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2024 AUGS Coding Webinar Series Part I: New 2024 U ...
New 2024 Urogynecologic CPT Codes and HCPCS Codes ...
New 2024 Urogynecologic CPT Codes and HCPCS Codes - Best Practices for Accurate Reimbursement
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Good evening, friends, and welcome to the Oggs Coding Webinar Series. My name is Charles Thompson. I am the chair of the Oggs Coding Committee and the moderator for today's webinar. Today's webinar is entitled, New 2024 Urogynecologic CPT Codes and HCPCS Codes, Best Practices for Accurate Reimbursement. Our speaker today is Mr. Mark Painter. Mr. Painter is the CEO of PRS Managed Services, LLC, and the vice president of Coding and Reimbursement Information for Physician Reimbursement Systems, Incorporated. Since co-founding PRS in 1989, Mr. Painter has served as the primary coding resource for the PRS products, including hotlines, coding manuals, and quick reference tools. The internet-based application codingtoday.com and seminars. He has lectured extensively on healthcare operations and reimbursement. Mr. Painter's extensive knowledge of physician reimbursement issues has allowed him to assist insurance companies, physicians, and their staff members, legal counsel, actuaries, specialty societies, and consultants on a daily basis. He has served as an expert to legal counsel and big device companies and pharmaceuticals. Mr. Painter is a CPMA. Mr. Painter received his Bachelor of Arts from Grinnell College in Grinnell, Iowa. Just a few reminders. The presentation will run about 45 minutes, and the last 15 minutes of the webinar will be dedicated to questions and answers. Now, before we begin, I'd like to review some housekeeping items. This webinar is being recorded and live-streamed. A recording of the webinar will be made available in the Augs eLearning portal. During the presentation, please use the Q&A feature of the Zoom webinar to ask any of the speaker's questions. We will answer them at the end of the presentation. At this point, I would also like to introduce Jill Rappern, who will be keeping tabs on all questions and will present those questions to our speaker. Jill is a long-time health policies consultant with Augs and works with the Augs Coding and Reimbursement Committee. Please use the chat feature if you have any technical issues. Augs staff will be monitoring the chat and can assist. So remember, the Q&A feature is for questions. The chat is for technical issues. Mr. Painter, you can begin. Very good. Well, thank you very much, and good evening to everyone. So we're going to run through a few updates tonight, and we're going to start in general with some changes that Medicare has made moving into 2024. So obviously, many of you are aware of the fact that we did see a conversion factor decrease of about 3.3%. This decrease was actually a combination of a number of different things. You may recall that last year, in 2023, we were headed for a very steep decrease in the conversion factor, but the Consolidated Appropriations Act of 2023, Congress stepped in and actually gave a bump of 2.5% for the conversion factor in support of keeping it close to where we were the year before. It seems like every year, of course, we celebrate about a zero for the conversion factor. Not fair to physicians, as overall, we've seen physician reimbursement within the Medicare system remain relatively flat, while our colleagues in the ambulatory surgical centers and hospitals have seen an increase in order to keep up with inflation year after year. So that, of course, is where we are, unfortunately, with Medicare at this point in time. Now, we were again facing a little bit more of a decrease, potentially for 2024, but Congress did give us a little bit of a bump last year in the Consolidated Appropriations Act for this year. They gave us about a 1.25% increase. And as you'll note, we only had a 3.3% decrease, I put that in quotes, that increase, half of that savings there, and some of that 3.3% decrease came from the fact that the increase that Congress allowed for 2023 was cut in half for 2024. Then again, we always have a budget neutrality adjustment within Medicare. The budget neutrality adjustment for this year was a negative 2.17%. And a portion of this, about a 1% or almost half of this, came because Medicare has introduced a new code, the G2211. This G2211 actually represents an opportunity for urogynecology to get back some of that 3.3% decrease because they look at physicians as a whole. They don't take into account everything related to each individual specialty until they get to some of the other adjustments. And that is reflected in the RVU change impact, where we see that urology and OBGYN, as urogynecology isn't called out specifically in the Federal Register, both were up about 1% when they're projecting same use of codes and billing for 2023 as compared, or excuse me, for 2024 as compared to 2024. And then we do have one additional area that we're keeping an eye on for 2024, and that is the Geographic Cost of Practice Index, which is commonly referred to as the GIPC. This is an adjuster that is used in each locality across the United States to vary the final fee schedule from area to area. Right now, and until March 8th at this point in time, there is a legislative block so that no area in the country has a GIPC lower than one. If that is removed, that will result in some additional fee schedule drops in some parts of the country and raises in other parts of the country based on the local marketplace and the CPI. Now you'll also see that Congress is still considering some action with a March 8th health care extender legislation that Congress could step in and potentially raise the conversion factor above its current rate of 3,274. That March 8th deadline or that March 8th date that you see in a couple of different places is tied to the continuing resolution that the Congress has agreed to when they basically kick the can down the road on the budget for the federal government or at least a portion of the federal government. So we'll be keeping an eye on this activity and the activities of Congress as they move forward, hoping that they decide to do the right thing and adjust the conversion factor for at least a portion of the year. We'll have to see whether or not that actually occurs, but we are all watching and many groups are lobbying to make sure that we get a better shake relative to the Medicare conversion factor. A couple of other changes that were implemented as of January 1st of 2024. One is relative to telehealth. Now telehealth is continuing to be covered through the end of 2024 as directed by the Consolidated Appropriations Act of 2023. So Medicare and right now we're seeing most of your private sector payers are still covering telehealth and telephone only codes regardless of the patient's location relative to a Medicare approved facility. So we can still provide telehealth services to patients in their home. Now you do have a slight change in that Medicare has asked that we no longer use the modifier 95 for those services provided to patients in their home, those E&M services and those other services that are approved on the telephone approved list or the telehealth approved list. You would submit with a place of service 10, which means the patient was at home when they received the services. Instead of modifier 95, Medicare made this change really for a couple of reasons. One, the place of service 10, which has actually existed for a few years, is more of a long-term solution for the use of telehealth for Medicare than the 95 modifier, which was essentially put in place because the only existing place of service when the public health emergency came into effect was a 02 and we didn't have the place of service 10. Medicare used the 95 to make sure that you were paid at the same in-office rate that you would have seen if you had seen the patient in person. By making this change to place of service 10 and continuing to pay for telehealth services at the same rate as you would receive if you saw the patient in your office, Medicare has acknowledged that the amount of work and really the overall investment that you have from a cost standpoint is roughly the same for a telehealth visit as it is for an in-person visit. That's actually something that bodes well for the future that they made this adjustment moving forward. Now they do have a couple of areas where you would still use the 95 modifier in the place of service 10, but those are only for non-physician providers that are allowed to currently use telehealth, PTs, OTs, those types of individuals. The other thing that Medicare made permanent is the allowance for remote supervision of staff. Now what this means is that if a physician were unable to get into the office and they were able to use audio and visual supervision of the staff that is still in the office providing care for your patients, that those services can be billed as if the physician were in the office using place of service 11, but you would just have to have the physician available or, excuse me, participating in the visit using telehealth technology. So in the end, we are seeing a couple of bills in Congress that they are trying to make telehealth permanent, but at this point in time, we're good to use telehealth through the end of 2024. Medicare has also introduced a new program in 2024. This program, which I'll cover in a little bit more detail, is really focused on helping patients who have social determinants of health barriers to getting healthcare, things like food and rent and financial insecurities. And they're calling this the Community Health Integration and the Principal Illness Navigation. They've assigned some new G codes to these. And again, I'll cover a little bit more of this as we move through the program. I'll also cover a little bit later the delay in the changes to the shared split visit rule. We're hoping that this delay is really long term. Right now, they've labeled it as indefinite. We were expecting it to change for 2024 to allow for billing of a shared split visit only based on time. That did not occur. And we'll show you kind of what the background is there a little bit further. The other thing that Medicare did do at the final rule is they decided not to raise the threshold scores for MIPS and MACRA. So we're continuing under last year's rules for MIPS and MACRA, moving at least for 2024. All right, so let's move a little bit to the G2211. There's been a fair amount of confusion around this code as it's been implemented. And hopefully, all of you have heard about it and are working through some of the nuances of using this. So as you can see by the definition, this is for a visit complexity inherent to E&M codes, which are associated with medical care in which the physician providing the service is the focal point for either all needed healthcare services for that patient or for those physicians and groups that are the center of care for a single serious or a complex condition. This can be billed in addition to and actually is an add-on code to your office visits. So new or established patient office visits can do this, can use this code. And it does pay an additional $16.04. It is really focused when they drove down in the final rule to talk about this as a reflection of the patient-physician relationship. And that's really the piece that they're focused on in all of this. And that's where the rules are kind of set in place. But they did say in order for the impact of this code not to be as large as they originally proposed it, was they are not going to allow the G2211 if you're billing an office visit code, even if it is focused on the single serious or complex condition, if you are using a modifier 25 in order to get that E&M code paid. So it can't be used in the same date using E&M with a modifier 25. So basically when we look at this, what we're recommending and what we're seeing from the payers is you obviously cannot report the G2211 if the E&M code is submitted on the same date with a modifier 25. You do need to have an E&M code reported on the same date. So you can't use the G2211 without an E&M code. You are not going to report a G2211 if the patient is not under your ongoing care for a single serious or complex condition or the total health care for a problem that is actually a shorter term that you're dealing with. So a few examples of this would be if a patient is coming to you for a second opinion, even though it is a complex or a serious condition and you are not going to assume that long-term care, you would not report the G2211. Same would be true for a short-term condition like a UTI or a stone or some other problem that the patient has that you're not assuming a long-term care or a long-term relationship with that particular patient. Now if the patient visit, new or established, is a point in which you are working with that patient and are going to be that long-term care provider for any of the list of single serious complex conditions which you treat, things like incontinence, any type of cancer, a recurrent UTI or a renal cyst, something that you're going to continue to follow that patient and it's important for you to have a relationship with that patient, you can add the G2211 to every visit as long as that modifier 25 is not being used. So there's not a frequency limitation on this. So you can bill it each time you see the patient throughout the year. And they have also said because of that long-term relationship or that longitudinal care, if you've got a patient that you're following for cancer, for example, and they come in with an interim or an UTI, even though that visit wouldn't normally qualify for a G2211, because you're working with that patient for the long-term for the care of their cancer, you can still use the G2211 even though that visit was not focused on that long-term problem. So it's really about the relationship that you have with the patient based on that condition and the care that you're providing. One of the other questions that we get routinely is what if the physician in your group is the one who is caring for the patient for that cancer and the patient comes back to the office and now sees a mid-level for that particular visit? Because Medicare looks at you as a group relative to that individual patient, you are going to still be allowed to bill the G2211. Documentation, specifically Medicare said that they would not be looking for any specific documentation relative to these G2211 visits when you bill that. But they are very focused on the fact that the long-term care or the relationship would be implied by the documentation that you have for that particular encounter. So obviously looking at a visit which is focused on that complex condition, making sure that you've mentioned that plan of care and that follow-up visit are really kind of the areas that support that G2211. And for those visits which you're seeing the patient in which the care is unrelated or not obviously a part of that visit or that normal long-term care or single serious complex condition, it might be a good idea to mention there that the patient would keep their normal scheduled visit for their long-term care follow-up as an additional clue to the auditors if they ever decide to look for additional documentation for the G2211. So hopefully everybody's using that and using that frequently. One last thing I might mention is Medicare's initial projection on the use of G2211 was that the first year as people kind of sorted out how to use it and the information was disseminated by Medicare, that it would be billed with about 36% of E&M codes. But the long-term projection is that we will see this used in roughly 58% of E&M codes submitted to Medicare. So they do expect a fairly high utilization. And ultimately, it's going to depend on your specialty and your patient mix as to how often you're going to use this code. So those target numbers of 36 and 58 really are overall Medicare and they do take into account that it's all specialties. Specialists like oncologists that aren't necessarily the focus of total care but provide specific treatment within the mix probably won't use G2211 very much, meaning other specialties will use it more frequently. So it's important to do that. Next, I just wanted to briefly mention the community health integration and the principal illness navigation. Now as I read this in the Federal Register, I do see there are some opportunities for urogynecology to participate in this program. This program is in addition to principal care management or chronic care management, which some of you may be providing to your patients. The issue we've got as we see this starting to roll out is Medicare mentioned that this does require some additional training or certification for the staff who would be providing the support for community health integration or principal illness navigation. We are continuing to research this and certainly looking for potential ways to get staff educated and appropriately trained on this. But it is something that we think probably mid-year we'll see a little bit more clarity and it might be something to look at to add to your practice depending upon your patient mix. There is also a G code that is at this point in time not required to be utilized only by those who provide CHI or PIN for a social determinants of health evaluation or an assessment. There are some specifics around this code, which does give you some extra value. It's also an add-on code. But so one of them is that the test can or the assessment can only be administered every six months. And more importantly, I think, is that the patient needs to have been identified as having a potential need. So this is something, an assessment that can't be provided as a pure screening tool. It is more an assessment based on the patient's admission or the knowledge of the physicians that they are or the APPs that this patient does have some access issues or some financial issues that are blocking the overall care that they can receive. So they have to be identified as having a potential need and it can only be administered every six months. And then finally, of course, Medicare has mentioned that they don't expect people to have administer an SDOH assessment and not at least guide the patients to some resource within the community to help them with those issues. All right, so those are kind of the major changes from Medicare that we wanted to bring to your attention tonight. Now I'm going to move to CPT 2024. There were a couple of changes. Some were essentially editorial, but this one was a big step from CPT in that they wanted to weigh in and really support what they felt was appropriate for shared or split visits based on Medicare's continuing attempt to make it based on time. So CPT actually added a definition of what a shared split visit was. CMS decided to accept this and will continue to allow for shared split visits to be billed by the individual, the physician or the APP in the facility setting. So this does not apply to the office. This is for the facility setting based on the MD or the APP that provided the substantial portion of the visit based on either time or medical decision making. Based on what CPT has put forth, we are recommending that if you do have a shared or split visit, that the support, the documentation support should either include both the physician and the APP time, and whoever recorded the most time would be the billing provider or the billing clinician for that. If the APP documents the work done by, that they've done and the physician comes back in, we're recommending you add an addendum and very clearly document what the patient problem is. Any data that was reviewed by the physician and the plan of care should be documented again, even if it's similar to the APP and then sign off on the note. And then the last potential here is that if the APP note clearly indicates that the physician was really directing the care throughout the visit, not that they reviewed the care after the visit and approved, but directed the care during the visit, then the physician can bill and of course would want to sign off on that record. Another or one of the new codes that was added into CPT this year is code 99459. This is also an add-on code and it can be added on to E&M services or to preventive medicine services. The payment for this code is around $22, but they did not assign a work value to this. This is a practice expense value only. And basically it captures the expenses surrounding a female pelvic exam that are extra. Bottom line, this is something that was put in place and when we look at the development of the value for this, it was predominantly based on the pelvic exam pack. So I know there was some information circulated that you had to have a chaperone and that actually does not fit really the definition of the code, nor does it actually supported by the development of the payment, the practice expense value. So of course you want to document well the pelvic exam that's done and whether or not a chaperone was part of the visit, but that chaperone is not required to use that particular code. Some additional code changes, code 64590 was changed specifically to reflect that this code was intended for the insertion or replacement of a generator that required a pocket and a connection to the electrode array. So that was a change that was made to both 64590 and 64595. This is typically codes that you'd recognize for sacral neuromodulation with some of the tools that we have available to us and have for a number of years. To accommodate the fact that we now have a very specific separate pulse generator, we have new codes for the open insertion of the percutaneous nerve stimulators, the ECOIN, the REVI, and I know there are some new ones coming out. They came out with two separate codes for the insertion, the 0816T, which is subcutaneous, which is consistent with the implantation of the ECOIN, and the subfascial, the 0817T, which is consistent right now with the implantation of the REVI. Those two codes have the mirrored codes with the revision or removal. It does include programming of the receiver on the initial insertion date. However, if the programming is done on a date separate or subsequent to the implementation, They've added two new codes, the 0589T and the 0590T, which I'll show you in a minute. They have also added new codes for the new devices, which have the sacral modulation, but they have an integrated neurostimulator and programming. This hasn't been, I haven't seen these out in the market very much, but we do have new codes for the insertion, revision, and the programming, but again, the programming is typically included on the date of the device insertion. And here are the specific descriptions related to the reprogramming codes, the 0589T and the 0590T for those reprogramming visits that are provided after the insertion date has been completed. I do want to take this moment just to make sure everyone understands that these are professional fees and ultimately do require that your staff is directing the reprogramming of that and that documentation should support that your staff was clearly directing the reprogramming, not just something that was done by someone not employed by your practice like a rep. We also had two additional new codes added, the 0811T and the 0812T for remote multi-day complex uroflow. These are specific to devices that are supplied to the patient for their measurement of their uroflow and when they void and is up typically to 10 days that that device is given to the patient and reports are sent back to the practice for those. Now you'll notice that a lot of the codes that we talked about today were Category 3 codes because they ended in a T unlike our standard CPT codes which are five digits. So it's important to know that when a Category 3 code exists that you are required to use it and it is directed really across Medicare and all of your private payers under HIPAA and CPT. CPT is pretty specific in stating that if there is a code that describes the service or procedure that you are providing that you should use that code and not use an unlisted code to potentially dodge maybe some coverage issues or reimbursement issues. If you do find that you're providing a service that doesn't have a code, either Category 1, Category 2 or HCPCS, then you would move to an unlisted code and you would select that unlisted code from a section within the CPT book that actually supports the approach, your technique, really kind of the location of where you are providing that service and use an unlisted code from that particular area within CPT. Now when you are using a Category 3 or an unlisted code, we recommend very strongly that you want to put together what you would probably do anyway, a very complete and descriptive note regarding the technique approach and equipment used. But because these codes don't have the same status as Category 1 codes, we would encourage you to also add a reason for the service, maybe a little bit above and beyond what was normally done. Why did you choose this over some other existing technology, for example? And the other thing is that a number of these Category 3 codes, in fact there are only two or three Category 3 codes, which Medicare actually develops RVUs for. So a work RVU, a practice expense and a malpractice RVU. So they are typically labeled as carrier priced. This means that the payer is the one who's going to ultimately determine based on information supplied by either the industry or the general data sets or by the practice, some way to determine an appropriate reimbursement. So you're going to want to make sure that if you are submitting information, you do a good job of comparing it to potentially an existing service code within that summary of the operative note to help guide that payer to selecting the appropriate reimbursement. And again, I remind you to include medical necessity and choice of this device over existing devices. Before you use a Category 3 code, as you do with anything, you're going to want to try and obtain prior authorization. If you can't get it in writing for Category 3 codes or unlisted codes, we do recommend that you document that you attempted this and certainly record who you spoke to and when in that process. You also, when you bill it, want to make sure you include a very concise description of the procedure. Obviously, with the Category 3 codes, you're going to have a description of the procedure. You may want to add in Box 19 some additional support in 80 characters or less as to why you use this particular device or, as we've seen with many payers, you want to add in a comparative code that gives some guidance to why you charged what you did and why you think you should be reimbursed how you did. And of course, you're going to look at many payers that are going to require some additional documentation. So including in any submission, either in Round 1 or Round 2 when you requested some additional information, you want to provide a good, clear, concise operative note. Anything that was done, you might want to provide a cover letter, which really talks about why you decided to use this and some of the comparative information that's there, any rationale for performing the operation, and any certificates of medical necessity if you've got those for that particular service. You want to include specifically any key factors within that and maybe call them out a little bit more. The difference in work between the CPT code that you're reporting on listed or Category 3 and the comparative codes using a percentage. This was twice as difficult or 20% more difficult, something along those lines, again, trying to guide the payer to the appropriate reimbursement. And then, again, if as much as you can use those comparison codes, those are good things to do. You also want to watch your Medicare carriers for local coverage articles and if you've got chances to connect with your medical directors or those folks that are in the role of advising Medicare to consider releasing an LCA. We also have a directive from CMS for those Medicare carriers, the MACs, to develop pricing and payment for those items they are going to cover. They should or can develop LCAs or local coverage articles describing when those services would be reimbursed and they can add specifically what they will reimburse for the physician payment using either a crosswalk to an existing procedure or a process called gap filling, which they would take a look at other available relative value datasets or usual and customary databases or what other MACs have done to provide a final price. Many of your MACs have the ability on their websites for you to check for carrier price codes even if they don't put those into the LCA. Patient payers will follow similar paths, but they are often more restrictive with Category 3 codes and have some coverage criteria that make it a little more difficult to do. So you may have to fight a little bit harder to get those paid and, of course, you may have to have some payers that you just know that you are not going to be able to get paid for those and change those to a patient payment by notifying them before the device is placed in before that whole process begins. And remember as well, as I've kind of alluded to, we have two different parts for every one of our services that we provide. One is coverage and one is reimbursement. Reimbursement is the dollar amount. Coverage is the conditions under which the patient will pay for those. We do have a number of payers that may designate Category 3 codes as a block, as experimental. But there are folks that have been able, through appeal, to get some of those services designated as experimental covered because the efficacy and safety have been well documented, but you need to make sure that you are looking at the appropriate coverage guidance that is provided by the FDA. So you want to look at everything that's available to you and really coordinate those things ahead of time with your billing staff. So clinical and billing staff integration is absolutely key when you're looking at any service you provide, but especially related to Category 3 codes and those services for which the coverage and reimbursement is not standardized. I did want to let you know that a lot of times, even though the procedural portion or the professional portion of a Category 3 code is carrier priced, Medicare can and does frequently set payment rates under the APP system, now the APC system. Now these are the rates that are used to pay hospitals and ambulatory surgical centers, and you can see that Medicare has in fact set reimbursement rates for the OPPS, that's the hospital rate, for the 8016T and the 0817T. So there are payments set up for that and pathways so that your facilities can know what they're being paid, making it potentially a little bit easier for you to jump into this particular area if you do feel it is appropriate for your patients for those Category 3 codes. And then the last thing I'll mention relative to all of these unlisted codes and Category 3 codes is that you really need to not jump into this blindly. You want to make sure you know what you're up against, know what payers are greased or ready to go, those payers that are not, you want to have discussions between your clinical staff and your billing staff, you want to make sure that your personnel, equipment and space are all on board, and everybody is well committed to the program before you jump into these new devices. There is a payment pathway for many of these. More importantly, as demand continues to increase, because payers tend not to be forward-looking, they tend to be reactive, so in those cases, if we have more folks using them, they'll be more likely to set up a standardized payment and coverage process as we move forward throughout the year. All right, at this point in time, I will stop with the presentation. All right, thank you, Mr. Painter. It is now time for questions. Just a reminder, please use the Q&A button to submit your questions. And Jill, what kind of questions do we have now? So, I'm just going to start at the top from the first ones that were put into the second. So, the first question, would the removal of the gypsy floor primarily impact the rural area, and would it be a negative impact if Congress doesn't extend it after March 8th? Yeah, and Jill, as you know, that is a negative impact, and it does target the rural areas. And some of those drops are up to 2.6%, so that's the biggest ones. Most of them fit around the 1% rate, but it is one of those areas where the rural areas would feel that impact. And Mark, do we, so on OGS coding today, do we list the gypsies from CMS's website? So, we don't specifically list the gypsies in the OGS website. However, there is a way to actually add in your local area so that your fee schedule can be customized on OGS coding today for your area, and those will remain in effect until we see the change. So, you'll be able to see what the new fee is for each CPT code using those gypsies to calculate it. Great. Okay, our next question is about G2211. So, the question is, if you are a solo provider managing patients with incontinence and they come in for a UTI, can you bill G2211 with their E&M code for that UTI visit? Yeah, absolutely. Right now, the way it's all set up, and obviously we'll see what Medicare does longer term, but right now, because it's so focused on that long-term relationship, those interim issues, you can still use the G2211. Great. Okay, our next question, can you report 99459 with G0101? So, at this point in time, what we saw in the code itself was a restriction to the E&M codes and the preventative medical exams. Now, that's because it was included in CPT. So, ultimately, you would think that the G0101 should allow the 99459 within Medicare, obviously, where you're required to use those. But I will tell you, we have not yet tested that from a reimbursement, Jill. I don't know if you've seen that out there tested, but I haven't yet. I haven't yet either. So, and as part of that, also, this person has been consistently told that a chaperone is a significant portion of the new pelvic exam add-on code. If that is not the case, what documentation requirements does this code have in regards to the patient's record or the records? Okay. Yeah. So, we heard this from a lot of folks, and we can probably trace it back to a couple of statements by some folks that were from ACOG that weren't really involved with the CPT process when they were talking about this. So, I actually went and did a deep dive on the direct expense calculations. And you can see that the generous payment they gave for allocated for staff for this code was $1.99.2. The majority of the cost was related to the pelvic exam pack, which was about $20. So that gets your 22. So yeah, the real issue is about the equipment, not the personnel. And as far as the documentation for the exam, right now, really what you should be documenting is really that you did a full pelvic exam for that patient and not focused on all the other extraneous issues at this point. Now, I do think that there may be a point in time where they look at the kit pack as a requirement, but we haven't seen that yet. And the second thing I would say is just for your own medical legal protection, you want to reference whether or not a chaperone was offered and accepted or refused. Great. So, we're going to stay on this new pelvic exam code. We have two more questions and then we'll jump back to this other post-op visit question that we have. So, this question shows kind of mark the complexity of the E&M visit. And so, this is the first I've heard of the new CPT code for the female pelvic exam, the new add-on code for the practice expenses. If we do an exam at a new patient visit, am I correct in thinking that we should be billing E&M level four or five as appropriate and code for the pelvic exam pack add-on code? If you do this and you are billing for a new visit based on time, am I to assume that you cannot use the time of the pelvic exam and the total time dedicated to the patient that day? Also, can you use this code when also using a modifier-25? Yeah. So, a couple of those I can answer. The other one I can speculate. We haven't seen it, so I'll take the speculation first. We haven't seen any restrictions related to the 25 modifier and 99459 at this point. So, right now, I'm going to say yes. The other part I can answer pretty solidly that there is no work value assigned to this 99459. So, the amount of work that you do from an E&M standpoint, a four or a five or whatever it is, that should be documented and charged in addition to the 99459. This is not about the work. This is about the equipment and the extra expense that you incur by doing a female pelvic exam. And on our next webinar on March 13th, we're going to be delving into this even more and doing some of these examples like I just read, and Dr. Mitch Schuster will hopefully be with us. He was instrumental in his work with AUGS and ACOG to create this new add-on code to cover the practice expense costs of doing a female pelvic exam that were not included in a regular E&M visit from the practice expense RVU perspective. So, we're going to have more on these kind of scenarios that we just had in this question. So, make sure you mark your calendar to be with us then. So, here's another one. Also about the dash 25 modifier. So, we'll get that clarified before the 13th because we're going to have more experience with 99459 by then. So, I'm just going to, we have one more question here. Are private payers paying for G2211 and 99459, both new codes? Have our private payers picked those up yet? Okay. So, I can tell you that we have seen private payers paying for both codes as we've tried this so far. We're early on. I definitely would say that our Medicare Advantage PANs are playing for this, but we are having some issues because the G2211 was, it was a code that was introduced in 2021, but it was status B as bundled. So, we do have a few of our Medicare Advantage plans in which we've been asked to use a modifier 59 with G2211 until they update their fee schedules to the latest version. So, there is, you know, it's not the ideal thing and not certainly one of those where I would have said, hey, 59 makes a lot of sense, but we've actually had specific instructions from a couple of payers in the Medicare Advantage world to use that 59 for the G2211. And then I'll also add, we've had a couple of odd responses to the G2211 in which the payer erroneously stated that this, and this was a MAC, has said that it could only be used by primary care, which is wrong. And clearly you can use, there's a great MLN article that specifically states this is not specialty specific. So, if you run into some twists and turns, I'd keep pushing a little bit. Now, private payers are a different story on the pure commercial side, not on Medicare Advantage, but the pure commercial side. That one, there is some leeway for them not to do that. So, that's one you might want to probe, appeal, see what happens on some of those things, but we are seeing some pay. Great. Another G2211 question, would it be appropriate to put G2211 on your E&M visits for all your incontinence patients that you see on a regular basis? So, I think there's an underlying question here that I'm going to answer on all this. So, any visit, again, that you're not using, you are using an E&M without a 25, that you are the center of care or the pivot position for their incontinence, I think fits the G2211. So, but the one thing I will mention is that, you know, if you've got, and that's why I put in second opinion, you know, if you've got a patient that's coming through that has incontinence, but you're not the pivot point for that incontinence care, you can't use it for that one. So, you really need to be the group that's providing their incontinence care to use the G2211. And then, yes, you should use it. Great. Okay. Question on a different topic. Can the shared billing be applied to post-op visits? So, the post-op visit, I'm assuming you're talking about the global period. That really is a zero pay code overall. So, you know, you could certainly use a physician and an APP for a post-op visit and document those. But the real focus of the shared split visit is on the reimbursement and a typical post-op visit that's in the global doesn't have a reimbursement assigned to it. So, we don't see that much of a focus surrounding that 99024 and the shared split visit requirements. Great. Another question totally off what we talked about, but I think others might have it. And Mark, you probably know this off the top of your head. What code do you use for a bladder scan procedure? So, the typical post-void residual bladder scan is 51798. I know. Yep. And so, the 51798, because it's a 5, or starts with a 5, a lot of folks have assumed you need a modifier 25 on your E&M code. But the 51798 actually has a global period of XXX assigned to it, which means you actually don't have any bundling issues relative to your E&M service with Medicare, unless they were to add it in as part of the NCCI or the National Correct Coding Initiative. They have not done that with 51798. So, if you're billing 51798 and you bill an E&M code, you should still be able to add the G2211 because the E&M code doesn't require a modifier 25. Great. We have a question about 99459. Pelvic exam does not need a modifier 25. It's an add-on code. It's not an E&M code per se, even though it's listed in the E&M section of the book. But therefore, because it doesn't need a dash 25, Mark, would you still be able to use G2211 with it? Yes. I'll give a short answer on that one. There we go. Okay. We do have folks who are running into this chaperone issue on 99459. Are there any resources, besides probably our slide set for the March 13th, where we'll show all these practice expense inputs as well as the CBT changes descriptors and things? Mark, have you seen any other resources regarding the chaperone issue? You know, I haven't yet seen any other good resources. My resource that I had to deal with when this started coming up was to really show them the direct input calculations. And so, that's a spreadsheet that you can download from the Medicare website. Look for direct inputs and look for code 99459. And you can show them that it's based on supplies, not people. And that'll be one of our slides from the next webinar. So, and we'll be doing a coding fact sheet on the new pelvic exam add-on code, and that will be part of that too. So, a couple of weeks for that, but we'll be in touch more. Okay. Our last question, and then we're going to have a little housekeeping, and then we're going to call it an evening. If a patient's incontinence is resolved through surgery and the patient comes in just for follow-up but is not experiencing continence issues, can you still add G2211 to that E&M visit code? Yes. Again, it's focused on the long-term care relationship, not on the services provided on that particular date. So, you should absolutely be able to add that code, G2211, even if the focus of the visit is not the incontinence or the reason that you're having the patient back that day. All right. Well, thank you very much, Mark Painter. And on behalf of AUGS, I'd like to thank all of our faculty today for this excellent webinar, and I'd like to remind you to be sure to attend part two of the AUGS coding webinar series, Coding for Your Gynecology Patients. This is going to be on March the 13th. The date was recently changed from March 28th, but now it is March the 13th. You can submit questions in advance to coding at augs.org and register for our upcoming webinar on March the 6th, where Dr. Melanie Meister will be presenting a webinar entitled Pelvic Floor Myofascial Pain and Dysfunction. Follow AUGS on Twitter and Instagram or check out our website for information on all upcoming webinars. We thank you all for joining tonight, and I hope you have a great evening. Thank you.
Video Summary
The webinar discussed new 2024 Urogynecologic CPT codes and HCPCS codes and provided insights on best practices for accurate reimbursement. The speaker, Mr. Mark Painter, covered various topics, including changes in Medicare conversion factor for 2024, telehealth coverage and documentation requirements, the G2211 code and its eligibility criteria, the Community Health Integration and Principal Illness Navigation program, and updates on CPT codes for urogynecologic procedures. He also addressed questions from attendees. Some key takeaways from the webinar are:<br /><br />1. Medicare has made changes to the conversion factor for 2024, and there may be further adjustments depending on congressional decisions.<br />2. Telehealth services are covered through the end of 2024, and there have been changes in coding and documentation requirements for telehealth visits.<br />3. The G2211 code can be used to bill for visit complexity inherent to E&M codes, but there are eligibility criteria based on the patient-physician relationship.<br />4. The Community Health Integration and Principal Illness Navigation program offers opportunities for urogynecology and is focused on addressing social determinants of health barriers.<br />5. New CPT codes have been introduced for urogynecologic procedures, including codes for sacral neuromodulation and remote multi-day uroflow measurements.<br />6. Category 3 codes should be used when a specific code exists, and proper documentation and understanding of coverage and reimbursement policies is important when using these codes.<br />7. Private payers may have different coverage and reimbursement policies for new codes, so it is important to verify with each payer.<br />8. The webinar also addressed specific questions related to codes for pelvic exams, post-op visits, bladder scans, and the use of modifiers.
Keywords
2024 Urogynecologic CPT codes
HCPCS codes
accurate reimbursement
Medicare conversion factor
telehealth coverage
G2211 code
eligibility criteria
urogynecologic procedures
social determinants of health
Category 3 codes
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