Wednesday, July 22, 2015

Global Surgery General Information part 2

What services are included in the global surgery payment?

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

Global Surgery General Information part 1

Definition of a Global Surgical Package

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.

Friday, June 26, 2015

List of Preventive Services and Screenings Covered by Medicare

•    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    Colonoscopy
                 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.

Thursday, June 18, 2015

How to avoid denial CO/PR B7 CO 97 Remark Code - M15, M144

Denial reason code CO/PR B7

We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take to avoid this denial?
Provider was not certified/eligible to be paid for this procedure/service on this date of service.

You received this denial, because the date of service on the claim is prior to the provider’s Medicare effective date, or after his/her termination date, or because you are billing for a procedure code beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or the laboratory service is missing a required modifier.
Submit claims for services rendered when the provider had active Medicare billing privileges.

Review the Medicare Remittance Advice (RA), and verify the date of service.
• If the date of service is not correct, follow procedures for correcting claim errors.
• If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.
• View enrollment information through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and confirm provider’s Medicare effective date.
Note: The effective date can be retroactive, 30 days from receipt of application, or for a future date of up to 60 days after receipt of application.
• If you require additional assistance, you may contact Provider Enrollment.
Submit claims for laboratory services within the scope of the provider’s CLIA certification.
• Verify service/procedure code is listed as approved under the scope of the provider’s certification.
• Refer to the complete list of downloads of Categorization of Tests on the Centers for Medicare & Medicaid Services (CMS) website.
• Refer to the List of Waived Tests from the CMS website to determine which codes require the modifier QW (CLIA waived tests).
• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.
Make the necessary correction(s), and resubmit the claim. Submit the corrected line only. Resubmitting the entire claim will cause a duplicate claim denial.
Or, if applicable, request a telephone reopening. Note: The First Coast Service Options Part B interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.

Denial reason code CO 97 

We received a denial with claim adjustment reason code (CARC) CO 97. What steps can we take to avoid this denial?

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

A: There are a few scenarios that exist for this denial reason code, as outlined below. Please review the associated remittance advice remark codes (RARCs) noted on the remittance advice and then refer to the specific resources/tips outlined below, as applicable, to avoid this denial.

M15 – Separately billed services/tests have been bundled as they are considered components of that same procedure. Separate payment is not allowed.
• The service billed was already paid as part of another service/procedure for the same date of service. Payment for this service is always bundled into payment for other service(s) not specified. Separate payment is never made.

An example of a “bundled service” is a telephone call from a hospital nurse regarding a patient. Another example is procedure code A4550, surgical tray.
• Check the procedure code.

M144 – Pre/post-operative care payment is included in the allowance for the surgery provided.
• The cost of care before and after the surgery or procedure is included in the approved amount for that service. Evaluation and management (E/M) services related to the surgery, and conducted during the post-op period of a surgery, are considered not separately payable.
• If billing for split care, coordinate split-care billing activities with other provider(s) involved in the patient’s care, and ensure the surgical code is billed before the services for post-operative care are billed.
• If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim. Submit corrected line(s) only. Resubmitting the entire claim will cause a duplicate claim denial.
• Modifier 54: pre-and intra-operative services performed
• Modifier 55: post-operative management services only
• Modifier 56: pre-operative services only

N70 – Consolidated billing and payment applies.
• The claim dates of service fall within the patient’s home health episode’s start and end dates. Before providing services to a Medicare beneficiary, determine if a home health episode exists.
• Ask the beneficiary (or his/her authorized representative) if he/she is presently receiving home health services under a home health plan of care.
• Always check beneficiary eligibility prior to submitting claims to Medicare.
• The services billed are subject to consolidated billing requirements by the Home Health Agency (HHA), while the beneficiary is under a home health plan of care authorized by a physician. The HHA is responsible for providing these services, either directly or under arrangement.

Monday, June 8, 2015

Face-to-Face Encounters and Certification for Home Health Care and Physician Documentation Requirements

Physician play a key role in documenting eligibility and medical necessity for home health care for Medicare beneficiaries. If you certify the need for home health care for any of your patients, we encourage you to review this article carefully. As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face (FTF) encounters with your patients regarding home health care and certification of need. Medicare provides payment for physician initial and re-certification of Medicare-covered home health services under a home health plan of care (G0180 and G0179).

Background: Qualifying Criteria for the Medicare Home Health Benefit
To qualify for the Medicare home health benefit, under section 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act, Medicare beneficiaries must meet all of the following requirements:
•    Be confined to the home;
•    Under the care of a physician;
•    Receiving services under a plan of care established and periodically reviewed by a physician;
•    Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or
•    Have a continuing need for occupational therapy.
The Centers for Medicare & Medicaid Services (CMS) further defines “intermittent,” for purposes of this benefit, as “skilled nursing or home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and fewer than 35 hours per week).” CMS also defines home confinement; we strongly encourage you to review the definition of home confinement in its entirety in the CMS Medicare Benefit Policy Manual (the web address to access this manual is provided at the end of this letter).

Major Documentation Errors
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a nationwide, significant, and continuing increase in denials related to documentation for the FTF.  The most common error is insufficient documentation of clinical findings by the physician/non-physician practitioner (NPP) to show:
•    The encounter was related to the primary reason for home care
•    How the patient’s condition supports the patient’s homebound status; or
•    How the patient’s condition supports the need for skilled services
Acceptable FTF documentation does not have to be lengthy or overly detailed.  However, the FTF documentation must show the reason skilled service is necessary for the treatment of the patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound.
Following are examples of FTF documentation that, used alone, are considered insufficient documentation.
Homebound Status    Need for Skilled Services
“Functional decline”    “Family is asking for help”
“Dementia” or “confusion”    “Continues to have problems”
“Difficult to travel to doctor’s office”    List of tasks for nurse to do
“Unable to leave home”/ “Unable to drive    “Patient unable to do wound care”
“Weak”    “Diabetes”
“Status post total hip”   
Examples of appropriate documentation include:
•    “Wound care to left great toe. No s/s of infection, but patient remains at risk due to diabetic status.  Skilled nurse visits to perform wound care and assess wound status.  Patient on bed to chair activities only.”
•    “Lung sounds coarse throughout. Patient finished antibiotic therapy today for pneumonia, and to see pulmonologist tomorrow for follow up due to COPD and emphysema.  Short of breath with talking and ambulation of 1-2 feet.  Nurse to assess respiratory status for s/s of recurring infection/ changes in respiratory status.”
•    “CHF, CLL, weakness, 3+ edema in R & L legs; needs cardiac assessment, monitoring of signs & symptoms of disease, and patient education; homebound due to shortness of breath with minimal exertion, e.g., walking 5 feet.”
•    “Status post right total hip replacement. Needs physical therapy to restore ability to walk without assistance. Homebound temporarily due to requiring a walker, inability to negotiate uneven surfaces and stairs, inability to walk greater than 5 - 10 feet before needing to rest. ”
In all cases, your documentation must be specific to that patient’s condition at the time of your encounter with him or her.

Who May Document the FTF Encounter?
The FTF encounter must be performed by the certifying physician, a physician who cared for the patient in an acute or post-acute facility during a recent acute or post-acute stay and has privileges at the facility, or a qualified nonphysician practitioner (NPP) working in conjunction with the certifying physician.  An NPP in an acute or post-acute facility is able to perform the FTF encounter in collaboration with or under the supervision of the physician who has privileges and cared for the patient in the acute or post-acute facility.  That NPP can then report the FTF encounter to the certifying physician.

Medicare guidelines also contain specific documentation requirements

The certifying physician must document that the FTF visit took place, regardless of who performed the encounter.

If the FTF encounter was not performed by the certifying physician, the NPP or physician who cared for the patient and performed the FTF must provide the face-to-face record of the FTF encounter to the certifying physician.  NPPs performing the FTF encounter in an acute/post-acute facility must inform the physician they are collaborating with, or under the supervision of, so that the physician can inform the certifying physician of the clinical findings of the FTF.

The certifying physician cannot merely co-sign the encounter documentation if performed by an NPP.  He or she must complete/sign the form or a staff member from his or her office may complete the form from the physician’s encounter notes, which the certifying physician would then sign.
The FTF encounter documentation must be clearly titled, dated, and signed by the certifying physician before the home health agency submits a claim to Medicare and must include:
The date of the FTF encounter, and

Clinical findings to support that the encounter is related to the primary reason for home care, the patient is homebound, and in need of Medicare covered home health services.

Finally, because the FTF encounter is a requirement for payment, when the FTF encounter requirements as outlined above are not met, the home health agency’s entire claim is denied.  For cases in which the beneficiary’s condition otherwise warrants Medicare coverage of skilled home health services, but FTF encounter documentation is insufficient, the beneficiary’s ability to receive this skilled care may be jeopardized.

Home health agencies may ask you to provide supporting documentation from your medical records to ensure that Medicare will cover home health services. You are permitted, and strongly encouraged, to provide this documentation, the disclosure of which is permitted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). No specific authorization is required from your patients in order to do this. Also, please note that you may not charge the home health agency for providing this information. We ask you to work in partnership with these agencies so they can provide appropriate and medically necessary care for your homebound patients.

Wednesday, June 3, 2015

EHR incentive program update

Modifications to Meaningful Use for 2015 through 2017: Realigning the EHR Incentive Programs to support health information exchange and quality improvement 

On April 10, 2015, the Centers for Medicare & Medicaid Services issued a new proposed rule for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs to align Stage 1 and Stage 2 objectives and measures with the long-term proposals for Stage 3, to build progress toward program milestones, to reduce complexity, and to simplify providers’ reporting. These modifications would allow providers to focus more closely on the advanced use of certified EHR technology to support health information exchange and quality improvement.

Better Care, Smarter Spending and Healthier People
The proposed rule is just one part of a larger effort across HHS to deliver better care, spend health dollars more wisely, and have healthier people and communities by working in three core areas: improving the way providers are paid, improving the way care is delivered, and improving the way information is shared to support transparency for consumers, health care providers, and researchers and to strengthen decision-making.

Vision for the Future
The proposed rule issued today is a critical step forward in helping to support the long-term goals of delivery system reform; especially those goals of a nationwide interoperable learning health system and patient-centered care. CMS is also simplifying the structure and reducing the reporting requirements for providers participating in the program by removing measures which have become duplicative, redundant, and reached wide-spread adoption (i.e., are “topped out”). This will allow providers to refocus on the advanced use objectives and measures. These advanced measures are at the core of health IT supported health care which drives toward improving the way electronic health information is shared among providers and with their patients, enhancing the ability to measure quality and set improvement goals, and ultimately improving the way health care is delivered and experienced.

Simplifying and Streamlining
The proposed rule would streamline reporting requirements. To accomplish these goals, the NPRM proposes:
Reducing the overall number of objectives to focus on advanced use of EHRs;
Removing measures that have become redundant, duplicative or have reached wide-spread adoption;
Realigning the reporting period beginning in 2015, so hospitals would participate on the calendar year instead of the fiscal year; and
Allowing a 90 day reporting period in 2015 to accommodate the implementation of these proposed changes in 2015.

Supporting Interoperability and the Adoption of Electronic Health Records
The EHR Incentive Programs support the adoption and meaningful use of certified EHR technology to allow providers and patients to exchange and access health information electronically and support interoperability broadly. The program supports interoperability by requiring the capture of data in structured formats as well as the exchange of data in standardized form as well as the sharing of this data electronically with other providers and with patients.

The proposed rule would reduce required reporting, allowing providers to focus on objectives which support advanced use of EHR technology and quality improvement, including health information exchange.

Improving Outcomes for Patients
The rule would support improved outcomes and measurement of those outcomes. By proposing to simplify the reporting requirements, the proposed rule would allow providers to focus on objectives that support advanced use of EHR technology, including quality measurement and quality improvement. The rule supports providers leveraging their resources and health IT to coordinate care for patients, to provide patients with access to their health information, and to support data collection in a format that can be shared across multiple health care organizations.

Program Registration and Participation Milestones
As of March 1, 2015, more than 525,000 providers have registered to participate in the Medicare and Medicaid EHR Incentive Programs. In addition, more than 438, 000 eligible professionals, eligible hospitals, and CAHs have received an EHR incentive payment. As of the end of 2014, 95% of eligible hospitals and CAHs, and more than 62% of eligible professionals have successfully demonstrated meaningful use of certified EHR technology.

Thursday, May 28, 2015

End Stage Renal Disease Facility Providers

This page provides basic information about being certified as a Medicare and/or Medicaid End Stage Renal Disease (ESRD) provider and includes links to applicable laws, regulations, and compliance information.

ESRD is that stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplant to maintain life.

Types of ESRD Facilities:
•    Renal Transplantation Center
A hospital unit which is approved to furnish, directly, transplantation and other medical and surgical specialty services required for the care of ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement.  A renal transplantation center may also be a renal dialysis center.
•    Renal Dialysis Center
A renal dialysis center is a hospital unit that is approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of ESRD dialysis patients (including inpatient dialysis furnished directly or under arrangement and outpatient dialysis).  A hospital need not provide renal transplantation to qualify as a renal dialysis center.
•    Renal Dialysis Facility
A renal dialysis facility is a unit that is approved to furnish dialysis service(s) directly to ESRD patients.
•    Self Dialysis Unit
A self-dialysis unit is a unit that is part of an approved renal transplantation center, renal dialysis center, or renal dialysis facility, and which furnishes self-dialysis services.

ESRD Application Requirement
Filing of Application
To establish eligibility to provide ESRD services under Medicare, an applicant must complete Part I of the End Stage Renal Disease Application and Survey and Certification Report, Form CMS-3427.
Application must be made:
•    To request initial approval;
•    To request expansion or addition of stations;
•    For change in location;
•    For change of ownership (CHOW).  Ownership means the responsibility and liability for operational decisions of a health care enterprise.  A CHOW only occurs when there is a change in the identity of the governing body having ultimate operational responsibility for carrying out ESRD care in the facility; and/or
•    For change in service(s) provided, including reuse.

The State Survey Agency certifies compliance with health and safety standards, using the Survey Procedures and Interpretive Guidelines for End Stage Renal Disease Facilities.  Additional statutory and regulatory requirements include furnishing data and information for ESRD program administration, and participation in network activities.  The State Survey Agency assists the CMS Regional Office in gathering specified information relating to these regulations.

Monday, May 18, 2015

How do you determine whether prescription drug coverage is creditable coverage? and about Home Health Providers

How do you determine whether prescription drug coverage is creditable coverage?

Prescription drug coverage is creditable if the actuarial value of the prescription drug coverage offered by the entity equals or exceeds the actuarial value of the standard prescription drug coverage under Medicare (Part D coverage). Entities must determine creditable coverage status for each benefit option offered. In general, the actuarial value test measures whether the expected amount of paid claims, on average, for all Medicare eligible individuals covered under the entity’s prescription drug coverage is expected to pay at least as much as the expected amount of paid claims under the standard prescription drug benefit under Medicare Part D. Entities should calculate the value of the standard Medicare prescription drug benefit for a given plan year based on the initial coverage limit, cost-sharing and out-of-pocket threshold for the standard prescription drug coverage under Part D in effect at the start of the entity’s plan year.

If an entity is not an employer or union that is applying for the Retiree Drug Subsidy, it can use the simplified determination of creditable coverage status annually to determine whether its prescription drug plan’s coverage is creditable or not.

Home Health Providers

This page provides basic information about being certified as a Medicare and/or Medicaid home health provider and includes links to applicable laws, regulations, and compliance information.

A Home Health Agency (HHA) is an agency or organization which:
•    Is primarily engaged in providing skilled nursing services and other therapeutic services;Has policies established by a group of professionals (associated with the agency or organization), including one or more physicians and one or more registered professional nurses, to govern the services which it provides;
•    Provides for supervision of above-mentioned services by a physician or registered professional nurse;
•    Maintains clinical records on all patients;
•    Is licensed pursuant to State or local law, or has approval as meeting the standards established for licensing by the State or locality;
•    Has in effect an overall plan and budget for institutional planning;
•    Meets the federal requirements in the interest of the health and safety of individuals who are furnished services by the HHA; and
•    Meets additional requirements as the Secretary finds necessary for the effective and efficient operation of the program.
For purposes of Part A home health services under Title XVIII of the Social Security Act, the term “home health agency” does not include any agency or organization which is primarily for the care and treatment of mental diseases.

A Home Health Agency may be a public, nonprofit or proprietary agency or a subdivision of such an agency or organization.

1.    Public agency is an agency operated by a State or local government.  Examples include State-operated HHAs and county hospitals.  For regulatory purposes, “public” means “governmental.”
2.    Nonprofit agency is a private (i.e., nongovernmental) agency exempt from Federal income taxation under §501 of the Internal Revenue Code of 1954.  These HHAs are often supported, in part, by private contributions or other philanthropic sources, such as foundations.  Examples include the nonprofit visiting nurse associations and Easter seal societies, as well as nonprofit hospitals.
3.    Proprietary agency is a private, profit-making agency or profit-making hospital.

Wednesday, May 6, 2015

"Incident to" and the Initial Visit - Evaluation & Management (E/M) Service Guidelines

Novitas Solutions Medical Review (MR) Department has observed a continued trend of the utilization of non-physician practitioners to perform initial office visits as "incident to" services. Documentation reviewed by the MR Department indicates that a non-physician practitioner performs the initial visit and the supervising physician documents a note in the medical record similar to the following:

"I have reviewed the Physician Assistant's note, examined the patient and agree with..."
“Nurse practitioner performed the history and physical and I was present for the entire encounter and my treatment plan is as follows……”

This is incorrect use of the non-physician practitioner and incorrect billing under the "incident to" guidelines. This article explains the Medicare definition of "incident to" services and the criteria that must be met to properly bill "incident to" services.

An initial history and physical performed by a non-physician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the "incident to" guidelines. As outlined below, the physician MUST perform the initial service. This includes the history and physical, examination portion of the service, and the treatment plan. It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.

Novitas Solutions MR will deny or down code claims for initial office visits billed as "incident to" when a non-physician practitioner performs the initial history and physical .
CMS defines "incident to" services as “services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”

In order to be covered as "incident to" the physician’s service, the following criteria must be met:
services must be an integral, although incidental, part of the physician’s professional service,
commonly rendered without charge or included in the physician’s bill,
of a type that are commonly furnished in physician’s offices or clinics, and
furnished by the physician or by auxiliary personnel under the physician’s direct supervision

"Incident to" services must be performed under the direct supervision of the physician. CMS directs that “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

CMS further indicates, under direct supervision, “This does not mean, however, that to be considered "incident to", each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be "incident to" when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment.” Hospital and skilled nursing facility services cannot be billed as "incident to" at any time.

Wednesday, April 29, 2015

The Differences Between Crossover and Medigap


Crossover is an automatic claim filing service used by Railroad Medicare and Medicare Part B contractors to send claim information to your supplemental insurance after Palmetto GBA has processed a Medicare claim for you. This saves you the time of filing a claim with your supplemental insurer.

In order for you to be in the crossover program, you must enroll with your supplemental insurer. Once you have enrolled, Railroad Medicare will receive, on a regular basis from the supplemental insurer, a list of patients in the crossover program. Once the lists are received from the crossover companies, claim information is electronically compared with the list to determine if there is a match.

If there is a match, the information is transferred to the requesting crossover company. The information forwarded to the requesting company is similar to the information provided on a Medicare Summary Notice (MSN). If your name and Health Insurance Claim (HIC) number appear on the list, your claims processed during that month will be forwarded to your supplemental insurer. You may be enrolled in the crossover program with more than one supplemental insurer. You can only enroll in the crossover program through your supplemental insurer, not through Railroad Medicare. Likewise, if you want to stop the crossover program, you must do this through your supplemental insurer.

The first claim submitted to Railroad Medicare will not cross over. This is because your eligibility information must be added to Railroad Medicare's system. As long as your name and HIC number appear on a company's monthly crossover listing, Railroad Medicare will continue to forward claims information to the supplemental insurer.

Some supplemental insurers do not offer crossover. You should contact your insurance company to see if your policy is eligible for the crossover program.

Medicaid offers a crossover program with Medicare. The crossover list consists of eligible Medicaid recipients. However, if you are on crossover with a supplemental insurer, we will only forward information to the supplemental insurer, not to Medicaid. In order for you to be on crossover with Medicaid, you cannot be on crossover with any supplemental insurer. If you have both Medicare and Medicaid, your health care providers must accept assignment on all Medicare claims.

Medigap is a health insurance policy or other health benefit plan offered by a private entity to people entitled to Medicare benefits. It is specifically designed to supplement Medicare benefits by filling in some of the 'gaps' that Medicare does not cover, such as deductibles, coinsurance amounts or other limitations. It does not include limited benefit coverage available to Medicare beneficiaries such as 'specified disease' or 'hospital indemnity' coverage. It explicitly excludes a policy or plan offered by an employer to employees or former employees as well as that offered by a labor organization to members or former members.

Medigap eliminates the need for you or your participating health care providers to file separate claims to Medigap insurers. Railroad Medicare will automatically send claim information to Medigap insurers, if you have elected to assign your Medigap benefits to a participating provider.

The Medigap plan differs slightly from the crossover process. In order for information to be forwarded to a Medigap insurer, the following criteria must be met:
1. Physicians must be participating (PAR)
2. The supplemental policy must meet the definition of a Medigap policy
3. Physicians must include the following Medigap policy information on the CMS-1500 claim form or electronic claim:
o Name of Medigap insurer (Item 9)
o Enter the other insured's policy or group number preceded by MEDIGAP, MG OR MGAP (Item 9a)
o Leave blank (reserved for NUCC use) (Item 9b)
o Leave blank (reserved for NUCC use) (Item 9c)
o Enter the Coordination of Benefits Agreement (COBA) Medigap-based Identifier (ID) (Item 9d)

Medical Billing

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.

Insurance verification

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

Insurance enrollment

Charge entry

Insurance verification

Billing and reconciling of accounts

Payment posting

Insurance authorization

Medical coding

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

* Refunds

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.


All the contents and articles are based on our experience and our knowledge in Medical billing. All the information are educational purpose and we are not guarantee of accuracy of information. Before implement anything do your own research. All our contents are protected by copyright laws and guidelines.
If you feel some of our contents are misused please mail me at medicalbilling4u@gmail.com. We will response ASAP.