Medical Review Frequently Asked Questions - November 2005
The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly quarterly "Frequently Asked Questions" related to coverage and local coverage determination issues. Providers may submit questions to the website at http://www.cignamedicare.com/customer_service/disclaimer.html.
- Multiple Level Joint Injections
Q: How should multiple level bilateral paravertebral facet joint injections be billed?
A: Providers may have received denials for bilateral paravertebral facet injections when more than one add-on level was billed without a modifier 59 or an electronic notepad indicating the add-on levels were distinctly different. For example, if a provider treats bilaterally three thoracic levels (such as T7-8, 8-9, and 9-10), the provider should bill 64470-50 for the first level then 64472-50 for each of the two additional levels except the last level should include a modifier 59 or a notepad explaining the three different levels treated.
- Electrical Stimulation
Q: How should electrical stimulation HCPCS codes G0281 and G0283 be billed?
A: These codes are not timed codes but do specify (treatment to) "one or more areas." Therefore, these codes should be billed by encounter and not by site.
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Stress Tests
Q: How should physician bill for supervision and interpretation of stress test done in an outpatient facility?
A: CPT code 93015, could not be billed by the physician as this is a global code including both technical and professional components; and, since the stress test in this example is being done outside of the office setting, then the physician is not due the technical component. Providers should note that there are a series of codes for cardiovascular stress test. CPT code 93016, is for physician supervision only without interpretation and report whereas 93017 is for the stress test tracing (also without interpretation and report). Finally, 93018 is the last of this code series and is for stress testing interpretation and report. In the scenario where a provider provides supervision for the stress test done outside of the office setting and also interprets the report, the provider may bill 93016 and 93018 but not 93015 and 93017.
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Initial Hospital Visits and Global Procedures
Q: Can an initial hospital visit be billed on a patient admitted for a procedure?
A: If the patient was admitted for a planned procedure, then an initial visit would be considered part of the global package and should not be billed with a modifier prompting separate payment.
If a patient was admitted to the hospital and during that initial visit the circumstances led to the decision was made to perform a major surgery that day or the very next day, then the initial hospital visit would need to be billed with modifier 57 in order to be separately paid. Likewise, if during an initial hospital visit the decision was made to perform a minor procedure (i.e. "minor" only as defined by the number of global days being "0" or "10") then a provider may bill the initial hospital visit with modifier 25 appended only as long as the patient's condition required an evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed.
Take for example the stenting of a coronary artery. This is a very serious and complex procedure (CPT code 92980); but, per the Medicare Physicians' Fee Schedule database, this is a minor procedure in terms of global days (i.e. CPT code 92980has "0" global days). If the stent procedure was planned prior to admission to the hospital, then the physician should not bill an initial hospital visit (CPT code 99221-99223) unless there existed a medically necessary reason for that specific patient beyond the normal or expected pre-operative work that is included in the global reimbursement for the stent procedure.
