Medical Billing Articles

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 view the document here – COVID-19 Vaccine Billing and Coding Reference

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.

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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.

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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!

5 Signs You Need to Call a Medical Billing Specialist July 1, 2021

Medical Billing Specialist

There are still doctors who think outsourcing their medical billing process would deprive them of a healthy cash flow. However, most doctors swear by their outsourced billing services and wouldn’t consider bringing it in-house ever again. No matter where you fall on the spectrum, there might still be leaks in your revenue cycle. Here are five signs that you need to tap into the expertise of an experienced medical billing specialist.

1. Revenue Stream Slowing

You might not notice your revenue stream reducing when you’re focused on the day-to-day duties of patient care. First and foremost, assess how well your in-house billing department is operating, how much it costs, and if you’re paid on time. Then, start adding up what you spend on phone bills, internet, information systems, physical space, support staff salary, and billing supplies to get a handle on your billing expenses. When comparing the cost of a third-party medical billing specialist, this figure will come in handy.

2. Recruiting and staffing challenges

Because the process of filing claims and following up on them can be time-consuming, independent practices often find it difficult to maintain staff while being cost-effective. Any practice will suffer from high personnel turnover, leaving the billing department particularly vulnerable. The revenue cycle, on the other hand, will not run properly without up-to-date and constant staffing. If you’re having trouble finding and keeping the right billing employees, outsourcing might be the way to go.

3. Services rendered without payment and late payments

Payment problems can cause the revenue cycle to wind down quickly. Medical billing has evolved into a complex science, and most practices deal with multiple payers regularly, making it easier for unpaid bills to slip through the cracks. An outsourced billing system can help by taking care of the time-consuming and inconvenient task of following up on outstanding claims and notifying patients about their costs.

4. A high number of rejected claims 

A rejected claim must be reviewed, altered, and sent again immediately by your billing or office staff. The procedure can take up a considerable amount of their time and decrease the insurer’s productivity, not to mention making a new claim submission a second time. As a result, your billing process is not as efficient as possible if you notice an increase in rejected claims. With the help of a medical billing specialist, you will get fewer rejections and better service.

5. The billing and coding process is not up-to-date.

You may be overlooking inefficiencies in your practice if your billing staff cannot keep up with changing rules and trends. Errors in medical billing are costly and all-too-common. A third-party medical billing specialist will retain a high level of competence while also providing you with efficiency reports, which will give you vital, real-time feedback.

Benefits of Outsourcing your Billing Process

Working with experienced medical billing specialists has many benefits. Here the top 3 benefits of outsourcing your medical billing process:

  • Healthy Revenue Cycle

Medical billing companies are experts in the field. Entrusting your revenue cycle management to renowned specialists will be the best choice you can make for your practice.

  • Committed and licensed professionals

You’ll need the assistance of a devoted and licensed staff, and you won’t necessarily need to go through the training and hiring process. The experts will advise you to keep track of all of your claims. Their primary focus will most likely be on maintaining and improving the status of one’s practice.

  • Maintaining regulatory compliance

Medical billing companies are always up-to-date in changes in regulatory compliance and coding procedures. 

  • Save money

You can save a ton by outsourcing because you won’t have to spend as much money on overhead costs, hardware, and software. Management software can cost up to $200 per month per physician, and it isn’t inexpensive. Those concerns do not present once you have decided to outsource maintenance, and the cost of the equipment appears to be around $500.

  • More time with patients

Who doesn’t want more time and energy to devote to their patients? When you outsource medical billing services, you free up time and resources to focus on your key strengths, such as healthcare. Once your medical billing professionals take care of your billing and insurance processing, you’ll have hours on your hands.

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At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding services. 

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How to Achieve Clean Claims at First Submission July 1, 2021


What does a clean claim mean?

A clean claim is “free of any errors.” It is critical to submitting these the first time to ensure a smooth procedure. You can determine your clean claim percentage by the average rate of paid claims on the first submission. It’s best to keep this percentage high when running a lucrative surgery facility with limited resources and time constraints. So, how exactly can you secure a high percentage of clean claims while also establishing a consistent process? Here are seven steps that will help ensure clean claims submissions rate over 95%:

1) Be accurate and timely on patient information

Always ensure that patient information on claims is accurate and up to date. Patient demographic information, policy information, and medical information are all things to double-check. Detailed and up-date documentation allows your coders to give the most relevant procedure and diagnostic code(s) to support your claims. It will enable your practice to receive reimbursement for the service on time. Not only should the particular diagnosis and data about the surgery or treatment be included, but so should the patient’s medical history.

2) Verify patient eligibility as soon as possible

Providing patient eligibility verification at least two days before the DOS (Date of Service) will result in more accurate claim submission and fewer claim rejections. This eligibility verification approach also aids healthcare practices in maintaining a healthy cash flow by reducing write-offs and improving patient care. You must check all co-pays, deductibles, policy effective dates, in-network/out-of-network benefits, and other requirements during this step.

3)  Perform quality checks 

In the medical billing process, quality checks are critical in ensuring the submission of clean claims. Before submitting a claim, check it for demographic, coding, and submission issues. You need to double-check demographic inaccuracies, medical coding problems, and errors that arise throughout the submission process. Establish a system that gathers pre-authorization data on the front end and allows your billing staff to correctly measure denials for “no-authorization” so that the physician receives fast feedback. 

4) Submit prior authorization at least five days before DOS

To minimize prior authorization-related denials, submit it at least five days before the DOS. Use the best system to capture pre-authorization information on the front end accurately and allow your billing team to track “no-authorization” denials in real-time. It guarantees that the healthcare provider receives prompt input. The type of operation, which procedures require prior authorization, and whether the patient plan covers the treatment are all items that you must verify in this phase.

5) Know carrier-specific coding guidelines  

Claims may be rejected if their program doesn’t recognize a modifier. As a result, it’s essential to know what payers will and won’t cover. Using the correct modifier and adding the modifier to the correct method is among the details you should double-check.

Verify CPT and ICD compatibility, as well as the submission mechanism (paper or electronic). To ensure coding compatibility, create carrier-specific Local Coverage Determination (LCD) rules. Medical practices could also automate the claims cleaning process by developing rules engine software systems or outsourcing. You must know the answers to the following questions: 

  • What modifiers are accepted by the payers? 
  • Should you use a –50 modifier or a mixture of –RT and –LT for a bilateral procedure? 

6) Be up-to-date on new medical coding regulations

Some of the most significant difficulties affecting medical reimbursements are insurance claim denials and claim rejections. Medical coding guidelines and standards are also too complicated for healthcare providers to keep up with.

Outsourcing the claim submission process to the best medical billing firms can keep you up to date on all medical coding changes and ensure that your claims are accurately classified before submission. Claim denials are frequently the result of faulty coding or late claims filing. Claim scrubbing, in this case, swiftly detects and corrects coding problems before submission.

Healthcare practices can also leverage the automation process known as electronic claim submission to handle claims faster by installing the best medical billing software. This stage requires the verification of ICD and CPT compatibility and the kind of submission mechanism (paper-based or electronic claim filing) to ensure coding compliance.

7) Develop an effective denials management review process.

Most doctors are eager for documentation feedback, especially if their work is causing denials and hurting the practice’s bottom line. You can minimize clinical documentation difficulties by holding regular in-service events that keep physicians up to date on payer changes or new documentation needs.

Identifying all payer requirements in detail, from documentation and pre-authorization to allowable claims and proper formatting, and then applying that information to build a clean claims submission process can mean the difference between quick payments and late payments, or even non-payment some cases.

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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.

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Key to Successful Billing Oral Sleep Appliances to Medical Insurance June 2, 2021

Oral Sleep Appliances

As more dentists move into procedures to aid sleep, questions about how to bill oral appliances to medical insurance are becoming more prevalent. Oral appliances for obstructive sleep apnea (OSA) have no specific dental codes, and it’s almost unheard of for dental plans to pay for these products. However, medical insurers often reimburse them. Here are some effective tips for dental practices in billing medical insurance. 

OSA Billing for High Deductibles and Policy Limitations

It is between the patient and their insurance provider if the patient has a high deductible. For certain patients, having the oral appliance add to their deductible is also a plus. If the health company has a continuous positive airway pressure therapy (CPAP) clause or a Policy Limitation, an oral appliance case would be quickly disqualified from billing to medical insurance.

Policy Limitations

Other insurance companies only cover OSA appliance therapy every three years. So, if a patient had treatment and the insurer paid for it a year ago, the insurance would not pay for another oral appliance treatment until the time requirement is met. In this scenario, the patient will have to wait for their appliance or pay cash. If they don’t want to wait for the insurance time limit, they can use financing like CareCredit to get the appliance now.

Your dental office is not responsible for the coverage provided by the patient’s medical policy. It is your duty to manage the patient and assist them in improving their general health and quality of life. Begin billing medical insurance as a service you offer to your patients in order to reduce their patient section.

CPAP Requirements

If the patient’s medical insurance includes the use of a CPAP, the patient must use it for at least 30 days before exploring other options. This treatment is much more difficult, requiring the patient to jump through additional hurdles.

The Key Is Proper Documentation 

Proper and accurate documentation is crucial to successfully bill medical insurance for OSA. The minimum requirements are as follows:

  1. Sleep test results

A copy of the sleep test is a necessary part of your documentation.  A polysomnogram (PSG) or a home sleep test (HST) are two types of sleep tests. Some insurance companies have limitations on the types of tests they would cover. For instance, before Medicare can pay for PSG, it now requires that home sleep tests be used first. A number of sleep test machines are also available.

Some diagnostic devices are not FDA cleared. For this reason, a few payers refuse to accept them as diagnostics. As a guideline, you can use the same sleep test findings that the board-certified sleep specialist used to interpret them. As a consequence, the findings of your sleep test will fit the perception. To be eligible for treatment, certain payers recommend that a patient have a certain AHI. As a consequence, it’s important that the patient’s AHI be clearly stated in your sleep test reports. These will be repeated in the clinical notes, which we will go through in more detail later.

  1. Diagnosis from a board-certified sleep specialist

To cure sleep apnea, a patient must first be diagnosed. Only a board-certified sleep specialist may make this diagnosis. The sleep specialist will score the outcomes of the sleep test to decide the seriousness of the patient’s apnea.

It makes no difference if the sleep test was conducted in a lab or at home. An interpretation is a term for the scoring and diagnosis process. The board-certified sleep specialist interprets the results, confirms the diagnosis, and then documents the extent of the patient’s sleep apnea, as well as treatment guidelines. Diagnoses never actually expire, but only a few insurance providers have a time limit or expiration date from the date of interpretation, as long as it is before the treatment.

  1. The dentist’s clinical chart notes

The Subjective, Objective, Assessment, and Plan (SOAP) notes can be a source of anxiety or irritation in offices. In a SOAP note, you’re describing the patient’s symptoms, the diagnostic details you’ve gathered (which would include the sleep test as well as the severity interpretation), and the treatment recommendation you’ve made. You’ll also make notes about the patient’s comfort, updating home instructions, and the delivered titration position of the appliance.

In general, dentists perform intra- and extra-oral exams as part of their sleep appliance assessment. You want to make sure a patient is a successful candidate before treating them. Prior to care, you should perform a comprehensive examination of the jaw, including a range of motion and muscle palpation, and ensure that any jaw or tooth conditions your patient has been reported. A patient might complain after six months that your oral appliance has harmed their jaw joint or teeth. You would be able to prove that the patient had certain previous problems by having good documentation.

  1. CPAP affidavit

Not all payers require a CPAP affidavit, but enough of them do that we recommend you collect one on every patient. This affidavit does not prevent them from later getting treated with a CPAP machine. The affidavit simply states that they have been given both treatment options, and they are choosing the oral appliance for whatever reason they give.  They will sign the affidavit and include any detail about why they feel a CPAP wouldn’t work for them. Again, reiterate this to your patient, this does not prevent them from getting a CPAP at a later date. It simply states they choose the oral appliance at this time.

  1. Presenting Medical Billing To The Patient

Now you know exactly what documentation you’ll need to bill an oral appliance to medical insurers. From here, you’ll need a copy of the patient’s medical insurance card, as well as full benefits, to check to see if the patient is covered.

You’ll learn if they have a remaining deductible to meet and if they have any plan exclusions during the verification of benefits (VOB). if they have a history of using continuous positive airway pressure (CPAP) or if there are any other explanations why the device might not be covered. You won’t know the allowable at this stage since they don’t release a fee schedule unless you’re a participating provider.

Don’t let possible roadblocks stand in the way while you learn more about the method of billing medical insurance for oral appliances. Don’t be afraid to give medical billing to your patients as a payment option. Keep in mind that the ultimate aim is to lower the patient portion while increasing case acceptance.

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

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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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