Fall Risk Prevention Program: Part 1

Question:

We want to institute a Fall Risk Prevention Program in our practice to take advantage of CMS's Merit-based Incentive Payment System (MIPS). Based on CMS’s 2024 Quality Measures List, what codes should we report, and can our practice's medical assistant (MA) capture this work? 

Answer:

It is great that your practice will institute a Fall Risk Prevention Program to capture MIPS. According to CMS’s 2024 Quality Measures list, there are 2 measures reportable in this category. 

Quality measure number 155 - Falls: Plan of Care. This measure is designed to capture the percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months. 

Quality measure number 318 – Falls: Screening for Future Fall Risk. This measure is designed to capture the percentage of patients 65 years of age and older screened for future fall risk during the measurement period. 

Per CPT, these quality measures should be reported with Category II tracking codes, which are used for performance measurement. 

The applicable category II CPT codes for these MIPS measures are as follows: 

• 1100F: Patient screened for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year (GER). 

• 1101F: Patient screened for future fall risk; documentation of no falls in the past year or only 1 fall without injury in the past year (GER). 

An MA can capture the work to assist the clinician when reporting these Category II CPT codes. 

*This response is based on the best information available as of 9/5/24.

 

 

 

Transcutaneous Magnetic Nerve Stimulation

Question:

How is this service reported, we are having trouble locating a CPT code, should we use an unlisted code?

Answer:

This service should not be reported with an unlisted code.New Category III codes were created in 2023 to report transcutaneous magnetic nerve stimulation of peripheral nerve by focused low frequency electromagnetic pulse with noninvasive electroneurographic localization. This new technology is used in the management of chronic pain following a traumatic injury. The treatment is repeated over several months. Injured nerve is localized using magnetic stimulation at the time of the initial treatment. The skin is marked with photographic record to facilitate rapid localization of the correct site for subsequent treatments and the appropriate amplitude of magnetic stimulation.  

Nerve conduction may be used as guidance to confirm precise localization of the injured nerve but is not separately reported as a diagnostic study. If a separate diagnostic nerve conduction study is performed prior to the decision to treat with transcutaneous magnetic stimulation, then it may be reported separately.  

• 0766T Transcutaneous magnetic stimulation by focused low frequency electromagnetic pulse, peripheral nerve, initial treatment, with identification and marking of the treatment location, including noninvasive electroneurographic location (nerve conduction location) when performed; first nerve  

• +0767T Each additional nerve (List separately in addition to code for primary procedure 

*This response is based on the best information available as of 7/11/24.

 

 

 

Platelet Rich Plasma (PRP) Injections

Question:

What codes should we be reporting when we do PRP injections in our office?

Answer:

Code 0232T, Injection (s), platelet rich plasma, any site, with image guidance, harvesting and preparation when performed, is used to report this procedure. A PRP injection is bundled into the tendon sheath, trigger point, and joint injection CPT codes, thus, these codes should not be coded in addition to 0232T. Code 0232T is only reported when it is the only procedure performed. As a Category III code, it is not valued by Medicare (has 0 RVUs assigned), so payment is problematic, and most Medicare carriers do not pay for PRP. Billing a PRP injection as a trigger point injection is a misrepresentation of the actual service provided.

*This response is based on the best information available as of 6/20/24.

 

 

 

Acupuncture

Question:

We are having trouble getting our acupuncture claims paid, can you advise if this is covered per Medicare and other payors? 

Answer:

In general, many payors do not cover acupuncture.  Therefore, it is the patient's responsibility to pay.  Check your payor policies regarding coverage criteria. 

Medicare recently released Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N).  https://www.cms.gov/files/document/mm13288-national-coverage-determination-3033-acupuncture-chronic-low-back-pain.pdf 

CMS will cover acupuncture for chronic low back pain – up to 12 visits in 90 days under the following circumstances: 

• For the purpose of this decision, chronic low back pain (cLBP) is defined as: Lasting 12 weeks or longer; nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); not associated with surgery; and not associated with pregnancy. 

• An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. 

• Treatment must be discontinued if the patient is not improving or is regressing. 

Refer to Medicare’s coverage policy for the type of provider that may furnish the service and for other information. 

*This response is based on the best information available as of 6/6/24.

 

 

 

Intradiscal Steroid Injection

Question:

Is there a CPT code for an intradiscal steroid injection for “discogenic pain?”   

Answer:

There is no CPT code for an intradiscal steroid injection. You will report an unlisted code, 22899 or 64999. Most payors consider non-thermal glucocorticoid injections as not medically necessary. Follow your payor policies for reporting unlisted procedures and procedures that may be denied as not medically necessary.  

*This response is based on the best information available as of 5/23/24.

 

 

 

Moderate Sedation Documentation

Question:

Is use of the nurse flow sheet when billing for moderate sedation with our pain injection procedures allowed?

Answer:

Per CPT coding guidelines, when billing for moderate sedation an independent trained observer is required.  An independent trained observer is an individual who is qualified to monitor the patient during the procedure, who has no other duties (e.g. assisting at surgery) during the procedure. 

Moderate sedation must be documented in the body of the procedure report; a separate flow sheet is not sufficient for the surgeon documentation.  Document “ I personally supervised Mary Brown RN providing 45 minutes of moderate sedation with XX mg Versed and XX mg Fentanyl”. 

*This response is based on the best information available as of 5/23/24.