Friday, August 28, 2015
(AAA) and Screening Fecal-Occult Blood Tests (FOBT) 82270-82274
Provider Types Affected
This MLN Matters Article is intended for physicians, physician assistants, nurse practitioners and clinical nurse specialists submitting claims to Medicare Administrative Contractors (MACs) for ultrasound screening for Abdominal Aortic Aneurysms (AAA) and Screening fecal-occult blood tests (FOBT) ordered for Medicare beneficiaries.
Provider Action Needed
Effective for dates for service on and after January 27, 2014, MACs shall pay claims for ultrasound screening for AAA and screening FOBTs per the modified requirements in 42 CFR 410.19 and 410.37. See the details of the changes in the Background section below. Make sure that your billing staffs are aware of these changes.
Medicare Part B coverage of screening FOBTs and ultrasound screening for AAA is covered for certain beneficiaries that meet eligibility requirements as described in regulations. As part of the CY 2014 Physician Fee Schedule rule, the Centers for Medicare & Medicaid Services (CMS) revised he Medicare Part B coverage requirements for Ultrasound Screening for AAA (42 CFR 410.19) and Screening FOBT (42 CFR 410.37).
As a result of CR8881, the following policy changes are effective for dates of service on and after January 27, 2014:
• Ultrasound Screening for AAA : Coverage of AAA screening is modified by eliminating the one year time limit with respect to the referral for this service. This requiring them to receive a referral as part of the Initial Preventive Physical Examination (IIPE, also commonly known as the "Welcome to Medicare Preventive Visit"). The practitioner, or clinical nurse specialist. All other coverage requirements for this service remain unchanged, per 42 CFR 410.19.
• Screening FOBTS : In addition to the beneficiary's attending physician, the beneficiary's attending physician assistant, nurse practitioner, or clinical nurse specialist may furnish written orders for screening FOBTs, per section 42 CFR 410.37(b). All other coverage requirements for this service remains unchanged, per 42 CFR 410.37
Friday, August 21, 2015
First Coast Service Options Inc. (First Coast) recently conducted data analysis due to the high comprehensive error rate testing (CERT) error rates for evaluation and management services pertaining to Current Procedural Terminology®(CPT®) codes 99223(initial hospital visit) and 99233(subsequent hospital visit). The CERT November 2014 forecasting report indicates a projected error rate of 39.8 percent for CPT®code 99223 and a projected error rate of 34.4 perc for CPT®code 99233. The data indicates that the specialty of internal medicine is the primary contributor to the CERT error rate: internal medicine error rates are currently trending at 36.6 percent for CPT®code 99233 and 33.3 percent for CPT®code 99223.
The American Medical Association (AMA) CPT®manual defines code 99223as follows:
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:
A comprehensive history;
A comprehensive examination; and
Medical decision making of high complexity
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the problem(s) requiring an admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient’s hospital unit.
The AMA CPT®manual defines code 99233 as follows:
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:
A detailed interval history ;
A detailed examination;
Medical decision making of high complexity
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family needs.
Usually, the patient is unstable or has developed a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital unit.
First Coast and the Centers for Medicare & Medicaid Service (CMS) offer multiple resources addressing the documentation guidelines for E/M service levels at:
First Coast’s Evaluation and Management (E/M) services page, offering links to tools, FAQs, online learning, and additional resources.
CMS Internet-only manual (IOM) guidelines addressing multiple types and settings pertaining to E/M services.
First Coast actions
In response to the high percentage of error rates and the continual risks of improper payments associated with hospital care visits billed by internal medicine specialists, First Coast will be implementing a prepayment medical review audit for CPT®codes 99223 and 99233 billed by internal medicine specialty. The new audit will be based on a predetermined percentage of claims in an effort to reduce the error rates for these hospital services. The audit will be implemented effective October 21, 2014.
Friday, August 14, 2015
The Centers for Medicare & Medicaid Services (CMS) finalized new rules which require physicians and, when applicable, other eligible professionals who write prescriptions for Part D drugs to be enrolled in an approved status or to have a valid opt-out affidavit on file for their prescriptions to covered under Medicare Part D.
According to CMS, prescribers of Part D drugs must submit their Medicare enrollment applications or opt-out affidavits to their Medicare administrative contractors (MAC) by June 1, 2015, to ensure that MACs have sufficient time to process the applications or affidavits.
Medicare patients’ prescription drug claims will be denied by their Part D plans, beginning December 1, 2015, if the prescriber does not have a valid enrollment or opt-out status with Medicare.
Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) finalized CMS-4159-F “Medicare
Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and
the Medicare Prescription Drug Benefit Programs” on May 23, 2014. This rule requires
physicians and, when applicable, other eligible professionals who write prescriptions for
Part D drugs to be enrolled in an approved status or to have a valid opt-out affidavit on file
for their prescriptions to be covered under Part D. The final regulation stated that the effective date for this requirement would be June 1, 2015. However, CMS is announcing that it will delay enforcement of the requirements in 42 CFR 423.120(c)(6)until December 1, 2015. Nevertheless, prescribers of Part D drugs must submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by June 1, 2015, or earlier, to ensure that MACs have sufficient time to process the applications or opt out affidavits and avoid their patients’ prescription drug claims from being denied by their Part D plans, beginning December 1, 2015. Note that enrollment functions for physicians and other prescribers are handled by Part B MACs.
If you write prescriptions for covered Part D drugs and you are not enrolled in Medicare in
an approved status or have a valid record of opting out, you need to submit an enrollment
application or an opt out affidavit to your Medicare Administrative Contractor (MAC) by
June 1, 2015, or earlier. You may submit your enrollment application electronically using the Internet
-based Provider Enrollment, Chain, and Ownership System (PECOS) located at https://pecos.cms.hhs.gov/pecos/login.do or by completing the paper CMS-855I or CMS-855O application, which is available at http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-
Forms-List.html on the CMS website. Note that an application fee is not required as part of your application submission. If you wish to enroll to be reimbursed for the covered services furnished to Medicare beneficiaries, you must complete the CMS-855I application. The CMS-855O, which is a
shorter, abbreviated form, should only be completed if you are seeking to enroll solely to order and refer and/or prescribe Part D drugs. (While the CMS-855O form states it is for physicians and non-
physician practitioners who want to order and refer, it is appropriate for use by prescribers, who also want to enroll to prescribe Part D drugs.) If you do not see your specialty listed on either of the applications, select the Undefined Physician/Non-Physician Type option and identify your specialty in the space provided.
If you are a physician or eligible professional who wants to opt out of Medicare, you must submit an opt-out affidavit to the MAC within your specific jurisdiction. Your opt-out information must be current (an affidavit must be completed every 2 years, and a National Provider Identifier (NPI)
is required to be submitted on the affidavit). For more information on the opt-out process, refer to
MLN Matters® article SE1311, titled “Opting out of Medicare and/or Electing to Order and Refer Services,” which is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/downloads/SE1311.pdf on the CMS website.
In an effort to prepare the prescribers and Part D sponsors for the December 1, 2015 enforcement date, CMS is making available an enrollment file that identifies physician and eligible professional who are enrolled in Medicare in an approved or opt out status. The first iteration of the enrollment file is now available at https://data.cms.gov/dataset/Medicare-Individual-Provider-List/u8u9-2upx on the CMS website. The file contains production data but is considered a test file since the Part D prescriber enrollment requirement is not yet applicable. An updated enrollment file will be generated every two weeks and continue through the December 1, 2015 enforcement date. The file displays physician and eligible professional eligibility as of and after November 1, 2014,(i.e., currently enrolled, new approvals, or changes from opt-out to enrolled as of November 1, 2014). Any periods, prior to November 1, 2014, for which a physician or eligible professional was not enrolled in an approved or opt-out status will not be displayed on the enrollment file. However, any periods after November 1, 2014, for which a physician or eligible professional was not enrolled in an approved or opt-out status will be on the file with its respective end dates for that given provider. For opted out providers, the opt out flag will display a Y/N (Yes/No) value to indicate the periods the provider was opted out of Medicare. The file will include the provider’s:
• First and Last Names;
• Effective and End Dates; and
• Opt Out Flag
After the enforcement date of December 1, 2015, the applicable effective dates on the file
will be adjusted to December 1, 2015, and it will no longer be considered a test file. All
inactive periods prior to December 1, 2015, will be removed from the file and it will only
contain active and inactive enrollment or opt out periods as of December 1, 2015, and after.
The file will continue to be generated every two weeks, with a purposeful goal toward more
frequent updates on a set schedule. Part D sponsors may utilize the file to determine a
prescriber’s Medicare enrollment or opt out status when processing Part D pharmacy claims.
The file will not validate the provider’s ability to prescribe under applicable laws.
Thursday, August 6, 2015
The Provider Enrollment, Chain, and Ownership System (PECOS) allow the contractor to verify all national provider identifiers (NPIs), regardless of the jurisdiction in which they are enrolled.
Beginning April 1, 2015, physicians and suppliers billing anti-markup and reference laboratory claims must report the national provider identifier (NPI) of the physician or supplier who actually performed the service. This new requirement applies to all claims, including claims for services where the performing provider is out of the processing contractor's jurisdiction.
This article is based on Change Request (CR) 8806, which provides guidance for physicians and suppliers billing anti-markup and reference laboratory claims. Effective for anti-markup and reference laboratory claims submitted with a receipt date on and after April 1, 2015, billing physicians and suppliers are required to report the name, address, ZIP code, and the National Provider Identifier (NPI) of the performing physician or supplier when the performing physician or supplier is enrolled in a different contractor's jurisdiction. Make sure your billing staffs are aware of this update.
The Health Insurance Portability and Accountability Act of 1996 (HIPPA) requires that all covered health care entities follow the same standard for submitting and processing electronic claims transactions. According to the instructions for use of the American National Standards Institute (ANSI) X12 837 professional electronic claim transaction, suppliers must submit the NPI that matches the name and address of the servicing provider/supplier identified on the claim.
On anti-markup and reference laboratory claims, physicians and other suppliers are required to identify the supplier's name, address, and ZIP code in Item 32 of the CMS-1500 claim, or the corresponding loop and segment of the ANSI X12 837 professional electronic claim format. The NPI of the physician or supplier who actually performed the service is required in Item 32a of the CMS-1500 claim form or the corresponding loop and segment of the ANSI X12 837 professional electronic claim transaction.
However, prior to the implementation of the Provider Enrollment, Chain, and Ownership System (PECOS), MACs used systems that were specific to each MAC and did not allow MACs from one State to view provider enrollment information from another State. This systems limitation prevented MACs from being able to share information about existing providers/suppliers, and increased the potential for fraud. As a result, physicians and suppliers that were enrolled in another MAC's jurisdiction could not validate the NPI in Item 32a of the CMS-1500 claim form or on the ANSI X12 837 professional electronic claim format, because the function was not available in PECOS.
Since the NPI of the physician/supplier that actually performed the test may not be available to the billing physician or supplier, the "Medicare Claims Processing Manual" currently instructs physicians and suppliers to submit their own NPI with the name and address of the actual performing physician or supplier in Item 32a (and its electronic equivalent) when billing for reference laboratory services, or services subject anti-markup, when the performing physician or supplier is enrolled in another contractor's jurisdiction.
Effective April 1, 2015, changes to PECOS will allow MACs the ability to verify all physician and supplier NPIs, regardless of the jurisdiction in which they are enrolled. Therefore, beginning with claims received on or after April 1, 2015, physician and suppliers billing anti-markup and reference laboratory claims must report the NPI of the physician or supplier who actually performed the service in Item 32a of the CMS-1500 claim form or the corresponding loop and segment of the American National Standards Institute (ANSI) X12 837 professional electronic claim format. This new requirement applies to all claims, including claims for services where the performing physician/supplier is out of the processing MAC's jurisdiction.
Anti-mark up claims will be identified by the presence of the "Yes" indicator in ITme 20 of th eCMS-1500 or its electronic equivalent. Reference laboratory claims will be identified by the presence of 90 on any service line.
MACs will return as unprocessable a claim:
• Where the NPI in Item 32a (or its electronic equivalent) does not belong to the entity whose name and address are identified in Item 32 (or its electronic equivalent)
• For a reference laboratory or anti-markup service that is performed outside the MAC's billing jurisdiction when submitted without the name, address, and ZIP code of the performing physician/supplier in Item 32, and the NPI of the performing physician/supplier in Item 32a of the CMS-1500 claim form, or on the ANSI X12 837 professional electronic claim format, in the appropriate loops/segments
• For a reference laboratory or anti-markup service performed outside the contractor's billing jurisdiction when the NPI in Item 32A (or its electronic equivalent) does not match the name and address of a valid servicing physician/supplier identified on the existing table in PECOS.
MACs use the following codes for claims returned as unprocessable:
• Claim Adjustment Reason Code (CARC) 16-Claim/service lacks information which is needed for adjudication.
• For reference lab claims, Remittance Advice Remarks Code (RARC) N270 - Missing/incomplete/invalid other provider primary identifier.
• For anti-markup claims, RARS N283- Missing/incomplete/invalid purchased service provider identifier.
• Group Code : Contractual Obligation (CO).
Friday, July 31, 2015
CMS has posted a complete list of the 2016 ICD-10-CM valid codes and code titles on the 2016 ICD-10-CM and GEMs web page
. The file is named icd10cm_codes_2016.txt. This file will be useful for physician offices and other providers who want to check to make sure that they are reporting all characters in a valid ICD-10-CM code. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure if additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.
A similar list of the 2016 ICD-10-PCS valid codes and code titles is available on the 2016 ICD-10 PCS and GEMs web page. The file is named icd10pcs_codes_2016.txt.
Use of Unspecified Codes in ICD-10-CM
CMS has a number of resources that explain unspecified codes and how they should be used in ICD-10-CM:
• MLN Matters® Article SE1518, “Information and Resources for Submitting Correct ICD-10 Codes to Medicare”
• ICD-10 Basics MLN Connects National Provider Call - Call Materials from August 22, 2013
•More ICD-10 Coding Basics MLN Connects Call - Call Materials from June 4, 2014
• ICD-10 Coding Basics MLN Connects Video - January 2014
• Coding for ICD-10-CM: More of the Basics MLN Connects Video - December 2014 Visit the ICD-10 Medicare Fee-For-Service Provider Resources web page for a complete list of Medicare Learning Network educational materials
Thursday, July 30, 2015
Implement Operating Rules - Phase III ERA EFT: CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) Rule - Update from CAQH CORE
Provider Types Affected
This MLN Matters Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice
(HH&H) MACs and Durable Medical Equipment MACs (DME MACs) for services to Medicare Beneficiaries.
Provider Action Needed
Change Request (CR) 8983 deals with regular update in Council for Affordable Quality Healthcare (CA QH) Committee on Operating Rules for Information Exchange (CORE) defined code combinations per Operating Rule 360 - Uniform Use of CARCs and RARCs (835) Rule. CAQH CORE will publish the next version of the Code Combination List on or about February 1, 2015, and CR8983 instructs the MACs to use that list as of April 1, 2015. This update is based on November 1, 2014, CARC and RARC updates as posted at the Washington Publishing Company (WPC) website.
The Department of Health and Human Services (HHS) adopted the Phase III CAQH CORE Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Operating Rule Set that must be implemented by January 1, 2014, under the Affordable Care Act. The
Health Insurance Portability and Accountability Act (HIPPA) amended the Social Security Act by adding Part C-Administrative Simplification - to Title XI of the Act, requiring the Secretary of the Department of HHS (the Secretary) to adopt standards for certain transactions to enable health information to be exchanged more efficiently and to achieve greater uniformity in the transmission of health information.
Through the Affordable Care Act, Congress sought to promote implementation of electronic transactions and achieve cost reduction and efficiency improvements by creating more uniformity in the implementation of standard transactions. This was done by mandating the adoption of a set of operating rules for each of the HIPAA transactions. The Affordable Care Act defines operating rules and specifies the role of operating rules in relation to the standards.
Note: Per Affordable Care Act mandate, all health plans, including Medicare, must comply with CORE 360 Uniform Use of CARCs and RARCs (835) rule or CORE developed maximum set of CARC/RARC/Group Code for a minimum set of four Business Scenarios. Medicare can use any code combination if the business scenario is not one of the four CORE defined Business Scenarios but for the four CORE defined business scenarios, Medicare must use the code combinations from the lists published by CAQH CORE.
Wednesday, July 22, 2015
When the physician who furnishes the surgery also furnishes the following services, Medicare includes them in the global surgery payment:
•Pre-operative visits after the decision is made to operate. For major procedures, this includes pre-
operative visits the day before the day of surgery. For minor procedures, this includes pre-operative
visits the day of surgery;
•Intra-operative services that are normally a usual and necessary part of a surgical procedure;
• All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room;
• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery;
• Post-surgical pain management by the surgeon;
• Supplies, except for those identified as exclusions: and
• Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
What services are not included in the global surgery payment?
The following services are not included in the global surgical payment. These services may be billed and paid for separately:
• Initial consultation or evaluation of the problem by the surgeon to determine the need for major
surgeries. This is billed separately using the modifier -57 (Decision for Surgery). This visit may be billed separately only for major surgical procedures:
Note: The initial evaluation for minor surgical procedures and endoscopies is always included
in the global surgery package. Visits by the same physician on the same day as a minor surgery or
endoscopy are included in the global package, unless a significant, separately identifiable service
is also performed. Modifier -25 is used to bill a separately identifiable evaluation and management
(E/M) service by the same physician on the same day of the procedure.
• Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications;
Note: A new post-operative period begins with the subsequent procedure. This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure.
• Treatment for post-operative complications requiring a return trip to the Operating Room (OR).
An OR, for this purpose, is defined as a place of service specifically equipped and staffed for
the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a
laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room,
a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would
be insufficient time for transportation to an OR);
• If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;
•Immunosuppressive therapy for organ transplants; and
• Critical care services (Current Procedural Terminology (CPT) codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
How are minor procedures and endoscopies handled?
Minor procedures and endoscopies have post-operative periods of 10 days or zero days (indicated by 010 or 000, respectively). For 10-day post-operative period procedures, Medicare does not allow separate payment for post-operative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major
surgery on the same day or in the 10-day period, the major surgery is payable separately. Services by other physicians are generally not included in the global fee for minor procedures.
For zero day post-operative period procedures, post-operative visits beyond the day of the procedure are not included in the payment amount for the surgery. Post-operative visits are separately billable and payable.
Friday, July 10, 2015
This fact sheet is designed to provide education on the components of a global surgery package. It includes information about billing and payment rules for surgeries, endoscopies, and global surgical packages that are split between two or more physicians. Medicare established a national definition of a global surgical package to ensure that Medicare contractors make payments for the same services consistently across all Medicare contractor (Medicare Administrative Contractor (MAC)) jurisdictions.
This policy helps prevent Medicare payments for services that are more or less comprehensive than
intended. In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, co-surgeons, and team surgeries. The information that follows describes the components of a global surgical package and billing and payment rules for surgeries, endoscopies, and global surgical packages that are split between two or more physicians.
The global surgical package, also called global surgery, includes all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical procedure includes the pre-operative, intra-operative and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.
Frequently Asked Questions:
Is the global surgery payment restricted to hospital inpatient settings?
Global surgery applies in any setting, including an inpatient hospital, outpatient hospital, Ambulatory
Surgical Center (ASC), and physician’s office. When a surgeon visits a patient in an intensive care or critical care unit, Medicare includes these visits in the global surgical package.
How is Global Surgery classified?
There are three types of global surgical packages based on the number of post-operative days.
Zero Day Post-operative Period , (endoscopies and some minor procedures).
•No pre-operative period
•No post-operative days
•Visit on day of procedure is generally not payable as a separate service
10-day Post-operative Period , (other minor procedures).
•No pre-operative period
•Visit on day of the procedure is generally not payable as a separate service
•Total global period is 11 days. Count the day of the surgery and 10 days following the day of the
surgery 90-day Post-operative Period(major procedures)
•One day pre-operative included
•Day of the procedure is generally not payable as a separate service
•Total global period is 92 days. Count 1 day before the day of the surgery, the day of surgery, and the
90 days immediately following the day of surgery
Where can I find the post-operative periods for covered surgical procedures?
The Medicare Physician Fee Schedule (MPFS) look-up tool provides information on each procedure code, including the global surgery indicator
The payment rules for global surgical packages apply to procedure codes with global surgery
indicators of 000, 010, 090, and, sometimes, YYY.
•Codes with “000” are endoscopies or some minor surgical procedures (zero day post-operative period).
•Codes with “010” are other minor procedures (10-day post-operative period).
•Codes with “090” are major surgeries (90-day post-operative period).
•Codes with “YYY” are contractor-priced codes, for which contractors determine the global period. The global period for these codes will be 0, 10, or 90 days. Note:not all contractor-priced codes have a “YYY” global surgical indicator. Sometimes the global period is specified as 000, 010, or 090.
While codes with “ZZZ” are surgical codes, they are add-on codes that you must bill with another service.
There is no post-operative work included in the MPFS payment for the “ZZZ” codes. Payment is made for both the primary and the add-on codes, and the global period assigned is applied to the primary code.
Sunday, July 5, 2015
Versions 5010 and D.0 This website contains background, regulatory, educational, and implementation information.
Versions 5010 and D.0 This website contains background, regulatory, educational, and implementation information.
Medicare Fee-for-Service (FFS) 5010 – D.0 Health Insurance Portability and Accountability Act (HIPAA) EDI standards, comparisons, and the Medicare FFS Companion Guide (coming soon) are available on this website.
Transaction and Code Sets Standards Electronic transaction and code sets standards and information can be downloaded from this website.
Electronic Billing & EDI Transactions Help Lines Part A and B EDI Help lines are available on this website.
HIPAA Eligibility Transaction System (HETS) Help (270/271) The HETS Help website is available to provide technical system support to CMS business partners
The Accredited Standards Committee (ASC) An online website for ASC X12 Implementation Guides and resources.
ASC X12 Interpretations Portal This portal provides access to information about existing versions of ASC X12N Implementation Guides and ASC X12 Technical Report Type 3 (TR3)
Friday, June 26, 2015
• Abdominal Aortic Aneurysm Screening
• Alcohol Misuse Screening and Behavioral counseling Intervention in Primary Care
• Annual Wellness Visit (Including Personalized Prevention Plan Services)
• Bone Mass Measurements
• Cancer Screenings
• Breast Cancer (mammograms and clinical breast exam)
• Cervical and Vaginal Cancer (pap test and pelvic exam [includes the clinical breast exam])
• Colorectal Cancer
o Fecal Occult Blood Test
o Flexible Sigmoidoscopy
o Barium Enema
• Prostate (PSA blood test and Digital Rectal Exam)
• Cardiovascular Disease Screening
• Depression Screening in Adults
• Diabetes Screening
• Diabetes Self-Management Training
• Glaucoma Screening
• Hepatitis C Screening
• Human Immunodeficiency Virus (HIV) Screening
• Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)
• Initial Preventive Physical Examination (IPPE) (also commonly referred to as the “Welcome to Medicare” Preventive Visit)
• Intensive Behavioral Therapy for Cardiovascular Disease
• Intensive Behavioral Therapy for Obesity
• Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease)
• Sexually Transmitted Infections (STIs) Screening and High-Intensity Behavioral Counseling (HIBC) to prevent STIs
• Tobacco-Use Cessation Counseling
As a result of the Affordable Care Act, Medicare now covers many of these services without cost to patients, including the Annual Wellness Visit that was created under the Affordable Care Act.
What is the overall Billing process?
The physician doesn’t get paid for his services immediately after they are rendered. Majority of the patients have insurance coverage and details of such coverage are provided to the physician before treatment. It is the responsibility of the physician to submit claims to the insurance company and get paid for his services. Submitting Claims and getting paid is a lengthy process and involves a lot of rules and regulatory systems and is very complicated. The physician needs to adhere to all these rules before submitting claims. This is the concept of Medical Billing. Sometimes the physician cannot provide his entire attention to this activity. He entrusts this activity to Billing Companies. This is a process of the physician providing rights to Billing Companies to bill Medical Insurance claims in order to save his time energy, and money.
After the provider renders services to the patient, the billing company will submit bills to the insurance company/ payer, using the insurance information that was last provided, as well as information about the reason for the examination, and the exact type of procedure performed.
Medical coding is the process of converting Medical terms to numeric code and it required Medical knowledge skills.
Medical billing is the process of submitting the claims and get paid behalf of provider.I have listed the important process in Medical Billing. Each process is very important.
1. Insurance verification.
2. Demo and Charge entry process.
3. Claim submission.
4. Payment posting.
5. Action on denials or Denial management or Account receivables.
Process started from here and usually front desk people are doing this process. Its a process of verifying the patients insurance details by calling insurance or through online verification. If this department works well, we could resolve more problem. We have to do this even before patient appointment.
Demo and Charge entry process
Demographic entry is nothing but capturing all the information of patients. It should be error free.
Charge-entry is one of the key departments in Medical Billing. Key department?? Yes, that's true. It is the keying-in department in Medical Billing. After receiving the super bills from the Doctor's office, it gets passed through the coding department, and then comes to the charge-entry department.
A Charge-entry person also has one other vital role to perform. That is, to look-up the codes entered in the claim, and to assign the relevant charges for those codes.
Claim submission Process
The next step after demographics and charge entry is claim generation. Claims may be paper claims or electronic claims. There are various types of forms for paper claims. The most widely used form is Health Care Finance Admin-1500 designed by the Health Care Financing Administration.
Electronic transmission of claims is the modern way of sending claims with less paper work. The most common means of transmission are through internet . The claim information is directly loaded into the insurance company's computer system or to the clearing house.
Payment Posting Process
Once the claims reach the carriers and they complete processing, they issue a check and prepare an Explanation of Benefits . The checks and the Explanation of Benefits would be sent to the pay-to address with the carrier or in the Health Care Finance Administrators.
In this processing we have accounted the money into the account as per the Explanation of Benefits. Now a days we are using Electronic payment posting also.
Action on denials or Denial management or Account Receivables
This is a most important function in the process flow of data. Unless this is taken care of, insurance balance will only be on an upward trend.
Problem in Medical Billing
•Inaccurate or lack of coding
• Incomplete claims
• Lack of supporting documentation
• Poor communication with the payer
• Not billing for services rendered
* Not being follow up AR balance claims
The person who is doing this process will be called Medical billing specialist.
Who is Medical Billing Specialist.
Medical billing Specialist is the one who is handling the below process and having well knowledge in each and every process.
* Insurance verification process
* Patient demographic and charge entry process.
* Submitting the claims by electronic as well as paper method. Tracking various claim submission report.
* Payments posting process for insurance as well as patient.
* Denial management.
* Insurance followup management.
* Insurance appeal process.
* Handling patient billing inquiries.
* Patient statement process.
* Preparing monthly reports such as revenue report and account receivable report and as per the provider requirement.
Medical Billing Specialists are in charge of reviewing patient charts and documents. They prepare and review all medical insurance claims based on the rules and regulations of insurance companies. Medical Billing Specialists also review insurance communications, payment and rejection notices to properly track all claims and payments.
Medical Billing specialist Professional
If a person is computer literate he is a fit enough candidate to take up the profession of medical billing and medical coding. However he will need to be trained and be aware of a lot of new information before he can start working effectively. He has to learn about the medical billing software and must be familiar with and master the various commands used while working with it.
Who are medical coders and how is it related to medical billing? Medical billing is a sub specialty of medical coding. Medical coding is the first step in the billing process. All patient records are maintained using the ICD-9 index system so that it is compliant with the federal rules.
A medical Biller’s most important skill includes filling up of the various medical forms correctly without any mistakes what so ever. All information required should be complete without any mistake at all. And the work will be include the following
Patient demographic entry
Billing and reconciling of accounts
Scheduling and rescheduling
Account receivable follow-ups and collections
Is it worth taking a medical billing program?
Usually don't spend too much cost on Medical billing program because the program will not do anything with real experience. What you learn from these kind of program will not be going to match with when you are working in the real environment. Hence just use as the start kind of program and get the real time experience even in small salary and later you can come up with more demanding one.
Problem of In House Processing of Medical Claims
Medical claims are generally very complex and have long extended details. While processing medical claims, one has to be highly critical and do efficient follow-up in order to get results. The process requires a lot of time and effort. And even after all this, there can be cases where files get lost or a small error can ruin the entire lot and everything has to be re-submitted again. Usually practice staff can be held up with lot of current work rather than submitting the claim and resubmitting the corrected claim hence it will lead to time delay on payment flow and it will affect all the relationship with in the practice. Even cost wise is also not effective when compare to outsourcing.
Advantage of Medical Billing Outsource
Medical Billing Company helps you in managing all your billing requirements proficiently. By choosing right medical billing company, you can get benefit such as improved financial strength.
Medical Billing task is very tedious and time consuming. However, billing must require more accuracy and special attention to strengthen the financial condition of clinical or hospital. You can do this task at own or assign to clinical staff but you have to be pleased with low patients satisfaction. Medical billing company can help you in supportive task. By efficient medical service, you will get highly satisfied patients.
A Medical Billing service can improve the efficiency of your billing system, reduce denials, cut down operating costs, boost reimbursements and save valuable time that can be devoted to patient care. These services are better equipped to adapt to continuously changing billing codes and industry requirements.
* Prince is low compare to doing it in house
* Dedicated Highly Skilled Professionals
* No need to maintain the hardware . Ability to perform Medical Billing remotely, using the software of your choice
* Usually Maximum reimbursements and fewer denials
* Accuracy is high when compare
* Faster transaction
Question need to ask when Medical Billing Outsourcing
1. Check with their referral and how long they are doing this business.
2. Are they HIPAA compliance
3. Where they are doing their work. If possible just visit there.
4. Data security.
5. Compare the price with others.
6. what are the reports they will provide
7. Your specialty wise question
8. Their software skills.
Services and process involved in Medical Billing
* Coding ( CPT, ICD-9, and HCPCS)
* Patient Demographics Entry
* Charge Entry – All specialties
* Payment Posting (Manual and Electronic)
* Payment Reconciliation
* Denials/rejections analysis, re-billing
* Accounts Receivable Follow-up
* Systemic A/R projects, re-billing
* Collection Agency Reporting
Medical Billing Salary Range
Depending on the education qualification, the hourly rate varies from $12-$15. Another most important factor that affects billing pay is how long someone has worked in the field. Medical specialist with experience of 1 year earns around $12 per hour. Those who have more experience in billing earn up to $16 per hour. However, the geographic location also plays a role in pay scale. For instance, areas where cost of living is high, the pay will be more. Billers who work in New York City, Houston, Chicago and California are able to pull a good amount of salary. Work locations such as hospital, billing company or private practice will also affect the salary. Since there are lots of factors which affect the salary of billing, it is really not easy to predict the pay scale. Studies have shown that 50% of people earned around $35,000-$45,000 annually.
Most of the medical Billers are paid hourly, rather than annually. While Biller who is experienced can earn around $40,000 a year as an independent contractor working from home, a billing and coding specialist who runs his own firm can earn $100,000 a year. However, people who are searching for home based job should be very careful. There is lots of fraud going on in this field. These spammers charge hundred to thousand dollars and in exchange they claim they will help to get a placement in billing. They also promise that medical billing job can earn a substantial amount of money and no experience required. But in reality, those who paid to get a job end up with no job, no money. Billing is a very competitive field, so without experience or training in medical billing field, it is almost impossible to get a job.
Selecting Medical Billing Software - 10 things to consider
1. The first step is to evaluate your needs. And when evaluating different systems look for a package that goes one step ahead of billing. Choose a medical practice management system MPP. This will handle considerably more that just medical billing.
2. Determine whether the system handles electronic transmission of claims, direct billing for patients, co-pays, co-insurance, and expenses not covered by insurance.
3. Weigh the pros and cons of different medical billing systems and ask to see a system in operations. Always check out the references yourself.
4. Look for a medical billing management system that is user friendly. When a vendor demonstrates get your office staff to be present. This way you will be able to check how the software functions. Any software must be easy to use to be productive. The system should be fool proof.
5. Ask whether the medical billing software is a traditional system, one that will work on your office computers or an application service provider system (ASP), one that will process data at the software company’s data center.
6. Always get quotes from at least three medical billing software providers.
7. Ask whether they are offering an evaluation period or trial. This will enable you to know in actuality whether the system works or not.
8. Find out about training your office people, up-gradation of system, and whether the software is compatible with your office computer systems
.9. Find out whether the system will handle appointment scheduling, maintenance of records and so on apart from electronic medical records, SOAP notes, and billing. Choose a system that is comprehensive.
10. An ideal Medical Billing software system must include aspects like payment posting, reconciliation; follow up, secondary submission, and patient billing.Choose a transparent billing system that enhances your office efficiency. Install a system that you can use not one that will lead to frustration and problems.Medical billing systems must free your time and that of your office staff not make you run in circles. Choose a system with care.
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