Coding

Important Information From a Medicare Standpoint Regarding X-rays

2023 E/M Coding Changes

Explanation of Phrases in the Elements of Medical Decision-Making Table as of January 1, 2023 in Order to Select the Most Appropriate Level of E/M Service

So, an established patient is scheduled to be seen for “At Risk,” Routine Foot Care. The patient had a NEW complaint of heel pain at the same encounter. In other words, this is an established patient with a new problem. In addition to the performance of “At Risk,” Routine Foot Care, the affected foot with the heel pain was X-rayed and a steroid injection was administered into the painful heel. The big question is: “Can The E/M service, Routine Foot Care, the X-rays and the injection be billed for?” Well, yes.

When it comes to the dispensing of a postoperative, surgical shoe, the appropriate HCPCS Level II code is L3260 which is defined as the following: Surgical shoe/boot, each. With respect to Traditional Medicare, a postoperative shoe is NOT separately payable when it is dispensed in conjunction with a surgical procedure code. It is considered to be part of the procedure. Like orthotics, this item is a statutorily excluded benefit by Medicare and DME and will not be covered under any circumstances.

Most of the time, the responsibility for obtaining prior authorization falls on the provider or the physician. Why? The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient’s insurance provider, or by calling the appropriate telephone number to obtain prior authorization or obtaining prior authorization online.

A new patient is an individual who has not received any professional services, evaluation and management (E/M) service, or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspecialty) within the previous 3 years.

Understand the new utilization parameters and documentation requirements for CPT Codes 11730 and 11750.

What is a Medicare NCD? An NCD or National Coverage Determination defines coverage for a particular item or service nationwide.

Effective January 1, 2009, the term “decubitus ulcer” was changed to “pressure ulcer.” A six-part staging system for pressure ulcers was put into effect on January 1, 2009, as well. This is what ICD-10 has incorporated to base the series of L89- upon. Classification systems, whether Wagner, University of Texas, etc. for ulcer grading do not apply to pressure ulcers.