CPT 99459 Pelvic Examination Billing for Medicare
CPT 99459 was added to CPT coding for 2024 as an add-on code service, which means that this code is only payable if provided and billed on the same day, on the same claim, as the appropriate service(s) allowed per coding guidelines.
From National Government Services:
CPT 99459 is a work expense only add-on code. It’s for four minutes of clinical time chaperoning a pelvic exam as well as the supply pack. If a pelvic exam or pap/pelvic is provided, these services are bundled into the service. This code would be used when the patient is receiving an E/M level service and the physician feels it is necessary to do a pelvic exam as part of the service that day. The office/other outpatient E/M codes are the only services on this list billable to Medicare.
CPT has clearly defined this add-on code can only be billed with 99202-99205, 99212-99215, 99242-99245, 99383-99387, 99393-99397.
CPT 99383-99387 and 99393-99397 are actual examination services and are appropriate for this add-on code for payers other than Medicare.
This service would not be an add-on code for an annual wellness visit because it’s not a medical examination or procedure, therefore, add-on guidelines would not apply.
Providers Accepting CHAMPVA: Enroll in Direct Deposit Now
Are you a health care provider who submits claims to Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)? Enroll in direct deposit to get your claim payments by electronic funds transfer (EFT). Getting paid by EFT is convenient, but it’s also a federal requirement.
EFT is secure, efficient, and helps safeguard Veterans’ family members’ access to benefits.
If you haven’t already:
- Visit the VA Financial Services Center Customer Engagement Portal
- Enroll using the Payment Account Setup web form
Your payments will be automatically deposited into a bank account.
If you aren’t enrolled in EFT, your claims payments will be paused until you are. Make the move today.
For assistance with the webform, call 877-353-9791.
About CHAMPVA
CHAMPVA is a health care program for qualified spouses, widows(ers), and children of eligible Veterans. Through CHAMPVA, VA shares the cost of certain health care services and supplies with eligible beneficiaries.
More Information:
Aetna: Check Authorization Requirements on our Provider Portal on Availity
Aetna has added a new inquiry feature within the Authorization Add request on their provider portal on Availity called “Is Authorization Required,” that allows you to check authorization requirements without having to submit a request.
It takes place in step 3
Start your Authorization Add request on Availity as you normally would. Add provider and patient information, diagnosis and procedure codes, place and date of service, and quantity. In step 3 of the request process, we’ll check whether the requested service(s) requires authorization and return one of the following responses:
- No authorization required means you’re done. You can print a copy of the response for your records and move on with your day.
- Authorization required means we require authorization for at least one of the requested services. Use the “Next” button to finish and submit your request on Availity.
- Undetermined means the inquiry function is unable to determine whether authorization is required. That might be because the patient’s plan has special conditions. Treat this response the same as “authorization required” and continue with your request as usual.
We’ll even tell you when services are handled by another entity
When another entity handles authorization, we’ll tell you the name of the entity and how to contact them. When EviCore handles services, not only will we tell you to contact EviCore, but you’ll also see a “Take me to EviCore” button. Use it to go directly into EviCore’s portal to complete your request.
Aetna: Missing Modifier 54 Expansion to POS 20 and 49
This update applies to our commercial and Medicare members.
Beginning September 1, 2024, we will expand our modifier 54 policy to include place of service 20 (urgent care) and 49 (independent clinic). We will pay for surgical procedures performed in these places of service billed with or without modifier 54 (surgical care only) at 75% of the contracted surgery rate. In addition, beginning September 1, 2024, when services are rendered in the ER, we will reduce payment for surgical procedures when billed by nurse practitioners or physician assistants with or without modifier 54.
CareFirst Partnering with EviCore for UM Services for Cardiology and Radiology Imaging
Effective July 22, 2024, ordering providers will need to submit a prior authorization for outpatient services to EviCore for these members for dates of service beginning July 22, 2024. Providers will be able to enter and submit authorizations up to five days prior, starting July 15, 2024, for dates of service beginning July 22, 2024.
Services performed without authorization may not be reimbursed for healthcare services, and providers may not seek reimbursement from members. Additional information on the specific services that will require authorization will soon be available on our provider website under Programs/Services > Pre-Cert/Pre-Auth (In Network). Here is a direct link to that page: Pre-Cert/Pre-Auth (In-Network) (carefirst.com)…
…To help familiarize you with these changes, we have scheduled several live webinars in July for you to attend. To register, you can select the ‘Register Now’ link for the date/time that works best for you.
Date Time Registration Link Tuesday, July 2 10:00 a.m. – 11:00 a.m. Register Now Wednesday, July 10 1:00 p.m. – 2:00 p.m. Register Now Wednesday, July 17 1:00 p.m. – 2:00 p.m. Register Now Thursday, July 25 10:00 a.m. – 11:00 a.m. Register Now Tuesday, July 30 10:00 a.m. – 11:00 a.m. Register Now Wednesday, July 31 1:00 p.m. – 2:00 p.m. Register Now Registration links are also available on our Webinars page on the Learning and Engagement Center.
Fidelis Care Remittance Advice CARC/RARC Codes
Effective May 12, 2024, the Fidelis Care remittance advice will include Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC), along with a description of the codes.
From Fidelis Care:
CARCs describe why a claim or service line was paid differently than it was billed and RARCs provider additional explanation for an adjustment already described by a CARC or convey information about remittance advice.
There are two types of RARCs, supplemental and informational. The majority of RARCs are supplemental; these are generally referred to as RARCs without further distinction. Supplemental RARCs provide additional explanation for an adjustment already described by the CARC. The second type of RARC is informational; these RARCs are all prefaced with “Alert”. Alerts are used to convey information about remittance processing and are never related to a specific adjustment or CARC.
Wellcare By Fidelis Care – Explanation Codes on Dual Access Remittances
Fidelis Care would like to make you aware new explanation codes you may see on remittances for Wellcare By Fidelis Care Dual Access members:
Explanation Code
- 918 – Member Liability
- The member is responsible for these out-of-pocket cost share amounts.
- 919 – Non-Billable Cost Share
- Do Not Bill Member; for this scenario the member is not liable for the cost share as the amount paid to the provider meets the contractual reimbursement.
- 920 – Bill Cost Share to Medicaid
- For this scenario, the associated cost share needs to be billed to Medicaid.
CARC Code
- 209 – Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA)
Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated.
New Claims Appeal Function Now Available on the Fidelis Care Provider Portal
Methylprednisolone & Methotrexate: Codes & Billing Updated
On April 1, the Centers for Medicare & Medicaid Services (CMS) released its first quarter Healthcare Common Procedure Coding System (HCPCS) update with revisions for methylprednisolone and methotrexate. All HCPCS code changes are effective and should be used for claims with dates of services on or after April 1, 2024. The procedure codes described below have been revised and/or discontinued effective April 1, 2024.
Methylprednisolone
There is a single, new HCPCS code, J1010, for methylprednisolone acetate, injection, 1 mg. This was previously reported with three HCPCS codes:
- J1020 (Injection, methylprednisolone acetate, 20 mg) [DELETED]
- J1030 (Injection, methylprednisolone acetate, 40 mg) [DELETED]
- J1040 (Injection, methylprednisolone acetate, 80 mg) [DELETED]
J1010 now represents “1 mg,” so each milligram reported will be as a unit. For example, if the provider injects methylprednisolone 80 mg, this will be reported as J1010 x 80 units. Also, the National Drug Code (NDC) number will need to be reported on the claim to alert the insurance carrier as to which strength/concentration was used (J1020, J1030, J1040).
Methotrexate
HCPCS code J9250 (Methotrexate sodium, 5 mg) has been deleted. The word “injection” has been added to the descriptor for HCPCS code J9260, so it now reads: J9260 (Injection, methotrexate sodium, 50 mg).When billing Medicare for methotrexate, providers must either use J9255 (Injection, methotrexate (Accord), not therapeutically equivalent to J9260, 50 mg) or J9260. To determine which code to use, doctors must first note the unit change from 5 mg (for J9250) to 50 mg (for J9255 and J9260). Second, they must verify which methotrexate manufacturer is being used and utilize the appropriate J code; for example, Accord’s methotrexate is assigned to J9255, effective Jan. 1, 2024. This follows a protocol that the CMS has established with other codes, creating separate codes for each manufacturer’s non-therapeutically equivalent version of the drug.
If providers continue to have issues coding for methotrexate, they should reach out to their Medicare Administrative Contractor for guidance.