The Office of Inspector General (OIG) has updated its 2025 Work Plan and is focusing on reviewing postoperative services that are part of the global surgery period. With the recent changes in the global surgery coding system for 2025, it’s essential for healthcare professionals to stay up-to-date.

The OIG (Office of Inspector General) is examining how these postoperative services are being provided and billed during the global surgery period. This could involve checking for compliance, accuracy in billing, or identifying issues like overbilling or lack of quality of care.

For healthcare providers, it is important to understand the 2025 global surgery updates as it could impact their practices of documenting the surgery procedures and billing for services. However, for patients it is also vital as it lets them receive proper care during the recovery period and improve transparency.

This guide will help you walk through the new coding requirements, postoperative services, and how to comply with Medicare regulations. But, first let’s discuss the global surgical period.

What Is a Global Surgery Package?

A Global Surgery Package, also known as global surgery or the global period is a Medicare concept where payment for a surgical procedure includes the surgery itself and related services provided before, during, and after the surgical procedure. These services are bundled into a single payment, covering preoperative visits, the surgical procedure, and postoperative care (follow-up visits) within a specified time frame usually ranging from the day of surgery to 10 or 90 days after the surgery.

If providers in the same group and specialty are involved in the surgical procedure, they must submit their bills and accept payment as if they’re one provider. This keeps billing simple and avoids double charges.

Global Surgery Package Duration and Procedure Types

CMS Guidelines for Global Surgery Period—What Is Included in The Global Surgery Package?

For Medicare claims, CMS (Centers for Medicare & Medicaid Services) includes the following services in the global surgery payment:

• Preoperative Visits
• Intraoperative Services
• Other Medical or Surgical Services in the Postoperative Period
• Postoperative Follow-Up Visits
• Post-Surgical Pain Management
• Supplies
• Miscellaneous Services

Preoperative Visits

These are visits that happen after the decision to operate has been made during the evaluation and management process (E/M). This includes minor surgeries or endoscopy procedures performed by the same provider on the same day as the surgery.

Intraoperative Services

These are services provided during the actual surgery, including everything necessary to perform the surgical procedure.

Other Medical or Surgical Services in the Postoperative Period

All other medical or surgical services after the surgical procedure include any additional medical or surgical care that the surgeon provides to the patient during the designated recovery time after the surgery.

Postoperative Follow-Up Visits

These are check-ups or follow-up appointments to monitor the patient’s recovery during the postoperative period. Usually the code 99024 is used to track the follow-up visits. 

Post-Surgical Pain Management

Post-Surgical Pain Management includes care provided to help the patient manage pain after the surgery, such as medication or therapy.

Supplies

These are materials used during the surgery and recovery period, except for certain excluded items. For example, bandages or surgical tools.

Miscellaneous Services

These are smaller, routine tasks related to surgery, such as bandage changing, local incision care, operative pack removal, cutaneous sutures and staples removal, etc.

CMS guidelines for global surgery Period— What Isn’t Included in the Global Surgical Package?

Here are certain services that CMS does not include in the global surgical package, and what providers can bill separately and get paid.

• Initial Evaluation for Surgery
• Services by Other Providers
• Unrelated Visits
• Treatment for Separate Health Conditions
• Diagnostic Tests
• Additional Surgeries
• Complication Treatment in OR (Operating Room)
• Failed Minor Procedure Leading to Major Surgery
• Organ Transplant Medications
• Critical Care Services

Initial Evaluation for Surgery

The surgeon’s decision on the first visit to evaluate if major surgery is needed is not part of the global surgical package. The evaluation visit (E/M) can be billed separately using modifier 57.

Services by Other Providers

If other providers (not the surgeon) perform surgery-related services, these are excluded from the package unless there’s an agreement to transfer care between the surgeon and other providers. This agreement must be documented in the patient’s medical records.

Unrelated Visits

Follow-up visits for conditions unrelated to the surgery or its diagnosis are not included in the global surgery package, except when visits are due to surgery complications.

Treatment for Separate Health Conditions

If a patient needs treatment for an underlying or unrelated health condition, or begins a new treatment unrelated to surgery recovery, it’s billed separately.

Diagnostic Tests

Tests or procedures to diagnose issues (like X-rays or other scans) are not included in the package and require separate billing.

Additional Surgeries

Surgeries performed during the recovery period that are not part of the original surgery or related to surgery complications are excluded from the Medicare global surgery package. 

Complication Treatment in OR (Operating Room)

If the patient needs to return to the OR for postoperative complications, the treatment is billed separately.

Failed Minor Procedure Leading to Major Surgery

When a less serious surgery doesn’t work and a major surgery is needed, Medicare covers the major surgery separately.

Organ Transplant Medications

Medications used to manage the immune system after an organ transplant are not part of the global surgical package.

Critical Care Services

Critical care provided (CPT codes 99291 and 99292) after surgery for issues unrelated to the surgical procedure is excluded. These services should be billed separately using modifier FT.

2025 Global Surgery Updates

The 2025 global surgery package updates bring key changes, including the introduction of HCPCS code G0559, which is used for postoperative follow-up visits provided by a different healthcare professional who didn’t perform the surgery, within the 90-day global period, and without a formal transfer of care.

Modifiers 54, 55, and 56 are now more strictly required for managing preoperative, surgical, and postoperative care within 90-day global packages, with modifier 56 now requiring formal documentation for preoperative care transfers.

The updates also focus on the Office of Inspector General’s (OIG) review of postoperative services, ensuring proper reporting and preventing overreporting of services during the global period. These updates aim to improve billing practices and ensure accurate Medicare reimbursement for global surgeries.

The Role of the OIG and CMS in Global Surgery Coding 2025

The Office of Inspector General (OIG) is investigating how well postoperative services are reported under Medicare’s global surgery payment system. Since July 1, 2017, Medicare requires healthcare providers to report follow-up visits after surgery using a specific code, CPT code 99024. This code is for postoperative visits where the doctor checks the patient’s recovery after surgery.  Although these visits are part of the global period and aren’t paid separately during the global period, reporting them helps Medicare track how often patients need follow-ups after surgery.

Here is when providers have to report postoperative visits using code 99024 under specific conditions:

• Practitioners in certain states (like Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, Rhode Island) who work in groups with 10 or more practitioners.
• Providers in those states need to check a list from Medicare each year to see if their surgeries are on the list of surgeries that need the code.
• This code applies only to specific types of surgeries or procedures. These procedures are selected by Medicare because they are either very common (performed over 10,000 times a year) or very expensive (with charges over $10 million a year).

The OIG (Office of Inspector General) is monitoring that doctors are reporting these follow-up visits correctly. They will look at a sample of global surgeries, compare the number of follow-up visits in the CMS records with what doctors reported to Medicare, and verify if the payments made for the surgeries match the actual care provided to Medicare beneficiaries. If doctors don’t report this information properly, it could lead to Medicare paying less for those surgeries. If providers don’t report this information properly, it could lead to devaluation of the Medicare global surgery payment.

Basically, Medicare wants to check the follow-up visits after surgery are being properly tracked, and if doctors aren’t reporting them correctly, it might affect their payment.

Importance of Using Modifiers During Global Surgery Period 

Sometimes, a patient may need other procedures that aren’t related to the surgery they just had, but these procedures still happen during the global period. The usage of global surgery modifiers (24, 25, 54, 55, 57, 58, 78, 79, FT) facilitate healthcare providers to get paid for these services. These modifiers are used to separate unrelated procedures from the global surgery, so they can be paid for separately, even if they happen during the global period.

In the Medicare Physician Fee Schedule (MPFS), there are certain payment policy indicators that show which services are billable (can be paid for) and whether a modifier is needed.

Some examples of global modifiers include:

• Modifier 24: Used for services unrelated to the surgery but happening during the global period.
• Modifier 25: Used for an unrelated service provided on the same day as the surgery.
• Modifiers 54, 55, 57, 58, 78, 79: Indicate different situations where services are not included in the global period.
• Modifier FT: Used for specific cases defined by Medicare.

➜ Modifiers 24

Modifier 24 is used when a doctor or healthcare provider performs unrelated evaluation and management (E/M) service. These services must be after the procedure but within the global period and are unrelated to the original surgical procedure.

For example:

On March 10, a patient visits their orthopedic surgeon for a knee arthroscopy (CPT 29881), which has a 90-day global period. On March 15, the patient returns to the same surgeon, complaining of new back pain unrelated to the knee surgery. The surgeon evaluates the patient’s back condition and recommends physical therapy for the back pain. Since this visit is not related to the knee arthroscopy, the surgeon will code the appropriate office visit E/M code with modifier 24. This allows the surgeon to be separately paid for the back-pain evaluation, even though it falls within the global period for the knee surgery.

➜ Modifier 25

This modifier is used when the same physician or other qualified healthcare professional performs a significant, separately identifiable evaluation and management (E/M) service on the same day as a procedure or other service.

For example:

A patient arrives at the doctor’s office on the same day they are scheduled for gallbladder removal surgery (CPT 47562 – Laparoscopic Cholecystectomy). During the pre-surgery evaluation, the doctor notices that the patient has significantly high blood pressure. The doctor spends extra time assessing the patient’s blood pressure, determining the cause, and prescribing immediate medication to stabilize the patient before proceeding with surgery.

In this case, the additional evaluation and management (E/M) service for high blood pressure is beyond the usual preoperative care related to the gallbladder surgery. The doctor can use Modifier 25 to bill separately for the extra E/M service.

➜ Modifier 57

Use of Modifier 57 indicates that a decision for surgery was made during an evaluation and management (E/M) service, and that the decision occurred on the same day as the E/M service. This modifier tells the payer that the E/M visit led to a decision for surgery, and because the decision was made during the same visit, the surgery is being reported separately from the usual preoperative care.

For example:

A patient arrives at the emergency room (ER) after experiencing severe abdominal pain. The ER physician performs an evaluation and determines that the patient may have acute appendicitis. After a thorough examination and some tests, the physician discusses the situation with the patient and recommends immediate surgery to remove the appendix.

The decision for surgery is made during the evaluation and management (E/M) service in the ER. The patient is then taken to the OR on the same day for an appendectomy (removal of the appendix).

Since the decision for surgery was made during the E/M service on the same day, the ER physician uses Modifier 57 when reporting the E/M code. This modifier indicates that the E/M visit led directly to the decision for surgery, which occurred on the same day.

➜ Modifier FT

Using Modifier FT indicates an unrelated evaluation and management (E/M) visit during a postoperative period or on the same day as a procedure or another E/M visit. The key aspect here is that the E/M service is unrelated to the procedure that was performed or is planned, and it may be billed separately. This modifier applies when an E/M service is provided that is unrelated to the surgery or procedure performed on the same day or within the global surgical period. It is particularly relevant when a patient requires critical care during the postoperative period, which is unrelated to the surgery.

For example:

A patient undergoes gallbladder surgery (CPT® 47562) on March 10. On the same day, the patient develops a severe allergic reaction unrelated to the surgery, requiring urgent treatment and evaluation. The physician uses Modifier FT to report the E/M service provided on March 10 for the allergic reaction as unrelated to the gallbladder surgery. This ensures the physician gets reimbursed for both the surgery and the unrelated E/M service provided on the same day.

Procedural Modifiers 54, 55, 56

Modifiers 54, 55, and 56 are used to split reimbursement between two different healthcare providers when the surgical procedure and preoperative/postoperative care are managed by separate physicians. This is often referred to as a “transfer of care” and helps ensure that both the surgeon and the other providers (such as a primary care physician) are appropriately reimbursed for their role in the patient’s care.

• Modifier 54 (Surgical Care Only)

Modifier 54 is used by the surgeon who performs the surgery but does not provide preoperative or postoperative care.

• Modifier 55 (Post-Operative Management Only)

Modifier 55 is used by the physician or provider who takes over post-operative care after the surgery is completed. It applies when the provider does not perform the surgery but manages the recovery phase instead. After a surgery is performed in one hospital, the patient may be transferred to a different location, and a different physician will provide follow-up care for the post-operative recovery period.

• Modifier 56 (Pre-Operative Management Only)

This modifier is used when the physician or provider who manages the preoperative care of the patient. It applies when the provider does not perform the surgery but is responsible for preparing the patient before the surgery, such as clearing them for anesthesia or managing their health conditions. For example, a primary care provider may ensure the patient is ready for surgery, while a different physician performs the procedure.

These modifiers are used when two different healthcare providers (such as a surgeon and a hospitalist or a primary care physician) are involved in a patient’s surgical care, especially when the care is split between preoperative, surgical, and postoperative periods.

According to 2025 global surgery updates, CMS will require these modifiers for all 10 to 90-day global surgical packages, ensuring accurate reimbursement for each phase of surgical procedure.

For example:

A patient comes to the ER with a dislocated shoulder. The ED physician performs a closed reduction and reports the procedure with Modifier 54 for surgical care only. The patient is then referred to an orthopedic specialist for postoperative care, and the orthopedic doctor reports the same procedure code with Modifier 55. If the patient had seen a primary care provider (PCP) before the surgery for preoperative management, the PCP would have reported their care with Modifier 56 for preoperative care only. All providers use the same date for the procedure on their claims.

➜ Modifier 58

Adding modifier 58 indicates that a staged or related procedure was performed by the same physician (or other qualified healthcare professional) during the post-operative period of a previous procedure. This modifier specifies that the new procedure or service is planned, expected, or necessary due to the patient’s condition and is related to the initial surgery. Modifier 58 resets the global period, starting a new one for the next procedure.

For example:

A patient undergoes a knee replacement surgery. As part of the surgical plan, the surgeon schedules a follow-up arthroscopic procedure to inspect and adjust the placement of the knee prosthesis after the initial healing phase. This follow-up procedure is planned in advance and is related to the initial surgery. When the patient returns during the global period of the knee replacement for the planned arthroscopic procedure, the surgeon reports the follow-up procedure with Modifier 58 to indicate that it is a staged and related procedure.

➜ Modifier 78

Modifier 78 is used for an unplanned return to the operating room when a patient requires a related procedure during the postoperative period due to complications from the initial surgery, such as infection or bleeding. This modifier indicates that the same physician, or a healthcare professional from the same specialty group, performs the second procedure to address the issue. The second procedure is considered part of the original surgery and does not start a new global period. For repeat procedures, Modifier 76 should be used. 

For example:

During the global period of a surgery, the patient experiences excessive bleeding, requiring the surgeon to return to the operating room to control it. This procedure is reported with Modifier 78 to indicate it is an unplanned related procedure performed during the postoperative period.

➜ Modifier 79

Modifier 79 is used when a physician performs an unrelated procedure or service during the postoperative period of a prior surgery. This procedure is not related to the initial surgery and must be billed separately, as it is not covered by the original surgery’s global package. If a procedure is repeated on the same day, Modifier 76 should be used.

For example:

On March 5, a patient undergoes knee replacement surgery on the right leg. On April 5, the patient undergoes the same surgery on the left leg. Even though it’s the same procedure for the same diagnosis, the surgeries are performed on two different surgical sites, making them unrelated. Modifier 79 is appended to the medical code for the surgery on April 5 to indicate it is a separate, unrelated procedure performed during the postoperative period of the first surgery.

Best Practices for Global Surgery Coding Compliance

By following these best practices, healthcare providers can stay compliant with global surgery coding requirements:

Use Proper Documentation

• Keep complete and accurate documentation for all care services provided before, during, and after the surgical procedure.
• Maintain clear records for transfer of care, especially when other providers are involved in preoperative, surgical, or postoperative care.

Know the Global Surgery Period

• Understand the global surgery period for each surgical procedure and apply it correctly. For example, some procedures may have a 10-day, 90-day, or 0-day global period as explained in the table above.
• Review the global surgery indicators assigned to each procedure (e.g., 000, 010, 090) to confirm the global period for billing purposes.

Use Proper Modifiers

• Use the correct modifiers when services are provided that are outside the scope of the global surgery package.

Properly Apply HCPCS Code G0559

• According to the 2025 global surgery period, use HCPCS code G0559 for post-operative follow-up visits by a healthcare provider who did not perform the surgery, and there was no formal transfer of care.

Review Medicare Physician Fee Schedule (MPFS)

• Check the MPFS for global surgery package indicators (e.g., 000, 010, 090) and understand the rules for each CPT code.

Comply with OIG Guidelines

• Adhere to Office of Inspector General (OIG) requirements for reporting postoperative services, especially for evaluation and management (E/M) services.
• Use CPT code 99024 for postoperative E/M visits where required, particularly in states that require reporting for global surgeries.

Accurate Reporting of Postoperative Care

• Report only care services that are directly related to the original surgical procedure. Do not report services outside of the global package unless they are unrelated or involve complications.
• If a procedure or service is unrelated to the original surgery, apply the correct modifier (e.g., modifier 79).

Provide Transfer of Care Documentation

• Document formal transfers of care when the patient’s care is transferred between providers, especially for preoperative and postoperative care.
• Use modifier 56 for preoperative services and modifier 55 for postoperative services when the care is performed by different providers.

Stay Updated on CMS and OIG Changes

• Regularly review updates from CMS and the OIG to stay compliant with new coding guidelines or updates as they released global surgery period 2025 updates, such as the use of HCPCS code G0559 for postoperative follow-up visits.

FAQs

For example, providers use CPT 78264 to bill the stomach imaging only when the procedure lasts 4 hours or less. On the other hand, they use CPT code 78265 for imaging the stomach and small bowel, and the procedure lasts for 24 hours to 26 hours. In addition, the use of CPT 78265 involves imaging of both the stomach and small intestine to monitor the passage of food. Furthermore, providers use a different code (CPT 78266) to bill for imaging the small bowel and colon transit, where the procedure lasts for 24 to 26 hours.

For more detail and information about CPT codes for gastric studies and treatments, let’s discuss what a gastric emptying study is.

What is a Gastric Emptying Study?

Gastric emptying study is the process of tracking gastric motility. The study tracks how long food (meal or drink) takes to move through a patient’s stomach and excrete or empty from it. This passage of food and liquid through the stomach is also called gastric motility.

Healthcare providers test patients’ gastric motility to determine whether it works normally. The procedure assesses the conditions that can affect the process of food when it leaves the stomach and enters the small intestine. If the coordinated passage of food is faster or slower than usual, the patient has a medical condition and needs medical treatment.

The method usually applied for testing gastric mobility is gastric emptying scintigraphy (GES). GES is a type of medicine imaging test that generates images by scanning radiation in patients’ bodies. For better results, patients must ingest a meal with a radioactive tracer in it to make their stomach show up in the scan. This is what healthcare practitioners mean when they suggest patients undergo a gastric emptying imaging study.

Another method of gastric emptying scan is Gastric Emptying Breath Test (GEBT). Physicians can track the progress of a meal through a patient’s digestive system by measuring gases in a breath. To undergo the test, a patient must consume a special meal containing a carbon molecule (carbon-13), producing a specific and measurable form of carbon dioxide (CO2-13).

CPT Codes for Gastric Emptying Study

The CPT codes for gastric emptying imaging study are:

CPT 78264

CPT code 78264 refers to a gastric emptying imaging study, a procedure used to calculate the rate at which the stomach empties. This imaging study involves using a radiopharmaceutical or tracer to obtain real-time images of the stomach’s functionality. The procedure is particularly useful for diagnosing conditions like gastroparesis, where the stomach empties its content too slowly, or dumping syndrome, where it empties food too quickly.

CPT 78265

Providers use CPT code 78265 for a gastric emptying imaging study that includes the assessment of small bowel transit. This CPT code represents a more comprehensive assessment compared to CPT 78264 because it involves not only tracking how quickly the stomach leaves food, but also how the small intestine processes the ingested meal.

CPT 78266

CPT code 78266 refers to a more comprehensive gastric emptying imaging study. This procedure assesses the transit time of food through the stomach, small bowel, and colon over multiple days. It involves the ingestion of a meal containing a tracer, with continuous imaging to evaluate the functioning of the digestive muscles.

Do CPT 78264 and 78265 Codes Need a Modifier?

Healthcare providers must understand the context of services provided when adding modifiers to CPT codes 78264 and 78265 after performing a gastric emptying imaging study. Here is a list of appropriate modifiers.

Modifier 26 (Professional Component)

The Modifier 26 is used with code 78264-65 when practitioners bill for services that include a professional component. Adding modifier 26 indicates that the provider is billing for the interpretation of the imaging study. However, when healthcare providers use equipment, they use modifier TC to bill the procedure.

For example ➜ A patient undergoes a gastric emptying study, and the same healthcare provider performs the imaging (technical component) and the image interpretation (professional component). According to old billing practices, modifier 29 would indicate that both aspects are being billed together. However, in practice, providers typically wouldn’t use modifier 29. Instead, separate billing for the professional (26) and technical components (TC) might be more appropriate based on modern billing practices.

Modifier 59 (Distinct Procedural Service)

Healthcare providers add modifier 59 when the procedure is different or independent from other treatment services performed on the same day. The use of a modifier indicates that the service is not part of the bundled procedure.

For example ➜ A patient visits the hospital for a gastric emptying study due to delayed gastric emptying symptoms. During the same visit, the physician performs a hepatobiliary scan to check for any additional issues affecting the patient’s biliary system. To indicate that these two procedures are distinct from each other, the codes are:

● CPT Code 78264 – (Gastric emptying study)
● Modifier 59 – (Distinct procedural service)
● CPT Code 78227 – (Hepatobiliary scan

Modifier 76 (Repeated Procedure by Same Physician on The Same Day)

If the gastric emptying imaging study needs to be repeated on the same day by the same physician, this modifier would be used to indicate the repeated service. Healthcare providers should use modifier 76 with codes CPT 78264 and 78265 if the same physician needs to repeat the gastric emptying imaging study on the same day.

For example ➜ A patient visits the hospital for a gastric emptying study to diagnose a motility disorder. After receiving immediate treatment, the same physician conducts another gastric emptying study later in the day to confirm the effectiveness of the treatment.

Modifier 77 (Repeated Procedure on The Same Day by Different Physician)

Adding modifier 77 to CPT 78264 indicates the administration of the same service or procedure on the same day by a different physician or healthcare professional. When a patient needs to undergo the gastric imaging study again on the same day, but due to the unavailability of the same physician, providers assign another doctor to perform the task and add a modifier to bill the process.

For example ➜ A patient undergoes a gastric emptying study by Dr. AAA in the morning. Later in the day, Dr. BBB repeats the procedure to verify the results. Because a different physician is performing the repeat procedure, so modifier 77 is added.

Modifier 91 (Repeated Clinical Diagnostic Laboratory Test)

Healthcare providers add modifier 91 to the existing CPT codes, typically for laboratory tests if the imaging study is repeated for clinical reasons. The modifier indicates the necessity of repeated procedures to get accurate results.

For example ➜ A patient undergoes an initial gastric emptying study early in the morning. Due to the patient’s symptoms and to gauge the impact of different meals, the physician orders repeat gastric emptying studies after lunch and dinner.

Modifier 52 (Reduced Services)

Providers use the modifier if the gastric emptying study is reduced or discontinued with the physician’s consent. Modifier 52 is used to show that the service provided was less than usually required. It indicates partial reduction or elimination of procedures and services. The modifier 52 provides a reason to insurance providers for billing reduced services.

For example ➜ A patient visits a hospital for a gastric emptying study. The physician determines that a shorter duration of monitoring is sufficient for this patient’s diagnostic needs. As a result, the study is partially reduced, and the physician bills for the reduced procedure using modifier 52.

Modifier 53 (Discontinued Procedure)

Modifier 53 is applied to bill the incomplete procedure if the gastric emptying study is started but discontinued due to extenuating circumstances that threaten the patient’s health and well-being.

For example ➜ A patient undergoing a gastric emptying study starts experiencing severe adverse reactions, such as sharp abdominal pain or vomiting. The physician decides to discontinue the study to ensure the patient’s safety.

Reimbursement for Gastric Emptying Study Services

Medicare reimburses CPT codes 78264, 78265, and 78266. The Physician Fee Schedule provides practices with a standard payment structure for covered services, including gastric emptying studies represented by codes CPT 78264, 78265, and 78266.

Moreover, these reimbursement rates vary depending on various factors, such as the geographical location where practices operate and the policies of the local Medicare Administrator Contractor (MAC).

Therefore, before providing gastric emptying study services to Medicare-covered patients, providers must consult the Physician Fee Schedule and MAC to get full reimbursement for their services.

FAQs

What is the difference between CPT code 78264 and 78265?

CPT code 78264 is used for imaging studies that assess the emptying of the stomach only. The procedure typically lasts 4 hours or less. The study, which uses CPT code 78265, involves assessing the stomach and small bowel transit to monitor the passage of food through the digestive system. The procedure typically lasts 24 to 26 hours.

Who needs a gastric emptying test?

Patients may need this test if they have symptoms of gastroparesis, which include:

• Abdominal (belly) pain
• Bloating
• Nausea and vomiting
• A feeling of fullness after just a few bites of food
• Loss of appetite
• Weight loss

It is very important for healthcare providers to use the right ICD-10 codes when removing skin tags. Wrong coding can cause insurance companies to deny claims or delay payments. Insurers usually do not pay for skin tag removal if it is only for physical appearance. The procedure must be medically required.

Finding the correct ICD-10 code for skin tags can be tricky. This is because other skin problems can look like skin tags but are not the same. So, these conditions should not use ICD-10-CM L91.8 or any other code for skin tags.

The ICD-10-CM L91.8 code is generally used for other hypertrophic skin diseases in the absence of a specific skin tag diagnosis. Healthcare providers need to know the ICD-10 codes for skin conditions and diseases. This helps them code correctly and get paid on time.

Skin Tag ICD-10 Codes List

This article gives a simple overview of common ICD-10 codes for skin tags. It includes easy clinical information and states if each code can be billed or not. This will help healthcare providers pick the right code for their patients’ conditions and improve the chances of getting paid back.

Billable ICD-10 Codes for Skin Tags

There are several ICD-10 codes that can be used to bill for the removal of skin tags that are causing symptoms or for medical reasons. These valid ICD-10 codes include L91.8 for other specified hypertrophic disorders of the skin and L98.8 for other specified disorders of the skin and subcutaneous tissue. Using one of these codes along with the appropriate CPT code allows providers to be reimbursed for medically necessary skin tag removal procedures.

Here are the billable ICD-10 codes for skin tags:

ICD-10 L91.8 — Other hypertrophic disorders of the skin

The ICD-10 code L91.8 means “Other hypertrophic disorders of the skin.” This code is used to record skin tag diagnoses when there is no specific code available. This code includes different skin problems that are overgrown, like skin tags.

It’s important to note that ICD-10 L91.8 is a general code. Therefore, healthcare providers should try to use more specific codes when they can. However, in cases where a more precise diagnosis cannot be made, L91.8 serves as a catch-all code for documenting and billing for skin tag-related encounters.

When using ICD-10 L91.8 for skin tags, it is important to write clear notes in the patient’s medical record. This includes a simple description of the skin tag(s), where they are located, and any related symptoms or worries. Documentation that is complete not only backs up the chosen code, but it also makes it easier to talk to other healthcare workers who are caregiving the patient.

D23.9 — Benign neoplasm of skin, unspecified

Another ICD-10 code for skin tags is D23.9 – Benign neoplasm of skin, unspecified. This code covers any type of benign skin growth, including skin tags. So when a patient comes in with a skin tag, you can diagnose it using D23.9. If you do a removal, you can charge for both the diagnosis and the procedure with this code.

Billing with ICD-10 codes such as D23.9 for skin tags is simple:

• Diagnose the skin tag using D23.9
• Bill for your diagnostic exam using D23.9
• If removing the skin tag, perform the removal procedure
• Bill for the skin tag removal using D23.9

The D23.9 code falls under the D22-D23 category for benign neoplasms of the skin. Using this specific code tells the payer that you diagnosed and addressed a benign skin growth, which includes skin tags.

L98.8 — Other specified disorders of the skin and subcutaneous tissue

The ICD-10 code for skin tags that do not belong to any specific group is L98.8 – Other specified disorders of the skin and subcutaneous tissue. This code is used by medical coders to document and bill for the removal of skin tags.

It’s important to note that the L98.8 code includes many skin and tissue problems, not just skin tags. Healthcare practitioners should thus make sure that the coding and documentation are correct in order to facilitate the use of this code for skin tag removal.

When billing for skin tag removal with the L98.8 code, healthcare providers must also add the correct CPT code for the exact procedure done. This mix of ICD-10 and CPT codes will help with correct billing and payment for the services provided.

K64.4 — Residual hemorrhoidal skin tags

Skin tags from hemorrhoids are loose pieces of skin that stay after hemorrhoids are treated or go away. These skin tags are not the hemorrhoids themselves but rather a byproduct of the healing process. They can feel uncomfortable, cause irritation, and might need more treatment or removal.

ICD-10 code K64.4 is intended to document and bill for residual hemorrhoidal skin tags. Since this code is billable, medical professionals can use it to request payment for services provided in the diagnosis and management of this illness.

In cases where a patient still has skin tags after hemorrhoids have been treated or resolved, the K64.4 code should be applied. This code should not be used if you have active hemorrhoids or other problems with the rectum or anus.

When using the K64.4 code, healthcare providers must make sure their records clearly show if there are leftover hemorrhoidal skin tags. This has clear notes about the patient’s health history, results from the physical exam, and any tests or procedures done.

Non-Billable ICD-10 Codes for Skin Tags

In contrast to the billable codes, there are also ICD-10 codes for skin tags that do not justify medical necessity for removal. These non-billable codes denote skin tags that are asymptomatic and not causing any medical problems.

In general, removal of skin tags purely for cosmetic reasons is not considered medically necessary and therefore not billable to insurance. However, providers may inform patients with asymptomatic skin tags of their cosmetic options, which may be paid out-of-pocket if desired. Using non-billable skin tag codes on claims will likely lead to denial of reimbursement.

Here are the non-billable ICD-10 codes for skin tags:

L72.3 — Miliaria Rubra

One code that might initially seem relevant but is not billable for skin tags is L72.3 – Miliaria Rubra. This code talks about a condition called “prickly heat” or “heat rash.” It has small, raised bumps that look like skin tags at first.

Miliaria rubra is a kind of heat rash. It happens when sweat glands get blocked. This traps perspiration under the skin. This condition often happens in hot and humid places or when you sweat a lot. It usually shows up as groups of red, itchy bumps or blisters.

The ICD-10 coding system helps to record medical conditions, procedures, and diagnoses clearly and correctly. Each code is given to a specific condition or group of symptoms. This helps with correct billing and payment for healthcare services.

In the case of L72.3 (Miliaria rubra), this code is intended for documenting and billing instances of prickly heat or heat rash. This code is not right for skin tags because these two conditions are different and not connected.

L91.0 — Hypertrophic Scar

ICD-10 number L91.0 for hypertrophic scars is something that doctors and nurses often ask medical coders about. This code is for skin disorders in the ICD-10 system.

Hypertrophic scars are thick, raised scars. They may develop after an injury, burn, surgery, or skin inflammation. They form when there is excessive collagen production during the healing process, causing the scar tissue to grow larger than normal.

Hypertrophic scars can look like skin tags, but they are different. Skin tags are small, soft, harmless growths on the skin that hang from a thin base.

L91.0 is for hypertrophic scars, not for skin tags. It is important for providers to know that hypertrophic scars are a normal part of healing. As a result, the L91.0 code is not billable and cannot be applied to reimbursement.

L72.0 — Epidermal Cyst

The ICD-10 code L72.0 is for epidermal cyst. It is useful but cannot be used for billing by healthcare providers who treat patients with skin tags. When a doctor looks at a skin tag and finds it is an epidermal cyst, which is a kind of skin cyst filled with keratin and covered with skin cells, they might write down the skin tag using the L72.0 code. This explains their clinical impression completely.

The L72.0 code is useful for keeping records, but it cannot be used for billing. Skin tags are seen as a beauty problem, not a health problem. Since epidermal cysts can develop anywhere on the body and are not limited to skin tag form, the L72.0 epidermal cyst code is also non-specific.

Key Points about Skin Tags

• Skin tags are small, soft growths on the skin. They are usually harmless and can appear anywhere on the body.
• They feel soft and smooth. They are usually small and can be light brown or a bit darker.
• The neck, armpits, groin, eyelids, underarms, anal region, and lower torso are some of the places they can appear.
• Skin tags do not hurt unless they are touched a lot or rubbed by clothes or jewelry.
• These are seen more often in middle-aged people, older people, and those who are overweight or obese.
• Skin tags can develop for a few reasons. One reason is hormonal changes during pregnancy. Another reason is medical conditions like diabetes.
• Skin tags are safe and cannot spread to others. Some people, however, choose to have them removed for comfort, aesthetic, or medical reasons.
• Insurance companies won’t pay for skin tag removal if it’s done only for aesthetic reasons.
• Common procedures used by physicians to remove skin tags include cauterization, freezing with liquid nitrogen, and sterile scissors.
• Skin tags are not the same as moles, warts, or cysts. They have different ways to be treated and diagnosed.

FAQs

How to code ICD-10 for skin tags?

It can be hard for some healthcare providers to enter the right codes for skin tags. This is because there are many different codes and it can be complicated to diagnose similar skin problems. The coding team needs to understand:

• Different types of skin tags and associated codes
• Documentation and Medical Necessity
• Proper use of Modifiers
• Compliance with AAPC (American Academy of Professional Coders) guidelines

In-house coding teams can fall short in addressing skin tag coding issues, which can result in claim rejection and denial and, eventually, poor revenue. The best course of action is to outsource third-party medical coding services.

Using BellMedEx, a top company for medical billing and coding, for skin tags coding service can give good results. Their facility employs professional coders who are skilled and knowledgeable in writing accurate codes, handling documentation-related activities, and following industry standards.

What are other names for skin tags?

Other names used for skin tags are:

• Acrochordons
• Fibroepithelial polyps
• Soft fibromas
• Cutaneous papillomas
• Skin tabs

Do insurance companies pay for skin tag removal?

Variations exist regarding skin tag eradication coverage. Insurance companies typically don’t fund skin tag removal if it’s only cosmetic. However, insurance companies will pay for skin tag removal or therapy if it is medically necessary and the tags are causing a lot of discomfort.

Medical Claim Submission is one of the key steps in the medical billing process. It is a critical phase, as even a small mistake can trigger a chain of events that delays reimbursement.

In this guide, we will take a closer look at the physician claim submission phase, exploring the various aspects of the process. We will walk through the steps of healthcare claim submission, discuss the different types of claims, and much more.

The Basics of Claim Submission Process in Medical Billing

The phase in the medical billing process where a claim form is submitted to the insurance company by a healthcare provider or a medical billing company on behalf of the healthcare provider is known as “Claim Submission”.

Several steps lead up to this phase, and all of these steps, including the final submission, are collectively referred to as the Claim Submission Process. While the billing process as a whole is delicate, the submission of the claim requires a higher level of attention and responsibility.

The reimbursement amount a healthcare provider will receive, as well as the total time taken for the entire process, directly depends on this single claim form. Even a minor error can result in the insurance company denying the claim. A well-prepared claim not only minimizes errors but also increases the likelihood of receiving the maximum reimbursement from the insurance company. Therefore, the overall quality of the claim matters as much as its accuracy.

What is Included in a Medical Claim?

A medical claim has key details of the patient’s diagnosis that helps a healthcare provider with correct processing of the patient’s claim and get reimbursement from the insurance company.

Each part of the claim form has a specific job, like listing the patient and provider, describing the services given in the form of CPT and ICD-10 codes, and showing the total costs.

Knowing what’s in a medical claim is important for both doctors and insurance companies to make sure payments are made on time and are accurate.

Patient Information

This section includes basic demographic details about the patient, such as their name, gender, date of birth, and the purpose of the visit.

Provider Information

This section contains information about the healthcare provider, including their name, address, and identification number (NPI). It also includes details about the facility where the services were provided.

Procedure Information

Here, you’ll find the diagnosis codes (ICD-10 codes) and the services provided at the facility, identified using CPT codes.

Charges

This section outlines the expenses for the services provided at the medical facility, detailing what the healthcare provider expects to receive from the insurance company.

Insurance Information

This section includes detailed information about the insurance, such as the name of the insurance company, the coverage details, and the policy number.

Steps of the Medical Billing Claim Submission Process

Claim submission is one of the most crucial steps in the medical billing process, serving as the central point of the entire billing cycle. Let’s take a quick overview of the claim submission process:

Step 1: Patient Registration

The medical billing process begins with the registration of the patient. During this stage, the medical office collects basic patient information such as:

• Name
• Age
• Gender
• Insurance Information
• Purpose of Visit
• Medical History
• Financial Information

Following this, the insurance is verified by professional billers, who determine the insurance status and coverage in relation to the required treatment. This information is then shared with the patient.

Step 2: Determination of Financial Responsibility

In some cases, insurance companies do not cover the entire cost of treatment. When this happens, the patient becomes responsible for the remaining balance. To ensure transparency, it’s important that the patient is informed in advance about any financial responsibilities.

During this step, the financial responsibility for the services to be provided is determined and communicated to the patient. This ensures both the healthcare provider and the patient have clarity from the start, allowing the patient to decide whether they can afford any copayments. The treatment is then provided based on the agreed terms.

Step 3: Medical Coding

Once the treatment has been provided, the diagnosis and procedures are translated into codes through medical coding. There are two main types of medical coding:

➜ ICD-10 Codes: The International Classification of Diseases (ICD) codes are used to represent the symptoms detected and treated by the healthcare provider. Currently, ICD-10 codes are in use, and ICD-11 codes are expected to be implemented by 2025.

➜ CPT Codes: Current Procedural Terminology (CPT) codes, developed by the American Medical Association (AMA) in 1966, correspond to the specific treatments or procedures given to the patient.

These codes are crucial for determining reimbursement amounts, making them an essential part of the claim process. The medical coding service is completed by a professional medical coder.

Step 4: Superbill Creation (only applies to out-of-network healthcare providers)

After the patient receives treatment and medical coding is completed, the next step is to compile the codes and create a superbill. This superbill serves as the foundation for the medical claim form.

The superbill contains the patient’s basic demographic information, medical history, healthcare provider details, and clinical information. It also includes the medical codes that represent the symptoms diagnosed and the treatments provided.

*Note: A superbill is created if the patient has seen a doctor outside of those affiliated with their insurance company, aka “out-of-network provider”.

Step 5: Claim Submission

The medical biller then carefully prepares the claim form. Once the form is completed, the biller reviews it thoroughly to ensure compliance with payer and HIPAA standards, including medical coding accuracy and proper formatting.

The claim form is then submitted to the relevant insurance company, with the expectation of timely reimbursement. The most commonly used claim forms are CMS-1500, UB-04, and ADA Dental forms.

If the claim is error-free (a clean submission), payment is typically processed by the insurance company as soon as possible. However, if errors are found, additional steps may be required to resolve the issue via a Coding Claim Denial Management Service.

Methods of Claim Submission

There are two major methods for submitting medical claims:

Electronic Submission

Thanks to advancements in technology, claim submission can now be done electronically. This method has become more popular than paper submission due to its efficiency. Electronic claims, submitted through a clearinghouse, are faster and less prone to errors, allowing for a more streamlined and accurate submission process.

Paper Submission

In paper submission, medical claim forms and supporting documentation are physically mailed to the insurance companies. While electronic claims have largely replaced paper submissions, many healthcare providers still use paper claims in certain circumstances, such as when the insurance company does not accept electronic submissions, when there are technical issues with electronic systems, or when a specific type of claim requires paper processing due to the nature of the service or provider.

Difference Between Electronic and Paper Claim Submission Process

Top 10 Reasons for Claim Denial by Insurance Companies

Here are the major reasons why a claim might be denied by insurance companies in medical billing:

Wrong Information

One of the most common reasons for claim denial is incorrect or incomplete information. This could involve missing details or errors in the information provided on the claim form.

Late Claim Submission

Claims may be denied if they are not submitted within the required timeframe. Some insurance companies allow 90 days for claim submission, while others may require it within 30 days. It’s important to be aware of the deadlines set by your insurance company.

Errors in Coding or Billing

Medical billing is a complex and precise process. Any error in medical coding or billing can result in a claim denial. It is essential to double-check the codes and billing details to ensure accuracy and avoid denials.

Services Not Covered

Insurance companies only cover a specific set of medical services. If the services provided are not included in the patient’s policy, the claim will be denied. Be sure to review the patient’s policy to confirm coverage before submitting the claim.

Unnecessary Medical Services

Claims can be rejected if the insurance company deems the treatment unnecessary. In such cases, you may need to resubmit the claim with additional documentation or a letter from the doctor justifying the need for the treatment.

Pre-existing Conditions

Some insurance policies exclude coverage for pre-existing conditions. If the treatment is related to a pre-existing condition, the claim may be denied. It’s essential to understand your policy’s terms regarding pre-existing conditions.

Expired Policy

Claims submitted after a policy has expired are often denied. To avoid this, consider setting up automatic payments to ensure your premiums are paid on time, keeping your policy active.

Lack of Pre-approval

For certain services, insurance companies require pre-approval. If this approval is not obtained before the service is provided, the claim will likely be denied. Always check in advance which procedures require pre-approval.

Duplicate Claim Filed

Claim submission can be a hectic process, and duplicate claims are a common mistake. Keeping a record of all submitted claims can help prevent the error of submitting the same claim more than once.

Claim Lost by the Insurance Company

While rare, claims can be lost by the insurance company itself. This unfortunate situation can lead to a denial. To avoid this, always keep a duplicate of the claim for your records.

Wrapping Up

Claim submission is the backbone of the medical billing process. The goal with every claim submission is to achieve a clean submission—one that is free of errors and fully compliant with all requirements. While it may not be possible to achieve a 100% clean submission rate every time, even a small increase in your clean submission rate can yield significant benefits.

Understanding the claim submission process is crucial for anyone working in the medical billing or healthcare industry. Familiarity with the entire procedure will help you minimize errors that can hinder the best results and significantly improve your chances of successful reimbursement.

You might have heard about the Trojan Horse…

“If the Troy troops had inspected the Trojan Horse, the Troy would not have fallen.”

So, be cautious about forthcoming risks before it’s too late, and you sit scratching your head, saying, “Would that I had audited claims before submitting them to the payers…”

Types of Medical Coding Audits in Healthcare

The healthcare industry conducts medical coding audits using a variety of methods. They are:

• Internal Audits
• External Audits
• Focused Audits
• Prepayment Audits
• Post-payment Audits

Internal Audits

Internal audits are audit processes conducted by the in-house team of a healthcare practice within an organization. They are comparatively less expensive, but due to the internal auditors’ incomplete knowledge and lack of experience, they may not produce effective results.

Internal audits evaluate internal control, risk management processes, and operational efficiency within a healthcare organization. They also play a crucial role in identifying weaknesses and areas for improvement, thereby enhancing the practice’s overall performance.

Furthermore, they also assess coding accuracy and adherence to organizational policies and procedures.

Some examples of internal audit are:

1). Compliance Audits

Compliance audits fall under the umbrella of internal audits. Their primary purpose is to ensure adherence to regulatory standards. Internal auditors check whether a healthcare practice complies with HIPAA, Affordable Care Act (ACA), and other regulations related to the healthcare industry.

2). Coding and Documentation Audits

During the coding and documentation audit, auditors assess the accuracy of medical coding, related modifiers, and completeness of documentation for treatment procedures. They ensure that a medical coder at the healthcare practice adequately documents patient visits and can support medical necessity for the services rendered to get proper reimbursement.

3). Quality Assurance Audits

Quality Assurance Audits are another subtype of internal audits that focus on evaluating the quality and effectiveness of patient care at a healthcare facility. The internal auditors review medical records, treatment protocols, and the facility’s performance to identify areas for improvement.

4). Privacy and Security Audits

Privacy and security audits review the handling of PHI (Protected Health Information) and ensure its protection. They also execute compliance guidelines issued by the HHS (Department of Health and Human Services).

5). Pharmacy Audits

Pharmacy audit is the process of reviewing medication dispensing, inventory management, and compliance with pharmacy regulations. The auditors verify that prescriptions are appropriately documented and medications are dispensed accurately.

External Audits

An external audit is a medical coding audit process conducted by an independent external auditing firm, State, or Insurance provider.

Here a team of professionals typically conducts the external audit to deliver the best results to a healthcare practice. They have extensive knowledge in the field of medical coding. The purpose of the external audit, carried out by a third-party firm, however, not by Insurance providers or the State, is to review the overall performance of a healthcare organization, find and correct any error that can raise a red flag for insurance payers, and to verify coding guidelines and regulations.

Some examples of external audits are:

1). Commercial Payer Audits

Commercial payer audits are conducted by insurance companies or commercial payers. The auditors review claims and billing procedures. The primary purpose of this audit is to ensure accuracy, detect fraudulent activities, and assess compliance with payers’ policies. Healthcare facilities usually conduct these audits when they raise a red flag due to not following healthcare protocols.

2). Federal Government Audits

In addition to insurance providers, when your healthcare practice raises a red flag, it can become vulnerable to federal government audits. Audits performed by government agencies, such as CMS, are called federal government audits.

The main aim of these audits is to ensure compliance of the practice with government healthcare programs like Medicaid and Medicare, reviewing claims and billing procedures, and monitoring the overall performance of the practice’s transparency in services provided to patients.

3). Third-Party Expert Audits

Third-party expert audits are proactive, independent reviews of a healthcare organization’s operations, conducted by specialized audit firms. They help identify deficiencies and vulnerabilities before government audits, allowing time for corrections. Healthcare providers commonly outsource these audits across areas like billing, coding, cybersecurity, HIPAA compliance, and patient safety. By self-identifying issues ahead of time, providers can avoid penalties and scrutiny from payers and regulators.

For example, a medical group might hire an auditing firm to evaluate its charge capture and coding processes annually. The audit would inspect a sample of past claims to check for errors or upcoding issues. It would also examine the workflows, technology, and staff training related to billing and coding. The group could then fix any problems prior to a Medicare audit.

Other Types of Medical Coding Audits

Internal and external audits are the two main types of medical coding audits. However, there are some more types of coding audits in healthcare as well. These are:

Focused Audits

A focused medical coding audit is a strategic quality assurance initiative that entails an in-depth examination of a specific subset of codes or coding areas identified as high-risk or error-prone within a healthcare provider’s revenue cycle operations.

Unlike comprehensive audits that assess coding accuracy across all areas, these audits channel resources toward evaluating coding practices in targeted domains where coding errors, overcoding, or undercoding may have an outsized impact on reimbursement and compliance. Common targets include high-dollar procedure codes, complex diagnosis coding for conditions like sepsis or respiratory failure, and coding for services furnished in high-risk clinical areas like the emergency department.

Prepayment Audits

In Prepayment or Prospective audits, professional auditors review and audit claims before submitting them to the payers. They identify and correct errors that could impact reimbursement.

Post-payment Audits

Post-payment audits, called Retrospective audits, are conducted after the claims are submitted, processed, and reimbursed. The coders review the submitted claims during the current audit and understand the current trends in medical coding while comparing past audits with present ones.

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Key Benefits of Medical Coding Audits

It is essential to remember that medical coding audits are crucial for managing healthcare facilities’ revenue cycles and protecting them from fraudulent activities. Here are some expected benefits of medical coding audits for healthcare practices.

Improved Accuracy

Medical coding audits allow healthcare providers to enhance coding accuracy, reduce claim denials, and ensure proper reimbursement. During the audit process, auditors identify and correct errors that improve coding quality and mitigate the risks of external audits conducted by the federal government or insurance providers.

Fraud Prevention

Medical coding audits detect fraudulent activities in billing procedures, such as upcoding, unbundling, duplicate billing, and billing for unnecessary services provided. This will help the healthcare practice reduce losses and avoid being vulnerable to legal penalties.

Increased Revenue Flow

Medical coding auditing ensures timely reimbursement for services provided, increasing revenue flow to your healthcare practice. Approximately 70% of healthcare practices revealed that they had made losses due to improper coding and billing. Auditing mitigates these errors. So, correct documentation of services and submitting bills with appropriate codes can reduce the risks of losses.

Correct Use of Modifiers

Audits ensure the correct usage of modifiers, which is usually considered a complex procedure. Sometimes, expert coders make mistakes while adding a modifier to the CPT code. A medical coding audit helps to find missing or wrongly placed modifiers and correct them before submitting claims to payers to lessen the ratio of denials.

Improved Documentation Accuracy

Accurate documentation within a healthcare practice is essential for patient quality care, proper billing, and legal purposes. Medical coding audits ensure all related documents regarding diagnosis and treatment procedures are complete and accurate. However, inaccurate documentation can lead to misinterpretation of the treatment procedures, resulting in delayed payment or denied claims.

Medical Coding Audits Process

For healthcare providers, a medical coding audit is a comprehensive process to evaluate the healthcare practice and alarm the providers before any forthcoming activity that can negatively affect their healthcare, i.e., claim denials and vulnerability to fraudulent allegations.

Here is the step-by-step process that medical audit providers should undergo while auditing their healthcare practices.

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1⃣ Selecting Internal or External Coding Audit

Choose whether to undergo an internal or external audit as the first step in the audit process for your healthcare practice. Having your own in-house audit team for regular audits may seem convenient. However, most practices highly recommend an external audit by outsourced medical coding professionals.

External coding auditors offer expertise and an objective perspective that even the most experienced internal auditor may not have. They provide detailed insights into the impacts of coding errors and patterns of non-compliance that internal staff may miss or downplay. External auditors stay up-to-date with the latest regulations and compliance mandates, while internal auditors may become complacent over time.

External auditors have no vested interests in maintaining the status quo or concealing potential problems. They assess deficiencies and provide specific, actionable steps to fix coding issues. This stops revenue loss from denials and maintains your practice’s good standing with regulatory authorities. Internal audits offer benefits, but external audits provide essential knowledge and transparency that help control risks and drive continuous improvement.

‍2⃣ Searching for an auditor

If you have decided to go for an external audit, contact medical coding companies that provide audit services. There are various companies you can choose from to outsource your audit process. They have a team of experts in each specialty. These auditors are not only coding experts but also have vast knowledge about regulations and get updated with the changes applied by the state or insurance providers.

For Compliant, Optimized Medical Coding, Turn To The Experts at BellMedEx!

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If you’re looking to outsource your medical coding audit, BellMedEx should be your top choice. As a leading medical coding company, we have a dedicated team of certified professional coders with expertise across all specialties. Our auditors go beyond checking accuracy – they analyze your coding practices to identify opportunities for improvement, ensuring you receive the maximum appropriate reimbursement.

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3⃣ Establishing the scope of the audit

The scope defines the specific areas, timeframes, and types of medical records that will be examined during the audit. By clearly defining the scope, healthcare providers can ensure that the audit is targeted, efficient, and aligned with their objectives.

Before initiating the audit, it is essential to engage in open communication with the auditors. This collaboration allows both parties to understand the provider’s goals, concerns, and specific areas of interest.

The scope should be tailored to address the provider’s unique needs and priorities. It may involve reviewing a specific subset of medical codes, focusing on high-risk or high-volume procedures, or evaluating coding practices within a particular department or timeframe. By narrowing the scope, the audit can be more targeted and provide valuable feedback on areas that require improvement or validation.

Some points that should be incorporated in the scope of the audit include:

• Auditing the proper use of CPT codes
• Determining the correct places of service
• Looking for missing modifiers
• Looking for incorrect use of modifiers
• Detecting incorrect diagnoses
• Identifying coding and documentation accuracy
• Verifying if supporting documentation is adequate
• Checking if services are necessary

4⃣ Looking for irregularities

While conducting an audit, you should filter these irregularities, which can help you detect errors leading to claim denials and affecting the revenue cycle:

• Writing the correct code for the reason for the visit
• Avoiding use of outdated codes
• Using modifiers that support primary codes
• Using only the latest and updated codes
• Correcting all improper medical codes

5⃣ Finding unrelated codes

It is also included in the audit process to check codes and modifiers unrelated to diagnosis or treatment procedure. If the medical coders have used unrelated codes, it can raise a red flag for payers and audit by the state or insurance payers.

For example, if a patient receives treatment for a broken arm, but the medical coder assigns codes for a heart condition, this is an unrelated code. Auditors pay special attention to irrelevant codes since they may be indicative of coding errors or even fraud.

Medical Coding Audit Checklist

The medical coding audit checklist describes what to review during the audit process.

• Verification of patient records
• Verification of provider information
• Investigate for duplicate records attached by mistake
• Verification of the electronic health records (EHR)
• Completeness of medical history and physical visits
• Verification of diagnostic reports
• Completeness of diagnosis and treatment plan
• Details of the procedures conducted
• Documents on prescribed medications
• Verification of codes assigned and formats used

Medical Coding Audit Best Practices

Apply these practices to get the best results from medical coding audits:

• Establish audit objectives
• Use reliable coding guidelines
• Train auditors
• Implement corrective actions
• Review and update audit procedures
• Utilize automated tools
• Document findings clearly
• Provide feedback and education
• Ensure compliance with regulations

Need help with CCM coding?

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Chronic care management plays a vital role in the healthcare industry, especially for common chronic diseases.

Almost 129 million people in the US suffer from at least one major chronic disease. This significantly impacts their lives and contributes to a large portion of healthcare costs.

In addition, nearly 90% of the annual budget (which totals $4.1 trillion) goes to treating chronic diseases and mental health conditions.

People can enhance their overall quality of life by keeping up with regular check-ups and managing their medications.

The Center of Medicaid and Medicare Services (CMS) has established standard CPT codes to facilitate medical billing and reimbursement for Chronic Care Management (CCM) services. Healthcare professionals find these codes helpful for recording the time and effort spent on all CCM activities.

This blog provides an overview of CPT codes and billing guidelines for CCM.

Chronic Care Management CPT Codes 

Chronic Care Management (CCM) codes help physicians get paid for managing patients with chronic conditions. These codes capture the non-face-to-face care coordination services furnished to Medicare beneficiaries, such as communication with the patient and caregivers, medication management, and remote monitoring of health conditions.

The CCM codes fall into two categories: complex and non-complex chronic care management.

➜ The complex CCM codes, 99487 and 99489, describe care for patients with multiple chronic conditions that pose a significant threat to health or psychosocial status and require comprehensive care plan oversight.

➜ The non-complex CCM codes, 99490 and 99491, are for patients with two or more chronic conditions that are expected to last at least 12 months or until the death of the patient, but do not require the intensive management of complex CCM codes.

Medicare uses these CCM codes to pay separately for non-face-to-face care coordination services. This helps physicians improve care for beneficiaries with multiple chronic conditions.

COMPLEX Chronic Care Management CPT Codes

Complex chronic care management codes (CCMC) are specialized medical billing codes used by healthcare providers to report non-face-to-face care coordination and management for patients with multiple chronic conditions. Physicians and care teams employ these codes when a patient’s condition requires extensive management and monitoring due to the severity and complexity of their illness.

To report CCMCs, physicians must spend at least 60 minutes of qualified time per calendar month providing care coordination, monitoring patient conditions, adjusting treatment plans, and ensuring patients have access to necessary healthcare resources. The time spent reviewing medical records, communicating with other physicians, patient education, and arranging referrals and procedures are all considered qualified time.

Complex Chronic Care Management CPT Codes include:

CPT Code 99487

CPT code 99487 is for what’s called “Complex Chronic Care Management.” It’s used for patients who have multiple chronic conditions all at the same time – what doctors call “comorbid conditions.” These are serious illnesses that need a good deal of care and time to manage properly.

Now, for this CPT code to apply, the clinical staff at the doctor’s office or healthcare practice has to spend at least 60 minutes per month on non face-to-face care coordination for the patient. So lots of time on the phone or doing paperwork – whatever it takes to get that patient the care they need from all their different doctors. Medicare will reimburse the practice $133 per month for each patient getting this complex care.

Some examples of conditions that would qualify someone for the 99487 code are things like arthritis, heart disease, COPD, and high blood pressure. But it’s not limited to just those. The main thing is the patient has multiple ongoing illnesses that all need management at the same time.

Let me give you an example of how this might look for a real patient:

Say someone has type 2 diabetes, heart failure, and chronic kidney disease all together. To give them the best care, you’d need to monitor their blood sugar, blood pressure, and kidney function continuously. And you’d likely need a whole team of specialists like nephrologists, endocrinologists, and cardiologists to make a comprehensive treatment plan. The 99487 code helps make sure caring for patients with these complex chronic conditions is feasible for healthcare practices.

CPT 99489

CPT code 99489 is for complex chronic care management of patients with severe conditions. This code is for when a patient has a really bad illness – think end stage kidney failure, or advanced heart disease, or some neurological disorder that has them all messed up. These patients need a lot of care and time from their healthcare team to manage all their needs. The doctor and nurses have long talks about the best treatments, how to handle side effects, what to expect down the road, and how to keep spirits up when the road ahead is rough.

To bill 99489, the care team has to spend at least 30 minutes beyond the regular chronic care management codes working on the patient’s case. And they can keep adding 99489 for each extra 30 minutes they spend coordinating care, reviewing labs and records, talking to specialists, and having those long empathetic chats about options and quality of life that these complex cases need. Medicare reimburses $76.50 for each 30 minutes billed under 99489.

Let’s imagine a scenario. Say there’s a man with early stage pancreatic cancer. He’s gotta have frequent visits to weigh multiple treatment options, figure out palliative medicines for the pain and nausea he’ll likely get, and talk over hospice care down the line. His care team talks through all this with him and his family, being there for emotional support too. For all that non-face-to-face time spent managing his complex condition, the doctor can bill 99489.

CPT Code 99487 vs CPT 99489

NON-COMPLEX Chronic Care Management CPT codes

Non-complex Chronic Care Management (CCM) CPT codes are used to report non-complex services given to patients with chronic conditions. These codes help healthcare providers accurately record the time and services provided for managing chronic patients who do not qualify for complex CCM.

A doctor or qualified healthcare worker needs to spend at least 20 minutes each month on care activities for the patient with simple CCM. These tasks can involve looking over patient records and test results, talking with other health care workers who are part of the patient’s care, teaching patients and their families, and creating, putting into action, and updating care plans.

Non-complex CCM codes can be billed once a month for patients who have two or more ongoing health issues that are likely to last at least a year or until the patient’s death.

To bill for non-complex CCM, the practice needs to have a patient already established and a care plan ready. They must offer 24/7 access to care and ensure continuity of care. It’s important to carry out regular assessments of the patient’s medical, functional, and psychosocial needs, and provide care management services guided by a physician or another qualified healthcare professional.

Non-complex Chronic Care Management CPT Codes include:

CPT 99490

CPT code 99490 covers at least 20 minutes per month of non-face-to-face time spent by clinical staff providing care management to Medicare patients with two or more ongoing health issues requiring continuous medical attention. For their services, Medicare reimburses the provider $62 per patient per month.

CPT 99490 applies in cases such as a Medicare patient coping with both hypertension and asthma at the same time. Managing the blood pressure and lung function for an individual with these chronic diseases takes regular monitoring, medication adjustments, and lifestyle recommendations from their healthcare team. By using 99490 for chronic care management, the provider gets paid for the behind-the-scenes work involved in keeping complex patients as healthy as possible.

So in summary, CPT code 99490 offers a way for providers to receive compensation for the extra time needed to coordinate care for Medicare patients with multiple chronic conditions. It covers a 20 minutes minimum per month of non-face-to-face chronic care management services. For a patient battling both high blood pressure and asthma, for example, 99490 would pay for the medical team’s ongoing work guiding their treatment plan.

CPT 99439

The CPT code 99439 is for chronic care management of patients with one or more ongoing health conditions that need continuous tracking. It is used when the patient’s situation is less complex or severe than what would call for the codes 99490 or 99487. 

Specifically, 99439 is for each additional 20 minutes of non-face-to-face care coordination services when the initial code 99490 has already been billed. Medicare reimburses $47 for each 20-minute increment.

This code covers things like regular patient contact and medication reviews to ensure proper disease management. It is for the ongoing supervision of care, not just responding to issues as they arise. The goal is to prevent exacerbations and complications through vigilant monitoring and care planning.

For instance, take a diabetes patient who needs daily blood sugar checks and consistent advice about diet, exercise, and insulin dosing. The work involved in providing structured self-management support falls under 99439. This code helps cover the time spent enabling the patient to stay as healthy as possible.

CPT 99491

CPT code 99491 for chronic care management is used when a doctor or qualified healthcare worker spends at least 30 minutes in a face-to-face visit with a Medicare patient who has one or more chronic conditions. It’s for the patient’s first visit. Medicare reimburses the practice $83 for this initial chronic care management visit.

So in plain terms, 99491 is a billing code that doctors use to get paid for the first monthly visit with a Medicare patient who needs ongoing care for chronic illnesses like diabetes, COPD, or heart disease. The visit has to be at least 30 minutes of facetime with the doctor or nurse practitioner. And Medicare pays the clinic $83.

To understand how this CPT code works, let’s look at a hypothetical patient example. Say we have a 68-year-old woman with diabetes, high blood pressure, and arthritis – three chronic conditions. She comes to see her primary care doctor for the first time to set up a care management plan. The doctor spends 35 minutes with her, talking about all three conditions, adjusting medications, setting diet and exercise goals, and mapping out a schedule for follow-up visits and coordination with specialists.

In this case, after the visit, the doctor would bill Medicare using CPT code 99491, since this was the initial face-to-face chronic care management visit for this patient with multiple chronic diseases. And Medicare would reimburse the practice $83.

CPT 99437 

The CPT code 99437 is used for subsequent visits for patients with chronic care management needs. This code allows physicians to bill for additional 30 minute increments of face-to-face time beyond the initial 60 minutes covered by code 99491. Medicare reimburses $21.88 for each additional 30 minutes billed under 99437. 

This code applies well for patients like Anna Leigh, who suffers from diabetes, hypertension, and obesity. These chronic conditions require regular monitoring and care coordination between visits. During a follow-up appointment, Anna’s physician may spend 45 minutes reviewing his blood sugar logs, adjusting medications, providing health education, and communicating with his endocrinologist. The initial 60 minutes would be covered under 99491. The extra 15 minutes of face-to-face time would be billed using 99437.

Billing code 99437 for subsequent chronic care management encounters enables physicians to receive payment for the additional time needed to properly coordinate care for patients with multiple chronic illnesses. This supports high quality, patient-centered care. The CPT guidelines require detailed documentation showing the additional time spent on chronic care management during each visit billed under this code. When used appropriately, 99437 provides fair compensation to physicians providing ongoing care to complex patients like Anna.

CPT Code 99490 vs 99439 vs 99491 vs 99437

Note: The real rate of reimbursement for the CPT code of CCM may be different in each area. Always check the Physician Fee Schedule (PFS) to see the most recent payment rates.

Application Rate of High-Volume Chronic Care Management CPT Codes

Chronic care management (CCM) services are becoming increasingly important as our population ages and more patients suffer from multiple chronic conditions. Proper coding of these services is essential for practices to receive reimbursement and continue providing high-quality care.

Recent data reveals interesting trends in the utilization of common CCM CPT codes.

1⃣ ➜ The most widely used code is 99490, for at least 20 minutes of non-face-to-face chronic care management services per month. This code accounted for 64.7% of reported CCM services. This high rate shows the demand for basic CCM services to coordinate care for chronically ill patients.

2⃣ ➜ The second most used CPT code was 99439, for each additional 20 minutes of chronic care management services in a calendar month. At 18.9%, this demonstrates many patients require more than the initial 20 minutes allowed under code 99490. Complex patients benefit from additional time spent on care planning, medication management, and care coordination.

3⃣ ➜ Rounding out the top three was code 99487, for complex chronic care management services requiring 60 minutes per month. While utilized less frequently at 5.9%, this code is rapidly increasing as practices take on more patients with multiple comorbidities needing intensive management.

The popularity of these codes underscores the value of CCM services. With rising chronic disease burden, CCM provides continuous proactive care between office visits. Tracking utilization of these codes over time will show if care management services are keeping pace with population needs. Wise use of CCM codes allows practices to be reimbursed for this vital non-face-to-face care coordination.

What Conditions/Diagnoses Need to Qualify for Chronic Care Management (CCM)?

To qualify for the CCM program, patients must have at least two chronic conditions that require ongoing medical care and management for at least 12 months or until the end of life.

The chronic conditions should be severe enough to potentially lead to functional decline, acute exacerbation/decompensation, or a life-threatening event if not properly managed.

Some common chronic conditions that often qualify for CCM include:

• Cardiovascular diseases (e.g., heart failure, coronary artery disease)
• Respiratory diseases (e.g., COPD, asthma)
• Metabolic disorders (e.g., diabetes, hyperlipidemia)
• Neurological conditions (e.g., Parkinson’s disease, multiple sclerosis)
• Chronic kidney disease
• Alzheimer’s disease and other dementias
• Autoimmune disorders (e.g., rheumatoid arthritis, lupus)
• Cancer (active or in remission)
• HIV/AIDS
• Mental health conditions (e.g., major depressive disorder, bipolar disorder)

Note: The above list is not exhaustive, and other chronic conditions may also qualify for CCM if they meet the criteria of requiring ongoing medical management and monitoring. The key factor is the presence of multiple chronic conditions that significantly increase the risk of functional decline, acute exacerbations, or life-threatening events if not properly managed through coordinated care.

Chronic Care Management Billing Guidelines

The CCM billing guidelines outline requirements providers must meet in order to bill for these important services. This includes details on eligibility, required services, consent, and billing specifics. This section will provide an overview of the CCM billing guidelines as outlined by CMS and commercial payers. It will cover requirements around eligibility, patient consent, scope of services, time thresholds, billing codes, and reimbursement to help practices appropriately bill for CCM services.

Key Requirements for Billing Chronic Care Management (CCM) CPT Codes

Managing billing for Chronic Care Management (CCM) services requires careful attention to key requirements. As outlined in the Medicare Learning Network (MLN) guidance, both complex and non-complex CCM codes have specific elements for appropriate billing:

1. Initiation Through a Face-to-Face Visit — A qualifying visit with the billing practitioner lays the groundwork for CCM services. This visit establishes the patient’s consent, ensures they meet eligibility criteria, and begins care planning.
2. Non Face-to-Face Services — CCM codes cover remote care coordination, not direct patient contact. Time spent on non face-to-face care management activities like phone calls, chart review, care plan oversight, and team conferences counts toward time requirements.
3. Written or Verbal Consent — Patients must provide their agreement to receive CCM services, which is documented by the billing practitioner. Consent can be obtained at the initiating visit or separately.
4. Certified Billing Practitioner — To bill CCM codes, the provider must be the one who furnishes and oversees the patient’s care management. Nurse practitioners, physician assistants, and clinical nurse specialists can provide CCM services.
5. Patient Eligibility — CCM services are for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until death, and that place the patient at significant risk of death or functional decline.
6. Minimum Time Requirement — Both complex and non-complex CCM codes have a minimum time spent on care coordination activities per calendar month that must be met to qualify for billing.
7. General Supervision of Auxiliaries — The billing practitioner provides general oversight of any clinical staff involved in delivering CCM services. Auxiliary personnel do not bill independently.

Closely following CCM billing rules ensures claims are submitted accurately and patients receive comprehensive, coordinated care management.

Requirements for Submitting Chronic Care Management Claims to CMS

Correct and comprehensive patient documentation is essential for filing clean claims. Healthcare providers need to present a complete collection of data in order to prevent denials. Below is an extensive checklist to help with the CCM claim submission procedure.

1). Patient Eligibility

To qualify for Chronic Care Management (CCM) services and submit claims to the Centers for Medicare & Medicaid Services (CMS), patients must meet specific eligibility criteria. CCM aims to provide comprehensive care coordination and management for individuals with multiple chronic conditions, ensuring they receive proactive, personalized care to improve their overall health outcomes.

The key requirements for patient eligibility are as follows:

➜ The patient must be under the care of a qualified healthcare provider, such as a physician, nurse practitioner, or physician assistant.

➜ The patient must have a significant risk of functional decline or mortality within the next 12 months due to their chronic conditions.

➜ The patient must have two or more chronic conditions that require ongoing management and monitoring, including medications, therapy, or other interventions.

Additionally, it is important to note that:

• The healthcare provider must establish a comprehensive care plan for the patient, addressing all health issues and outlining treatment goals.
• The patient (or their authorized representative) must provide consent to receive CCM services and agree to the associated cost-sharing responsibilities.
• The healthcare provider must document all CCM activities, including care coordination, medication management, and communication with the patient and other healthcare professionals involved in their care.

2). Documentation of Care

A comprehensive patient assessment should clearly describe the encounter, medical history, recent symptoms, and current functional status. Ongoing care plans outline treatment strategies, monitoring, and coordination of care between providers. Complete medication lists with any adjustments must be included. Counseling and patient education sessions require detailed notes about topics discussed.

Key documentation requirements include:

• Detailed patient assessment and care plan based on medical history, symptoms, and functional status
• Complete medication list with any dosage changes
• Counseling and education session notes covering discussed topics
• Care coordination with other providers like specialists and home health
• Any other patient encounters, assessments, or care plan updates

3). Time Spent on CCM Tasks

When submitting claims for Chronic Care Management (CCM) services to the CMS, it is vital to accurately document the time spent on each task. This is because reimbursement is directly tied to the time allocated per patient.

Healthcare providers must diligently maintain a record of the time spent on various CCM activities, such as:

➜ Comprehensive patient assessment — Gathering and reviewing the patient’s medical history, current health status, and any potential risk factors.

➜ Care plan development and implementation — Creating a personalized care plan tailored to the patient’s needs, addressing their chronic conditions, and ensuring its effective execution.

➜ Medication management — Reviewing and optimizing the patient’s medication regimen, monitoring for potential interactions or side effects, and providing education on proper medication adherence.

➜ Patient counseling and self-management education — Conducting counseling sessions to empower patients with the knowledge and skills necessary for self-care, including lifestyle modifications, disease management techniques, and preventive measures.

Additionally, healthcare providers should consider including the following relevant activities in their time documentation:

• Coordinating care with other healthcare professionals involved in the patient’s treatment plan.
• Providing 24/7 access to care management services for urgent or emergent needs.
• Facilitating transitions of care, such as hospital discharges or referrals to specialists.
• Conducting regular follow-up appointments or remote patient monitoring.

4). Billing Codes for CCM Services

Proper billing code assignment is needed for receiving reimbursement for chronic care management (CCM) services from CMS. By using specific CPT codes, practices can accurately report the CCM services provided and get paid for caring for patients with chronic conditions.

CCM services have designated CPT codes that should be used:

• 99490 – Chronic care management for patients with 2 or more chronic conditions
• 99439 – Chronic care management for patients with 1 or more chronic conditions
• 99487 – Complex chronic care management for patients with multiple comorbid conditions
• 99491 – Chronic care management for patients with 1 or more chronic conditions (first visit)
• 99489 – Chronic care management for patients with severe or complex conditions
• 99437 – Chronic care management for patients with 1 or more chronic conditions (subsequent visits)

5). Claim Submission Frequency

Submitting claims for CCM services to the CMS also requires adherence to specific guidelines regarding claim submission frequency. Healthcare providers have the flexibility to submit CCM claims on a monthly, quarterly, or annual basis, depending on their preferences and the frequency of services provided to patients. It’s important to note that the claim submission frequency should align with the actual CCM services rendered to ensure accurate billing and reimbursement.

However, it’s crucial to remember that different insurance payers, including private insurers and Medicare Advantage plans, may have varying requirements regarding billing frequency for CCM services.

Therefore, healthcare providers should familiarize themselves with the specific guidelines set forth by each payer to ensure compliance and avoid potential claim denials or payment delays.

Key points to consider regarding CCM claim submission frequency:

➜ CCM claims can be submitted monthly, quarterly, or annually, aligning with the frequency of services provided.

➜ The claim submission frequency should accurately reflect the CCM services rendered to patients.

➜ Different insurance payers may have varying requirements for billing frequency, which healthcare providers must adhere to.

➜ Failure to comply with payer-specific guidelines can result in claim denials or payment delays.

➜ Regularly reviewing and updating billing practices based on payer guidelines is recommended to ensure compliance and timely reimbursement.

We’ll handle every detail, from time tracking to cost reports, to capture all the reimbursement you’ve earned.

Optimize your CCM Revenue Stream

Submitting Claims for CCM Services to CMS: A Step-by-Step Guide

As a healthcare provider offering Chronic Care Management (CCM) services, getting reimbursed from the Centers for Medicare & Medicaid Services (CMS) is important. However, the claims submission process can be daunting if you’re not well-prepared.

To ensure a smooth reimbursement process, follow these simple steps:

Step 1: Gather All Necessary Information

Before submitting your CCM claim, make sure you have all the required information at hand. This includes:

• Accurate CPT codes for the CCM services provided
• Detailed records of all CCM activities performed
• Complete patient demographics (name, date of birth, etc.)
• Patient’s insurance information (Medicare number, policy details, etc.)

Step 2: Choose the Right Claim Form

CMS accepts claims on the CMS-1500 form, which is specifically designed for professional services. Ensure that you fill out all fields accurately and completely to avoid any delays or denials.

Step 3: Submit Your Claim

The preferred method for submitting claims is through electronic means, such as a Certified Electronic Health Record Technology (CEHRT) or a clearinghouse. This streamlines the process and reduces the risk of errors. However, if electronic submission is not an option, you can still submit your claim via paper.

Step 4: Monitor Claim Status

After submitting your claim, it’s essential to monitor its status. You can do this by accessing the Medicare Provider Portal or contacting your insurance payer directly. This will help you stay on top of any issues or delays and take appropriate action if needed.

Step 5: Handle Claim Denials

If your claim is denied, don’t panic. Carefully review the reason for the denial and ensure that you have followed all the necessary guidelines. If you believe the denial was unjustified, you can resubmit your claim with additional supporting documentation or formally appeal the decision.

Remember, timely and accurate claims submission is key to receiving prompt reimbursement for your CCM services. By following these steps and staying organized, you can navigate the claims process with ease and ensure a steady revenue stream for your practice.

The Revenue Potential of Chronic Care Management (CCM)

Chronic Care Management (CCM) services offer a significant revenue opportunity for medical practices in 2024. With the latest Medicare reimbursement rate adjustments, CCM can become a valuable source of recurring revenue while improving patient outcomes.

The 2024 National Payment Rates for common CCM CPT codes are:

CPT 99490

• Non-facility: $61.56
• Facility: $48.79

CPT 99439

• Non-facility: $47.15
• Facility: $34.05

These rates are slightly lower than 2023, due to a 3.34% decrease in the Medicare conversion factor. However, CCM services remain profitable.

The bottom line is that practices can generate significant revenue through Chronic Care Management in 2024, while also improving care coordination for their patients with chronic conditions.

CCM allows practices to be reimbursed for non-face-to-face care management services like:

• Regular patient check-ins and communication
• Medication management
• Care plan oversight and revision
• Care coordination with specialists

Making CCM a standard part of care delivery ensures patients get proactive support between office visits. This leads to better health outcomes and lower hospitalizations.

For any practice, focusing on CCM in 2024 is a smart financial move and an impactful way to elevate chronic care. The revenue potential is substantial, while the benefits for patients are even more meaningful.

FAQs

Is it possible CCM services can be billed for patients with only one chronic disease?

Yes, CCM services can absolutely be billed for patients with just one chronic condition. As long as that disease requires ongoing management and care coordination, you can bill CCM codes for those patients. The number of conditions doesn’t matter.

Can Chronic Care Management (CCM) be billed for telehealth visits?

Yes, you can bill CCM codes for telehealth services, as long as the platform used meets CMS guidelines and standards for telehealth. The telehealth medium itself does not impact CCM billing.

Can we bill more than one unit for CCM CPT code 99490 if we provide more than 20 minutes of CCM services?

No, only one unit of 99490 can be billed per patient per month. Even if you spend more than 20 minutes providing CCM services, you still can only bill for 1 unit. The threshold is 20 minutes per month.

What patient consent is needed to bill CCM codes?

Written consent is required before billing CCM codes. Patients must sign a document consenting to CCM services. Verbal consent alone is not enough. Make sure signed consent is on file.

How often can 99490 be billed? Is there a limit?

CPT code 99490 can be billed once per patient each calendar month. There is no annual limit on the number of times it can be reported as long as time requirements are met.

Can we bill 99490 if the patient is in a skilled nursing facility?

Unfortunately no. CCM services cannot be billed for patients who are in a skilled nursing facility, hospital, or similar institutional setting. The patient must be living at home.

What documentation is needed to bill CCM codes?

Thorough documentation of CCM services is required, including total time spent, care coordination activities, medication management, and creation of a care plan. Document everything in detail.

Do telehealth E/M services count toward the 99490 time requirement?

No. Time spent on E/M or telehealth visits cannot be counted toward the 20 minutes required for 99490. Only time spent on specific CCM activities can be included.

Can we bill 99490 if the patient only has 15 minutes of CCM services?

No, the threshold is 20 minutes per month. If the total time spent on CCM activities is less than 20 minutes, then 99490 cannot be billed. There are no exceptions for close calls.

How long should the care plan be for CCM billing?

There are no strict length requirements, but the care plan should thoroughly document the patient’s health issues, treatment goals, self-management, and coordination of care. Strive for 1-2 pages focusing on the patient’s chronic conditions.

The healthcare providers must stay updated with the latest trends and changes related to billing and coding.

In a recent development, American Medical Association (AMA) just updated the CPT code sets for vaccines of 2024-2025 influenza season.

The AMA releases the updated code for respiratory illness including COVID-19 and influenza.

According to CDC, vaccination protects against severe outcomes of COVID-19 and flu, including hospitalization and death. In 2023, more than 916,300 people were hospitalized due to COVID-19 and more than 75,500 people died from COVID-19. During the 2023-2024 flu season, more than 44,900 people are estimated to have died from flu complications.

Trivalent Vaccine for the 2024-2025 Season

The public health community is once again marshalling its defenses against influenza by formulating updated vaccines for the 2024-2025 flu season. This year’s trivalent vaccine will contain antigens to protect against three targeted viral strains: a version of H1N1, H3N2, and a component from the B/Victoria lineage. 

This combination represents the experts’ best efforts to anticipate the strains most likely to spread through communities in the coming months. The vaccine spurs the body to generate protective antibodies against these three targets. Though the circulating flu strains often mutate and evade the vaccine’s defenses, immunization still reduces severe outcomes.

Flu Vaccine Code Changes

Medicare has yet to publish the payment rates and effective dates for the 2024-2025 flu season. However, there are a couple of new flu vaccine codes that will take effect on July 1st, 2024 worth taking note of.

The first is code 90637 for a quadrivalent influenza mRNA vaccine with a 30 microgram per 0.5 mL dose for intramuscular injection. The second is code 90638 for the same quadrivalent vaccine but with a 60 microgram per 0.5 mL dosage. Both of these new vaccines are still pending approval by the FDA.

There is also a revised code to make note of. Code 90661 is for a trivalent influenza vaccine derived from cell cultures that is preservative and antibiotic free with a 0.5 mL dose for intramuscular use. The descriptor for this code will change effective January 1st, 2025.

Other Vaccine Code Changes in 2024

The American Medical Association has approved some new vaccine codes for the 2025 edition of the Current Procedural Terminology manual. This reference work provides medical codes that physicians and other providers use for billing and record-keeping.

One of the newly accepted codes is 90684, for the 21-valent pneumococcal conjugate vaccine given by intramuscular injection. The Food and Drug Administration approved this vaccine on June 20, 2024, and the new CPT code is effective as of June 17, 2024. This shot protects against 21 strains of the bacterium that causes pneumococcal disease.

There is also a new code, 90624, for a combination meningococcal vaccine given intramuscularly. This pentavalent vaccine includes components against meningitis types A, C, W, and Y plus recombinant proteins against type B disease. It is pending approval from the FDA and will take effect on October 1, 2024 assuming it gets the green light. This should provide broad protection against all major forms of meningitis in one shot.

FDA Approves RSV Vaccine

The FDA has given the green light to Moderna’s respiratory syncytial virus vaccine, approving it for use on May 31st. This new mRNA vaccine, delivered via lipid nanoparticles into the arm muscle, will be assigned the CPT code 90683 when it is published in the 2025 edition of CPT.

Meanwhile, RSV-positive test results and hospitalizations have remained low nationwide, as have vaccination rates, according to the Centers for Disease Control and Prevention.

The CDC continues monitoring influenza-like illnesses as we move into summer, when most respiratory viruses take a break. With flu season in the rearview mirror, it seems we’ve dodged a viral bullet this year. But it’s never too early to start thinking about getting next season’s flu shot, especially for those at high risk of complications.

Guidelines for Medical Facilities and Providers

Doctors could recommend both the COVID-19 and influenza vaccinations during the same visit if the patient needs both.

As long as the physician billed for both vaccinations together when a patient received them at the same appointment, there wouldn’t be any duplicate charges.

The medical practices simply have to remember to use the correct, up-to-date codes for the vaccinations to prevent claims from being denied by insurance companies. They also need to accurately document the names of the influenza strains along with the corresponding codes.

The billing software systems need to be updated to properly translate the diseases and bill them correctly.

The official website of the American Medical Association, as well as various medical billing blogs, should be checked regularly for the latest updates, changes, and other important details regarding the new vaccine codes.

Here’s a detailed breakdown of what “sequela” means and how the 7th character “S” is used:

What is a Sequela?

Imagine you broke your arm a few months ago. The break itself has healed, but you still experience some pain, unease, or stiffness in the arm. This lingering pain or condition is a sequela.

It’s a complication or condition (pain) that arises directly from the original injury (the broken arm) and persists even after the initial healing process.

Sequela can take many forms:

Scarring: This is a common sequela after burns or surgeries.

Chronic pain: Pain that continues long after the initial injury has healed.

Joint stiffness: Injuries to joints can leave them feeling stiff or limited in movement.

Muscle weakness: Damage to muscles can lead to lingering weakness.

How to Use the 7th Character “S” of Sequela?

The key to using the 7th character “S” correctly lies in differentiating between a sequela and an initial complication.

• Sequela (7th character “S”): A late-arising complication that requires treatment after the initial healing process (e.g., treating scars after a burn).
• Initial Complication (7th character “A”): An immediate complication that requires active treatment during the initial healing phase (e.g., endophthalmitis after an injection).

For example:

• A patient suffers a burn of first degree of left hand (coded as T23.102).
• Months later, the patient develops scar contracture – sequela, that requires treatment. The code for this scenario would be T23.102S. The “S” added to the burn code indicates the scar contracture is a late effect – resulting from the initial condition “A”.

The Use of Placeholder X

The placeholder “X” in sequela encounter code is used to place the “S” of Sequela at the 7th number. When a code has 5 or less than 5 characters, the character “X” is added to fill in the empty space/s.

For instance:

The code for fatigue fracture of the vertebra “M48.40” consists of 5 characters. When its aftereffects arise, the “S” of sequela is placed at the 7th character, and the placeholder “X” is added. The sequela code for fatigue fracture of the vertebra is “M48.40XS”.

Using Z Codes Vs. 7th Character “S”

Another important distinction is between sequela “S” and aftercare “Z”. Aftercare codes – Z codes, are used for routine follow-up visits after treatment, not for complications.

Say for example:

If a patient undergoes surgery (coded based on the surgical procedure), a follow-up visit to remove stitches wouldn’t be coded with the 7th character “S”. It would likely be coded with a Z code specific to post-surgical care.

Examples and Codes for the 7th Character of Sequela

Here are some examples of how the 7th character “S” is used with different sequela and their corresponding codes:

Benefits of Using the 7th Character “S”

Using the 7th character “S” accurately offers several benefits:

Clear Communication: It provides a complete picture of the patient’s condition, including any lingering effects from past injuries or illnesses.

Proper Care: Healthcare providers can understand the root cause of the patient’s current issues and provide the most appropriate treatment.

Accurate Billing: It ensures that insurance companies are billed correctly for treating sequela.

Some Additional Examples for 7th Character of Sequela

• Malignancy (Cancer) in remission: While cancer itself might not be coded with the “S”, some late effects of cancer treatment, like fatigue or neuropathy, could be coded with the original cancer code followed by “S”.
• Mental health conditions: Sequelae can also occur in mental health. For example, post-traumatic stress disorder (PTSD) following a traumatic event might be coded with the trauma code and “S”.

Our medical coding staff at BellMedEx is certified and trained by the Certified Professional Coder (CPC) certification and adheres to the correct coding guidelines. If accurate coding is taking a toll on your nerves, schedule a free 1:1 medical coding consultation today and outsource your coding tasks at a fair price and 100% accuracy.