American Academy of Family Physicians
Friday Nov 08, 2013

Billing E/M services with allergy procedures is getting Medicare's attention

If you routinely bill evaluation and management (E/M) services with allergy testing or allergy immunotherapy, expect to receive increased scrutiny from Medicare in the future.

The latest issue of the Medicare Quarterly Provider Compliance Newsletter highlights that recovery auditors have identified this type of coding combination as a potential problem, resulting in what auditors determined were overpayments.

According to the Medicare Claims Processing Manual (Chapter 12, Section 200, subsection C), to receive payment for a visit service provided on the same day that you also provide an allergen immunotherapy service (i.e., any service in the series from 95115 through 95199), you must bill a modifier 25 with the visit code. This indicates that the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service you provided. The newsletter also notes that obtaining informed consent is included in the immunotherapy service and should not be reported with an E/M code.

Medicare assumes that allergy injections are typically pre-scheduled and that no other services beyond the injection are usually scheduled at the same encounter. Also, Medicare doesn't believe an E/M code is needed to report the minimal amount of work used to determine if the patient is fit to undergo an allergy injection, believing the injection code already includes that work. However, Medicare recognizes that things don’t always go according to schedule, and you may properly bill for these significant, separately identifiable services using modifier 25 for claims processing.

To see if you're potentially running afoul of these rules, Medicare recommends that physicians pull the documentation for a sample of past instances where they billed Medicare for E/M services tied to scheduled services and compare the “visit intent” against the content of the notes.

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

Wednesday Apr 10, 2013

Medicare to deny claims with no NPI

The day of reckoning is finally coming for those who order or refer items or services for their Medicare patients but who lack the proper identification.

On May 1, the Centers for Medicare & Medicaid Services (CMS) will begin instructing its contractors to deny Medicare claims from individuals who don't include a valid National Provider Identifier (NPI).

Section 6405 of the Affordable Care Act requires physicians or other eligible professionals to be enrolled in the Medicare program to order or refer items or services for Medicare beneficiaries. Also, Medicare requires that a physician or supplier that bills Medicare for a service or item show the name and unique identifier (i.e., the NPI) of the attending physician on the claim if that service or item was the result of an order or referral.

Beginning in October 2009, Medicare contractors began alerting billing providers if the identification of the ordering/referring provider was missing, incomplete, or invalid, or if the ordering/referring provider was not eligible to order or refer. The alerts were merely warnings, however, that the claims lacked the required information, and the claims were paid anyway. Beginning next month, however, CMS will deny Part B, durable medical equipment, and Part A home health agency claims that fail the ordering/referring provider edits.

Physicians and others who want to continue ordering and referring items and services need to establish their Medicare enrollment record and make sure they're of a specialty that is eligible to order and refer. You can enroll in the Medicare program here: Internet-Based Provider Enrollment, Chain, and Ownership System (PECOS). Physicians who have a valid opt-out affidavit on file are not required to enroll in Medicare. CMS also has a shorter enrollment form, known as the CMS-855-0, for use by physicians and other health professionals who refer and order services but do not bill Medicare directly.

More information on the new edits can be found in this Medicare bulletin.

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

Monday Oct 17, 2011

5010 and 2012: Time for a backup plan?

As we near the end of 2011, you may notice a lot of fuss about the transition to the HIPAA version 5010 electronic transactions. The reason is that your claims must reach your payers in the 5010 format beginning on Jan. 1, 2012, or they will be rejected. As the deadline approaches, it may again be time to assess your practice's readiness to submit and receive electronic claims and other transactions in the HIPAA 5010 format. Has your vendor upgraded your claims software, and have you begun testing with your clearinghouse and payers? If not, what is the vendor's message to you about having this work completed before the deadline? How confident are you that you will be able to send and receive claims data to keep payments coming in after the first of the year? If your confidence isn't high, it is probably time to consider a backup plan. Here are some options for those practices whose software vendors are not showing promise:

1. Contact the clearinghouse through which your claims are submitted to find out if it will offer conversion services. Most clearinghouses will be able to receive claims in the current 4010A format and convert them to the 5010 format before relaying the data to the payers. Likewise, when the payers send back acknowledgements or claims reports in 5010, the clearinghouse may convert that data back to 4010A before delivering it to your practice. (They will likely be doing the reverse for payers that are not ready for 5010.)

2. If your software vendor is requiring a costly upgrade, consider whether it is time to look at other options. (This may be especially relevant if an EHR is in your near future. You may want evaluate how EHRs integrate with practice management systems.)

3. Use free software from your Medicare contractor to submit your Medicare claims. This will keep at least that portion of your cash flow intact. Though the software is free, using it will likely require extra data entry work, since the software does not connect to your billing system.

4. If your vendor is planning a last-minute upgrade and you have some level of confidence that any delay beyond the first of the year will be short, you may want to hold your billing for that time and let other claims be applied to patient deductibles. Your billing staff can use the time to work with the software vendor and clearinghouse and also do some intensive follow-up on this year's unpaid balances. (This could result in a better-than-typical January cash flow.)

Some have recommended that physicians secure a line of credit just in case of a disastrous transition. This may not be needed and is probably easier said than done; however, a line of credit is always a good idea and could be needed for many other reasons (e.g., a severe reduction in the Medicare fee schedule, RAC audits, and other disasters like flooding). If you have the credit and banking relationship to secure a line of credit, it might be worth discussing with your banker.

Many of you have survived Y2K, the first HIPAA transition, the introduction of the national provider identifier (NPI), and the Medicare enrollment process. I am confident that you will get past 5010 as well. I think the doomsday authors are wrong about the world ending on Jan. 1, 2012. Even if they are right, 5010 won't be to blame. Let's save the paranoia for the real scary stuff, like Congress in session and arsenic in apple juice.

Tuesday Mar 29, 2011

The old "new patient" conundrum

In its most recent Medicare Quarterly Provider Compliance Newsletter (PDF download) the Centers for Medicare and Medicaid Services (CMS) highlighted an issue that apparently continues to be a problem for some physicians. Namely, when is a patient "new" for purposes of billing evaluation and management (E/M) services?

CMS defines a "new" patient in Chapter 12 Section 30.6.7 (PDF download) of the Medicare Claims Processing Manual as "a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years." This is essentially the same definition as in Current Procedural Terminology (CPT), which states, "A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." CPT defines "professional services" as "those face-to-face services rendered by a physician and reported by a specific CPT code(s)." 

A simple way to determine if a patient is new is to ask yourself this question: "Have I (or another physician of my specialty within our group practice) provided a face-to-face service to this patient within the past 3 years?"  If the answer is no, then the patient is new to you for purposes of coding and billing the E/M service that you are providing to him or her.  If the answer is yes, then you must consider the patient established. Determination of whether the patient is new or established should not be made solely on whether the chart presented was new. Coding or charge entry staff should search for past billing records using the patient's social security number and date of birth, and if a billing record is found, contact the appropriate staff to compare the charts and determine if the patient is established. 

While some of your patients may be new, this issue is not, and apparently, it continues to sufficiently confuse some physicians that CMS felt it necessary to remind folks about the definitions involved. CMS issues the Medicare Quarterly Provider Compliance Newsletter to help physicians and their billing staffs understand the claims submission problems found by Medicare contractors and how to avoid certain billing errors and other improper activities when dealing with the Medicare. In light of that, you may want to check your own understanding of the new patient issue and related coding and billing practices, lest this become a compliance issue in your practice. 

Thursday Jul 08, 2010

Have you seen your Medicare "raise"?

It's official. The Medicare Physician Fee Schedule is updated with a 2.2 percent increase for services from June 1, 2010, through Nov. 30, 2010. After failing once again to address the flawed SGR methodology that creates these expensive and cumbersome short-term fixes, Congress passed and the President signed this latest legislation on June 24. But have you seen the money?

If not, it should be forthcoming in short order. The Centers for Medicare & Medicaid Services (CMS) responded promptly to the fix with a message to its contractors to stop paying claims with dates of service after June 1 at the 21.3 percent cut enacted on that date and to hold those claims until the new rates were loaded into the payment system and tested. Claims held during this period will be processed as quickly as possible in the order received, according to CMS. (Some members of the AAFP coding discussion list report having already received payments that reflect the increase.)

In addition to watching for claims paid under the updated fee schedule, your staff may be dealing with claims that were previously paid at the reduced rate and reprocessed to pay the difference. These claims may present some challenges as the co-insurance amounts increase along with the amounts paid by Medicare. Some secondary payers may receive the adjusted Medicare payment notices electronically and automatically pay the difference in co-insurance; others will not. Likewise, any co-insurance due from a patient would increase.

So if you have a patient who previously paid their co-insurance at the reduced level, do you have to send out a statement for an $2 or $3? Not necessarily. The Office of the Inspector General has also responded to the change in fee schedules by issuing guidance that indicates they will not penalize physicians who choose not to bill patients for the difference as long as this is under a policy that applies equally to all Medicare patients or offered in response to financial hardship and does not relate to any kind of inducement to receive more services. Bottom line: If it will cost you more in staff time, printing and postage than the amount being billed, you may want to either write-off the amount or hold the patient balance and bill it when additional charges are incurred.

In the meantime, we will be watching Congress for a solution before Nov. 30, but don't hold your breath. This is an election year. 

Monday May 17, 2010

Signatures take on new significance

The Centers for Medicare & Medicaid Services (CMS) recently published new guidance on what constitutes a legible signature. An alphabet soup of auditors (MICs, RACs, CERTs and ZPICs) have been contracted to find and recover Medicare overpayments – like money paid for services when the documentation has no legible signature – so you should familiarize yourself with the rules.

For medical review purposes, Medicare requires that signatures for services provided or ordered be authenticated by the author with a handwritten or electronic signature. Stamped signatures and typed names without a signature are not acceptable.

If medical records are requested for review and you find that signatures are missing or illegible, do not add late signatures (beyond the delay that occurs during the transcription process). Instead, provide a signature log or attestation statement in support of the records.

A signature log contains the full name and credentials or title of everyone in the practice who might write in a medical record, their signature as they usually sign and any other forms of signature they might use (e.g., initials), and the date. If you don't want to create a comprehensive signature log for the practice, a simple one could be included as a separate entry on the actual page where the initials or illegible signature were used. (Tip: A list of commonly used abbreviations may provide additional support for your documentation, as these can be a source of confusion for auditors.)

An attestation statement is a signed statement that may be sent with unsigned medical documentation to attest that the services were performed and documented by the person who signs the attestation statement. This example is provided in the CMS guidance:

"I, [print full name of the physician/practitioner], hereby attest that the medical record entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [insert provider credentials, e.g., MD] when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability."

The attestation statement must contain sufficient information to identify the patient. Be sure to include the patient's name and insurance number.

Records or orders signed with a squiggle or what sometimes appeared to be the output from an ECG are giving way to electronic signatures generated by electronic health record systems, but even electronic signatures must be used correctly. Providers using electronic systems need to use software products and administrative procedures that protect against modification and comply with recognized standards and laws.

One final note from the CMS guidance: If reviewers identify a pattern of missing or illegible signatures, it will be referred to the appropriate program integrity contractor for further development.

Don't let something as easy to correct as a missing or illegible signature allow the auditors to take back money you earned.

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").

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