Part B News | Ask a Part B News Expert

Be careful about upcoding; DOJ may come after it as a false claim

02/13/2023

Question: I recently saw a Department of Justice settlement in North Carolina that seemed to be entirely based on a pattern of upcoding E/M. I didn’t know federal prosecutors did that! Is it common?

Don’t try to DIY when you need alternative language options for ABNs

01/09/2023

by: Julia Kyles, CPC

Question: Medicare creates advance beneficiary notices of noncoverage (ABN) in English and Spanish, but the majority of our limited English proficiency patients speak Korean. Does our practice need to create an ABN in the appropriate language when an official version isn’t available?

Give coders a chart, not a calculator to find new prolonged threshold times

12/05/2022

by: Julia Kyles, CPC

Question: We are trying to understand the time requirements for G0316, G0317 and G0318. We thought CMS added an extra 15 minutes to the threshold times listed in the new CPT guidelines.

Know how to report a hypertensive crisis in ICD-10-CM

12/05/2022

by: Savannah Schmidt

Question: What is a hypertensive crisis and how is it reported in ICD-10-CM?

Virtual incident-to visits are still a choice during COVID-19 PHE

10/31/2022

by: Julia Kyles, CPC

Question: We conducted a sample review of claims for 2021 and found two visits that were performed by the physician assistant (PA) but billed incident-to on days when the physician was not in the office. When we investigated, we found more claims with the same problem. According to the documentation for each visit the physician was at home but “present” through a real-time, audio/visual Zoom connection. Is there an exception that allows us to bill incident-to this way?

Virtual incident-to is an option through 2023

10/31/2022

by: Julia Kyles, CPC

Physicians can provide virtual direct supervision thanks to one of the many waivers that CMS created in response to the COVID-19 pandemic. Virtual direct supervision gives the practice more flexibility to bill incident-to services, but it is not a permanent policy.

Check state scope laws on who may debride mycotic nails

10/31/2022

by: Laura Evans, CPC

Question: I would like clarification on whether only MDs, DPMs, APRNs or PAs are allowed to perform and bill Medicare for debridement of mycotic nails (codes 11720 and 11721) in the office setting, when all the other criteria for the procedures have been met. Recently, I have been asked about a nail technician or medical assistant performing these procedures under supervision of a MD or DPM and billing the services to Medicare as incident to. I have found no information to suggest that this is appropriate. Am I correct in stating that nail technicians or medical assistants are not qualified to perform this service?

‘After-hours’ codes can add dollars, and so can ‘during-hours’ codes

10/24/2022

by: Roy Edroso

Question: One of our commercial payers offers extra payment from the add-on codes 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed [eg, holidays, Saturday or Sunday], in addition to basic service) and 99051 (Service[s] provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service). I get the first code, but the second one just sounds like normal service during normal hours. What’s the deal?

When the patient brings a drug and you inject? Largely OK; charge a penny

10/10/2022

by: Roy Edroso

Question: We have a patient whose testosterone therapy is ordered elsewhere and will be sent to us for injection. I’ve had it drilled into me that we never leave off the drug code when we bill administration, but we clearly can’t charge for the drug. How do we bill?

Use these strategies when a payer inappropriately uses modifier 50

08/29/2022

by: Laura Evans, CPC

Question: We recently sent a claim to Blue Cross of Alabama that included 20610-LT for a left shoulder diagnosis and 20610-RT for a right knee diagnosis. The payer responded that we should have billed these procedures on one claim line with a 50 modifier (bilateral procedure). We replied that this was not a bilateral procedure, but rather two separate procedures done in two separate joints. The payer then stated that because code 20610 has a bilateral surgery indicator of “1” in the Medicare physician fee schedule, modifier 50 should be used rather than RT/LT. There doesn’t seem to be any way to report a major joint arthrocentesis done on different joints on opposite sides of the body. Is there a way to correct the situation?

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