New CMS-1500 Claim Form Must Be Submitted on April 1, 2014

The CMS-1500 claim form has been updated for ICD-10. Form Version 02/12 will replace the CMS-1500 claim form, 08/05, effective for claims received on/after April 1, 2014.
Below are key dates for compliance with the claim submission rules:

• Medicare began accepting claims on the revised form, version 02/12, on January 6, 2014;
• Medicare will continue to accept claims on the old form, version 08/05, through March 31, 2014;
• On April 1, 2014, Medicare will only accept paper claims on the revised CMS-1500 claim form, version 02/12; and
• On and after April 1, 2014, Medicare will no longer accept claims on the old CMS-1500 claim form, version 08/05.

The grace period for providers to transition to the new form expires on April 1, 2014. Providers need to plan ahead to ensure that claims submitted on the "old" 08/05 claim form mailed or sent via a courier service reach the Noridian offices located in Fargo, ND by March 31, 2014. Claims on the "old" claim form received on/after April 1, 2014 will not be processed. Providers will receive a letter stating that the incorrect form was submitted and that they will need to submit the claims on the current, 02/12 version of the paper claim form.
Note: Updating the print layout for the new claim form will require fairly significant adjustments. The revised form, version 02/12, has a number of revisions which require changes to the print layout for proper data alignment.
Those most notable changes to the 02/12 claim form are for Items 17, 21 and 24E.
Item 17 must have a qualifier entered to the left of the dotted vertical line in Item 17 to indicate the type of provider being reported in this field, as outlined below:

• DN - Referring Provider
• DK - Ordering Provider (this is the appropriate qualifier for DME claims)
• DQ - Supervising Provider

Item 21 now allows for 12 diagnosis codes, rather than 4 and the diagnosis pointers have changed from 1-4 to A-L. In addition, the diagnosis codes are now read left to right, rather than up and down.
Item 24E now requires the corresponding alphabetic, rather than numeric, diagnosis pointer. See Item 21.
Providers are encouraged to start their claim form transition now, by updating your print layouts and obtaining the new claim form for testing. Proper preparation and testing will ensure your ability to properly submit claims on the new form by April 1, 2014.
For more information, see the following:

• CMS Medicare Learning Network (MLN) Matters (MM) 8509 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8509.pdf 

• CMS-1500 Instructions for 02/12 Version at https://med.noridianmedicare.com/web/jeb/topics/claim-submission/instructions

Last Updated Feb 06, 2014

New Influenza Virus and Hepatitis B Virus Vaccine Codes: Noridian/Medicare

MLN Matters® Number: MM8249
Related Change Request (CR) #: CR 8249
Related CR Release Date: May 2, 2013
Effective Date: November 20, 2012 (For code 90661); January 1, 2013 (For codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033)
Related CR Transmittal #: R2693CP Implementation Date: October 7, 2013

Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), carriers and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 8249, which provides instructions for payment and Common Working File (CWF) edits to be updated to include influenza virus vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, and Q2033; and hepatitis B virus vaccine code 90739 for claims with dates of service on or after January 1, 2013, but processed on or after October 7, 2013. The CR also provides instructions for payment and Medicare Common Working File (CWF) edits to be updated to include influenza virus vaccine code 90661 for claims with dates of service on or after November 20, 2012, processed on or after October 7, 2013. Make sure that your billing staffs are aware of these updates.

Background
Vaccines that are described by codes 90653, 90685, 90687, 90688, and 90739 are currently pending Food and Drug Administration (FDA) approval. Vaccines that are described by codes 90661, 90672, 90686, and Q2033 have already been approved.
The Centers for Medicare & Medicaid Services (CMS) will notify Medicare contractors once FDA approval is obtained for the vaccines that are described by codes 90653, 90685, 90687, 90688, and 90739. In addition, Medicare contractors are adding Q2033 as an acceptable influenza vaccine code. As a result of CR8249:

• Effective for claims with dates of service on or after January 1, 2013, vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033 will be payable by Medicare.
• Effective for claims with dates of service on or after November 20, 2012, code 90661 will be payable by Medicare.

Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination must take assignment on the claim for the vaccine.

On professional claims, for dates of service between January 1, 2013 and September 30, 2013, Medicare contractors shall use local pricing guidelines to determine payment rates for influenza virus vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, and Q2033; and hepatitis B virus vaccine code 90739. For dates of service on or after October 1, 2013, Medicare contractors will use Medicare Part B payment limits for these codes. Effective for dates of service between November 20, 2012, and September 30, 2013, contractors shall use local pricing guidelines to determine payment rates for influenza virus vaccine code 90661.

On institutional claims, hospitals (type of bill (TOB) 12X and 13X), skilled nursing facilities (TOB 22X and 23X), home health agencies (TOB 34X), hospital-based renal dialysis facilities (72X), and critical access hospitals (85X), payment will be based on reasonable cost for codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033 with dates on service on or after January 1, 2013. For the same facilities billing code 90661 on or after November 20, 2012, the payment is also based on reasonable cost.

For Indian Health Services (IHS) facilities (including IHS critical access hospitals), comprehensive outpatient rehabilitation facilities, and independent renal dialysis facilities, payment will be based on the lower of the actual charge or 95% of the Average Wholesale Price (AWP).
Medicare contractors shall deny claims for vaccines containing codes 90653, 90685, 90687, 90688, and 90739 if vaccines described by these codes have not obtained approval from the FDA by October 1, 2013. In doing so, they will use:

• Claims Adjustment Reason Code (CARC) 114: Procedure/product not approved by the Food and Drug Administration.
• Remittance Advice Remark Code (RARC) M51: Missing/incomplete/invalid procedure code.
• Group Code: CO

Contractors shall also deny claims containing vaccine codes 90653, 90685, 90687, 90688, and 90739 if no product is located as a result of utilizing local pricing guidelines.

Additional Information
The official instruction, CR 8249, issued to your Medicare contractor regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2693CP.pdf  on the CMS website.

Last Updated Nov 07, 2013

Courtesy of: https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/new-influenza-virus-and-hepatitis-b-virus-vaccine-codes

Medicare/Noridian New Waived Tests - Revised November 2013

New Waived Tests - Revised

MLN Matters® Number: MM8439 Revised
Related Change Request (CR) #: CR 8439
Related CR Release Date: October 28, 2013
Effective Date: January 1, 2014
Related CR Transmittal #: R2804CP
Implementation Date: January 6, 2014

This article was revised on October 29, 2013, to reflect a new Change Request (CR). The CR corrects the spelling of "Premier Integrity Solutions P/Tox Drug Screen Cup." The transmittal number, CR release date and web link to the transmittal was also changed. All other information remains the same.

Provider Types Affected
This MLN Matters® Article is intended for clinical diagnostic laboratories submitting claims to Medicare Claims Administration Contractors (Medicare Contractors) for services to Medicare beneficiaries.

Provider Action Needed
If you do not have a valid, current, Clinical Laboratory Improvement Amendments of 1998 (CLIA) certificate and submit a claim to your Medicare Carrier or A/B MAC for a Current Procedural Terminology (CPT) code that is considered to be a laboratory test requiring a CLIA certificate, your Medicare payment may be impacted.
CLIA requires that for each test it performs, a laboratory facility must be appropriately certified. The CPT codes that the Centers for Medicare & Medicaid Services (CMS) consider to be laboratory tests under CLIA (and thus requiring certification) change each year. Change Request (CR) 8439, from which this article is taken, informs carriers and MACs about the latest new CPT codes that are subject to CLIA edits.
Make sure that your billing staffs are aware of these CLIA-related changes for 2014 and that you remain current with certification requirements.

Background
Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA. The Current Procedural Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test. However, the tests mentioned on the first page of the list attached to CR8439 (i.e., CPT codes: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.
The CPT code, effective date and description for the latest tests approved by the FDA as waived tests under CLIA are the following:  

• G0434QW, January 23, 2008, Phamatech At Home 12 Drug Test (Model 9308T); 
• G0434QW, January 23, 2008, Phamatech At Home 12 Drug Test (Model 9308Z); 
• 81003QW, January 29, 2013, Henry Schein Urispec Plus Urine Analyzer;  
• G0434QW, February 27, 2013, CLIA waived, Inc. Rapid Drug Test Cup; 
• G0434QW, February 27, 2013, Clinical Reference Laboratory, Inc. Intelligent Transport Cup; 
• G0434QW, February 27, 2013, Noble Medical Inc. Noble 1 Step Cup; 
• G0434QW, February 27, 2013, Premier Integrity Solutions P/Tox Drug Screen Cup; 
• G0434QW, February 27, 2013, US Diagnostics ProScreen Drugs of Abuse Cup; 
• 84443QW, March 5, 2013, BTNX Rapid Response Thyroid Stimulating Hormone (TSH) Test Cassette (Whole Blood); 
• 86308QW, March 11, 2013, Henry Schein OneStep Pro+ Mono {Whole Blood}; 
• G0434QW, May 15, 2013, UCP Biosciences, Inc. UCP Home Drug Screening Test Cups; 
• G0434QW, May 17, 2013, Alere Toxicology Services, Inc. Tox Screen Drugs of Abuse Test Cup; 
• G0434QW, June 24, 2013, Advin Multi-Drug Screen Test; and 
• 87880QW, July 3, 2013, Henry Schein OneStep Pro+ Strep A Cassette.

Additional Information
The official instruction, CR8439, issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2804CP.pdf  on the CMS website.  

Last Updated Nov 04, 2013

Improve Medical Practice Efficiency by Offering Group Visits

As reimbursement declines and overhead increases, many practices are struggling to keep up. But rather than attempting to squeeze more patient visits into each day, has your practice considered seeing more patients per visit?

Perhaps it should. The number of practices offering group visits has increased from about two percent to three percent just two years ago to about 10 percent this year, practice management consultant Owen Dahl recently told Physicians Practice.

Here's more on how a group visit works, what it entails, and why your practice may want to consider it.

How a group visit works. During a group visit, multiple patients with similar chronic conditions (such as diabetes, osteoporosis, congestive heart failure, or COPD) meet at the same time with their physician and other appropriate staff.  The visit is held in a private area in the practice, such as a conference room.
The visits may include the following components:

• The taking of vital signs;
• An educational piece, such as a 30-minute discussion with a nutritional counselor, dietician, exercise physiologist, podiatrist, or an ophthalmologist;
• A group discussion, during which patients talk with each other about their particular needs, struggles, challenges, lessons learned, and so on;
• And an individual assessment, during which the physician pulls patients out of the group individually for private exams.

"You see these 15 patients in an hour and half, so you're very efficient there," said Dahl. "The other thing that happens is you free up time slots on your schedule to see other patients."
How a group visit is reimbursed.  After the group visit, the practice bills the appropriate visit (99213 or 99214) for each patient that attends. "You don’t bill based on time, you bill based on the criteria for the level of visit they had," said Dahl, noting that documentation must support the level of code.

How a group visit benefits patients. Group visits provide patients with a support group facing similar issues, and they give patients an opportunity to receive more in-depth education about their condition. That often translates to better outcomes, said Dahl.

"You're actually improving patient care, and I say that with some conviction," he said. "The research that’s been done indicates clearly that there’s a positive outcome with patients being more compliant with their treatment plans ... seeking care, getting involved. There are all of these spinoff benefits that come together.

"How a practice can get involved. Assess your patient population to determine if you have enough patients with similar chronic conditions for which a group visit would be beneficial. Then, determine if enough of your patients would participate, said Dahl.

If you determine that a group visit is something you can and should offer, promote it to patients through one-on-one discussions, handouts, and if applicable, on your practice's website or patient portal.

Before the visit, require all participants to sign group-visit specific HIPAA forms noting that they understand that they will be talking about personal health information with other patients, and stating that they will keep the information shared during the group visit confidential.

Article By Aubrey Westgate of Physicians Practice

Do you offer group visits at your practice? What tips would you share with other physicians?

2013-2014 Influenza (Flu) Resources for Health Care Professionals

MLN Matters® Number: SE1336
Provider Types Affected

This MLN Matters® Special Edition article is intended for all health care professionals who order, refer, or provide flu vaccines and vaccine administration to Medicare beneficiaries.
What You Need to Know

Keep this Special Edition MLN Matters® article and refer to it throughout the 2013 - 2014 flu season.

Take advantage of each office visit as an opportunity to encourage your patients to protect themselves from the flu and serious complications by getting a flu shot.
Continue to provide the flu shot as long as you have vaccine available, even after the new year.
Don't forget to immunize yourself and your staff.

Introduction

The Centers for Medicare & Medicaid Services (CMS) reminds health care professionals that Medicare Part B reimburses health care providers for flu vaccines and their administration. (Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies.)

You can help your Medicare patients reduce their risk for contracting seasonal flu and serious complications by using every office visit as an opportunity to recommend they take advantage of
Medicare's coverage of the annual flu shot.

As a reminder, please help prevent the spread of flu by immunizing yourself and your staff!

Know What to Do About the Flu!

Educational Products for Health Care Professionals
The Medicare Learning Network® (MLN) has developed a variety of educational resources to help you understand Medicare guidelines for seasonal flu vaccines and their administration.

1. MLN Influenza Related Products for Health Care Professionals

• MLN Matters® Article MM8433: Influenza Vaccine Payment Allowances – Annual Update for 2013-2014 Season – http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8433.pdf
• Quick Reference Information: Medicare Part B Immunization Billing chart - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_immun_bill.pdf
• Quick Reference Information: Preventive Services chart - http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf
• Preventive Immunizations booklet – http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Preventive-Immunizations-ICN907787.pdf
• MLN Preventive Services Educational Products Web Page  - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html
• Preventive Services Educational Products PDF – http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/education_products_prevserv.pdf

2. Other CMS Resources

• Seasonal Influenza Vaccines 2013 Pricing - http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2013ASPFiles.html
• Immunizations web page is located at http://www.cms.gov/Medicare/Prevention/Immunizations/index.html
• Prevention General Information is located at http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html
• CMS Frequently Asked Questions - http://questions.cms.gov/faq.php  
• Medicare Benefit Policy Manual - Chapter 15, Section 50.4.4.2 – Immunizations - http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf   
• Medicare Claims Processing Manual – Chapter 18, Preventive and Screening Services http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf

3. Other Resources

The following non-CMS resources are just a few of the many available where you may find useful information and tools for the 2013 – 2014 flu season:

• Advisory Committee on Immunization Practices -  http://www.cdc.gov/vaccines/acip/index.html  
• Flu Clinic Locator - http://www.flucliniclocator.org
• Other sites with helpful information include:
  • Centers for Disease Control and Prevention - http://www.cdc.gov/flu;
  • Flu.gov - http://www.flu.gov; 
  • Food and Drug Administration - http://www.fda.gov;
  • Immunization Action Coalition - http://www.immunize.org;  
  • Indian Health Services -  http://www.ihs.gov/;  
  • National Alliance for Hispanic Health - http://www.hispanichealth.org;  
  • National Foundation For Infectious Diseases - http://www.nfid.org/influenza;
  • National Library of Medicine and NIH Medline Plus - http://www.nlm.nih.gov/medlineplus/immunization.html;
  • National Network for Immunization Information - http:/www.immunizationinfo.org;
  • National Vaccine Program - http://www.hhs.gov/nvpo;
  • Office of Disease Prevention and Health Promotion - http://odphp.osophs.dhhs.gov;   
  • Partnership for Prevention - http://www.prevent.org; and
  • World Health Organization - http://www.who.int/en

Beneficiary Information
For information to share with your Medicare patients, please visit http://www.medicare.gov on the Internet.

Noridian Telephone Reopening: Requests Containing Ambulance, Critical Care and MolDX Services No Longer Accepted (Medicare)

Effective immediately, claims containing the below procedure codes now require documentation be submitted with their Reopening request and will no longer be corrected via a Telephone Reopening.

• Ambulance: A0021-A0999
• Critical Care: 99291 and 99292
• Molecular Diagnostic (MolDX): 81200-81383, 81400-81479, 88380-88381, G0452, 81479, 84999, 85999, 86849, 87999, 88199, 88299, 88399, 89398, 83890-83914, and 88384-88386

When documentation is required to process a Reopening, providers must submit the request as a Written Reopening with a completed "Reopening Form" or through Endeavor. If a request is more complex, beyond clerical errors or omissions, it is appropriate to submit a Redetermination via the "Redetermination Form."

For more Telephone Reopening information, go to https://med.noridianmedicare.com/web/jeb/topics/appeals/telephone-reopening.

Last Updated Oct 17, 2013 By Noridian

https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/telephone-reopening-requests-containing-ambulance-critical-care-and-moldx-services-no-longer-accepted

How to Code, Negotiate After-Hours Reimbursement at Your Practice

There are codes in the CPT® code book to report services a physician provides during "nontraditional" hours. If you prove that it’s in the payer’s best interest, third-party insurers may allow additional reimbursement for after-hours services.

Medicare and payers that strictly follow CMS guidelines will not pay additional reimbursement for after-hours services. However, you might succeed with private payers in negotiating payment for after-hours codes as part of a contractual agreement, especially if you use savings potential as leverage. Have your negotiator make it clear to the insurer’s representative that you’ll willingly send patients to the emergency department (ED) instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than comparable physician services.

To further demonstrate cost savings, you could also start billing all applicable after-hours codes for your practice. Over time, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.

Know the Codes

Based on the CPT®/AMA guidelines, you may report 99050 — Services provided in the office at time other than regularly scheduled office hours, or days when the office is closed (e.g., holidays Saturday or Sunday), in addition to basic service — for any service provided in the office at a time when the practice would normally be closed (e.g., weekends or evenings). Code 99050 is reported in addition to the code for the basic service.

If your practice already maintains regular hours on evenings, weekends, or holidays, and you provide a service during those times, you should skip 99050 and use 99051 — Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

If a 24-hour facility requests that your physician provide a redeye or early-bird service, AMA guidelines allow you to claim 99053 — Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service, in addition to the basic service. Code 99053 can be used whether the provider is already at the facility, or if the physician has to make a special trip to care for the patient. The code 99053 can only be used if the service provided occurs at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).

Emergency department physicians may report 99053 for services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians fully supports this use of 99053, stating that this code is appropriate for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."

G. John Verhovshek, MA, CPC, is the managing editor for AAPC's publications. He has written, co-written, and edited dozens of coding and compliance resource manuals, including the Part B Survival Guide (1st edition) and The Official CPC Certification Study Guide (1st edition). E-mail him here.

Article By G. John Verhovshek, MA, CPC http://www.physicianspractice.com/coding/how-code-negotiate-after-hours-reimbursement-your-practice?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03102013

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
• J3590 UNCLASSIFIED BIOLOGICS
• 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 https://www.noridianmedicare.com/je/docs/unlisted_procedure_and_not_otherwise_classified_codes.html

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 Modifiers 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. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf   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 https://www.noridianmedicare.com/je/docs/telephone_reopening_request_guidelines.html

COMMON SETS OF CODES USED TO BILL FOR EVALUATION AND MANAGEMENT SERVICES

When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer. These reviewers may assist with selecting codes that best reflect the provider’s furnished services. However, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

The provider must ensure that medical record documentation supports the level of service reported to a payer. The volume of documentation should not be used to determine which specific level of service is billed.

In addition to the individual requirements associated with the billing of a selected E/M code, in order to receive payment from Medicare for a service, the service must also be considered reasonable and necessary. Therefore, the service must be:

• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition (i.e., not provided mainly for the convenience of the beneficiary, provider, or supplier); and
• Compliant with the standards of good medical practice

The two common sets of codes that are currently used for billing are: Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) diagnosis and procedure codes.

CURRENT PROCEDURAL TERMINOLOGY CODES
Physicians, qualified non-physician practitioners (NPP), outpatient facilities, and hospital outpatient departments report CPT codes to identify procedures furnished in an encounter. CPT codes are used to bill for services furnished to patients other than inpatients and for services being billed on claims other than inpatient claims. Therefore, CPT codes should be used to bill for E/M services provided in the outpatient facility setting and in the office setting.

INTERNATIONAL CLASSIFICATION OF  DISEASES DIAGNOSIS AND PROCEDURE CODES 
The use of ICD-9-Clinical Modification (CM) diagnosis and procedure codes is limited to billing for inpatient E/M services on inpatient claims. All other provider types should continue to use CPT codes to bill for E/M services.

The compliance date for implementation of the International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/ PCS) is for services provided on or after October 1, 2014, for all Health Insurance Portability and Accountability Act covered entities. ICD-10-CM/PCS is a replacement for ICD-9-CM diagnosis and procedure codes. The implementation of ICD-10-CM/PCS will not impact the use of CPT and alpha-numeric Healthcare Common Procedure Coding System codes.

All providers billing for inpatient services provided to inpatient beneficiaries will use ICD-10-CM diagnosis codes instead of ICD-9-CM diagnosis codes for services furnished on or after October 1, 2014.

 ICD-10-CM/PCS will enhance accurate payment for services rendered and facilitate evaluation of medical processes and outcomes. The new classification system provides significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine. 

ICD-10-CM/PCS consists of two parts: 

• ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3 – 7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and
• ICD-10-PCS – The procedure classification system developed by the Centers for Medicare & Medicaid Services for use in the U.S. for billing inpatient hospital claims for inpatient services ONLY. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.

Courtesy of: CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

GENERAL PRINCIPLES OF EVALUATION AND MANAGEMENT DOCUMENTATION: If It Isn’t Documented, It Hasn’t Been Done.

“If it isn’t documented, it hasn’t been done” is an adage that is frequently heard in the health care setting.

Clear and concise medical record documentation is critical to providing patients with quality care and is required in order for providers to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received and are used to record pertinent facts, findings, and observations about the patient’s health history. Medical record documentation assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring the patient’s health care over time.

Health care payers may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate:

• The site of service;
• The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided;    and/or
• That services furnished have been accurately reported.

There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, the following general principles help ensure that medical record documentation for all E/M services  is appropriate:

• The medical record should be complete and legible;
• The documentation of each patient encounter should include:
•  Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
• Assessment, clinical impression, or diagnosis;
• Medical plan of care; and
• Date and legible identity of the observer.
• If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred;
• Past and present diagnoses should be accessible to the treating and/or consulting physician; Appropriate health risk factors should be identified;
• The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented; and
• The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter.

Courtesy of: CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

E/M Tip: CPT Modifier 25 (Critical Care)

Services, such as endotracheal intubation (CPT code 31500) and the insertion and placement of a flow directed catheter, e.g., Swan-Ganz (CPT code 93503), are not bundled into the critical care codes. Separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with CPT modifier 25. The time spent performing the pre, intra and post procedure work of these unbundled services, e.g., endotracheal intubation, shall be excluded from the determination of the time spent providing critical care. This policy applies to any procedure with a 0, 10 or 90 day global period, including cardiopulmonary resuscitation (CPT code 92950). CPR has a global period of 0 days and is not bundled into critical care codes. Therefore, critical care may be billed in addition to CPR if critical care was a significant, separately identifiable service and it was reported with CPT modifier 25. The time spent performing CPR shall be excluded from the determination of the time spent providing critical care. In this instance, it must be the physician who performs the resuscitation who bills for this service. Members of a code team must not each bill Medicare Part B for this service.

 

For more information, please visit the Medicare Claims Processing Manual, 100-04, chapter 12, Section 30.6.12. K at CMS website (PDF, 1 MB).

 

Courtesy of: Palmetto GBA http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~9ARGCD8313?opendocument&utm_source=J1BL&utm_campaign=J1BLs&utm_medium=email

Medicare Preventative Services National Provider Call

JE Medicare Part B Processing Changes Using CPT Modifier 52-Reduced Services - Effective September 16, 2013

Noridian has identified a claim processing difference between contractors .This notification is to make all Part B providers served by Jurisdiction E (JE) aware of this difference. 
Palmetto GBA, the current J1 contractor, requires the submission of documentation along with the claim. A concise statement that explains the nature of the reduced service along with any other supporting documentation the provider deems relevant. The concise statement may appear on the operative report but, it must be clearly identified. This statement may be entered in the electronic documentation field or submitted via the fax attachment process. For paper claims, this documentation must be submitted as an attachment to the CMS-1500 claim form. Services that are submitted with CPT modifier 52 that do not include a concise statement will be rejected as 'unprocessable' and must be resubmitted as new claims
Noridian requires the provider to determine the charge amount, reduce normal fee by percentage of service not provided e.g., if 75% of normal service provided, reduce amount billed by 25% Medicare reimburses lower of actual charge or fee schedule allowance.

Example: Provider performs 75% of service and appends modifier 52
Medicare Physician Fee Schedule (MPFS) allowed amount	$300
Reduced Billed Amount ($300 x 75%)	$225

• Reflect statement “reduced services” in Item 19 (narrative or electronic equivalent)
• Documentation reflecting “reduction” reason retained in patient’s medical record
• Do not confuse with “terminated procedure” modifier 53
• Never use with evaluation and management or anesthesia codes

Appeals

• When submitting the Redetermination request include:
•  A separate, concise statement explaining the necessity for allowable reduction
•  An operative report or chart notes

Example

• Performed on one eye; unilateral
• Do not use RT or LT

Treatment Description	CPT/Modifier
Fundus photography with interpretation/report; bilateral	92250 52

JE Medicare Part B Processing Changes for Use of CPT Modifier 22 - Effective September 16, 2013

Noridian has identified a claim processing difference between contractors. This notification is to make all Part B providers served by Jurisdiction E (JE) aware of this difference. 
Palmetto GBA, the current J1 contractor, requires the submission of documentation along with the claim. Documentation required with the claim is a concise statement and operative report which is either entered in Item 19 of the CMS-1500 claim form for paper claims or submitted with an electronic claim via the fax attachment process. Failure to submit the appropriate information results in a denial of the claim. Claims submitted with CPT modifier 22 are reviewed on an individual basis. Additional reimbursement allowance will be dependent on the documentation.
Noridian pays claims with the CPT modifier 22 at the established fee schedule rate. Providers may appeal for additional payment with sufficient documentation demonstrating the work performed was substantially greater than typically required and explains why the surgery was unusual.

When appealing:

• Redetermination requests require a separate, concise statement explaining the necessity for additional reimbursement be included.
• Need operative report or separate letter
• Medical Review addresses each request individually with no assurance of additional payment 

Example

Treatment Description	CPT/Modifier
Pharyngolaryngectomy, with radical neck dissection; with reconstruction	31395 22

Resource
Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 40.2 “Billing Requirements for Global Surgeries” – Unusual Circumstances at  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/bp104c12.pdf 

In Medical Coding, Apply the Right Rules at the Right Time

When submitting medical claims, not only do you need to get the codes right but you have to apply the right rules. Coding guidelines are found in the CPT® code book and payer policies. HIPAA mandates that providers and payers use the same codes but payers can vary the payment policies and coding requirements. For example, bilateral procedures can be reported in different ways. The "right" way is to follow payer preference which can vary from payer to payer.
    
Some of the options for reporting bilateral knee arthrocentesis include:
      

• 20610-50 with two units 
• 20610-LT, 20610-RT with one unit each
• 20610, 20610-50 with one unit each

In the CPT® code book, there are coding guidelines throughout the sections and subsections that provide valuable information for proper code selection. Often the coding guidelines include a description of the procedures and additional procedures that can be billed when performed. For example, the coding guidelines preceding malignant excisions codes (11601-11646) state that a simple closure is included in the procedure. If the excision site requires an intermediate or complex closure, the closure can also be reported if performed. If you did not pay attention to this guideline, you could be losing money if you did not code the intermediate or complex closure.

The parenthetical notes found in the CPT® code book are also valuable. The intent is to assist in proper coding. These instructions are often overlooked which leads to coding errors. For example, following code 64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure). CPT® states "Do not report 64492 more than once per day." This instruction informs you it would not be appropriate to submit multiple units of the code on the same date of service.

One of the biggest mistakes a practice can make is applying Medicare rules to all payers. This can cause improper reimbursement. There are some procedures Medicare does not cover that private payers will and vice versa. For example, Medicare allows for a Pap smear every two years for a female who is not considered high risk or of childbearing age. Private payers may cover the Pap smear once per year. If you applied the Medicare frequency limitation, you would lose out on the reimbursement from the private payers.

The good news is the information for private payers can be found in the provider-payer contract, payment policies, and provider manuals. Most payers provide payment polices and provider manuals on their website. Coding requirements for Medicare can also be found on the CMS website in the Medicare Claims Processing Manual, Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs). There is a lot of information available that provides guidance for submitting the codes correctly.

You need to make the time to read and understand the rules and remain up to date. Keep in mind, policies periodically change, which requires you to stay updated on those changes.

Article By Raemarie Jimenez, CPC - : http://www.physicianspractice.com/blog/medical-coding-apply-right-rules-right-time#sthash.f6W2pbDx.dpuf

Proper Coding Can Help Prove Medical Necessity

For a service to be considered medically necessary, it must be reasonable and necessary to diagnosis or treat a patient’s medical condition. When submitting claims for payment, the diagnosis codes reported with the service tells the payer "why" a service was performed. The diagnosis reported helps support the medical necessity of the procedure.             

For example, a patient presents to the office with chest pain and the physician orders an electrocardiogram (ECG). A 12-lead ECG performed in the office and interpreted by a physician is reported with CPT® code 93000. The reason the physician orders the ECG is because the patient is complaining of chest pain. The diagnosis code for unspecified chest pain is 786.59.

The provider must document the diagnosis for all procedures that are performed. The provider also must include the diagnosis for each diagnostic test ordered. A common error seen when reviewing medical documentation is that the provider will document a diagnosis and indicate tests ordered, but it is unclear that all the tests ordered are for the diagnosis documented in the assessment. For example, the patient presents with right knee pain and the physician performs an arthrocentesis. He also orders a chest X-ray. The only diagnosis documented is knee pain. The knee pain supports the medical necessity for performing the arthrocentesis, but it does not support the medical necessity for the chest X-ray.

In this case, the provider should be queried why the chest X-ray was ordered so the proper diagnosis can be reported. The provider may have wanted a knee X-ray and made a mistake when writing his orders. By asking the provider for clarification, you have prevented the performance of an unnecessary test because the provider really intended to order a knee X-ray. In this case, the knee pain would support the order of the knee X-ray. If the provider intended to order a chest X-ray, by asking for clarification you can report the service with a more appropriate ICD-9-CM code and eliminate a claim denial. In this example, the arthrocentesis is reported with procedure code 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) and diagnosis code 719.46 Pain in joint; lower leg. The code for the X-ray is selected based on the anatomic site and number of views obtained.

Not all diagnoses for all procedures are considered medically necessary. Medicare and commercial payers have coverage policies that specify the diagnosis codes that support medical necessity for certain procedures. Also included in the coverage policies are documentation requirements. The documentation requirements can include diagnostic test values that must be met, that less invasive treatments be attempted before the service is determined to be medically necessary, or — for a repeat procedure — a statement of the outcome of the previous procedure of the same type. Knowing the coverage polices for the services provided in your office can help eliminate denied claims later.

The coverage policies are available for providers to review and adhere to when submitting claims. The coverage policies for Medicare are found at the Medicare Coverage Database. This database includes NCDs (National Coverage Determination), which are nationwide determinations for Medicare covered services; and LCDs (Local Coverage Determination), which are determinations if a service is covered carrier-wide by a MAC (Medicare Administrative Contractor). Using this database, you can search for coverage determination by CPT® or HCPCS Level II codes, and by your geographic region.

Private payers (e.g. Cigna, United Healthcare, etc.) have coverage policies as well. Most private payers have their coverage polices available on their website. Provider contracts with payers also include coverage policies. Review the coverage polices for the private payers you contract with, as well as Medicare if your provider participates in the Medicare program.

Word of caution: Do not alter the diagnosis code for a patient to match one of the diagnosis codes listed in the coverage policy as supporting medical necessity. The diagnosis code submitted must be supported by the medical record. It is inappropriate to report a diagnosis solely because it is on the approved list of diagnosis codes that meet medical necessity. Reporting a diagnosis that the patient does not have to receive payment for the service is fraud, which may result in fines and, in some cases, criminal prosecution.

When submitting claims, you must report the diagnosis that is indicated in the medical record for the procedures performed and ordered. Knowledge of coverage policies will help you to be proactive in avoiding claim denials and to educate your providers on the documentation required to support the services rendered. This is not to say that the provider should not perform the service if the circumstances may deem the service not medically necessary. If the physician determines the procedure is medically necessary even though the coverage policy does not approve it, this gives you the opportunity to educate your patients that the service may be denied by their insurance carrier. The patient then has the choice whether to have the procedure.

Article by Raemarie Jimenez, CPC  - See more at: http://www.physicianspractice.com/blog/proper-coding-can-help-prove-medical-necessity#sthash.gaQDAPLq.dpuf

Selecting the Right E&M Codes at Your Medical Practice

The focus on educating providers and coders on the selection of evaluation and management (E&M) services has increased over the years due to numerous factors, including: E&M codes make up the majority of procedures reported by physicians and mid-level providers; audits (e.g. OIG audit focus on E&M especially documentation using EHRs); and the fact that complexity of code selection can be confusing and ambiguous.     

Most of the education focuses on the three key components (history, exam, and medical decision making). Proper documentation of these elements is extremely important but we cannot lose focus on the most important criteria for E&M code selection, which is medical necessity. Codes should not be solely selected based on the volume of the documentation of the three key components, but the nature of the patient’s presenting problem and medical intervention required by the provider.

As more and more physicians implement EHRs, there is an increase in the volume of documentation. EHRs are very useful tools if used appropriately, but can be abused to create pages of useless information that does not pertain to the date of service or the patient’s complaint for the encounter. We often see this with the review of systems and past, family, and social history components when elements from a previous encounter are carried forward. When you see the same information documented for the patient each time she is seen, it makes you wonder if the information is obtained each time or a system default. If it is obtained each time, is the information pertinent to the presenting problem?

An effective way to incorporate the focus on medical necessity of the service into your E&M training is to relate it to the provider’s typical patient. When a patient presents to the office, the provider can usually tell quickly how sick the patient is. The patient’s complaint for the day will dictate the questions the provider asks regarding the patient’s presenting problem. This information makes up the history component of the encounter.

Next, the provider examines the patient. The provider should exam all body areas and/or organ systems that are pertinent. Some providers may prefer to perform an eight-system exam for each patient but it might not be medically necessary. For example, a patient presents with an earache. An eight-system exam may not be warranted depending on the last time the patient was seen. If the patient was seen recently for a complete physical and is presenting for only an evaluation of the earache, the complete exam might not be necessary. However, if the patient has not been seen in over a year, the provider will take the opportunity to address the presenting problem(s) and perform a complete exam for preventive measures or conditions the patient may have. Sometimes a patient will present for one problem and “oh by the way” something else is also bothering them.

The medical decision making component includes the provider’s assessment, data collected (e.g. diagnostic tests), and treatment plan. Once the exam is complete, the provider will determine what tests are needed if any. When ordering tests, providers must document the reason for the test. If a definitive diagnosis has not been determined, the reason for the tests will be the patient’s signs and symptoms. Although differential diagnoses are not reported, they should be included in the documentation to support the severity of the patient’s condition.

If the patient is presenting with a headache and the provider is ruling out neurological conditions, it should be included in the documentation. The treatment plan should be documented. It can include medications prescribed, therapies ordered and/or procedures needed.

In addition to using the CMS documentation guidelines for E&M education, incorporate the nature of the presenting problems found in the CPT® E&M coding guidelines. Although the nature of the presenting problem is not one of the three key components, it helps the provider understand the types of conditions that qualify for the different levels of E&M. Focus your education on the patient’s condition, work needed to treat the patient, and the proper documentation to support the services rendered.

Article written By Raemarie Jimenez, CPC- See more at: http://www.physicianspractice.com/blog/selecting-right-em-codes-your-medical-practice#sthash.Z26Zg8gz.dpuf

How to Code, Negotiate After-Hours Reimbursement at Your Practice

There are codes in the CPT® code book to report services a physician provides during "nontraditional" hours. If you prove that it’s in the payer’s best interest, third-party insurers may allow additional reimbursement for after-hours services.

Medicare and payers that strictly follow CMS guidelines will not pay additional reimbursement for after-hours services. However, you might succeed with private payers in negotiating payment for after-hours codes as part of a contractual agreement, especially if you use savings potential as leverage. Have your negotiator make it clear to the insurer’s representative that you’ll willingly send patients to the emergency department (ED) instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than comparable physician services.

To further demonstrate cost savings, you could also start billing all applicable after-hours codes for your practice. Over time, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.

Know the Codes

Based on the CPT®/AMA guidelines, you may report 99050 — Services provided in the office at time other than regularly scheduled office hours, or days when the office is closed (e.g., holidays Saturday or Sunday), in addition to basic service — for any service provided in the office at a time when the practice would normally be closed (e.g., weekends or evenings). Code 99050 is reported in addition to the code for the basic service.

If your practice already maintains regular hours on evenings, weekends, or holidays, and you provide a service during those times, you should skip 99050 and use 99051 — Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

If a 24-hour facility requests that your physician provide a redeye or early-bird service, AMA guidelines allow you to claim 99053 — Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service, in addition to the basic service. Code 99053 can be used whether the provider is already at the facility, or if the physician has to make a special trip to care for the patient. The code 99053 can only be used if the service provided occurs at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).

Emergency department physicians may report 99053 for services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians fully supports this use of 99053, stating that this code is appropriate for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."

Article written by: By G. John Verhovshek, MA, CPC from: http://www.physicianspractice.com/blog/how-code-negotiate-after-hours-reimbursement-your-practice?utm_source=dlvr.it&utm_medium=twitter&mkt_tok=3RkMMJWWfF9wsRoluqXKZKXonjHpfsX57ugqXKS3lMI/0ER3fOvrPUfGjI4ETMNrI%2BSLDwEYGJlv6SgFSbXHMbl60bgMUhg%3D

Yes, you can bill a separate problem during a well check visit

Watch for significant service that could boost pay.
When a patient come to your office for a preventative wellness visit, don't automatically assign a code from 99381-99397 and think your claim is complete. If the patient mentions a health problem or other concern during the preventative visit, the encounter might qualify for two codes.

Checkpoint: If the problem ranks as "significant" you can report your work to address is in addition to the preventative care. This may take the form of a problem-oriented E/M code (e.g. 99201-99215). a procedural service,or both.

Here's how: If the patient's problem necessitated additional work required to perform the key components of a problem-oriented E/M service in addition to the preventative medicine visit, submit the appropriate preventative medicine code from 99381-99397 and the appropriate problem-oriented E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure of other service) appended to the problem-oriented code.

If the problem required you to perform a procedural service, then you would submit the relevant procedure code, plus the appropriate preventative medicine code from 99381-99397 with modifier
25 appended to indicate the preventative visit was significant and separately identifiable form the procedure (just as you would if billing a problem-oriented E/M code and an office procedure on the same date of service).

If you were reporting a preventative medicine E/M service, a problem-oriented E/M service, and a procedural service for the same encounter (a rare occurrence), you may need to append modifier 25 to both E/M codes to indicate that each is separately identifiable from the procedure and each other.

Key: Although poorly covered in the past, many payers now recognize and pay for these separate, significantly identifiable services addressed during preventative medicine visits. Of course, those additional services, if covered, may also result in a patient financial obligation (e.g. deductible, copay, or coinsurance) that would not accrue with a simple preventative visit. Managing patient expectations in this situation is important.

"Under the Affordable Care Act, health plans are generally prohibited from financially obligating patients for a covered preventative service, so patients presenting for a preventative medicine visit typically expect that there will be no charge for them for any portion of the encounter," notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, KS. "However, problem-oriented E/M services and procedures may be subject to deductibles and patient-cost sharing, so if you are going to provide either one during a preventative visit, the patient needs to understand the possible financial implications of that, which avoids any surprises when the explanation of benefits and your bill arrives later," adds Moore.

Example: A 52-year-old established patient comes in for a preventative medicine service (99396, Periodic comprehensive preventative medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years). During the visit, she mentions a sore spot on the bottom of her foot, which the physician immediately diagnoses as a plantar wart and offers to remove it with cryotherapy (17110, Destruction [e.g. laser surgery, electro-surgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions). The patient agrees, and the physician treats the wart with liquid nitrogen.

 What to report: You should code the encounter as 99396-25 and 17110. Link diagnosis V70.0 (Routine medical examination at a health care facility) to 99396 and diagnoses 078.12 (Plantar wart) to 17110.

3 tips: If you're still unsure whether you're justified in billing s problem-based E/M code along with the preventative visit, keep a few criteria in mind:

• If the problem is significant enough that it would require or justify the patient to come back for another visit if the physician doesn't address it, that could be a clue that you're dealing with a problem-based E/M situation.
• Check whether the problem has its own ICD-9 diagnosis code. If so, that means addressing the issue could be a stand-alone (and separately reportable) service.
• Look for additional evaluation and treatment options, such as X-ray or lab tests, or written prescriptions. These can be other signs that the physician is addressing a significant problem.

Courtesy of: The Coding Institute, Family Practice Coding Alert