Minor Surgical procedures vs. Major Surgical Procedures When Billed by An NPP

By Lisa Kropp, PracticeFirstCoding and Credentialing Manage

Minor surgical procedures (10-day global period) are generally covered when billed by an NPP:

  • if determined to be within the usual training of a PA/NP/CNS;
  • if determined that the risk of performing the procedure would be acceptable when provided by a non-physician practitioner; and
  • if determined that the usual training includes expertise required to make the decision to perform the procedures

Major surgical procedures (90-day global period) are generally not a covered service when billed by a NPP.

However, National Government Services Contractor Medical Directors (CMDs) have been questioned about certain musculoskeletal surgical procedures (90-day global period) and asked to clarify their coverage when rendered and billed by an NPP.

As a result, to clarify coverage under National Government Services Medicare we are publishing a list of procedures deemed payable when medically necessary and billed by an NPP. This list will be updated and published as needed.

Refer to the CMS Physician Fee Schedule Look Up at http://www.cms.gov/apps/physician-fee-schedule/overview.aspx to search for specific code related global periods.





Per the April 2012 NYS Medicaid Update, effective immediately, Medicaid coverage will no longer be provided for arthroscopic knee surgery when the primary diagnosis is osteoarthritis. This coverage will no longer be provided to Medicaid Managed Care and Family Health Plus enrollees effective June 1, 2012. Specific procedures are outlined in Medicaid’s coverage policy. Please refer to the link below for these guidelines.


Per the April 2012 NYS Medicaid Update, effective immediately, Medicaid coverage will no longer be provided for certain treatments for chronic low back pain. This coverage will no longer be provided to Medicaid Managed Care and Family Health Plus enrollees effective June 1, 2012.

For complete coverage guidelines for both of these policies, please access the Department of Health’s website and refer to the 2012 DOH Medicaid Updates – Volume 28; April pdf file:



HIPAA Violations Abound! Is Your Practice at Risk?

By Emilie J DiChristina, MBA, CPHQ, Six Sigma BB for PracticeFirst

HIPAA, HIPAA, HIPAA…everyone is tired of the threat of HIPAA, and it has now become like an incessant alarm in an Intensive Care Unit. Unfortunately, the threat of HIPAA is very real, not because the law exists, but because people in healthcare keep violating the confidentiality of their patients.

The issue of HIPAA violations is not being overblown. In fact, they continue to happen with some frequency. In a recent poll by HcPro’s Compliance Monitor in which respondents were asked if they had ever had to discipline an employee for inappropriately accessing a medical record…surprise, surprise, the yes answers came in at 80%!

80% of the respondents had to discipline someone for a HIPAA violation! These violations were not always newsworthy, but they are scary nonetheless. The scary violations hit the news – “RN posts patient photo on Facebook”, “Local Medical Billing Company Records Found Blowing Down Major Highway”, etc.

HIPAA violations continue in large part because of a “lack” on the part of smaller healthcare entities such as medical and dental practices.

1) A lack of formal policies on HIPAA, compliance and a whole host of other important topics (including those falling under a human resource heading).

2) A lack of yearly training for staff and providers on HIPAA and other topics such as Harassment, Compliance, etc.

3) A lack of training on HIPAA, Compliance and more for the new employee.

4) A lack of formal disciplinary policies for violations of any of the practices policies.

5) A lack of a policy against the use of social media in the office, or even regarding the business itself.

6) A lack of a policy about the use of personal cell phones while at work.

The items lacking as listed above can provide protection for the practice, not only against HIPAA violations, but also against wrongful termination lawsuits and it may help mitigate any lawsuits or civil complaints filed against the practice.

The reasons many practices do not have these policies in place range from the absurd (their CPA advised them that having policies places them at more risk), to the simple (the practice does not have the staff depth to write and enforce the policies/provide the training and the practice feels they cannot afford to “hire the task out”).

The simple truth is that well written policies, staff training and enforcement will save your practice money in the long run by lessening risk to your practice, but insuring that your practice will weed out the non-compliant employees more quickly, and by protecting the reputation of you as a provider and your practice as a business.

Further, having policies about the use of cell phones and the use of social media can enhance the productivity of your practice, improve morale, and avoid the potential for HIPAA violations.

Social media is often used by disgruntled staff to complain about their company or their coworkers. Even if the posts are not about the practice, when they are happening during work hours, the practice productivity decreases. Many businesses are now blocking access to Facebook, Twitter, etc. from work computers, while others are demanding that they employees show their FB pages to the owner, manager or HR person regularly.

Blocking access on company computers is no longer enough when you  consider the fact that almost everyone has a smart phone now. If you don’t also have a policy restricting the carrying (not just the use) or cell phones during work hours, you are encouraging the potential for HIPAA violations and of course for decreased productivity.

It is quite simple really. If there is no phone or video immediately at hand, there is less impulse to click away. Without immediate access to the internet, there is less likelihood that that photo or video (or a complaint about a coworker) will hit the web BEFORE the brain can be engaged.

So if you have a need for policies, training or just a consultant to look around, please give Tom Maher CEO of PracticeFirst a call or email to see what we can do for you. Phone is 716-834-1191 or tom@pracfirst.

Procedure Code Description
20240 Biopsy, bone, open; superficial (e.g., ilium, sternum, spinous process, ribs, trochanter of femur)
20615 Aspiration and injection for treatment of bone cyst
20950 Monitoring of interstitial fluid pressure (includes insertion of device, e.g., wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome
21400 Closed treatment of fracture of orbit, except “blowout”; without manipulation
21800 Closed treatment of rib fracture, uncomplicated, each
21920 Biopsy, soft tissue of back or flank; superficial
22305 Closed treatment of vertebral process fracture(s)
22310 Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing
23030 Incision and drainage, shoulder area; deep abscess or hematoma
23065 Biopsy, soft tissue of shoulder area; superficial
23500 Closed treatment of clavicular fracture without manipulation
23540 Closed treatment of acromioclavicular dislocation; without manipulation
23570 Closed treatment of scapular fracture; without manipulation
23600 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation
23620 Closed treatment of greater tuberosity fracture without manipulation
24500 Closed treatment of humeral shaft fracture without manipulation
24560 Closed treatment of humeral epocondylar fracture, medial or lateral; without manipulation
24576 Closed treatment of humeral condylar fracture, medial or lateral; without manipulations
24650 Closed treatment of radial head or neck fracture without manipulation
24670 Closed treatment of ulnar fracture, proximal end (e.g., olecranon or coronoid process(es); without manipulation
25065 Biopsy, soft tissue of forearm and/or wrist; superficial
25500 Closed treatment of radial shaft fracture; without manipulation
25530 Closed treatment of ulnar shaft fracture; without manipulation
25560 Closed treatment of radial and ulnar shaft fractures; without manipulation
25600 Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation
25622 Closed treatment of carpal scaphoid (navicular) fracture; without manipulation
25630 Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); without manipulation, each bone
25650 Closed treatment of ulnar styloid fracture
26011 Drainage of finger abscess; complicated (e.g., felon)
26600 Closed treatment of metacarpal fracture, single; without manipulation, each bone
26720 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb without manipulation, each
26740 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each
26750 Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each
27086 Removal of foreign body, pelvis or hip; subcutaneous tissue
27193 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; without manipulation
27200 Closed treatment of coccygeal fracture
27238 Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; without manipulation
27323 Biopsy, soft tissues; superficial
27516 Closed treatment of distal femoral epiphyseal separation; without manipulation
27520 Closed treatment of patellar fracture, without manipulation
27530 Closed treatment of tibial fracture, proximal (plateau); without manipulation
27560 Closed treatment of patellar fracture; without anesthesia
27750 Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation
27760 Closed treatment of medial malleolus fracture; without manipulation
27767 Closed treatment of posterior malleolus fracture; without manipulation
27780 Closed treatment of proximal fibula or shaft fracture; without manipulation
27786 Closed treatment of distal fibular fracture (lateral malleolus); without manipulation
27808 Closed treatment of bimalleolar ankle fracture (e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation
27816 Closed treatment of trimalleolar ankle fracture; without manipulation
28400 Closed treatment of calcaneal fracture; without manipulation
28430 Closed treatment of talus fracture; without manipulation
28450 Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each
28470 Closed treatment of metatarsal fracture; without manipulation
28470 Removal of indwelling tunneled pleural catheter with cuff
28490 Closed treatment of fracture great toe, phalanx or phalanges; without manipulation
28510 Closed treatment of fracture, phalanx or plalanges, other than great toe; without manipulation each
28530 Closed treatment of sesamoid fracture
28540 Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia
28635 Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia
29355 Application of long leg cast (thigh to toes); walker or ambulatory type
29358 Application of long leg cast brace
29520 Strapping; hip
29720 Repair of spica, body cast or jacket
29740 Wedging of cast (except clubfoot casts)
29799 Application of post-op shoe