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Coding and Billing
Can I Bill This?
August 2005
E ach day, I receive numerous billing inquiries from dermatologists around the country. Although the questions reflect a myriad of subjects, the same themes are often repeated.
In this article, I decided to compile a sampling of readers’ queries to reflect some of the more commonly asked questions. I hope my answers will provide you with some insight and billing guidance.
Q: We are performing pregnancy tests for our female patients who are undergoing treatment with isotretinoin [Accutane, Amnesteem, Claravis, Sotret]. We want to bill CPT code 81025. Is this correct? Do I need a CLIA [Clinical Laboratory Improvement Amendments] certificate in order to bill this?
A: CPT code 81025 is correct for a pregnancy urine test, and this test is included in the CLIA Certificate of Waiver. Any person or facility performing laboratory tests on human specimens for the purpose of diagnosis and/or treatment is required by federal law to have CLIA certificate. Medicare requires the CLIA certificate number before any claims can be processed. Certificates must be renewed every 2 years as long as testing is being performed. Changes in ownership, locations, and type of testing performed must be reported to your local CLIA Licensing and Certification agency within 30 days of the change.
It is the facility’s responsibility to make sure that the level of testing performed matches the facility’s type. Reimbursements by Medicare may be denied if the test submitted does not match the certificate. CLIA certificates come in four different types. They include the following:
1. Certificate of Waiver
These tests have been approved by the FDA for home use and require very little training to perform. The only requirements for this type of testing are that the manufacturer’s instructions are followed exactly and that documentation exists to validate that the testing personnel have been formerly trained to perform the test. Proficiency testing is not required for this level of testing, but the quality of the tests performed must be evaluated at least twice a year.
This is the type of certificate you need to obtain.
2.Provider Performed Microscopy
These are tests performed by a healthcare provider such as a doctor, physician's assistant or nurse practitioner. These tests include wet preps, KOH preps, and other microscope-based procedures. All waived tests may be performed with this level of certificate and with the same requirements as a certificate of waiver. Proficiency testing is not required for this level of testing, but the quality of the tests performed must be evaluated at least twice a year.
3.Certificate of Compliance
Tests performed under this type of certificate have been classified as moderate or high-complexity and have regulations that are more stringent. Facilities performing moderate or high-complexity testing must be enrolled in an approved proficiency testing program for each regulated analyte. Analyte tests that do not have a proficiency testing program available must be evaluated at least twice a year. Each facility must establish a quality assurance program that includes quality control, personnel policies, patient test management, and proficiency testing. These facilities are inspected every 2 years to ensure compliance with federal regulation.
4. Certificate of Accreditation
Facilities with this type of certificate have opted to have an accrediting agency approved by the Centers for Medicare & Medicaid Services (CMS) perform the biannual inspections instead of CMS (for an additional fee, of course). These facilities must follow the accrediting agency’s guidelines in addition to the federal regulations. Occasionally, a validation inspection is conducted to evaluate the accrediting agency inspection process. Each state has its own CLIA certifying agency, so check your local Web sites for more information.
Q: My doctor recently excised a nevus on the breast of a female patient. Based on its size and location, I feel that using CPT code 11421 is appropriate. This code includes lesions 0.6 to 1 cm in diameter and involves scalp, neck, hands, feet, and genitalia. I looked up genitalia in the medical dictionary, and it doesn’t look like it applies to the breast. Should we be using CPT code 19120 instead for this procedure?
A: The definition of CPT code 19120 is as follows:
“Excision of cyst, fibroadenoma, or other benign or malignant tumor; aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female on one or more lesions.”
In order to use this code, you must be excising a tumor that involves actual breast tissue, not just skin of the breast. Most likely, the nevus involves only the skin of the breast and therefore, CPT code 19120 is not appropriate. Use CPT code 11421, and don’t forget to bill for the repair, in addition to the excision, if the defect is closed using either an intermediate or complex repair.
Q: A patient came into the office and wanted us to bill a preventative care visit as her primary reason for coming in. She is an established patient and evidently has this type of insurance coverage that covers these types of visits in full without a co-payment or it being applied to her deductible. A regular office visit would require her to pay a co-payment. We do not participate with her insurance plan. Upon examination, the doctor had diagnosed several benign seborrheic keratoses that didn’t need treatment, as well as several actinic keratoses, which we did treat. We performed a full-body exam because the patient had history of precancerous lesions. The exam was clearly documented in the chart. Since the patient had not been in the office in several months and because of her age, we also updated her history.
In this scenario, can a dermatologist bill 99396? If so, should there be a primary ICD-9 diagnosis code other than 702.19 and 702.0?
A: I’m glad you asked this. Let me answer your question in three parts.
1. Never let patients tell you how to bill, code, or advise you on anything else regarding billing. I’m sure you want to help the patient, but misrepresenting your services can lead to lots of trouble. Bill what you do and do what you bill for, regardless of the requests of your patient.
2. Yes, dermatologists can bill the Preventive Medicine Services codes, but dermatologists do not perform these types of services. CPT clearly states:
“If an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201 to 99215 should be reported. Modifier -25 should be added to the E/M visit to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service.”
Obviously, your visit required additional work (for example, treating the AKs), and the patient also had a pre-existing condition (for example, history of precancerous lesions that had been treated).
3. The codes are not appropriate for dermatologists. They’re designed and used to report the preventive medicine evaluation and management of infants, children, adolescents and adults. The codes are divided by the age of the patient, and the extent of the visit is determined largely by the age group into which the patient falls.
Look at the definition of 99396:
“Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures (40 to 64 years).”
In dermatology, most visits are initiated by the patient and based on chief complaints (for example, a patient is worried about a lesion). There are usually pre-existing dermatologic conditions that the dermatologist (or patient) is following, and, in many cases, the extent of the history and exam is predicated on the patient’s chief complaint. So, an immunization or diagnostic lab work is not routinely ordered as part of this type of visit.
Dermatologists order tests or do procedures based solely on a diagnosed problem, not on the basis of preventing future problems. In other words, dermatologists don’t order routine complete blood counts. Lab work is only ordered when it’s needed to diagnose or treat a skin condition or because the physician has diagnosed a lesion that requires attention.
In short, these codes are not designed for dermatologic encounters. Stick with the E/M codes 99241 to 99245 and 99201 to 99215.
E ach day, I receive numerous billing inquiries from dermatologists around the country. Although the questions reflect a myriad of subjects, the same themes are often repeated.
In this article, I decided to compile a sampling of readers’ queries to reflect some of the more commonly asked questions. I hope my answers will provide you with some insight and billing guidance.
Q: We are performing pregnancy tests for our female patients who are undergoing treatment with isotretinoin [Accutane, Amnesteem, Claravis, Sotret]. We want to bill CPT code 81025. Is this correct? Do I need a CLIA [Clinical Laboratory Improvement Amendments] certificate in order to bill this?
A: CPT code 81025 is correct for a pregnancy urine test, and this test is included in the CLIA Certificate of Waiver. Any person or facility performing laboratory tests on human specimens for the purpose of diagnosis and/or treatment is required by federal law to have CLIA certificate. Medicare requires the CLIA certificate number before any claims can be processed. Certificates must be renewed every 2 years as long as testing is being performed. Changes in ownership, locations, and type of testing performed must be reported to your local CLIA Licensing and Certification agency within 30 days of the change.
It is the facility’s responsibility to make sure that the level of testing performed matches the facility’s type. Reimbursements by Medicare may be denied if the test submitted does not match the certificate. CLIA certificates come in four different types. They include the following:
1. Certificate of Waiver
These tests have been approved by the FDA for home use and require very little training to perform. The only requirements for this type of testing are that the manufacturer’s instructions are followed exactly and that documentation exists to validate that the testing personnel have been formerly trained to perform the test. Proficiency testing is not required for this level of testing, but the quality of the tests performed must be evaluated at least twice a year.
This is the type of certificate you need to obtain.
2.Provider Performed Microscopy
These are tests performed by a healthcare provider such as a doctor, physician's assistant or nurse practitioner. These tests include wet preps, KOH preps, and other microscope-based procedures. All waived tests may be performed with this level of certificate and with the same requirements as a certificate of waiver. Proficiency testing is not required for this level of testing, but the quality of the tests performed must be evaluated at least twice a year.
3.Certificate of Compliance
Tests performed under this type of certificate have been classified as moderate or high-complexity and have regulations that are more stringent. Facilities performing moderate or high-complexity testing must be enrolled in an approved proficiency testing program for each regulated analyte. Analyte tests that do not have a proficiency testing program available must be evaluated at least twice a year. Each facility must establish a quality assurance program that includes quality control, personnel policies, patient test management, and proficiency testing. These facilities are inspected every 2 years to ensure compliance with federal regulation.
4. Certificate of Accreditation
Facilities with this type of certificate have opted to have an accrediting agency approved by the Centers for Medicare & Medicaid Services (CMS) perform the biannual inspections instead of CMS (for an additional fee, of course). These facilities must follow the accrediting agency’s guidelines in addition to the federal regulations. Occasionally, a validation inspection is conducted to evaluate the accrediting agency inspection process. Each state has its own CLIA certifying agency, so check your local Web sites for more information.
Q: My doctor recently excised a nevus on the breast of a female patient. Based on its size and location, I feel that using CPT code 11421 is appropriate. This code includes lesions 0.6 to 1 cm in diameter and involves scalp, neck, hands, feet, and genitalia. I looked up genitalia in the medical dictionary, and it doesn’t look like it applies to the breast. Should we be using CPT code 19120 instead for this procedure?
A: The definition of CPT code 19120 is as follows:
“Excision of cyst, fibroadenoma, or other benign or malignant tumor; aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female on one or more lesions.”
In order to use this code, you must be excising a tumor that involves actual breast tissue, not just skin of the breast. Most likely, the nevus involves only the skin of the breast and therefore, CPT code 19120 is not appropriate. Use CPT code 11421, and don’t forget to bill for the repair, in addition to the excision, if the defect is closed using either an intermediate or complex repair.
Q: A patient came into the office and wanted us to bill a preventative care visit as her primary reason for coming in. She is an established patient and evidently has this type of insurance coverage that covers these types of visits in full without a co-payment or it being applied to her deductible. A regular office visit would require her to pay a co-payment. We do not participate with her insurance plan. Upon examination, the doctor had diagnosed several benign seborrheic keratoses that didn’t need treatment, as well as several actinic keratoses, which we did treat. We performed a full-body exam because the patient had history of precancerous lesions. The exam was clearly documented in the chart. Since the patient had not been in the office in several months and because of her age, we also updated her history.
In this scenario, can a dermatologist bill 99396? If so, should there be a primary ICD-9 diagnosis code other than 702.19 and 702.0?
A: I’m glad you asked this. Let me answer your question in three parts.
1. Never let patients tell you how to bill, code, or advise you on anything else regarding billing. I’m sure you want to help the patient, but misrepresenting your services can lead to lots of trouble. Bill what you do and do what you bill for, regardless of the requests of your patient.
2. Yes, dermatologists can bill the Preventive Medicine Services codes, but dermatologists do not perform these types of services. CPT clearly states:
“If an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201 to 99215 should be reported. Modifier -25 should be added to the E/M visit to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service.”
Obviously, your visit required additional work (for example, treating the AKs), and the patient also had a pre-existing condition (for example, history of precancerous lesions that had been treated).
3. The codes are not appropriate for dermatologists. They’re designed and used to report the preventive medicine evaluation and management of infants, children, adolescents and adults. The codes are divided by the age of the patient, and the extent of the visit is determined largely by the age group into which the patient falls.
Look at the definition of 99396:
“Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures (40 to 64 years).”
In dermatology, most visits are initiated by the patient and based on chief complaints (for example, a patient is worried about a lesion). There are usually pre-existing dermatologic conditions that the dermatologist (or patient) is following, and, in many cases, the extent of the history and exam is predicated on the patient’s chief complaint. So, an immunization or diagnostic lab work is not routinely ordered as part of this type of visit.
Dermatologists order tests or do procedures based solely on a diagnosed problem, not on the basis of preventing future problems. In other words, dermatologists don’t order routine complete blood counts. Lab work is only ordered when it’s needed to diagnose or treat a skin condition or because the physician has diagnosed a lesion that requires attention.
In short, these codes are not designed for dermatologic encounters. Stick with the E/M codes 99241 to 99245 and 99201 to 99215.
E ach day, I receive numerous billing inquiries from dermatologists around the country. Although the questions reflect a myriad of subjects, the same themes are often repeated.
In this article, I decided to compile a sampling of readers’ queries to reflect some of the more commonly asked questions. I hope my answers will provide you with some insight and billing guidance.
Q: We are performing pregnancy tests for our female patients who are undergoing treatment with isotretinoin [Accutane, Amnesteem, Claravis, Sotret]. We want to bill CPT code 81025. Is this correct? Do I need a CLIA [Clinical Laboratory Improvement Amendments] certificate in order to bill this?
A: CPT code 81025 is correct for a pregnancy urine test, and this test is included in the CLIA Certificate of Waiver. Any person or facility performing laboratory tests on human specimens for the purpose of diagnosis and/or treatment is required by federal law to have CLIA certificate. Medicare requires the CLIA certificate number before any claims can be processed. Certificates must be renewed every 2 years as long as testing is being performed. Changes in ownership, locations, and type of testing performed must be reported to your local CLIA Licensing and Certification agency within 30 days of the change.
It is the facility’s responsibility to make sure that the level of testing performed matches the facility’s type. Reimbursements by Medicare may be denied if the test submitted does not match the certificate. CLIA certificates come in four different types. They include the following:
1. Certificate of Waiver
These tests have been approved by the FDA for home use and require very little training to perform. The only requirements for this type of testing are that the manufacturer’s instructions are followed exactly and that documentation exists to validate that the testing personnel have been formerly trained to perform the test. Proficiency testing is not required for this level of testing, but the quality of the tests performed must be evaluated at least twice a year.
This is the type of certificate you need to obtain.
2.Provider Performed Microscopy
These are tests performed by a healthcare provider such as a doctor, physician's assistant or nurse practitioner. These tests include wet preps, KOH preps, and other microscope-based procedures. All waived tests may be performed with this level of certificate and with the same requirements as a certificate of waiver. Proficiency testing is not required for this level of testing, but the quality of the tests performed must be evaluated at least twice a year.
3.Certificate of Compliance
Tests performed under this type of certificate have been classified as moderate or high-complexity and have regulations that are more stringent. Facilities performing moderate or high-complexity testing must be enrolled in an approved proficiency testing program for each regulated analyte. Analyte tests that do not have a proficiency testing program available must be evaluated at least twice a year. Each facility must establish a quality assurance program that includes quality control, personnel policies, patient test management, and proficiency testing. These facilities are inspected every 2 years to ensure compliance with federal regulation.
4. Certificate of Accreditation
Facilities with this type of certificate have opted to have an accrediting agency approved by the Centers for Medicare & Medicaid Services (CMS) perform the biannual inspections instead of CMS (for an additional fee, of course). These facilities must follow the accrediting agency’s guidelines in addition to the federal regulations. Occasionally, a validation inspection is conducted to evaluate the accrediting agency inspection process. Each state has its own CLIA certifying agency, so check your local Web sites for more information.
Q: My doctor recently excised a nevus on the breast of a female patient. Based on its size and location, I feel that using CPT code 11421 is appropriate. This code includes lesions 0.6 to 1 cm in diameter and involves scalp, neck, hands, feet, and genitalia. I looked up genitalia in the medical dictionary, and it doesn’t look like it applies to the breast. Should we be using CPT code 19120 instead for this procedure?
A: The definition of CPT code 19120 is as follows:
“Excision of cyst, fibroadenoma, or other benign or malignant tumor; aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female on one or more lesions.”
In order to use this code, you must be excising a tumor that involves actual breast tissue, not just skin of the breast. Most likely, the nevus involves only the skin of the breast and therefore, CPT code 19120 is not appropriate. Use CPT code 11421, and don’t forget to bill for the repair, in addition to the excision, if the defect is closed using either an intermediate or complex repair.
Q: A patient came into the office and wanted us to bill a preventative care visit as her primary reason for coming in. She is an established patient and evidently has this type of insurance coverage that covers these types of visits in full without a co-payment or it being applied to her deductible. A regular office visit would require her to pay a co-payment. We do not participate with her insurance plan. Upon examination, the doctor had diagnosed several benign seborrheic keratoses that didn’t need treatment, as well as several actinic keratoses, which we did treat. We performed a full-body exam because the patient had history of precancerous lesions. The exam was clearly documented in the chart. Since the patient had not been in the office in several months and because of her age, we also updated her history.
In this scenario, can a dermatologist bill 99396? If so, should there be a primary ICD-9 diagnosis code other than 702.19 and 702.0?
A: I’m glad you asked this. Let me answer your question in three parts.
1. Never let patients tell you how to bill, code, or advise you on anything else regarding billing. I’m sure you want to help the patient, but misrepresenting your services can lead to lots of trouble. Bill what you do and do what you bill for, regardless of the requests of your patient.
2. Yes, dermatologists can bill the Preventive Medicine Services codes, but dermatologists do not perform these types of services. CPT clearly states:
“If an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201 to 99215 should be reported. Modifier -25 should be added to the E/M visit to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service.”
Obviously, your visit required additional work (for example, treating the AKs), and the patient also had a pre-existing condition (for example, history of precancerous lesions that had been treated).
3. The codes are not appropriate for dermatologists. They’re designed and used to report the preventive medicine evaluation and management of infants, children, adolescents and adults. The codes are divided by the age of the patient, and the extent of the visit is determined largely by the age group into which the patient falls.
Look at the definition of 99396:
“Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures (40 to 64 years).”
In dermatology, most visits are initiated by the patient and based on chief complaints (for example, a patient is worried about a lesion). There are usually pre-existing dermatologic conditions that the dermatologist (or patient) is following, and, in many cases, the extent of the history and exam is predicated on the patient’s chief complaint. So, an immunization or diagnostic lab work is not routinely ordered as part of this type of visit.
Dermatologists order tests or do procedures based solely on a diagnosed problem, not on the basis of preventing future problems. In other words, dermatologists don’t order routine complete blood counts. Lab work is only ordered when it’s needed to diagnose or treat a skin condition or because the physician has diagnosed a lesion that requires attention.
In short, these codes are not designed for dermatologic encounters. Stick with the E/M codes 99241 to 99245 and 99201 to 99215.
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