Category Archives: Medicare

When Medicare says 365 days, they mean 365 days.

Gentle readers,

It is flu shot season. And do-the-physicals-on-your-Medicare patients-before-they-go-somewhere-else-and-another-office-bills-the-physical season. And I am seeing a lot of the same question from both my billing service providers, and from you, my gentle readers.

Specifically, you billed/coded the flu shots and physicals the way I taught you and they are still getting denied! What gives?

And here is your unfortunate answer.

Medicare will pay a flu shot once every 365 days. They will pay a physical once every 365 days. They will pay a pap once every 730 days for a woman at normal risk and once every 365 days for a woman at high risk. They will pay the pneumo vaccine once every 365 days.

That means that if a patient came in on Feb 17th 2016 to get their flu shot last year and then came in this year on Jan 25th and got another flu shot, you will not get paid. Even if you bill with ICD10 Z23. Even if you bill with the Q-code for the vaccine. Medicare does not care that it is a different flu season. They do not care that your patient will be visiting their newborn grandson in a couple weeks and they need to be up to date on their immunizations. They do not care that your patient is going for a month long cruise in the caribbean and this is the last date they have available until they get back and they would prefer to get it done before they are rubbing elbows with a bunch of strangers who may have the flu.

Medicare does not care.

And they really mean 365 days. Not 364. So, when a patient needs a preventive service, please try and train your doctors and your office staff to check the date the patient received their last preventive service. The Medicare site also has a tab under the eligibility lookup section to check and see when the patient is next eligible for a preventive service. Here is a screenshot of the page and what it looks like:

medicare-prev-screen-shot-1

As you can see, the date the patient is going to be eligible for any specific service is indicated on the right. Flu and Prevnar are not included in this list, so you will need to rely on your records to track those. 

Below is the link to a good website for more information on the Medicare policies for preventive services. 

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

Keep emailing your questions and I’ll keep giving you answers. 

 

 

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Filed under Flu Shot, Immunizations, Medical Billing, Medicare, Preventative services, Vaccinations

Heads up for my ophthalmologist friends

Hello my ophthalmologist friends!

Medicare is changing the rules for the 92235 and the 92240. Up until 2017 we would bill two line items of those codes with RT/LT modifiers. According to the new edits, as of 2017 those codes are bilateral. If you separate them and use the RT/LT modifiers your claim will be denied. 

If you already sent them that way, you can use your local Medicare site to do a simple claim correction and get that updated. 

For the FA and the ICG this year, you bill just one line item with no modifiers. And, yes, we will get paid less. 

Sorry. 

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Filed under CMS, Medical Billing, Medicare, Modifiers, ophthalmology

Have you heard about MACRA?

MACRA is the law that congress passed regarding Medicare in 2015. I found out about the new legislation a couple weeks ago. And, I have to tell you guys, I am not excited. 

There are going to be a LOT of changes coming for providers once the law goes into effect in 2019 and small practices will be bearing a considerable burden. 

But you all know that I would not be posting scare tactic articles here about something that won’t happen for over two years. So, the statistics that determine whether your providers (or you, if you are a provider) are going to get penalized up to 9% are going to be drawn from self reported data from 2017.

That means that in order not to be penalized in 2019, you and your providers need to make changes as of the 1st of the year. In two months.

New Generation and our sister company, J&J Billing, Inc. are putting on four free one hour trainings. Normally we charge for our webinars, but it is so important that providers know about MACRA and the changes that are coming, that we are waiving the fee. So, fill this form out, and fax it back to me and I will make sure that the online classes we schedule will accommodate everyone .

MACRA Training Availability Form

Fax (909) 367-2922

I will post the final schedule on the blog once we have all the feedback. You will need to email me to sign up for the class. I am working on a fancy-pants sign up sheet for my classes, but it is still quite a work in progress. I am a very good biller and a very bad coder. 

Seriously people, print the form, send it back. This is free. You NEED this information. Tell your friends. 

 

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Filed under CMS, Doctor's Office, MACRA, Medical Billing, Medicare, Online classes

Medicare Unlikely Edits – or – The Rules Private Insurances Quote to Deny Your Claims

I recently billed an extended ophthalmoscopy to Blue Cross. What does this have to do with the Medicare Unlikely Edits you ask? Not much, just an intro. If you want to get right into it, skip down to the second paragraph. OK, back to the story. As those of you who bill for an ophthalmologist know, we used two line items of the 92225 with the RT/LT modifiers. Blue Cross paid the 92225 RT but denied my charge for the 92225 LT stating that according to the Medicare Unlikely Edits, only one unit of that code was allowed per day.

OK. Two things.

  1. Why is it ALWAYS Blue Cross? Seriously, Aetna doesn’t give me these kinds of problems.
  2. I am 100% sure that the Medicare Unlikely Edits realize that people have TWO eyes and TWO units of that code are allowed per day. Now I need to look up the table, verify that information, and deconstruct the CMS terminology to write my appeal letter.

The Medicare Unlikely Edits (MUE) are a table of guidelines that CMS puts out to indicate how many units of any given service are allowed for a single date of service. Here is a link to the MUE page on the CMS site. And, to make your life much easier, here is the MUE Table. The table has the CPT/HCPCS code in the first column, the Practicioner Services MUE Values in the second column, the MUE adjudication indicator in the third column, and the “MUE Rationale” in the fourth column. There is a fair amount of terminology that CMS made up specifically for these guidelines, and there is a PDF file 43 pages long that explains what that terminology means. But I am going to give you the cliff notes version, directly from the CMS manual.

Practicioner Services MUE Values = Maximum number of units allowable for a single beneficiary on a single date of service.

MUE adjudication indicator = Claim line or date of service edit. 1 = claim line edit, 2 & 3 = DOS edit.

  • A claim line edit means that appropriate modifiers ( e.g. 59, 76, 77, 91, anatomic) can be used to report the same code on separate lines of the claim. Example: A patient is in the emergency room with an asthma attack and he gets a breathing treatment. You use 94644 for the first hour, and up to two units of 94645 for the next two hours and the patient is no longer wheezing. However, before being discharged, he starts having another attack. You bill an additional line item of 94645 with the 76 or 77 modifiers with up to two additional units.
  • Indicator 2 means that there is no situation ever in which more than the indicated number of units would ever be payable. For example, in my situation, the code 92225 has an indicator of two. That is because every person in the world has a maximum of two eyes and there is no situation in which an insurance would need to pay for more than two units for a single patient one one visit.
  • Indicator 3 means that it is “possible but medically highly unlikely that higher values would represent correctly reported medically necessary services.” So, you do have some room to appeal with these codes if you can prove the services were medically necessary.

MUE Rationale = The criteria CMS used to determine the number of units allowed for each service. **Warning* Giant list of terminology ahead**

  • Anatomic considerations – A limit on the number of units based on anatomic structures. Ex: CPT 24357 – Tenotomy of the elbow, This code has a max of two units allowable, because each person has a max of two elbows.
  • Code descriptor/CPT Instruction – A limit on the number of units based on coding instructions directly from the CPT manual. Ex: CPT 73565. The CPT description says “Radiologic examination, knee; both knees, standing, anteroposterior” and the total number of units allowed is one. The one code already includes both knees for a single unit, so no additional units are payable. Unless the test had to be re-done for some medically necessary reason. Which you would then have to prove.
  • CMS Policy – A limit on the number of units based on established CMS guidelines. Those policies and guidelines can be found on the Medicare Coverage Database
  • Nature of an analyte – A limit on the number of units based on one of the following three factors:
    1. The nature of the specimen may limit the units of service – Ex: a test requiring a 24-hour urine specimen
    2. The nature of the test may limit the units of service – Ex: a test that requires 24 hours to perform.
    3. The physiology, pathophysiology, or clinical application of the analyte is such that a maximum unit of service
      for a single date of service can be determined. Ex: the MUE for RBC folic acid level is one since the test would only be necessary once on a single date of service.
  • Nature of service/procedure – A limit on the units of service, determined in general by the amount of time required to perform a service. Ex: an overnight sleep study
  • Nature of equipment – A limit on the units of service, determined in general by the number of items of equipment that would be utliized. Ex: cochlear implants

So, when I look up the code 92225 here is what I see:

CPT     MUE Values     MUE Adjudication Indicator    MUE Rationale

92225                   2                   2 Date of Service Edit: Policy         CMS Policy

This means that for CPT code 92225 a provider can bill two units of the service, and that is per CMS policy. So, now I can write an appeal to Blue Cross, with a copy of that line of the table, and a letter stating “As you can see, per CMS policy, two units of 92225 are reasonable and customary. Since you are adhering to the Medicare Unlikely Edits, please reprocess and pay line item 92225 LT.”

I hope you can use this as an additional weapon in our never ending war against the insurance companies. As always, if you need any additional help, want to set up a training for your office, or are so touched by my helpfulness and eloquence that you would like to thank me personally (j/k) please call (909) 374-5439 or email newgenerationbilling@gmail.com.

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Filed under Health Care, Medical Billing, Medicare

How to bill Medicare HMOs

I know that is a very ambitious title, but a few people here have been emailing me with questions on this topic. I figure, if a few of my readers are taking the time to email me, then there are far more of you out there with questions. The good news is, the answer is fairly simple.

The emails I have been receiving fall into three main categories.

1. How do I bill a pap smear to a Medicare Risk HMO?

2. How do I bill flu shots/pneumococcal shots to a Medicare Risk HMO?

3. When Medicare says a patient has an HMO, is Medicare secondary?

And here are your answers:

1.  How do I bill a pap smear to a Medicare Risk HMO?

As you might remember from my previous post, Everything you ever wanted to know about pap smears, each HMO has its own way of doing things. Some want the diagnosis V72.31, others want V76.2. Some want to follow Medicare rules, and some want to pay with the preventative code.  Some won’t pay anything at all, instead they capitate it. The best way to find out how your HMO will pay your provider’s claim is to get a copy of the provider’s contract.  

2. How do I bill flu shots/pneumococcal shots to a Medicare Risk HMO?

By and large, the Medicare Risk HMO plans want us to use the Medicare codes for the flu and pneumonia substances. For the flu, use the Q-codes for the substance and the G0008 for the administration. For the pneumo, use 90732 for the substance and G0009 for the administration.  For a more thorough explanation, go take a look at my Medicare and Immunizations post.  Please remember, not all IPAs have the same fee schedule. If this doesn’t work, a quick call to the provider relations department will point you in the right direction.

3. When Medicare says a patient has an HMO, is Medicare secondary?

No.

Please, let me reiterate.

No. The HMO replaces the patient’s Medicare. The claims go to the HMO. We have to follow the HMO rules. The patient may have a copay and you may need an auth. I am training a front desk right now, and this is the policy I have in place.

If a new patient calls to make an appointment, check the insurance online while the patient is on the phone. It takes 30 seconds to check Medicare on the Noridian Endeavor site. If the patient has an HMO, make a note on the schedule and ask the patient to bring in their HMO card as well as their Medicare card.

If an established patient is returning to the office, go online and check the Medicare eligibility. The status of a patient’s Medicare can change month to month. PLEASE do not assume that if a patient had straight Medicare last month, he will again this month.

Once the doctor performs the service, good luck trying to collect from the patient. People hate to pay after they have already received their service.

So, as always, if you have any questions, please call or email. If you want us to come into your office and train your front desk or your billing department, we can do that. We do on-site training for those in our area and online training and Skype conferences for our far away clients.

EDIT: I have had a couple people ask me what you can do when you see the patient before you find out they have a MR Risk HMO.  You can try billing the patient your cash price. Or, you can send the claim to the IPA (medical group) with your medical records attached asking them to review the charge for a retro authorization based on medical necessity. In box 19 on the physical claim form write “please review notes for retro authorization.” I also like to send a letter. Here is a good example of a medical necessity template appeal letter. And everyone who gets paid due to this can thank Molly and David for their rather pertinent emails.

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Filed under Billing, Doctor's Office, Flu Shot, HMO, Medicare, Pap smears, Pneumo, Vaccinations, Well woman exam

Please post your payments

This is along the lines of the cash in the office post. One of my doctors has lost an insane amount of money, and I would like you all to learn from his mistake.

I have a small Internal Med with an emphasis in Cardiology in Montclair. I go to their office once a week, after hours, and do all the charges and claims in about an hour. This isn’t bragging, they are small, and I am fast, and they only have me enter charges and send electronic claims. I have been doing their billing for four years and, until recently, I had never even seen one of their EOBs. They don’t want to pay me to post the payments, because they think it will cost them too much money.

I finally signed them up for a user name and password on the Online Provider Services Medicare website, against the office manager’s strenuous objections. On the first EOB I pull up, I immediately notice that ALL the EKGs I billed had been translating as 93005 instead if 93000.  The reimbursement for a 93005 is $8.93 (allowed $11.16 minus the 20% coinsurance) and the reimbursement for the 93000 is $15.14 (allowed $18.93 less $3.79 for the coinsurance). That means my Internal Med has been losing $6.21 on every EKG for at least the last four years. He probably does 20 EKGs per week. So, ($6.21) x (20 EKGs per week) x (52 weeks) x (4 years) = $25,833.60. This does not account for the fact that over the last four years Medicare reimbursements have been decreasing.

Even after this, I have not been able to convince them that it would be more cost efficient in the long run to have me post the payments as well as the charges. Please, please, please use this as a warning and properly reconcile your EOBs with your payments. Every EOB for every charge.

Also, do it by line item and not by charge, because it is too easy to miss something important. Something like this.

$25k. Gah.

P.S. If you have any questions about what you should be getting paid for things, use the Medicare Fee Schedule Look-Up. Most companies will pay a similar amount, so you are mostly safe using that as a standard.

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Filed under Accounts receivable, Billing, Claims, CPT, Denials, Doctor's Office, Follow up, Health Care, Medical Billing, Medicare, Office policy, Uncategorized

Psych Secrets

This post is about doing billing for the psychiatrist or psychologist in your life. It’s going to be a long one, guys.

The new CPT codes for mental health services for 2013 are going to have to be a whole post themselves. If you absolutely, positively need an easy explanation before I can get the post up, please remember, you can call or email. The diagnosis that are categorized as mental health conditions range from between ICD9 code 290-319 (ICD10 F01-F99) and if you are not a psych or a therapist and you bill any of these dx primary, you might end up with a denial, so please be careful.

The most important part of the process is the insurance verification. I know that a lot of health plans show the mental health benefits online. Unfortunately, the information they give you online is incomplete, so you are going to be making some calls. The number for the mental health information line is on the back of the card. Also called behavioral health, the people at this number will become your new best friends. Well, at least until you have to call about a claim. Here is where you learn some new terminology. Below is a list of the questions to ask when you’re on the phone with eligibility.

1. Does this plan require authorization?
2. Do the claims carve out?
3. Are there different benefits for parity and non-parity?

A plan carves out when the financial responsibility for mental health services changes from the health plan to another company. For example, Health Net carves out the mental health to CHIPA quite often. So you would send your psychotherapy claim to CHIPA rather than Health Net. You would get your authorization from CHIPA as well. Parity diagnosis are the “serious” ones. I wish I could give you a better definition. Parity dx include most of the chemical imbalances and a few others. Here is the full list, edited for ICD10:

1. Anorexia – 307.1 (ICD10 F50.00 through F50.02)
2. Bipolar Disorder – 296.40 through 296.80 (ICD10 F30.0 through F31.9)
3. Bullimia – 307.51 (ICD10 F50.2)
4. Major Depression – 296.20 through 296.36 (ICD10 F32.0 through F33.9)
5. Obsessive-Compulsive Disorder 300.3 (ICD10 F42)
6. Schizoaffective Disorder – 295.70 through 295.75 (ICD10 F25.0 through F25.9)
7. Schizophrenia – 295.00 through 295.65 (ICD10 F20.0 through F24)

When I was first learning psych billing, I printed this list and taped it to my wall. One of the most useful tools I had.   You also need to know whether you are calling for inpatient or outpatient benefits and substance abuse or mental health. Please remember, all of this information, it is most efficient to get from one phone call. In our office we actually have an insurance verification form that we fill out when we get benefits for new patients. You can use our insurance verification form or you can make your own, but taking a few moments to write down this information saves you from having to call back multiple times. 

Once you have this information, sending the claim out is pretty straightforward. However, if your doctor is contracted with Medicare or Medi-Cal, please give me a call or shoot me an email. There is a LONG explanation regarding getting paid by those companies and it won’t translate well into blog form.

There have been a lot of changes in the psych billing world in the past few years, and it is quite possible that any number of things could have slipped through the cracks in your office. If you still have a lot of money sitting on your AR and your reimbursements aren’t as high as you think they should be,  we can come in and take a look for you, we do that for free. If everything looks fine, we give you a high-five and a few of our cards to pass out to your colleagues. If you do need help, you can hire us to fix it, or we’ll tell you how to fix it yourself. Email me at newgenerationbilling@gmail.com.

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Filed under Authorizations, Billing, CPT, Doctor's Office, Health Care, ICD9, Medi-Cal, Medical Billing, Medicare, Psych