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Posts Tagged ‘reimbursements’

Billing For Consults After “The Apocalypse”

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Fi-Med Services, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

“Orchestral music rises as the first glimmers of an ominous sunrise brings light to a dusty and desolate landscape, where once-plentiful streams of revenue have been vaporized by statute. Small bits of paper with numbers such as “99254″ and “99241″ blow across the feet of our stethoscope-clad hero, as he faces a future full of financial uncertainty and unwanted adventure…”.

We are now two weeks into a world where Medicare has eliminated reimbursement for inpatient and outpatient consultation codes. To many specialists for whom consultations have become a way of life, it is tempting to see themselves as a manufactured post-apocalyptic film character similar to the one above. It is my duty, as a compliance officer, certified coder and budding writer of screenplays to inform you that it doesn’t have to be that way.

In a previous post on this blog, I demonstrated one way to navigate the imperfect crosswalk that exists between inpatient consultations and the CPT codes for initial inpatient encounters (99221 through 99223) that are now to be used in its place. In the past weeks, the Medicare administrative carriers have released their own guidance about what should be billed in place of a consultation code if the documentation does not meet the requirements of CPT code 99221.

For Palmetto GBA, First Coast and WPS, the suggestion is that CPT code 99499 (Unlisted evaluation and management service) be utilized for services formerly billed as 99251 or 99252. When using this code, be aware that it lacks a set payment. The reimbursement of this code is driven on a case-by-case basis and is determined by carrier review of documentation for the service. When billing 99499 to a carrier that accepts it, always be certain to include the documentation for the service.

National Government Services, as well as other carriers, is suggesting that the appropriate inpatient follow-up code (99231 through 99233) be billed in place of a low-level consultation. The choice of code would depend on the depth of the documentation for the service.

The second challenge that has been brought forth is the question of consultations when Medicare is the secondary payer (MSP). In the final revision of the new consultation policy in MedLearn Matters article MM6740,  there are two solutions that can be used. You can either choose not to bill consultations at all to a commercial payer and be reimbursed for E/M services by both commercial and MSP, or you can bill the consultation to the commercial payer, then report the amount paid and bill an equivalent E/M code to Medicare to determine whether additional reimbursement is due.

The first solution is the path of least resistance, as this eliminates consultation billing from your practice immediately and entirely. Financially, this may not be the most advantageous approach. While commercial payers are expected to eventually follow CMS’ lead and eliminate reimbursement for consultations, these codes are still active with commercial payers at reimbursement rates that are typically larger than equivalent E/M codes based on documentation.  Contractually, if you are still receiving healthy reimbursements from commercial payers for consultations, the second approach may be more to your advantage.

The reimbursement landscape has changed, but it has not been irrevocably altered for the worse. The road to reimbursement commensurate with services performed now has a few more detours than it did a month ago, but water recedes and bridges can be rebuilt. With increased attention to documentation detail and increased awareness of the new rules of the road, providers can successfully navigate a world without consultation reimbursement.

Paul Spencer CPC, CPC-H

Denial Management Made Easier With Version 5010 Billing Standard

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, In the Press, Industry Updates, J. Paul Spencer, CPC CPC-H

We are often told that life has no instruction book. Personally, I have seen this blatantly come true in the form of my daily dealings with my 3-year-old son. I also longed for a better set of rules back in 1990, when I found myself briefly dating a woman who thought she was telekinetic, but was actually a hypochondriac. No worries, though. I came out unscathed and not once was she able to throw me across the room using only the power of her mind.

In the realm of Medicare denials, currently, under Version 4010 of the X12 electronic billing standards, Medicare offers very little in the way of pointing the EOMB recipient to a solution for a denial. With time, an experienced follow-up specialist can train themselves to understand in what direction each claim adjustment reason code (CARC) and remittance advice remark code (RARC) is pointing, leading to faster resolution.

Version 5010, set to be implemented by CMS beginning on January 1st, 2012, is slated to make this process much easier. As part of Version 5010, if a claim is denied due to a conflict with a Local Coverage Determination (LCD) or a National Coverage Determination (NCD), the Explanation of Medicare Benefits will indicate what LCD or NCD is being applied in the denial of this claim.

Given that local carriers now have their LCD’s categorized on the CMS website, first by carrier, then in alphabetical order (which is helpful roughly 30 % of the time),  referring the follow-up specialist to the exact coverage determination will cut down on the amount of time needed to research these denial issues.  As someone with daily involvement in Fi-Med’s denial management process, I cannot begin to tell you how I welcome this change.

While there are many other benefits to Version 5010, such as compatibility with ICD-10 and the removal of some redundancies found in the current version, finding a clearer path to a denial solution may turn out to be its most substantive change.

I look forward to the day when my lack of psychic powers ceases to be an impediment to the timely correction of Medicare denials. This whittles down my list of  ”50-10″ challenges in my life down to what happens in 7 years when I’m 50 and my son is 10. I really need to get in shape….

Referring Physician PECOS Phase II Delayed

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, In the Press, Industry Updates, J. Paul Spencer, CPC CPC-H

Following up on an earlier post here, CMS announced today that Phase II of Change Requests 6417 & 6421, dealing with referring physician mismatches between the NPI database and the PECOS system, has been delayed until April 5th, 2010.

Phase II of this change request orders the denial of any services referred by a physician who has a conflict between information found on the national NPI registry (NPPES) and the PECOS system. The change to the implementation schedule is being undertaken to give those physicians with conflicting information sufficient time to correct any irregularities.

For the present time, providers who bill for services referred by providers with this conflict will continue to get warning messages stating that the referring physician’s information is inaccurate. If this information has not been updated by the referring provider by April 5th, 2010, these services will be denied.

Coding for the Non-Coder

Posted by Lisa Velasquez in Fi-Med Services, Industry Updates, Webinars

For over 30 years, Frank Cohen has worked as a health care data analyst, knowledge engineer and consultant. He has written many books and is the Senior Analyst for MIT Solutions. I have attended several of Franks webinars, which are scheduled 3-4 times a month, covering such topics as coding, code and modifier utilization, cost accounting, work RVUs, etc. This is a great resource that I want to share with all of you and best of all it’s free! Here is a brief intro to one of his webinars that I particularly liked: Coding for the Non-Coder

“Health care, like other industries, has its own language; and not just from a clinical perspective, either. Diagnosis and treatment codes are necessary in order to get paid for the services you provide and determine your level of compliance with the myriad of complex rules and regulations we face day to day. As the industry continues to tighten up with respect to finances  and regulation, physicians, practice managers, consultants, advisors and others are finding that understanding the relationship of coding to other areas of the practice has reached critical mass. You don’t have to be a coder to acquire a basic, foundational understanding of medical coding; the language of the business of medicine. Coding for the Non-Coder was specifically designed with the non-coder in mind.

In this short (and free) webinar, Frank Cohen (a non-coder himself) will help you understand the relationship between coding, billing, reimbursement and compliance without teaching you how to become a coder. It focuses on the big picture; understanding the language of coding, its importance within the medical practice and most importantly, how to identify and understand coding problems; from the common to the arcane.”

Although this webinar has already been presented, it is available to view by going to Frank’s website.

Did you find this information helpful? If you have information that you think would be valuable to the medical community and would like me to post the information on our blog, please submit your request for review to my attention at (or via DM on Twitter @fimed).

Start Now to Collect E-Prescribing Bonus

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Industry Updates, J. Paul Spencer, CPC CPC-H

Beginning on January 1st of this year, CMS is allowing the reporting of codes related to the electronic prescribing of drugs for your patients in the office setting. As long as you are paid at least 10% of your total Medicare Part B reimbursement for services in the office, with the consistent reporting of these codes, you may be eligible for a 2% bonus payment at the end of 2009.

The following are the three codes that can be reported in addition to the E/M service for the office encounter:

G8443 – Used when all prescriptions during the encounter were generated using an e-prescribing system

G8445 – Used when there are no prescriptions dispensed during the encounter.

G8446 – Used when some or all of the prescriptions at the encounter were hand-written. This would be due to the affect of state or federal law based on what was prescribed. The prescription of Schedule II drugs (narcotics) falls into this category.

In 2010 and 2011, this bonus will decrease by .5% per year. Beginning in 2012, if you are not prescribing electronically, you face being penalized with reductions in your payments for office services through Medicare Part B.

If you currently do not have the ability to prescribe electronically, there are several vendors who offer technology that will fit the needs of your practice. While CMS does not recommend one vendor more than another, it advises practices to takes into account compliance with the HIPAA rules for privacy and security when choosing software for e-prescribing.

The AMA has comprehensive information available on their website at the following link to assist you in preparing your practice for e-prescribing:

As in every case, I am available to you at any time to assist you with this and other needs of your practice. Feel free to leave a comment or contact me directly.