A 73-year-old female established patient with rheumatoid arthritis affecting multiple joints and with positive rheumatoid factor returns to the office for an infliximab infusion. She denies any fevers, cough, dyspnea or concurrent illness. She has joint pain of 6 on the pain scale. She is on an NSAID, weekly methotrexate subcutaneous injections, folic acid and…
UnitedHealthcare Implementing Risk Adjustment Audit Program
Beginning in June 2018, UnitedHealthcare (UHC) will implement their risk adjustment data validation (RADV) audit program. UHC states that through the mandatory requirement by the U.S. Department of Health and Human Services (HHS), Medicare Advantage health plans will be reviewed for supporting medical documentation to check for accurately reported patient data. UHC will send requests…
Avoid Billing Risks for New vs. Established Patients
When coding evaluation and management (E/M) services provided to a patient, one of the most persistent concerns is whether a patient is new or established to the practice. Although this may seem like a simple coding answer, the distinction is an important one, because it enables providers to appropriately bill and receive reimbursement correctly. E/M…
Rheumatology Coding Corner Answer: Billing for an Inflectra Infusion
Take the challenge. CPT codes: 96413, 96415, 96375, Q5103x20, J1200 ICD-10: M07.9 Coding Rationale This procedure is billed with CPT code 96413 for the initial hour of the intravenous infusion and CPT code 96415 for each additional hour. The patient was given 50 mg of diphenhydramine prior to the infusion to prevent reactions and should…
Rheumatology Coding Corner Question: Billing for an Inflectra Infusion
A 68-year-old female patient returns to the office for a second round of Inflectra (infliximab-dyyb) infusion for her rheumatoid arthritis with rheumatoid factor of multiple joints without organ or systems involvement. She reports pain, stiffness and swelling in her left and right knees and right elbow and rates the pain at a 9 on a…
Rheumatology Coding Corner Answer: RA Follow-Up with Imaging
Take the challenge. CPT codes: 99214, 71045, 86580 ICD-10: M05.79, R05, R06.2 History—Detailed: The history of present illness (HPI) was extended; the review of systems (ROS) was extended; and the past medical, family and social history (PFSH) were documented. All three components of the HPI, ROS and PFSH are needed to achieve the detailed history…
Rheumatology Coding Corner Question: RA Follow-Up with Imaging
History A 39-year-old woman returns for follow-up for her rheumatoid arthritis. She has positive rheumatoid factor, but no organ or systemic involvement. She has joint swelling and pain in her left hand, right elbow and right knee. Her pain is at an 8 on a 10-point scale. She states the pain is worse in the…
Rheumatology Coding Corner Answer: Follow-Up Knee Injection
Take the challenge. CPT codes: 20611-LT, 20611-RT, J7326x2 or 20611, 20611-50, J7326x2 ICD-10: M17.0 Coding Rationale CPT Codes: 20610-LT, J7325x16 ICD-10 Code: M17.12 This claim is rejected by the insurance carrier because the injection was outside of the preauthorization window that ended on Oct. 31. Most insurance carriers enforce their preauthorization dates for procedures. In…
Rheumatology Coding Corner Question: Follow-Up Knee Injection
On Nov. 4, a 55-year-old female patient presents to the office for a follow-up visit for injection of the left knee for osteoarthritis. This is her third of three injections that were preauthorized through Oct. 31. She reports pain and swelling in her left knee and rates the pain at an 8 on a 10-point…
Anthem Cancels Planned Modifier 25 Cuts
Anthem, a Blue Cross Blue Shield company that operates in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, Virginia and Wisconsin, has decided not to move forward with a policy that would have resulted in decreased reimbursement for evaluation and management (E/M) services when billed with modifier 25. As reported…
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