Medical Billing Articles

Billing and Coding Guidelines for General Surgery December 1, 2021

Billing and Coding guidelines for General Surgery

Billing and coding for general surgery include a wide range of procedures, from gastrointestinal (GI) tract surgery, kidney, pancreas, liver, and thoracic and abdominal surgery to breast surgery and elective surgery. The coding and billing of general surgery can be challenging due to numerous guidelines. Moreover, the general surgeons in 2019 faced 135 changes to ICD-10 codes and more than 69 changes to CPT codes. 

The Health Common Procedure Coding (HCPCS) describes medical devices, supplies, products, and services and aids Medicare and other insurance companies in processing health claims. Physician billing companies should be up to date with all the latest changes in CPT, ICD, and HCPCS codes to submit accurate claims to payers. 

In this article, we’ll discuss billing and coding guidelines for general surgery.

CPT Codes 20000-29999: Top Surgical Procedures

Surgery CPT Codes Description

Coding updates for Surgery Section 2021:

Integumentary System-Breast Repair and Reconstruction

In the breast repair and reconstruction subsection (19316-19499) of the Integumentary System, 15 codes were updated, and two were deleted (19324 and 19366) in 2021. Moreover, this subsection includes new instructions for each code and new fundamental guidelines for coders. 

Breast Reconstructions

The following code descriptions were updated:


Tissue expander placement in breast reconstruction, including subsequent expansion(s)(previously stated breast reconstruction, immediate or delayed, including subsequent expansion)   The subsequent expansions of the tissue expander are included in code 19357.

Breast reconstruction; with latissimus dorsi flap (had said the same plus “without prosthetic implant”)    The extensive notes for this code explain what not to report.  If there is the insertion of an implant in addition to latissimus dorsi flap on the same day, additionally code 19340 to 19361. If it is on a separate day, use 19342.

Codes 19364-19369 cover breast reconstruction using different types of flaps, such as fTRAM, DIEP, SIEA, bi=pedicled TRAM, TRAM with and without separate microvascular anastomosis or “supercharging.” The supercharging procedure increases blood flow in TRAM flaps with marginal circulation to ensure flap survival. All of these procedures are the same as in 2020. The only difference is that they now all mention: “including the closure of donor sites.”  Of course, this is just part of the code. Notes before each code explain what each type of flap entails.

Revisions for Breast Procedures

In the past, coders found it difficult to distinguish between breast reconstruction and revision. The descriptions of the three codes were revised:


Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy (had stated open periprosthetic capsulotomy, breast)  
In most cases, this is done to fix a displacement of an implant.

Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (had stated open periprosthetic capsulectomy, breast)  Complete capsulectomy with implant removal is the key here. This was added for clarity. A partial capsulectomy is 19370. Physicians must document clearly.(Do not report 19371 with 19328, 19330, or 19370 in the same breast.  For removal and replacement with a new implant, use 19342)

Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction (had stated revision of reconstructed breast).   In terms of revisions, this code description has been revised extensively. There is a full listing of codes not to report this within the CPT tabular, so coders must refer to it.

Indeed, the documentation of all breast procedures codes is crucial. It may be good to discuss with surgeons to review the changes above so the documentation needed for coders will be included in operative reports.

Thus, we encourage coders to use the Breast Reconstruction in CPT Action Plan and to look at photos of the various breast reconstruction techniques online. Visualizing these can sometimes make it easier to understand what should be done.

On the other hand, the guidelines clarify which reconstruction method should be used for each breast. Codes have been updated: mammary is now known as breast, and language has been added that indicates whether a breast implant was inserted simultaneously or after a significant mastectomy.


Respiratory System: The Nose


Unique, and was created to explain the repair of a nasal valve collapse with subcutaneous or submucosal lateral wall implants.
Furthermore, a code was also required to recognize the opening of the nasal collapse using minimally invasive methods and absorbable lateral wall implants.
Report for a bilateral system
Add modifier 52 to the process if it is performed unilaterally.

Respiratory System: The Lungs and Pleura


For 2021, to report core needle biopsy of the lung or mediastinum using all imaging guidance types, including, but not restricted to, CT, MRI, ultrasound, and fluoroscopy.
The current guidelines for 32408 state that imaging guidance is not to be listed separately, and the code is only used once per lesion tested in a single session. If multiple lesions are tested on a corresponding day, select 32408 for each lesion examined simultaneously, including modifier 59.

Male Genital System: Prostate

Code is used to report transrectal, high-intensity-focused ultrasound (HIFU) guided ablation of malignant prostate tissue.

Before 2021, coders were following an unrecorded code to communicate that method.

Female Genital System: The Cervix Uteri

57465A unique add-on code generated to report computer-aided colposcopy to assist in the cervix’s biopsy.
Used in combination with vaginal colposcopy procedures (57420, 57421) and cervical colposcopy procedures (57452-57461).
The specification states that it combines optical dynamic spectral imaging that aids in the mapping of abnormal measures for biopsy.

Auditory System—Other Procedures: 

There are new codes designed to practice the nasopharyngoscopy technique for the dilation of the eustachian tube. Eustachian tube balloon dilation (ETBD) is the name of this procedure. In the past, coders reported this procedure using unlisted code 69799 because no specific code was available. 

Nasopharyngoscopy, surgical, with dilation of the eustachian tube (i.e., balloon dilation); unilateral (effective 1/1/2021)
Nasopharyngoscopy, surgical, with dilation of the eustachian tube (i.e., balloon dilation); bilateral (effective 1/1/2021)
Unlisted procedure, middle ear HCPCS C9745 Nasal endoscopy, surgical; balloon dilation of the eustachian tube 

Notice: CPT codes, descriptions, and materials are the property of the American Medical Association (AMA). The Centers for Medicare and Medicaid Services (CMS) owns the copyright to HCPCS codes, descriptions, and materials.

Therefore, the following surgery coding guidelines 2021 have been updated recently. For more accurate billing and coding for general surgery, refer to this website.

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Medical Billing and Coding Guide for Substance Abuse: All You Need to Know December 1, 2021

Medical Billing and Coding for Substance Abuse

In simple terms, substance abuse refers to the pattern of harmful use of any substance to change one’s mood.  Furthermore, the term “substances” can encompass not only alcohol and drugs ( legal or illegal) but also substances that do not technically qualify as drugs. On the other hand, “abuse” involves using a substance in a way that is not intended or recommended or when you consume too much of it. 

The substance abuse medical billing process is only one element of revenue cycle management, which begins with gathering accurate patient information. In this guide, we’ll guide you all you need to know about the Medical Billing and Coding Guide for Substance Abuse.

This table shows Outpatient SUD Services:

HCPCS or CPT® CodeModifierDescriptionServiceTaxonomy
H0001HDAlcohol and/or drug assessSubstance use disorder assessment, Pregnant and Parenting Women (PPW)261QR0405X
H0001HFAlcohol and/or drug assessSubstance use disorder assessment261QR0405X
H0004HF Alcohol and/or drug servicesIndividual therapy, without family present, per 15 minutes261QR0405X
H0038HFSelfhelp/peer svcSUD Peer Services 261QR0405X 
H0020HFAlcohol and/or drug servicesOpiate Substitution Treatment, methadone administration See the Opioid Treatment Programs (OTP) section of this guide for more information about Opioid Substitution Treatment. 261QM2800X
T1017HF Targeted case managementCase management, each 15 minutes251B00000X
96164HFHealth behavior intervention, group, face-to-face; initial 30 minutesGroup/ Face to face261QR0405X
96165HFHealth behavior intervention, group, face-to-face; each additional 15 minutesGroup/ Face to face261QR0405X
96167HFHealth behavior intervention, family (with the patient present), face-to-face; initial 30 minutesFamily w/ patient present/ face to face 261QR0405X
96168HFHealth behavior intervention, family (with the patient present), face-to-face; each additional 15 minutesFamily w/ patient present/ face to face 261QR0405X
96170 HFHealth behavior intervention, family (without the patient present), face-to-face; initial 30 minutesFamily without patient present, face to face261QR0405X
96171HFHealth behavior intervention, family (without the patient present), face-to-face; additional 15 minutesFamily without patient present, face to face261QR0405X

This table shows Residential SUD Services:

HCPCS or CPT® CodeModifierDescriptionServiceTaxonomy
H0010HAAlcohol and/or drug servicesYouth subacute withdrawal management3245S0500X
H0010 HFAlcohol and/or drug servicesAdult subacute withdrawal management324500000X
H0011HAAlcohol and/or drug servicesYouth acute withdrawal management3245S0500X
H0011HF Alcohol and/or drug servicesAdult acute withdrawal management324500000X
H0018HAAlcohol and/or drug servicesYouth recovery house3245S0500X
H0018HFAlcohol and/or drug servicesAdult recovery house324500000X
H0018HVAlcohol and/or drug servicesAdult intensive inpatient residential, w/o room and board, per diem324500000X
H0019HAAlcohol and/or drug servicesYouth intensive inpatient residential, w/o room and board, per diem3245S0500X
H0019HB Alcohol and/or drug services Residential treatment, Pregnant and Parenting Women (PPW) w/Children, w/o room, and board, per diem324500000X 
H0019HD Alcohol and/or drug servicesResidential treatment, Pregnant and Parenting Women (PPW) w/o Children, w/o room and board, per diem324500000X
H0019TGAlcohol and/or drug servicesResidential treatment, long term recovery324500000X
H2036HAA/D Tx program, per diemYouth room and board*3245S0500X 
H2036HFA/D Tx program, per diemAdult Room & Board*324500000X
H2036 HDA/D Tx program, per diemPPW room and board*324500000X

For more assistance on the billing guide, refer to this site.

Substance Abuse Diagnosis

Psychiatrists, psychologists, and licensed drug counselors are often involved in the evaluation process for diagnosing alcoholism, drug addiction, or other substance use disorders. Testing blood, urine, or other tests can assess drug use but not a diagnostic test for addiction. These tests can help monitor recovery as well as treatment.

Mental health professionals diagnose substance abuse using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

How to identify correct substance abuse ICD-10-CM codes?

ICD-10-CM uses the format F1x.xxx for substance use codes. In ICD-10-CM, the letter F indicates that the code belongs to Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders. Furthermore, the number 1 represents a mental or behavioral disorder due to the use of psychoactive substances. The first x, the next digit, indicates the problematic substance (see table below in Step 1). After the decimal point, all numbers indicate the severity and nature of the problem (see Table in Step 2 below). For example,  F10.121 refers to alcohol abuse with intoxication delirium. Not all specifiers are used for every substance (primarily perceptual disturbance), so users should refer to the complete ICD-10-CM code set.

Code1Mental and Behavioral Disorders due to… 
F10…use of alcohol
F11…use of opioids
F12…use of cannabis
F13…use of sedatives, hypnotics, anxiolytics
F14…use of cocaine
F15…use of other stimulants, including caffeine
F16…use of hallucinogens
F17…use of nicotine
F18…use of inhalants
F19…use of other psychoactive substances and multiple drug use
Specifiers for Substance CodingCode1
With intoxication.12
…with perceptual disturbance.122
With [insert substance] – induced mood disorder.14
With [insert substance] – induced psychotic disorder.15
…with delusions.150
…with hallucinations.151
With other [insert substance] – induced disorder.18
…anxiety disorder .180
…sleep disorder .182
…other [same-substance] – induced disorder .188
With unspecified [insert substance] – induced disorder.19
In remission.21
With intoxication.22
…with perceptual disturbance.222
With withdrawal.23
…with perceptual disturbance.232
With [insert substance] – induced mood disorder.24
With [insert substance] – induced psychotic disorder.25
…with delusions.250
…with hallucinations.251
With [insert substance] – induced persisting amnestic disorder.26
With [insert substance] – induced persisting dementia.27
With other [insert substance] – induced disorders.28
…anxiety disorder.280
…sexual dysfunction.281
…sleep disorder.282
…other [same-substance] – induced disorder.288
With unspecified [insert substance] – induced disorder.29
Use, unspecified.9
With intoxication.92
…with perceptual disturbance.922
With withdrawal.93
…with perceptual disturbance.932
With [insert substance] – induced mood disorder.94
With [insert substance] – induced psychotic disorder.95
…with delusions.950
…with hallucinations.951
…sleep disorder .959
With [insert substance] – induced persisting amnestic disorder.96
With [insert substance] – induced persisting dementia.97
With other [inset substance] – induced disorders.98
…anxiety disorder.980
…sexual dysfunction.981
…sleep disorder.982
…other [same-substance] – induced disorder.988
With unspecified [insert substance] – induced disorder.99

For more information, you can visit the Centers for Disease Control and Prevention.

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How Automated Billing Helps Healthcare Workers November 15, 2021

Medical Billing Automation

The ongoing battle against COVID-19 has left doctors, nurses, medical assistants, and other frontline hospital staff members exhausted and overwhelmed — adding to the burnout that has long existed before the pandemic even began. In an article published by NPR, many healthcare professionals offered insights on solving this crisis, often by focusing on smaller details of the work. One thing that bothers many healthcare workers is the paperwork that sucks up their after-hours and weekends.

Managing insurance forms and billing statements is a frustrating reality of clinical experience. As time-consuming and tedious it may be, however, handling the bills is a vital part of operations. The financial success of any healthcare institution depends on translating patient visits into actual reimbursements, which is why streamlining medical billing through automation is necessary. Here are three ways automated billing can greatly assist healthcare providers:

Reduces billing errors

Medical billing is a complex process that involves monitoring, calculating, and evaluating bills for each patient. As many as 250 people may be involved in this process, from nurses to medical coders, and manual data entry can result in errors. Even the most competent employees are not above an occasional mistake, more so if every member of the staff is stretched thin by administrative tasks. With an estimated 80% of medical bills containing mistakes, professors from John Hopkins University are campaigning to standardize metrics for billing quality. They argue that financial difficulties patients encounter in medical care is also a medical complication, and healthcare institutions should provide care for the patient’s entire person — not just their body.

Automating the billing process ensures each bill is prepared correctly every time. Bots can accurately calculate the total amount patients have to pay, and take into account costs for tests, medications, doctor fees, and insurance claims. The billing software can automatically notify patients and collect payments to speed up account settlements, opening up enough resources for activities and tasks which can’t be automated.

Minimizes overall workload

One study from the peer-reviewed journal Nursing Open revealed that many healthcare workers take on multiple roles to reduce gaps in primary care. Nurses, in particular, are in charge of paperwork related to assessments, admissions, and evaluations. They also work as relationship builders, patient outreach professionals, program facilitators, and care coordinators; Maryville University’s outlook for doctor of nursing practice graduates points out that advanced nurse practitioners are often called to provide services in health assessment, pathophysiology, and pharmacotherapeutics on top of their general nursing duties.

Juggling all these tasks can cause burnout, even for the most experienced of nurses, so automated billing can lessen their workload and allow them to focus on patient outcomes. Instead of entering data by hand, an automated billing system manages information between systems, saving healthcare workers administrative time and improving overall efficiency.

Improves budgeting and resource management

In our blog post on ‘5 Signs You Need to Call a Medical Billing Specialist’, we discussed how being focused on day-to-day patient duties can leave you to neglect a dwindling revenue stream. Payment problems cause revenue cycles to slow down quickly, especially as medical billing deals with multiple payers at a time. The unpaid bills slip through the cracks, and incorrect reimbursements cause your organization to lose money.

An automated billing system can follow up on outstanding claims and reduce the administrative workload, which can cut overtime staffing costs so you can funnel additional funding into areas like patient care. Automation enriches data collection and reporting as well. With more accurate and organized information, you can make strides in closing any financial gaps. The automated process delivers a continuous feedback loop, so you can optimize your practice and scale-up.

If you’re interested in an automated medical billing and coding solution, call us at 5 Star Billing Services today.

Specially written for drbillingservice.com by Josephine Hawkins

How to Code Common Cardiac Conditions October 28, 2021

How to Code Common Cardiac Conditions

The term cardiovascular disease (CVD) refers to conditions that affect the heart or blood vessels. Also, the World Health Organization (WHO) estimates 17.9 million people died from cardiovascular diseases in 2019, representing 32% of all global deaths. A majority of these deaths resulted from heart attacks and strokes. Overall, CVD is the most severe disorder afflicting the majority of Americans. 

Before discussing CVD in further detail, let’s examine documentation and diagnosis coding for cardiac conditions to ensure accurate and compliant practices. 

The table below shows the ICD-10 diagnosis codes for common cardiac conditions.

Arch obstructionQ25.1Coarctation of the aorta
Q25.21Interrupted aortic arch
ArrhythmiasI47.0-I47.9Re-entry ventricular arrhythmia
I47.1Supraventricular tachycardia 
147.2Ventricular tachycardias
147.9Paroxysmal tachycardia, unspecified
Cardiac arrestI46.2Cardiac arrest due to underlying cardiac condition
I46.8Cardiac arrest, due to other underlying condition
I46.9Cardiac arrest, due to unspecified condition
CardiomyopathiesI42.0Dilated cardiomyopathy
142.1Obstructive hypertrophic cardiomyopathy
142.2Other hypertrophic cardiomyopathy
142.3Endomyocardial (eosinophilic) disease
142.4Endocardial fibroelastosis
142.5Other restrictive cardiomyopathy
142.6Alcoholic cardiomyopathy
142.7Cardiomyopathy due to drug and external agent
142.8Other cardiomyopathies
142.9Cardiomyopathy, unspecified
Source:  Extracorporeal Life Support Organization 2021

Common arterial trunkQ20.0Truncus arteriosus
Congenital malformations of pulmonary and tricuspid valvesQ22.0Pulmonary valve atresia and intact ventricular septum
Q22.1Congenital pulmonary valve stenosis
Q22.2Congenital pulmonary valve insufficiency
Q22.3Other congenital malformations of the pulmonary valve including bicuspid and quadricuspid valves
Q22.4Congenital tricuspid stenosis
Q22.5Ebstein’s anomaly
Q22.6Hypoplastic right heart syndrome; tricuspid atresia
Q22.8Other congenital malformations of the tricuspid valve
Q22.9Congenital malformations of the tricuspid valve, unspecified
Discordant ventriculoarterial connectionQ20.3D- transposition of the great arteries, Aorta from the right ventricle, and pulmonary artery from the left ventricle.
Q20.5Corrected transposition of the great vessels, L-TGA
Double inlet left ventricleQ20.4Single ventricle
Double outlet right ventricleQ20.1Origin of both great vessels from the right ventricle. Includes Taussig-Bing anomaly
EndocarditisI33.0Acute and subacute infective endocarditis
Heart FailureI50.1-150.9Heart failure includes systolic, diastolic, and combined heart failure as well acute heart failure, chronic heart failure, and acute chronic heart failure.
I50.41Acute systolic (congestive) and diastolic (congestive) heart failure
I5.43Acute on chronic systolic (congestive) and diastolic (congestive) heart failure
I50.9Heart failure, unspecified
Hypoplastic left heart syndromeQ23.4HLHS includes all combinations of mitral stenosis/atresia and aortic stenosis/atresia
Q21.0Ventricular septal defect
Atrial septal defectQ21.1Includes PFO, Secundum ASD, coronary sinus ASD, and sinus venosus ASD. Does not include ostium primum ASD
Atrioventricular septal defectQ21.2Includes all forms of AVSD or endocardial cushion defects including primum ASD
Tetralogy of FallotQ21.3Includes TOF, TOF with pulmonary atresia, and TOF with absent pulmonary valve
Q21.4Aortopulmonary septal defect
Q21.8Other congenital malformations of cardiac septa
Q21.9Congenital malformation of the cardiac septum, unspecified
Total anomalous pulmonary venous connectionQ26.2Includes cardiac, supra cardiac, and infra cardiac TAPVC
Malformation of coronary vesselsQ24.5Includes anomalous origins of coronary arteries; coronary artery atresia; arteriovenous fistula; coronary aneurysm; myocardial bridging; and others
MyocarditisI40.0Infective myocarditis (excludes rheumatic heart disease)
140.1Isolated myocarditis
140.8Other acute myocarditis
140.9Acute myocarditis, unspecified
Source:  Extracorporeal Life Support Organization 2021

Myocardial InfarctionI21.01-I21.4ST elevation and non ST elevation myocardial infarction
Poisoning with cardiovascular effectsT46.0X1A-T46.996DPoisoning by, adverse effect of and underdosing of agents primarily affecting the cardiovascular system
Pulmonary EmbolismI26.0-I26.01
I26.02Saddle embolus of the pulmonary artery with acute cor pulmonale
ShockR57.0Cardiogenic shock
R57.8Other shock
Aortic Valvular DiseaseI35.9Nonrheumatic aortic valve disorder, unspecified
Mitral Valvular DiseaseI34.0-I34.9Nonrheumatic mitral valve disorders
I34.9Nonrheumatic mitral valve disorder, unspecified
Source:  Extracorporeal Life Support Organization 2021

Through this guide, ordering physicians can ensure accurate ICD-10 diagnostic codes for cardiac conditions.

Coronary Artery Disease (CAD)

The other term for coronary artery disease (CAD) is sometimes called ischemic heart disease. CAD is the narrowing and hardening of the coronary arteries (the blood vessels that supply oxygen and blood to the heart). According to the Centers for Disease Control and Prevention (CDC), coronary artery disease (CAD) is the most common form of heart disease in the United States.

The table below shows ICD-10 codes for CAD:

I25Chronic ischemic heart disease
I25.1Atherosclerotic heart disease of native coronary artery
I25.10Atherosclerotic heart disease of native coronary artery, without angina pectoris
I25.11Atherosclerotic heart disease of native coronary artery with angina pectoris
I25.110Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.111Atherosclerotic heart disease of native coronary artery with unstable angina pectoris, with documented spasm
I25.118Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris

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For professionals in the healthcare industry, knowledge of ICD-10 codes is essential in reporting common cardiovascular diseases. Our team can ensure accurate medical billing and coding for optimal reimbursement, as well!

At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality cardiology billing services. Entrust your practice with our professionals in cardiology outsourced billing.

Differentiating Between Inpatient and Outpatient Coding October 28, 2021

Inpatient and Outpatient Coding

Medical coding is essential in medical practice. In this area, accuracy is crucial, as it will impact patient care, clinic operations, and revenue for your practice. The American Academy of Professional Coders (AAPC) describes healthcare coding as translating diagnoses, treatments, and even equipment into universal alphanumeric codes. In simple terms, it is the process of translating crucial medical information into codes to maintain accurate medical records and billing. The coding process assigns numerical or alphanumeric codes to every healthcare data element—outpatient and inpatient. It is essential to identify whether a patient is an outpatient or an inpatient as part of the hospital coding and billing process.

Let’s first understand the definition of Outpatient and Inpatient Coding:

What is Inpatient Coding?

Inpatient coding refers to the formal admission of a patient to a medical facility for a prolonged stay. It specifies the diagnosis of the patient and the services provided to them during their extended stay.

Inpatient coding allows accounting departments to determine the correct billing and reimbursement from insurers by providing a detailed overview of patients’ treatments during their extended stay. It has two standard coding guidelines: ICD-9/ICD-10-CM and ICD-10-PCS. But inpatient coders prefer to utilize ICD-10-PCS as the basis for procedural Coding. Furthermore, inpatient coding requires an admission status indicator (POA), distinguishing between a patient’s health status upon admission and new symptoms that develop throughout their stay.

What is Outpatient Coding?

In contrast, outpatient Coding is for patients who receive treatment but do not remain in a facility for an extended period. Outpatient Coding refers to a patient’s stay lasting less than 24 hours. Patients can still be classified as outpatients even after staying for 24 hours.

The outpatient coding system uses ICD-9/10-CM diagnostic codes but utilizes CPT or HCPCS for procedural Coding. Outpatient services and supplies fall under the latter category. CPT and HCPCS codes for services rely on documentation as well.

Outpatient settings do not allow the use of words such as “likely” or “probable” to describe a patient’s diagnosis. Instead, they must code conditions with certainty for signs, symptoms, or abnormal test results. In a single outpatient visit, the physician has limited time to observe the patient. A physician’s job is not to search for a comprehensive explanation of a patient’s health condition; instead, it is to form an educated conclusion based on the medical evidence at hand.

The Difference Between Inpatient and Outpatient Coding

  • Outpatient Coding differs from inpatient Coding by the length of the patient’s stay. The outpatient Coding is done for patients who do not stay for long and can leave within 24 hours of admission, while under the doctor’s prescription, the inpatient coders handle patients admitted for several days with a thorough diagnostic report.
  • The Medicare Part B program covers outpatient services, while Medicare Severity-Diagnosis Related Groups (MS-DRGs) cover inpatient services. Both types of services are eligible for Medicare reimbursement, but they use different plans.
  • The Outpatient Prospective Payment System (OPPS) manages reimbursements for outpatients. For inpatients, the Inpatient Prospective Payment System (IPPS) seeks reimbursement. 
  • The inpatient coding process stays longer and has greater complexity of care. For instance, patients who remain in the hospital for several days may receive medical care from an ER physician, nurses, a surgeon, an anesthesiologist, and others, which should be recorded in their medical records.
  • Outpatient Coding requires the coders to know codes and guidelines of ICD-10-CM and HCPCS Level II, whereas an inpatient coder should be proficient in ICD-10-PCS and ICD-10-CM.
  • The coders should have enough knowledge of the outpatient coding guidelines, including ICD-10-CM and HCPCS Level II. On the other hand, the inpatient coders should be an expert in ICD-10-PCS and ICD-10-CM.

The inpatient and outpatient coding guidelines for treatment also differ in numerous ways. Both settings use different codes and guidelines for reporting services. Refer to the table below:

Facility/ Inpatient Coding Guidelines for Treatment 

Physician/ Outpatient Coding Guidelines for Treatment
ICD-10-CM for diagnosesICD-10-CM for diagnoses
Coding for “probable,” “suspected,” or “rule-out” conditions are allowedCoding for “probable,” “suspected,” or “rule-out” conditions are NOT allowed
Medical/Surgical procedures: ICD-10-PCSMedical/Surgical procedures: CPTⓇ and HCPCS Level II
The basis of reimbursement is on the diagnosis-related group (DRG)The reimbursement basis is on physician fees, insurance contracted rates, ambulatory surgical center rates, etc.
Require a hospital stay (usually with a two-day minimum)It does not require a hospital stay.
The basis of code assignment is on the entire admission (length of stay)The basis of code assignment is on the encounter/visit
Services are billed on the UB-04 formServices are billed on the CMS-1500 form

According to the American Academy of Professional Coders (AAPC), the American Medical Association maintains the Current Procedural Terminology (CPT) code range for Office or Other Outpatient Services 99202-99215. These can also be the guide for outpatient hospital CPT codes. In contrast, the initial hospital care codes (99221-99223) report “the first inpatient visit by the admitting physician with the patient.” 

By understanding the differences between inpatient and outpatient coding, health care providers can reduce overhead costs. These medical codes are both essential for billing and for outpatient billing services. Coders must therefore have an in-depth understanding of medical coding to perform their duties efficiently. 

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It may take some time for your medical practice to adjust. So, you can also hire a medical coding company with mastery of the official coding guidelines!

At 5 Star 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.

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Pain Management Reporting in ICD-10-CM September 30, 2021

Pain Management Codes

The diagnosis and the determination of an appropriate treatment plan are vital. To ensure total accuracy in pain management coding, here’s a full guide to the ICD-10 classification of pain, as well as the rules of sequencing pain codes.

Categories of Pain Codes

  • Pain in which a particular body system is affected is under the body system chapters like low back pain and testicular pain. Low back pain belongs to the Musculoskeletal section (M54.5). The ICD-10 code for pain M54.5 will be a non-billable code and will be  replaced with the following three code options:
    • M54.50   Low back pain, unspecified
    • M54.51   Vertebrogenic low back pain
    • M54.59   Other low back pain

Meanwhile, testicular pain belongs to Other and unspecified disorders of male genital organs (N50.81).  Diagnosis Code N50.81 is not appropriate for reimbursement purposes as multiple codes below contain more detail.

  • Pain that does not indicate a specific body system is under Symptoms and Signs. Abdominal pain is under (category R10.9). R10.9 is a billing/specific ICD-10-CM code that suggests a diagnosis for reimbursement purposes.
  • Distinct sets of pain are under category G89 (Pain, not elsewhere classified) in the Nervous System section.

Read on more to know the three types of pain codes. Always make sure that the physician’s documentation aligns with the patient’s diagnosis. Refer to the ICD-10-CM Index and follow whatever instructions it provides.

Abdominal Pain

In category R10 of ICD-10-CM, over 30 different codes describe various types of abdominal and pelvic pain. Pain codes in other parts of the abdomen are as follows:

  • Pain code for acute abdominal pain category (R10.0). It is a diagnosis code for acute abdominal pain that is severe, localized, and rapid-onset. Many disorders, conditions, and diseases may result in acute abdominal pain. If you have this type of pain, it can be a condition that requires surgery. For example, a medical condition that is peritonitis or acute appendicitis.
  • Abdominal tenderness pain code (R10.81-). Tenderness also means being “sensitive to pain.” During an examination of the abdomen, a physician may know if the patient experiences abdominal tenderness. 
  • Rebound abdominal tenderness pain code (R10.82-): When the examiner presses on the abdomen, “tenderness” discomfort may occur. A rebound tenderness can also occur when the examiner releases the pressure. Thus, peritonitis may be the cause.
  • Colic pain code (R10.83): Colic pain refers to the discomfort from smooth muscle contractions in the intestine or ureter.
  • The “Pain, flank” entry in the ICD-10-CM Index shows a note to “see Pain, abdominal.” If the physician does not provide additional information about the location of abdominal pain (lower part or upper), you must code flank pain as unspecified abdominal pain (R10.9).
  • The code for pelvic and perineal pain is (R10.2). Patients male and female can use this code for pelvic pain. Perineal pain occurs between the anus and the scrotum in men while anus and vulva in women.

Chest Pain

The pain code for angina (I20.9) refers to “ischemic” chest pains. The codes for other types of chest pain are under category (R07) (Chest and throat pain). Post-thoracotomy pain, however, is an exception.

Code types for chest pain ICD-10-CM:

Pain for Unspecified Site

  • There are times the radiology department will receive a request that states “Pain” without a specific pain location. The ordering physician should provide a complete clinical history of flank pain, knee joint pains, or precordial pain. Otherwise, poor-quality documentation can be a big problem.
  • According to the AHA Central Office, if the request doesn’t specify where the pain occurs, the code for pain at the imaging site is acceptable. Whenever the clinical history for a hand x-ray says, “Pain,” you should code it as “hand pain.” ICD-9-CM was the focus of this guidance, not ICD-10-CM.
  • R52 is the code for pain NOS as per the ICD-10-CM Index. This type of code is vague, and reimbursement may have issues. When possible, seek a more precise diagnosis.
  • R51.9 is the code for Headache, Unspecified. Other international versions of Headache ICD-10 R51.9 may differ from the American ICD-10-CM version R51.9.

G89 Codes

The category G89 consists of codes for acute and chronic pains, neoplasm-related pains, and two pain syndromes. The physician or doctor must document that the pain is acute, chronic, or neoplasm-related to assign these codes.

If you know the cause of pain, don’t use the pain code for it. The ICD-10-CM guidelines require you to assign a code for the underlying diagnosis. In contrast, if the objective of the encounter is to manage the pain instead of the underlying condition, then first assign and sequence a pain code. 

  • One example is an interventional radiologist who performs a facet joint injection on a patient. The patient has chronic low back pain due to degenerative disc disease (DDD) of the thoracic spine with radiculopathy. Due to the nature of this encounter, you should code for the pain first, not the DDD evaluation or treatment. It has a primary diagnosis of G89.29 (Other chronic pain) and a secondary diagnosis of M51.14 (Thoracic intervertebral disc disorders with radiculopathy).

Meanwhile, pain diagnosis codes from category G89 are only valid for reporting as a primary diagnosis when:

  • If the chronic pain or acute and neoplasm-related codes provide additional detail from other categories.
  • If the cause of the service is for pain management or pain control.

Furthermore, it is not advisable to report a code from category G89 as a first-listed diagnosis if you know the underlying (definitive) diagnosis and the purpose of the service is to manage or treat that condition. You may report the acute/chronic pain code (G89) as a secondary diagnosis if the diagnosis provides additional, relevant information not adequately explained by the primary diagnosis code. Also, if the primary diagnosis codes lack additional and relevant information, you can report chronic pain/acute code (G89) as a secondary diagnosis. 

If the patient has a document that has a more comprehensive diagnosis (acute/chronic pain), but the purpose of the visit/service is pain management or pain control, then it is best to report a diagnosis code from category G89 as the primary ICD-10-CM code. 

Additionally, the ICD-10-CM guidelines recommend assigning G89 codes and codes from other categories or chapters to provide more specific information about acute/chronic pain and neoplasm-related pain. Using the G89 code, you can indicate whether the pain is acute or chronic. First, assign the site-specific pain code unless the visit is for pain management, in which case assign the G89 code. 

Postoperative Pain

Acute and chronic post-thoracotomy pain (G89.12, G89.22) and other postprocedural pain (G89.18, G89.28) are from the category G89. In the ICD-10-CM, there’s a coding restriction into “routine or expected postoperative pain immediately after a surgery.” The physician must also document that the patient’s pain is a complication of the surgery before assigning these codes.

In a case where a patient experiences pain with a specific postoperative complication (painful wire sutures), the difficulty may be on the primary diagnosis. If necessary, you can assign a code from category G89 as a secondary diagnosis to indicate whether the pain is acute or chronic.

Whenever a benign or malignant tumor produces pain anywhere on the body, use diagnosis code G89.3 to report. The coding is separate from other categories. In cases involving pain management, the pain code should be first on the list. Otherwise, the primary diagnosis will be for neoplasm. There is no need to assign a site-specific pain code with G89.3, according to ICD-10-CM guidelines.

What is the difference between these two codes for pain syndrome?

According to the National Institute of Neurological Disorders and Stroke (NINDS), central pain syndrome is a neurological condition characterized by damage or dysfunction of the central nervous system (CNS), including the brain, brainstem, and spinal cord. The condition may result in stroke, multiple sclerosis, neoplasm, epilepsy, CNS trauma, or Parkinson’s disease. The ICD-10-CM code for central pain syndrome is G89.0.

The ICD-10-CM code for chronic pain syndrome is G89.4. Take note that Chronic pain syndrome is not similar to chronic pain. A study says that chronic pain syndrome is a chronic pain that relates to psychosocial dysfunction. Depression, anxiety, or even drug dependence are psychosocial problems. Before coding this condition, make sure that the physician documents it accurately.

Tap Into Our Expertise

Maintaining to assign these codes, the stability and revenue in your medical facility are essential by following pain management coding and reporting procedures. Entrust your practice to the experts in pain management billing services .

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!

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 
Moderna COVID-19 Vaccine 
91301:SARSCOV2 VAC 100MCG/0.5ML IM 
Janssen COVID-19 Vaccine 

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!

How to Optimize Pain Management Coding and Billing 2021 September 9, 2021

Pain Management Code

Change is inevitable in healthcare. Providers are seeking ways to streamline medical billing and coding. Therefore, advanced technology is vital to achieving optimum efficiency in coding and billing processes. 

Pain Management Crisis

Chronic pain is a colossal public health issue. It costs billions of dollars in lost productivity and creates major health problems. According to the Centers for Disease Control (CDC), more than 50 million U.S adults suffer from chronic pain or one in five adults. As incidents of long-term arthritis and age-related conditions go up, this number will continue to rise. There will be more demand for pain medicine in the future. Additionally, payer demands are becoming a hassle. Prior authorization requirements put pain management at risk, affect fee schedules, and require patients to shoulder financial responsibility. 

How to Optimize Coding and Billing in Pain Management Practices

Utilizing the latest technology in revenue cycle management allows your practice to get paid for work in a timely and efficient manner. In pain management, coding and billing solutions are readily available to help your practice. We will explore the latest solutions that help optimize pain management medical billing and coding:


Medical practices know that medical billing is a vital but demanding task. Revenue cycle tasks such as patient scheduling, insurance verification, claims management, AR follow-ups, and payment collection can be challenging. When revenue is at stake, the quality of patient care goes down. That’s why many healthcare providers in pain management consider medical billing outsourcing. 

Outsourcing billing and coding allows practices to:

  • Achieve a flexible schedule for staff.
  • Maintain continuity and manage risks.
  • Boost growth.
  • Manage the basic tasks efficiently.
  • Ensure operational control.
  • Make sure reimbursements are prompt.
  • Reduce expenditures.
  • Increase productivity.
  • Cut revenue leaks.
  • Balance AR (account receivables)

Outsourcing is an effective way for medical practices to grow and expand while minimizing costs. Indeed, the best pain management billing company will help you ensure profitable revenue.

Automation of coding and billing

Automation is the future of medical billing and coding. Software automation can assist healthcare providers in cutting down unnecessary expenditures. Furthermore, it eliminates time-consuming tasks.. Billing automation can also bring considerable benefits to insurance pre-authorization. Moreover, the process of verifying eligibility and payment limits is simplified.. Thus, patients can get immediate care as soon as they need it.

Accurate pain management coding

Pain management coding always must be accurate. It’s the first step towards optimizing your healthcare revenue cycle management. A correct coding initiative is essential from a compliance standpoint. It is also helpful for reducing rejections, claim denials and ensures optimum reimbursements. Claims must be error-free and precise before they are sent out.

Here are coding initiatives that will increase collection and reduce denials:

  • Hire coding specialists for accuracy and efficiency. Partnering with a certified medical coder that focuses on pain management practices can quickly improve your cash flow.
  • Avoid non-specific diagnoses codes. In comparison with ICD 9, ICD 10 documentation requirements are much more detailed.
  • Avoid incorrect modifier usage.Make sure your coding follows payer-specific guidelines so that you don’t face denials or underpayments.
  • Avoid using a higher-paying code on a claim to receive big reimbursements. This refers to upcoding. This issue can cause more claim denials.
  • Stop upcoding and unbundling, as both are  illegal. Unbundling involves submitting bills piecemeal to maximize the reimbursement for tests and procedures that require billing together.
  • The process of Prior Authorization is necessary.
  • Stay away from under-coding – omitting or exchanging codes for a lower level of codes or less expensive code is leaving money on the table.
  • The medical necessity needs more documentation.

Switching to Telehealth 

The concept of a virtual visit is an interaction between patient and provider that doesn’t take place in the same room. It is also becoming more common in health care. For medical practitioners, virtual visits affect medical billing. The new CPT codes reflected the billing and procedures changes, so insurers had to update their policies right away. COVID-19 prompted many new treatments and protocols, which resulted in modifications to coding and billing. Health care providers lost a lot of money in the transition period due to denied claims. That’s why pain management billing software for your practice helps incorporate these changes. In addition, it prevents revenue leaks and ensures maximum future compatibility. 

New Software for Revenue Cycle Management (RCM)

What is Revenue Cycle Management software? It helps physicians and healthcare providers track and manage revenue from a patient’s lifecycle. Revenue cycle management solutions augment medical billing software functionality. It includes:

Seamless integration with EHR/EMR software – an easier way for exchanging data with the billing system.

Insurance eligibility and pre-authorization tools ensure the revenue collection process starts on the right path.

Advanced A/R management enables you to assist your facility’s staff and patients with the payment process.

Clearinghousean in-house intermediary service reduces  the time spent on the remittance process.

More important than ever, these features support financial operations throughout the life cycle of a medical facility.

Tap Into Our Expertise

It’s crucial to rely on current medical coding and billing solutions in light of these changes. These processes can further enhance your— billing processes, revenue cycle, and pain management practice.

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!

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