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Coding Guidelines for COVID-19 Treatment and Vaccination September 30, 2021

icd10 code for covid19

As the COVID-19 vaccines are in operation, we compiled a list of medical codes for Coronavirus vaccination and treatment.

ICD-10 Codes for COVID-19

Last March 2020, the World Health Organization (WHO) declared COVID-19 a pandemic outbreak. By this time, the WHO also developed ICD-10-CM codes for the Novel Coronavirus Disease (U07.1 COVID-19). The Centers for Disease Control and Prevention (CDC) adopted these codes in March 2020. Likewise, the Centers for Medicare and Medicaid Services (CMS) has developed 20 ICD-10-PCS codes for recording COVID-19 treatments and vaccines since April 2020. The six vaccine administration codes are as follows:

XW013S6 XW013T6 XW013U6 XW023S6 XW023T6 XW023U6
Introduction of COVID-19 vaccine dose one into the subcutaneous tissue, percutaneous approach, new technology group 6Introduction of COVID-19 vaccine dose two into the subcutaneous tissue, percutaneous approach, new technology group 6Introduction of COVID-19 vaccine into the subcutaneous tissue, percutaneous approach, new technology group 6Introduction of COVID-19 vaccine dose one into muscle, percutaneous approach, new technology group 6Introduction of COVID-19 vaccine dose two into muscle, percutaneous approach, new technology group 6Introduction of COVID-19 vaccine into muscle, percutaneous approach, new technology group 6

COVID-19 ICD-10-PCS Coding

According to CMS, the new 21 PCS codes will “describe the use of vaccines or monoclonal antibodies for COVID-19 treatment and infusion of therapeutics.” The PCS codes do not affect MS-DRG assignment.

XW013F5Introduction of other new technology monoclonal antibody into subcutaneous tissue, percutaneous approach, new technology group 6
XW013K6Introduction of leronlimab monoclonal antibody into subcutaneous tissue, percutaneous approach, new technology group 6
XW013S6Introduction of COVID-19 vaccine dose 1 into subcutaneous tissue, percutaneous approach, new technology group 6
XW013T6Introduction of COVID-19 vaccine dose 2 into subcutaneous tissue, percutaneous approach, new technology group 6
XW013U6Introduction of COVID-19 vaccine into subcutaneous tissue, percutaneous approach, new technology group 6
XW023S6Introduction of COVID-19 vaccine dose 1 into muscle, percutaneous approach, new technology group 6
XW023T6Introduction of COVID-19 vaccine dose 2 into muscle, percutaneous approach, new technology group 6
XW023U6Introduction of COVID-19 vaccine into muscle, percutaneous approach, new technology group 6
XW033E6Introduction of etesevimab monoclonal antibody into peripheral vein, percutaneous approach, new technology group 6
XW033F6Introduction of bamlanivimab monoclonal antibody into peripheral vein, percutaneous approach, new technology group 6
XW033G6Introduction of REGN-COV2 monoclonal antibody into peripheral vein, percutaneous approach, new technology group 6
XW033H6Introduction of other new technology monoclonal antibody into peripheral vein, percutaneous approach, new technology group 6
XW033L6Introduction of CD24Fc immunomodulator into peripheral vein, percutaneous approach, new technology group 6
XW043E6Introduction of etesevimab monoclonal antibody into the central vein, percutaneous approach, new technology group 
XW043F6Introduction of bamlanivimab monoclonal antibody into central vein, percutaneous approach, new technology group 6
XW043G6Introduction of REGN-COV2 monoclonal antibody into central vein, percutaneous approach, new technology group 
XW043H6Introduction of other new technology monoclonal antibody into central vein, percutaneous approach, new technology group 6
XW043L6Introduction of CD24Fc immunomodulator into central vein, percutaneous approach, new technology group 6
XW0DXM6Introduction of baricitinib into mouth and pharynx, external approach, new technology group 6
XW0G7M6Introduction of baricitinib into upper GI, via natural or artificial opening, new technology group 6
XW0H7M6Introduction of baricitinib into lower GI, via natural or artificial opening, new technology group 6

COVID-19 Vaccine CPT Codes

You can now identify the appropriate CPT code combination to use for the type and dose of vaccine you are using. The Centers for Disease Control and Prevention (CDC) integrate these codes for their tracking needs.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) identify two code groups:

  • Provides a vaccine administration code that is both a vaccine and has a specific dose.
  • Help determine the type of vaccine

It is essential to choose the correct manufacturer’s vaccine code.

Vaccine CodeVaccine NameVaccine Administration CodeManufacturerNDC 10/ NDC 11
91300Pfizer-BioNTech COVID-19 Vaccine0004A (Booster)Pfizer, Inc59267-1000-1 59267-1000-01
91300Pfizer-BioNTech COVID-19 Vaccine0001A (1st Dose)Pfizer, Inc59267-1000-1 59267-1000-01
91300Pfizer-BioNTech COVID-19 Vaccine0002A (2nd Dose)Pfizer, Inc59267-1000-1 59267-1000-01
91300Pfizer-BioNTech COVID-19 Vaccine0003A (3rd Dose)Pfizer, Inc59267-1000-1 59267-1000-01
91301Moderna COVID-19 Vaccine0011A (1st Dose)Moderna, Inc80777-273-10 80777-0273-10
91301Moderna COVID-19 Vaccine0012A (2nd Dose)Moderna, Inc80777-273-10 80777-0273-10
91301Moderna COVID-19 Vaccine0013A (3rd Dose)Moderna, Inc80777-273-10 80777-0273-10
91302AstraZeneca COVID-19 Vaccine0021A (1st Dose)AstraZeneca0310-1222-10 00310-1222-10
91302AstraZeneca COVID-19 Vaccine0022A (2nd Dose)AstraZeneca0310-1222-10 00310-1222-10
91303Janssen COVID-19 Vaccine0031A (Single Dose)Janssen59676-580-05 59676-0580-05
91304Novavax COVID-19 Vaccine0041A (1st Dose)Novavax80631-100-01 80631-1000-01
91304Novavax COVID-19 Vaccine0042A (2nd Dose)Novavax80631-100-01 80631-1000-01
91305Pfizer-BioNTech COVID-19 Vaccine0054A (Booster)Pfizer, Inc59267-1000-1 59267-1000-01
91305Pfizer-BioNTech COVID-19 Vaccine0051A (1st Dose)Pfizer, Inc59267-1000-1 59267-1000-01
91305Pfizer-BioNTech COVID-19 Vaccine0052A (2nd Dose)Pfizer, Inc59267-1000-1 59267-1000-01
91305Pfizer-BioNTech COVID-19 Vaccine0053A (3rd Dose)Pfizer, Inc59267-1000-1 59267-1000-01
91306Moderna COVID-19 Vaccine0064A (Booster)Moderna, Inc80777-273-10 80777-0273-10
Source: American Medical Association (AMA)

Medical Billing and Coding Guidelines

Coding Guidelines

In an update to the Current Procedural Terminology (CPT®) code set, the American Medical Association (AMA) included new vaccine-specific codes for reporting immunizations against the novel Coronavirus (SARS-CoV-2, COVID-19).

The specificity level allows keeping track of the vaccine dose even when you don’t report the vaccine product. For example, a patient may receive a vaccine for free. These CPT codes record the actual work of providing the vaccine, along with any necessary counseling and updating the electronic health record.”

Pfizer-BioNTech Vaccine 
91300:SARSCOV2 VAC 30MCG/0.3ML IM
0001A:ADM SARSCOV2 30MCG/0.3ML 1ST
0002A:ADM SARSCOV2 30MCG/0.3ML 2ND
0003A:ADM SARSCOV2 30MCG/0.3ML 3RD 
Moderna COVID-19 Vaccine 
91301:SARSCOV2 VAC 100MCG/0.5ML IM 
0011A:ADM SARSCOV2 100MCG/0.5ML 1ST
0012A:ADM SARSCOV2 100MCG/0.5ML 2ND
0013A:ADM SARSCOV2 100MCG/0.5ML 3RD
Janssen COVID-19 Vaccine 
91303:SARSCOV2 VAC AD26 .5ML IM
0031A:ADM SARSCOV2 VAC AD26 .5ML

Billing Guidelines

“The American citizens can now get free vaccine doses using taxpayer dollars. However, vaccination providers may charge administration fees for the procedure. In this case, health insurance companies can reimburse them for the amount or the Health Resources and Services Administration’s Provider Relief Fund (HRSA) if the patient is uninsured.”

Ensure you enter the appropriate CPT codes for the vaccine and the administration fee in your billing system.

Vaccine CPT CodeICD-10 CodeVaccine NameVaccine Admin Code(s)Unit of CoverageNDC 11 Digit Product ID 
91300Z23Pfizer BioNTech COVID-19 Vaccine0001A (1st dose)

0002A (2nd dose) 

0003A (3rd dose)
0.3mL59267-1000-01 59267-1000-02 59267-1000-03 
NDC Units reported as “UN1”
91301Z23Moderna COVID-19 Vaccine 00011A (1st dose) 

0012A (2nd dose) 

0013A (3rd dose)
0.5mL80777-0273-10 80777-0273-99 
NDC Units reported as “UN1”
91303Z23Janssen COVID-19 Vaccine0031A0.5mL59676-0580-05 59676-0580-15 
NDC Units reported as “UN1”

In order to submit a claim to Medicare for administering the COVID-19 vaccine, providers must be Medicare-eligible. If you want to look for another reference, you can click here.

Tap Into Our Expertise

The COVID-19 codes and billing guidelines are new obstacles for your medical practice. However, worrying too much cannot help your practice grow. You can always count on coding and billing experts to help you.

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

Schedule a call with our experts today!


Pain Management: Signs You Need to Outsource Your Billing and Coding September 9, 2021

Medical billing and coding

Medical billing and coding are a great challenge for healthcare providers. Veteran surgeons and seasoned healthcare professionals see it as a struggle.  Regardless of the resources and assets, hindrances still occur.  It’s a parade of medical codes, insufficient time, and failure to follow-up for collections. How do you make more time for your patients? 

Medical practices are now finding ways to find the appropriate solution. In particular, pain management practices continue to deal with complex billing and coding. If your pain management practice seems to face many issues, you can always ask for our assistance. At 5 Star Billing Services, we offer comprehensive pain management billing services and collections. We can help your pain management practice grow.  So what are the signs that you need to outsource your billing and coding?

Late Payments

Following up on payments causes frustration. The increased reliance on patient payments requires an increased collection budget. Hiring a pain management billing service makes billing collections and claims easier. Our pain management billing experts track late payments quicker, so the in-house staff can focus on other tasks. About 54% of insured patients have trouble understanding their medical bills. We can also help patients clarify their confusion with their claims and other processes. 

The Decline of Patient Care

Spending more time on billing and coding than patient care is a big problem. Medical exams may get delayed when your nurses are busy with billing processes. In the end, your patients may end up walking out and never return to your practice.  Your staff is probably finding it hard juggling multiple tasks. That’s why outsourcing your billing and coding is the best option. Our pain management billing experts are always available to handle all the complex billing tasks on your behalf.

Pressure on staff

The administrative staff also faces difficulties with in-house medical billing. It’s time-consuming and frustrating. Training is necessary for up-to-date changes in rules and codes. However, it also takes significant time away from dealing with other admin tasks. In that case, you may need to assign tasks to other departments. Many practices are still hesitant to outsource their billing and coding. They fear that the cost will be prohibitive, but you can save a lot of money by outsourcing medical billing. It will help your practice become more efficient and help your staff maintain a work-life balance.

Loss of Workforce

High staff turnover is always a problem. When a staff member leaves, the remaining work might get divided among your team members. Often, these members lack medical billing and coding expertise, and new hires may leave before they complete their training. These issues reduce revenues, increase billing and coding errors, and erodes the quality of care. That’s why healthcare providers want the best for their pain management practices. Your patients can benefit from the services, and your pain management practice will be stable. In contrast, if staff resignations are piling up, it may be time to look for pain management billing services. Let the experts handle the tough job.

Struggle to find Staff Replacement

Finding qualified staff for your pain management practice can be hard. Both urban and rural areas are experiencing a shortage of skilled workers. Coding experts, medical billers, and administrative staff are especially hard to find. Other physician offices have high turnover rates due to problems with managers or office politics. According to the Medical Group Management Association (MGMA), practice costs have risen by 50%. 

Increase in Insurance Denials

To maintain compliance with insurance coverage requirements, AR and billing staff must continually handle insurance denials. A high rate of insurance denials could indicate a poor denial resolution process. Experts can help you expedite your transactions. Our AR management and electronic claims in pain management reduce delays. Also, we provide an initial evaluation of your practice before we move forward. 

Account Receivables are Too High

In a short time, account receivables (AR) can mount up. That might be because of faulty software or an inexperienced biller. You may need to restructure your entire patient-to-pay revenue cycle. Likewise, you may not have enough staff to handle claims errors and denials right away. AR levels can rapidly rise due to any of these reasons or a combination of them. The American Medical Association (AMA) stated that the average is now 24%, with half of that percentage collected at the point-of-service—thereby adding to the overall A/R increase. Further, an unclear collections success rate results in administrative waste, unnecessary write-offs, and a loss of bottom-line profit.

Tap Into Our Expertise

Pain management coding and billing are indeed strenuous. That is why we provide you with several reasons to consider medical outsourcing. With the help of an outsourcing billing company, your pain management practice will grow.

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

Schedule a call with our experts today!


Medical Billing and Coding Changes in 2021 July 30, 2021

Medical Billing and Coding

Every year comes with change.


The content of the Current Procedural Terminology (CPT) coding manual is no exception. The American Medical Association consistently adds, erases, or reexamines codes/descriptors. Often, we are the ones who expect and monitor these changes since we need to update coding, billing, and documentation rules. In the new version, doctors practicing anesthesia and pain management will have less burden to bear. The guide also provides information on documentation, utilization, and coding from the 2021 CPT manual. 

  1. Code Changes in CPT Manual 2021

The CPT code changes are the most important announcement in the CPT code manual. Here are a few of them:

  • Transforaminal Injections under ultrasound guidance were deleted from the Pain Management section (CPT codes 0228T- 0231T), and are now reported by the unlisted code 64999.
  • The CPT code changes for 2021 involved codes found in the Surgery Section, Pathology/ Laboratory Section, and Category III Section of the CPT manual. The CPT code for High Intensity Focused Ultrasound (HIFU) — ablation of malignant prostate tissue is 55880. However, carrier policies are still reporting this process to be a trial and need approval before reimbursement begins. The FDA thus approves the CPT code, so any updates in reimbursement status will be reviewed.
  • The 2021 CPT edition contains 206 new codes, 69 revised codes, and 54 omitted codes. 

This change is meant to bring the process up to date with current standards. According to AMA, it highlights the increase of certain medical conditions that were minor before together with other codes.

  1. Changes in E/M 2021 Coding Guidelines 

The Evaluation and Management (E/M) 2021 coding guidelines related to Office Outpatient visits (CPT 99202-99215) have changed. Here are some of them:

  • CPT 99201 is not anymore in the CPT code manual.
  • Providing guidance is necessary for medical decision-making about latent illnesses and comorbidities.
  • Physical exams and history are not necessary for code selection.
  • It is necessary to add details in coding guidelines and descriptions to promote payer consistency.
  • Medical decision-making (MDM) levels or total time spent on each date dictate the code selection for 99202-99205, which includes “a medically appropriate history and/or physical examination.”
  • Office/Outpatient 2021 E/M Codes — New Patient

Furthermore, the 2021 coding guidelines 99202-99205 follow the same structure as 99203 example below:

  • 99203 – Office and Outpatient visits for E/M of new patient coding guidelines require “a medically  appropriate history and/or examination” and low level of MDM. A total time of 30-44 minutes is spent on the date of the encounter for code selection.
    Code             History/ExamMDMTotal Minutes
99202    Medically appropriate history and/or examination Straightforward 15-29 
99203  Medically appropriate history and/or examination Low 30-44
99204  Medically appropriate history and/or examination Moderate 45-59
99205  Medically appropriate history and/or examination High 60-74

Additionally, the CPT code +99417 was created by AMA for prolonged E/M services longer than 74 minutes of the primary procedure. This code would be used as follows:

Code/sTotal Duration of New Patient Office/Outpatient Services (with the use of code 99205)
No separate report< 75 minutes
99201 X 1 and 99417 X 175 – 89 minutes
99205 X 1 and 99417 X 290 – 104 minutes
99205 X 1 and 99417 X 3 or more for additional (15 minutes each)105 minutes or greater than
  • Office/Outpatient 2021 E/M Codes — Established Patient

New patient codes and established patient codes require different times for each level. The illustration below states level 5 established-patient code 99215 lists 40-54 minutes while level-5 new-patient code 99205 lists 60-74 minutes.

CodeHistory/ExamMDMTotal Minutes
99212 Medical appropriate history and/or examination Straightforward 10-19
99213 Medical appropriate history and/or examination Low 20-29
99214 Medical appropriate history and/or examination Moderate 30-39
99215 Medical appropriate history and/or examination High 40-54

Therefore, payers who follow AMA can now use the new prolonged services code +99417. For services 55 minutes or longer, this code can be an add-on. 

  • 2021 E/M Guidelines for MDM

The CPT proclaims that MDM “includes diagnosing, assessing conditions, and selecting appropriate management options.” In 2021, three components characterize MDM for office/outpatient visits. These components are comparable, however not the same as those of 2020:

  1. The number and complexity of the problem or problems the provider addresses during the E/M encounter.  

They will address the problem after the evaluation and treatment at the encounter physician or other qualified professional. 

  1. The amount and/or complexity of data to be reviewed and analyzed. 

The 2021 guidelines list divided the data into three: 

  • Tests, documents, orders, or independent historians
  • Independent interpretation of tests
  • Discussion management with external physicians/appropriate sources
  1. The risk of complications and/or morbidity or mortality of patient management decisions made at the visit. 

In the 2021 guidelines, options still need consideration but not for selection. They are still taken into account after the patient and family hear about the MDM. Some examples can be:

  • Deciding whether to hospitalize a psychiatric patient with adequate support for outpatient treatment.
  • Decide palliative care for a patient with advanced dementia and acute condition of sickness.

The basis for meeting requirements for two out of three elements is also at the level of the MDM column. Notably, physicians should be familiar with the column for Amount and/or Complexity of Data to be Reviewed and Analyzed. Indeed, the categories on it are essential for understanding the structure.

In the table, codes 99203 and 99213 need to meet the criteria for at least one of two categories. For codes 99204 and 99214, the service has to meet the requirements for one of three categories. For the highest-level codes, 99205 and 99215, the service needs to meet the requirements for two of three categories. Lower-level codes don’t have categories in that column.

  • Codes link to Technology Development.

There is more consideration to these progressions when it comes to advanced technology. Medical billing guidelines and code changes are gradually improving quality treatment in the health care system. Rather than coordinating with codes to new methods, doctors and medical billing clinical staff now have efficient documentation services for patients. In addition, there is increasing recognition that not all patient care occurs in the doctor’s office. As part of the new coding guidelines, some tasks also happen at other times, such as coordination of care or telehealth visits.

These 2021 coding guidelines will also help progress documentation to inpatient care, though there may be hurdles and pins. Also, you can inquire for assistance from medical billing experts. They are willing to help shape up these changes and make your medical practice foster.

Tap Into Our Expertise

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

Schedule a call with our experts today!


Billing & Revenue Cycle Problems in Pain Management July 30, 2021

Pain Management

Maintaining a profitable practice means ensuring a healthy revenue cycle for any pain management practice. However, pain management practices still encounter hardships due to their complexities in billing and coding. It can be challenging to manage the processes when it involves stakeholders and obtaining payment relies on consistent interactions. Keeping departmental and payer communications open can help keep accurate information sorted and categorized throughout the process. The following are the most common billing and revenue cycle issues in Pain Management Practices:

  1. A manual process on claims denial management
  • Using a manual process for managing denials can slow down your cash flow. At the same time, it can still lead to more inaccuracies and errors.
  • According to Michelle Tohill, Director of Revenue Cycle Management at Bonafide Management System, healthcare providers should switch to automated systems to avoid denials. In addition, staying on top of diagnostic codes and different insurance policies can be exhausting. However, many software providers will automatically update requirements and coding procedures.
  • She also added that there are still many software providers who are constantly updating codes and requirements. In this way, your billing staff can double-check claims. Making sure they meet the demands and saving research time.
  • Furthermore, your staff needs to be aware of future happenings to get reimbursements, less time figuring things out, and detect necessary parties.
  • Automating claim denial management in medical billing can help providers identify errors before submitting claims.
  • There may still be difficulties toward submitting claims and associated labors in managing denials, stated Brendan FitzGerald, HIMSS Analytics Director of Research. Surprisingly, software providers have not automated the denial management process through a vendor-provided solution.
  • If managing denials are a lot, productivity might be slow through a manual process.
  • Denial management is still a question, whether it is outsourcing or in-house. The HIMSS study found that 44% of healthcare professionals preferred outsourcing such as revenue cycle management, clearinghouses, or EHRs, while 18% implemented an automated system in-house.
  • Medical billing teams from denial management draw data over healthcare industries and handle multiple payer rules and codes.

  1. Coding Errors

Incorrect codes will lead to deferred, denied, or half-paid claims. Pain management practices continue to struggle with the complexities of codes for pain management coding procedures. These are the top coding issues:

  • Inaccurate coding on clinical coverage
  • Improper procedural codes
  • Out-of-date codes

These can bring about mistakes that become costly to your pain management practice. On the other hand, money is not always an issue. It can also lead to legal consequences like:

  • Imprisonment – for penalties and false claims submitted per file
  • Clinical Maltreatment – If there’s proof of deliberate distortion throughout quite a while and across countless patients. 

 Even though these may seem alarming, the most well-known result of billing issues is that insurance agencies will not reimburse your cases.

  1. Prior Authorization Delays

Prior Authorization (PA) setbacks can deprive physicians of time in catering to patients and increase their expenditures. Some medical insurance companies require prior authorizations (PA) before providing pain management procedures. It serves as a significant barrier for physicians to deliver quality care. PA helps with:

  • Monitoring healthcare costs
  • Proper approval from patients plan
  • Providing payers with a secure prescription for medicine and drugs

Despite this, the process can slow down the delivery of needed services and care for patients. To improve PA performance, physicians adopt the usage of Pain Management EMR Software. Electronic Prior Authorization integrates directly with your electronic medical records (EMRs). Healthcare professionals can use it to obtain prior authorization in real-time. Additionally, it eliminates the need for time-consuming paper forms, faxes, and telephone calls.

  1. No proper staff training

Unskilled staff in the healthcare industry might cause revenue cycle management issues. In relation, they might not bill or capture patient data correctly. Proper staff training is necessary to capture patient’s demographic information on the front end. Also, on how to translate that data to successful insurance claims after that. With that, patient schedules and registrations must also be accurate to avoid problems in revenue. Conducting staff training might be time-consuming, but it is worthwhile. It can increase cash flow well after, although it might also be costly. Moreover, your pain management practice will boost these areas:

  • Enhance job proficiency
  • Boost staff self-esteem
  • Employees will stay longer to your business

If you also think of outsourcing your revenue cycle management, talk to a Pain Management Billing specialist. Working with them can save you time and resources.

  1. Failure to follow up on Accounts Receivable (A/R)

A/R follow-up process can be a handful at most times. The team assigned for this is to consistently handle interactions with patients, healthcare providers, and insurance agencies. There are also processes that your team needs to complete:

  • Verification,
  • Charge entry
  • Payment posting

Medical billing specialists regulate the precise diagnosis and exact procedure codes based on the treatment plan. If your A/R team has issues regarding this, your practice might be at stake. Your practice cannot establish good revenue without a proper A/R process. Without it, it can lead to high collections of A/R, and backlogs will occur. The worse thing is that insurance companies will deny claims if your A/R team fails these processes. If you want to increase your profitability, you can read these 8 Tips in Pain Management Practice.

Tap Into Our Expertise

These are just some of the common problems associated with pain management practices. Think about outsourcing your revenue cycle management to trained and experienced medical billers and coders. Having people take charge of your medical practice problems and provide solutions is always a great idea to boost revenue.

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.

Schedule a call with our experts today!


Effective Coding Habits for Sleep Medicine June 2, 2021

Coding Habits for Sleep Medicine

Sleep medicine is a growing field that is very daunting to coders and physicians as it’s a subspecialty of neurology. It comes with highly complex technicalities in the guidelines and procedure code descriptions. Fortunately, code selection is simple when codes are grouped and compared by elements. Doctors, medical providers, and medical coders can be uncertain of how to code sleep studies and other services for patients with sleep disorders. This article will outline effective coding habits for sleep medicine practices to ensure the best reimbursement possible while providing accurate documentation in patient records. 

Different Types of Code Sets for Sleep Medicine.

The CPT® code range 95803-95783, as well as the HCPCS Level II code range G0398-G0399, comprise sleep medicine procedure codes. Miscellaneous sleep diagnostic testing, home sleep study tests, sleep studies, and polysomnography are the different types of code sets.

Miscellaneous Sleep Diagnostic Testing Codes

Two different types of sleep diagnostic tests can be used.

  • 1st Test 

95805  –   Multiple sleep latency or wakefulness monitoring, recording, examination, and interpretation of physiological sleep measurements during multiple trials are used to determine sleepiness.

Multiple sleep latency monitoring consists of four or five brief naps arranged a few hours apart in the office environment. During these nap sessions, the patient’s brain waves, muscle function, and eye movements are all tracked and documented. This information can be used to identify narcolepsy and prolonged daytime sleepiness, as well as evaluate the effectiveness of breathing disorder therapies. Modifier 52 Reduced services should be added if there are less than four nap opportunities reported.

  • 2nd Test

95803  – Testing, documenting, analyzing, interpreting, and reporting on actigraphy (minimum of 72 hours to 14 consecutive days of recording)

Patients should be given an actigraph device to put on their wrist in the home setting for this test. Over three to 14 days, the actigraph device records sleep and movement. When the unit is returned to the provider’s office, the data can be accessed to a computer and analyzed using advanced software to aid in the evaluation and monitoring of sleep disturbances including circadian rhythm disorders and sleep-disordered breathing.

Home Sleep Studies Codes

Since they are conducted at the patient’s home, home sleep studies are less expensive than in-office/hospital sleep studies. Overnight, a piece of special equipment monitors breathing, oxygen levels, and breathing effort. To diagnose sleep disorders, this data is extracted from the device and interpreted using specialized software.

There are three HCPCS Level II codes for documenting home sleep study studies, with the number of channels used during recording being the distinguishing factor:

  1. G0400

Unattended home sleep test (HST) with type IV portable monitor; minimum of three channels Both in-office/hospital sleep studies are coded in the CPT® code range 95806-95783. These are either sleep studies or specialized polysomnography.

  1. G0399

Unattended home sleep test (HST) with type III portable monitor; at least four channels: two respiratory movement/airflow, one ECG/heart rate, and one oxygen saturation.

  1. G0398

Unattended home sleep study test (HST) with type II portable monitor; at least 7 channels: EEG, EOG, ECG/heart rate, EMG, airflow, respiratory effort, and oxygen saturation

Sleep Studies (Non-polysomnographic) Codes

Sleep studies that are not polysomnographic can be attended to or left unattended. An attended, non-polysomnographic sleep study has only one code which is:

  • 95807

A technologist is present during the sleep analysis, which includes a simultaneous recording of breathing, respiratory effort, ECG or heart rate, and oxygen saturation.

The code is chosen based on the parameters used during the recording. Modifier 52 should be included if the total recording time is less than six hours. Three CPT codes exist to report unattended, non-polysomnographic sleep studies which are:

  • 95806

Simultaneous monitoring of heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) during an unattended sleep study.

  • 95801

Simultaneous monitoring of minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone) during an unattended sleep study.

  • 95800

Simultaneous monitoring of minimum heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time during an unattended sleep study.

Polysomnography Codes

Polysomnography is a form of sleep study that records brain waves, blood oxygen levels, heart rate, breathing, eye movements, and leg movements in an office or hospital setting. It may be used for diagnostic, therapeutic, or “split” purposes.

Diagnostic Polysomnography

To disclose strictly diagnostic polysomnography, use one of three codes:

  1. 95782 Sleep staging with four or five additional sleep parameters for children under the age of six, with a technologist present.
  1. 95808  Sleep staging with 1-3 additional sleep parameters for anyone of any age, supervised by a technologist
  1. 95810 Sleep staging with four or five additional sleep parameters for children aged six and up, with a technologist present.

The number of parameters used during recording and, in the case of 95810 and 95782, the patient’s age are used to determine the code. If the total recording time is less than six hours, add modifiers 52 to 95808 and 95810. If the cumulative recording time is less than seven hours, add modifier 52 to 95782.

Therapeutic and Split Polysomnography Codes

For patients with a history of sleep apnea, therapeutic polysomnography is used. The test aims to figure out what titration levels of therapies like continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) are adequate for treating the patient’s apnea. On the other hand, split polysomnography is a part of the research that is diagnostic. If the patient is discovered to have sleep apnea during recording, CPAP or BiPAP titration is started to assess therapeutic levels for the patient.

Therapeutic and split polysomnography are reported using two codes, which are chosen solely based on the patient’s age:

95811   Sleep staging with 4 or more extra sleep parameters at the age of 6 years or older, with the initiation of continuous positive airway pressure therapy or bi-level ventilation under the supervision of a technologist.

If the total recording time is less than six hours, add modifier 52.

95783    Sleep staging with four or more additional sleep criteria, as well as the implementation of continuous positive airway pressure therapy or bi-level ventilation, with a technologist present. If the cumulative recording time is less than seven hours, add modifier 52.

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Podiatry Coding Tips to Improve Your Bottom Line April 16, 2021

Doctor looking at Podiatry Coding

People who have been dealing with medical coding for a long time know the frustrations of its complexity. A simple coding error can lead to increased claim rejection rates and decreased reimbursement rates. Doctors in Podiatric Medicine are not strangers to the intricacies of coding. They have to strictly use the appropriate modifiers, protocol codes, and patient diagnosis codes. Here are several tips that can help you avoid podiatry coding mistakes:

Review podiatry coding updates

The healthcare industry has undergone significant transformation in recent years, and podiatry is no exemption. Every year, there are coding improvements for all specialties, and coders must be aware of these changes to receive adequate compensation from payers. Furthermore, it has been noted that the podiatry coding standards have changed, and practices that are ignorant of these changes incur losses.

The Medicare Physician Fee Schedule requires billing and coding workers to be mindful of various fees and regulatory updates. Knowing these rules will help practices minimize the amount of paperwork they have to deal with when it comes to Medicare billing.

Use the correct modifiers

Correct modifiers allow for accurate payment of all podiatry procedures, including bunionectomy procedures. We highly recommend checking Correct Coding Initiative (CCI) edits, which can be found on the CMS website or in podiatry-related websites like the American Podiatric Medical Association (APMA) Coding Information Center.

When coding Evaluation and Management (E/M) modifiers, coders are often confused. The -24, -25 and -57 modifiers are three basic assessment and management (E/M) modifiers. For E/M programs, these modifiers must be used. Assert declination would occur if these modifiers are used for other utilities.

Specific E/M codes are paid rather than being combined for a single payment. If the E/M service is “important and separately identifiable” from the treatment a podiatrist is doing on the same day, use modifier 25. If medical attention was not needed, do not use this modifier.

 Be careful in “Unbundling” 

Unbundling, also known as fragmentation. refers to reducing the billing and base process of each component that can result in a higher payment than billing the entire comprehensive code. However,  take note that unbundling for the sake of obtaining a higher payment can be considered fraudulent billing.

Use the appropriate modifier to unbundle services properly

There are many legally unbundled cases. When two codes are performed at two different anatomical locations, they can be bundled together but are paid separately.

For example, billing for an arthroplasty code and a bunion code. If you’re not using any modifiers, group them. When performing these procedures on a lesser digit, using the right modifier would cause a bunion procedure as well as an arthroplasty procedure to be properly compensated. Another example is paying for several “single” procedures where there is a code for the same treatment that is classified as “multiple.”

Double-check for any downcoding

Another common blunder is downcoding. Upcoding entails paying for a higher quality of operation or different services than would normally be necessary. On the other hand, downcoding doesn’t have any useful purpose.

The idea is that if you obtain and bill a lower-level code (usually an E/M service), you’ll “go under the radar,” lowering your chances of being audited by insurance agencies. An insurance provider may be worried that, although you are costing the insurance company less money, your billing can still be considered fraudulent.

You could be cheating yourself out of legal money if you downcode. Changes in relative value units (RVUs), sequestration, and fines for not engaging in the Merit-Based Incentive Payment System (MIPS)/Medicare Access and CHIP Reauthorization Act (MACRA) scheme all appear to be eroding the reimbursements. Downcoding means you’re losing more money. Get paid for what you do and keep a copy of the chart note on hand to support your billing.

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Changes in CPT Codes in 2021 March 1, 2021

cpt codes for 2021

The 2021 Current Procedural Terminology (CPT®) code set was released earlier last fall by the American Medical Association (AMA). There are 329 editorial changes, including 206 new codes, 54 deletions, 69 revisions, along with the “first massive revamp of office codes and guidelines and other outpatient assessment and management (E/M) services in more than 25 years.” Changes became effective earlier this year, last January 1, 2021. Here are some highlights about the changes that you should know:

E/M Services

The office and outpatient E/M Services have the biggest changes. According to the AMA, these modifications include:

  • History and physical exams are no longer an element for code selection.
  • Letting physicians choose the best patient care by permitting code level selection according to the medical decision-making (MDM) or total time.
  • Promoting payer consistency with more detail added to CPT code descriptors and guidelines.

The new CPT standards retain 5 coding levels for established patients and decrease the number of levels to 4 for new patients’ office/outpatient E/M visits. The AMA RVS Update Committee (RUC) also amended the values for the office/outpatient E/M visit codes, which will raise Medicare and possibly other payers’ payments for these services.

According to AMA President Susan R. Bailey, M.D., health care organizations need to understand and be ready to use the revisions to get the full benefit of the burden relief from the E/M office visit changes. She also adds that the AMA will help physicians and health care organizations with the transition and offers resources to understand the operational, infrastructural, and administrative workflow adjustments that will result from the pending transition.

The 2021 code set also represents the continuing pandemic of COVID-19 that devastated the globe in 2020. In the 2021 CPT code set, the following SARS-CoV-2 based CPT codes were accepted and officially issued, although some have been in use since earlier this year.

  • 87635: Added to report infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique. (Effective March 13, 2020.)
  • 86318: Revised to report immunoassay for infectious agent antibody(ies) and to be a parent to 86328. (Effective April 10, 2020.)
  • 86328: Added to report single-step antibody testing for severe acute respiratory syndrome coronavirus 2. (Effective April 10, 2020.)
  • 86769: Added as a child code to report multiple-step antibody testing for severe acute respiratory syndrome coronavirus 2. (Effective April 10, 2020.)
  • 0202U: Added to report the BioFire® Respiratory Panel 2.1 (RP2.1) test. (Effective May 20, 2020.)
  • 87426: Added to report infectious agent antigen detection by immunoassay technique of SARS-CoV and SARS-CoV-2.
    • PLA codes 0223U and 0224U: Added for detection of SARS-CoV-2.
  • 86408-86409: Added for reporting coronavirus 2 (SARS-CoV-2) neutralizing antibody screen and titer. (Effective Aug. 10, 2020.)
    • PLA codes 0225U and 0226U: Added for detection of SARS-CoV-2. (Effective Aug. 10, 2020.)
  • 99072: Added for the additional supplies and clinical staff time required to mitigate transmission of respiratory infectious disease while providing evaluation, treatment, or procedural services during a public health emergency, as defined by law. 
  • 86413: Added for reporting quantitative antibody detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
  • 87636: Added for reporting combined respiratory virus multiplex testing for either SARS-CoV-2 with Influenza A&B.
    • PLA codes 0240U and 0241U: Added for detection of SARS-CoV-2, Influenza A, and Influenza B.
  • 87637: Added for reporting combined respiratory virus multiplex testing for either SARS-CoV-2 with Influenza A&B and RSV.
    • PLA code 0241U: Added for detection of RSV.
  • 87811: Added for antigen detection of SARS-CoV-2 by direct optical (i.e., visual) observation.  
  • 87301, 87802, and their subsidiary codes: Revised immunology guidelines.
  • Accepted addition of code 87428 for reporting multiplex viral pathogen panel using antigen immunoassay technique for SARS-CoV-2 testing along with influenza A and influenza B.
  • 91300, 91301: Added to report Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccines.
    • 0001A, 0002A, 0011A, 0012A: Added to report the immunization administration of these vaccines

Prolonged Services

A few new codes, including direct and indirect medical interaction given in varied settings beyond normal assessment and management services, have been applied to the bill for prolonged services.

  • Direct Patient Contact – Outpatient

Codes 99354-99357 are utilized where long-term treatment requiring direct patient interaction is given by a physician or other trained healthcare provider and is provided in either the inpatient, observation or outpatient area (not including office or other outpatient E/M services) beyond the normal service.

99354-99355 is used to document on a given date the average amount of face-to-face time spent by a doctor or other trained healthcare provider delivering extended outpatient service. 

The first hour of prolonged service is recorded using 99354. And if the time spent is not constant, it can be used only once per date, per venue. If prolonged service is given for more than one hour, 99355 is used to record every additional 30 minutes after the first hour.

Prolonged service with a cumulative length of fewer than 30 minutes on a specified date is not recorded separately. Prolonged service of fewer than 15 minutes after the first hour or less than 15 minutes after the last 30 minutes is often not separately recorded.

  • Direct Patient Contact – Inpatient

Codes 99356-99357 are used to document the cumulative amount of time spent in the hospital or nursing home by a physician or other trained health care provider offering prolonged treatment to a patient at the bedside and on the floor or unit of the patient.

The first hour of extended service is recorded using 99356. And if the time spent is not constant, it can be used only once per date, per venue. If extended service is given for more than one hour, 99357 is used to record every additional 30 minutes after the first hour.

Prolonged service with a cumulative length of fewer than 30 minutes on a specified date is not recorded separately. Furthermore, prolonged service of fewer than 15 minutes after the first hour or less than 15 minutes after the last 30 minutes is not separately recorded.

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How COVID-19 Is Changing the Medical Billing Process November 19, 2020

The pandemic continues to overwhelm the globe. Economies are in a recession. And hospitals and private practices throughout the United States are absorbing a lot of the brunt. They are barely holding on due to the decline of outpatient and non-urgent treatment procedures. In addition, the pandemic also brought a lot of changes in medical billing. Thus, adapting to your practice’s survival has never been more critical. 

How Medical Practices are Thriving

The Inbox Health Survey reports that 21% of 1200 medical billers forecast that 10-25% of their practices may shut their doors for the next six months. Luckily, over $100 billion has been provided by the US Congress to help medical practices, hospitals, doctors, and other healthcare professionals through the Public Health and Social Services Emergency Fund. However, many fear that it may not be enough.

Changes in Patient Interactions and Collections

Most of the 1,200 Inbox Health Survey respondents observed a great decline in their patient volume and interactions. Subsequently, it results in a 10% to 25% drop in collections. It intensifies the struggle to survive and cope in the middle of a global pandemic and recession. 

How to Cope with the Medical Financial Crisis

The following are the vital keys that you need to consider to cope and survive and achieve financial sustainability amidst the pandemic:

  1. Adjust operational accommodations
  2. Record changes in standard referral requirements
  3. Adapt to the rapidly changing rules and regulations in billing and coding, especially with Medicare and Medicaid.
  4. Take note of the following questions regarding Telehealth: 
  • The total sum of coverage
  • Extra documentation for medical necessity
  • Prior authorizations and required approvals
  1. Tighten remote medical billing plans to minimize cash flow issues
  2. Account for changes in copays and deductibles
  3. Optimize your resources according to a surge or drop in patient volume

How to Adapt Effectively to the Changes

For healthcare organizations struggling to cope with the pandemic, it is vital to keep their facilities open and to improve their medical billing operations. The Strata Decision Technology reported a massive drop in inpatient procedures at the start of the pandemic. Here are some keys to generating revenues and rebuilding financial capacity: 

  • Provide telehealth services
  • Implement s safe social distancing plan in the clinic
  • Adapt innovative healthcare technologies like telemedicine
  • Gain the patient’s trust and confidence
  • Secure necessary supplies for a patient surge
  • Conduct strict precautionary measures in the clinic

Telemedicine’s Role in the New Normal

Telemedicine services and technologies have been the greatest help in medical advances in health care due to the pandemic. It played a great role in keeping healthcare organizations afloat and lowering the risk of infection for patients. Undoubtedly, it will continue to do so in the post-COVID era. The CMC even reports that telemedicine catered to over 9 million patients during the first few months of the pandemic.

Telemedicine technologies made it possible for healthcare facilities to provide safe treatments to non-COVID and COVID patients. It enables small practices to continue their operations and even extend the lengths of their services. Patients can easily book their consultations online. It opened new gates of healthcare convenience, proving to the world that it is not just a mere temporary aid for the pandemic. Hopefully, it will continue to widen the scope of remote services well into the future. 

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At 5 Star Medical Billing, we offer the highest level of performance for high-quality medical billing. Let us help you during these dire times.

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How to Turn Your Revenue Cycle Management Process Around September 25, 2017

Revenue Cycle Management

The efficiency of the your practice’s revenue cycle can have a critical impact on financial performance, and effective management of the cycle is of utmost importance to your practice. However revenue cycle management within health practices is becoming increasingly difficult, with greater administrative responsibilities and regulatory pressures. This article outlines the problems practices are facing and how to turn the revenue management process around.

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