WOMEN S HEALTH CONNECTION REIMBURSEMENT SCHEDULE FY 15 OFFICE VISITS

Transcription

1 Reimbursement rates are based on the Medicare rates for Nevada. Total payment is not to exceed these approved rates If the provider bills at less than the approved rates, the provider will only get reimbursed for the billed amount Provider must accept the CPT rate as full payment for services. Balances may not be billed to client Provider shall give WHC clients a written estimate of additional charges that are not allowable under the program prior to procedure Provider is encouraged to write off charges not reimbursed by the program Ambulatory surgical center (ASC) services are those surgical procedures that are identified by the Centers for Medicare & Medicaid Services (CMS) on an annually updated ASC listing. The Medicare definition of covered facility services includes services that would be covered if furnished on an inpatient or outpatient basis in connection with a covered surgical procedure All billing claims must indicate an associated ICD-9 code for reimbursement OFFICE VISITS New Patient; history, exam, straightforward decisionmaking; 10 minutes New Patient; expanded history, exam, straightforward decisionmaking; 20 minutes New Patient; detailed history, exam, straightforward decisionmaking; 30 minutes New Patient; comprehensive history, exam, moderate complexity decision making; 45 min-consultations must meet the criteria of this code. This code is not appropriate for screening visits New Patient; comprehensive history, exam, moderate complexity decision making; 60 min-consultations must meet the criteria of this code. This code is not appropriate for screening visits $44.88 Office visits should be face to face $76.94 $ $ $ CPT codes should reflect the level of complexity of the history, exam, and decision-making A new patient is defined as a woman who is new to the WHC and/or is at their first annual appointment with the WHC. If the patient hasn t been seen in three years they are considered a new patient. If less than three years they are considered an established patient All consultation visits should be billed through the standard office visit CPT codes. Consultations billed as or must meet the criteria for these codes of moderate complexity for 45 minutes or high complexity for 60 minutes, respectively, during a new patient visit. A summary report of this visit must be attached to the reimbursement request Neither the program nor the patient, can be billed for no show visits Established Patient; evaluation and management, may not require presence of physician; 5 min Established Patient; history, exam, straightforward decisionmaking; 10 min $20.83 $ Established Patient; expanded history, exam, low complexity decision-making; 15 min $75.35

2 RADIOLOGY Radiologic exam, surgical Global Professional- 26 Technical- TC $20.14 $8.40 $11.73 May be billed for each lesion Ultrasound $ $ Alone or with mammogram Mammary ductogram or galactogram, single duct Diagnostic Mammography, unilateral Diagnostic Mammography, bilateral Screening Mammography, bilateral G0202 G0204 G0206 Digital Screening Mammography, bilateral Digital Diagnostic Mammography, bilateral Digital Diagnostic Mammography, unilateral Magnetic Resonance Imaging (MRI), breast, with and/or without contrast, unilateral Magnetic Resonance Imaging (MRI), breast, with and/or without contrast, bilateral $62.83 $18.22 $44.61 Used for evaluation of abnormal nipple discharge $93.98 $36.51 $57.46 A diagnostic mammogram can be performed as the initial $ $45.27 $75.60 screening mammogram for women with cosmetic/reconstructive implants, history of breast cancer, and abnormal CBE results $86.04 $36.51 $49.53 For women age 50+ annually $ $36.14 $ For women age group 50+ annually $ $45.27 $ A diagnostic mammogram can be performed as the initial $ $36.14 $99.41 screening mammogram for women with cosmetic/reconstructive implants, history of breast cancer, and abnormal CBE results $ $84.71 $ Approval required $ $84.71 $ Breast MRI can be reimbursed in conjunction with a mammogram when a client has a BRCA mutation, a first-degree relative who is a BRCA carrier, or a lifetime risk of 20-25% or greater as defined by risk assessment models such as BRCAPRO that are largely dependent on family history Breast MRI can also be used to better assess areas of concern on a mammogram or for evaluation of a client with a past history of breast cancer after completing treatment Breast MRI should never be done alone as a breast cancer screening tool Breast MRI cannot be reimbursed for to assess the extent of disease in a woman who is already diagnosed with breast cancer

3 Breast Diagnostic Procedures Bilateral procedures at the same session need to be reported as a single unit on two separate lines or with 2 in the units field on one line, in order for both procedures to be paid. The rate will be reimbursed at 50% of the original fee. Some pre -operative tests are allowed with pre-approved procedures. These procedures should be medically necessary for the planned surgical procedure. Please contact a WHC care coordinator for pre -approval of these tests Fine needle aspiration w/o guidance; breast Non- ASC $ $74.65 $ , may be billed by the lab/pathology Fine needle aspiration w/imaging guidance; breast $ $68.84 $ May be billed with , may be billed by the lab/pathology Puncture aspiration of cyst of breast Puncture aspiration; each additional cyst Breast biopsy, with placement of localization device and imaging of biopsy, percutaneous; stereotactic guidance; first lesion each, including stereotactic guidance $ $46.20 $ may be billed once per breast $28.00 $ may be billed with may be billed for each Office visit codes on the day of the $ $ $ may only be billed once per breast regardless of the number of biopsies may be billed for one $ $ may be billed for each may be billed for up to 3 biopsy s per breast fee may only billed once Office visit codes on the day of the Do not report in conjunction with , 76098, 76942, 77002, for same lesion

4 19083 Breast biopsy, with placement of localization device and imaging of biopsy, percutaneous; ultrasound guidance; first lesion each, including ultrasound guidance Breast biopsy, with placement of localization device and imaging of biopsy, percutaneous; magnetic resonance guidance; first lesion each, including magnetic resonance guidance Biopsy of breast, percutaneous, needle core w/o imaging guidance Non- ASC $ $ $ may only be billed once per breast regardless of the number of biopsies may be billed for one $ $ may be billed for each may be billed for up to 3 biopsy s per breast fee may only billed once Office visit codes on the day of the Do not report in conjunction with , 76098, 76942, 77002, for same lesion $1, $ $ Approval required may only be billed once per breast regardless of the number of biopsies may be billed for one $ $ may be billed for each may be billed for up to 3 biopsy s per breast For surgical radiography, use fee may only billed once Office visit codes on the day of the Do not report in conjunction with , 76098, 76942, 77002, for same lesion $ $72.84 $ and many only be billed once per breast Imaging guidance( 10022,19290, 19291, 19295, 77031, and mammograms cannot be billed with fee may only billed once may be billed for up to 3 biopsy s per breast Office visit codes on the day of the

5 Non- ASC Biopsy of breast, open, incisional Excision of cyst, fibroadenoma or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion; open; one or more lesions Excision of breast lesion identified by placement of radiological marker, single lesion each - Excision of breast lesion identified by preoperative placement of radiological marker, open; $ $ $1, may be billed only once per breast may be billed for each fee may only billed once may be billed for up to 3 biopsy s per breast may be billed for the total anesthesia provided Imaging guidance (10022,19290, 19291, 19295, 77031, and mammograms cannot be billed with Office visit codes on the day of the procedure and during the 10 day post-operative period are not payable 10 day global period $ $ $1, may only be billed once per breast regardless of the number of biopsies may be billed for each may be billed for up to 3 biopsy s per breast fee may only billed once may be billed for the total anesthesia provided 19120FA may be billed with a facility code Office visit codes on the day of the procedure and during the 90 day post-operative period are not payable 90 day global period $ $ $1, may only be billed once per breast regardless of the number of biopsies may be billed for one 90 day global period $ $ may be billed for each may be billed for up to 3 biopsy s per breast may be billed for the total anesthesia provided fee may only billed once

6 Non- ASC Placement of breast localization device, percutaneous, mammographic guidance; first lesion each, including mammographic guidance (in conjunction with 19281) Placement of breast localization device, percutaneous, stereotactic guidance; first lesion each, including stereotactic guidance (in conjunction with 19283) Placement of breast localization device, percutaneous, ultrasound guidance; first lesion each, including ultrasound (in conjunction with 19285) Placement of breast localization device, percutaneous, magnetic resonance guidance; first lesion 19120FA may be billed with a facility code Office visit codes on the day before the procedure, the day of the procedure, and during the 90 day post-operative period are not payable 90 day global period $ $ May be billed with 19120, $ $ may be billed for each may not be billed with mammograms or Office visit codes on the day of the Do not report in conjunction with , 76942, 77002, for same lesion $ $ May be billed with 19120, may be billed for each $ $ may not be billed with mammograms or Office visit codes on the day of the Do not report in conjunction with , 76942, 77002, for same lesion $ $91.87 May be billed with 19120, may be billed for each $ $ may not be billed with mammograms or Office visit codes on the day of the Do not report in conjunction with , 76942, 77002, for same lesion $ $ Approval required May be billed with 19120, may be billed for each may not be billed with mammograms or 76645

7 19288 each, including magnetic resonance (in conjunction with 19287) Non- ASC $ $66.00 Office visit codes on the day of the Do not report in conjunction with , 76942, 77002, for same lesion Cytology Breast Evaluation of fine needle aspirate Evaluation of fine needle aspirate, interpretation Global Professional- 26 Technical- TC $56.15 $36.85 $19.29 To be used with 10021, $ $73.35 $79.01 Cervical Diagnostic Procedures Colposcopy of the cervix, without biopsy Colposcopy with biopsy of the cervix and endocervical curettage Colposcopy of the cervix with biopsy Colposcopy of the cervix with endocervical curettage Non- ASC $ $98.06 $51.32 May be billed only once Office visit codes on the day of the period $ $ $ may be billed only once regardless of the number of biopsies performed may be billed with for up to 4 s to reflect multiple biopsy sites on the cervix & one (1) ECC biopsy Office visit codes on the day of the period $ $ $66.09 May be billed only once may be billed with for up to 3 s to reflect multiple biopsy sites on cervix Office visit codes on the day of the period $ $ $63.87 May be billed only once may be billed once with Office visit codes on the day of the period

8 57460 Colposcopy with loop electrode biopsy of the cervix Colposcopy with loop electrode conization of the cervix Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration Non- ASC $ $ $ Authorization is required May be billed only once may not be billed with colposcopy: 57452, 57454, 57455, or may be billed for up to 4 s per cervical procedure Office visit codes on the day of the period $ $ $ Authorization is required May be billed only once may not be billed with colposcopy: 57452, 57454, 57455, or may be billed for up to 4 s per cervical conization procedure may not be billed with may be billed for the total anesthesia provided Office visit codes on the day of the period day surgery facility $ $81.18 $ may be billed with for up to 3 s to reflect multiple biopsy sites on cervix Office visit codes on the day of the period Endocervical Curettage $ $97.83 $56.49 May be billed only once Conization of cervix, with or without fulguration, with or without dilation and currettage, with or without repair, cold knife or laser may be billed once with Office visit codes on the day of the procedure and during the 10-day postoperative period are not payable 10 day Global period $ $ $1, Authorization is required May be billed only once may be billed with for up to 4 s per cervical conization procedure may be billed for the units of anesthesia provided

9 Non- ASC Office visit codes on the day before the procedure, the day of the procedure, and during the 90-day postoperative period are not payable 90 day Global period Loop electrode excision (LEEP) $ $ $ Authorization is required May be billed only once and may not be billed with colposcopy (57452, 57454, 57455, or 57456) may be billed with or for up to 4 s per cervical conization procedure may be billed for the total units of anesthesia provided. Office visit codes on the day before the procedure, the day of the procedure, and during the 90-day postoperative period are not payable 90 day Global fee period Endometrial sampling (biopsy) with or without endocervical sampling, without cervical dilation and method Endometrial sampling (biopsy) performed in conjunction with colposcopy $ $94.26 $50.22 Authorization is required May be billed only once Must be billed with a colposcopy Office visit codes on the day of the period $50.87 $43.69 May be billed only once must be billed with a colposcopy: 57452, 57454, 57455, 57456, or Reimbursable only after Pap test result of Atypical Glandular Cells (AGC) or greater, if client 35 or more years of age, or at risk for endometrial neoplasia. Code related to another service and is always included in the global period of the other service

10 CYTOLOGY CERVIX HPV, amplified probl technique $47.87 Used for cytology and HPV co-testing every 5 years When a conventional Pap tests results is ASC-US, a follow up office visit may be billed to complete the HPV test When a liquid based pap test results is ASC-US, the HPV test can be done on the original and follow up visit for HPV testing cannot be billed Refer to cervical algorithms for indications for HPV testing Cytopathology (conventional Pap test), cervical or vaginal, any reporting system, requiring physician interpretation Cytopathology (liquid-based Pap test), cervical or vaginal, collected in preservative fluid, automated thin layer preparation, manual screening under physician supervision Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin layer preparation, manual screening and rescreening under physician supervision Cytopathology (conventional Pap test), slides cervical or vaginal reported in Bethesda System, manual screening under physician supervision $32.88 Only abnormal or reparative/reactive Pap results, as determined by the cytotechnologist, can be reimbursed for physician review Bill with 88142, 88143, 88164, 88174, as the technical pap service $27.64 Pap tests are subject to frequency guidelines. See Provider Manual and Cervical Clinical Guidelines $27.64 $ Cytopathology (conventional Pap test), slides cervical or vaginal reported in Bethesda System, manual screening and rescreening under physician supervision $ Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin layer preparation, screening by automated system, under physician supervision Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin layer preparation, screening by automated system and manual rescreening, under physician supervision $29.15 $36.14

11 ANESTHESIA Rates for time based codes are calculated using base units plus time spent (15 minutes = 1 unit). Base unit is 3 x $23.09 = $ time unit spent $23.09 Rates for time based codes are calculated using base units plus time spent (15 minutes = 1 unit) Base unit is 3 x $23.09 = $ time unit spent PATHOLOGY Surgical pathology/biopsy lab, breast or cervical s Surgical pathology, breast, excision of lesion Pathology consultation during surgery, first tissue block, frozen section, single Each additional tissue block with frozen sections Global Professional- 26 Technical- TC $73.04 $39.01 $34.03 $ $85.81 $ $ $63.85 $38.19 $45.00 $31.76 $13.25 G0461 Immunohistochemistry or immunocytochemistry, per ; first stain $92.24 $31.38 $60.87 G0462 Each additional stain $71.76 $12.78 $58.98 SUPPLIES Supplies and materials (except spectacles $15.50 Provided by physician over and above those usually included with the office or other services rendered PREOPERATIVE TESTING Some pre-operative tests are allowed with pre-approved procedures. These procedures should be medically necessary for the planned surgical procedure. Please contact WHC care coordinator for pre -approval of these tests Chest x-ray, 1 view $ Chest x-ray, 2 $ Basic metabolic panel $ Comprehensive metabolic panel $ Urinalysis $ Pregnancy test $8.63 Should only be performed when there is concern that the client may be pregnant. This test should not be routinely performed Hematocrit $ Hemoglobin $ CBC with diff. WBC count $ CBC with differential $ EKG $17.47