For the Week of October 17, 2016

Can you add the charge for the magnetic resonance (MR) cardiac velocity flow (75565) to an MR angiography, chest 71555? Or is it only to be used with a cardiac code?

Code 75565 may not be reported with 71555. It is only for use with the cardiac MR imaging codes.


In the new lab payment system, CMS discusses “applicable” labs and reporting entities. Are these the same thing or different?

In SE1619, the Centers for Medicare & Medicaid Services (CMS) explain the difference between applicable lab and reporting entity. To determine whether your lab is “applicable” to report data, it must be certified under the CLIA and must bill under its national provider identifier (NPI). In the memo, CMS also explains the meaning of the “Medicare revenues threshold” and “low expenditure threshold,” which also figure into whether a lab is applicable. It is the tax identification number (TIN) level entity that actually reports the applicable information individually for all its NPI-level applicable laboratories.

To understand the above and more go to


I am looking for information about coding of MTM services performed by pharmacists and also what payers will cover this service. Can you provide help for this?

One source for coding information for the medication therapy management CPT codes and other billing information is the website of the Pharmacist Services Technical Advisory Coalition (PSTAC) website at Another good source of information is, of course, the website of the Centers for Medicare & Medicaid Services at


I was asked to find the Medicare Physician Fee Schedule (MPFS) reimbursement rate for CPT code 78492. However, the MPFS does not list a fee for the technical component or for global billing. Does this mean that a physician’s office or imaging center may only bill the professional component?

No, it means that Medicare has never established relative value units (RVUs) for the global and technical components. Each contractor determines these fees. Your Medicare Administrative Contractor (MAC) should have the fee published on its website under carrier-priced codes.


Can you provide some general guidelines for getting correct payment for RT?

Receiving correct reimbursement while maintaining regulatory compliance for respiratory therapy and pulmonary function studies requires adherence to the following concepts:

• Complete documentation of services rendered and their medical necessity
• Accurate code assignment
• Valid charge-capture procedures
• Logical fee structures
• Efficient data-collection and information regarding processes
• Effective billing and reporting procedures.

The payment that hospitals receive from third-party payers for an outpatient service depends on codes and related charges recorded on the claim form. Two types of codes dominate: CPT/HCPCS codes and revenue codes. The CPT/HCPCS procedure/ service codes are part of the CMS coding system. The revenue codes are prescribed by CMS to identify the facility’s cost classification of the product or service.


It is not always possible to avoid assigning an unspecified code but I understand that CMS now expects more specific diagnosis codes, but for FY 2017 there are so many codes to choose from. Do you have any advice for making this manageable?

While the number and specificity of diagnosis codes can appear daunting, if everyone works together and follows the steps below, there be fewer claim denials and more accurate payment, and better quality data will be accumulated to help improve the quality of patient care.

  • Report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs or symptoms or unspecified codes are the best choice to accurately reflect the healthcare encounter.
  • Avoid unspecified ICD-10 codes whenever documentation supports a more detailed code. Check the coding on each claim to make sure that it aligns with the clinical documentation.
  • Code each healthcare encounter to the level of certainty known for that encounter.