I thought I would take a few newsletters and discuss several of the good questions we have received recently:

Question: How do you bill the CPT code 17250 along with an office visit and make sure to get paid by Medicaid? Is there any specific language that you know of that they are looking for in the medical record? We normally put a modifier 25 on the code for the visit, and fax medical records from the visit. Sometimes they pay both, and sometimes they just pay the exam portion.

Answer: CPT code 17250 (Chemical cauterization of granulation tissue) is used commonly with infants with an umbilical granuloma that is cauterized using Silver Nitrate applicators but can be used for any cauterization of other areas in any age patient. It is appropriate to bill this code when the procedure is performed. There are two ways to do this:

If the patient presents because of this problem, and all you do is the lesion destruction (including pre- and post-procedure education) then you would only bill for the procedure 17250 with the appropriate diagnosis.

If the patient presented for another reason such as a Health Maintenance exam (99391), then you would bill the primary codes 99391 with diagnosis V20.2. The secondary procedure 17250 would get a -25 modifier and the appropriate diagnosis. If payment is refused, then you should appeal it with the appropriate documentation.

Unfortunately, I have found many payers have policies in place that they will not pay for certain procedures and the same time as office visits. Many of the dermatology codes fall into this trap (especially warts 17110). It has nothing to do with correct documentation or coding guidelines. It is simply their "rule" that you agreed to when you signed a contract with them. Either way, you need to find out why any particular payer does not pay.

Question: We were looking at purchasing a Welch Allyn spot vision screener, are you familiar? Is there any other code (higher, since we will be using more accurate and technologically advanced screening tools) that you know of that Medicaid will cover for vision screening besides 99173, which is what we bill for when using the Snellen Chart for vision screening during an exam?

Answer: I'm not familiar with the spot vision screener. I have used their SureSight screener (around $4,000) and the appropriate code for that is 92015 (determination of refractive state) because if gives data for both eyes that includes the amount of astigmatism and the diopter measurement of their vision. When it pays, it pays pretty well. We don't use this in my practice anymore because many of our payers quit paying for it.

Some of the responses from the insurance companies include things like "Medicare statutorily excludes payment for determination of refractive state", "92015 is only paid to optometrists or ophthalmologists", or my favorite: "determination of refraction is not necessary when screening for vision." Before buying an expensive piece of equipment, you need to do the analysis and find out from your 3 biggest payers what they will reimburse for the service. 92015 has an RVU value of 0.79 which corresponds to the $27 range. That means it will take 150 screenings in order to pay for the machine. How many will you do in a year? If half of your payers deny payment, how long will it take to do 300 of these tests? Or if all your major payers cover this and they pay $40, then it will only take 100 to cover your costs.

The main thing when purchasing any piece of equipment has to be this analysis of payer vs. cost vs. number of procedures. Hope this helps. We will cover some more Q&A in our next newsletter.