Wednesday, September 25, 2013

Update – ACA Increased Medi-Cal Payments for Primary Care Physicians (California MediCaid)

The Department of Health Care Services (DHCS) plans to implement increased fee-for-service Medi-Cal payments for primary care physicians in late October 2013.
The Patient Protection and Affordable Care Act (ACA), as amended by House Resolution 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, requires that payments to primary care physicians be increased to the Medicare equivalent for certain Evaluation and Management and Vaccine Administration services.
These increased payments are contingent upon pending Centers for Medicare & Medicaid Services (CMS) approval of a DHCS State Plan Amendment (SPA). The increased payments are retroactive for dates of service on or after January 1, 2013.
The first interim payment will be issued in October. A final settlement of payment owed but not reimbursed by the interim payment will be issued as early as February 2014.
The increased payments are not automatic. Providers must attest to their eligibility, but DHCS estimates that less than half of eligible providers have self-attested. Completing your attestation prior to CMS approval of the SPA and system updates will ensure you receive increased payments as soon as possible. Visit the Medi-Cal ACA Program Page on the Medi-Cal website for more information or to submit a self-attestation form.
You should complete your attestation form as soon as possible.

Wednesday, September 18, 2013

Health Insurance Exchange Information for Physicians and Patients

A primary mission of the Affordable Care Act is to provide universal health coverage through the creation of health insurance exchanges or marketplaces. The triad of employer-sponsored coverage, marketplace insurance exchanges, and expanded Medicaid coverage should cover most Americans under 65 years old, with some exceptions.

Unfortunately, there will be coverage gaps for low-income people who fall between certain income levels and live in states where the Medicaid expansion was rejected, according to Jennifer Tolbert, director of state health reform for the Kaiser Family Foundation.

Tolbert is charged with monitoring state implementation of the Affordable Care Act and the establishment of state insurance exchanges for Kaiser. She recently discussed in a webinar some consumer-based elements of the law that are also helpful for medical practices to understand and communicate with current or potential new patients.

Consumers will be able to shop and enroll in new insurance plans through the federal government's website (, or their own state's website if available, beginning Oct. 1, 2013. Open enrollment will continue through Mar. 31, 2014, with the option of enrolling after that date if a qualifying event occurs.

Coverage through the marketplaces and the expanded Medicaid program (where approved by individual states) will begin Jan. 1, 2014, when insurance market rules also go into effect. That is also when the individual mandate to have insurance coverage begins.

The exchanges will offer a choice between four plans (figures are for single coverage; family coverage would be double):
  • Bronze – typical deductible $5,000 / typical coinsurance 30 percent
  • Silver – typical deductible $2,000 / typical coinsurance 20 percent
  • Gold – typical deductible $0 / typical coinsurance 20 percent
  • Platinum – typical deductible $0 / typical coinsurance 10 percent
They will also offer a catastrophic plan for people up to age 30, with a typical deductible of $6,350 and no coinsurance. While these levels of cost sharing may seem prohibitive, most consumers will be eligible for federal subsidies and tax credits.

The cost of premiums will vary by state and locality; and also by age. Consumers who wish to get a ballpark estimate of the costs of different plans can use the Health Insurance Subsidy Calculator provided by Kaiser.

For example: A 40-year-old pre-school teacher making $30,750 — or 250 percent to 300 percent of the federal poverty level —  would be required to pay 8 percent to 9.5 percent of her income for healthcare premiums on the exchange. Her subsidized cost for the Silver Plan would be $2,633 annually. (The unsubsidized annual cost would be $3,857.)

All of the plans offered on the health insurance exchanges are mandated to offer "essential health benefits," said Karen Pollitz, a senior fellow on health reform and private insurance for Kaiser:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and wellness services, and chronic disease management
8. Pediatric services, including oral and vision care

There are multiple health-reform resources available online through Kaiser and that would be helpful additions to your own medical practice website; even if your own patients don't need this information, most everyone has a family member who may benefit from knowing the facts, e.g. a young adult child who does not receive health insurance from her workplace, or perhaps a single professional who does freelance work or is self-employed.

As leaders in the health community, it is important for physicians to be knowledgeable about the coming changes in health insurance coverage. It also allows physicians to make informed choices about the types of new insurance they will participate in, and the numbers of new patients they take into their practices.

Article By Erica Sprey, Courtesy of Physicians Practice

Noridian Online Provider Services for Medicare Eligibility, Claim Status and More

Noridian has launched their online provider services (OPS). If you were already a member of the Palmetto OPS then you should receive an email from Endeavor (Noridian OPS). The email will give you a login and password to log into the site.

You will be prompted to change your password. There is a ridiculously long list of can and cannot for your password:

Password Policy: 
  • Maximum Length: 8  
  • Minimum Length: 8  
  • Minimum Lowercase: 1  
  • Minimum Number of Character Type Rules That Must Pass: 4  
  • Minimum Numeric: 1  
  • Minimum Special: 1  
  • Minimum Uppercase: 1  
  • Must not contain values of attributes: accountID, email, firstname, lastname  
  • Must not contain words: ", `, ~, !, (, ), _, -, +, =, {, [, }, ], |, \, :, ;, ^, ', <, ,, >, ., ?, /, 0, 1, o, O, i, I, l, L, &

On Endeavor you will be able to:
  • Verify beneficiary eligibility
  • Claim status
  • Remittance advice
  • Reopening/appeal status
  • DME overpayment inquiries
  • PMD prior authorization status

Once you verify a beneficiaries eligibility you can review the following benefit information:
  • Eligibility
  • HMO/MCO coverage
  • MSP (Medicare secondary payer) coverage
  • HHEH (home health eligibility history)
  • Hospice, hospital, SNF (skilled nursing facility)
  • ESRD (end stage renal disease)
  • Preventative services

I particularly like the preventative services information. Endeavor lists the CPT code for a preventative service, then a description of the service and the next eligible date that the beneficiary can receive these benefits. This takes the guess work out of, "have you received a physical anywhere else in the last year?". I wish they would do this with more limited/global services.

Endeavor offers tutorials for use of their OPS site.

Tuesday, September 17, 2013

California State Medicaid Will Discontinue Use of ZS Modifier as of December 31, 2013

Public Comment Forum: HIPAA Code Conversion for Local Modifier ZS 

As part of the continuing effort to comply with the federally mandated Health Insurance Portability and Accountability Act (HIPAA), the following change is slated to be effective for dates of service on or after December 1, 2013: 
The Department of Health Care Services (DHCS) will discontinue use of local modifier ZS, which is used to bill for the full professional (26) and technical (TC) components of a procedure. 

This article provides information about a public comment forum for this change. 

Claim Completion
Providers will be instructed to use one of the following scenarios when submitting a claim for split- billable procedures or services: 

Scenario 1: The facility and physician each bill for their respective component of the service with modifiers 26 or TC. Each provider/facility submits their own claim with one line of service and the appropriate modifier (26 or TC) designating the service they provided. 

Scenario 2: Full Fee Billing – The physician bills for both the professional and technical components and subsequently reimburses the facility for the technical component, according to their mutual agreements. The physician submits a CMS-1500 claim form and completes two separate claim lines as follows: The first line contains the split-billable procedure code and one of the two modifiers (26 or TC). The second line contains the same procedure code and the corresponding modifier (26 or TC).

Scenario 3: Standard Billing – The facility bills for both the technical and professional components and reimburses the physician for the professional component, according to their mutual agreements. The facility submits a UB-04 claim form and completes two separate claim lines as follows: The first line contains the split-billable procedure code and one of the two modifiers (26 or TC). The second line contains the same procedure code and the corresponding modifier (26 or TC). 

TAR Completion
Providers will be instructed to use one of the following scenarios when submitting a Treatment Authorization Request (TAR) for split-billable procedures or services: 

Scenario 1: One TAR and one provider for both the professional (26) and technical (TC) components of service. The TAR must be submitted with two lines of service. The first line must have the CPT-4 code and one of the two modifiers (26 or TC). The second line must have the same CPT-4 code and the corresponding modifier (26 and TC). 

Scenario 2: One TAR and two different providers for the professional (26) and technical (TC) components of service. One of the providers submits the TAR on behalf of both providers of the two components of service (26 and TC). Both providers use the same TAR for claim submission. The TAR is submitted with two lines of service. The first line must have the CPT-4 code and one of the two modifiers (26 or TC). The second line must have the same CPT-4 code and the corresponding modifier (26 and TC). 
This is the preferred method for two different providers. 

Scenario 3: Two TARs and two different providers for the professional (26) and technical (TC) components of service.
Each provider submits their own TAR with one line of service and the appropriate modifier designating the service (26 or TC) they provided or will provide. 

Comment Period
Notice is hereby given that DHCS will conduct written public proceedings, during which time any interested person or such person’s duly authorized representative may present statements, arguments or contentions relevant to the action described in this notice. 

There has been a correction to the start date of the comment forum, which was previously posted as September 15, 2013. The comment forum will begin September 16, 2013, and end at 4:00 PM on October 30, 2013. The proposed changes will be available by clicking the “Public Comment Forum Coming: HIPAA Code Conversion for Local Modifier ZS” line in the NewsFlash area of the Medi-Cal website. This link will direct providers to the “Medi-Cal Comment Forum” where they can view the article. Providers may call the Telephone Service Center (TSC) at 1-800-541-5555 or visit the Medi-Cal website if they have questions or need additional information.

Courtesy of :

Monday, September 16, 2013

Norodian Redetermination and Other Forms

Here is a link to Noridian Medicare forms. It included Medicare redetermination, one of my most used forms as well as the following PDF downloads:
  • Appeals
  • CMS
  • Education
  • Enrollment
  • General inquiries
  • Medical review
  • Medicare Secondary Payer (MSP)
  • Patient screening
  • Policies
  • Professional providers telecommunication network (PPTN)
  • Publication order forms
  • Recoupment
  • Roster claims
Follow this link:

JE Part B Mailing Addresses for Written Correspondence - Effective September 16, 2013

Noridian has established PO Boxes as outlined in the Tables below. Please use this information to ensure timely processing. We have included the mailing address for FedEx/Certified Mail in the Specialized Correspondence table. When mailing to the street address, please include the PO Box specific to your state on the second line of the mailing label. This will help assist in the mail sorting.

Table 1 provides the mailbox address that should be used for each JE state.  Please use these P.O. Boxes to submit all Claims, Written Correspondence and Non Specialized Correspondence

Example:  A Northern California JE provider would use the following address:
Medicare Part B Claims
P.O. Box 6774
Fargo, ND 58108-6774

Part B StateAddress
Hawaii, American Samoa, Guam, and the
Northern Mariana Islands
PO Box 6777, Fargo ND 58108-6777
NevadaPO Box 6776, Fargo ND 58108-6776
Northern CaliforniaPO Box 6774, Fargo ND 58108-6774
Southern CaliforniaPO Box 6775, Fargo ND 58108-6775

Table 2 provides the mailbox addresses for Specialized Correspondence. These addresses should be used for all JE states. 

Example: A mailing from any JE state would be:
Medicare Part B Overpayment Redetermination Request
P.O. Box 6785
Fargo, ND 58108-6785

Specialized CorrespondenceAddress
ALJ Hearing NotificationsPO Box 6781, Fargo ND 58108-6781
Benefit Protection / FraudPO Box 6780, Fargo ND 58108-6780
ChecksNoridian JE B Refunds; PO Box 511381, Los Angeles, CA 90051-7936
CMD MailPO Box 6781, Fargo ND 58108-6781
Congressional MailPO Box 6781, Fargo ND 58108-6781
EDI Support ServicesPO Box 6729, Fargo ND 58108-6729
EWIF ClaimsPO Box 6783, Fargo ND 58108-6783
FedEx/Certified Mail900 42nd St. S., PO Box XXXX, Fargo, ND 58103-2119
FOIA RequestsPO Box 6783, Fargo ND 58108-6783
LCD ReconsiderationsPO Box 6783, Fargo ND 58108-6783
Overpayment Redetermination RequestsPO Box 6785, Fargo ND 58108-6785
Post Pay Medical ReviewPO Box 6783, Fargo ND 58108-6783
Paperwork (PWK)PO Box 6783, Fargo ND 58108-6783
RAC RedeterminationsPO Box 6789, Fargo ND 58108-6789

Wednesday, September 11, 2013

Interview: How to Start A Medical Billing Service - Part 2 - Business Opportunities Weblog

Interview: How to Start A Medical Billing Service - Part 2 - Business Opportunities Weblog

Modifiers 58, 78, and 79 to be used on Surgical CPT Codes Only During a Global Surgical Period

Modifier 58: Staged or Related Procedure or Service by the Same Provider During the Postoperative Period

Modifier 58 can be used when a second surgery is performed in the postoperative period of another surgery when the subsequent procedure was:
▪ planned or “staged” or
▪ more extensive than the original procedure; or
▪ for therapy following a surgical procedure; or
▪ for the reapplication of the cast within the 90-day global period.

An example of when to use modifier 58 would be if a patient had a removal of a breast lesion (CPT 19120) followed in less than 90 days by the removal of the entire breast (CPT 19307).  Bill CPT 19307-58 for the second procedure.  Another postoperative period begins when the second procedure in the series is billed.

Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period

Modifier 78 is used for an unplanned return trip to the operating room for a related surgical procedure during the postoperative period of the initial major surgery.  The allowance will be reduced, since pre and postoperative care is included in the allowance for the prior surgical procedure. 
An “operating room” is defined as a place of service specifically equipped and staffed for the sole purpose of performing surgical procedures.  The term included a cardiac catherization suite, a laser suite, and an endoscopy suite.  It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit unless the patient’s condition was so critical there would be insufficient time for transportation to an operating room.

Modifier 79:  Unrelated Procedure or Service by the Same Provider During the Postoperative Period

Modifier 79 is used for unrelated procedures by the same provider (or provider of the same specialty in the same surgical group) during the postoperative period.  Unrelated procedures are usually reported using a different ICD-9-CM diagnosis code. Another postoperative period begins when the second procedure in the series is billed.

Note: The use of RT and LT modifiers is helpful, and should be billed as the second modifier following modifier 79, but not in place of it.

The Medicare Claims Processing Manual, further states: “Do not allow separate payment for an additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior procedure and if billed without modifier “-58,” “-78” or “-79.”  These services should be denied.” (CMS Publication 100-04, Chapter 12, Section 40.4A) 

Courtesy of CMS

Collecting Patient Payment during Scheduling

Scheduling is the first contact with the patient and by far one of the most important. It is a time you can obtain all the information needed to check eligibility, notify the physician in advance for the reason of the visit, set the expectation that payment is owed at the time of service, and start building a rapport with the patient.

Obtaining all information needed to check eligibility and perform pre-visit preparation can be time consuming, but is by far worth its weight in collected dollars when reviewing financials at the end of the month.During scheduling, the following minimum information should be obtained: Patient demographics (name, cell number, address, work number, social security number, date of birth) Insurance information (ID number, group number, payer ID, guarantor information) Reason for visit An answer to the question: Are there records or test results needed before being seen? After the information is obtained, the scheduler should request payment of any balance on the patient’s account. This can sometimes be an uncomfortable process for staff, but by providing staff with scripts and role playing, they can perfect the process in no time.  It can even make patient collections feel natural. For example, instead of saying, “Ms. Smith you have a balance on your account. Would you like to pay that today?” Train your staff to say, “Ms. Smith I see you have a past due amount of $50.How would you like to take care of that today? We accept Visa, MasterCard, or do you have a FSA card?” It is amazing how many more payments practices can collect, just by being prepared and having the proper scripts in place.
Once the practice has obtained all the needed information, checking eligibility and benefits in advance is a piece of cake. The process should no longer be considered an option for practices today. It is estimated that only 41 percent of providers collect at the time of service, while 36 percent collect at the time of service some of the time. This is surprising considering it costs approximately $7 a statement (if not sent electronically) and eligibility costs between $0 to $0.74. So at worst-case scenario the practice saves $6.26 per patient if the money is collected at the time of service. If the patient is sent more than one invoice the number continues to increase.

 Let’s compare the two different approaches:

Collection at the time of service (patient responsibility minus cost of eligibility check):
• $50- $0.74 = $49.26

Patient is billed for amount owed (patient responsibility minus cost of statements):
• $50 – 7= $43 (1st statement)
• $43 - $7= $36 (2nd statement)
• $36 - $7= $29 (3rd statement)

(If utilizing an electronic statement process the cost for three statements can vary between $2.25 to $5 depending on the process and vendor).

Comparing the two scenarios, it seems there would be no question as to which process is more efficient, but 49 percent of providers are still using the second scenario. In previous years, it was a cumbersome process to investigate patient responsibility in advance. Many times insurance feedback would not be current or correct. This in turn made the process frustrating and in many cases a waste of time and money. This made it understandable why many practices avoided the process. However, today the process could not be easier. There are various options for practices depending on their practice-management software and clearinghouse vendor.

These options include:

• Automating the process by utilizing your practice management software if offered. This will allow the practice to set up the system to check eligibility and benefits in advance before the patient is seen without staff utilizing time to retrieve the data. The information is commonly imported directly into the patient’s chart and can be viewed immediately.
• If automation is not an option for checking eligibility and benefits then centralize. Centralization can be done by utilizing a clearinghouse or other vendors that specializes in these types of services. (Tip: Make sure the vendor works closely and is compatible with your practice management software).
• Lastly, if the above options do not work, practices should go directly to their payers’ websites or call their payers. This option is more time consuming and costly considering hourly employees are performing the process manually, instead of automating after hours.

Once the process has been determined, the criteria must be decided. The information should be obtained at minimum of three days in advance of the appointment. This will allow the practice to compare the patient coverage to their fee schedule. By comparing the two, the patient responsibility can be estimated in advance, allowing the practice to contact the patient in advance. The more the process is utilized the more savings the practice will endure over time. This allows the practice to not only know patient financial responsibility, but also issues with insurance or coverage such as invalid insurance ID or that the service will not be covered.

Regardless of the method, the key is being prepared. Once the practice is prepared the practice can reach out to the patient to discuss their financial responsibility and payment expectations before treatment is performed. Before reaching out to the patient regarding their responsibility, the practice should have insight as to what will be owed. In order to calculate responsibility, fee schedules and contracts will have to be examined and compared by the practice to the patient’s coverage. Many practice management software programs have the ability to calculate this information, if it is set up and maintained properly. If the practice management software does not have the functionality, the information can even be calculated by utilizing an Excel spreadsheet if needed.

Once the amount owed is calculated, the patient counselor should contact the patient regarding the balance. The patient counselor should have strong customer service skills with a high level of billing knowledge, and the ability to be compassionate and considerate when speaking to the patients. Many times if handled properly, the patient will pay in advance or set up payment arrangements before being seen in the practice. More importantly, the patient is entering the practice with an understanding of their financial responsibility and can take ownership of the bill.

Healthcare is one of the few expenses that can unexpectedly occur but be as high as the cost of an automobile or mortgage. Isn’t it only fair we prepare our patients and set the expectation that money is to be paid at the time of service?

Article By Chastity Werner, RHIT
Courtesy of:

What Practices Need to Do Now to Prepare for HIPAA Omnibus Changes

The September 23, 2013, deadline for when covered entities such as physician practices must be in compliance with the HIPAA Omnibus Final Rule is quickly approaching. The rule marks the most sweeping changes to the HIPAA Privacy and Security Rules since they were first implemented.

While the final rule brings about many changes, there are three in particular that likely warrant the most attention from practices now. The following column identifies those changes and provides practical guidance to meet the new requirements.

Change 1: The definition of what a "breach" is has been modified.
What it means: Under the old law, a breach was an event that "compromises the security or privacy of the protected health information (PHI) such that the use or disclosure poses a significant risk of financial, reputational or other harm to the affected individual." Under the new rule, the definition of a breach is expanded to include even just the "risk" of impermissible use or disclosure of PHI. For example, if you have patient records on a thumb drive and that drive is lost, if the records are not password-protected or encrypted, that will be considered a breach even if the data is never accessed by anyone. An incident report should be filed with your HIPAA officer. If you lose a laptop but can prove the computer is encrypted and nobody is able to access the information without a secure ID, thus indicating a low probability of the PHI becoming compromised, you will not have committed a breach.
What practices should do: Perform a complete risk assessment in an effort to minimize security holes and prevent possible breaches. Three of the most common causes of breaches are stolen laptops, lost or stolen external hard drives or thumb drives, and sending PHI through unsecured email.
Change 2: The definition of a "business associate" (BA) has been completely reworded.
What it means: A BA is essentially a company or any person who is not a member of the workforce for the covered entity but has access to PHI. This would include contractors and now, under the new rule, subcontractors under the BA. 
What practices should do: Review all BA agreements to see if they need to be revised or replaced. With older agreements, a BA could potentially include a clause that says the BA cannot be held liable for PHI breaches. Now, a BA can be held directly liable. BAs can still try to include the clause to remove themselves and their subcontractors from liability, but a practice would be wise to object to such a request and a BA will lack a strong argument for the clause's inclusion. An example of when a BA might be liable: If an IT company has an off-site data backup and somebody steals the backup device, the BA can be found personally liable for breach of all of the health records on that device. An example of when a subcontractor might be liable: If the IT company were to bring in a subcontractor to run network cable and electric lines in a new service center, that subcontractor would then be considered a BA and potentially liable since it could have access to PHI.Since all BAs are more stringent under the new HIPAA security laws, BAs themselves need to now remain HIPAA compliant.
Change 3: HIPAA audits will happen more frequently, fines will be substantially higher, and auditors will be incentivized to find security problems.
What it means: Periodic HIPAA audits by HHS were already authorized and underway, but covered entities can expect them to happen more frequently once the new rule is enacted.In addition, fines associated with penalties due to HIPAA violations will become significantly higher and essentially without a limit.Finally, auditors will receive what amounts to a "kickback" for each security violation discovered during an audit, which incentivizes auditors to dig deep and find any and all holes. 
What practices should do: The best practice is to perform at least quarterly risk assessments. This will help ensure security hole fixes put in place are working and holding and identify other potential problems. If you can indicate to an auditor that you performed a risk assessment, identified a problem, and have a plan in place to fix it, the auditor is more likely not to consider the problem an issue unless it remains unresolved. Many covered entities rely upon an external company to perform such risk assessments. These companies are not only skilled in identifying security problems and issues often overlooked by covered entity staff members, they have the knowledge and ability to take care of requirements such as creating policies and procedures for administrative safeguards, setting up employee training and changing all IT systems so they have a data backup plan, specific user names, and password policies in place.
Larger organizations may consider hiring someone to handle these responsibilities, but this may be cost prohibitive. For smaller organizations, it's often more cost-effective to hire a company to handle all of these tasks and help ensure year-round compliance.
Article By Nelson Gomes and Michael Daly of Physicians Practice

Great American Physician Survey 2013

Use of Modifier 25 Explained

By Betsy Nicoletti from Physicians Practice

Just the facts, ma'am. It is easy to find both CPT and CMS guidance about the use of modifier 25, and if a group needs "just the facts," the facts are only a few keystrokes away. But if the facts are clear, why does the Office of Inspector General's (OIG) website continue to post notices of physician practices and hospital systems paying back millions of dollars for the use of modifier 25? Do healthcare providers not understand the facts or is there judgment in the interpretation of the guidance in the use of modifier 25?

Let's start with the facts. Modifier 25 is appended to an Evaluation and Management (E&M) service (never to a procedure) to indicate that a significant and separately identifiable E&M service was provided on the same day as a minor surgical procedure. Although I joke that any procedure done on me is a major procedure, a minor procedure is defined as a procedure with zero to ten global days in the CMS Physician Fee Schedule. The catch is the definition of a "significant and separately identifiable." Healthcare professionals often mistakenly believe that assessing the condition and deciding to perform a minor procedure entitles them to an E&M service on the same day as the procedure. This is incorrect.

The National Correct Coding Initiative (NCCI) manual states "The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. …If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.

"And the CMS manual states that "The initial evaluation is always included in the allowance for a minor surgical procedure."

That is, the payment for evaluating the condition and deciding to perform a procedure is considered part of the payment for the procedure, unless there is a significant and separately identifiable service performed. Do not report a separate E&M service for a planned procedure. Many minor procedures on healthy patients do not require a separate E&M, such as lesion destruction or punch biopsy. The clinician is paid for the evaluation of the lesion as part of the destruction or biopsy. It is permissible to report an E&M service for an unrelated problem or when the problem being evaluated wouldn't necessarily result in the procedure. A patient presents with abnormal vaginal bleeding. The physician assesses the problem prior to deciding to perform the endometrial biopsy. Or, a patient presents with multiple non-healing wounds, and the physician addresses the patient's vascular status, compliance with diabetic regimen, and decides to debride an ulcer. Both the procedure and the E&M may be reported.

So, do healthcare providers not understand the facts or is there judgment in the interpretation and guidance? Both are true. On the provider side, we haven't heeded the statement that the decision to perform a minor procedure is included in the payment for the minor procedure. On the payer side, what constitutes significant and separately identifiable work is not clearly defined. Physician practices might remember this mantra: Using modifier 25 is not always or never, but sometimes. CMS, payers, and the OIG have the use of modifier 25 on their watch lists, so stop and consider whether the E&M service is above and beyond evaluating the site and deciding to perform the service.

Courtesy of:

Unlisted Procedure and Not Otherwise Classified Codes: Noridian

Processing Changes: Effective 9/16/13, items requiring an invoice must follow the below criteria. Faxes will only be reviewed for PWK processing.
When billing for a service or procedure, select the CPT, HCPCS, or drug code that accurately identifies the service or procedure performed. If no such code exists, then report the service or procedure using the appropriate "unlisted procedure code or Not Otherwise Classified (NOC) code (which often end in 99). Noridian will not correctly code unlisted codes when a valid code is available.

Correct Coding Guidelines

  • It is the responsibility of the provider to ensure all information required to process unlisted procedure codes or (NOC) codes is included on the CMS-1500 form or the electronic media claim (EMC) when the claim is submitted.
  • If required information is missing, the code will be denied or deemed unprocessable.
  • Descriptions of the unlisted procedure codes include, but are not limited to, narratives, trip notes for ambulance claims, etc.
  • Enter a concise description of the services rendered in Item 19 on the CMS-1500 claim form. If the description does not fit in Item 19, an attachment describing the services must be submitted for providers who submit paper claims.
  • When submitting attachments (e.g., operative report, office notes, invoices) to support the unlisted code billed, unless it is immediately evident, identify the unlisted procedure with a written description, or by underlining or marking the billed service on the attachments. Highlighters should not be used as this obliterates the text and is not visible after the document is photocopied or scanned.
  • The electronic equivalent for Item 19 on EMC submissions will hold up to 80 characters for the concise statement and should be enough space to describe the unlisted procedure code.

Unclassified Drug Billing

The following unclassified drug codes should be used only when a more specific code is unavailable:
  • J3490 Unclassified drugs
  • J9999 Not otherwise classified, anti-neoplastic drug
When submitting a claim using one of the codes listed above, enter the drug name and dosage in Item 19 on the CMS 1500-claim form or the electronic equivalent. Pricing will be based on the information entered in these fields. The quantity-billed field must be entered as one (1).

Compound Drug Billing Exception

An exception to the unclassified drug code instruction above is the billing of compound drugs (often prepared by special pharmacies), which should be billed as outlined in the companion articles published simultaneously with this article:
  • Compounded Drugs Reimbursement Billing Revised – November 2011
  • Infusion Drugs Reimbursement Billing Revised – November 2011
If there is a valid J-code for the drug billed, the unlisted code will not be correctly coded by Noridian. The unlisted code will be denied as a billing error. Medicare payment will be based on the information submitted. If the required information is not submitted, any unlisted procedure or service will be denied as unprocessable.
Source: Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 26, Section

Courtesy of Noridian

Friday, September 6, 2013

Top 10 E-mail Etiquette Tips

Who do you and your colleagues communicate with via e-mail at your medical practice? At a minimum, it is likely you communicate with patients, vendors, and each other. Is there anyone that you exclusively (or almost exclusively) communicate with via e-mail?

E-mail is a wonderful tool, but unlike phone or face-to-face communication, the medium poses challenges when it comes to conveying the tone you are trying to imply. E-mail can also be damaging, especially when an e-mail is misunderstood. Here are 10 tips to help keep the perception of your e-mails on point.
1. Keep e-mails brief and to the point. Make your most important point first, and then provide supporting details if necessary. Paragraphs should be short and easy to read.
2. Watch your tone. Without the nonverbal cues of face-to-face conversation, your tone can get lost in the translation of an e-mail. The more to the point you can be the better. Also using words like "please" and "thank you" can go a long way. 
3. Don't assume the tone or intent of an e-mail you receive. In the same respect that you should watch your tone, never assume the intent or tone of an e-mail you receive either. It is always best to ask specifically the intent of the e-mail, as we all know what happens when you assume. 
4. Don't reply when irritated or angry. When sending and receiving e-mail, the best solution when you feel offended is simply not to be offended (pretty good general life advice too). You are likely getting worked up over something that is simply an error in the translation of the tone. If you find yourself reading an e-mail and becoming irritated, step away for a minute and calm down before replying.
5. One e-mail per subject. Even when you are e-mailing patients, it is best to send one e-mail per subject so that it is easily referenced again by the subject line. If you find yourself sending three or more e-mails, consider sending one e-mail with multiple attachments rather than including pages of text in the body of a single e-mail.
6. Use zip files when sending attachments. Also make sure that the receiving person will be able to open the file. PDF is often the best format for documents; most systems can open it.
7. Always use "if –then" options. Using "if-then" options cuts down on the back and forth of e-mailing, especially for appointment times. For example:
"Can you bring Mary in for a follow-up appointment at 3 p.m. on Wednesday? If not then please give me three additional days and time frames you could bring her in (For example, Wednesday before 10 a.m. or Friday after 1 p.m.)."
 8. Avoid typing in all small caps or all upper caps. This can make your e-mail look lazy (small caps) or like you are shouting (all upper caps). This is one of the most basic rules. However, with so many people communicating from their mobile devices, it often falls by the wayside.
9. Limit text formatting. Just because your e-mail service or program offers text formatting options doesn't mean you should use them. Avoid underlining unless it is a link. Various fonts and colors can make the e-mail difficult to read, and can often times seem unprofessional.
10. Always sign off with care. Use words such as "Thanks," "Sincerely," "Best regards," for closing e-mails. This is polite, respectful, and conveys a nice tone.
Be sure to use care and common sense when using e-mail as a tool to communicate with your colleagues, staff, and patients.

Article By Audrey "Christie" Mclaughlin, RN

Health Reform Doesn't Mean the End of Independent Medical Practices

By Wayne Lipton, Physicians Practice                                                   

There seems to be much public and private hysteria these days over the Affordable Care Act (ACA), or what many call "Obamacare." The rush for implementation of the health insurance exchanges has made real the intended changes to the healthcare system both locally and nationally. In the midst of all this uncertainty, I'm reminded of the British philosophy of, "Keep calm and carry on."

While a good message, I do understand why physicians are concerned. Physicians' earnings have been stagnant over the past several years, despite so-called bonuses for primary care and EHR implementation. Worse has been the uncertainty over Medicare —Will it or won't it get slashed? Because the work keeps getting harder, patients' needs are increasing, and the risks of operating an independent business grow more intense, many physicians feel driven to seek out "protection" by accepting employment with their local hospitals. After all, aren't the hospitals with their layers of administration better prepared for the changes this national "mandate" has created?

Not so fast say some practice management experts. One of the odd consequences of the political shift which accompanied the reform law is a focus on the way hospital systems are reimbursed. Many hospitals are not only seeing reductions in Medicare revenue but are also seeing state-based initiatives in the form of direct taxes on services with the thought that greater reimbursement of uncompensated care will shore up their bottom lines.

If anything, hospital administrators are looking more and more critically at physician employee compensation with an eye toward reducing their outpatient costs and increasing physician productivity. The message is that the fat package offered at the outset to physicians who "sell" to the institution is likely to be reduced significantly when renewal time arrives.

So it's time to take a closer look at decisions to sell or merge a medical practice. And this is where we get back to the infamous British philosophy.

Physicians who want to remain independent or who don't want to feel forced to sell their practices need to stop and really consider what is really happening in the market and what it means for their practice and patients.

Here are some important points to consider:

1. The ACA makes a point of assuring adequate primary-care reimbursement in two different ways. First is the broader definition of preventative services and the means by which providers are paid. Many of the newly insured patients registered with the exchanges will be facing large deductibles. However, the preventative services (those without copays) are paid first by these insurers so physicians will have fewer burdens chasing those patients for money initially.

2. A further mandate for those primary care physicians who provide Medicaid services is that their evaluation and management (E&M) services will now be paid at the federal Medicare level rather than the state, meaning more stability in revenue.

3. Those completing EHR conversion are beginning to see their checks. If you are with a large medical system or hospital, as a physician employee, you may not see those monies. If you have your own practice, you will.

4. Many physicians are beginning to recognize the value of alternative practice models such as full model or hybrid concierge programs. These programs give physicians who want to remain independent that option — plus, and this is important — they provide real choices and options for patients.

Most advisors I speak with have recognized for a long time that solvency in independent medical practice is dependent upon growth. Many primary-care practices have focused on reducing overhead and securing better fees. This "hunker down" mentality has resulted in stunted growth and reduced compensation. It's understandable why those practices would feel the need to consider selling. However, those practices that have embraced growth by looking at alternative practice models, or growing their practice by adding more physicians, extenders, and other specialized services, continue to see growth. This often involves financial investment in a practice by way of loans, but the added revenue often more than offsets the related expenses and improved income can be expected.

The message is — don't panic — and don't sell because you think there are no options. Independent primary-care practice should be able to flourish in this new environment giving physicians who want it the ability to own and maintain their destinies. In fact, the current environments make them more valuable as there are fewer independents physicians, making those services greater in demand.

The key is an eye toward growth and diversification of the medical delivery model. Implementing and/or expanding the physician extender model and incorporating an element of concierge care to facilitate compensation growth while ensuring the practice continues to meet the needs and preferences of all patients.

Article By Wayne Lipton, Physicians Practice   

Getting Patients to Pay Early at Your Medical Practice

In many parts of the country, the economy is still in recovery while healthcare costs are continuing to rise. The end result for physician practices? More stress when it comes to getting patients to pay in a timely manner, and less-than-ideal collection rates.

Technology now allows practices to offer prepayment services to patients. But can such technology really help a practice collect payments at (or even before) the time of service? And will patients actually take to the idea of paying earlier rather than later? For Holly Springs Pediatrics in Holly Springs, N.C., the answer to both these questions is yes. But there has to be a good incentive in place. “It’s very hard getting money from people up front,” practice billing manager Judy Downing told Physicians Practice. “With the economy the way it is, we have so many people out of work. And they don’t look at a doctor’s office as an actual business. They look at it as ‘oh, let me bring you my chicken, and we’ll trade this chicken for your healthcare.’” Tapping into its eligibility verification technology from its billing vendor, InstaMed, which is integrated with its Office Practicum practice management software, Holly Springs Pediatrics recently started offering “prompt-pay” benefits for patients who pay their bills early. Charges are based on the estimated cost of the medical services. “We give them three different options,” said Downing, noting that these options are presented in a self-pay agreement form. “They can pay the estimated charges and receive a 30 percent discount if they pay the balance in full. Or they can pay 50 percent of their estimated charges and if they pay within 30 days, they get a 20 percent discount. They can pay a minimum payment and make an arrangement with the billing department.” By offering these three options, practice has improved collections, and is seen as more flexible by patients. It has also reduced patient no-shows. “We have had a lot of success with people paying it because they get that discount,” said Downing.Aspen Valley Hospital, which uses the same InstaMed program, has also seen a 124 percent increase in collections over the last four years since it started offering a 20 percent adjusted discount off the patient’s portion of the bill for paying in full at the time of service. Along with their two satellite practices, the hospital initially offered a 5 percent discount but found the 20 percent discount to be more successful.  Additionally, the practice reduced overall patient collection costs by 65 percent. “We start by telling a patient when we schedule, then the financial counselor will call and go over the expectation and say, ‘by the way, we offer 20 percent [adjustment] if you take care of your payment in full,” Debby Essex, the hospital’s director of admissions, told Physicians Practice. “Also, there’s a call before the patient comes to the front desk, and when they come to the front desk. They’re fully informed.”

Article by Marisa Torrieri
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Revenue Cycle Management Is More Than Billing Patients

Revenue cycle management (RCM) is the lifeblood of any practice — private or nonprofit. Effective patient registration, insurance and benefit verification, charge capture, and claims processing are essential to maintaining practice viability. Before you can improve any process, you need to assess where you are now. Here are some questions you should think about:

• Do you know if you are achieving best practice standards in accounts-receivable management? • Does it take your practice too long to collect, and/or are your write-offs and adjustments too high? • Do you know your claim-denial rate on first submission (4 percent of claims or fewer is best practice)? • Have you determined that you are not leaving any money on the table with a reimbursement analysis? • What are your days in A/R? What percentage of your accounts receivable is more than 120 days old (10 percent or less is best practice)?

Patient registration The revenue cycle starts with patient registration. Patient registration begins with a phone call for an appointment request. Your front-desk staff should interview the patient on the phone to collect billing and insurance information;  invite the patient to go online to your website to complete their registration information; and follow up if registration isn't completed two days prior to the appointment — so that the patient's insurance coverage can be verified. You can use an in-office kiosk for patient check in and to collect demographic information. Some kiosks will automatically verify insurance eligibility too.  Charge capture Transferring patient charges from the EHR to your practice management (PM) system should be seamless — electronically transmitting data is an example of efficient workflow. But, if you are forcing your providers to first complete a paper visit-encounter form, and then transfer that information to the EHR, it can lead to inconsistencies, lost data, and redundant work processes. Furthermore, asking your check-out station to compare electronic patient information against the paper encounter form is burdensome and creates even more work when discrepancies arise.  Automatic payment posting Automatic payment posting can significantly reduce staff work, so why don't more billing staff embrace and drive implementation of auto-post opportunities? Holding tight to the status quo — manual payment posting and reconciliation — is an inefficient use of our most costly resource: staff. Routinely ask your payers, clearinghouses, and software vendors about new services coming online, and roll out every new payer as electronic remittance and auto-posting become available. Investigate a bank lockbox service that converts the paper explanation of benefits (EOBs) to electronic transactions (837s) for automatic posting to patient accounts.  Insurance eligibility verification Investigate and incorporate automatic insurance eligibility verification into your work flows. You can use your clearinghouse service to upload the appointment schedule a couple of days in advance, in a batch process. For walk-in patients, use real-time verification through your PM system. An integrated verification solution creates a history within the patient's record that supports follow-up collection efforts, if there are later discrepancies with the payer.

Article by Rosemarie Nelson - See more at:

Medicare: Noridian Telephone Reopening Request Guidelines

Beginning September 16, 2013, Part B providers can contact Noridian Telephone Reopening through a single toll free service phone number, 855-609-9960, which includes the Part A and B Provider Contact Centers (PCC), Electronic Data Interchange Support Services (EDISS), Provider Enrollment and User Security.
Telephone Reopenings will be staffed to respond to Part B inquiries Monday – Friday from 6 a.m. – 5 p.m. PT. We will continue to accept telephone reopening requests for items and services Palmetto previously allowed; however, we would also like to inform you of additional telephone reopening services we provide.
Additional Telephone Reopening Services
5 Reopenings per call
Diagnosis additions or changes due to medical necessity (including Local Coverage Determination (LCD) and National Coverage Determination (NCD) denials)
Add modifier AS, 80, 82, 52, 24
Add GV and GW modifier to Hospice claims
Change the MSP type

Who Can Request a Telephone Reopening?

  • Physician or supplier
  • Third party authorized by physician or supplier. (Clearinghouse, biller, coder)
  • Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency for Medicare Part B claim determinations

Complete Claim(s) Research before Calling Reopenings

  • Claim status inquiries call Interactive Voice Recognition (IVR) at the single toll free customer service number.
  • All other inquiries contact Provider Contact Center (PCC) at the single toll free customer service number.
  • If your facility has received an Electronic Remittance Advice (ERA) or Standard Paper Remittance (SPR) indicating that a claim has denied as unprocessable (e.g. MA130 and CO16), it does not have rights to a reopening or an appeal and must be corrected and submitted as a new claim.
NOTE: To ensure that the claim in question is truly finalized, wait 4–5 days following your ERA receipt to call Reopenings.

Be Prepared

When calling Telephone Reopenings the following information must be available when you call. If the following information is not available, you will be referred back to the IVR to obtain the information prior to completing any telephone reopenings. Please remember there’s a limit 5 reopening requests per call.
  • Caller’s name and phone number
  • Provider name and Medicare billing number, National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) (individual or group) *
  • Beneficiary’s Medicare Health Insurance Claim (HIC) number *
  • Beneficiary’s last name and first initial*
  • Beneficiary’s date of birth *
  • Date of Service (DOS)
  • Internal Claim Number (ICN) of the claim
  • Billed amount
  • Procedure code (CPT or HCPCS) in question
  • Corrective action to be taken on the claim
*The elements with an asterisk must be verified for compliance with the Privacy Act.

Corrections (changes/additions/deletions) can be made for the following clerical errors or omissions:
Diagnosis additions, changes and deletions
Place of service changes
Clinical Laboratory Improvement Act (CLIA) Numbers changes or additions
Mammography Certification Numbers changes or additions
Month/Day of service changes
Procedure code changes – up and down code
Modifiers additions, changes and deletions
Add or change post operative dates
Assignment changes (Participating to Non-Participating)
Changes that may cause an overpayment (ex. down coding)
Change the MSP Type – must match the type and primary insurer on file
Add 25 modifier to paid Critical Care (99291-99292, 99298)
Prolonged Services (99354-99359)
All Psychology codes
Initial Preventive Physical Examination (IPPE) Codes (G0402-G0405)
Change rendering NPI & PTAN of provider – must be within the same group
Ground Ambulance miles changes – up to 50 miles
Ground Ambulance (A0428) when billed modifiers HH, RH, NH, EH, SH, PH, HI, and IH
Ambulance claims denied duplicate when there were two trips at different times

Corrections (changes/additions/deletions) cannot be made for the following clerical errors or omissions:
Unprocessable claims
Claims that require documentation to make a change (too complex)
Year of service
Claim line additions and deletions
MSP Type changes
Recoupment issues
Claim(s) with initial determination dates over one year old
Erythropoietin (EPO) (J0881-J0886, Q4081)
Vertebroplasty (22520-22525)
Paravertebral Facet Joint (64493-64495, 64635-64636)
Claims paid by another contractor (denial message 610)
Modifier additions – GA, GY, GX, GZ, QA, QU, QV, Q1, QJ, 21, 22, 23, 66, and 74 must be requested in writing
Air Ambulance
Transitional codes 99495-99496

Corrections (changes/additions/deletions) may be made for the following clerical errors or omissions, depending on situation.
Units /number(s) of service
Unlisted procedure codes (if code is on adjudication list, we can adjust)
Hospice modifiers
May add date span and fractions only (77427, 77336, 77417)

Note: Lists included above are not all-inclusive.

Reopening Filing Limits

  • Requests must be received by Noridian within one (1) year from the original claim processing date determined by the original Medicare Summary Notice (MSN), ERA, or SPR date.
  • Requests received after the one (1) year time limit will be dismissed as untimely.
  • Good cause for late filing will not be considered over the phone and is not applicable for Telephone Reopenings as described in the Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 29, Section 240.  

Reopening Timeline Calculator available on the Noridian “Appeals” webpage

  • Type remittance advice date in box
  • Click “Check” button
  • Displays date the request must be received at Noridian
CMS mandates that Reopening requests be completed by the Medicare Contractor (Noridian) within 60 days from the date the request was received at the Noridian office.

Reopening Determination Notification

  • Approved Determination – An ERA or SPR will contain the payment determination. A separate determination letter for fully favorable reopenings is not sent.
Per CMS, IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 34, Section 10.2, "If a contractor receives a reopening request and does not believe they can change the determination, they should not process the request."
Disclaimer: If any of the above requested changes, upon research, are determined to be too complex, the requestor will be notified that the request needs to be sent in writing, with the appropriate documentation, as a Redetermination.

Courtesy of: Noridian