Home | News & Analysis
Benchmark of the Week
Providers don’t like to use unlisted codes if they can help it, and no wonder — the denial rates are ridiculous.

Most practices have been hesitant to tap into the prolonged service codes that are allowed when clinical staff spend extra time with a patient. Even as service utilization increased about 97% between 2016 and 2017, total claims remain scarce.

CMS’ plan in the proposed 2019 Medicare physician fee schedule to cut either a E/M charge or a procedure charge when modifier 25 is used would, if finalized, require some billing changes – and result in varying degrees of loss -- in common scenarios.
Practices that bill for critical care services (99291-99292) should make sure everyone understands the coding rules for these high-value codes, as well as the use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with critical care services. The combination of critical care and modifier 25 is on auditor radar and could trigger denials.
There are 115 CPT codes accepted by Medicare that relate to the removal of a foreign body, and in 2016, the most recent year for which we have Medicare data, they were used only 491,376 times, with 18 codes being used fewer than 100 times, and 62163 (Neuroendoscopy, intracranial; with retrieval of foreign body) used zero times.
As CMS considers significant E/M pay revisions, your reimbursement may vary based on the exact proposals the agency winds up adopting. The chart below compares the pay-rate differences between the current E/M rates and the single-stream rates for codes 99212-99215. The chart also details the positive impact of the proposed add-on codes that would apply to a dozen specialists.

Many specialists who often report blood-draw code 36415 (Collection of venous blood by venipuncture) outperform their peers in a comparison of national denial rates, according to Medicare claims data from 2016, the latest year available.


If you’re wondering whether you have a good chance of getting paid for the patient monitoring code 99091, newly unbundled in 2019, the current utilization and denial rates of other remote care codes give you some reason for optimism

Some specialties, including podiatry and dermatology, would see a significant pay increase for E/M services should CMS’ proposal to group level 2 through 5 outpatient codes into one payment basket go into effect on Jan. 1, according to a reimbursement estimates contained in the proposed 2019 Medicare physician fee schedule released July 12.
Modifier 25 (Significant, separately identifiable E/M service) is, as the name implies, supposed to be used with E/M codes to distinguish the work done on those codes from other services that would ordinarily be bundled with them. But some non-E/M codes were logged with 25 on claims, and a few had surprisingly low denial rates.


User Name:
Welcome to the new Part B News Online. If you are a returning user having trouble logging in, please click here.
Back to top