Tag Archives: Insurance

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! 

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

How to get a fat check for your obesity counseling.

Full disclosure, I am not that funny. That title was suggested to me and it was too good not to use.

Moving on.

Insurances have come a long way in the last 15 years. Even the best PPO plans in 2003 wouldn’t pay for “weight loss” even for morbidly obese patients. Patients had to jump through hoops to get mental health services and your insurance probably still laughs at you if you need chiropractic or acupuncture. 

However, insurances have started to realize that weight management, mental health, and pain management without addiction are vital to a patient’s overall health. Many insurances have incentivized obesity reduction , both with fee for service payments, and bonuses, as part of a focus on a patient’s health, rather than their illness. 

Insurances differ, though, on HOW they are going to pay for obesity counseling. Many offices end up not receiving their proper reimbursement because each insurance company wants the service reported a different way. This guide will help you get paid for your obesity counseling in addition to your regular office visit. 

All insurances will only pay for obesity counseling if the patient has a BMI over 30. If the patient’s BMI is under that, but they are still overweight, by all means please continue to help them bring their weight to a healthy level, but you won’t be reimbursed separately. Also, see the disclaimer at the bottom of the article please. 

Medicare and Medi-Cal – Use the Z-code for BMI as the primary diagnosis on the line item and use CPT code G0447. Put a 25 modifier on your office visit.  

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                 Z68.32                                                                  G0447

I am not sure if the Medicaid programs in other states will pay for obesity counseling, I know they will in California. 

Blue Cross, Blue Shield, Aetna, Cigna, Health Net PPO/MC/EPO plans – Use the Z-code for BMI as the primary diagnosis on the line item and use CPT code 99401. Put a 25 modifier on your office visit. 

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                 Z68.32                                                                  99401

Not all Health Net plans or BlueCross Blue Shield plans pay for obesity counseling, but most of them are coming out of the dark ages. 

United HealthCare Commercial PPO/MC – Use the E-Code for morbid obesity as the primary diagnosis on the line item. Use the Z-code for BMI as the secondary diagnosis on the line item and use CPT code 99401. Put a 25 modifier on your office visit. 

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                E66.01          Z68.32                                              99401

United HealthCare Medicare Advantage plan – Use the E-Code for morbid obesity as the primary diagnosis on the line item. Use the Z-code for BMI as the secondary diagnosis on the line item and use CPT code G0447. Put a 25 modifier on your office visit and a 59 modifier on the G0447.

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                E66.01          Z68.32                                              G0447           59

HMO Plans – It’s capped. Do whatever you want. If you have a fee for service contract, the 99401 usually gets paid a little more than the G0447, so I suggest you use the format for the regular commercial plans. 

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                 Z68.32          E66.01                                             99401

Some senior plans will give providers a bonus for treating patients with more severe diagnosis. Not a fee for service bonus, but a quarterly bonus. So, also add the appropriate E-code to help your doctor increase their score. 

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Here is the disclaimer. One of my favorite things to remind you is that in the billing world, the rules change every 10 minutes. So, if you are reading this in 2020, there may be different regulations to follow. Email me. 

Also, if you are billing the obesity counseling with any other type of counseling, you will probably have to be quite liberal with the 59 modifiers in order to get each line item paid separately. In fact, if my doctor does an obesity counseling and a smoking cessation counseling, I will switch the 99401 to a G0447 for the commercial plans (UHC is the exception) so it doesn’t get bundled. Blue Cross requires a 25 modifier on the G0447 if you bill it that way. 

If you want me to help you by reviewing a couple of your claims for the correct coding, I will be happy to do that. 

As always, call (909) 610-9524 or email newgenerationbilling@gmail.com with questions or to schedule an online training seminar. 

 

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Filed under Medical Billing, Modifiers, Obesity Counseling, Office Visit

Timely filing limits

One of the things we try and do to make sure we receive maximum reimbursement is to make all of our reference material easily available, and update it often. Like you know, I have been doing this for over 10 years now, and I have a LOT of information in my head. But my head is also significantly slower to update than the insurance companies, so I make sure that I have lists and spreadsheets with anything that will help make follow up easier. What I tell my trainees is that the rules change around here every 10 minutes because we have to constantly update to changes the insurance companies and the AMA are throwing at us.

Recently, we went through and updated all of our timely filing information guidelines for the insurances we deal with most. Here is the list for you guys. If there is anything you want added to the list, just use your Excel or Open Office program and insert those lines. We also included the timely filing limits for appeals, to make this tool actually useful. For those of you using keywords to search, this list includes timely filing information for Blue Cross, Apple Care, Blue Shield, TriCare, Cigna, Health Net, Medicare, Medi-Cal, and a couple dozen others.

Please click here to view or download the Timely Filing Guide . I also added this to the reference page for you. Please remember, if you bookmark any page on this blog, that would be the best one.

Share this with your friends and call or email if you have any questions or want any one on one or office wide training. (909) 610-9524. As always, thanks for reading.

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Filed under Billing, Consult, Medical Billing, Timely filing, Uncategorized

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.

 

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

Modifer 25 and 59

We are training several new employees right now. Glad to be expanding, progressing as expected, blah, blah, blah. But they are having a great deal of trouble with understanding when to use the modifiers 25 and 59. If we are having issues in here, some of you out there might be as well, and I want to make your life easier. First, for you technical types here are the exact descriptions from the CPT book.

Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service:
It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

Modifier 59 – Distinct Procedural Service:
Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

Now for some practical application. The modifier 25 goes on the office visit.  Here are the situtations in which you need a modifier: 1) If a patient gets a procedure on the same day as an office visit, 2) medication injected same day as an office visit, 3) pap smear done same day as an office visit, 4) physical done same day as an office visit. Don’t worry, we’re about to go through and lay out how we are supposed to use them.

If you need to bill an office visit and a procedure, you would use a modifier 25 on the office visit line. A procedure counts as any CPT code between 10000 and 69999. Plus, you need a different diagnosis on the procedure than you have on the office visit. Here is an example:

A patient comes in with ear pain and the doctor diagnoses her with an ear infection and does an ear lavage. If you want to get both the 99213 and the 69210 paid on the same visit here is how you would enter that charge:

Ear pain/otalgia (ICD9 388.70) (ICD10 H92.09)           99213  –  25

Ear infection (ICD9 382.9) (ICD10 H66.90)                   69210

When you put it in with a different dx on the office visit and  a 25 modifier the insurance will pay each line item separately.

Paps and physicals work in a similar way. The medical dx go on the office visit and the V-codes go on the preventive service. I could write a whole post on paps (and probably will) but we are going to keep it simple here.

465.9 (ICD10 J06.9)    462 (ICD10 J02.9)                      99213  –  25

V70.0                                                                               99395

When you need to bill an office visit and an injection on the same day, you have two options. The cpt 96372 is for an intramuscular injection of a J-code. You can bill the office visit and the substance all day and they will all get paid separately with no modifiers. The injection administration is what the insurances like to include in the office visit. However, you will get paid about $20.00 for each administration billed correctly and that can add up. Say a patient comes in with knee pain and the doctor diagnoses him with osteoarthritis and wants to give him an injection of Toradol. You put the symptom on the office visit with a 25 modifier and the substance and the admin have the condition. Then, you put a 59 modifier on the 96372. So, it would be three line items and it would look like this:

Knee pain       719.46 (ICD10 M25.569)                        99213  –  25

Osteoarthritis  715.96 (ICD10 M17.9)                            J1885

Osteoarthritis  715.96 (ICD10 M17.9)                            96372  –  59

I have attached an Updated modifier chart that will tell you when a service needs a modifier. We printed this out and gave it to all the new people and it seemed to clear up most of the confusion.

As always, call or email if you have any specific questions about something that didn’t make it through here on the blog.

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Filed under Billing, Claims, CPT, Health Care, ICD9, Medical Billing, Modifiers