CPT for Fluoroscopy

spine fluoro is 77003 you are correct.....fluoro of other anatomy is 77002. You shouldnt be doing 5-10 minute fluoro of much at all in pain medicine...more like a few seconds....they pay about $25. And yes there is still a professional fluoro fee if u do it in a hospital.

just append modifier 26 to 77003 for spine stuff... but dude you are a bit late because they made this change in january....

and you really should be doing your procedures in under 10 seconds of fluoro (for most procedures) - if you aren't then for your sake and everybody else getting radiated, you should get some additional training

"if you aren't then for your sake and everybody else getting radiated, you should get some additional training".

5 minutes is more like a stimulator trial, with two leads, or technically challanging. I have an electrophysiology buddy of mine using over 45minutes of fluoro per case, which shocked me... I told him to have kids ASAP...

any more code changes for this upcoming year that we should be aware of?🙄

I think united healthcare keeps sending info about needing office-based certification in the future, in order to use fluoro, but I have not seen any changes as yet.

stim4u

I don't thnk he meant 5 minutes of active fluoro time. Or conversely, one could say I hope you guys take longer than 10 seconds to do a procedure...

GOOD NEWS: The best change for 2008 is CMS recently issued that they will now pay for conscious/moderate sedation (99144) performed by the same physician doing the procedure. If you were denied payment for billing these to Medicare, you can appeal them back to January 2007 *if you have proper documentation*

Many of the other carriers are falling in line with this.

FYI: The codes are changing (AGAIN) for contrast
Q9967= LOCM 300-399 mg/ml iodine, 1ml
Q9966= LOCM 200-299 mg/ml iodine, 1ml
Q9965= LOCM 100-199 mg/ml iodine, 1 ml


FYI: The codes are changing (AGAIN) for hyaluronate injections (J7321-J7324)

BAD NEWS: Pain procedure fees in office are going to get hacked again (about 20%).

BAD NEWS: They are changing the stimulator lead fees in ASCs. Instead of paying for the leads separately (L8680) they are increasing the fee on 63650 for the facility portion to cover the cost of the leads. Not terrible, but less than we were making the other way. You will bill per LEAD now, instead of per ELECTRODE. You will do this by listing 63650 for each lead implanted. They have changed the ASC fee schedule COMPLETELY and will be paying less for many procedures, but allowing more types of procedures to be performed at ASCs.

BAD NEWS: The OIG (office of the inspector general at CMS) has made it a PRIORITY to investigate the dramatic increase in interventional pain procedures. This is not limited to investigating the interventional pain physicians, but any physicians reporting these procedures. They haven't said how exactly they are going to go about this, but don't be surprised if you start seeing requests for chart notes and op notes. **It would be wise for you or the office manager to look at all records requests to see what they are fishing for and that the notes are acceptable before they leave the office**
If you don't have your documentation for medical necessity bullet proof already, it would be wise to start now. And donate lots of money to your senator/congress person while you're at it...

There are also a bunch of new BS codes for Team Meetings, phone calls, and "screening interventions" for alcohol and substance abuse, most of which will not be paid for by most carriers.

good news: they will still pay per electrode for office procedure SCS leads.

Ligament said:

GOOD NEWS: The best change for 2008 is CMS recently issued that they will now pay for conscious/moderate sedation (99144) performed by the same physician doing the procedure. If you were denied payment for billing these to Medicare, you can appeal them back to January 2007 *if you have proper documentation*

Many of the other carriers are falling in line with this.

FYI: The codes are changing (AGAIN) for contrast
Q9967= LOCM 300-399 mg/ml iodine, 1ml
Q9966= LOCM 200-299 mg/ml iodine, 1ml
Q9965= LOCM 100-199 mg/ml iodine, 1 ml


FYI: The codes are changing (AGAIN) for hyaluronate injections (J7321-J7324)

BAD NEWS: Pain procedure fees in office are going to get hacked again (about 20%).

BAD NEWS: They are changing the stimulator lead fees in ASCs. Instead of paying for the leads separately (L8680) they are increasing the fee on 63650 for the facility portion to cover the cost of the leads. Not terrible, but less than we were making the other way. You will bill per LEAD now, instead of per ELECTRODE. You will do this by listing 63650 for each lead implanted. They have changed the ASC fee schedule COMPLETELY and will be paying less for many procedures, but allowing more types of procedures to be performed at ASCs.

BAD NEWS: The OIG (office of the inspector general at CMS) has made it a PRIORITY to investigate the dramatic increase in interventional pain procedures. This is not limited to investigating the interventional pain physicians, but any physicians reporting these procedures. They haven't said how exactly they are going to go about this, but don't be surprised if you start seeing requests for chart notes and op notes. **It would be wise for you or the office manager to look at all records requests to see what they are fishing for and that the notes are acceptable before they leave the office**
If you don't have your documentation for medical necessity bullet proof already, it would be wise to start now. And donate lots of money to your senator/congress person while you're at it...

There are also a bunch of new BS codes for Team Meetings, phone calls, and "screening interventions" for alcohol and substance abuse, most of which will not be paid for by most carriers.

Click to expand...

Hi Ligament,
Got a question for you. If I did not bill for 99144 the entire last year for Medicare patients since it was a bundle service, can I retroactively bill for it to 1/07 now that it a billable code? Thanks for your answer in advance. If anyone else knows, feel free to answer.

mdtails said:

Hi Ligament,
Got a question for you. If I did not bill for 99144 the entire last year for Medicare patients since it was a bundle service, can I retroactively bill for it to 1/07 now that it a billable code? Thanks for your answer in advance. If anyone else knows, feel free to answer.

Click to expand...

I have been told that you can only appeal denied claims. It was recommended to call your local office and tell them you have umpteen sedation claims denied as bundled in error and how do they want to handle it. Supposedly they will not require you to complete an appeal request for each claim. Also, you do not have to send them your documentation for a bundling error. A copy of the denied claim should suffice.

However, lets ponder sending *corrected* claims. You would have to re-submit the entire claim for the visit, with the additional service line for moderate sedation. The total balance remaining on the claim would be your charge for sedation. Corrected claims typically go to a separate PO Box from the regular claims address. What's the worse that could happen? They say no? Oh well, at least you tried...

But wait a minute! You usually need to send a copy of your notes with the corrected claim, so you would want to read the notes with a fine tooth comb and make sure everything is documented correctly for the ENTIRE service, including the sedation. If you submit the request for more money for the sedation and the Medicare Reviewer reads the notes and sees that you billed for 3 levels of facet joint blocks and only documented TWO levels, they would pay you for the sedation, and do a take back on the extra facet joint and you would end up owing them $$$$! DOH! Now you just sent in 25 claims with incorrectly billed facets and they decide you probably have more they can cash in on and want to audit you.... 😱

So now the worse that could happen is you LOSE money.

Also, your sedation records need to show
1- that the medication was titrated until the patient achieved
MODERATE SEDATION
not light or minimal sedation
not heavy or to slurred speech sedation
not conscious sedation
MODERATE SEDATION is what is covered under the guidelines. The ASA has some recently created definition of what constitutes "moderate sedation." I don't have this available immediately. Maybe someone else does?
2- need to list the meds used and amounts
3- need to list how long the patient was sedated (99144 is paid by time- up to 30 minutes of sedation; 99145 for each additional 15 minutes.)
4- need to list that the patient's status was monitored by a "qualified" assistant- this can be a Medical Assistant or Nurse- very unclear who would be considered qualified, but it has to be someone besides the surgeon. This person's primary job is to keep an eye on the patient- similar to how an anesthesiologist's primary job is to keep the patient alive during surgery. Sometimes the notes will simply name the person who monitored the patient. You can also list whatever equipment you always use to monitor vitals (this would be easy to add to a dictation template).
5- the medical necessity (reason) for the sedation- could be the patient was too agitated to hold still, procedure anxiety, positional pain, etc.

In short, trying to bill for these 2007 sedations may be too much trouble. Probably better to get your documentation set to go forward. Also, you can always call your medicare office and ask them what they recommend, it doesn't hurt.

Can you 'moderately' sedate a patient with oral valium (or fentanyl oral preparations), with the extensive aforementioned written documentation, and get paid? Or does it have to be intravenous sedatives?

How much does medicare/private insurance pay for moderate sedation anyway?(PM me if you don't mind).

What types of nurses, or aids are people using for IV sedation, APRN, nurse, aid, etc?

Thanks.

pays something like 50-90 dollars for spinal injections for moderate sedation provided by a separate anesthesiologist as of 2007 (depends on time needed for injection). They pay something like 1.50 for 10 mg triamcinilone so I can't see them paying much for sedation given by the provider.
You really can end up s_$t creek provding sedation and something happens, especially without the proper airway skills and equiptment, so beware....

I would like to thank Kwijibo for bringing up the fact that I am NOT discussing how to give sedation in a safe and effective manner. I am ONLY DISCUSSING THE REQUIREMENTS FOR DOCUMENTATION AND PAYMENT. Having a crash cart, etc, is not listed as a requirement for insurance payment purposes, but I assume you would have one anyway... other threads have detailed these issues.

this article has the guidelines for the definition of moderate sedation and will answer most questions...
http://www.asahq.org/publicationsAndServices/sedation1017.pdf

Some of you may notice that the AMA pretty liberally quoted from this article (without credit) in the 2007 CPT book.

Sorry, oral meds are defined in this article as "minimal sedation"

lobelsteve, your template looks pretty good- I give you a B+. You need to include that the patient was monitored by "an independent trained observer" (that's what the CPT book calls it- not sure what that means).

Also make sure that the patient record shows what time the sedation ended. I typically see what time the sedation was administered in office charts, but not always what time the physician transfers care to "postoperative supervision" and when you leave to do the next procedure, your face-to-face time ends, so does the billing time.

I have seen payments in a large range- $25-$125 for 99144, plus the J-codes ($1-$2 for meds). I have seen many commercial insurers adopting these guidelines. If the insurance company claims to follow Medicare guidelines, I would send them a copy of the Medicare clarification to pay, not bundle. Some of the companies have special rules. Some companies wanted a copy of the intra-operative notes detailing the sedation to be sent with the claim to pay. Another one required the code be billed with modifier -59 to pay. Call your carriers or get on their websites and ask what they want.

Ligament - can you give a few pointers regarding what should specifically be addressed in a clinic note when we are documenting support for the medical necessity of an axial procedure? Lets take a typical TFESI for a lumbar radic, for example. I routinely explain that the patient has undergone extensive conservative treatment, including PT, a trial of NSAIDS, any other pain meds used, adequate time (often >6 weeks), and I mention my exam and imaging findings supporting the diagnosis. Is there anything else I should add? Thanks.

My billing assistant has reported that CMS will sometimes just not pay for procedures (and I'm conservative with them), despite the documentation I describe above. That kinda pisses me off.

knoxdoc said:

Ligament - can you give a few pointers regarding what should specifically be addressed in a clinic note when we are documenting support for the medical necessity of an axial procedure? Lets take a typical TFESI for a lumbar radic, for example. I routinely explain that the patient has undergone extensive conservative treatment, including PT, a trial of NSAIDS, any other pain meds used, adequate time (often >6 weeks), and I mention my exam and imaging findings supporting the diagnosis. Is there anything else I should add? Thanks.

Click to expand...

You are definitely headed in the right direction! My "indication for procedure" is similar to yours:

Mrs. Pain is here today for L3/L4 transforaminal epidural. She has failed physical therapy, a course of chiropractic, rest and anti-inflammatory medications, including a course of prednisone. Her imaging shows a medial disc bulge at L3 and her physical exam correlates with weakness and numbness in an L4 pattern with the primary symptom of pain down her leg to the arch of her foot.

What many insurance companies are looking for these days is NOT reduction of pain, but the next line, the coveted "objective increase in function":

We have scheduled todays treatment with the hopes of decreasing her weakness so she can walk without risk of falling and resume her activities, including exercise, grocery shopping and caring for her grandchildren.

(I like to throw in a "heartstring" functionality like "returning to work so he can support his family" or "continue lifting her disabled child." Sorry to be stereo-typing, but it is usually women reading these things and they appreciate stuff like that. It also makes the insurance company look more heartless when they deny the visit. 😉 )

The final piece of medical necessity is unfortunately, future treatment plan. In pain patients this is always difficult, but you should list the next steps in the differential diagnosis:

Post Op: Mrs. Pain is feeling some soreness after the procedure. We will contact her tomorrow to check her status and send her home with a Pain Diary. If the injection today is successful, she may return for repeated procedure every 2-3 months. If she does not have adequate improvement, I will consider also injecting at L4/5 or attempting a retro-discal transforaminal at L3/4 in 2-3 weeks.

knoxdoc said:

My billing assistant has reported that CMS will sometimes just not pay for procedures (and I'm conservative with them), despite the documentation I describe above. That kinda pisses me off.

Click to expand...

I like to have copies of the insurance company's clinical guidelines handy. Sometimes they limit the procedure you can do by symptom, time between treatments, etc. If you can parrot some of their own guidelines back at them, that is always helpful. If you get a rejection, it has to have some reason why. If not, send an appeal stating specifically how you have met the guidelines and you expect payment or a detailed explanation as to why the service is rejected. Many times I have called the insurance company and "played dumb" (easy for me 😀 ) and find out the real reason for the rejection has nothing to do with the rejection listed on the EOB- the monkey pushed the wrong button, essentially, and I'm arguing the wrong point. For example the treatment was denied for "not medically necessary" when in fact the patient maxed out her benefits for the year- it's a completely different (and more difficult) process to get an insurance company to consider extending extra benefits, as opposed to justifying a treatment regimen for a diagnosis.

Sometimes the insurance company wants a copy of the MRI report or the notes from failed treatment. This can be tricky, because you need to READ what these notes say so they don't bite you. I've reviewed cases where the notes essentially contradict themselves. For example, the physician documented adequate relief one week, and then failed to mention a re-injury that brought the patient back in less than 1 month. Or the PT will discharge the patient with home exercise and "complete pain relief" and then he is getting an injection 2 weeks later, with no explanation as to why. Or the MRI will say "minimal disc bulge." Mention this- state the extent of the clinical symptoms, or that you personally reviewed the films and you felt it was actually "moderate disc bulge". I also see frequent transcription typos on the spinal level, which make everyone look stupid- "so doctor, why were you doing a L7 transforaminal???"

Always feel free to PM me with further questions or for information on consultations.

Excellent - thanks for the help Ligament!