Tag Archives: Medi-Cal

Any anesthesiologists in the house? And by “the house” I mean California.

I don’t know how many of my California anesthesiologist readers are contracted with Medi-Cal, but I am sure there are a few of you. 

I am also sure that you know how little they pay you. But, I have recently figured out a way to get them to pay you a small amount more. 

Usually, Medi-Cal will only pay for anesthesia for one service per day. It had never mattered that the anesthesia was for a different surgery at a different time on a different body part. 

But in 2015 CMS started using the X (EPSU) modifiers. Applying them to the appropriate line item has allowed me to increase my provider’s reimbursement from Medi-Cal to all line items submitted on the claim. The modifiers are as follows: 

  • XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.
  • XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”
  • XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”
  • XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”

Use the modifier on the line that pays less, just in case the automatic processing system decides it hates your particular claim. Also, since Medi-Cal does not accept more than one modifier per line, remember to use your 99 and indicate the modifiers in box 19. 

Call or email with any questions. 

Leave a comment

Filed under Anesthesia, Medi-Cal, Medical Billing, Modifiers

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

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.

Leave a comment

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