By Karin Bajak, Director of Billing; and, Lisa Kropp, Director of Coding for PracticeFirst

Despite this being in our July Newsletter, the time to order flu vaccines and prepare for the vaccination rush is now!


CMS Announces New Flu Vaccine Code (Effective 7/1/2012)

Effective for dates of service on or after July 1, 2012, for claims processed on or after October 1, 2012, Medicare will recognize Healthcare Common Procedure Coding System (HCPCS) code Q2034.

Q2034 – Influenza virus vaccine, split virus, for intramuscular use (Agriflu)

Don’t Forget Modifier 25!

Remember that if you provide vaccinations (or any injection) during a visit at which you provide another service, you should bill for both services. Often, an evaluation and management (E/M) service is provided on the same date as a vaccination. As this is a significant and separately identifiable E/M service provided on the same date as vaccination, the E/M service should be reported with modifier 25.

There is An Exception Though! For Medicare and other payers who follow the National Correct Coding Initiative, code 99211 is not reportable with a vaccine administration code on the same date of service.


Remember to code for the administration of vaccines!

The CPT code for the vaccine is only part of the claim; payment for this code is intended to cover only the costs associated with the vaccine itself (such as the cost of the vaccine, delivery and storage). To get paid for the costs associated with administering the vaccine (counseling, injection time, syringe and documentation), you also need to report a code for the administration. This is usually a CPT code or, in a few instances, a Healthcare Common Procedure Coding System (HCPCS) code.

The CPT immunization administration codes run from 90465 through 90474. Codes 90465 through 90468 are for vaccinating patients younger than eight years of age when the physician counsels the patient or family, which is a critical influence on patients’ willingness to be vaccinated.

Codes 90471 through 90474 are for vaccine administration when the patient is eight or older or when the physician does not counsel the patient or family.

In both code sets, the correct choice depends on the route of administration and whether the vaccine administered was the first one or an additional one.

Warning – Medicare has some special HCPCS administration codes for the vaccines it covers:

  • G0008 Administration of influenza virus vaccine,
  • G0009 Administration of pneumococcal vaccine,
  • G0010 Administration of hepatitis B vaccine.

A guide to using HCPCS codes for immunizations is available on the CMS Web site at

Remind Your Staff to Code the Diagnosis for Vaccines Correctly

One of the most common reasons for rejections and denials of vaccines is a mismatch between the diagnosis code and CPT or HCPCS code you use.  These simple mistakes result in practices experiencing delays in receiving payment for the vaccine and its administration until the error is corrected.

The diagnosis codes supporting prophylactic vaccination begin with V03.0 (“Need for prophylactic vaccination and inoculation against bacterial diseases; cholera alone”) and end with V06.9 (“Need for prophylactic vaccination and inoculation against combinations of diseases; unspecified combined vaccine”).

One vaccine may not seem like much in the overall reimbursement scheme, but practices should not be giving anything away. If you add up all the time and costs associated with vaccine administration, you will understand why it is important to claim everything you legally can. Common examples include practices billing for the vaccine but not for the corresponding vaccine administration code or !WORSE! billing for administering an injection but failing to bill for the vaccine itself injected. These can be extremely costly mistakes.

Practice Preparation for Flu Season

Here is a list of FDA Approved Influenza Virus Vaccines, Trivalent, Types A and B




Medicare is expanding the Multiple Procedural Payment Reduction (MPPR) to the Professional Component (PC) in addition to the Technical Component (TC) of certain diagnostic imaging procedures.

EFFECTIVE DATE: January 1, 2012


Section 3134 of the Affordable Care Act (ACA) added section 1848(c)(2)(K) of the Social Security Act which specifies that the Secretary shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service.

As a further step in implementing this provision, Medicare is making a change to the multiple procedure payment reduction (MPPR) on the TC of certain diagnostic imaging procedures.

Specifically, we are applying the MPPR to professional component (PC) services as well as to TC services.


Background: Section 3134 of the Affordable Care Act (ACA) added section 1848(c)(2)(K) of the Social Security Act which specifies that the Secretary shall identify potentially mis-valued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. As a further step in implementing this provision, Medicare is making a change to the multiple procedure payment reduction (MPPR) on the TC of certain diagnostic imaging procedures. Specifically, we are applying the MPPR to professional component (PC) services as well as to TC services. The proposal will be discussed in future rulemaking. This advanced notice is provided so contractors can begin making the necessary systems changes for the policy to go in effect January 1, 2012.

Policy: The MPPR on diagnostic imaging applies when multiple services are furnished by the same physician to the same patient in the same session on the same day. Currently, the MPPR on diagnostic imaging services applies only to technical component (TC) services. It applies to both TC-only services and to the TC portion of global services. Full payment is made for the service with the highest TC payment under the Medicare Physician Fee Schedule (MPFS). Payment is made at 50 percent for the TC of subsequent services furnished by the same physician to the same patient in the same session on the same day.

We are expanding the MPPR by applying it to professional component (PC) services. Full payment is made for each PC and TC service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent PC services furnished by the same physician to the same patient in the same session on the same day. Payment is made at 50 percent for subsequent TC services furnished by the same physician to the same patient in the same session on the same day. The complete list of codes subject to the MPPR on diagnostic imaging is in Attachment 1.

The individual PC and TC services with the highest payments under the MPFS of globally billed services must be determined in order to calculate the reduction. The current and proposed payments are summarized in the following example:

Procedure 1 Payment Procedure 2 Payment Current Total Payment Current Payment Calculation Proposed Total Payment Proposed Payment Calculation
PC $68 $102 $170 No reduction $153 $102 + (.75 x $68)
TC $476 $340 $646 $476 + (.50 x $340) $646 $476 + (.50 x $340)
Global $544 $442 $816 $170 + $476 + (.50 x $340) $799 $102 + (.75 x $68) + $476 + (.50 x $340)

Procedures to Which This Applies:


By Emilie J DiChristina, MBA, CPHQ for PracticeFirst

As the July 2012 PracticeFirst Client Memo and Newsletter noted, the use of  Electronic Health Records can be very helpful, but EMRs also offer a wide variety of shortcuts which can lead to a compliance audit for documentation. These audits will not just arise from CMS, but also from private payors and the NY State Medicaid Office of the Inspector General.

So what are the shortcuts that can lead to trouble?

First, BEWARE of the “copy and paste” function, which is also known as “cloning”.

The use of “copy and paste” allows past notes (or portions of notes) to be pulled forward into the documentation for a current visit. Obviously, it is a time saver when used appropriately, but it can result in a misrepresentation of the reason for the patient’s visit and cause fraudulent billing claims.

It may be appropriate to “copy and paste” the following: “Patient is a 42 year old well nourished woman here for an annual physical.” Unfortunately it is easy to start out your documentation with that statement (because of “cut and paste”) when in fact the woman was in your office for an acute problem such as fatigue. People who are not familiar with EMR, or who type poorly, or who are busy may forget to stop the “copy and paste” at “Patient is a 42 year old well nourished woman here for”…subsequently choosing the current presenting symptom to complete the statement.

As helpful as you and your staff may find the practice of “cut and paste” or “cloning” may be, carrying forward information without word for word review can inadvertently cause contradictions in a patient’s chief complaint documentation or history of present illness.

Obviously this is not only a compliance issue, but also poses a med-mal risk as previous  complaints or symptoms in current documentation can lead to errors, including misinformed treatment and billing/coding.

Think this never happens? Do a bit of research in your professional journals where you will even find accounts of “clinical plagiarism” where physicians have cut and pasted large blocks of text, or even complete notes, from other physicians. The consequences for patients when this happens can be significant.

Once “cloning” becomes a habit, each record in which the individual provider or staff member documents is now suspect, from the medical malpractice viewpoint right through into the inability to prove that procedures and tests were done and reviewed, medications were modified based on correct lab work (e.g. Coumadin, antibiotics), and much more.

Next, beware of “Macros”. Macros represent the potential for significant efficiency in the EHR if all patients were unisex, and presenting with the same problem.

Basically, “macros”are templates of “standard” or “usual” review of systems, taking of a HPI, or description of a procedure. These became somewhat common during the use of dictation to save the provider and the transcriptionist time. The provider would dictate “use standard cardiac exam macro”, and the transcriptionist would push a button whereupon the words would fill in while the dictation continued.

Now, with many EHRs there is no transcriptionist, so the provider has these “macros” built in to drop down when a box is pushed. Imagine how a tired provider with bleary eyes can accidentally hit one macro above or below the one he or she wanted!

Here is an excellent example of how badly documentation can be badly messed up – it comes from Emergency Physicians Monthly in their May 6, 2011 edition:

Macro Medicine
by Michael Frank, MD, JD on May 6, 2011

Macros, whether dictated or from an EMR, may be quickly, inadvertently, and inappropriately invoked. The result can be more than just embarrassing. For example, a female patient who sustained some minor injuries from a fall obtained a copy of her ED medical record and wrote a letter complaining about multiple discrepancies between the documentation and what actually happened in the ED.  The chart read as follows:

“KNEE EXAMINATION: The patient has full range of motion of the knee. There is no local swelling or tenderness. There is no instability with the medial or collateral lateral ligament stress. There is normal Lachman test with no instability. McMurray’s test is done with no locking or clicking & no significant pain. There are no effusions.”

In response to this, the patient wrote, “Not done at all. Had one been done, it would have been evident that I had multiple knee surgeries including a total knee replacement from the scars on my right knee.” The chart went on to say,

“There is normal external female genitalia & normal vaginal introitus & mucosa. There is no cervical motion tenderness or lesions. The uterus & adnexa have no masses or tenderness. There is no purulent vaginal discharge.”

The patient responded with, “Not done at all, nor would I expect it due to a fall landing on my shoulder. Also, I had a total hysterectomy in 1982. Therefore, I do not have a cervix, uterus, or ovaries. I am understandably upset about the inaccurate information concerning my physical exam and would not like to see my insurance company billed for things that were not done. Nor, do I want inaccurate information in my health record.”

A quick check with the doc confirmed a bad case of “documentation with brain-disengaged” syndrome. His correcting addendum included the following: “My normal template components were transcribed.” Fortunately for the doc, the patient directed her concerns to the EP group, rather than bringing what appeared to be a case of fraud to the attention of her insurer or federal authorities.

Finally, Re-consider the Use of Scribes. “Scribes” essentially are staff members that are in the room with the provider when he/she is performing exams, procedures, and tests for the purpose of documenting in the EHR and insuring prescriptions or tests are ordered electronically as stated by the provider. 

Scribing, or authenticating notes made by another person, can be a fraudulent act if not clearly acknowledged by the provider for whom the scribe was scribing.

Scribing can be more risky and hard to detect in an EHR, even though scribing has long been in use on paper charts. The reason is simple, no handwriting to compare, so it is harder to track if the scribe made an error or if the provider made the error.

Another major risk of the EHR when scribes are used, is the fact that once the provider logs in to add any documentation, or simply to sign off on the order, the provider has now “over-written” the note. In essence, unless the provider checked everything line by line, double checked each decimal point in the prescriptions, etc., his or her access to the record now result in the provider erasing any way to check what, if anything, the scribe may have done incorrectly.

“Over-writing” in EHRs can also misrepresents who provided the service. This has ramifications for scope of care (unlicensed vs. licensed personnel) and for billing and compliance. By misrepresenting who provided the “scribed” service and then submitting that for billing, providers may both be violating their own license by allowing (or appearing to allow) unlicensed personnel to perform services, and committing fraud by signing that they performed a service done by another person (such as a HPI taken by a medical assistant).

Also, if a provider simply “over-writes” without making necessary checks and amendments, he/she may miss errors made inadvertently by themselves or their scribes. For example, two of the most common types of medication errors include prescribing or administering the wrong drug,  and names of medication are confused because of similarities. Do you think it is possible that a scribe could confuse “Tramadol and Toradol”? Of course you can – that is why it is one of the most common mistakes!

Bottom Line?

The INAPPROPRIATE use of “copy & paste”/”cloning, macros, and scribes can place you at risk of complaints of billing fraud and of course medical negligence.Think this may be an overstatement?

You have to remember that as the provider of record for the patient, you are responsible for the contents of the medical record for any service you provide, So whether you (or someone else) pushed the wrong button, cloned too much, or entered the wrong diagnosis/medication, etc. – YOU are the one doing the explaining of why you did not commit fraud or medical negligence. (see the definitions of each below)

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person (this includes anyone who does not insure that material cloned, scribed or entered by macro is an accurate representation of what he/she as the provider actually did).

Medical negligence occurs when a healthcare provider injures a patient by failing to provide a standard of care. Healthcare providers owe patients a certain standard of duty. When actions or lack of actions are done in a negligent manner (this includes failing to insure that material cloned, scribed or entered by macro is an accurate representation of what he/she as the provider actually saw, heard and prescribed) that results in injuries, the healthcare provider may be held liable for those injuries, including the medical treatments necessary to help correct the new injuries that have occurre


By Karin Bajak, PracticeFirst Billing Manager


Effective September 1, 2012, reimbursement fees for sclerotherapy services will change!

Current reimbursement rates have become unsustainable and Blue Cross is faced with the challenge of containing the cost for these services.

To view the reimbursement changes please visit website Go to News& Updates, Volume 18, 2012 bulletins, and then to Issue 14.



Effective July 2012, United Healthcare will introduce a new portfolio of products in New York called United Healthcare Navigate.

United Healthcare Navigate is a new portfolio that emphasizes the role of the primary care physician. United Healthcare Navigate will be available in New York July 2012.


New HCPCS code G0447 – Face to face behavioral counseling for obesity, 15 minutes.

This code is applicable to all MVP Medicare Advantage plan members when services occur in the primary care setting. MVP’s fee schedules are updated to include this new code.


Stay ahead of Medicare!

All physicians who order items and/or refer patients MUST have a valid enrollment record in the Medicare database.

Phase II of their initiative involves implementing edits to deny claims for providers that do NOT have an active enrollment record in PECOS.  They have NOT announced a date the edits will begin but are warning physicians in advance!

If you’ve received a request from Medicare to revalidate your enrollment; make sure you comply!  Remember we can help!

For Billing questions, please contact Karin Bajak at 716-348-3923 or


By Lisa Kropp, Director of Coding and Credentialing; and; Emilie J DiChristina, Consultant to PracticeFirst

Comparative Billing Reports (CBR’s)

CMS Began Release of Comparative Billing Report on E & M Services – 6/4/2012

Purpose of CBR’s: – Compare provider’s billing and payment patterns to those of their peers located in the state and across the nation.

Will everyone get one? – No.  Safeguard Services LLC has been contracted by CMS to develop topics for study such as E & M.

What should I do when and if I receive a CBR report? – Analyze the info and look for areas of potential risk.  For example, if you are higher than your peers in submitting level 5 office visits, you will need to identify why. Send a copy to Practicefirst!  We can help you interpret the information and can offer audit services to help you further identify risk areas.

What Does The CBR Mean to Providers and Can CBRs Trigger an Audit?

The first question providers ask is whether or not the CBRs are a precursor to a Medicare Audit. If you ask this you are not being paranoid, but rather have a good understanding of causality.

Certainly, the Centers for Medicare and Medicaid Services (CMS) statement that the CBR is a tool to educate providers about their individual billing practices is true. Any information such as CBRs can show individual providers how their billing patterns for various codes and procedures compare to the state average and the national average for their peers.

Any comparative study of coding and billing patterns are designed to help providers review their coding and billing habits and utilization patterns. This type of study is something that we as a third party biller and coding company recommend for our clients because it can enhance revenue and avoid compliance issues. This is a proactive approach that shows that your practice has an effective compliance plan. NOTE: some studies have shown that minimum of yearly billing and coding audits can identify legitimate revenue being left on the table.

In implementing the CBRs, CMS has stated that “the CBR is not intended to be punitive or sent as an indication of fraud. Rather it is intended to be a proactive statement that will help the provider identify potential errors in their billing practice.” But CBRs may also reveal issues that leave providers vulnerable to future audit activity (or put them on notice of overpayments) – the big difference here is that when you request the audit be done for your practice, you may still find issues and overpayments, but you can then self-report and demonstrate that YOU as the provider are on top of these issues.

Up to now the provider types that CMS identified to receive CBRs were chiropractors, ambulances, hospices, podiatrists, physical therapists and providers of sleep studies and spinal orthotics.These providers were identified because of certain billing vulnerabilities that had been noted by CMS. The question is what billing or coding outlier will trigger the next provider type to be subjected to the CBR process…it may be your specialty next.

A maximum of 5,000 providers in each provider class will be selected to receive CBRs. Medicare updates the data twice a year. CBRs are only available to the provider who receives them and they only contain summary billing information to insure privacy. The purpose of to encourage providers to use the summary as a tool to improve compliance with Medicare billing rules and correct any current billing errors. .

Now for the really scary stuff… CBR data analysis uses the same data-mining tools used by Medicare audit contractors to identify candidates for audit so you can honestly extrapolate that any vulnerabilities identified in the CBR may eventually be identified by CMS contractors who select providers for audit. Simply as a result of both systems looking for outliers within the same data-mining process, and using the same data exception rules, providers who are identified as outliers in CBRs will likely be subject to audits.

Upon receiving a CBR, it is vital that providers evaluate the information included and involve PracticeFirst (as well as your current coding auditor if you use another service) in reviewing the data and in performing an internal compliance audit.

Sometimes these outliers may be explained by a different population being served by the provider, or simple errors, however without an effective compliance plan, the provider may have quite a bit of explaining to do without the support of compliance policies for any identified or high risk areas.

We recommend that you consider a compliance plan for your office (did we mention the New York State Medicaid OIG is also looking for providers WITHOUT an effective compliance plan) and give our office a call for any help you may need in understanding CBRs, RAC audits, or the need for a compliance program.

Minimally, we recommend that you look for more information and to review a sample of the Evaluation and Management Services CBR, by visiting call the SafeGuard Services’ Provider Help Desk, CBR Support Team at 530-896-7080.


Attachment 1
Diagnostic Imaging Services Subject to the Multiple Procedure Payment Reduction
CPT/HCPCS Code Short Descriptor
70336 Magnetic image jaw joint
70450 Ct head/brain w/o dye
70460 Ct head/brain w/dye
70470 Ct head/brain w/o & w/dye
70480 Ct orbit/ear/fossa w/o dye
70481 Ct orbit/ear/fossa w/dye
70482 Ct orbit/ear/fossa w/o&w/dye
70486 Ct maxillofacial w/o dye
70487 Ct maxillofacial w/dye
70488 Ct maxillofacial w/o & w/dye
70490 Ct soft tissue neck w/o dye
70491 Ct soft tissue neck w/dye
70492 Ct sft tsue nck w/o & w/dye
70496 Ct angiography head
70498 Ct angiography neck
70540 Mri orbit/face/neck w/o dye
70542 Mri orbit/face/neck w/dye
70543 Mri orbt/fac/nck w/o & w/dye
70544 Mr angiography head w/o dye
70545 Mr angiography head w/dye
70546 Mr angiograph head w/o&w/dye
70547 Mr angiography neck w/o dye
70548 Mr angiography neck w/dye
70549 Mr angiograph neck w/o&w/dye
70551 Mri brain w/o dye
70552 Mri brain w/dye
70553 Mri brain w/o & w/dye
70554 Fmri brain by tech
71250 Ct thorax w/o dye
71260 Ct thorax w/dye
71270 Ct thorax w/o & w/dye
71275 Ct angiography, chest
71550 Mri chest w/o dye
71551 Mri chest w/dye
71552 Mri chest w/o & w/ dye
71555 Mri angio chest w/ or w/o dye
72125 Ct neck spine w/o dye
72126 Ct neck spine w/dye
72127 Ct neck spine w/o & w/dye
72128 Ct chest spine w/o dye
72129 Ct chest spine w/dye
72130 Ct chest spine w/o & w/dye
72131 Ct lumbar spine w/o dye
72132 Ct lumbar spine w/dye
72133 Ct lumbar spine w/o & w/dye
72141 Mri neck spine w/o dye
72142 Mri neck spine w/dye
72146 Mri chest spine w/o dye
72147 Mri chest spine w/dye
72148 Mri lumbar spine w/o dye
72149 Mri lumbar spine w/dye
72156 Mri neck spine w/o & w/dye
72157 Mri chest spine w/o & w/dye
72158 Mri lumbar spine w/o & w/dye
72159 Mr angio spine w/o&w/dye
72191 Ct angiograph pelv w/o&w/dye
72192 Ct pelvis w/o dye
72193 Ct pelvis w/dye
72194 Ct pelvis w/o & w/dye
72195 Mri pelvis w/o dye
72196 Mri pelvis w/dye
72197 Mri pelvis w/o & w/dye
72198 Mr angio pelvis w/o & w/dye
73200 Ct upper extremity w/o dye
73201 Ct upper extremity w/dye
73202 Ct uppr extremity w/o&w/dye
73206 Ct angio upr extrm w/o&w/dye
73218 Mri upper extremity w/o dye
73219 Mri upper extremity w/dye
73220 Mri uppr extremity w/o&w/dye
73221 Mri joint upr extrem w/o dye
73222 Mri joint upr extrem w/dye
73223 Mri joint upr extr w/o&w/dye
73225 Mr angio upr extr w/o&w/dye
73700 Ct lower extremity w/o dye
73701 Ct lower extremity w/dye
73702 Ct lwr extremity w/o&w/dye
73706 Ct angio lwr extr w/o&w/dye
73718 Mri lower extremity w/o dye
73719 Mri lower extremity w/dye
73720 Mri lwr extremity w/o&w/dye
73721 Mri jnt of lwr extre w/o dye
73722 Mri joint of lwr extr w/dye
73723 Mri joint lwr extr w/o&w/dye
73725 Mr ang lwr ext w or w/o dye
74150 Ct abdomen w/o dye
74160 Ct abdomen w/dye
74170 Ct abdomen w/o & w/dye
74175 Ct angio abdom w/o & w/dye
74176 Ct abd & pelvis
74177 Ct abd & pelv w/contrast
74178 Ct abd & pelv 1/> regns
74181 Mri abdomen w/o dye
74182 Mri abdomen w/dye
74183 Mri abdomen w/o & w/dye
74185 Mri angio abdom w orw/o dye
74261 Ct colonography dx
74262 Ct colonography dx w/dye
75557 Cardiac mri for morph
75559 Cardiac mri w/stress img
75561 Cardiac mri for morph w/dye
75563 Card mri w/stress img & dye
75571 Ct hrt w/o dye w/ca test
75572 Ct hrt w/3d image
75573 Ct hrt w/3d image congen
75574 Ct angio hrt w/3d image
75635 Ct angio abdominal arteries
76604 Us exam chest
76700 Us exam abdom complete
76705 Echo exam of abdomen
76770 Us exam abdo back wall comp
76775 Us exam abdo back wall lim
76776 Us exam k transpl w/doppler
76831 Echo exam uterus
76856 Us exam pelvic complete
76857 Us exam pelvic limited
76870 Us exam scrotum
77058 Mri one breast
77059 Mri both breasts