Our experts answer questions about billing vasectomy and sperm analysis, coding for ED visit when the patient is admitted for surgery, billing glucose reading before a PET scan, documentation required for the functional limitation codes, and appropriate reporting of observation.
In January 2013, CMS introduced 42 therapy functional reporting G codes (nonpayable). These G codes are to be reported in conjunction with therapy services (physical, occupational, and speech). CMS also introduced seven complexity/severity modifiers to be used with these G codes.
Providers setting charges based on an understanding of their costs is not a new concept, says Jugna Shah, MPH, president and founder of Nimitt Consulting. However, providers struggle with this or fail to do it correctly, and then stand to deteriorate their future payment rates since CMS relies on provider data to set payment rates not only for inpatient and outpatient services, but also for laboratory services.
Eight CPT® codes for multianalyte assays with algorithmic analyses (MAAA) procedures are now classified as not covered under OPPS (status indicator E), retroactive to January 1, 2013. These codes are now subject to I/OCE edit 9.
CMS is reexamining inpatient criteria because it has seen a significant increase in the number of patients spending more than 24 hours in observation. Providers are worried that a Recovery Auditor will deny a short inpatient stay for lack of medical necessity and recoup payment years later. So instead, some facilities place patients in observation for longer time periods.
