Wednesday, February 28, 2007

Illinois Locality 16 Fees downloadable file issue

During the dates of February 12 - February 20th of 2007 if you downloaded Medicare of Illinois Localty 16 fees please reivew this alert -

ALERT
WPS Medicare inadvertently posted the incorrect fees for Illinois Locality 16 affecting the downloadable file version only on 02/12/07. We posted the correct fees to the Website on 02/20/07.

MOST PROVIDERS NOT AFFECTED
If you sent in claims for Illinois Locality 16 for 2007 dates of service, AND you only billed the allowed amount based upon the fee schedule allowed amounts, AND you used the fees from the version of the downloadable file for Illinois Locality 16 posted between 02/12/07 - 02/20/07, you may be affected.

Please note this DOES NOT AFFECT YOU IF:
• You did not download IL locality 16 fees from our Website between February 12-20, 2007
• You used the "Download All States" feature
• You used the viewable PDF for Illinois Locality 16
• You used the downloadable Illinois Locality 16 feature previous to or after February 12-20, 2007

If you submit your claims with actual billed amounts, and do not adjust your billed amount to reflect the Medicare allowed amount, this error will not affect you. In other words, if you do not bill based on the Medicare Physician Fee Schedule Relative Value File allowed amount, but rather on your own individually determined pricing, this error will not have affected your reimbursement. You will have received the correct allowed amount when your claim processed. This error only affects providers who bill the Medicare allowed amounts based upon the allowed amounts for Illinois Locality 16 posted to the WPS Medicare Website February 12, 2007 - February 20, 2007.

WHAT SHOULD I DO IF I AM AFFECTED?
Please call 877-867-3418 and request a telephone reopening in order to receive your correct reimbursement amount. Please mention that you are requesting a telephone reopening based on the "Website fee error" and that you need to change the amount you billed. This is carrier error and we will reprocess it to reflect the correct reimbursement level. If you prefer to request a reopening in writing, please submit our new reopening request form found at http://www.wpsmedicare.com/provider/appeals.shtml on our Website.

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Tuesday, February 27, 2007

LT (Left) and RT (Right) Modifiers

A medical biller will use these modifiers to identify when a procedure was performed on both the Left and Right side of the body.

When
billing insurance carriers you will run into times where the provider treated both sides of the body and will indicate the procedure two times. If you bill your insurance carrier without the proper modifiers one of the line items will be denied as a duplicate.

In this case you will attach the RT modifier to one of the procedure codes and the LT modifier to the other procedure code.

An Example of when to use Left and Right modifiers:
A patient is referred to an imaging center for carpal tunnel on both wrists. The technician indicates they performed procedure code 73100 LT and a 73100 RT.


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Monday, February 26, 2007

Procedure 92065 Orthoptic/Pleoptic Training

When using procedure code 92065 Orthoptic and/or Pleoptic training, with continuing medical direction and evaluation you can bill as:

92065
92065 TC (technical component)
92065 26 (professional component - certain procedures are a combination of a physician component and a technical component. When the physician component is reported seperately, the service may be identified by adding modifier 26 to the usual procedure number)

Terminology identifies this procedure as including services for both eyes meaning this code is unilateral OR bilateral. You will not need to use modifier 50.

You will not use RT or LF modifiers and you won't want to bill using two units.

Suggestion: if you receive a denial "reject incorrect # of units billed" you will want to edit your claim and rebill . Usually you can do this with just a few
click and submit electronic claims whenever you can for quicker turn around on your insurance payments.

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How to identify a New Patient when billing an Evaluation and Management (E/M) code?

Classification of Evaluation and Management (E/M) Services
When reviewing E&M services they are split up into broad categories like office visits, hospital visits and consultations. Most of the categories are further divided into two or more subcategories of Evaluation and Management services.

First identify if the patient is a new patient by asking yourself the following questions:
1. Has your provider ever treated this patient before?
2. Has any of the other providers within the same specialty who belongs to the same group practice ever treated this patient within the last 3 years?
If you answered No to both of these your patient is a New patient.

An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years

If the doctor has another provider “on call” for him, the patient’s encounter will be classified as if the patient had been treated by his normal doctor.

Emergency departments do not look at patients as New or Established.


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Tuesday, February 20, 2007

Medical Billing and Coding using GA Modifiers

Medical billing and modifiers go hand in hand. As a medical biller you will need to know when to use a modifier in order to get paid out and sometimes it may feel like some crazy game that no one really understands the rules of. But play we must and so here is my take on the GA modifier.
When to use a GA Modifier?
- When you feel the item or service will be denied as not reasonable and necessary and a Advanced Beneficiary Notice (ABN) was given to the beneficiary for signature.
- When you feel you will receive so-called “Medical Necessity” denials
- The GA Modifier also may be used with assigned and unassigned claims for DMEPO’s where one of the following Part B “technical denials” may apply
o Prohibited telephone solicitation
o No supplier number
o Failure to obtain an advance determination of coverage

You are required to attach the GA modifier anytime you obtain a signed ABN form and you furnish services.

Example:
A patient with Medicare primary benefits visits her chiropractor for an adjustment on the back and has carpal tunnel symptoms. The patient requests an adjustment on the wrist for the carpal tunnel and the chiropractor explains that these services are not covered by Medicare. The patient insists she would still like the adjustment so the provider presents the patient with the ABN form. Once the ABN form is signed the chiropractor can complete services for the carpal tunnel.

Who pays on procedure codes with GA modifier?
Medicare will most likely deny the claim and indicate on the EOB that the beneficiary (patient) is responsible for these services.

What happens if I don’t use the GA modifier?
Medicare will most likely deny the claim and indicate on the EOB that the beneficiary (patient) is NOT responsible for these services and you CAN NOT collect from the patient. If you billed this incorrectly you can go through the appeals process. Medicare does state the office is responsible for attaching the GA modifier anytime the office has that patient sign an ABN form. Failure to attach this modifier may result in fraud and abuse implications by Medicare.

Suggestion:
Identify if your
medical billing software allows you to default modifiers per procedure code per carrier. Once this is setup you won’t have to worry about making sure the correct modifiers are attached.

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Saturday, February 17, 2007

Billing Medicare Secondary Payor or MSP claims

If your office bills to Medicare a lot you may have run into a situation when a patient calls you and says that Medicare is requesting them to fill out a SCD form. SCD means Secondary Claim Development and it's a questionnaire form Medicare requires the patient to fill out prior to processing YOUR claim.

When or if Medicare receives a claim from the medical office with a primary EOB attached it "flags" them to request this information from the patient if this form is not on file at Medicare.

The issue for the medical billing office is now the claim is on a hold status until Medicare receives the SCD form back from the patient (NO MONEY). To resolve this issue train the front office to have a Medicare Secondary Payor (MSP)form on file and have the patient fill it out prior to treatment. This is only necessary if a patient presents with a second medical insurance card.

Have the front office scan this form into the patients chart files in the medical billing software you use so you will always be able to reference back to it (and not bother the doctors office in the process)

If you received a EOB stating it's pending or you get a call from the patient pull the document up from the patient chart files and rebill your claim with the attached SCD form or call Medicare and identify if you can fax or email it to them. When you return the SCD in a timely manner, you help ensure correct payment of your Medicare claims and that means a happy doctor.

If you have questions or concerns about the MSP form you can call medicare at: 1-800-999-1118 or TTY/TDD: 1-800-318-8782 for the hearing and speech impaired with. Medicare Representatives are available to assist you Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays (don't you wish we got those?).

**As a side note Medicare estimates that they have saved $4.5 billion dollars by using MSP codes.

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Friday, February 2, 2007

Medical Billers be aware: Medicare will not pay Chiropractors if Modifier AT is not billed

Medical Billing for Chiropractic services seems easy enough. So, it came as a surprise to me when a medical billing service I consult for called me:

Jennifer, we are about to lose our new chiropractic provider because we can’t seem to get Medicare to pay out on his claims. We have called Medicare but they won’t help us with coding questions.

My question to them was, “Are you billing with Modifiers?” The response was a panicked, “Do we need to?”

YES!

If you are not familiar to medical billing for chiropractors let’s go over Medicare’s medical billing guidelines.

Chiropractors can bill the following procedure codes:
98940 Chiropractic Manipulation Treatment (CMT); Spinal, one or two regions
98941 Spinal 3-4 regions
98942, Spinal 5 regions

So, I know what you are thinking; what if the patient is treated for carpal tunnel, or knees popping can we bill for that? No, if the chiropractor treats anything outside of the spinal regions Medicare will not pay out on the claim.

Now the modifier gets a bit more interesting –
Modifier AT stands for Active/Corrective treatment and it needs to be billed when using the 3 procedure codes above. If you do not use it you are telling Medicare that this patient is being treated for maintenance therapy and therefore they will not pay.

So, in my example when my client called me saying they were getting denials Medicare wasn’t denying these claims they were sending the EOB to the client letting them know that they do not pay out on maintenance treatments.

How to get payment:
My suggestion would be to attach the modifier AT to each billed claim and rebill the medical HCFA 1500 claims as a corrected claim and request that they acknowledge the attached AT modifier.

**Medicare does not cover chiropractic treatment to extraspinal regions (CPT 98943), which includes the head, upper and lower extremities, rib cage, and abdomen.


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