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Ask The Expert
| Author: Dr. Sheila Dunn |
| Article Date: 12/1/2007 |
Ask the Expert December 15, 2007
Flu vaccine reimbursement
Q. We've been getting denials for flu vaccines. Can you verify how to code them properly?
A. There are several CPT codes for flu vaccines and one for administering it as well. See below for Medicare reimbursement for outpatient settings. Note that in hospitals and other inpatient facilities, the vaccine is not reimbursed as shown below, but at 95% of the average wholesale price (AWP).
The code for administering flu vaccine is G0008 and has a Medicare fee cap of $19.33. Moreover, physicians can bill an office visit (E&M code) if other services were performed when the patient had their flu shot.
Does urologist qualify as lab director?
Q. I'm a urologist and would like to perform PSA tests in my office on an immunoassay analyzer. I spoke to a representative from a company that manufactures a non-waived PSA analyzer, and it doesnÕt appear that I qualify to be a lab director. I donÕt want to take the online 20 CME course either. Are there any other options? Are there any PSA tests that are CLIA-waived?
A. I have good news and bad news. First, the bad news is that no PSA tests are yet CLIA-waived. The good news, though, is that you probably do qualify to be a lab director. If you're like most urologists who look at urine or semen specimens under the microscope in their offices, you should be classified under CLIA as PPMP, not CLIA-waived. Luckily, the PPMP category is a subcategory of CLIA moderately complex, so you will already have the one-yearÕs experience needed directing or supervising any moderately complex tests to qualify as the lab director. Hallelujah! The second option if you are now CLIA-waived and not PPMP, is to find a med tech with 4 years lab supervisory experience to act as lab director for the first year until you gain the one-yearÕs experience needed. Good luck!
Pregnancy restrictions for nitrous oxide?
Q. If an employee is pregnant, do additional precautions need to be taken for working with nitrous oxide? A. While OSHA does not have a permissible exposure limit (PEL) for N2O for employees, the National Institute for Occupational Safety and Health (NIOSH) has a limit of 25 ppm based upon a time-weighted average and research into the reproductive health effects of N2O. Presumably, therefore, exposures under this limit should not have a negative effect on pregnant employees. The only way to check whether the exposure level in your facility is less than 25 ppm, is to get a monitoring dosimeter badge for your pregnant employee. Check out www.cdc.gov/niosh/noxidalr.html for more information about keeping N2O leaks to a minimum.
Financials for PT/INR and A1c testing
Q. Our practice manages many patients who require PT/INR and HbAlC tests. We have been sending them to an outside lab, but now I would like to determine if there is financial gain in purchasing a machine to do these in the office. What are the CPT codes and the reimbursement for these studies?
A. Practices that have added a coumadin testing program or a diabetes monitoring program fare well. You wouldnÕt know it, though, from the Medicare reimbursement for the tests themselves (see Table below). If youÕve looked at instruments for performing these tests, youÕll know that the reimbursement per test isnÕt too much more than the cost of the test, but two other factors make it quite profitable: the clinical benefits and the office visit charges.
*At press time, CMS indicated that a new ŅGÓ HCPCS code would be issued for A1c. Presumably, the reimbursement will be the same. In either case, weÕll keep you apprised of this in next monthÕs Ask the Expert column.
LetÕs start with the clinical benefits. Physicians who get rapid A1C results in their office can give immediate, face to face counseling, which is known to be more effective in getting patients to comply with their therapy, which may help reduce their A1C. Research indicates that patients who get immediate feedback may lower their A1C by 1%. Lowering A1C levels reduces the risks of long-term complications; a 1% reduction in A1C lowers risk of eye, kidney and nerve disease by 40%.The same type of benefits are also seen for PT/INR.
Additionally, with referral lab testing, the patient wonÕt receive their results until after they have left your office, so face to face counseling isnÕt an option. Changes in the patientÕs treatment may not be made and the proven health benefits associated with rapid, point of care testing are lost. Finally, think of the time it takes your staff facing stacks of lab reports every day to contact patients. Time is money!
Tangible financial benefits derive from the additional reimbursement for an office visit. Most practices schedule these two particular tests several times per year for a particular patient. If the patient visit justifies a physical exam from a physician, then bill for an established office visit (99212-99215). If the visit includes additional services performed by a non-physician, such as a taking vital signs and assessing patient compliance with their medications, then you should also bill -in addition to the CPT codes for the tests- a 99211 (a non-physician office visit), which reimburses an additional $22 - $24, depending on your location. For Coumadin patients, you would want to do a cursory visual screen for bruising, petechiae and other indications of bleeding. To bill this additional E&M code, the nurse or medical assistant must document what was done during the visit. If only the test is performed during the patient visit, no additional encounter codes may be billed.
One other consideration for assessing actual profitability is the reimbursement from managed care plans. Although Medicare reimbursement is the benchmark for all other payers, payment from managed care plans is all over the board for procedures and tests. Some reimburse more than Medicare and others less, so I suggest looking at your top 5 managed care contracts to determine the actual reimbursement for these two codes. If these payers reimburse less than you would like, write them a letter asking for better reimbursement.
Finally, if you decide to purchase an instrument to perform A1c in your office, check your monthly Medicare Part B Bulletins carefully in the next month or so, in anticipation of a new CPT code for this test. We'll of course announce the new CPT code in our Ask the Expert column, but with the typical publishing delay, you may need to know sooner. A1c reimbursement will remain the same to my knowledge, though. Ź
Infection control tips for waiting areas
Q. We're planning to renovate our waiting room. What are your suggestions forŹinfection control in this area, such as for toys and upholstered furniture?
A. The best way to minimize transmission of infections in your waiting area is to avoid crowding, shorten waiting times and segregate symptomatic patients from well patients. Begin triage when the office visit is scheduled, so that infectious patients may be placed in an exam room upon entering the practice. Overall, the following suggestions will help you minimize the possibility of transmitting diseases among patients and staff in your waiting area:
Waiting Room Infection Control Do's and Don'ts
*Author's Note: With this question, it seems appropriate for a shameless promotion for Quality AmericaÕs Infection Protection Station Š a countertop unit that dispenses tissues, sanitizer, and face masks. Consistent with CDCÕs Respiratory Hygiene/Cough Etiquette Guidelines, it also features signage reminding patients to cover their coughs. Learn more at www.quality-america.com.
Can bites transmit bloodborne pathogens?
Q. A patient bit one of our nurses, intensely enough so that she bled. Is this a bloodborne pathogens exposure?
A. Yes, OSHA defines an exposure incident as a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's job duties. Parenteral contact includes needlesticks, bites, cuts, abrasions, and similar injuries that result in a piercing of the skin.
CLIA waived test for thyroid testing?
Q. IÕd like to do thyroid testing in my office. Is there a CLIA-waived test for this?
A. Yes and no. There are at least two qualitative CLIA-waived TSH tests, indicated only for screening for hypothyroidism. Both tests http://www.invernessmedicalpd.com/poc/products/tsh.html and http://www.accutest.net/products/md801.php show positive results when patientÕs fingerstick blood sample exceeds the cutoff value of 5mIU/L of TSH.
If you need more thorough thyroid studies for other clinical conditions besides hypothyroidism, you'll want quantitative results for TSH and also at least T3 uptake and T4 tests. In this case, you will need to purchase an instrument classified as moderately complex by CLIA.
Flu vaccine reimbursement
Q. We've been getting denials for flu vaccines. Can you verify how to code them properly?
A. There are several CPT codes for flu vaccines and one for administering it as well. See below for Medicare reimbursement for outpatient settings. Note that in hospitals and other inpatient facilities, the vaccine is not reimbursed as shown below, but at 95% of the average wholesale price (AWP).
The code for administering flu vaccine is G0008 and has a Medicare fee cap of $19.33. Moreover, physicians can bill an office visit (E&M code) if other services were performed when the patient had their flu shot.
Does urologist qualify as lab director?
Q. I'm a urologist and would like to perform PSA tests in my office on an immunoassay analyzer. I spoke to a representative from a company that manufactures a non-waived PSA analyzer, and it doesnÕt appear that I qualify to be a lab director. I donÕt want to take the online 20 CME course either. Are there any other options? Are there any PSA tests that are CLIA-waived?
A. I have good news and bad news. First, the bad news is that no PSA tests are yet CLIA-waived. The good news, though, is that you probably do qualify to be a lab director. If you're like most urologists who look at urine or semen specimens under the microscope in their offices, you should be classified under CLIA as PPMP, not CLIA-waived. Luckily, the PPMP category is a subcategory of CLIA moderately complex, so you will already have the one-yearÕs experience needed directing or supervising any moderately complex tests to qualify as the lab director. Hallelujah! The second option if you are now CLIA-waived and not PPMP, is to find a med tech with 4 years lab supervisory experience to act as lab director for the first year until you gain the one-yearÕs experience needed. Good luck!
Pregnancy restrictions for nitrous oxide?
Q. If an employee is pregnant, do additional precautions need to be taken for working with nitrous oxide? A. While OSHA does not have a permissible exposure limit (PEL) for N2O for employees, the National Institute for Occupational Safety and Health (NIOSH) has a limit of 25 ppm based upon a time-weighted average and research into the reproductive health effects of N2O. Presumably, therefore, exposures under this limit should not have a negative effect on pregnant employees. The only way to check whether the exposure level in your facility is less than 25 ppm, is to get a monitoring dosimeter badge for your pregnant employee. Check out www.cdc.gov/niosh/noxidalr.html for more information about keeping N2O leaks to a minimum.
Financials for PT/INR and A1c testing
Q. Our practice manages many patients who require PT/INR and HbAlC tests. We have been sending them to an outside lab, but now I would like to determine if there is financial gain in purchasing a machine to do these in the office. What are the CPT codes and the reimbursement for these studies?
A. Practices that have added a coumadin testing program or a diabetes monitoring program fare well. You wouldnÕt know it, though, from the Medicare reimbursement for the tests themselves (see Table below). If youÕve looked at instruments for performing these tests, youÕll know that the reimbursement per test isnÕt too much more than the cost of the test, but two other factors make it quite profitable: the clinical benefits and the office visit charges.
*At press time, CMS indicated that a new ŅGÓ HCPCS code would be issued for A1c. Presumably, the reimbursement will be the same. In either case, weÕll keep you apprised of this in next monthÕs Ask the Expert column.
LetÕs start with the clinical benefits. Physicians who get rapid A1C results in their office can give immediate, face to face counseling, which is known to be more effective in getting patients to comply with their therapy, which may help reduce their A1C. Research indicates that patients who get immediate feedback may lower their A1C by 1%. Lowering A1C levels reduces the risks of long-term complications; a 1% reduction in A1C lowers risk of eye, kidney and nerve disease by 40%.The same type of benefits are also seen for PT/INR.
Additionally, with referral lab testing, the patient wonÕt receive their results until after they have left your office, so face to face counseling isnÕt an option. Changes in the patientÕs treatment may not be made and the proven health benefits associated with rapid, point of care testing are lost. Finally, think of the time it takes your staff facing stacks of lab reports every day to contact patients. Time is money!
Tangible financial benefits derive from the additional reimbursement for an office visit. Most practices schedule these two particular tests several times per year for a particular patient. If the patient visit justifies a physical exam from a physician, then bill for an established office visit (99212-99215). If the visit includes additional services performed by a non-physician, such as a taking vital signs and assessing patient compliance with their medications, then you should also bill -in addition to the CPT codes for the tests- a 99211 (a non-physician office visit), which reimburses an additional $22 - $24, depending on your location. For Coumadin patients, you would want to do a cursory visual screen for bruising, petechiae and other indications of bleeding. To bill this additional E&M code, the nurse or medical assistant must document what was done during the visit. If only the test is performed during the patient visit, no additional encounter codes may be billed.
One other consideration for assessing actual profitability is the reimbursement from managed care plans. Although Medicare reimbursement is the benchmark for all other payers, payment from managed care plans is all over the board for procedures and tests. Some reimburse more than Medicare and others less, so I suggest looking at your top 5 managed care contracts to determine the actual reimbursement for these two codes. If these payers reimburse less than you would like, write them a letter asking for better reimbursement.
Finally, if you decide to purchase an instrument to perform A1c in your office, check your monthly Medicare Part B Bulletins carefully in the next month or so, in anticipation of a new CPT code for this test. We'll of course announce the new CPT code in our Ask the Expert column, but with the typical publishing delay, you may need to know sooner. A1c reimbursement will remain the same to my knowledge, though. Ź
Infection control tips for waiting areas
Q. We're planning to renovate our waiting room. What are your suggestions forŹinfection control in this area, such as for toys and upholstered furniture?
A. The best way to minimize transmission of infections in your waiting area is to avoid crowding, shorten waiting times and segregate symptomatic patients from well patients. Begin triage when the office visit is scheduled, so that infectious patients may be placed in an exam room upon entering the practice. Overall, the following suggestions will help you minimize the possibility of transmitting diseases among patients and staff in your waiting area:
Waiting Room Infection Control Do's and Don'ts
*Author's Note: With this question, it seems appropriate for a shameless promotion for Quality AmericaÕs Infection Protection Station Š a countertop unit that dispenses tissues, sanitizer, and face masks. Consistent with CDCÕs Respiratory Hygiene/Cough Etiquette Guidelines, it also features signage reminding patients to cover their coughs. Learn more at www.quality-america.com.
Can bites transmit bloodborne pathogens?
Q. A patient bit one of our nurses, intensely enough so that she bled. Is this a bloodborne pathogens exposure?
A. Yes, OSHA defines an exposure incident as a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's job duties. Parenteral contact includes needlesticks, bites, cuts, abrasions, and similar injuries that result in a piercing of the skin.
CLIA waived test for thyroid testing?
Q. IÕd like to do thyroid testing in my office. Is there a CLIA-waived test for this?
A. Yes and no. There are at least two qualitative CLIA-waived TSH tests, indicated only for screening for hypothyroidism. Both tests http://www.invernessmedicalpd.com/poc/products/tsh.html and http://www.accutest.net/products/md801.php show positive results when patientÕs fingerstick blood sample exceeds the cutoff value of 5mIU/L of TSH.
If you need more thorough thyroid studies for other clinical conditions besides hypothyroidism, you'll want quantitative results for TSH and also at least T3 uptake and T4 tests. In this case, you will need to purchase an instrument classified as moderately complex by CLIA.