Wednesday, October 19, 2016

Procedure code 14040, 14000, 14020


14000-2 Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less $773.91

14001-2 defect 10.1 sq cm to 30.0 sq cm $1,136.94

14020-2 Adjacent tissue transfer or rearrangement, scalp, arms, legs; defect 10 sq cm or less $764.11

14021-2 defect 10.1sq cm to 30.0 sq cm $1,392.02

14040-2 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck axilae, genitalia, hands, and/or feet; defect 10 sq cm or less $1,078.05

All these codes require prior Authorization

Edit Rule

Separate Reimbursement

Use the procedure  code that best describes the procedure, the location and the size of the lesion. If there are multiple lesions, multiple codes from 11300 through 11446 or 17106 through 17111 may be used, but National Correct Coding Initiative guidelines apply for all submitted codes. For excision of benign lesions requiring more than simple closure, i.e., requiring intermediate or complex closure, report 11400-11466 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes. For reconstructive closure, see 14000-14300, 15000- 15261, and 15570-15770.

procedure  codes 11400-11446 should be used when the excision is a full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure.
Claims for removal of benign skin lesions performed merely for cosmetic reasons may not necessarily need to be submitted to Medicare unless the patient requests that a formal Medicare denial is issued. If a claim is filed, ICD-9 CM code V50.1 (Other plastic surgery for unacceptable cosmetic appearance) should be used in conjunction with the appropriate procedure  code

Tuesday, October 18, 2016

What is Customary charges

The Customary Charge

The customary charge is the amount that best represents the actual charges made for a given medical service or by other persons who supply other medical and health services to the general public. Therefore, obtain information on the customary charges from the following sources:

• Physicians and other persons not only from the Medicare program;

• Any other available sources;

• Other contractor programs;

• Other insurance programs;

• Federal Employee Health Benefit Program;

• TriCare;

• Any studies conducted by State or local medical societies;

• From public agencies;

• Any data volunteered from other sources.

Where circumstances warrant, MACs may also ask physicians or other persons for their charges for services rendered to the public in general. MACs should validate any information on charges obtained from sources against claims.

A. Charges for Rare or Unusual Procedures

 In suchA/B MACs (B) may incur situations where a new or rare procedure is performed and information on customary and prevailing charges is difficult to obtain.situations, in order to make the reasonable charge determination:

a. Obtain data, if possible, on the charges made for the unusual or rare procedure in other areas similar to the locality in which the service was rendered; or

b. Consult with the local medical society regarding the appropriate charge to be made for this procedure.

A relative value scale may be used together with available information about the physician’s customary charges and about the prevailing charges for more frequently performed services in the locality in order to fill gaps in the data available. Where there is insufficient information, consult with any medical authority that would be helpful, such as the medical personnel within the A/B MAC (B), the local or State medical society, or hospital medical personnel. In assessing the value of the procedure, the medical personnel should take into consideration:

a. Its complexity;

b. The time needed to perform the procedure; and

c. The prevailing charges in the locality for other procedures of comparable complexity.

A/B MACs (B) then determine reasonable charge for a given service on the best available medical opinion and information on customary and prevailing charges.

Friday, October 14, 2016

Criteria for Determining Reasonable Charge

There are two criteria in the Act that must be considered in determining the reasonable charge for a service. They are:

• The customary charges for similar services generally made by the physician or other person furnishing such services; and

• The prevailing charges in the locality for similar services.

Therefore, the reasonable charge for a specific service in the absence of unusual medical complications or circumstances, may not exceed the lowest of:

The customary charge for that service;

• The prevailing charge made for similar services in the locality; or

• The actual charge for the service. (Se

The law also provides that the reasonable charge for a service not exceed the charge applicable for a comparable service under comparable circumstances to the contractor’s policyholders or subscribers.  The A/B MAC (B) or DME MAC also determines if the charge for the specific item or service is inherently reasonable.

The income of an individual patient may not be considered in determining the amount of the reasonable charge.
Public Law 96-499 requires that reasonable charge payments be based on customary and prevailing charge screens in effect on the date the service is rendered. However, if the service was rendered at any time prior to the current fee year, payment is based on the screens in effect during the preceding fee screen year.

To implement this provision, the A/B MAC (B) must complete the following activities:

• Retain the prior year’s pricing files in the system so that reasonable charge pricing data is available for two years. As of July 1, 2003, all A/B MACs (B) operating the MCS system must retain at least five pricing files (current period plus four prior periods); and

• Price the service based on the date of service on the claim using pricing files in effect for the same year as the date of service.

Monday, October 10, 2016

Billing Guide Modifer KX and JW

Modifier KX

The KX modifier is a multipurpose, informational modifier and can be used to identify services for transgender, ambiguous genitalia, and hermaphrodite beneficiaries in addition to its other existing uses. Physicians and non-physician practitioners should use modifier KX with procedure codes that are gender specific in the particular cases of transgender, ambiguous genitalia, and hermaphrodite beneficiaries.

Note: The KX modifier may also be used in conjunction with other medical policies, for example durable medical equipment. Refer to the Durable Medical Equipment (DME) payment policy for more information.

Modifier JW

Effective for dates of service on or after April 1, 2015, providers must submit modifier JW to identify unused drug or biologicals from single use vials or single use packages for the last dose of the day for that drug or biological that is appropriately discarded.

Provider Type Modifiers

Tufts Health Plan requires provider organization-affiliated psychiatrists to append appropriate modifiers for services provided by a non-M.D. clinician in their office. The modifiers will affect compensation according to clinician type. Refer to the Modifier Table for a list of these modifiers. Codes 96101, 96102, 96103, 96118, 96119 and 96120 will be excluded from the modifier logic when billed with modifier AH and HP.

Note: Tufts Health Plan does not compensate for services provided by a non-independently licensed clinician providing services under the supervision of a provider organization–affiliated psychiatrist.

Therapy Modifiers

Effective for dates of service on or after October 1, 2015, Tufts Health Plan will not compensate for non-therapy services billed with modifiers GN, GO and GP.

Thursday, October 6, 2016

Why Modifier is Important and where to report in the claim -

Modifiers provide a means to report or indicate a service or procedure that has been performed has been altered can be altered by a specific circumstance without changing the procedure code. Modifiers are used to increase accuracy in compensation, coding consistency, editing, and to capture payment data.

Tufts Health Plan accepts all standard CPT and HCPCS modifiers submitted in accordance with the appropriate CPT or HCPCS procedure code(s). Certain modifiers, when submitted appropriately, will impact compensation.

Note: The absence or presence of the appropriate modifier may result in a claim denial. 


** Submit the appropriate modifier(s) with the corresponding CPT or HCPCS procedure codes on a CMS-1500 form for professional service in Box 24d Procedures, Services, or Supplies field

** Submit the modifier(s), when appropriate, in front of the corresponding CPT or HCPCS procedure codes on a UB-04 form for hospital services in Box 44 HCPCS/Rates field. Modifiers submitted after the procedure code may be incorrectly processed in the Tufts Health Plan system and delay payment or result in a denial.

Note: Annually and quarterly, HIPAA medical code sets3 undergo revision by CMS, AMA and CCI. Revisions typically include adding, deleting or redefining the description or nomenclature of new HCPCS, CPT procedure and ICD-CM diagnosis codes. As these revisions are made public, Tufts Health Plan will update its system to reflect these changes.

Additional Billing Information on Basic Modifiers

** Append modifier 26 to indicate the professional component that requires the use of a modifier whether in an office, inpatient or outpatient

** Append modifier TC to indicate the technical component that requires the use of a modifier, whether in an office, inpatient or outpatient setting.

** Submit global services on one line. Do not append a modifier when submitting claims for global services; providers should only bill globally when they have performed both the PC/TC components in an office setting.

** Append modifier 50 (bilateral procedure) to bilateral surgical procedure code(s) that require the use of a modifier.

** Submit bilateral surgical procedure code(s) on one claim line/service line with one unit.

** Append modifier 51 (multiple procedures) to surgical procedures that require the use of a modifier, that are billed in addition to the primary surgical procedure.

EDI Claim Submitter Information

** Submit claims in HIPAA compliant 837I format for institutional claims. Claims billed electronically with non-standard codes will reject.

** Claims submitted with non-standard modifiers will be rejected if submitted electronically.

Paper Claim Submitter Information

** Submit claims on an official claim form for professional services. Claim line(s) billed with non-standard codes will deny.

** All paper claims must be submitted on the official red claim forms. Black and white versions of these forms, including photocopied and faxed versions, will not be accepted and will be returned with a request to submit on the proper claim form.

** Submitted forms deemed incomplete will be rejected and returned to the submitter. The rejected claim and a letter stating the reason for rejection will be returned to the submitter, and a new claim with the required information must be resubmitted for processing.

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