Workers' Compensation Plans: Getting Patient Claims Paid

If you accept workers' compensation patients at your practice, it's a good idea to review the contracts for some of the finer details of how you will be paid. There are a few areas that you can look at today that will help you be paid tomorrow:

• State where the workers' compensation plan originated from. Believe it or not, different states use different codes. If you are seeing a patient for an extended visit and often code the same you would a patient that has Medicare for the same visit, you may not be getting paid. This can also be said that if you are coding for multiple workers' compensation patients, and one is an out of state plan, you may be paid for one and not the other using the same code. Investigate those adjustments to make sure this is not the case. You can find the codes you should be using in your contract, or at worst, you can call another physicians office in the state the plan originates from and ask them what code they use.

• What codes are actually paid by workers' compensation. Some workers' compensation plans will pay for a specific treatment, and others will not. It's important to track these items so you are aware of what will and won't pay. Otherwise, you are giving away care and losing a lot of money in the process.

• Oftentimes whether or not you are paid will simply rely on what is on the authorization form that came from the nurse case manager or adjuster. If there is something you'd like to do, and do not see it on the authorization, chances are you won't be paid for it on that appointment. Best to have your front-desk staff call and obtain authorization for the treatment you wish to perform. Sometimes you can get this authorization in as little as a few days up to several weeks, so plan accordingly.

• Are you contracted with Medrisk, but not Universal Smart Comp? If Universal Smart Comp is the actual payer on the claim, you won't be paid. I know this seems confusing, but when your staff verifies the insurance and contacts the adjuster, it's best to ask, "Who is the payer?" If it is a company you are not contracted with, you can request another payer whom you are contracted with.

Regardless of the reason for a denial, it is so important to really know and understand your contracts. There may be tips and ideas for getting paid that adjusters are not willing to share after-the-fact once the denial has happened. Many are not very helpful or are just plain hard to get a hold of.

With the changes coming over the next several months, I've found that workers' compensation groups are buying each other up, merging or partnering strategically like the big payers (Wellpoint with Blue Cross and Amerigroup, Aetna, and Coventry, etc.) this may bring many changes to the workers' compensation reimbursement structure.

As always, know your payer mix, know why your adjustments are as high as they are, and read your contracts closely.

By P.j. Cloud-moulds Courtesy of: Physicians Practice http://www.physicianspractice.com/blog/workers-compensation-plans-getting-patient-claims-paid?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=15102013

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

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: http://www.physicianspractice.com/coding/use-modifier-25-explained?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=05092013

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

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 

Jurisdiction 1 Part B: E/M Weekly Tip: Medical Necessity and Reasonable/Necessary

Jurisdiction 1 Part B

E/M Weekly Tip: Medical Necessity and Reasonable/Necessary

Palmetto GBA determines medical necessity largely through the experience and judgment of clinicians along with limited tools provided in the CPT code book and by CMS.
CMS issues National Coverage Determinations (NCDs) that specify whether certain items, services, procedures or technologies are reasonable and necessary under §1862(a) (1) (A) of the Act. In the absence of an NCD, Medicare contractors are responsible for determining whether services are reasonable and necessary. If no local coverage determination (LCD) exists for a particular item or service, the MACs, CERT, Recovery Auditors, and ZPICs shall consider an item or service to be reasonable and necessary if the item or service meets the following criteria:

• It is safe and effective
• It is not experimental or investigational
• It is appropriate, including the duration and frequency in terms of whether the service or item is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the beneficiary's condition or to improve the function of a malformed body member
  • Furnished in a setting appropriate to the beneficiary's medical needs and condition
  • Ordered and furnished by qualified personnel
  • One that meets, but does not exceed, the beneficiary's medical need

There are several exceptions to the requirement that a service be reasonable and necessary for diagnosis or treatment of illness or injury in order to be considered for payment. The exceptions appear in the full text of §1862(a) (l) (A) of the Act.
Resource: Program Integrity Manual, Chapter 3 (PDF, 437 KB). 

Courtesy of: CMS E-News MLN Connects http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~9A6HHE8705?opendocument&utm_source=J1BL&utm_campaign=J1BLs&utm_medium=email
 

Medicare Palmetto Jurisdiction 1 Part B: E/M Weekly Tip: Denials or Down codes

If you receive a denial or down code based on medical necessity, it is important to review the documentation submitted along with the E/M guidelines to determine the reason/cause for the denial. You may use the online E/M Checklist and Scoresheet Form to assist with auditing/selecting the E/M level. If you do not agree with the denial/down code you may appeal the service(s) within 120 days from the date of the initial determination.

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

American Medical Assn. V. United Healthcare

http://www.youtube.com/watch?feature=player_detailpage&list=PL76E72A2E143FAD10&v=8VXig5TvxK0