American Academy of Family Physicians
Tuesday Jun 17, 2014

Potential pitfall in Medicare billing: office visits billed for hospital inpatients

This week, we conclude our series (see previous posts here, here, and here) on how to avoid common Medicare billing errors by focusing on billing the wrong kind of evaluation and management (E/M) code for patient visits provided in a hospital inpatient setting.

If you are rendering an E/M service to a patient in an inpatient hospital setting, then you should typically report that service with a CPT code from one of the following families:

•    99221-99223 – Initial hospital care
•    99231-99233 – Subsequent hospital care
•    99238-99239 – Hospital discharge services

Unfortunately, Medicare contractors are finding that physicians sometimes use a CPT code from the 99201-99215 family (Office or other outpatient services) for encounters with hospital inpatients. The example given is an 80-year-old female admitted to a hospital for an inpatient level of care on Oct. 17 and discharged on Oct. 20. A physician billed CPT code 99205 (Office or other outpatient visit for the evaluation and management of a new patient) for the date of service of Oct. 18. Because Oct. 18 was during the inpatient hospital stay and the patient was not on a leave-of-absence from the hospital on that date, the contractor deemed the service an overpayment.

So, if you are billing E/M services for a patient in an inpatient hospital setting, then you need to use hospital visit codes to report those services and avoid office/outpatient visit codes for dates of service corresponding to the patient’s hospital stay.

For additional information, check out Medicare’s Evaluation and Management Services Guide and sections,, and 30.6.10 of chapter 12 of the Medicare Claims Processing Manual.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Jun 10, 2014

Potential pitfall in Medicare billing: modifer misuse

Over the past two weeks, we have discussed how to avoid common Medicare billing errors recently identified by the Centers for Medicare & Medicaid Services (CMS). This week, we’ll focus on the pitfalls associated with a commonly used billing modifier.

There are times when family physicians do multiple, separate procedures on the same patient at the same session or on the same day, for which separate payment may be allowed. Medicare rules state that the second and any subsequent procedures are subject to reduced payment in this situation. Physicians are to identify such services by appending modifier 51 (multiple procedures) to the codes for the second and subsequent procedures. Medicare, in turn, reduces the payment allowance by 50 percent for codes with modifier 51 attached.

Unfortunately, the CMS has identified situations in which physicians are appending modifier 51 to a procedure code even when that procedure is the only one provided to the patient on that date. In those situations, the physicians are generating inappropriate underpayments of up to 50 percent and shooting themselves in the foot financially. The easy answer is to NOT append modifier 51 to any code in the surgery section of Current Procedural Terminology (codes 10021 to 69990) if that is the only code from that section provided to the patient on that date.

For further resources, CMS advises that you read section 40.6 of chapter 12 and section 30 of chapter 23 of the Medicare Claims Processing Manual. Next week, we’ll wrap up this series of posts by looking at the pitfalls associated with billing office visits for hospital inpatients.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Jun 03, 2014

Potential pitfall in Medicare billing: preventive services

Last week, we began looking at some of the common Medicare billing errors identified by the Centers for Medicare & Medicaid Services (CMS) in its most recent Medicare Quarterly Provider Compliance Newsletter. This week, we’ll focus on another of those pitfalls, this one associated with Medicare-covered preventive services.

In recent years, the CMS has expanded Medicare coverage of preventive services to include many recommended with a grade of A or B by the United States Preventive Services Task Force. These services (and their corresponding Medicare billing codes) include:

•    Annual alcohol misuse screening, 15 minutes (G0442)
•    Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes (G0443)
•    Annual depression screening, 15 minutes (G0444)
•    Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes (G0446)

Unfortunately, Medicare contractors have determined that insufficient documentation is causing many improper payments for these services. “Insufficient documentation” in this context means that something was missing from the medical records, such as:

•    No record of the amount of time spent providing a timed service
•    No record of the billed service itself
•    No physician’s signature on the medical record

To avoid these potential problems, CMS advises physicians to:

•    Record start and stop times, or the total time spent, when providing a timed service
•    Sign entries in medical records at the time of service
•    Learn about the non-covered indications and frequency limits for preventive services under Medicare

To the last point, you should know that:

•    Screening for depression is not covered when performed more than once in a 12-month period
•    Alcohol screening is not covered when performed more than once in a 12-month period
•    Brief face-to-face behavioral counseling interventions are not covered when performed more than once a day
•    Brief face-to-face behavioral counseling interventions are not covered when performed more than four times in a 12-month period.

You can find additional information and links to other relevant resources in the newsletter. Next week, we’ll look at the pitfalls associated with misuse of a common coding modifier.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Aug 02, 2011

Four months left to ensure 5010 compliance: Are you ready to test?

We're entering the last month of summer and no doubt that means a plenty of students being rushed in for their school physicals and any necessary vaccinations. Before long, the students will be back in class and worrying about their next test. But they are not the only ones with tests to take. Your practice management or claims submission software vendor is being tested to ensure compliance with the 5010 HIPAA-compliant electronic transaction standards, and the Centers for Medicare & Medicaid Services (CMS) requires that they pass!

That is why CMS has announced a National 5010 Testing Week for Aug. 22 through Aug. 26. Practices whose software vendors have completed the necessary upgrades may take advantage of an opportunity to come together and test their work with the added benefit of real-time help desk support and direct and immediate access to the Medicare Administrative Contractors (MACs). This is a great opportunity to complete testing of the new transactions and move to production not only before the Jan. 1, 2012 compliance deadline but also before your practice must complete end-of-year tasks such as annual code updates and Medicare benefit changes for 2012.

If your software vendor or clearinghouse is handling the testing for you, be sure that you are aware of their progress and expected date of completion. The MACs will process both the current 4010 transactions and the 5010 transactions of those practices that have successfully tested. However, CMS has emphatically stated that on Jan. 1, 2012, only transactions in the 5010 format will be accepted. If you or your vendor have questions about testing or the formats for addresses or other claims fields, you can contact the Medicare Part B EDI helpline for assistance.

Don't let your claims submissions get an "F" on January 1st!

Monday Nov 22, 2010

Medicare preventive services: Are your patients calling?

From what I am hearing, your offices may already be getting requests from Medicare patients to schedule an appointment for the new  annual wellness visit that Medicare will begin covering on Jan. 1, 2011. We'll be bringing you a full article on this and other changes to Medicare coverage of preventive services in the January/February 2011 issue of Family Practice Management. A new encounter form for Medicare preventive service visits is also being developed.

Here are a few tips that you might want to know before scheduling appointments for annual wellness visits:

  1. Patients are being encouraged to get this service, and Part B pays at 100 percent with no out-of-pocket costs to the patient.
  2. Your staff need to verify the patient's Medicare Part B eligibility date. Patients in their first 12 months of Medicare Part B coverage are eligible for the Welcome to Medicare physical, not the new annual wellness visit.
  3. Patients who have received a Welcome to Medicare physical are not eligible for an annual wellness visit until 12 months after the date they received the Welcome to Medicare physical. If the patient has been eligible for Medicare Part B for more than 12 months but less than 24, staff should verify if and when a Welcome to Medicare physical was provided.
  4. The annual wellness visit includes a few things that the Welcome to Medicare physical does not, including:
    • A requirement to collect information on all other physicians and suppliers currently providing care to the patient,
    • An assessment of cognitive function,
    • Development of a five- to 10-year plan for obtaining recommended preventive care,
    • A list of patient risk factors that you've identified, with current or proposed treatment options including the benefits and risks associated with these options.
  5. Medicare will allow a significant and separately identifiable evaluation and management (E/M) service on the same date as the annual wellness visit when it is reported with a modifier 25. However, the Centers for Medicare & Medicaid Service (CMS) recommends against providing non-urgent acute care at the same encounter, as it may detract from the intended focus on preventive care. Patients may not appreciate making two visits, but providing information at the time of scheduling to advise patients that an annual wellness visit does not include treatment or management of problems may set expectations and limit frustration.
  6. The initial annual wellness visit payment is equal to a level-four new patient visit. Don't underestimate the time needed to provide and document these services. You may want to work with your scheduling and clinical support staff to establish new processes so that the history and other portions of the service that don't require a physician's skills can be performed and ready for your review before your with the patient begins. It will also be important to remind patients to come prepared to provide information on all the medications, supplements and vitamins they take and their personal and family history.

These services will no doubt be of benefit to Medicare patients who might otherwise not seek care beyond that for existing or bothersome new conditions. However, this ounce of prevention may feel like a ton of work for you and your staff, particularly if you don't plan ahead.

Thursday Oct 07, 2010

New tobacco-use cessation counseling benefits: Three billing scenarios

The Centers for Medicare & Medicaid Services released guidance this week on payment for expanded smoking and tobacco-use cessation counseling. This service is now covered for patients who use tobacco but do not have symptoms of related conditions, and the coverage is retroactive to Aug. 25, 2010. The counseling must be provided by a physician or other qualified health care professional (e.g., physician assistant).

Now for the not-so-good news. Allowing different benefits for the same service based on whether it is preventive or problem-oriented creates coding and payment guidelines that are, well, problem-oriented. Here's what I mean:

While asymptomatic patients became eligible for the counseling benefit on Aug. 25, 2010, the full benefit of the preventive service coverage does not begin until Jan. 1, 2011. For services delivered from Aug. 25, 2010, to Dec. 31, 2010, charges will be subject to any unmet deductible and to the patient's co-insurance. For dates of service Jan. 1, 2011, and after, the same services will not be subject to deductible and co-insurance (i.e., there will be no out-of-pocket expense for the patient who receives the service). This may require some patient education.

Here's what else you need to know to code and bill for these services now and in the future:

• For counseling provided to patients who use tobacco and have a condition that is adversely affected by tobacco use and/or are undergoing a treatment that is adversely affected by tobacco use, continue reporting CPT codes 99406 and 99407. The benefits for these patients have not changed. (If you're not familiar with these services, see the FPM article An Update on Tobacco Cessation Reimbursement.)

• For counseling provided to patients who do not have symptoms of conditions related to tobacco use and are not undergoing a treatment that is adversely affected by tobacco use, report unlisted CPT code 99199, "Unlisted special service, procedure, or report" for dates of service Aug. 25, 2010, through Dec. 31, 2010.  Submit ICD-9 codes 305.1, "Non-dependent tobacco-use disorder," or V15.82, "History of  tobacco use," as well. Be sure to inform patients that unless there is a secondary insurance that pays the balance after Medicare, they may be responsible for an unmet deductible and for co-insurance amounts.

• For counseling provided to asymptomatic patients beginning on Jan. 1, 2011, you should bill using the new Medicare G codes: G0436, "Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes," or G0437, "Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes." The same diagnosis codes, 305.1 or V15.82, will be required. Again, patients will not have an out-of-pocket expense for these services when they are delivered on Jan. 1, 2011, or after.

When reporting any significant and separately identifiable evaluation and management service on the same date as tobacco-use cessation counseling, append modifier 25 to the evaluation and management code.

These are some of the first changes for preventive services in response to requirements of the Affordable Care Act. There will no doubt be other guidance coming from CMS and private payers on coverage, coding, and payment for preventive services. Stay tuned, and we will deliver information as promptly as possible after its publication.

Monday Nov 02, 2009

Crossing the finish line

In a relay race, no matter how hard all the others run, if one runner drops the baton, the team will likely lose the race. Likewise, if you provide and document a patient's care and select the correct codes and modifiers for that care, but the claim gets sent to the wrong payer, denied, and written off as bad debt, you have likely missed the goal of getting paid for services provided. There are many steps and hand-offs in the race to getting paid so you need to be sure that each runner finishes his or her leg.

Now, I am not saying that there aren’t a lot of other factors influencing the financial health of your practice, such as payer fee schedules that are set too low. However, I’ve seen firsthand, and the statistics show, that a lot of the money that physicians should collect is left behind due to lack of training and discipline in the billing process. To collect all that is due your practice, you need trained and disciplined staff using a well-designed system.

I’m not talking about expensive computer systems or consultants. Much of this comes down to the basics that haven’t changed since the days of using a typewriter and a whole lot of White-Out to produce claim forms. Good billing practices have always depended on team work and efficient processes.

Some simple steps include the following:

  1. Verify the patient's insurance coverage each time a service is scheduled.
  2. Know what services may not be covered or require prior approval. 
  3. Get charges to the biller as soon as possible after services are provided.
  4. Verify charges billed against the sign-in sheets or other records of what patients were seen each day.
  5. Update insurance information every time charges are entered.
  6. Research all unpaid claims and take any necessary action within 45 days of date of service.
  7. Review a report of write-offs each month to determine appropriateness.


These steps illustrate that the process depends on a team of people (though in smaller practices, each person may run longer legs). The scheduler gets the initial information. The front desk staff copy the cards and update demographics. Clinical staff get any necessary prior approvals and document all charges promptly. Billing staff update information, enter charges correctly and follow-up on the account until paid. Finally, a manager or physician reviews what was paid and what was written off and makes adjustments as necessary to keep the team fit.

Need more information or some resources on billing and accounts receivable management? The AAFP has some resources to help. See the Billing & Claims section of the AAFP Coding Resources web page -- and, of course, the FPM Toolbox (click on the link titled "Billing, Collections and Claims Processing").

Friday Oct 02, 2009

Getting paid for H1N1-related services

Do you know where to obtain H1N1 vaccine for your patients and how to bill payers for its administration?

Free H1N1 vaccine kits are available through your state health agencies. The Centers for Disease Control has published a list of who to contact for information on obtaining the vaccine. If you do not wish to provide the vaccine in your practice, you can use this list to determine where to refer your patients.

Most privately insured patients will have benefits for the H1N1 vaccine administration even if their health plan does not typically cover preventive services; this is due to collaboration between the U.S. Department of Health and Human Services and payers. Medicare allows physicians to provide and bill for both H1N1 and seasonal influenza vaccines on the same date. Medicare created a new G code for administration of the H1N1 vaccine; submit code G9141 with diagnosis code V04.81. It is not necessary to report a separate code for the vaccine itself, but if you prefer to include it in your documentation, use code G9142. If billed, this code will be denied since the vaccine is provided at no cost. For the standard seasonal influenza vaccine and administration, use codes G0008 for the administration, V04.81 for diagnosis, and the appropriate CPT code for the vaccine itself (i.e., 90655, 90656, 90657, 90658 or 90660). Medicare will not pay for an office visit if the sole purpose of the visit is vaccine administration but will if a significant, separately identifiable E/M service is provided on the same date.

Your local private payers may still be deciding on the coverage and payment for the H1N1 vaccine, but most national payers have provided some guidance. The recent creation of CPT code 90470 for H1N1 vaccine administration may cause some plans to issue revised instructions. We have requested updated guidance from national health plans and will update the AAFP resources on H1N1 with this information as we receive it. As with all services, practices should check the individual patient’s benefits when scheduling the services.

Finally, it’s important to know how to code and bill for care provided to patients who are sick with the flu. New influenza diagnosis codes took effect Oct. 1, 2009. Code 488.1 is specific to influenza due to the H1N1 virus. Code 487.1 is still valid for patients with influenza not otherwise specified and other respiratory manifestations such as pharyngitis, laryngitis or URI. Code 487.0 for reporting influenza with pneumonia is also still valid. When providing in-office testing for influenza, code 87804QW represents CLIA-waived testing for influenza by immunoassay with direct optical observation. Most rapid tests do not differentiate between Influenza A and B. However, for those that do produce two separate results, payers may accept 87804QW on one claim line and 87804QW59 on a separate claim line. As always, you should check with your individual payers for specific coverage and billing guidelines.

Thursday Jan 29, 2009

ICD-10: Y2K all over again?

People often see things differently. Two neighbors may call their county government offices, one to ask that weeds be sprayed along the road and another asking for a no-spray ordinance. Health care is not immune to such conflicting priorities.

Some are anxiously counting the days until the Oct. 1, 2013, deadline for adoption of the ICD-10-CM codes and the "granularity" they promise. I doubt many practicing physicians are among that group. A letter to the Centers for Medicare & Medicaid Services from Jim King, MD, chairman of the AAFP Board of Directors, left no doubt the AAFP did not support this change. That said, I hope you are not losing sleep, hoarding canned goods or preparing to duck for cover. The transition from ICD-9 to ICD-10 will create some challenges but will not likely result in widespread calamity.

Don't get me wrong. This is not your average annual code update. As reported by the American Academy of Professional Coders, when the Blue Cross Blue Shield Association converted the 164 ICD-9 codes included in FPM's model superbill to ICD-10, the resulting mess was seven pages longer than the original list. (The FPM Superbill has been updated for 2009; you can download it from the FPM Toolbox.) Clearly the ICD-10 code set is cumbersome compared to ICD-9, but it's not as difficult as learning to diagnose and manage the 68,105 conditions that may be reported with ICD-10. You can handle this.

Here are some things to consider as the Oct. 1, 2013, implementation deadline approaches:

1. You will no doubt soon receive ads for ICD-10 products and educational resources. Please don't waste your money. Learning a complex coding system that you will not use for nearly five years isn't productive, and changes could be made to the code set before 2013. Keep reading FPM and plan to learn more when implementation is closer.

2. Don't let ICD-10 overshadow another change with the potential for significant financial impact, especially for solo and small practices -- the conversion to the HIPAA 5010 electronic transaction standards, which must be completed by Jan. 1, 2012. Version 5010 is an extensive revision and paves the way for submission of ICD-10-CM codes. If your software vendor charges for upgrades or floundered during prior changes, now is the time to start asking questions about implementation plans and considering your options (e.g., upgrade or change vendors).

3. If you think you might need to change your software, consider a combined EHR/practice management system. A combined system may relieve some of the ongoing burdens and costs of transitioning to ICD-10. Imagine having an ICD-10 look-up tool similar to the FPM ICD-9 Look-Up Tool built into your EHR and integrated with your billing system, or a system that automatically converts standardized nomenclature to codes.

Most of you have endured the Medicare enrollment process, so you are combat-tested. And you are not alone. The AAFP and FPM will continue to provide you with the best resources that we can find or create to help you make the transition to ICD-10.

Wednesday Jan 14, 2009

Injection rejections

It’s annoying. You’ve submitted your claims for subcutaneous injections with code 90772 for a couple years now and all of a sudden, rejections! The code has been changed to 96372. Who's responsible for this disruption to your cash flow?  It was the insurance companies, wasn’t it?

No. Insurance companies do have some influence on CPT code changes but really not that much. CPT code changes can be proposed by anyone who identifies a problem or gap in existing codes. Many originate from physician complaints made to specialty societies about payment policies that don’t align with CPT or current practices. All proposed changes are vetted and recommended for approval, modification or rejection by physician volunteers from each of the medical specialty societies that participates in the AMA's CPT process. Proposals are then approved, postponed or rejected by the AMA's 17-member CPT Editorial Panel. Most of the panel members are physicians nominated by their specialty organization and appointed by the AMA Board of Trustees. David Ellington, MD, of Lexington, Va., and the AAFP Board of Directors is a member of the panel. A handful of the panel members represent payers.

So what else has changed in CPT 2009 and how are you, a busy physician, supposed to care for your patients and your practice and keep up with all of this? You can look to Appendix M of your 2009 CPT book for a summary of the deleted codes and their replacements. Also, watch for an article in the January/February issue of FPM on the code changes most affecting family medicine. And finally, don’t hesitate to contact me ( or join the AAFP e-mail discussion list for coding issues to find help with coding questions and keep up-to-date. (The discussion list is also open to non-members so that your coding and billing staff can take advantage of this free resource.)

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