Modifier -X {EPSU}, Pneumococcal Immunizations

Q. Have there been any updates from CMS (Centers for Medicare & Medicaid Services) regarding the new -X modifiers that were introduced in January of this year? A. CMS released MLN Special Edition article SE1503 on January 22, 2015 (see http://www.cms.gov/Outreachand- Education/Medicare-Learning-Network-MLN/MLN MattersArticles/Downloads/SE1503.pdf), stating that there would be forthcoming guidance as to the appropriate use of the new -X {EPSU} modifiers and “that guidance will include additional descriptive information about the new modifiers” before implementing …

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Fracture Codes, Strapping and Splint Application Codes, S9088

Q. I was told that we can no longer use code 80100 for drug screens. We have several employers who send employees and potential employees to our urgent care center for pre-employment, random, and post-accident drug screens. What code should we use now? A. Effective January 1, 2015, several drug-screen Current Procedural Terminology (CPT) codes were deleted by the American Medical Association: 80100: “Drug screen, qualitative; multiple drug classes chromatographic method, each procedure” 80101: “. …

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Payor Contracts, Discounts, and Provider Signatures

Q. We sometimes have patients come in to our urgent care center with an insurance payor that we do not have a contract with. We do not want to turn them away, but we do want to guarantee our payment. Do we have to submit a claim to the insurance company in such cases? Currently, we offer these patients a self-pay discount, and they pay us in full at the time of service. A. Typically, …

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Fracture Codes, Strapping and Splint Application Codes, S9088 Code

Q. When is it appropriate to use fracture codes without manipulation? If a patient comes in with pain in a finger after a fall and an evaluation and management is performed, x-rays are taken to confirm a fracture, the finger is splinted, and the patient is referred to an orthopedist, would that treatment constitute billing for fracture care? If not, what must we do to be able to bill these? A. CPT suggests that only …

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Revenue Per Patient, Prescription Drug Management for MDM, Medicare and HCPCS J3301 Denials

Q. What is an acceptable income per patient visit for an urgent care clinic? A. The recent benchmarking survey completed by the Urgent Care Association (UCA) found that the average urgent care center collects $110 per patient. However, the “acceptable” net revenue per patient visit varies widely from center to center and state to state. It fluctuates based on many variables: Existing contracts from payors State (e.g., payors in California and Arizona typically have lower …

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Workers’ Compensation Visits, Cerumen Removal

Q. I have a question on coding Workers’ Compensation claims. I work in a hospital system and hospital coders oversee our charts. I feel they under code for the work we do. They are afraid of audits and refusal to pay. Typically, they will return the chart so that I can document my time and then they will charge for the time spent instead of the documentation. I’m told there are no “bullet points” or …

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New CMS Modifiers, Urgent Care Codes, Supply Codes

Q. What will be the impact of use of the new HCPCS modifiers related to modifier -59 beginning January 1, 2015? A. CMS recently announced the creation of four new HCPCS modifiers that will further refine modifier -59, “Distinct procedural service.” According to CMS, modifier -59 is the most widely used modifier, and it is being used inappropriately in most cases. Adding modifier -59 indicates that a code represents a service that is separate and …

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