By Lisa Kropp, Coding and Credentialing Manager


Revisions, addition and deletions to the CPT and HCPCS code set are effective January 1, 2014. Use of deleted codes will delay payment, as we will need to “Chart Return” the charge slips to your office for the correct code.

To determine which clients will be impacted by the 2014 changes, we have compared these changes to each client’s procedures performed in 2013.

We have faxed, mailed or delivered customized reports to our Clients that are impacted by the 2014 CPT changes.

We apologize for the late notice, but based on the complexity of CPT changes, it took some time to compile this information for you. 

If you would like a complete listing of all the Deleted, New, and Revised Codes, we can provide that upon request.




2014 brings four new consult codes (99446-99449), for inter-professional telephonic/Internet assessment and management service provided by a consultative physician, including a verbal or written report to patient’s treating/requesting physician or qualified healthcare professional.  Codes are based on time. 

**These codes may not be reported when a transfer of care has occurred, is expected, or is planned.  For detailed descriptions of these codes, please refer to your 2014 CPT ® book.


 There are at least 19 new cardiology procedure codes added in CPT ® 2014.  Highlights below:

  •  One of the biggest changes for peripheral vascular physicians is the creation of five new codes (37217 and 37236-37239) for peripheral stenting which bundle radiological supervision and interpretation.
  • Addition of 8 Category I codes (34841-34848) for fenestrated endovascular aorta repair (FEVAR) could be big news for interventional cardiologists that were reporting the procedure with Category III codes (0078T-0081T)
  • Four new codes (37241-37244) for reporting vascular embolization or occlusion, which also bundle supervision & interpretation, intra-procedural road mapping and image guidance.

*These codes are divided out for venous; arterial; tumors, organ ischemia or infarction; and arterial or venous with hemorrhage.  The codes will replace deleted codes 37204 (Transcatheter occlusion or embolization) and 37210 (Uterine fibroid embolization)


  •  Majority of changes for new endoscopic technology, multi-system image guidance techniques and more combined services.
  • Gastroenterology has 54 changes (23 new codes and 41 revisions to existing codes)
  • Endoscopy has major changes including the addition of 26 new codes, revision of 41 codes and deletion of 17.
  • In CPT ® 2014, providers will select their esophogoscopy codes based on whether the scope is rigid or flexible, transoral or transnasal, in addition to the actual procedure performed.


In 2013, Medicare released new CPT codes for billing a post hospital follow up visit in your office.  Here are the requirements to bill for these services:

99495 Transitional Care Management Services (Moderate Complexity)

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days post-discharge
  • Medical Decision Making of at LEAST moderate complexity during the service period
  • Face to face visit, within 14 calendar days post-discharge

 99496 Transitional Care Management Services (Moderate Complexity)

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days post-discharge
  • Medical Decision Making of HIGH complexity during the service period
  • Face to face visit, within 7 calendar days post-discharge<


By Becky Amann, Compliance Officer


The first week in January, we forwarded a Modifier Memo and corresponding letter to your office. A copy of both documents is attached in case you are unaware of our initial mailing. If we anticipate a claim will deny due to a lacking modifier, the Modifier Memo and the corresponding charge slip will be sent to your office as a “Chart Return” as explained in the Billing Updates section of this client memo. The Modifier Memo does not apply to PF’s PBS Medcode Corp. clients.   



National Government Services (NGS) will be conducting prepay audits for multiple Non-invasive Diagnostic Vascular Studies.

The CPT codes to be reviewed are as follows:

  • 93880 or 93882 when reported on the same day as 93970, 93971, 93925, and/or 93926
  • 93970 or 93971 when reported on the same day as 93880, 93882, 93925, and/or 93926
  • 93925 or 93926 when reported on the same day as 93880, 93882, 93970, and/or 93971

Providers can assist in this process by:

  • Reviewing all contractor provider publication and local coverage determinations (LCDs).
  • Understanding Medicare coverage requirements.
  • Ensuring office staff is familiar with claim filing requirements.
  • Performing self-audits of medical records against billed claims using coverage criteria, LCD, and coding guidelines.
  • Responding to request(s) for records in a timely manner. CMS requires that providers respond to an Additional Development Request (ADR) within 30 days of the request.
  • Ensuring documentation is legible and demonstrates that the patient’s condition warrants the services being reported and billed.


National Government Services (NGS) will be conducting prepay audits for Rhythm ECG’s, one to three leads; Interpretation and Report, CPT 93042.

Medical review data has recently identified a large volume of claims being billed for CPT 93042 reported in an in-patient place of service.

Per NGS, a review of medical documentation supports beneficiaries were receiving telemetry monitoring. It is not appropriate to bill this procedure code for reviewing monitor strips taken from a telemetry monitoring system.

The Coding Tip in the CPT Manual for reporting electrocardiographic recordings states:

“Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated. There must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report. It is not appropriate to use these codes for reviewing the telemetry monitor strips taken from a monitoring system. The need for an electrocardiogram or rhythm strip should be supported by documentation in the patient medical record.”

A prepayment review consists of a medical review of claims prior to payment. Request for records are most frequently electronically generated and referred to as ADR’s.

The primary focus of these edits will be to better identify common billing errors, develop educational efforts, and prevent improper payments. Providers will be receiving ADR’s asking for documentation to support the service billed. Medical Review encourages providers to respond with the requested documentation in a timely manner to expedite adjudication of these claims.



Blue Cross’s STAT dated December 13, 2013 is targeting providers who are participating with their Medicare Advantage plans.

The STAT indicates that Fraud, Waste and Abuse training is required for providers who render services to Medicare Part C enrollees (Medicare Advantage plan members).

What providers need to do:

  • If you are enrolled in Medicare, you fall under the “deeming” exception based on your enrollment with Medicare.
    • This means you can access Blue Cross’s website and enter basic information that will qualify you for the Fraud, Waste and Abuse training. Please access their website at: and complete the information requested. Your Medicare Enrollment Number is your Medicare PTAN. If you do not have a record of your PTAN, please contact your Medical Billing Specialist assigned to your account and PF and he/she can provide that number to you.
  •  If you have already completed Fraud, Waste and Abuse training that meets CMS’s requirements, Blue Cross will accept documentation of the training.
  • Blue Cross will also accept documentation confirming the completion of CMS’s Fraud, Waste and Abuse training, that is located at:
  • After accessing CMS’s website, click on the link to MLN Provider Compliance under the MLN Products list. Scroll down and click on the link to the Fraud, Waste and Abuse Educational Products and select the Web-Based Training Course.

To review the Blue Cross STAT regarding this requirement, please access

Click on Provider, → News & Events, → Provider Bulletins, → Volume 19, 2013, and scroll down to Issue 30 (Fraud, Waste and Abuse Training


By Sarah Howarth, Billing Manager


Charge slips / Encounters that cannot be submitted to the insurance carrier due to pertinent billing information that is lacking are returned to your office on a weekly basis, as a Chart Return. For PF’s non-PBS Medcode Corp. clients, examples of lacking information can pertain to missing CPT codes, diagnosis codes, modifiers, dates of service, etc. For PF’s PBS Medcode Corp. clients, examples of lacking information can pertain to size of laceration, final diagnosis missing, chart pages missing, etc.

At the end of each month, you will receive a summary of all outstanding Chart Returns. These claims have not been paid or submitted to the insurance carrier. Please keep in mind that any Chart Returns that you have recently addressed may not have been reviewed by our staff yet and subsequently still appear on the month-end Chart Return summary.  

If you do not have an understanding of why the Charge slip / Encounter has been returned to you, please contact us.


Beginning January 1, 2014, you may begin to see some Univera Healthcare member identification cards bearing the TPA (Third Party Administrator) logo.  Referral and preauthorization requirements for this line of business will be indicated on the back of the ID card.  Please provide Practicefirst with copies of the new insurance cards to ensure claim processing runs smoothly for your practice. 



If you are participating in the Medicare EHR Incentive Program, you must attest to demonstrating meaningful use of the data collected in 2013 by February 28, 2014. 

2014 is the last year to begin participation in the EHR Incentive Program. The first year of participation requires reporting for a continuous 90-day period.  Reporting for following years involves meeting the requirements for the entire calendar year.


January 1, 2014 will mark a new reporting period for the Medicare Physician Quality Reporting System. To avoid a payment reduction of 1.5% in 2016, providers must fulfill the reporting requirements for PQRS.  Providers must report on 3 measures or 1-2 measures for at least 50% of Medicare Part B patients seen in 2014. Additional information regarding the requirements for 2014 will be posted on the CMS website by December 31, 2013. 


One of the provisions included in the CY 2014 Physician Fee schedule final rule includes a separate payment for chronic care management services which will begin in 2015.

Primary Care and Chronic Care Management: As part of CMS’s ongoing efforts to appropriately value primary care services, Medicare will begin making a separate payment for chronic care management services beginning in 2015. In last year’s final rule, CMS established separate payment for transitional care management services for a beneficiary making the transition from a facility to the community setting. In this final rule, CMS further emphasized their support for advanced primary care through their establishment of policies to facilitate separate payment for non-face-to-face chronic care management services for Medicare beneficiaries who have multiple (two or more), significant chronic conditions.

Chronic care management services include the development, revision, and implementation of a plan of care; communication with the patient, caregivers, and other treating health professionals and medication management. Medicare beneficiaries with multiple chronic conditions who wish to receive these services can choose a physician or other eligible practitioner from a qualified practice to furnish these services over 30-day periods.

To review the final policy fact sheet, please access:


CMS has issued the following guidance for the Health Insurance Marketplace:

It is the beginning of the New Year and you’ll be verifying your patient’s insurance status when they show up in your office. With the beginning of the Health Insurance Marketplace, also known as Health Insurance Exchange, over a million people will have a new insurance plan. In many cases, this will be the first time they have had insurance in years.   Many of these people will have signed up for their plan within the past few days. They may not have received their card yet or they may be unaware of the need to carry their insurance information. You may find your office needing to verify their coverage.

 How do you verify their coverage?

If the marketplace in your state is run by the Federal government, it is best to call their plan’s customer service line, a list of all plans and their customer service numbers can be found at:

 A fact sheet can be utilized for using the data base which is located:

If you can’t find the number, call the Marketplace Call Center (1-800-318-2596).

If your state has its own health insurance exchange, contact your state. To find the website for your state exchange, select the name of your state in the box at the left hand side of the health care website at:

How else can you help your patient?

Remind your patients to keep all of their paperwork and receipts from all of their doctor’s appointments and from the pharmacy as well. They may need them for their insurer. Remind them they should carry their card at all times. If they don’t have a card, they can contact their plan to get a card.

 If the patient is uninsured, they have until March 31st to sign up for non-employer based coverage. They can go to to sign up for a plan and apply for financial assistance. The vast majority of uninsured will qualify for financial assistance to reduce their costs. You can also download copies of various fact sheets or educational material for your patients at:

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