How to Code, Negotiate After-Hours Reimbursement at Your Practice

There are codes in the CPT® code book to report services a physician provides during "nontraditional" hours. If you prove that it’s in the payer’s best interest, third-party insurers may allow additional reimbursement for after-hours services.

Medicare and payers that strictly follow CMS guidelines will not pay additional reimbursement for after-hours services. However, you might succeed with private payers in negotiating payment for after-hours codes as part of a contractual agreement, especially if you use savings potential as leverage. Have your negotiator make it clear to the insurer’s representative that you’ll willingly send patients to the emergency department (ED) instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than comparable physician services.

To further demonstrate cost savings, you could also start billing all applicable after-hours codes for your practice. Over time, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.

Know the Codes

Based on the CPT®/AMA guidelines, you may report 99050 — Services provided in the office at time other than regularly scheduled office hours, or days when the office is closed (e.g., holidays Saturday or Sunday), in addition to basic service — for any service provided in the office at a time when the practice would normally be closed (e.g., weekends or evenings). Code 99050 is reported in addition to the code for the basic service.

If your practice already maintains regular hours on evenings, weekends, or holidays, and you provide a service during those times, you should skip 99050 and use 99051 — Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

If a 24-hour facility requests that your physician provide a redeye or early-bird service, AMA guidelines allow you to claim 99053 — Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service, in addition to the basic service. Code 99053 can be used whether the provider is already at the facility, or if the physician has to make a special trip to care for the patient. The code 99053 can only be used if the service provided occurs at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).

Emergency department physicians may report 99053 for services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians fully supports this use of 99053, stating that this code is appropriate for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."

G. John Verhovshek, MA, CPC, is the managing editor for AAPC's publications. He has written, co-written, and edited dozens of coding and compliance resource manuals, including the Part B Survival Guide (1st edition) and The Official CPC Certification Study Guide (1st edition). E-mail him here.

Article By G. John Verhovshek, MA, CPC http://www.physicianspractice.com/coding/how-code-negotiate-after-hours-reimbursement-your-practice?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03102013

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Medicare Palmetto Jurisdiction 1 Part B: E/M Weekly Tip: Denials or Down codes

If you receive a denial or down code based on medical necessity, it is important to review the documentation submitted along with the E/M guidelines to determine the reason/cause for the denial. You may use the online E/M Checklist and Scoresheet Form to assist with auditing/selecting the E/M level. If you do not agree with the denial/down code you may appeal the service(s) within 120 days from the date of the initial determination.

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Billing Medicare for Non-Physician Providers

Become Fluent in the Federal Rules

An article by Richard R. Wier, Jr., Esq., taken from the May/June issue of HBMA Billing (hbma.org)
The Centers for Medicare and Medicaid Services (CMS) and federal law enforcement agencies have increased efforts to combat healthcare fraud. In order to help fund these efforts, the Patient Protection and Affordable Care Act (PPACA) has increased the Health Care Fraud and Abuse Control Program's funding by $350 million from fiscal year 2011 to fiscal year 2020. As a result of these increased efforts and funding, in October 2012, the Medicare Fraud Strike Force charged 91 individuals, including doctors, nurses, and other licensed medical professionals, for their participation in falsely billing the Medicare program, resulting in approximately $429.2 million in penalties.

According to the False Claims Act, fraudulent billing under Medicare includes, but is not limited to, billing for tests not performed, performing inappropriate or unnecessary procedures, upcoding by using more expensive billing codes when lower priced procedures were performed, and various other billing inflation practices. When billing, health care providers must remain vigilant of the ever-changing billing and coding laws and pertinent state regulations to ensure that they are not improperly submitting Medicare claims.

One billing issue that may arise is the improper billing of Non-Physician Providers (NPPs), such as physician's assistants, nurse practitioners, and clinical nurse specialists. NPPs are able to enroll and bill Medicare for services that they are licensed or certified to perform within the state. When NPPs work independently, they are recognized under Medicare for professional billing and are able to bill Medicare under their own Medicare provider numbers; however, the reimbursement by Medicare is only 85% of the Medicare Physician Fee Schedule (MPFS). The MPFS provides the billing codes and proper coding methods that are required when requesting reimbursement from Medicare for services provided. Conversely, NPPs who perform services that are incident to the physician's course of treatment, which are known as "incident-to services," can bill Medicare for the services provided by the NPP under the physician's Medicare provider number, and the health care provider would receive 100% reimbursement from Medicare under the MPFS. In order for NPPs to bill incident-to services, Medicare requires that the physician perform an initial visit with the patient in order to establish the physician-patient relationship. After the initial visit, the physician does not need to be involved in each patient visit, but must actively participate in the management of the course of treatment for the patient. Although not required by Medicare, some carriers require that the physician meet with the patient every third visit or when a new symptom or medical issue arises.

When determining whether to bill for services provided by the NPP independently or incident-to the physician's services, health care providers must verify the scope of practice for the NPP, the place of service, and physician supervision over the NPP. There are a variety of resources available for guidance, including Title 42 of the Code of Federal Regulations (CFR); coding and billing under the Medicare Physician Fee Schedules (MPFS), as previously mentioned; and state laws and regulations. The CFR is a federal law that provides minimal standards necessary for billing under Medicare. Health care providers must keep in mind, however, that it is imperative to look at state law first because it may be more stringent than the federal law. State law will specify the scope of practice, certification and licensing, and level of supervision required for each type of NPP, and these factors determine whether the NPP can bill incident-to services under the physician's Medicare provider number, which will result in 100% reimbursement under the Medicare Physician Fee Schedule for services performed. Therefore, the health care provider who employs NPPs must fully review state laws in order to ensure that proper billing is submitted to Medicare for reimbursement.

The most important state law regulation to consider when billing incident-to services is the level of supervision required by a physician when an NPP treats a patient. Some state laws allow NPPs to bill under the physician's Medicare provider number when conducting incident-to services that relate to the physician's course of treatment without requiring the physician to be physically present during the meeting. The incident-to services must be part of the physician's course of diagnosis or treatment of an injury or illness, and the physician must supervise the services provided to the patient by the NPP. State law will define "supervision" as it is to be applied to Medicare billing. For instance, some states do not require the supervisory physician to be present in the room, nor does the physician have to provide any care during a patient visit. However, a physician in a supervisory role must still be "present on the premises" and immediately available to assist the NPP in providing services if necessary. State law can also define the specific meaning of "present on the premises." Similarly, the location where the services are provided will affect the way in which billing is submitted to Medicare, because incident-to services performed by an NPP in a hospital are directly paid to the hospital, and hospitals are reimbursed differently under Medicare. With these factors in mind, it is imperative for the health care providers who employ NPPs to verify state law for regulations regarding the location, scope of practice, and level of supervision required for an NPP when billing Medicare – especially since these laws are constantly changing.

Preparing your clients practices' for the government's increased scrutiny of fraudulent billing and overpayments are crucial. Therefore, it is important to meet with your legal counsel to identify risks and discuss preventive measures to ensure your doctors are in compliance with state and federal laws and regulations.

Courtesy of HBMA
Billing Medicare for Non-Physician Providers - HBMA - Healthcare Billing and Management Association for 1st and 3rd Party Billers - Medical Billing, Practice Management

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Palliative Care Helps Ease the Pain of Illness

 

People with a serious or chronic illness often get lost in a healthcare system that seems focused on treating their illness and ignoring their symptoms. That’s where palliative care, an emerging branch of medicine, comes in.
Palliative care aims to improve the quality of life for patients with serious illnesses and their families through symptom prevention, treatment and relief. It’s provided by a team of specially trained doctors, nurses and other healthcare specialists who work alongside a patients’ other doctors. Rather than treating the illness per se, palliative care offers comfort, symptom management and a focus on respecting the patient’s medical care wishes.

Mandela’s Illness Puts The Spotlight on Palliative Care
This week, Dr. Richard Besser, chief health medical correspondent for ABC News, along with American Cancer Society Cancer Action Network, hosted a Twitter chat on palliative care to help readers better understand what it is, where to find it and how to ask for it when needed. A full chat transcript can be found here. For highlights from the chat, including some of the best tweets from participating experts, read on.

Who needs palliative care?
Palliative care is appropriate for anyone who receives a diagnosis for a serious or chronic disease. Anyone with cancer, heart and lung disease, renal disease, and dementia is a likely candidate to receive palliative care, regardless of the stage of the disease.
Fortunately, palliative care has grown exponentially in the past few years. Nearly 65 percent of hospitals with more than 50 beds – over 1500 hospitals — now offer some form of palliative care, according to the Center to Advance Palliative Care, a non-profit group based in New York City.
However, the Center notes that only 24 percent of people said they were familiar with the term palliative care. If you are a loved one are diagnosed with a serious illness, ask your treating doctor if palliative care is available and request a palliative care consultation.

By ABC News

Jul 18, 2013 12:02pm
By Anita Rao, ABC News Medical Unit
http://abcnews.go.com/blogs/health/2013/07/18/palliative-care-helps-ease-the-pain-of-illness/

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A very informative video about medical terminology for any medical biller

READ MORE - A very informative video about medical terminology for any medical biller