Coding Pearls

For an unannounced Durable Medical Equipment (DME) site visit, you'll need to have readily available documentation demonstrating compliance with DMEPOS supplier standards, including licensure, insurance, inventory, complaint resolution protocols, and instructions for beneficiary use. The inspector will verify this information and may also take photographs of the facility. This should not be a surprise. When you applied for your DME ID number, you filled out the Medicare enrollment application, form CMS-855S, and when you signed the application, you agreed to follow the rules. Here are the rules for what needs to be present when an unannounced DME on site visit occurs.

“My clinic is at the local hospital. I send X-rays to the radiology department. They are eventually read by a radiologist. However, I actually evaluate the x-rays and interpret them myself. Can I bill that component of the radiology fee? And if I do, will it affect the radiologist reimbursement?”

“With the loss of CPT 99343, is time a justification for the use of CPT 99344? My initial home visits (and now assisted and congregate living facilities) easily meet or exceed sixty minutes. Before I see patients, they completed a five page demographics that includes two pages of review of systems. I also have the chart notes from the referring physician and/or the CMS-485 from a home care agency (or the input paperwork from the hospice agency) that is all reviewed while face to face with the patient. The physical exam is quite time consuming in and of itself followed by assessment, treatment, plan of care and coordination of care. It seems that everything I can read says that I am justified in billing CPT 99344 using time. Thoughts?”

“Which ICD 10 code should one use for postoperative x-rays after a bunionectomy, a hammertoe repair, or amputation? United Health Care denied payment for post op x-rays. This hasn’t happened before. Thank you.”

“I billed A5500 and A5512 with modifiers -KX, -RT, -LT. L1940 KXRTLT L2330 KXRTLT L2820 KXRTLT I billed these on separate lines. This claim was rejected so we re-billed putting the KX modifier in the 3rd spot and it was still rejected for the same reason. The comment was: 4 – the procedure code is inconsistent with the modifier used or a required modifier is missing Any thoughts on how to tackle this denial?”

“My billing team and I have a difference of opinion. If we apply more than one graft, they have been using modifier -76. It is getting paid, but I am not sure that is the appropriate use of the modifier. I just assumed that we would bill for total units. However, each graft has a unit number. So, if we bill double the units, we need a way to alert the insurance company why the units are doubled. This is why we started using the 76 modifier. Any input would be appreciated.”

“I have a question concerning Medicare’s rules when billing for repeat CPT 11750. What is the recommendation for billing these for a regrowth following a previous CPT 11750? In another scenario, on the same subject, what if the procedure needs to be performed on a nail border that is adjacent to one that was already billed? Can and should we use an ABN and upon denial, bill the patient?”

“How are fracture care codes used? If a patient comes into the clinic with a fracture that you plan on eventually operating on, can you bill a closed fracture care code and then bill the surgical code when the open reduction and internal fixation is performed in the operating room?”

“So, to be clear you can never use L3000KX for a diabetic with neuropathy and diabetic ulcers even if secondary will pay.”

By Dr. Michael G. Warshaw, DPM, CPC