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.
Thursday, June 18, 2015
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”
“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
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
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
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
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)
Monday, April 20, 2015
• Blood glucose self-testing equipment and supplies
• Therapeutic shoes and inserts
• Insulin pumps and the insulin used in the pumps
Blood Glucose Self-testing Equipment and Supplies
Blood glucose self-testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. This includes those who use insulin and those who do not use insulin. These supplies include:
• Blood glucose monitors
• Blood glucose test strips
• Lancet devices and lancets
• Glucose control solutions for checking the accuracy of testing equipment and test strips
Railroad Medicare covers the same type of blood glucose testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies.
1. Use insulin, you may be able to get up to 100 test strips and lancets every month, and 1 lancet device every 6 months
2. Do not use insulin, you may be able to get 100 test strips and lancets every 3 months, and 1 lancet device every 6 months
If your doctor documents why it is medically necessary, Railroad Medicare will cover additional test strips and lancets for you.
Medicare and Railroad Medicare will only cover blood glucose self-testing equipment and supplies if you get a prescription from your doctor which includes:
• That you have diabetes
• What kind of blood glucose monitor you need and why
• Whether or not you use insulin
• How often you need to test your blood glucose
Medicare will not pay for any supplies not asked for, or for any supplies that were sent to a beneficiary automatically from suppliers. This includes blood glucose monitors, test strips, and lancets. Also, if a beneficiary goes to a pharmacy or supplier that is not enrolled in Medicare, Medicare will not pay. The beneficiary will have to pay the entire bill for any supplies from non-enrolled pharmacies or non-enrolled suppliers.
All Medicare-enrolled pharmacies and suppliers must submit claims for blood glucose monitor test strips. You cannot submit a claim for blood glucose monitor test strips yourself. You should make sure that the pharmacy or supplier accepts assignment for Medicare-covered supplies. If the pharmacy or supplier accepts assignment, Medicare will pay the pharmacy or supplier directly. You should only pay your coinsurance amount when you get your supply from your pharmacy or supplier for assigned claims. If your pharmacy or supplier does not accept assignment, charges may be higher, and you may pay more. You may also have to pay the entire charge at the time of service and wait for Medicare to send you its share of the cost.
Before you get a supply, be sure to ask the supplier or pharmacy the following questions:
• Are you enrolled in Medicare?
• Do you accept assignment?
If the answer to either of these two questions is 'no,' you may wish to consider calling another supplier or pharmacy in your area that answers 'yes' to be sure your purchase is covered by Medicare.
Therapeutic Shoes and Inserts
If you have Medicare Part B, have diabetes, and meet certain conditions (see below), Railroad Medicare will cover therapeutic shoes if you need them. The types of shoes that are covered each year include one of the following:
• One pair of depth-inlay shoes and three pairs of inserts or
• One pair of custom-molded shoes (including inserts) if you cannot wear depth-inlay shoes because of a foot deformity and two additional pairs of inserts
Note: In certain cases, Medicare may also cover shoe modifications instead of inserts.
In order for Medicare to pay for your therapeutic shoes, the doctor treating your diabetes must certify that you meet all of the following three conditions:
• You have diabetes
• You have at least 1 of the following conditions in one or both feet
o Partial or complete foot amputation
o Past foot ulcers
o Calluses that could lead to foot ulcers
o Nerve damage because of diabetes with signs of problems with calluses
o Poor circulation, or
o Deformed foot
• You are being treated under a comprehensive diabetes care plan and need therapeutic shoes and/or inserts because of diabetes
Medicare also requires the following:
• A podiatrist or other qualified doctor must prescribe the shoes, and
• A doctor or other qualified individual like a pedorthist, orthotist, or prosthetist must fit and provide the shoes to you
Medicare helps pay for one pair of therapeutic shoes and inserts per calendar year, and the fitting of the shoes or inserts is covered in the Medicare payment for the shoes.
Insulin Pumps and the Insulin Used in the Pumps
Insulin pumps worn outside the body (external), including the insulin used with the pump, may be covered for some people with Railroad Medicare coverage who have diabetes and who meet certain conditions. If you need to use an insulin pump, your doctor will need to prescribe it.
Railroad Medicare covers the cost of insulin pumps and the insulin used in the pumps. However, if you inject your insulin with a needle (syringe), Medicare Part B does not cover the cost of the insulin, but your Medicare prescription drug benefit (Part D) covers the insulin and the supplies necessary to inject it. This includes syringes, needles, alcohol swabs and gauze. Your Medicare Part D plan will cover the insulin and any other medications to treat diabetes at home as long as you are on the Medicare Part D plan’s formulary.
Coverage for diabetes-related durable medical equipment (DME) is provided as a Medicare Part B benefit. The Medicare Part B deductible and coinsurance or copayment applies after the yearly Medicare part B deductible has been met.
Sunday, April 5, 2015
Before the AWV exam, the ‘Welcome To Medicare’ exam (also called your Initial Preventive Physical Exam, or IPPE) benefit was available to you during the first twelve months of your Railroad Medicare eligibility. This initial exam established your health baseline from which the doctor could measure changes.
The new Annual Wellness Visit is the next step towards using all the information gathered in your 'Welcome to Medicare' exam. In addition, there is no co-pay, and it is not charged toward your Railroad Medicare deductible.
Your Annual Wellness Visit will:
• Update medical and family history
• Update measurement of height, weight, body-mass index and blood pressure
• Document changes you made in using other health care professionals
• Document changes other health care professionals may have made, like medications
• Look for any cognitive changes or impairments
• Update your screening schedule
• Update the list of risk factors
• Provide health advice based off this AWV information and make referrals if needed
Though it may sound like a routine physical exam, the Annual Wellness Visit isn’t - the AWV is a preventive service. Medicare does not consider a routine physical exam a preventive service.
When you schedule your AWV with your doctor’s office, make sure they document it so Railroad Medicare can pay for this annual benefit.
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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