Applied Evidence

10 billing & coding tips to boost your reimbursement

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6. Watch your words when billing for derm procedures

To maximize your reimbursement of dermatologic procedures, you need to be especially mindful of the terminology you use and the descriptive details you record.

Start with terminology. A biopsy generally indicates that only a portion of a lesion was removed to obtain a histologic diagnosis, as in the case of a punch biopsy. When you remove an entire lesion, you use either a shave (horizontal partial-thickness cut that does not include the entire dermal layer) or an excision (a full-thickness removal of the lesion through the dermis to the adipose tissue). Using the correct terminology will ensure that you are properly reimbursed for the procedure you performed.

Focus on measurements. Size matters, too: The larger the lesion, the greater the reimbursement.

To bill for an excision, the size of the lesion must be documented and the excised area calculated by adding the lesion’s maximum diameter plus the sum of the narrowest margin.4 While margins are counted for excisions, that’s not the case with shaved lesions. The margins of a shaved lesion are not factored into the reimbursement formula, so document only the measurement of the lesion itself.

Location also dictates the scale of reimbursement, which is typically lower for procedures involving the trunk, arms, or legs than for those on the face or in the anogenital area. Malignant lesions also generate higher charges.

File multiple claims for multiple lesions. When multiple lesions are biopsied or removed during a single visit, file multiple claims, using modifier -59 for distinct (separate) procedural services.8 Be aware, however, that third-party payers may not provide full reimbursement for each lesion. For Medicare enrollees, routine excision of skin lesions is considered cosmetic and is not covered unless the lesions have malignant or potentially malignant, symptomatic, or functionally impairing features.

7. Use a template for the “Welcome to Medicare” exam

All new Medicare Part B beneficiaries are entitled to a “Welcome to Medicare” exam within their first 6 months of enrollment. It has 7 elements, all of which are required for full reimbursement. To appropriately conduct and bill for this exam, create a template listing all the requisite elements:

  1. A comprehensive review of the patient’s medical, social, and family history
  2. A review of risk factors for depression
  3. A review of functional ability and level of safety
  4. A focused physical exam (weight, height, blood pressure, and visual acuity are the only requirements)
  5. An electrocardiogram, with interpretation
  6. Brief education, counseling, and referral to address any issues discovered in the first 5 elements
  7. Brief education, counseling, and referral, with a written plan for the patient regarding preventive services covered by Part B.9

To be reimbursed for the Welcome to Medicare exam, it is necessary to use 2 separate billing codes: G0344 for the physical examination (paid at a rate equal to a 99203 visit) and G0366 for the electrocardiogram.9 Although CMS does not provide coverage for a general preventive examination other than this initial “Welcome to Medicare” visit, many recommended preventive health services are covered by Medicare at specified intervals (TABLE 3).9

TABLE 3
Preventive services covered by Medicare

  • Vaccinations
    Influenza (yearly)
    Pneumococcal (once)
    Hepatitis B (1 series)
  • Bone mass measurement
    For those at risk for osteoporosis (every 2 years)
  • Cardiovascular disease screening
    Fasting lipid panel (every 5 years)
    Ultrasound screening for abdominal aortic aneurysm for men who have a family history or are between the ages of 65 and 75 and have smoked at least 100 cigarettes
  • Colorectal cancer screening
    (according to risk category)
    Colonoscopy
    Flexible sigmoidoscopy
    Barium enema
    Fecal occult blood testing
  • Glaucoma screening (yearly)
  • Diabetes screening
    Fasting blood glucose or oral glucose tolerance test yearly for those who are at risk for diabetes or have at least 2 of the following:
      —Obesity
      —Family history of diabetes
      —Age >65
      —History of gestational diabetes
    Twice yearly screens for those diagnosed with prediabetes
    Diabetes outpatient self-management training and medical nutritional therapy for patients with diabetes and/or renal disease
  • Mammography (yearly, with baseline at age 40)
  • Pap test and pelvic screening exam
    (every 2 years unless high risk)
  • Prostate cancer screening (yearly)
    Digital rectal examination
    Prostate-specific antigen (PSA) assay
Adapted from: Centers for Medicare and Medicaid Services.9

8. Code injections with care

Whether you are administering vaccines or analgesics, coding for injections presents multiple opportunities for error. Physicians often include the code for a vaccine, but forget the procedure code for its administration.

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