Tag 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

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

Medicare and Immunizations

Medicare routinely pays for two immunizations and will pay for two others under specific circumstances. Specifically, they will pay for influenza and pneumococcal as preventive, and Medicare will pay for the tetanus and hepatitis B vaccines in certain cases with medical necessity. Read on.

The new Medicare flu codes have been around for a while,  but we recently ran into a few offices in 2012 who told us they have been having a hard time getting paid for their flu shots from Medicare. Long story short, they were using the wrong substance AND administration codes. And since Medicare will pay  just under $30 for the administration of the injection and $7-$15 for the substance itself, missing out on those can turn into a loss of hundreds of dollars per year. So, lets fix that, shall we?

All of our posts are going to follow the same format; we are going to first explain the important bits, and then we give you the charts and links that we personally use and distribute to our customers. So remember to bookmark us or add us to your favorites, because here you can keep all of your invaluable tools in one place.

The CPT codes for Medicare to bill the flu shot break down by the brand the doctor purchases. If you’re at the office, take a look in the fridge, but if you are at a billing service, you need to please call your office manager and get that information. The reimbursement varies significantly depending on the code, and we can get our providers audited if we just make that decision ourselves. Medicare uses codes Q2034–Q2038, and here is the specific breakdown.

Brand         CPT

Agriflu      Q2034
Afluria      Q2035
FluLaval   Q2036
Fluvirin     Q2037
Fluzone    Q2039

Remember to bill the G0008 administration code along with the vaccine. The Q-code is only for the substance. It is the G-code that we bill for the actual service–the process of injecting the immunization into a patient’s–ahem–hip. If the patient is ONLY seen for the flu shot, then you would simply bill those two codes. If the patient had an exam on the same visit you can bill an E&M code as well and Medicare will pay them all separately without any modifiers necessary. Just remember to put your V04.81 (ICD10 Z23) diagnosis primary on the Q-code and the G-code and your medical diagnosis on the E&M. Please remember, these codes are just for Medicare. For the rest of your private insurances, you still use the 90658 for the substance and the 90471 or 90472 for the admin.

The pneumo, Hep B, and the tetanus are a little bit easier.

For the pneumococcal, you bill with the diagnosis of V03.82 (ICD10 Z23) and the CPT code 90732. Use G0009 for the administration. Easy.

Medicare will pay for the tetanus immunization, however, they will not pay it as a preventive service. Patients who come in with wounds (ICD9 codes 860.xx0-894.xx and ICD10 codes S00-T14) are eligible for reimbursement on the tetanus vaccine. Remember to use the wound diagnosis primary and the V03.7 (ICD10 Z23), tetanus toxoid alone, as secondary. The tetanus can be billed with 90471 as the administration.

For hep B, Medicare will only pay for the immunization series for patients they consider as “high risk.” A high risk patient is one with renal disease, or hemophilia, or a client of institutions for the mentally handicapped.

A word of caution: Medicare has VERY strict rules regarding the frequency of these immunizations. The flu and the pneumo vaccines can be administered once per year. If 365 days have not passed since the last immunization you WILL NOT be paid. No amount of appealing will change this. Please, make it clear with your front desk, your MA’s, and most importantly, with your doctors, that we need to check the date of the last immunization for our established patients BEFORE administering the vaccine.

Here are your tools:

  • For starters, we reference this handy-dandy chart for all of our customers that breaks down the Medicare flu shot codes. Print it out, stick it on your wall. That’s what I did.
  • This is a link directly to the CMS Medicare site with all the information you could ever want regarding their immunization policies.

If this doesn’t answer all of your questions, call us at (909) 374-5439 and ask for Heather. Or you can email us at newgenerationbilling@gmail.com.

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Filed under Administrations, Billing, CPT, Flu Shot, ICD9, Immunizations, Medical Billing, Medicare, Tetanus