Category Archives: Claims

Substance Abuse Counseling and Intervention

Insurances, legislators, and the general public are finally understanding what many of our physicians have known for years. Without significant and timely intervention, the opiod crisis will only get worse. Right now both insurances and legislators are flailing around trying to determine what “significant and timely intervention” consists of.

 

I know that many of you are seeing a greater number of patients whose insurances are beginning to deny their pain medication refills and insist that physicians help patients taper off of opiods. I know that, for years, many of you have seen patients who need help with both real pain and an opiod addiction.

 

One of my Internal Meds is also an addiction specialist and treats patients with substance abuse issues, so we have experience with how insurances want to see the screenings and counseling for these conditions. And what they want is an absolute mess. There is no standardized service code or diagnosis, each insurance has different policies for covering these services, and even different plans within each insurance company has new and interesting hoops for you to jump through. This guide will teach you the most common combinations of codes and give you the tools and terminology to unravel the rules for plans that don’t follow these guidelines. While most of you will be primarily using these codes for your opiod patients, please do use them for patients dependent on and/or abusing other substances as well. 

 

In order to first determine if a patient is dependent on or abusing substances, they first need to be screened. I suggest that your providers incorporate substance abuse and depression screenings into their routine for physicals, and also possibly for all new patients, if you haven’t already. Please remember that your E&M code or preventative code needs a modifier 25 if you are also doing a screening or counseling in the same visit.

For screenings, you would typically use ICD10 code Z13.89 and either CPT code G0442 or H0049. 

CPT code G0442 is limited to alcohol misuse, so any additional substances that you screen for along with alcohol with not be payable separately. Most insurances don’t accept H0049.

For Blue Cross, Blue Shield, Cigna, United Healthcare Medicare Solutions, and Medicare you would bill like this:

Z13.89                                    G0442 (some insurances require either a 25 or a 59 modifier)   

For Aetna, United HealthCare, and UMR, enter the charge like this: 

Z13.89                                   H0049 (has a low reimbursement rate)

 Some patients will come into the office and let you know they are there for help with a substance abuse problem, if that is the case, then skip this step. Counselings and screenings cannot be billed on the same date because they are mutually exclusive, so if a screening comes up positive and you are going to do counseling in your office, bill the counseling codes, the reimbursement is higher. 

 

If your patient is actively abusing substances, use the ICD10 code for substance dependency (F10.10–F16.998 and F18.10-F19.988) and the service code G0396, G0397 or 99408. This also goes for people on maintenance medication that are still abusing substances.

The charge would look like this: 

F11.20                                        G0396

 

If your patient is a former drug user that is on maintenance medication and NOT currently abusing substances use ICD10 code Z71.51 and service code 99401.

The charge would look like this:

Z71.51                                       99401

 

If your patient has been using opiods with no dependency or abuse problems, but the medication still needs to be tapered off, you would use ICD10 code Z79.891 and service code 99401.

The charge would look like this: 

Z79.891                                    99401

 

There are many plans that do not fit into these neat little boxes, and these are just guidelines anyway. If your claim isn’t getting paid, the first step is to call and check benefits for your patient. Be very specific and tell them you need to check the patient’s plan for any exclusions. Give them first the ICD10 codes and service codes you are using. If there are any exclusions for those codes, check some of the other ones. Please remember, you are NOT asking if these codes are “covered”. You are asking if this plan has an exclusion for any of your codes. 

 

If there are no exclusions, your next step is to ask if the ICD10 codes you are using “match” with the service codes. For example, I billed a charge with the F11.20 and the G0396 and it was denied stating that is not a benefit of the patient’s plan. I called for benefits and I was told that the G0396 is classified as preventative for that plan and I can only use preventative ICD10 codes. At that point, I have the choice to switch the service code to 99401 or switch the ICD10 code to Z71.51. 

 

Below is a complete list of the diagnosis and service codes that you can choose from for dependency screenings and counselings. 

Diagnosis Codes

Substance dependency (F10.10–F16.998 and F18.10-F19.988) 

Drug abuse counseling and surveillance of drug abuser (Z71.51)

Long term use of opiate analgesics (Z79.891) 

Encounter for screening for other disorders (Z13.89)

 

Service codes

Alcohol and/or substance (other than tobacco) abuse structured
assessment (for example, AUDIT, DAST) and brief intervention, 15 to 30
minutes (G0396)

Alcohol and/or substance (other than tobacco) abuse structured
assessment (for example, AUDIT, DAST) and intervention greater than 30
minutes (G0397)

Preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 15 minutes (99401)

Preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 30 minutes (99402)

 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services (99408)

Annual Alcohol Misuse Screening, 15 minutes (G0442)

Alcohol and/or drug screening (H0049)

 

My last tip is to change the text that displays on your codes to have the terms “Screening for dependency” or “dependency review” or “preventive medicine counseling”. Even for patients with active drug addictions, many of them object when they receive statements with line items containing the words “substance abuse”. Even when there is no charge to them for those line items, the fact that the words “substance abuse” appears on the statement at all is enough to upset them. Since your time and your staff’s time is valuable, changing those phrases can save you a lot of aggravation. 

If you need help with any of this or if you want to arrange an in-person or webinar training for your office, call us at (909) 610-9524 or email newgenerationbilling@gmail.com. Happy billing! 

Advertisements

Leave a comment

Filed under Billing, Claims, Counseling, Medical Billing, Preventative services, Screenings

The new forms are here!

Hello everyone!

April 1st is the deadline to switch over to the new CMS forms. And that is today. I know that there are a lot of you out there following this blog,  so I have a quick public service announcement.

Please make sure you have the new forms for your paper AND electronic submissions today. If you are not sure whether or not you have the new forms, call around. Call your clearinghouse! Call your software vendor! Call MY software vendor! Call support! You may need to upgrade your software or re-map your print image file and test everything to make sure it’s working properly.

If you need help today, and you can’t get hold of  your support people, please do actually call my support people. I use Lytec and I get it from Advanced Data Management. If you have an older version of Lytec and you don’t want to upgrade, they can get you the new CMS form for your current version (back through Lytec 2006 I believe). Even if you don’t have Lytec, they might be able to help you. You can find them here at http://www.adm1inc.com or call them at (800) 888-2361. They have been busily helping their customers get ICD10 ready for the last three months (including me–thanks Jo-Ann!) and if you left it to the last minute, please don’t leave it any longer.

Happy Billing!

 

1 Comment

Filed under Billing, Claims, Denials, ICD10

Modifiers 24 and 79

A few months ago we had to do some training on our ophthalmologist account regarding when to bill the 24 modifier versus the 79 modifier in the global period to a surgery or in-office procedure. I figure, if our employees are having questions, some of you might be too, and I want you to get the maximum reimbursement for your services. First, the exact descriptions of the modifiers from the CPT book:

24 – Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Post-operative Period:
The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.

79 – Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:
The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)

Many of our doctors do both minor and major surgeries, and we all know that patients need to come back in for follow up care on their various incisions, wounds, and ulcers to make sure everything is healing properly. The insurance companies will not pay for these follow up visits, or any visit done in a certain amount of time after the procedure without the proper modifiers as they consider the follow up visit to be an integral part of the original procedure. This time period is called the global period and the length of time varies depending on the procedure performed.  The issue with this no-payment rule comes in when the doctor diagnosis the patient with something additional during the follow up visit, or the patient needs another procedure. At that point, the doctor needs to do a complete visit including review of systems and exam and make a medical decision, and we can all agree that she should be paid for that. Here is how you get her paid. Modifier 24 goes on the office visit and you make sure you have a primary diagnosis that is different than the diagnosis on the original procedure. If the patient needs any in-office procedures, put a 79 on the procedure and make sure the diagnosis is different than the one on the original procedure. If the patient needs another major surgery in that time period, unrelated to the original, use modifier 79 as the first modifier on the surgery.  Just to avoid confusion, whether you use the modifier 24 or the modifier 79, the modifier would go on the visit subsequent to the surgery or in-office procedure.

To answer a popular question, yes, you can use modifier 79 when you are billing for the same surgery on a different body part. For example, if the patient had a cataract surgery on the left eye in January and he is getting cataract surgery on his right eye in February, you can use the same diagnosis of cataracts, the same CPT code for the surgery, and add the 79 modifier. Here is how that would look:

Date                          ICD9 code            CPT Code    Modifiers

01/13/14                 366.17                    66984             LT

02/18/14                366.17                    66984              79    RT

As for using the 24 modifier, there are all kinds of good, justifiable reasons to bill with that modifier and get your office visit paid separately. Here are just a few:

1) Patient is requesting a refill on medication for her chronic condition (hypertension, diabetes, hypothyroidism, migraines, neuralgia)

2) The patient came in with an unrelated chief complaint on his follow up visit

3) Patient came in for the follow up and the doctor identified symptoms of something else during the exam

This is by no means a comprehensive list, so if you are not sure whether or not your particular patient meets the requirements for using a 24 on the office visit, send me a quick email and I’ll let you know how I would bill it. Here is an example of how a charge like that would look.

Date                          ICD9 code                             CPT Code    Modifiers

01/13/14                  366.17                                    66984             LT

02/18/14                 250.60    362.01                  99214             24

I also have another chart for you (I love charts!) detailing the global period for each procedure. It is LONG. I do not suggest you print this one out, but save it on your own computer for reference. Oh, and, the global period for any given code is either going to be 10 days or 90 days, if it has one at all. FYI. As always, I saved the chart to my Links and Tools page for you.

EDIT: Just a quick FYI, global surgery rules do not apply to assistant surgeons. So, anyone who is billing a code for a provider assisting with a surgery, these rules don’t actually apply to you. Just go ahead and use modifiers 80-82 the way you’ve been doing. In fact, if we do send in a claim with modifier 79 (or 78 for that matter), the claim will actually be returned as unprocessable. Thank you, Adam, for helping to clear up the confusion.

Leave a comment

Filed under Billing, Claims, CPT, Doctor's Office, Follow up, Health Care, ICD9, Medical Billing, Modifiers, Office Visit

Modifier 25 and 59 update

I have an Updated modifier chart for you guys. We have been finding that the insurances are denying the immunization administration (90471) without a 25 modifier on the office visit and a 59 on the 90471. If you were using the old one, please replace it with the updated rules. For a more detailed explanation of how these modifiers work, please see the post from 01/11/13.

And this new chart is fancy and it’s typed and has examples. Hope it helps. I have also had a few inquiries on when to use the modifier 24 and 79, so my next post will be about how to use those effectively. Also, if anyone has a question for us, please do not hesitate to email or comment.

5 Comments

Filed under 96372, Billing, Claims, CPT, Doctor's Office, Medical Billing, Modifiers, Office Visit

Quick Workers Comp Tools

Have you ever wished that you could have a list of all the lists and tools and links you need for Workers Comp in one place? Well now you can! You’re welcome.

Doctor’s First Report

PR-2 Report

OMFS Schedule

OMFS DME Prices

NDC Numbers for substances

OMFS Fee schedule for pharmeceuticals

EAMS

Leave a comment

Filed under Claims, CPT, Doctor's Office, Follow up, Health Care, Medical Billing, OMFS, Workers Compensation

Medi-Cal and Psychiatry (Tip: It’s a Mess)

If your psychiatrist is contracted with Medi-Cal, you are probably beating your head against your desk in frustration at this very moment. I know I am. This post will attempt to make your life easier and save you the headache when it comes to billing for your Medi-Cal patients.

First things first. Medi-Cal does not cover psych services directly EXECPT when the patient is mentally retarded. That means your claim needs to have an ICD9 code between  317 – 319. If your patient is mentally retarded, you can send a claim directly to Medi-Cal and they will pay you. But only with 2012 codes or office visit codes. Medi-Cal hasn’t updated to the new 2013 codes for psychiatrists.

Treatment for any other diagnosis carves out to the county. Please note, this is NOT the county the patient currently resides in. The claim goes to the county of origin. Which you can find on your online Medi-Cal eligibility verification sheet. If you do not have online access to Medi-Cal eligibility, I suggest you stop reading this post and go sign up. Remember to come back though. The explanation gets more convoluted. Once you’ve determined where the claim should be filed, please also make sure your provider is properly contracted with the individual county plans. If she is a Medi-Cal provider but her Los Angeles County Mental Health contract has lapsed because the office manager did not do the credentialing in a timely manner, your claims will not get paid. For example.

If a patient walks in with a Medi-Cal based HMO such as IEHP or Blue Cross, the claim also goes to the county. However, if the plan is based on the Healthy Families program or a DualChoice program with Medicare and Medi-Cal combined, you would need to call the health plan to determine where to send the claim. And I am sorry, but there is no quick and easy guide for that; the claims address and financial responsibility for mental health depends on the individual plan.

For mentally retarded patients with Medi-Cal based HMOs, the claims STILL go straight to MC. Even if your office manager gets an authorization from the health plan, send your claim directly to Medi-Cal. I have attached a small flow chart  to help you get your claim to the correct place along with a list of county mental health carve outs. Unfortunately, I can only include the carve outs I have worked with.

So, any of you out there with carve out information not on this list, please shoot me a quick email at newgenerationbilling@gmail.com or comment on this post so I can add it. I will add the flow chart and the county carve out list to the links and tools page. Remember, if you are going to bookmark anything, the links and tools page would be the smart way to go.

Leave a comment

Filed under Authorizations, Billing, Claims, County carve out, Doctor's Office, Medi-Cal, Medical Billing, Psych

Everything you ever wanted to know about pap smears

**DISCLAIMER**  

***This post was written in 2014 and the rules have changed since then. I am going to be putting up a new post with the new rules updated to ICD10 very soon. There are some major changes to the way the insurances accept the charges and this an old post with the old rules. If you have any questions, and can’t wait for the new post, please email me directly and I will try and help you out.*** 

The first thing about paps is that every insurance pays them differently. To tell the truth, I don’t have most of it memorized. What I do have is a binder, with one page per insurance, and all of the pap rules are laid out there, in alphabetical order.

Of course, I’m going to give those to you. I suggest you do what I do and put them all in a three ring binder. However, I can only give you the PPO pap smear rules, because your HMO contracts will not be the same as the contracts for my doctors. I can show you a few of my HMO rules, though, so when/if you make your own reference sheets you know what the necessary information is.

You CAN get an office visit and a pap smear paid on the same date on the same claim. You just need to use proper modifiers. Also, most insurances allow patients to self refer for their annual exam, so you shouldn’t have to worry about authorizations.

Here are the Pap rules for PPO insurances. For your HMO insurances, all you need to do is call the provider relations department and get a copy of the doctor’s contract. The contract will be fairly short, and very clear about which codes are paid. However, you will need to ask the provider relations people which diagnosis they need to see on the claims.

If you want to review the high risk rules you can find those on the MR website. Here is a link, for the curious.

Remember to follow the blog; you’ll get an email every time I get a new post up. Also, if you have a specific question, please don’t hesitate to email me.

 

Leave a comment

Filed under Billing, Claims, CPT, Doctor's Office, Health Care, ICD9, Medical Billing, Modifiers, Pap smears, Well woman exam