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Hospitals must provide MOON

Hospitals must provide MOON


Hospitals and critical access hospitals (CAHs) must provide the Medicare Outpatient Observation Notice (MOON), or CMS-10611, to patients with Original Medicare who are receiving outpatient observation services for more than 24 hours, effective Feb. 21, 2017. The purpose of this change request (CR) is to update Chapter 30 of Pub. 100-04 to include the Medicare Outpatient Observation Notice (MOON), CMS-10611, form instructions.

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AMA Vaccination Codes

AMA Vaccination Codes

AMA Vaccination Codes 2017 CPT® introduces one new vaccine code, and revises the reporting criteria for nine others.


AMA Vaccination Codes


Code 90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use is added to improve reporting of quadrivalent vaccine (e.g., Flucelvax®). Quadrivalent vaccines contain two Influenza A strains and two Influenza B strains that the World Health Organization predicted to be prevalent during the current flu season. Note that the descriptor identifies the dosage as 0.5 mL, by intramuscular injection.

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New Add- on EM Visit Code

New Add-on EM Visit Code

EM Visit Code

The Centers for Medicare & Medicaid Services (CMS) proposed a new add-on EM visit code G0501 that could be billed with new and established patient office/outpatient Evaluation and Management codes (99201-99205 and 99212-99215), as well as transitional care management codes (99495, 99496), when the additional resources described by the code are medically necessary and used in the provision of care, effective January 1, 2017.

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Coding Tonsillitis

Coding Tonsillitis

Chapter J of the ICD-10-CM coding manual contains the diagnosis codes for coding tonsillitis.  The tonsils are part of the lymphatic and immunologic system. They are the body’s first line of defense and are similar to lymph nodes located in the neck, groin, and armpits.

The tonsils are oval shaped, pink structures in the back of the throat and act as filters by trapping germs that pass through the nose and mouth. They also produce antibodies that help fight infection. Tonsillitis may be either viral or bacterial. Streptococcus pyogenes, the bacteria that causes strep throat, is a common bacterial cause, accounting for approximately 30 percent of tonsillitis in children and 10 percent in adults. Other causes include adenovirus, influenza virus, and Epstein-Barr virus.

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OPPS Hospital Claim Issues by CMS

OPPS Hospital Claim Issues by CMS


New payment models

OPPS Hospital Claim Issues have been identified by CMS due to errors in the Medicare Claims Processing System, some Outpatient Prospective Payment System (OPPS) hospital claims with dates of service on or after January 1, 2017, may have been overpaid.

Claims with the following CPT® codes may be affected:

0253T, 0335T, 24361, 25420, 25444, 25445, 27442, 27871, 28715, 28730, 37229, 43266, 45389, 62360, 64580, 69717, and 75898.


In addition, eight Comprehensive Ambulatory Payment Classification (APC) Complexity Adjustment pairs were incorrectly omitted from the claims processing system:

Primary Code            Code 2                      Complexity-Adjusted APC

28300                          27698                          5115

28300                          28306                          5115

33208                          C9600                         5224

36902                          36908                          5193

36903                          36908                          5194

36904                          36908                          5193

36905                          36908                          5194

49653                          49650                          5362


A correction for these issues will be implemented on April 3, reports the Centers for Medicare & Medicaid Services (CMS) in the January 19, 2017, MLN Connects. Medicare administrative contractors will automatically reprocess impacted claims; providers do not need to take any action.


NCCI Edits for Institutional and Physician Claims

National Correct Coding Initiative (NCCI) edit updates for institutional claims have regularly been implemented one quarter behind the physician claim NCCI edits due to systems issues. As a result, some physician single-quarter-only edits were not implemented for institutional claims. Starting April 3, CMS will apply the same physician NCCI edits to institutional claims, including the single-quarter-only edits.



Coding Hearing Loss

Coding Hearing Loss

Coding hearing loss can be difficult to narrow down depending upon the system damaged and factors involved.  Hearing loss is a very common problem caused by factors such as noise, aging, disease, and heredity.


coding hearing loss

According to the American Speech-Language-Hearing Association, hearing loss can be categorized by which part of the auditory system is damaged.

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DRG issues caught by the eye of OIG

DRG issues caught by the eye of OIG

DRG issues

The Office of Inspector General (OIG) is reviewing Medicare’s billing and reimbursement integrity for two diagnosis-related groups (DRG) or DRG issues, 1) inpatient claims for kwashiorkor diagnosis, 2) mechanical ventilation in the 2017 Work Plan.

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Coding Ultrasound Breast Imaging.

Coding Ultrasound Breast Imaging.






In 2015, the CPT® codebook deleted breast ultrasound code and replaced it with two, more precise codes:

  • 76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed;complete
  • 76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed;limited

Code 76641 describes a complete examination of all four quadrants of the breast and the retroareolar region; 76642 describes a limited breast ultrasound (e.g., a focused examination limited to one or more elements of 76641, but not all four). To support the service performed and billed, the provider should document a thorough exam of the anatomic area(s), and provide image documentation and a final, written report of results, impressions, etc.

Report 76641 or 76442 once, per breast, per session. Both codes are unilateral: If medical necessity requires bilateral imaging, you may append modifier 50 Bilateral procedure. The 2017 National Physician Fee Schedule Relative Value File assigns a “1” bilateral indicator to 76641 and 76442, meaning that Medicare will allow 150 percent of the standard reimbursement for properly billed bilateral procedures.

Both 76641 and 76442 include examination of the axilla, if performed. For ultrasound exam of the axilla, only, see 76882 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific.


Source: AMA CPT Coding Book 2017.


Glaucoma Screening Coding

Glaucoma Screening Coding

According to the National Eye Health Education Program (NEHEP), if detected through preventive screening, however, glaucoma can usually be controlled and severe vision loss can often be prevented. Medicare provides glaucoma screening coverage for beneficiaries in at least one high-risk group:

  • Have diabetes mellitus
  • Have a family history of glaucoma
  • Are African-American aged 50 or older
  • Are Hispanic-American aged 65 or older

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Billing Telehealth Part B in 2017

Billing Telehealth

Billing Telehealth Part B in 2017


There are just a few changes for 2017 reporting of telehealth services of which providers and their medical coding and billing staff should be aware.

For Medicare Part B claims, one has a handful of new codes added to the list of payable telehealth services and a new place of service (POS) code.



Added Telehealth Services for 2017.


CMS received several requests in 2015 to add various existing services as Medicare covered telehealth services effective for 2017.

They finalized four CPT® codes:

  • 90967             End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age;
  • 90968             End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age;
  • 90969             End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12-19 years of age); and
  • 90970             End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older).


As a condition of payment, the required clinical examination of the catheter access site must be furnished face-to-face “hands on” (without the use of an interactive telecommunications system) by a physician, certified nurse specialist, nurse practitioner, or physician assistant.


New Codes for Critical Care Consultations:

CMS also determined that two advance care planning codes (99497 and 99498) are similar to the two annual wellness visit codes (G0438 and G0439).

CMS added two new HCPCS Level II codes:

  • G0508             Telehealth consultation, critical care, physicians typically spend 60 minutes communicating with the patient via telehealth (initial); and
  • G0509            Telehealth consultation, critical care, physicians typically spend 50 minutes communicating with the patient via telehealth (subsequent)


This new coding provides a mechanism to report an intensive telehealth consultation service, initial or subsequent, for the critically ill patient, such as a stroke patient, under the circumstance when a qualified healthcare professional has in-person responsibility for the patient, but the patient benefits from additional services from a distant-site consultant specially trained in providing critical care services.

These services are limited to once per day, per patient; and are valued relative to existing evaluation and management services.


A New POS Code:

Effective Jan. 1, 2017, physicians and practitioners furnishing telehealth services are required to report POS code 02.The location where health services and health related services are provided or received through telecommunication technology to indicate that the billed service is furnished as a telehalth service from a distant site.

This POS code does not apply to originating sites billing the facility fee. Originating sites are not furnishing a service via telehealth since the patient is physically present in the facility. Accordingly, the originating site should continue to use the POS code that applies to the type of facility where the patient is located.

Distant site providers are paid using the facility physician expense relative value units, regardless of their location. The setting of the patient does not affect the payment to the distant site provider.

Report POS code 02 in addition to the GT and GQ modifiers. CMS notes in the final rule that this may be redundant, and will consider removing the GT and GQ modifiers.


Coverage Parameters:

Several conditions must be met for Medicare to make payments for telehealth services under the MPFS.

The service must be on the list of Medicare telehealth services and meet all of the following additional requirements:

  • The service must be furnished via an interactive telecommunications system.
  • The service must be furnished by a physician or other authorized practitioner.
  • The service must be furnished to an eligible telehealth individual.
  • The individual receiving the service must be located in a telehealth originating site.

When all of these conditions are met, Medicare pays a facility fee to the originating site and makes a separate payment to the distant site practitioner furnishing the service.


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