the overhead that would be typically supplied (and usually billed) by the facility.  Therefore,  it would be appropriate for the physician to use POS 22  to bill for the services they provided and the facility to bill for the staffing, supplies, etc.

Conversely, if the physician billed a POS 11 (Physician’s Office) and the hospital billed a facility charge, this would be inappropriate.  The POS 11 would not account for a rate reduction, as the allowed rate to the physician would include the presumed overhead of a provider’s office.

I hope this was helpful. Please feel free to contact us if you have any additional questions.

E-stims as a diagnostic tool?

Question:

I have a provider who is performing Electrical Stimulations and billing 8 units,   I can find no other provider billing as many units.    The provider calls them  Russian stimulations and claims they are a diagnostic tool.   What is your take on this?

Dear Healthcare Fraud Shield Reader: 

We have a few questions that will provide some food for thought while you are investigating this issue, in addition to the following resources and comments below:

1)      Which code is the provider billing –  97032 or G0283? (G0283 would not be appropriate for multiple units)

2)      Has anyone reviewed any records or spoken to any patients yet?

3)      Research shows that Russian stimulation is actually used to improve muscle contraction.  As a result, a) without doing extensive research it appears this is not diagnostic 2) have you reviewed members’ history to see if they had/have muscle issues?

Any provider billing excessively for any procedure when no other provider is billing in that manner should be reviewed to determine if the services are a) appropriate and b) even being rendered at all.   So I think you are on the right track by being suspect of this provider.   FWA software such as PostShield will help you identify providers billing in a manner such as this one.  I’d request records or better yet, go onsite if you can and if onsite audits fall within your operational protocols.  It would also be a good idea to interview members if possible.

1)      APTA Article: http://ptjournal.apta.org/content/82/10/1019.full

2)      Good video showing it’s really all about muscle strengthening (which would not be diagnostic): http://www.youtube.com/watch?v=BgTcJSn_WhA

3)      If this would be considered “functional” or “Functional neuromuscular stimulation”  (FES) and is being used for PT type applications, most plans exclude it as a covered service.

4)      http://mcgs.bcbsfl.com/?doc=Neuromuscular%20Electrical%20Stimulator%20(NMES)

5)      http://www.aetna.com/cpb/medical/data/600_699/0677.html

 

Best of luck!

Have an SIU or coding question?

Email us at SIU@hcfraudshield.com!

Are you being needled by P-stim? See our latest coding question from one of our readers.

Question to Healthcare Fraud Shield

I have an outpatient surgery center doing P-Stim (auricular stimulation) for back pain and using CPT 64555 (percutaneous neurostimulator – peripheral nerve).  P-stim is FDA approved for acupuncture and is a small device that can be done in a physician’s office.   My situation is that I have a surgery center billing us (facility claims) and the rendering provider billing (professional claims).  Not much is written about using CPT 64555 for p-stim.  There is apparently an unpublished AMA letter that speaks to it, but no one is able to locate it!  How is using CPT 64555 a misrepresentation here?

Any chance you may have encountered this situation before and could offer some advice?  I need something a bit more solid to build a case on!

-Healthcare Fraud Shield Reader

Answer

This is very interesting.  We watched a quick youtube video on the procedure which we’ve linked here if you haven’t seen it (http://www.youtube.com/watch?v=P_Ro5kxnbgg). You can take a couple different approaches.  First of all, this procedure is not appropriate for an ASC setting.  No anesthesia is required. (I hope you aren’t seeing anesthesia claims as well!)  Check your policies and member’s benefits as they may speak to appropriateness of ASCs for minor procedures.  Secondly, it appears that this would fall under the category of acupuncture with electrical stimulation or possibly experimental/investigational.  It also does not appear to fit the code description of implantation of an electrode.  They are simply placing needles in the ear.  One source we read suggested billing the unlisted code CPT 64999.  Ideally, if your plan could quickly develop a medical policy that would help stop the bleeding.  This looks like a trend we may be seeing a lot of in the future!  Thank you for sharing.

-Healthcare Fraud Shield

Facet Joint Injection Question

Question:
We are investigating a provider who is performing facet joint injections and reporting the services with CPT® codes 64490-64495 (injection paravertebral facet joint- cervical, thoracic or lumbar).  I noticed that the code description includes the language “with image guidance (fluoroscopy or CT).”  Based on a review of the provider’s medical records, fluoroscopy is not used.  When the doctor was questioned, he said that he doesn’t need to use fluoroscopy as he knows he is in the facet joint by palpating the area.  My question is—does he have to perform fluoroscopy to be paid for this code?  If not, what is the correct code?  Thank you for your help.

Answer:
Great question!  In 2010, the AMA changed the CPT® codes and descriptions for facet joint injections.  Prior to this time, the fluoroscopic image guidance was billed separately.  This coding change opened the door for provider misuse of the codes as some practitioners, like the one in your investigation, do not have fluoroscopy equipment in their offices.  According to the CPT® coding instructions listed in the first paragraph in the “Paravertebral Spinal Nerves and Branches” section of the manual, “If imaging is not used, report 20552-20553.”  These codes which describe trigger point injections, have a much lower assigned RVU (relative value unit), therefore, payment is significantly less.  Based on the information you provided and the CPT® coding instructions, it would be appropriate to down-code the reported service to trigger point injections (codes 20552-20553).

Good luck with your investigation!

If you have any comments or questions, please email us at info@hcfraudshield.com.