In this week's newsletter, I would like to tackle a few more Coding Questions and Answers:

Question: When testing blood glucose for diabetes, do you use CPT code 36416 (finger stick) along with 82962 (home testing device), and would you use any modifiers to make sure we are properly reimbursed?

Answer: Yes, those are the codes I use. Typically I do not use modifiers. But if you are not getting paid, then try modifier -59 in addition to the office visit code. However, I have found that most payers deny this code. When I have contested the charges, usually I am informed that I did bill them correctly, but that it is their policy that they do not pay these codes. When that happens, you usually don't have much recourse.

Question: When sending a culture to lab, do you use CPT code 99000, do you use any modifiers, and do you get reimbursed.

Answer: That is the correct code to use. The previous answer applies to this question as well. You can use -59 modifier, usually you don't need to, and some payers have a policy of not paying this code. With any codes that you do not get paid for, I would contest them and find out why. Usually you can talk with a representative and find out if you are coding it incorrectly or if it is just their policy not to pay.

Question: When billing immunizations along with office visits, do you use modifier 25? And since many insurers stopped covering 90460 and 90461, are you coding immunizations any differently? After 5 (which is the max many payers will cover), how do you bill additional immunizations administered?

Answer: Last year, payers began refusing CPT codes 90461 because of the wording in the CPT book. The description is "Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component (list separately in addition to code for primary procedure)". The problem comes in the end of the description where it says 90461 is for each additional vaccine component. That means that for example, if you gave an MMR vaccine, you would bill 90460 for the 'measles component', 90461 for the 'mumps component', and 90461 again for the 'rubella component'. And in fact many providers were doing this. As you can imagine, many payers decided to quit paying.

Now the correct way to bill is by using the traditional immunization administration codes 90471 and 90472 for injectable vaccines and 90473-90474 for oral/nasal vaccines. We have been using these codes for our pediatric patients and getting paid. Some payers will want you to use modifiers like -59 or -25 but most will take it without any modifiers. If you are not getting paid appropriately for these codes, you need to contact the payer and ask them how it should be billed.

If you have any payers that do not cover more than 5 vaccines administered on a particular day of service, I would recommend only doing 5 on that day. If more are needed, inform that patient/parent that this is all their insurance will cover today and have them come back in a month to do more.