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General / General Discussion / Revenue Booster:5 Services You Shouldn't Offer for Free--And 3 That You Should
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on: Feb 20, 2015, 06:09:49 am
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Below is a very informative article from the publication, "Part B Insider (Multispecialty) Coding Alert." Please take a minute to read.
Part B Insider (Multispecialty) Coding Alert
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Part B Revenue Booster: 5 Services You Shouldn’t Offer for Free--And 3 That You Should
- Published on Fri, Feb 06, 2015
Not everything will be a ‘freebie’ in your practice.
Everyone likes free items and services, but your practice could be losing money if you’re offering visits at no charge when you could legitimately be reporting them. Read on for five of the most common services that you should be billing—and three things you must actually offer for free.
Collect for These Five
1. Copays and deductibles. Although there are some rare instances when you can write off a patient’s copay or deductible, as a rule you should be collecting these. Financial arrangements that differ from the billing obligations laid out in your contract with government or third-party payers can result in fraud charges, penalties, and loss of carrier contracts.
According to the OIG, “the routine waiver of Medicare coinsurance and deductibles can violate the Federal anti-kickback statute if one purpose of the waiver is to generate business payable by a Federal health care program.” In addition, offering inducements such as cost-sharing waivers to Medicare patients that you know might be likely to influence that patient’s selection of provider can violate separate statutes, the OIG says.
Best bet: If you ever encounter a situation in which you think a waiver or discount of fees is legally and ethically appropriate, contact your payer or a health care attorney to ensure that the arrangement would be in compliance with the payer’s contracts and policies.
2. Casting Materials. Although cast application coding can vary, you have one simple rule to remember for cast and splint supplies: they are always separately billable, assuming your physician incurred the expense for supplies.
Look to HCPCS for all your cast supply codes. Make your selection based on the patient’s age, type of cast/splint, and the type of cast material, but typically you’ll report codes Q4001-Q4048. These cover the gamut of cast supplies and application types. Each Q code fee includes the cast material, padding, and stockinette.
3. Complicated Procedures. With appropriate documentation and judicious application, modifier 22 (Increased procedural services) can yield increased payment for especially difficult or time-consuming procedures.
No payer will allow additional payment for a procedure unless you can provide convincing evidence that the service/procedure the physician provided was truly out of the ordinary or significantly more difficult or time-consuming than usual. The time to append modifier 22 is when the service(s) the physician provides are “substantially greater than typically required,” according to Appendix A of the CPT® manual.
CMS guidelines stipulate that you should apply modifier 22 to indicate an increment of work infrequently encountered with a particular procedure and not described by another code. These could include situations involving excessive blood loss or trauma, in addition to other scenarios.
The op report should clearly identify additional diagnoses, pre-existing conditions or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure, as well as the special circumstances of the additional time and/or effort necessary.
Include a physician’s letter that explains the unusual nature of the procedure with your claim so the payer can see that you didn’t perform a typical service, and let the payer know how much extra reimbursement you believe you deserve. For instance, if a procedure took 20 percent longer than it typically should, you might ask for an extra 20 percent over the normal fee.
4. Prolonged Services. CPT® includes add-on codes that you can report along with your E/M code to describe prolonged services with direct patient contact.
When your practitioner spends at least 30 minutes or more time beyond the typical time for a particular E/M code, you will report prolonged services in the outpatient setting or office with +99354 (Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [list separately in addition to code for office or other outpatient Evaluation and Management service]) for the first hour (actually, 30-74 minutes) of prolonged service. You can report every additional 30 minutes of direct patient contact with +99355 (Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes [list separately in addition to code for prolonged service]).
While reporting the encounter, make sure to document all the details regarding the total time spent by the physician for the encounter, the actual time of the visit spent in counseling/coordination of care and what topics were discussed.
5. No Shows. Although some practices are still hesitant to bill for missed appointments, these holes in your day have an impact on the physician’s schedule or the physician’s availability to other patients, and cost the practice real dollars. In some cases, charging patients a fee when they miss a visit will help your practice offset the lost time and money the open appointment time cost.
Your first step in evaluating whether to charge a fee to patients who do not show up for appointments is to check with your payers. Medicare allows charging for no-shows as long as it is the office policy and done universally to all patients (except Medicaid, which doesn’t allow no-show fees).
Key: Even if your contract allows you to bill for no-show visits, that doesn’t mean you can bill the payer. You need to bill the patient for the missed appointment. You should tell all of your patients about the policy and have them sign the policy with their other annual financial documents.
Your no-show policy should spell out exactly what fee you will charge for a missed appointment. Some may charge a fixed amount of $25 or $50, which won’t cover the missed reimbursement. Others may charge the actual amount of the missed visit; for example, a behavioral health professional may charge their normal fee for a one hour counseling appointment.
Make Sure You Offer These at No Charge
Of course, not every service you provide at your office will generate a charge—you’ll still bill nothing if the patient presents for any of the following.
1. Prescription pickups. If the only reason the patient comes into your practice is to pick up a prescription and the doctor does not see her for a documented E/M service, you cannot bill an E/M code.
In fact, CPT® specifically includes writing prescriptions as part of an E/M service. This is just part of the cost of seeing patients, much like office supplies. There is no CPT® code for writing a prescription that payers will reimburse.
2. X-Ray Re-Reads. If a patient presents to your office with x-rays from the emergency room along with the ER doctor’s x-ray interpretation, you can’t bill another interpretation just because your physician looks at the x-rays a second time. Each x-ray service is only billable once, and the ER physician most likely already reported it.
CPT® considers reviewing records as integral to the E/M service, and you should consider your x-ray re-read part of the E/M code that you report. Although CPT® does not include the time associated with records review in the E/M code descriptors, “the pre- and post-face-to-face work associated with an encounter was included in calculating the total work of typical services in physician surveys.”
3. Removing Stitches. If the same physician who placed a patient’s sutures removes them during the original procedure’s global period, you cannot report the removal separately. Instead, carriers consider it to be part of the standard follow-up care.
Tip: Payers associate a zero charge with 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason related to the original procedure), but you can use it to keep track of visits for risk management purposes to show that the patient did present for a follow-up visit within the surgical period.
Debra Farley
Billing Director
BILLPro Management Systems
2-20-15
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123
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Ohio Medicare DMEPOS / General Medicare DMEPOS Information / Modifier Requirements Due To Lack of a Physician's Order (Modifier EY)
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on: Feb 13, 2015, 04:44:58 am
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Please see the Jurisdiction B DMEMAC e-mail below addressing "Modifier Requirements Due To Lack of a Physician's Order (Modifier EY)" Debra Farley Billing Director BILLPro Management Systems 2-13-15 From: Jurisdiction B DME MAC < dmemaclistserve@anthem.com> To: debra@billpro.netDate: 02/12/2015 03:30 PM Subject: Modifier Requirements Due To Lack of a Physician’s Order (Modifier EY) We have recently received inquiries regarding the proper submission of modifiers EY, GY and GA when a denial is anticipated due to the lack of a prescription. To reduce errors related to this process, it is important to remember that all durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items require a prescription (physician's order). Some DMEPOS items require a detailed written order prior to dispensing (WOPD), while others require a detailed written order (DWO) prior to billing. The specific requirements for an order are specified in the Medical Policy (local coverage determination and/or policy article) for the specific item. Please remember that if you submit a claim to Medicare and specified requirements for an order are not met, you must append modifier EY ("No physician or other licensed health care provider order for this item or service") to the claim line. This informs the Durable Medical Equipment, Medicare Administrative Contractor (DME MAC) that you do not have a physician's order for the item. Additionally, items submitted with the EY modifier must be on a separate claim from those items not requiring an EY modifier. When lack of an order is expected to result in a medical necessity denial (ANSI 50 -"These are non-covered services because this is not deemed a 'medical necessity' by the payer"), you must execute an Advance Beneficiary Notice of Noncoverage (ABN) if you intend to protect your company from financial liability. If you have properly executed an ABN, you must append modifier GA ("Waiver of liability statement issued as required by payer policy, individual case") to the claim line in addition to modifier EY. However, when the lack of a physician's order is expected to result in a statutory denial, an ABN is not required. If you correctly submit the claim with modifier EY appended to the claim line, the claim will process and deny with ANSI 96 ("Noncovered charge "). Neither modifier GY ("Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit") nor modifier GA is required when an item is expected to deny on the basis of a statutory denial (ANSI 96).
As a reminder, all items specified in Change Request 8304 which are subject to the Affordable Care Act 6407 require a WOPD. This is a statutory requirement. You must have received a complete WOPD that has been both signed and dated by the treating physician and meets the requirements for a DWO before dispensing the item. If you deliver the item prior to your receipt of a written order, it will be denied as statutorily noncovered. Therefore, when you do not have an order for these items, you must submit the claim with modifier EY. Again, neither modifier GY nor GA would be required.
We encourage you to refer to the LCD and related policy article for specific order and other documentation requirements for the items you provide.
Related Content
Change Request 8304 - Detailed Written Orders and Face-to-Face Encounters
Medical Policy Center
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124
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Ohio Medicare DMEPOS / General Medicare DMEPOS Information / Proof of Delivery Reminder
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on: Feb 13, 2015, 04:37:00 am
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Below is an e-mail from Jurisdiction B DME MAC Debra Farley Billing Director BILLPro Management Systems 2-13-15 From: Jurisdiction B DME MAC < dmemaclistserve@anthem.com> To: debra@billpro.netDate: 02/12/2015 03:30 PM Subject: Proof of Delivery Reminder Proof of Delivery Reminder Joint Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Article Recently during claims review it was noted that suppliers have a misunderstanding about the purpose of proof of delivery (POD). All items of durable medical equipment, prosthetics, orthotics and supplies require POD. Proof of delivery serves multiple purposes, the most obvious being confirmation that the beneficiary received the item for which Medicare was billed. In addition to confirming receipt of an item, POD also serves other functions in Medical Review, specifically the ability of contractor's review staff to determine correct coding. As noted in the Documentation Section of the DME MAC local coverage determinations (LCDs): Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s), that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary. To enable review staff to make a correct coding determination, there must be sufficient details about the item delivered to ascertain whether or not the item(s) on the detailed written order are the same item(s) included on the claim and coded with the correct Healthcare Common Procedure Coding System (HCPCS) code. To accomplish this task, the POD must contain specific information about the products to make this determination. As noted in the DME MAC LCD Documentation Section for each of the three methods of delivery, one of the requirements for proper POD documentation is: Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description) Reviewers often see a reiteration of the HCPCS code narrative on the POD form as the detailed description of the item, particularly for orthotics and prosthetics. This is not adequate for POD purposes. Simply restating the HCPCS code narrative description does not allow review staff to determine what specific item(s) is being billed and if it is coded correctly. The preferred method is use of a brand name and model number, brand name and serial number, or manufacturer name and part number to identify the product. If this type of information is not available for the product, suppliers may use a detailed-narrative description of the item; however, it must contain sufficient descriptive information to allow a proper coding determination. This "narrative description" of the item is not the HCPCS code narrative. Proof of delivery documents that fail to properly identify durable medical equipment prosthetics, orthotics and supplies (DMEPOS) products and allow reviewers to make a correct coding determination will be denied for insufficient delivery information. For questions about correct coding, contact the Pricing, Data Analysis and Coding (Contractor) (PDAC) Contact Center at 877-735-1326 during the hours of 8:30 a.m. to 4:00 p.m. central time (CT), Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form. |
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125
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Ohio Medicaid (including managed care) / Managed Care Plan / CARESOURCE MYCARE OHIO AND AUTHORIZATIONS
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on: Feb 11, 2015, 05:35:55 am
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We received a notice from Caresource on 2/9/2015 which states:
"For All CareSource MyCare Ohio Members:
"No auth required for DME, Homecare, and all outpatient services until further notice for both participating and non-participating providers. This includes potential cosmetic codes.
"Please provide services and submit your claims.
"Thank you."
Debra Farley
Billing Director
BILLPro Management Systems
2-11-15
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128
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EHR/EMR/EPrescribe/PQRI / EHR/EMR / CMS Announces Intent to Engage in Rulemaking for EHR Incentive Prgm Changes 2015
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on: Jan 30, 2015, 05:48:03 am
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Attn: MDs, DOs, DPMs, Optometrists, Chiropractors and Nurse Practitioners (Nurse Practitioners only eligible for the Medicaid EHR Incentive Program, not the Medicare EHR Incentive Program.) CLIENTS: Please scroll down to the CMS e-mail titled "CMS Announces Intent to Engage in Rulemaking for EHR Incentive Program Changes for 2015." This is important reading. Debra Farley Billing Director BILLPro Management Systems 1-30-15 From: Centers for Medicare & Medicaid Services [mailto:cmslists@subscriptions.cms.hhs.gov] To: debra@billpro.net Sent: Thu, 29 Jan 2015 11:44:10 -0500 Subject: CMS Announces Intent to Engage in Rulemaking for EHR Incentive Program Changes for 2015 [EHR Incentive Programs ? A program of the Centers for Medicare & Medicaid Services] News Updates CMS Announces Intent to Engage in Rulemaking for EHR Incentive Program Changes for 2015 The Centers for Medicare & Medicaid Services (CMS) intends to engage in rulemaking this spring to help ensure providers continue to meet meaningful use requirements. In response to input from health care providers and other stakeholders, CMS is considering the following changes to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs: Shortening the 2015 reporting period to 90 days to address provider concerns about their ability to fully deploy 2014 Edition software Realigning hospital reporting periods to the calendar year to allow eligible hospitals more time to incorporate 2014 Edition software into their workflows and to better align with other quality programs Modifying other aspects of the programs to match long-term goals, reduce complexity, and lessen providers’ reporting burden These proposed changes reflect the Department of Health and Human Services’ commitment to creating a health information technology infrastructure that: Elevates patient-centered care Improves health outcomes Supports the providers who care for patients While CMS intends to pursue these changes through rulemaking, they will not be included in the pending Stage 3 proposed rule. CMS intends to limit the scope of the pending proposed rule to Stage 3 and meaningful use in 2017 and beyond. To read Dr. Conway’s blog on this announcement, go to: http://blog.cms.gov/. For more information about the EHR Incentive Programs, please visit http://www.cms.gov/EHRIncentivePrograms. |
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129
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CPT/HCPCS/ICD-9 / CPT updates / CMS: MLN Article SE1503 Continued Use of Modifier 59 after January 1, 2015
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on: Jan 26, 2015, 06:02:32 am
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As you have previously been made aware, CMS "established 4 new modifiers (XE, XP, XS, XU) to define specific subsets of the -59 modifier, a modifier used to define a 'Distinct Procedural Service.'" This was originally published in MLN Matters® Article #8863 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8863.pdfThe MLN Article #SE1503 addressed in the e-mail below is a separate article titled "Continued Use of Modifier 59 after January 1, 2015." Please share this article with your staff. I quote a portion from it, "Additional guidance and education as to the appropriate use of the new-X {EPSU} modifiers will be forthcoming as CMS continues to introduce the modifiers in a gradual and controlled fashion. That guidance will include additional descriptive information about the new modifiers. CMS will identify situations in which a specific -X {EPSU} modifier will be required and will publish specific guidance before implementing edits or audits...providers who wish to use the new modifiers may use them in accordance with their published definitions, and the X modifiers will function within CMS systems in the same manner as the 59 modifier..." NOTES: - This e-mail is being sent to all clients as these "X" modifiers will trickle to private payers. - Anthem has already stated they will consider the "X" modifiers as informational only until further notice and to continue your current billing practices until further notice. - It is BILLPro's suggestion, at this time, to continue using modifier -59 when appropriate; if a claim denies for the "need" for an "X" modifier the provider will be so contacted for the applicable "X" modifier. We shall keep you well informed of payer information and when they may require the applicable "X" modifier. Debra Farley Billing Director BILLPro Management Systems 1-26-15 From: CMS MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV] To: MLNMATTERS-L@LIST.NIH.GOV Sent: Fri, 23 Jan 2015 15:04:39 -0500 Subject: New Article Posted to MLN Matters New: SE1503 – Continued Use of Modifier 59 after January 1, 2015 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1503.pdf |
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130
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Ohio Medicare DMEPOS / General Medicare DMEPOS Information / Correct Coding - Cast Covers
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on: Jan 16, 2015, 04:49:30 am
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Please see the e-mail below from Jurisdiction B DMEPOS:
Debra Farley
Billing Director
BILLPro Management Systems
1-16-15
Correct Coding - Cast Covers
Joint DME MAC
Recently the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have received inquiries about coverage of covers for casts. These are typically constructed of latex or rubber and are designed to fit over a cast to allow bathing, showering or swimming without water infiltration. Medicare considers cast covers a convenience item; therefore, these items are noncovered. The proper Healthcare Common Procedure Coding System (HCPCS) code for cast covers is:
A9270 - Noncovered item or service
For questions about correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 8:30 a.m. to 4:00 p.m. central time (CT), Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form.
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132
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CPT/HCPCS/ICD-9 / CPT updates / An article, "The Ins and Outs of Coding Vaccines"
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on: Jan 07, 2015, 01:26:46 pm
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Please see the attachment which is a document from the internet titled "The Ins and Outs of Coding Vaccines" which is excellent and must be read in its entirety (there is no page 20 included as it was an advertisement page only). I particularly like the "examples" on the bottom of page 19 and continued on the top of page 20. Do note in "Example 3" that when 90471 and 90472 are billed, 90473 is NOT to be reported -- 90474 would be the proper code. One will have a thorough understanding of coding vaccines/administrations. The article is dated 2011 and the only outdated info is related to Medicare and flu vaccine codes.
Debra Farley
Billing Director
BILLPro Management Systems
1-7-2015
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