When billing to Medicare, there are a few issues of which you should be aware to ensure you are not sending claims that can create a ‘red flag’. With the new RAC audits that are coming, it is important to not send claims that can focus attention on your practice. Even if Medicare denies a claim, it is still in their system to help establish invalid or fraudulent billing patterns.
1. Follow Up Evaluation and Management (E&M) Codes – 9921X (1-5) –
There are two problem scenarios when billing E&M codes. They are:
A. Billing an Established Patient visit code in a global period. Medicare will always deny these claims unless the patient is seen for a completely different problem that is not related to the global period. To establish it is a different problem, the diagnosis must reflect the new chief complaint. Your documentation will need to reflect the new evaluation, diagnosis, and treatment plan of the new chief complaint. Do remember that a stab phlebectomy carries a 90 day global period and sclerotherapy carries a 10 day global period.
B. Billing an Established Patient visit code with a procedure. Medicare typically denies these codes as well because the re-evaluation of the patient must be ‘over and above’ the usual post-operative care associated with the procedure that was performed. For example, if the patient is coming in for a three month follow up appointment and you decide to perform sclerotherapy secondary to an ablation, you should not bill an additional E&M code as performing sclerotherapy is not unusual at the three month juncture.
2. Hematoma Billing (10140 and 10160) –
The treatment of a superficial hematoma is now considered part of the normal complications following a venous ablation and/or sclerotherapy procedure and will not be separately reimbursed by Medicare. A deep hematoma, typically with ultrasound guided needle placement, is still reimburseable as it is not a ‘normal’ complication.
3. Unbundling a Bundled Service (Billing for an ultrasound – 93971/76942 – during an ablation) –
The codes 36475 and 36478 are bundled codes which means the ultrasound services as well as the needle guided imagery and other additional services are included in the ablation code. Billing for the separate components is improper and will not be reimbursed. However, billing for a second insertion (36476 or 36479), stab phlebectomy, or sclerotherapy is allowed.
Some commercial payers follow Medicare guidelines while most others use them only as a basis. Our recommendation is to continue billing for those services like superficial hematomas to the commercial payers but not to Medicare. As we do not want the physician to double check the payer before treating a patient and coding, the onus should be on the billing department to ‘leave out’ inappropriate line items when billing Medicare.
Thursday, August 13, 2009
Medicare Audit Changes
Due to new healthcare legislation designed to catch overpayments, Medicare recently ‘hired’ several different organizations to begin auditing Medicare claims. There are a number of items of which you should be aware as they can impact – in a very negative fashion – your practice.
These organizations, generically called Recover Audit Contractors (RACs) are paid – and only paid by – a percentage of what they find! This means they are motivated financially to find problems and recoup money from you. Here’s what they are allowed to do…
A. They can request records/bills of up to 10 claims per NPI number (please keep in mind that any incorporated practice has at least two NPI numbers – one for the facility and one for the physician) every 45 days.
B. They can go back to October 1, 2007 in their search.
C. You have 45 days in which to respond to their request.
D. They will then do a chart-to-bill and bill-to-chart audit of those 10 (or 20) records
E. If they find something – and they only get paid if they find something – you can appeal the decision (and normally should).
F. If they show claims were paid in error, you have to either remit payment to them for the amount or they will deduct the monies beginning on day 41 from your current Medicare payments.
We highly recommend that you begin to audit your charts now before the RAC does it for you! We also recommend that someone else besides your normal biller conducts the audit. If you use a billing company, ask if they have the expertise to perform a bill-to-chart/chart-to-bill audit. Also ask if someone else besides the normal biller for your account will be performing the audit. If you use an in-house biller, we strongly recommend that you use an outside agency to conduct your review. It is simply too easy to assume what you have done is correct (sort of like proofing your own writing).
I will be sending out more information on some common billing/coding errors in regards to phlebology practices in the very near future. Do feel free to call or email with any questions about the above.
If a RAC audit team contacts you, you should also engage a company that specializes in assisting practices through a RAC audit. I am working with one right now and happy to give you their name/telephone number if you end up needing some support.
Blatant Advertisement – As I noted above, you should engage someone to do a chart-to-bill/bill-to-chart audit. American Physician has the expertise to provide these services to you. We have a certified coder, access to physician and sonography input if needed, and years of phlebology billing experience. For the sum of $450 we will perform the chart-to-bill/bill-to-chart audit, provide a written report, and telephonically review the report with you regarding any recommendations. If you are an existing billing client of APFS, the audit is free and we will ensure it is conducted by one of our team members who does NOT routinely perform your billing services. Please contact me at 719.233.0099 if you have questions or wish to schedule an appointment.
These organizations, generically called Recover Audit Contractors (RACs) are paid – and only paid by – a percentage of what they find! This means they are motivated financially to find problems and recoup money from you. Here’s what they are allowed to do…
A. They can request records/bills of up to 10 claims per NPI number (please keep in mind that any incorporated practice has at least two NPI numbers – one for the facility and one for the physician) every 45 days.
B. They can go back to October 1, 2007 in their search.
C. You have 45 days in which to respond to their request.
D. They will then do a chart-to-bill and bill-to-chart audit of those 10 (or 20) records
E. If they find something – and they only get paid if they find something – you can appeal the decision (and normally should).
F. If they show claims were paid in error, you have to either remit payment to them for the amount or they will deduct the monies beginning on day 41 from your current Medicare payments.
We highly recommend that you begin to audit your charts now before the RAC does it for you! We also recommend that someone else besides your normal biller conducts the audit. If you use a billing company, ask if they have the expertise to perform a bill-to-chart/chart-to-bill audit. Also ask if someone else besides the normal biller for your account will be performing the audit. If you use an in-house biller, we strongly recommend that you use an outside agency to conduct your review. It is simply too easy to assume what you have done is correct (sort of like proofing your own writing).
I will be sending out more information on some common billing/coding errors in regards to phlebology practices in the very near future. Do feel free to call or email with any questions about the above.
If a RAC audit team contacts you, you should also engage a company that specializes in assisting practices through a RAC audit. I am working with one right now and happy to give you their name/telephone number if you end up needing some support.
Blatant Advertisement – As I noted above, you should engage someone to do a chart-to-bill/bill-to-chart audit. American Physician has the expertise to provide these services to you. We have a certified coder, access to physician and sonography input if needed, and years of phlebology billing experience. For the sum of $450 we will perform the chart-to-bill/bill-to-chart audit, provide a written report, and telephonically review the report with you regarding any recommendations. If you are an existing billing client of APFS, the audit is free and we will ensure it is conducted by one of our team members who does NOT routinely perform your billing services. Please contact me at 719.233.0099 if you have questions or wish to schedule an appointment.
Billing 93965 with 93970
This multiple scan billing question has come up and caused a little controversy. Let me try to make it a little clearer.
First the basics:
93965 is defined as Non-invasive physiologic studies of extremity veins, complete bilateral study (e.g. Doppler waveform analysis with responses to phleborheography impedance plethysmography). This is a non-imaging study in response to compression and other maneuvers.
93970 is defined as Duplex scan of lower extremity veins including responses to compression and other maneuvers, complete bilateral study. This is both an imaging and non-imaging study. It includes the collection of BOTH physiologic in the form of Doppler analysis of bi-directional blood flow, the spectrum analysis, and B-mode imaging.
The two services are done with different equipment. 93970 is a study done with newer technology, more comprehensive and inclusive of the old study performed when billing 93965. Because they are different tests, done on different machines, they are technically not subject to a Correct Coding Initiative edit by Medicare, and can be billed together on the same day.
However, it is considered unnecessary testing to order both services on the same day when one service is sufficient to diagnose the patient (93970) as it is the more comprehensive test. CMS (Centers for Medicare and Medicaid services) considers the practice of performing both to be fraudulent billing.
One example is the FL Whistleblower case: Case No. 2:00-CV-558-FTM-29DNF
Radiology Regional Center (RRC), agreed to pay a 2.5 million dollar settlement on 06/23/2004 for filing false Medicare claims. The suit alleged that RRC billed for two venous or arterial studies on the same date that were not properly billable. Codes sited in this case as not being allowed to be billed together included, but were not limited to, 93965/ 93970 and 93965/ 93971.
A quote from this case: “This settlement again demonstrates the United States commitment to protecting federal funds from fraud,” said Peter D Keisler, Asst. Attorney General in charge of the civil division. A strong deterrent from ordering, and billing unnecessary testing…”
More research found multiple settlement cases for billing in the same fashion around the country. The penalties for this type of billing can amount to extremely large fines and possible revocation of license to practice medicine. Both consequences are not worth the few extra dollars this type of billing will net.
The inherent problem is not the question of if these services CAN be billed together, but if they SHOULD be billed together. According to CMS, it is not a condoned practice to order additional testing that is ultimately not needed to diagnose and treat a patient. If you do insist on performing both tests, then your documentation must reflect that both tests were performed, and have a definitive reason for doing so.
Written by:
Cheryl A. Nash, CIBS
Director of Operations
American Physician Financial Solutions
A.J. Riviezzo, MBA
Chief Executive Officer
American Physician Financial Solutions
First the basics:
93965 is defined as Non-invasive physiologic studies of extremity veins, complete bilateral study (e.g. Doppler waveform analysis with responses to phleborheography impedance plethysmography). This is a non-imaging study in response to compression and other maneuvers.
93970 is defined as Duplex scan of lower extremity veins including responses to compression and other maneuvers, complete bilateral study. This is both an imaging and non-imaging study. It includes the collection of BOTH physiologic in the form of Doppler analysis of bi-directional blood flow, the spectrum analysis, and B-mode imaging.
The two services are done with different equipment. 93970 is a study done with newer technology, more comprehensive and inclusive of the old study performed when billing 93965. Because they are different tests, done on different machines, they are technically not subject to a Correct Coding Initiative edit by Medicare, and can be billed together on the same day.
However, it is considered unnecessary testing to order both services on the same day when one service is sufficient to diagnose the patient (93970) as it is the more comprehensive test. CMS (Centers for Medicare and Medicaid services) considers the practice of performing both to be fraudulent billing.
One example is the FL Whistleblower case: Case No. 2:00-CV-558-FTM-29DNF
Radiology Regional Center (RRC), agreed to pay a 2.5 million dollar settlement on 06/23/2004 for filing false Medicare claims. The suit alleged that RRC billed for two venous or arterial studies on the same date that were not properly billable. Codes sited in this case as not being allowed to be billed together included, but were not limited to, 93965/ 93970 and 93965/ 93971.
A quote from this case: “This settlement again demonstrates the United States commitment to protecting federal funds from fraud,” said Peter D Keisler, Asst. Attorney General in charge of the civil division. A strong deterrent from ordering, and billing unnecessary testing…”
More research found multiple settlement cases for billing in the same fashion around the country. The penalties for this type of billing can amount to extremely large fines and possible revocation of license to practice medicine. Both consequences are not worth the few extra dollars this type of billing will net.
The inherent problem is not the question of if these services CAN be billed together, but if they SHOULD be billed together. According to CMS, it is not a condoned practice to order additional testing that is ultimately not needed to diagnose and treat a patient. If you do insist on performing both tests, then your documentation must reflect that both tests were performed, and have a definitive reason for doing so.
Written by:
Cheryl A. Nash, CIBS
Director of Operations
American Physician Financial Solutions
A.J. Riviezzo, MBA
Chief Executive Officer
American Physician Financial Solutions
Ultrasound Reimbursement
Decrease in Ultrasound Reimbursement
Medicare has come up with a somewhat sneaky way to reduce your reimbursement for bilateral and unilateral duplex ultrasounds (codes 93970 and 93971). Here’s how:
In 2006, Medicare implemented the Outpatient Prospective Payment System (OPPS) to curb facility based outpatient reimbursement which includes ultrasound services. Unfortunately for the individual physicians, Medicare has extended that OPPS program to some services rendered by physicians at an in-office setting.
For phlebology practices, the most noticeable result is a reduction in the technical component reimbursement by Medicare for the above ultrasound services. The technical portion is being reduced by approximately 50% or a total reduction of about 25% dependent upon your geographic area. This reduction started this past year and may only now be noticed dependent upon your Medicare service area.
The only good news to this story is that commercial payers still use RBRVS (Resource Based Relative Value System -- or Really Bad Reimbursement Very Slowly) as their basis for payment and do not use the OPPS model for re-calculating your reimbursement. As such, commercial payers have not followed Medicare in reducing reimbursement for duplex ultrasounds.
If you have a question on this or any other topic, please send me an email with your question.
Medicare has come up with a somewhat sneaky way to reduce your reimbursement for bilateral and unilateral duplex ultrasounds (codes 93970 and 93971). Here’s how:
In 2006, Medicare implemented the Outpatient Prospective Payment System (OPPS) to curb facility based outpatient reimbursement which includes ultrasound services. Unfortunately for the individual physicians, Medicare has extended that OPPS program to some services rendered by physicians at an in-office setting.
For phlebology practices, the most noticeable result is a reduction in the technical component reimbursement by Medicare for the above ultrasound services. The technical portion is being reduced by approximately 50% or a total reduction of about 25% dependent upon your geographic area. This reduction started this past year and may only now be noticed dependent upon your Medicare service area.
The only good news to this story is that commercial payers still use RBRVS (Resource Based Relative Value System -- or Really Bad Reimbursement Very Slowly) as their basis for payment and do not use the OPPS model for re-calculating your reimbursement. As such, commercial payers have not followed Medicare in reducing reimbursement for duplex ultrasounds.
If you have a question on this or any other topic, please send me an email with your question.
Medicare and Affiliated Products
MEDICARE AND AFFILIATED PRODUCTS:
There exists some confusion, both by the practice and by the patient, as to what Medicare or other Medicare related benefits a person may have. While this document will not solve all of the issues, we believe that some background information may be of use to you.
Medicare: If a patient has classic Medicare, a few rules apply. First, Medicare does have conservative therapy mandates now of compression stockings having been worn (at any time in the past) for ninety days or more. Second, the patient may have a Medicare deductible. Third, the patient will be subject to the 20 percent co-insurance.
You have to be accepting Medicare patients and the practice has to be contracted with Medicare. It is a good idea to make sure the physician is properly ‘linked’ to the practice or you can have some claims difficulties.
Medicare Advantage: This is NOT Medicare per se. The patient’s Medicare is replaced by a commercial plan. PacifiCare’s Secure Horizon’s is a classic example of a Medicare replacement plan. If you see a patient card that has the word Advantage on it or the patient is of Medicare age and is presenting what looks like a commercial insurance card, you should be aware of the following:
a. You must be contracted with that payer
b. You almost always have to preauthorize the services
c. You will almost always have to submit notes and a letter of medical necessity (even if preauthorized).
d. The patient may have a deductible, copayment or even a coinsurance that will need to be collected.
Medicare Supplemental: The patient’s primary insurance is still Medicare. These types of policies cover the deductible and coinsurance that classic Medicare leaves as the patient’s responsibility. Almost all of these plans cover the patient responsibility portion up to 100% of the Medicare allowable amount. You do not have to be contracted with these various Supplemental plans. If the patient has informed Medicare, the secondary plan should be automatically notified by Medicare (commonly called ‘crossover’) when a claim is adjudicated. It is essential to review your Medicare Explanations of Payments (EOP) to ensure the crossover was completed. If not, you will need to bill the Supplemental plan directly with a copy of the Medicare EOP. Examples of this type of plan are the United Health Care AARP Plan and Mutual of Omaha’s Supplement Plan.
Commercial Insurance: Some Medicare patients still have a standard commercial plan as their secondary insurance. Like a Supplemental plan, you do not have to be contracted in order to bill for the patient’s deductible or coinsurance. However, unlike a Supplemental plan, there is no guarantee that the patient’s Medicare deductible or coinsurance will be paid as the Commercial Insurance plan may have a deductible, copayment or coinsurance to which the patient is still liable. Patient’s can be quite adamant and agitated when their secondary insurance does not act like a Supplemental plan.
It is no wonder some of our seniors are a bit confused when it comes to Medicare and the various products out there. Many times the patient does not realize they have signed up for a Medicare Advantage plan which can sometimes severely limit the physicians they may see.
Please call me if you have any questions regarding the above or any other questions.
Yrs.
AJ Riviezzo, MBA
American Physician Financial Solutions
Your Phlebology Billing/Consulting Experts719.233.0099 www.apfsbilling.com
There exists some confusion, both by the practice and by the patient, as to what Medicare or other Medicare related benefits a person may have. While this document will not solve all of the issues, we believe that some background information may be of use to you.
Medicare: If a patient has classic Medicare, a few rules apply. First, Medicare does have conservative therapy mandates now of compression stockings having been worn (at any time in the past) for ninety days or more. Second, the patient may have a Medicare deductible. Third, the patient will be subject to the 20 percent co-insurance.
You have to be accepting Medicare patients and the practice has to be contracted with Medicare. It is a good idea to make sure the physician is properly ‘linked’ to the practice or you can have some claims difficulties.
Medicare Advantage: This is NOT Medicare per se. The patient’s Medicare is replaced by a commercial plan. PacifiCare’s Secure Horizon’s is a classic example of a Medicare replacement plan. If you see a patient card that has the word Advantage on it or the patient is of Medicare age and is presenting what looks like a commercial insurance card, you should be aware of the following:
a. You must be contracted with that payer
b. You almost always have to preauthorize the services
c. You will almost always have to submit notes and a letter of medical necessity (even if preauthorized).
d. The patient may have a deductible, copayment or even a coinsurance that will need to be collected.
Medicare Supplemental: The patient’s primary insurance is still Medicare. These types of policies cover the deductible and coinsurance that classic Medicare leaves as the patient’s responsibility. Almost all of these plans cover the patient responsibility portion up to 100% of the Medicare allowable amount. You do not have to be contracted with these various Supplemental plans. If the patient has informed Medicare, the secondary plan should be automatically notified by Medicare (commonly called ‘crossover’) when a claim is adjudicated. It is essential to review your Medicare Explanations of Payments (EOP) to ensure the crossover was completed. If not, you will need to bill the Supplemental plan directly with a copy of the Medicare EOP. Examples of this type of plan are the United Health Care AARP Plan and Mutual of Omaha’s Supplement Plan.
Commercial Insurance: Some Medicare patients still have a standard commercial plan as their secondary insurance. Like a Supplemental plan, you do not have to be contracted in order to bill for the patient’s deductible or coinsurance. However, unlike a Supplemental plan, there is no guarantee that the patient’s Medicare deductible or coinsurance will be paid as the Commercial Insurance plan may have a deductible, copayment or coinsurance to which the patient is still liable. Patient’s can be quite adamant and agitated when their secondary insurance does not act like a Supplemental plan.
It is no wonder some of our seniors are a bit confused when it comes to Medicare and the various products out there. Many times the patient does not realize they have signed up for a Medicare Advantage plan which can sometimes severely limit the physicians they may see.
Please call me if you have any questions regarding the above or any other questions.
Yrs.
AJ Riviezzo, MBA
American Physician Financial Solutions
Your Phlebology Billing/Consulting Experts719.233.0099 www.apfsbilling.com
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