Medical Billing and Coding | Help To Your Insurance Denials.

Electronic Claims Submission - introduction and benefits - can we use free software?

2012-02-10T16:53:00.000+05:30

Introduction

Submitting Medicaid claims via electronic media offers the advantage of speed
and accuracy in processing. Providers may submit electronic claims
themselves or choose a billing agent that offers electronic claim submission
services. Billing agents must enroll as Medicaid providers.

Benefits

The benefits of electronic claims submission include:
· Increase speed of claims payments, seven days in some cases.
· Correct data entry errors immediately, avoiding mailing time and costs.
· Eliminate the cost and inconvenience of claims paperwork.
· Reduce office space required for storing claim forms, envelopes, etc.
· Decrease mailing costs.
· Decrease clerical labor costs.
· Automate the office for a more efficient operation.

Free Software

The Medicaid fiscal agent has PC-based software, called WINASAP2003, which
enables providers to submit claims electronically on IBM compatible personal
computers (PC) in their offices.

Providers can transmit the claims via telephone lines directly to the Medicaid
fiscal agent.

The WINASAP2003 software, user manual and technical support is available
free of charge to Florida Medicaid providers.

How to Participate in Electronic Claims Submission

The fiscal agent’s field representatives will assist providers with installing
WINASAP2003 software as well as assist with initial testing and instructions for
ongoing claims submission. To schedule an appointment with a field
representative or for any non-software questions, call Provider Inquiry at 800-
289-7799.

insurance claims submission and mailing checklist

2012-02-06T16:50:00.000+05:30

Claims Submission Checklist

Introduction

Use the following checklist before submitting a claim to the fiscal agent for reimbursement.

Checklist

* Is the form typed or printed in black ink?
* Is the copy legible?
* Were instructions in the handbook followed? Some fields are not self explanatory or may be used for other purposes.
* Are the provider name(s) and number(s) entered?
* Is the claim signed and dated? Unsigned claims will be returned unprocessed.
* Are attachments required? Claims cannot be paid without the required attachments.
* Is the P.O. Box number for submitting the claim correct?

Claims Mailing Checklist
Introduction The following checklist may be used when mailing claims to the fiscal agent for
reimbursement.

Checklist

* Enclose only one claim type per envelope. Claims and adjustment requests
should be sent separately because they are processed separately by the
fiscal agent.

* The claims envelope should be addressed to the correct P.O. Box and
corresponding nine-digit zip code for each claim type being mailed.
Typewritten or machine-printed addresses speed up post office processing.

* Claims mailed in a large envelope or “flat” need to be marked “first class”
and paid for as first class postage. If first class is not specified, the post
office will send large envelopes as third class mail. This will delay delivery of
claims to the fiscal agent.

claim timely filing denial exceptions.

2012-02-02T16:45:00.000+05:30

The following scenario, claim will not be denied as timely filing limit exceeded.

Exceptions to the 12-Month Time Limit

Exceptions to the 12-month claim submission time limit may be allowed if the
claim meets one or more of the following conditions:

· New clean claim submitted within six months of the date of the void of the
original claim payment date;
· Court or hearing decision;
· Delay in recipient eligibility determination;
· Medicaid delay in updating eligibility file;
· Court ordered or statutory action; or
· System error on a claim that was originally filed within 12 months from the
date of service.

Any claim filed more than 12 months from the date of service that meets an
exception must be sent to the area Medicaid office for processing, not to the
fiscal agent.

Each of these exceptions is discussed below.

Original Payment is Voided
When an original Medicaid claim is voided, the provider may submit a new claim
and a written request for assistance to the area Medicaid office no later than six
months from the void date.

Court or Hearing Decision
When a recipient is approved for Medicaid as a result of a fair hearing or court
decision, there is no time limit for the submission of a claim.

Delay in Recipient Eligibility Determination

An exception may be granted when there is a delay in the determination of an
individual’s Medicaid eligibility by the Department of Children and Families or the
Social Security Administration. The provider must send in specific
documentation to the area Medicaid office no later than 12 months from the date
the recipient’s eligibility is updated on FMMIS. The claim submission must
include:
· A clean claim,
· A copy of the recipient’s proof of eligibility, and
· Documentation of the reason for late submission.

Medicaid Delay in Updating Eligibility File
If Medicaid delays updating a recipient’s eligibility on the Florida Medicaid
Management Information System (FMMIS), an exception may be granted. The
provider must submit the related clean claims to the area Medicaid office no
later than 12 months from the date the recipient’s eligibility file was updated.

Court Ordered or Statutory Action
If the Medicaid office takes corrective action due to a court order or due to final
agency action taken under Chapter 120, Florida Statutes, there is no time limit
for claim submission.

System Error

If a clean claim is denied due to a system error or any error that is the fault of
Medicaid or the fiscal agent, an exception may be granted if the provider
submits another clean claim along with documentation of the denial to the area
Medicaid office no later than 12 months from the date of the original denial.

Evaluate the Claim

The provider must evaluate any claim that is denied and determine if the claim
fits any of the conditions for an exception to the 12-month filing limit.

Medicaid claim submission time limit - primary and secondary claims

2012-01-28T16:45:00.000+05:30

Timely Claim Submission
Medicaid providers should submit claims immediately after providing services so
that any problems with a claim can be corrected and the claim resubmitted
before the filing deadline.

Clean Claim

In order for a claim to be paid, it must be a clean claim. A clean claim is a
Medicaid claim that:
· Has been accurately and fully completed according to Medicaid billing guidelines.
· Is accompanied by all necessary documentation.
· Can be processed and adjudicated by the fiscal agent without obtaining
additional information from the provider.

12-Month Filing Limit
A clean claim for services rendered must be received by the Medicaid office or
its fiscal agent no later than 12 months from the date of service.

Date Received Determined

The date stamped on the claim by any Medicaid office or by the Medicaid fiscal
agent is the recorded date of receipt for a paper claim. The fiscal agent date
stamps the claim the date that it is received in the fiscal agent’s mailroom.
The date electronically coded on the provider’s electronic transmission by the
Medicaid fiscal agent is the recorded date of receipt for an electronic claim.

Third Party Payer and Medicare Insurance Claims
Claims for recipients who have Medicare or other insurance must be submitted
to a third party payer prior to sending the claim to Medicaid.

For non-Medicare claims, the claim must be received by Medicaid or the
Medicaid fiscal agent no later than 12 months from the date of service or six
months from the date of the other insurance payment or denial.

The filing limit for Medicare claims crossing over to Medicaid is the greater of 36
months from the date of discharge or 12 months from Medicare’s adjudication
date.

New and Established CPT code list

2012-01-07T15:36:00.002+05:30

New and Established Patient Services

A new patient is one who has not received any professional services from a physician or from another physician of the same specialty who belongs to the same group practice, within the past three years. Providers must use procedure codes 99201, 99202, 99203, 99204, and 99205 when billing for new patient services provided in the office or an outpatient or other ambulatory facility. New patient visits are limited to one every three years, per client, per provider.

An established patient is one who has received professional services from a physician or from another physician of the same specialty within the same group practice, within the last three years. Providers must use procedure codes 99211, 99212, 99213, 99214, and 99215 when billing for established patient services provided in the office or an outpatient or other ambulatory facility:

When an office visit is billed with the same date of service as a THSteps medical checkup or exception to periodicity visit, the office visit must be billed as an established patient visit. If a new patient visit is billed with the same date of service as a THSteps medical checkup or exception to periodicity visit, then the new patient visit will be denied.

Modifier 25 may be used to identify a significant, separately identifiable E/M service performed by the same physician on the same day as another procedure or service. Documentation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client's medical record. The documentation must clearly indicate what the significant problem/abnormality was, including the important, distinct correlation with signs and symptoms to demonstrate a distinctly different problem that required additional work and must support that the requirements for the level of service billed were met or exceeded.

The date and time of both services performed must be outlined in the medical record and the time of the second service must be different than the time of the first service, although a different diagnosis is not required.

An established patient visit that is billed with the same date of service as a new patient visit by the same provider will be denied as part of another procedure except when the established patient visit is billed with a new THSteps medical checkup.

Office visits (procedure codes 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215) provided on the same date of service as a planned procedure (minor or extensive) are included in the cost of the procedure and are not separately reimbursed.

Office visit procedure code 99211, 99212, 99213, 99214, or 99215 must be billed by the same provider with the same date of service as a group clinical visit.

Procedures that are included in the E/M service (e.g., binocular microscopy, noninvasive ear or pulse oximetry for oxygen saturation, etc.) are denied as part of another procedure when billed by the same provider with the same date of service as one of the following office or outpatient consultation visit procedure codes:

Procedure Codes

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

99241

99242

99243

99244

99245

Emergency department-based physicians or emergency department-based groups may not bill charges for inconvenience or after hours services (procedure code 99050, 99056, or 99060).

New CLIA waived CPT list - 2012

2012-01-03T15:15:00.003+05:30

New Waived Tests

Effective Date : January 1, 2012

Implementation Date : January 3, 2012

STOP- Impact to you

If you do not have a valid, current, Clinical Laboratory Improvement Amendments of 1998 (CLIA) certificate and submit a claim to your Medicare Carrier or A/B MAC for Current Procedural Terminology (CPT) code that is considered to be a laboratory test requiring a CLIA certificate, your Medicare payment may be impacted.

CAUTION _ What you need to know

CLIA requires that for each test it performs, a laboratory facility must be appropriately certified. The CPT codes that the Centers for Medicare & Medicaid Services (CMS) considers to be laboratory tests under CLIA (and thus requiring certification) change each year. Change Request (CR) 7566, from which this article is taken, informs carriers and MACs about the latest new CPT codes that are subject to CLIA edits.

GO – What you need to do

Make sure that your billing staffs are aware of these CLIA-related changes for 2012 and that you remain current with certification requirements.

Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA. The CPT codes in the following table must have the modifier QW to be recognized as a waived test. However, CPT codes 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651 do not require a QW modifier to be recognized as a waived test.

CPT Code	Effective Date	Description
81003QW	14-Feb-11	Germaine Laboratories Inc. AimStrip Urine Analyzer
G0434QW	22-Apr-11	UCP Biosciences, Inc. UCP Drug Screening Test Cups
G0434QW	22-Apr-11	Diagnostic Test Group Clarity Multiple Drug Screen Test Cups
81003QW	24-Mar-11	Mediwatch urinewatch Urine Analyzer
G0434QW	17-Jun-11	Insight Medical Drug of Abuse Urine Cassette Test
G0434QW	17-Jun-11	Insight Medical Drug of Abuse Urine Cup Test
G0434QW	17-Jun-11	Instant Technologies, Inc. iScreen Drug of Abuse Urine (Cassette) Test
G0434QW	17-Jun-11	Instant Technologies, Inc. iScreen Drug of Abuse Urine (Cup) Test
G0434QW	17-Jun-11	Jant Pharmacal Accutest Drug of Abuse Urine (Cassette) Test
G0434QW	17-Jun-11	Jant Pharmacal Accutest Drug of Abuse Urine (Cup) Test
G0434QW	17-Jun-11	Total Diagnostic Solutions Drug of Abuse Urine (Cassette) Test
G0434QW	17-Jun-11	Total Diagnostic Solutions Drug of Abuse Urine (Cup) Test
G0434QW	30-Jun-11	Diagnostic Test Group Clarity Simple Drug Screening Cups
G0434QW	30-Jun-11	Diagnostic Test Group Clarity Multi-Drug Test Cards
81003QW	14-Jul-11	Stanbio Uri-Trak 120 Urine Analyzer
G0434QW	21-Jul-11	UCP Biosciences, Inc. U-Checker Drug Screening Test Cups

CPT 99212, 99213 visit history

2011-12-29T15:10:00.000+05:30

The only difference between the history requirements for a 99212 and a 99213 is the review of systems.

For a level-II visit, you need one point to meet the data requirement, which is considered minimal. You can earn one point by ordering or reviewing lab, radiology or procedure reports, or simply by obtaining old records about the patient or obtaining history from someone other than the patient (e.g., a family member or caregiver). The data for a level-III visit is considered limited and requires a total of two points. You can earn two points by reviewing or ordering two different types of tests (e.g., a complete blood count and a chest X-ray). You can also earn two points by summarizing old records or discussing the case with another health care provider.

Risk. The risk associated with an E/M visit is based on the chance that significant complications,

morbidity or mortality occur during the current encounter/procedure or between the present encounter and the next one. The guidelines characterize these in the context of the presenting problems, diagnostic procedures and management options. The highest level of risk in any one of the three categories determines the overall risk.

The risk associated with a level-II visit is considered minimal. Examples include a presenting

problem that is self-limited or minor; diagnostic procedures such as labs with venous puncture, chest X-rays, ECGs, EEGs, urinalysis, ultrasound and KOH preparation; or management options such as prescribing rest, gargles, elastic bandages and superficial dressings. Level-III visits are considered to have a low level of risk. Patient encounters that involve two or more self-limited problems, one stable

chronic illness or an acute uncomplicated illness would qualify. Diagnostic procedures with low risk include physiologic tests not under stress, non-cardiovascular imaging studies with contrast, perficial needle biopsies, labs requiring arterial puncture and skin biopsies. Lowrisk management options include prescribing over-the-counter drugs, minor surgery with no identified risk factors, physical therapy, occupational therapy and IV fluids without additives.

Time-based billing

Another option for coding level-II and level- III encounters is to use time as your guide. According to CPT, a typical level-II visit lasts 10 minutes, while a typical level-III visit lasts 15 minutes. If counseling or coordination of care account for more than 50 percent of the visit, then you can select your E/M code based on the length of the visit. In general, the time spent face-to-face with the patient (and the time spent in counseling) should meet or exceed the listed typical visit times. Remember,

the coders who audit your charts do so by counting required components as well as noting recorded visit times. If you decide to use time-based billing, make sure to include in your note that at least half of the face-to-face time was spent counseling or coordinating care (e.g., “total visit time was 15 minutes, half of which was counseling”). Your documentation should also describe the nature of the counseling or care coordination.

comparison of CPT 99212 & 99213

2011-12-27T15:01:00.000+05:30

CPT 99212 vs 99213

There is set of Evaluation and Management Guidelines that appear every year that the provider must become aware of. There are several physicians who might be wondering whether to use coding 99212 or 99213 this will help you to go through any ecision making process that is conducted without much difficulty.

The three things that one must keep in mind for the selection of the right E/M code are:

1. History

2. Exam

3. Decision making

When you consider CPT codes 99212 to 99215 they require that only two of the three key components meet or exceed the level of code that is chosen.

The Review of Systems (ROS) is the key difference between a PF (99212) and an EPF (99213) history. The CPT 99212 does not require a ROS and documentation.

The ROS is a list of signs or symptoms a patient has had in the past, or currently may be experiencing. It is not, per se, a list of previously diagnosed diseases. Previously diagnosed diseases are considered a different portion of the history called past diseases. The ROS serves a number of different functions. If a complaint is new to the physician, the ROS are the questions asked to aid the physician in arriving at a diagnosis related to various organ systems. Often this is helpful in eliminating a diagnosis from the differential diagnosis.

All medically necessary E/M encounters performed by a physician involve at least straightforward decision-making because straightforward decision-making is the lowest level possible. That is all that is required for a CPT 99212.

The three equal elements of medical decision making are:

1. The amount of data and medical records reviewed

2. The number of diagnoses or treatment options.

3. The risk associated with mortality or morbidity of a treatment option, diagnosis, or procedure. The highest level of risk associated with a procedure, problem, or management option determines the level of risk.

Only two of the three elements need to meet or exceed the level of decision-making which is selected.

If the level of history is counted as one of the two key components, for example a problem focused (PF) history, this is all that is required for the documentation of a CPT 99212.

You must always keep in mind the “Medical Necessity” of the visit is the highest priority for your final coding choice.

CPT code 99354 – Prolonged Visit

2011-12-24T15:00:00.000+05:30

CPT 99354 – Prolonged physician service in the office or other outpatient setting, requiring direct (face-to-face) patient contact beyond the usual service – first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)

The average reimbursement is in the range of $95.00, depending upon your region.

The Medicare Manual says:
The start and end times of the visit shall be documented in the medical record along with the date of service.

This code is one of many under-utilized codes in your office for many reasons. However, if you do the work and spend the prolonged time, face to face with the patient, document the progress note properly and provide the required medically necessary components, you deserve to use this code and get paid for your time.

Serious Illness Takes Serious Time

This code can be used for a seriously ill patient in your office, when you are spending a significant amount of time helping, while deciding the best course of action. This would include deciding to admit the patient to the hospital or sending the patient to the emergency room via a 911 call.

Usually, if you are spending over 40 minutes with the patient and have all of the criteria, you are going to document and bill for a 99215. However, if you end up spending any additional time, for example, over another 30 minutes with the patient, and your face-to-face total time counting all other services is 75 minutes or more, you may be entitled to capture the additional CPT code 99354.

Record Your Time!

It is prudent to report the start times and the ending times as well as the face-to-face time, in order to properly capture this code.

Overall, this really is not that difficult. For example, if you have a patient who comes into your office with an exacerbation of their COPD, you may start the patient on oxygen in your office while you perform your History, Physical and Medical Decision Making.

Keep Track of the Intensity of your Care

In the course of this you may order a nebulizer treatment for the patient and then leave the room to see another patient, you should document the time actually spent with the patient up to that point.
Once you return to the room the clock starts again. While speaking with the patient regarding how they feel after the nebulizer treatment, you may decide that they need an injection or another treatment. You document the time and then may have to leave the room to see another patient.

Once you return to the room, the clock starts again; so each time you decide on a treatment option for this patient, you continue to accrue time towards, not only the level CPT 99215 visit as the patient definitely will meet criteria for the intensity and medical necessity, you are potentially capturing the extra time needed to use the CPT 99354 code.
This code will enable you to be able to bill for the extra time you need to spend with the patient while you are stabilizing them, in order to decide if they can return home be transported to the hospital.

Many of us have the occasional patient who will use a significant amount of time in order for you to take proper care of them, to stabilize them and to decide whether the current problem they have can be handled from home or in the hospital.

Code Correctly for your Visit Too

If you provide the care, you deserve the code. That is why it is available in the first place. You owe it to yourself to maximize your revenue. Many providers will only bill this encounter as a CPT 99213 or CPT 99214. The reality is, if you do the work and properly document with the medical necessity in place, you can easily and comfortably bill for the appropriate code CPT 99215 and CPT 99354.

EHR incentive payment - How to register

2011-12-21T14:58:00.001+05:30

Registration Eligible Professional

Registration at the national level for the Medicaid EHR Incentive Program opened in January 2011. However, the Medicaid EHR Incentive Program is administered individually by each state, therefore registration start dates vary from State to State.

Eligible professionals are required to register on the national level through the CMS website and at the state level in Florida.

STEP1
Register on the CMS Medicare and Medicaid EHR Incentive Program Registration and Attestation System.

For the most up-to-date information about registration into the CMS Medicare and Medicaid EHR Incentive Program Registration and Attestation System click here.

Eligible Providers will need to complete the following in order to complete registration:

Meet the eligibility requirements (Be in one of the eligible professions; meet the minimum Medicaid patient volume, etc.)
Be fully enrolled as a Florida Medicaid Provider

Have a Florida Medicaid Provider Number and PIN in order to access the Medicaid Secure Area
Have a National Provider Identifier (NPI) number.

Have a National Plan and Provider Enumeration System (NPPES) web user account ID and Password (https://nppes.cms.hhs.gov/NPPES/Welcome.do)
Have an EHR Certification Number (http://onc-chpl.force.com/ehrcert)

STEP 2

Florida registration has begun. For assistance in registering call the EHR Incentive Payment Program Contact Center at 1(855) 231-5472 or view the User Guide for Eligible Professionals. Incentive Program staff have created a template to help you capture the information needed to determine volume. If you chose to use the template, please upload it as part of your application as it will assist the Agency in your pre-payment validation process

ERX payment adjustment 2012

2011-12-18T14:54:00.002+05:30

Assessing and Applying the 2012 eRx Payment Adjustment 2012 eRx Assessment

An eligible professional who meets the eRx program inclusion criteria will be subject to the 2012 eRx payment adjustment if (s)he did not submit the following:

• 10 valid 2011 eRx G-codes (G8553) via claims during the 6-month reporting period of January 1, 2011 – June 30, 2011; or

• A hardship exemption (G8642, G8643) via claims during the 6-month reporting period; or

• A G-code via claims indicating (s)he did not have prescribing privileges (G8644) during the 6-month reporting period; or

• (S)he requested and was granted a hardship exemption through the Quality Reporting Communication Support Page.

CMS analysis of all valid 2011 eRx QDCs submitted with a Date of Service during the 6-month reporting period determines whether or not the payment adjustment applies to the eligible professional.

Group practices participating in eRx GPRO who would be subject to the payment adjustment is defined as a TIN who:

• Failed to meet the 2011 eRx criteria for successful reporting during the 6-month reporting period of January 1–June 30, 2011; or

• Failed to indicate a hardship or lack of prescribing privileges to CMS

The analysis of successful reporting for group practices that participate in eRx GPRO will be performed at the TIN level to identify the group’s services and quality data. All NPIs under the TIN during the 6-month reporting period for 2011 (January 1, 2011 – June 30, 2011) will receive the payment adjustment if the group practice participating in eRx GPRO is subject to the payment adjustment.

For eligible professionals who submitted claims under multiple TINs, CMS groups claims by unique TIN/NPIs for analysis and payment adjustment purposes. As a result, an eligible professional who submitted claims under multiple TINs may be subject to an eRx payment adjustment under one of the TINs and not the other(s), or may be subject to a payment adjustment under each TIN.

Who is eligible for 2012 ERX incentive

2011-12-15T14:53:00.002+05:30

2012 Electronic Prescribing (eRx) Payment Adjustment: Assessment and Application

An eligible professional was included in the 2012 eRx payment adjustment analysis if they meet all of the following criteria:

• Was a physician (MD, DO, or podiatrist), Nurse Practitioner, or Physician Assistant as of June 30, 2011, based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES);

• Had prescribing privileges from 1/1/11-6/30/11;

• Had at least 100 cases containing an encounter code in the measure’s denominator from 1/1/11-6/30/11; AND

• Had 10% or more of their Medicare Part B allowable charges (per Tax Identification Number (TIN)) from 1/1/11-6/30/11 were for encounter codes in the measure’s denominator

Eligible professionals were automatically excluded from the 2012 eRx payment adjustment analysis if they did NOT meet one of the above criteria. In addition, eligible professionals could have taken the following steps from to avoid the 2012 eRx payment adjustment:

• Submitted 10 or more 2011 eRx quality-data codes (G8553) for Medicare Part B PFS services via claims from 1/1/11-6/30/11;

• Indicated that the eligible professional met criteria for a hardship exemption for either living in a rural area without sufficient high speed internet (G8642), or practiced in an area without sufficient pharmacies that can accept eRx (G8643) via claims from 1/1/11-6/30/11;

• Indicated that the eligible professional did not have prescribing privileges (G8644) via claims from1/1/11-6/30/11; OR

• Requested a hardship exemption via the Quality Reporting Communication Support Page on or before 11/8/11, and received CMS approval.

Can we get paid when CPT 99211 with Drug Admin code?

2011-11-28T17:22:00.001+05:30

Drug Administration Services and E/M Visits Billed on Same Day of Service

CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or non-chemotherapy drug infusion code, or therapeutic or diagnostic injection code. Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed in addition to a drug administration, the appropriate E/M CPT code should be reported with the 25 modifier. Documentation should support the level of E/M service
billed. For an E/M service provided on the same day, a different diagnosis is not
required.

Office/Outpatient or Emergency Department Visit on Day of Admission to Nursing Facility

A physician may not be paid for an emergency department visit or an office visit and a comprehensive nursing facility assessment on the same day. The E/M services on the same date provided in sites other than the nursing facility are bundled into the initial nursing facility care code when performed on the same date as the nursing facility admission by the same physician.

Patient seen group practice provider on same day?

2011-11-25T15:41:00.000+05:30

Physicians in Group Practice

Physicians of the same specialty in the same group practice must bill and be paid
as a single physician.

If more than one E/M (face-to-face) service is provided on the same day to the
same patient by the same physician or more than one physician in the same
specialty in the same group, only one E/M service may be reported unless the
E/M services are for unrelated problems. (Refer to instructions for use of the 76
modifier.)

Instead of billing separately, the physicians should select a level of service
representative of the combined visits and submit the appropriate code for that
level.

Physicians in different specialties in the same group practice may bill and be paid
without regard to their membership in the same group.

When can we bill highest level CPT code - 99215, 99205

2011-11-22T15:39:00.000+05:30

Use of Highest Levels of E/M Codes

To bill the highest levels of visit codes, the services furnished must meet the
definition of the code (e.g., to bill a Level 5 new patient visit, the history must
meet the CPT’s definition of a comprehensive history).

The comprehensive history must include a review of all the systems and a
complete past (medical and surgical) family and social history obtained at that
visit. In the case of an established patient, it is acceptable for a physician to
review the existing record and update it to reflect only changes in the patient’s
medical, family and social history from the last encounter, but the physician must
review the entire history for it to be considered a comprehensive history.

The comprehensive examination may be a complete single-system exam such
as cardiac, respiratory, psychiatric or a complete multi-system examination

Can we choose E & M level of visit based on Time

2011-11-18T15:36:00.000+05:30

Selection of Level of E/M Service Based on Duration of Coordination
of Care and/or Counseling

Time is the key factor in selecting the level of service when counseling and/or
coordination of care dominates (more than 50 percent) the face-to-face physician/
patient encounter or floor time (in the case of inpatient services). In general, the
physician must complete at least two out of three criteria applicable to the type/level of service provided to bill an E/M code. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.

Example:
A cancer patient has had all preliminary studies completed and a medical
decision is made to implement chemotherapy. At an office visit, the
physician discusses the treatment options and subsequent lifestyle effects
of treatment the patient may encounter or is experiencing. The physician
need not complete a history and physical examination to select the level of
service. The time spent in counseling/coordination of care and medical
decision-making will determine the level of service billed.

The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends on the physician service provided.

In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.

The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

HCPCS code J3490 and NDC number

2011-11-17T15:45:00.000+05:30

I am not getting paid when I submit HCPCS code J3490 with the drug name and NDC number. Why?

Answer:
HCPCS code J3490 is a non-specific code that should be used only when another 'J' code does not describe the drug being administered (i.e., CMS has not assigned a specific 'J' code to the drug used). The appropriate 'J' code should be used if one has been assigned to the drug. For the drug with no assigned 'J' code, the name, strength of the drug (if applicable) and the actual dosage administered must be indicated on the CMS-1500 form in Block 19 or Block 24 (listed with the procedure code). If the drug is compounded, the invoice/acquisition cost must be included with the description. This would ensure proper adjudication of your claim for J3490.

If the name, strength and dosage administered of the drug are not all listed, the claim will be denied for lack of information necessary to process the claim. At present, Railroad Medicare cannot identify a drug by only the NDC number.

How should I submit compounded drugs administered via implanted pump?

Answer:
Submit a single, combined line item for all drugs with HCPCS code J3490. Combine the charges for all drugs.

Electronic claims:

Indicate the name(s) and dose(s) of each drug being submitted in the documentation record

Paper claims:

Indicate 'compunded drugs, invoice attached' in Item 19 of the CMS-1500 Claim Form
Abbreviations are acceptable, but must use industry acceptable abbreviations (e.g., 'MS' for morphine sulphate)
Billed amount must be the invoice price for the compounded drug(s). To indicate this, we suggest using 'INV' next to the price (e.g., INV $250.00).

Medical records - Provider signature - Acceptable and unacceptable format - electronic signature

2011-11-15T15:29:00.000+05:30

Signature Requirements

Medicare requires a legible identifier for services provided/ordered. The method used must be handwritten or an electronic signature (stamped signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes.

Exception: Facsimile of original written or electronic signatures is acceptable for the certifications of terminal illness for hospice.

Providers using electronic systems should recognize that there is a potential for misuse or abuse with alternate signature methods. Facsimile and hard copies of a physician’s electronic signature must be in the patient’s medical record for the certification of terminal illness for hospice. For example, providers need a system and software products that are protected against modification, etc., and should apply administrative procedures that are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information being attested. Physicians should check with their attorneys and malpractice insurers regarding the use of alternative signature methods.

All state licensure and state practice regulations continue to apply. Where state law is more restrictive than Medicare, the state law standard will apply. The signature requirements described here do not assure compliance with Medicare conditions of participation.

Acceptable and Unacceptable Documentation Signatures

As a reminder, the treating physician’s signature must be present in the documentation associated with all services submitted to Medicare. Medicare requires the signature be a legible identifier for the provided/ordered services.
The physician’s signature can be in the form of either a handwritten signature or an electronic signature. Stamped signatures (i.e., rubber stamps) are not acceptable signatures.

The following list provides examples of acceptable electronic signatures:
 Chart “Accepted by” with provider’s name.
 “Electronically signed by” with provider’s name.
 “Verified by” with provider’s name.
 “Reviewed by” with provider’s name.
 “Released by” with provider’s name.
 “Signed by” with provider’s name.
 “Signed before import by” with provider’s name.
 “Signed: John Smith, M.D.” with provider’s name.
 Digitalized signature: Handwritten and scanned into the computer.
 “This is an electronically verified report by John Smith, M.D.”
 “Authenticated by John Smith, M.D.”
 “Authorized by: John Smith, M.D.”
 “Digital Signature: John Smith, M.D.”
 “Confirmed by” with provider's name.
 “Closed by” with provider’s name.
 “Finalized by” with provider’s name.
 “Electronically approved by” with provider’s name.

Examples of acceptable handwritten signatures:

 The handwritten signature must be legible.
 The handwritten signature must clearly identify the provider performing the billed services.

Examples of unacceptable signatures:
 The legible signature is missing from the documentation.
 The signature is illegible.
 The signature cannot be verified as that of the performing provider.
 The signature is typewritten but not authenticated by either a handwritten
signature or an electronic signature.
 The provider’s letterhead does not constitute legible identification.
 The provider’s initials do not constitute legible identification.

Choosing primary DX - How to determine

2011-11-12T15:23:00.000+05:30

Determining the Appropriate Primary ICD-9-CM Diagnosis Code for Diagnostic
Tests Ordered Due to Signs and/or Symptoms

Confirmed Diagnosis Based on Results of Test:

If the physician has confirmed a diagnosis based on the results of the diagnostic
test, the physician interpreting the test should code that diagnosis. The signs
and/or symptoms that prompted ordering the test may be reported as additional
diagnoses if they are not fully explained or related to the confirmed diagnosis.

Example 1: A surgical specimen is sent to a pathologist with a diagnosis of
“mole.” The pathologist personally reviews the slides made from the
specimen and makes a diagnosis of “malignant melanoma.” The
pathologist should report a diagnosis of “malignant melanoma” as
the primary diagnosis.

Example 2: A patient is referred to a radiologist for an abdominal Computed
Tomography (CT) scan with a diagnosis of abdominal pain. The CT
scan reveals the presence of an abscess. The radiologist should
report a diagnosis of “intra-abdominal abscess.”

Example 3: A patient is referred to a radiologist for a chest X-ray with a
diagnosis of “cough.” The chest X-ray reveals a 3 cm peripheral
pulmonary nodule. The radiologist should report a diagnosis of
“pulmonary nodule” and may sequence “cough” as an additional
diagnosis.

* Signs or Symptoms:

If the diagnostic test did not provide a definitive diagnosis or was normal, the
interpreting physician should code the sign(s) or symptom(s) that prompted the
treating physician to order the study.

Example 1: A patient is referred to a radiologist for a spine X-ray due to
complaints of “back pain.” The radiologist performs the X-ray and
the results are normal. The radiologist should report a diagnosis of
“back pain” since this was the reason for performing the spine X-
ray.

Example 2: A patient is seen in the emergency room for chest pain. An EKG is
normal and the final diagnosis is chest pain due to suspected
Gastroesophageal Reflux Disease (GERD). The patient was told to
follow up with his primary care physician for further evaluation of
the suspected GERD. The primary diagnosis code for the EKG
should be chest pain. Although the EKG was normal, a definitive
cause for the chest pain was not determined.

* Diagnosis Preceded by Words That Indicate Uncertainty:

If the results of the diagnostic test are normal or non-diagnostic and the referring
physician records a diagnosis preceded by words that indicate uncertainty (e.g.,
probable, suspected, questionable, rule out or working), then the interpreting
physician should not code the referring diagnosis. Rather, the interpreting
physician should report the sign(s) or symptom(s) that prompted the study.
Diagnoses labeled as uncertain are considered by the ICD-9-CM coding
guidelines as unconfirmed and should not be reported. This is consistent with the
requirement to code the diagnosis to the highest degree of certainty.

Example:
A patient is referred to a radiologist for a chest X-ray with a
diagnosis of “rule out pneumonia.” The radiologist performs a chest
X-ray and the results are normal. The radiologist should report the
sign(s) or symptom(s) that prompted the test (e.g., cough).

Test Orders
The referring physician is required to provide diagnostic information to the testing entity at the time the test is ordered. The physician who is treating the patient must order all diagnostic tests.

An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. An order may include the following forms of communication:

* A written document signed by the treating physician/practitioner, which is hand-
delivered, mailed or faxed to the testing facility.

* A telephone call by the treating physician/practitioner or his office to the testing facility. Note: If the order is communicated via telephone, both the treating physician/practitioner or his office and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.
Or,

* An electronic mail by the treating physician/practitioner or his office to the testing facility.

Incidental Findings

Incidental findings should never be listed as primary diagnoses. If reported, incidental findings may be reported as secondary diagnoses by the physician interpreting the diagnostic test.

Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms
When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the testing facility or the physician interpreting the diagnostic test should report the screening code as the primary diagnosis code. Any condition discovered during the screening should be reported as a secondary diagnosis.

Requirements That Certain Tests Must Be Ordered by the Treating Physician
Internet-Only Manual (IOM) 100-08, Chapter 3, Section 3.4.1.1D

All diagnostic X-ray services, diagnostic laboratory services and other diagnostic
services must be ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem.

Rules of DX code in CMS 1500

2011-11-08T15:22:00.000+05:30

DIAGNOSIS OVERVIEW

ICD-9-CM Codes

Physicians and Non-Physician Practitioners (NPP) must use the appropriate
diagnosis code or codes to identify symptoms, conditions, problems, complaints
or other reasons for the encounter or visit.

Claims will be returned as unprocessable when the ICD-9-CM code is invalid.

Rules for Reporting Diagnosis Codes

*Use the ICD-9-CM code that describes the patient’s diagnosis, symptom,
     complaint, condition or problem. Do not code a suspected diagnosis.

* Use the ICD-9-CM code that is chiefly responsible for the item or service
   provided.

* Assign codes to the highest level of specificity. Use the fourth and fifth digits
   where applicable.

* Code a chronic condition as often as applicable to the patient’s treatment. Code
    all documented conditions that coexist at the time of the visit that require or affect

patient care or treatment. Do not code conditions that no longer exist.
ICD-9-CM Codes and Date of Service

The ICD-9-CM codes must be coded to the highest level of specificity for the date of service, i.e., coding to the fourth or fifth digit. This is a requirement for all physician and NPP claims.

Diagnosis codes must be reported based on the date of service on the claim and not the date the claim is prepared or received.

Updated ICD-9-CM codes are effective each October 1.

DX code V01 - V82 & E800 - E999

2011-10-15T23:26:00.000+05:30

SUPPLEMENTARY CLASSIFICATION OF FACTORS INFLUENCING HEALTH
STATUS AND CONTACT WITH HEALTH SERVICES [V01-V82]

[V01-V06] Persons with potential health hazards related to communicable diseases.
[V07-V09] Persons with need for isolation, other potential health hazards and prophylactic measures.
[V10-V19] Persons with potential health hazards related to personal and family history.
[V20-V28] Persons encountering health services in circumstances related to reproduction and
development.
[V30-V39] Live born infants according to type of birth.
[V40-V49] Persons with a condition influencing their health status.
[V50-V59] Persons encountering health services for specific procedures and aftercare.
[V60-V68] Persons encountering health services in other circumstances.
[V70-V82] Persons without reported diagnosis encountered during examination and investigation of
individuals and populations.

SUPPLEMENTARY CLASSIFICATION OF EXTERNAL CAUSES OF INJURY AND POISONING
[E800-E999]
[E800-E807] Railway accidents.
[E810-E819] Motor vehicle traffic accidents.
[E820-E835] Motor vehicle non-traffic accidents.
[E826-E829] Other road vehicle accidents.
[E830-E838] Water transport accidents.
[E840-E845] Air and space transport accidents.
[E846-E848] Vehicle accident not elsewhere classifiable.
[E850-E858] Accidental poisoning by drugs, medicinal substances, and biologicals.
[E860-E869] Accidental poisoning by other solid and liquid substances, gases, and vapors.
[E870-E876] Misadventures to patients during surgical and medical care.
[E878-E879] Surgical and medical procedures as the cause of abnormal
reaction of patient or later complication, without mention of misadventure at the time of
procedure.

[E880-E888] Accidental falls.
[E890-E899] Accidents caused by fire and flames.
[E900-E909] Accidents due to natural and environmental factors.
[E910-E915] Accidents caused by submersion, suffocation, and foreign bodies.
[E916-E928] Other accidents.
[E929-E929] Late effects of accidental injury.
[E930-E949] Drugs, medicinal and biological substances causing adverse effects in therapeutic uses.
[E950-E959] Suicide and self-inflicted injury.
[E960-E969] Homicide and injury purposely inflicted by other persons.
[E970-E978] Legal intervention.
[E980-E989] Injury undetermined whether accidentally or purposely inflicted.
[E990-E999] Injury resulting from operations of war.

Identifying Adjustments and Voids on the Remittance Voucher

2011-10-07T18:39:00.001+05:30

Adjustments on the Remittance Voucher

Adjustment requests are printed on the remittance voucher as two different claim entries.

The incorrectly paid claim is listed exactly as it was when it was originally reported. The transaction control number (TCN) for this entry is not the same as the original claim, but is a system-assigned, unique “credit” TCN. The original incorrect payment is credited back to Medicaid’s account. A minus symbol ( - ) appears just to the right of the incorrectly paid amount. The adjusted request is printed directly following the original claim entry.

Incorrect claim information on the original now shows as corrected. The difference between these two entries is the “NET” amount on the remittance voucher.

An Adjustment Reason Code (ADJ-R) and the TCN of the claim being adjusted are listed following the two claim entries. Adjustment reason codes are defined in the summary section of the remittance voucher.

Voids on the RV

Void requests are printed as one claim entry. The entire claim is displayed and the payment amount is returned to Medicaid. A minus symbol ( - ) appears next to the amount.

Adjustment or Void Reason Codes

An Adjustment Reason Code appears with each adjustment or void shown on the remittance voucher. These numeric codes are explained on the remittance voucher.

INJURY AND POISONING [800-999]

2011-10-05T23:25:00.000+05:30

[800-829] Fractures.
[800-804] Fracture of skull.
[805-809] Fracture of neck and trunk.
[810-819] Fracture of upper limb.
[820-829] Fracture of lower limb.
[830-839] Dislocation.

[840-848] Sprains and strains of joints and adjacent muscles.
[850-854] Intracranial injury, excluding those with skull fracture.
[860-869] Internal injury of thorax, abdomen, and pelvis.
[870-897] Open wound o.
[900-904] Injury to blood vessels.
[905-909] Late effects of injuries, poisonings, toxic effects, and other external causes.
[910-919] Superficial injury.
[920-924] Contusion with intact skin surface.
[925-929] Crushing injury.
[930-939] Effects of foreign body entering through orifice.
[940-949] Burns.
[950-957] Injury to nerves and spinal cord.
[958-959] Certain traumatic complications and unspecified injuries.
[960-979] Poisoning by drugs, medicinal and biological substances.
[980-989] Toxic effects of substances chiefly non-medicinal as to source.
[990-995] Other and unspecified effects of external causes.
[996-999] Complications of surgical and medical care, not elsewhere classified.

The Benefits of Outsourcing - Process of Medical Billing outsource

2011-10-01T11:38:00.002+05:30

Are you a doctor who has a successful medical practice? Have you often heard friends suggesting you to switch outsourced medical billing if you are planning to expand your business further? If the answer to those two questions is “Yes!” you do not have to look any further. We are here to demystify the benefits of outsourcing for you.

First let’s understand what exactly outsourced medical billing is. Outsourcing your medical billing to a company that provides a more efficient solution to organize and arrange your medical billing records. These experienced firms bring their latest and trusted methods to manage your accounts after doing an in-depth analysis of your business. They may have one basic process but they fine-tune in to meet the needs of each client. So before you decide if you want to adopt this model for your business, let’s have a look at some of the benefits of outsourcing.

When you opt for an outsourcing firm to handle your medical billing, you can go back to doing what you do best. You can continue to be the friendly doctor you always dreamt to become, instead of constantly worrying about the financial aspects of the business. Healthcare billing has become quite complex in the last few years. Also the rules of insurance companies and other regulatory agencies change so frequently that it has become almost impossible to keep a tab on all of that. But when you pick a partner to handle your outsourced medical billing, they will resolve all your tensions. After all you have left the task of worrying to the experts.

Also with a company that is dedicated to your medical billing, the rate of defaulters is reduced. After all the company is only going to get paid if it completes the task it was assigned to do. Also, you may not believe it at first when we tell you; but you can actually lower your expenditure this way. It is true that the company will charge a fee for their services, but this cost will still be lower than what you would have spent to train your nursing staff to collect medical bills. And then you also have to worry about buying financial software with its constant updates. But the cost of this software is included in the outsourcing package now.

If you are still not happy with the benefits of outsourcing your medical billing, the last reason will surely make you reconsider your position. If you are suspicious that your employees are stealing from the medical bills, this is the best way to put that suspicion to rest once and for all. You still remain the head of the business, but you have only hired a company to handle one aspect of your business.

DX code 630.00 - 759.99

2011-09-26T23:24:00.000+05:30

COMPLICATIONS OF PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM [630-677]
[630-633] Ectopic and molar pregnancy.
[634-639] Other pregnancy with abortive outcome.
[640-648] Complications mainly related to pregnancy.
[650-659] Normal delivery, and other indications for care in pregnancy, labor, and delivery.
[660-669] Complications occuring mainly in the course of labor and delivery.
[670-677] Complications of the puerperium.

DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE [680-709]
[680-686] Infections of skin and subcutanious tissue.
[690-698] Other inflammatory conditions of skin and subcutaneous tissue.
[700-709] Other diseases of skin and subcutaneous tissue.

DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE [710-739]
[710-719] Arthropathies and related disorders.
[720-724] Dorsopathies.
[725-729] Rheumatism, excluding the back.
[730-739] Osteopathies, chondropathies, and acquired musculoskeletal deformities.

CONGENITAL ANOMALIES [740-759]
[740-744] Head and spine anomalies.
[745-747] Heart and circulatory system anomalies.
[748-751] Respiratory and digestive system anomalies.
[752-753] Genitals and urinary system anomalies.
[754-757] Musculoskeletal and integumentary system anomalies.
[758-759] Chromosonal and other anomalies.

CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD [760-779]
[760-763] Maternal causes of perinatal morbidity and mortality.
[764-779] Other conditions originating in the perinatal period.
SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS [780-799]
[780-789] Symptoms.
[790-796] Nonspecific abnormal findings.
[797-799] Ill-defined and unknown causes of morbidity and mortality.

Anesthesia Modifiers - P1 - P6 modifier

2011-09-25T22:50:00.000+05:30

Anesthesia Modifiers Including Physical Status Modifiers:

All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-01999) plus
the addition of a physical status modifier. The use of other optional modifiers may be appropriate.

Physical Status Modifiers
Physical Status modifiers are represented by the initial letter 'P' followed by a single digit from 1 to 6
defined below:

P1 - A normal healthy patient.
P2 - A patient with mild systemic disease.
P3 - A patient with severe systemic disease.
P4 - A patient with severe systemic disease that is a constant threat to life.
P5 - A moribund patient who is not expected to survive without the operation.
P6 - A declared brain-dead patient whose organs are being removed for donor purposes.

The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of
complexity of the anesthesia service provided.

Example: 00100-P1

Other Modifiers (Optional)
Under certain circumstances, medical services and procedures may need to be further modified. Other
modifiers commonly used in Anesthesia are included below. A complete list of modifiers and their
respective codes are listed in Appendix A.

-22 Unusual Procedural Services: When the service(s) provided is greater than that usually
required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure
number or by use of the separate five digit modifier code 09922. A report may also be appropriate.

-23 Unusual Anesthesia: Occasionally, a procedure which usually requires either no anesthesia or
local anesthesia, because of unusual circumstances must be done under general anesthesia. This
circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service
or by use of the separate five digit modifier code 09923. Note: Modifier '-47', Anesthesia by
Surgeon, (see modifier section) would not be used as a modifier for the anesthesia procedures 00100-
01999.

-32 Mandated Services: Services related to mandated consultation and/or related services (eg,
PRO, 3rd party payer) may be identified by adding the modifier '-32' to the basic procedure, or the
service may be reported by use of the five digit modifier 09932.

Medicine CPT code List

2011-09-24T23:04:00.000+05:30

Immunization Injections 90700 - 90749
Therapeutic/ Diagnostic Infusions ( excludes chemo) 90780 - 90781
Therapeutic or Diagnostic Injections 90782 - 90799
Psychiatry 90801 - 90899
Biofeedback 90901 - 90911
Dialysis 90918 - 90999
Gastroenterology 91000 - 91299
Ophthalmology 92002 - 92499
Special Otorhinolaryngologic Services 92502 - 92599
Cardiovascular 92950 - 93799
Non-Invasive Vascular Diagnostic Studies 93875 - 93990
Pulmonary 94010 - 94799
Allergy and Clinical Immunology 95004 - 95199
Endocrinology 95250
Neurology and Neuromuscular Procedures 95805 - 96004
Central Nervous System Assessments/Tests 96100 - 96117
Health and Behavior Assessment/Intervention 96150 - 96155
Chemotherapy Administration 96400 - 96549
Photodynamic Therapy 96567 - 96571
Special Dermatological Procedures 96900 - 96999
Physical Medicine and Rehabilitation 97001 - 97799
Medical Nutrition Therapy 97802 - 97804
Osteopathic Manipulative Treatment 98925 - 98929
Chiropractic Manipulative Treatment 98940 - 98943
Special Services Procedures and Reports 99000 - 99091
Qualifying Circumstances for Anesthesia 99100 - 99140
Sedation With or Without Analgesia 99141 - 99142
Other Services and procedures 99170 - 99199
Home Health Procedures/Services 99500 - 99539
Home Infusion Procedures 99551 - 99569

Medical Billing Code Changes - Keep up with updation.

2011-09-22T11:36:00.001+05:30

Medical billing coding is used to claim from insurance companies, and change frequently, usually on an annual basis. When billing codes become obsolete, insurance companies do not accept them, and as a consequence, claims are rejected.

There are a few methods which one can employ to stay in touch with changes and maintain a current medical billing code. The Code Books like CPT give a definition for each billing code, and list each billing code alphanumerically, making it easy to follow. Billing codes recorded in the CPT Code Books are revised with each issue on annual basis. Within each book is an appendix of changes, which show how a service has been modified from the current procedural terminology while maintain the same definition. By following the changes in the CPT Code Book every year, one is able to maintain an up to date database of billing code changes.
Another possible method to handle billing code changes involves using the International Classification of Diseases (ICD9). This system is used primarily as a means of reporting statistical data, and works by grouping the procedures of the related diseases. Similar to the CPT Code Books, ICD9 Books sort their diseases and diagnoses alphanumerically, and are updated annually.

Having to cross-reference billing codes with two referencing systems can be very time consuming, and there can be an element of human error involved. Using Medical Billing Software is a worthwhile alternative for referencing code books, which is likely to be updated frequently. Another advantage is that one does not require cross-referencing or the need to refer a range of billing code books when coding any medical procedure. Electronic software completely removes this problem, and more importantly, online referencing features are available that cannot be matched by using code reference books.

With such distinct advantages, one can see that medical software for code billing is the most effective way to handle changes in billing codes. Apart from being more efficient in filing claims with the billing codes, offices that make use of online billing and coding software will have an easier migration from outdated billing codes and procedures to current items. All this is possible since the software itself can handle most of the comparison and referencing, providing there are regular updates to its database.

Maintaining an up to date billing code database not only streamlines administrative work, but it ensures that the billing practices used and the standard of service one can provide to consumers is improved, and a high standard maintained.

RESPIRATORY, DIGESTIVE SYSTEM, GENITOURINARY SYSTEM - DX CODE

2011-09-15T23:22:00.000+05:30

DISEASES OF THE RESPIRATORY SYSTEM [460-519]
[460-466] Acute respiratory infections.
[470-478] Other diseases of the upper respiratory tract.
[480-487] Pneumonia and influenza.
[490-496] Chronic obstructive pulmonary disease and allied conditions.
[500-508] Pneumoconioses and other lung diseases due to external agents.
[510-519] Other diseases of respiratory system.

DISEASES OF THE DIGESTIVE SYSTEM [520-579]
[520-529] Diseases of oral cavity, salivary glands. and jaws.
[530-537] Diseases of esophagus, stomach, and duodenum.
[540-543] Appendicitis.
[550-553] Hernia of abdominal cavity.
[555-558] Noninfectious enteritis and colitis.
[560-569] Other diseases of intestines and peritoneum.
[570-579] Other diseases of digestive system.

DISEASES OF THE GENITOURINARY SYSTEM [580-629]
[580-589] Nephritis, nephrotic syndrome, and nephrosis.
[590-599] Other diseases of urinary system.
[600-608] Diseases of male genital organs.

[610-611] Disorders of breast.
[614-616] Inflammatory disease of female pelvic organs.
[617-629] Other disorders of female genital tract.

How costly is Medical Billing Mistakes and Fraud?

2011-09-13T11:35:00.001+05:30

Even though working from the comfort of home as a medical billing professional may seem like the near-perfect career, offering benefits and advantages that within a doctor’s office or healthcare center are unavailable, the ramifications of possible mistakes can be very costly.

An example of how things can go wrong can be shown by MSO Washington, Inc. MSO is a medical practice management and billing service company that had to agree a settlement against claims of healthcare fraud, to the value of $565,000. The Dept. of Justice alleges that the company made claims to Medicare and Medicaid for settlement which failed to include the proper records and claims for procedures that were deemed medically unnecessary. The Department found that in some cases the procedures claimed for were never completed, or they were executed but charged for at rates above the industry standard.

It seems as though the healthcare providers were allegedly not aware of the questionable billing practices, and consequently, they were not a part of the investigation. The system that was under investigation was a home visitation program, in which doctors and medical professionals visited homes to inspect the residence itself.

As a professional and highly-trained medical professional, one would be able to detect anomalies and point out possible fraudulent activities. There is great value placed on such individuals, and as a result, insurance companies and government-based agencies will depend heavily on that person’s skills and training, as well as their moral character. After all, one would have medical documentation of many patients at hand.

Throughout the education and billing services classes, one is expected to learn every part of the coding systems that are used and relate to procedures, medical products and the services that their respective companies provide. Important aspects that medical offices and hospitals seek out when looking for specialists include a concern and prioritization of getting their job done; correctly and efficiently.

Where claims are concerned, most companies/offices will seek out a fair reimbursement for their services. Companies can lose vast sums of money through malpractice, accidental or intentional.

The owner of MSO Washington Inc. did not admit liability, so it can be deemed that the fraud was accidental and not intentional. This only highlights the importance of personnel who can account for their work and ensure that there are no errors. High-quality personnel are able to seek out the correct compensation while preserving a fraud-free status.

ICD 9 - DX code Mandatory Fiftt digit

2011-09-12T23:17:00.000+05:30

Mandatory Fifth Digit

A 3-digit code is the primary classification for an illness or injury, a 4-digit code is a secondary classification of the same illness or injury, and a 5-digit code is a classification of the same illness or injury.

Notes are also used to list the fifth-digit sub classifications for subcategories – such as entries “Tuberculosis” or Diabetes mellitus.” Only the four-digit code is given for the individual entry, and you must refer to the note following the main term to locate the appropriate fifth-digit sub classification.

Not all ICD codes are valid for use on insurance claim forms. Carriers require the greatest specificity possible when using the codes. The idea is never to use a 3-digit code that has been sub-classified into 4-digit codes, and never use a 4- digit code that has been sub-classified as a 5-digit code.

Not all codes have fourth and fifth digits, but when a fourth or fifth digit is available, it must be used. It is a good idea to highlight codes with which a fifth digit is listed. This will serve as a reminder to you to always use that fifth digit. The following is a list of fifth digits that are used to identify location.

0 site unspecified
1 shoulder region
2 upper arm
3 forearm
4 hand
5 pelvic region and thigh
6 lower leg
7 ankle and foot
8 other specified sites
9 multiple sites

Pathology and Laboratory CPT code list

2011-09-09T23:03:00.000+05:30

• CPT Divided into fourteen subsections:

Organ or Disease Oriented Panels 80048* - 80076
Drug Testing 80100 - 80103
Therapeutic Drug Assays 80150 - 80299
Evocative/Suppression Testing 80400 - 80440
Consultations (Clinical Pathology) 80500 - 80502
Urinalysis 81000 - 81099
Chemistry 82000 - 84999
Hematology and Coagulation 85002 - 85999
Immunology 86000 - 86849
Transfusion Medicine 86850 - 86999
Microbiology 87001 - 87999
Anatomic Pathology 88000 - 88099
Cytopathology 88104 - 88199
Cytogenetic Studies 88230 - 88299
Surgical Pathology 88300 - 88399
Transcutaneous Procedures 88400
Other Procedures 89050 - 89399

Anesthesia Billing Guideline CPT 99200, 99000,99070

2011-09-07T22:48:00.000+05:30

Time Reporting:

Time for anesthesia procedures may be reported as is customary in the local area. Anesthesia time begins
when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating
room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendance, that
is, when the patient may be safely placed under postoperative supervision.

Physicians Services:
Physician's services rendered in the office, home, or hospital, consultation and other medical services are
listed in the "Codes" section entitled Evaluation and Management Services (99200 series). "Special
Services and Reporting" (99000 series) are presented in the Medicine section.

Materials Supplied by Physician:
Supplies and materials provided by the physician (eg, sterile trays, drugs) over and above those usually
included with the office visit or other services rendered may be listed separately. List drugs, tray supplies,
and materials provided. Identify as 99070.

How to Get Medical Billing and Coding Certification

2011-09-05T11:30:00.001+05:30

The number of people opting for medical and healthcare insurance has increased drastically in the last few years. With it the need has siren for a modern, efficient and streamlined method to manage the accounts and billing records of the medical facility. This has increased the demand for professional billing and coding specialists.

Medical billing and coding is actually the procedure of filing claims on insurance companies and following them to recover the medical expenditure of an insurance policy holder. Generally the pay for people handling this job is quite high and that has caused an increase in the number of people looking to acquire this job whether part-time or full-time.

If you want to work in a medical facility to manage the billing system, you should look at some certification courses to qualify for the job. Once you have completed the course you work at many medical establishments including medium and large sized hospitals, individual and physicians’ group clinics, medical offices infirmaries, diagnostic laboratories, and insurers.

If you are interested in joining this field, you should start searching for a college near you that offers certification and teaching of medical billing and coding. If you already have a job that makes it impossible for you to attend regular classes, you also have the opportunity to take an online course offered by many institutions.

If you are US, there are two programs for you; professional coder and coding specialist. Each study program is about a year long and has to be certified either by the Academy of Professional Coders, Registered Health Information Association (RHIA), Registered Health Information Technician (RHIT) or the American Health Information Management Association (AHIMA); if you want to eventually acquire a job in this profession. AMIHA certification is more appropriate for people who want to join this field and have little or no prior relevant experience. But if you are an experienced medical coder and are looking for a certification, you should contact the Professional Association of Healthcare.

Like everything else around you, medical billing has also become fast-tracked and easy by the help of revolutionary software packages. But before you start learning this software, you must familiarize yourself with the root words for body systems. Without learning the medical language, you cannot get very far. But by chance even if you do, you will be responsible for some major confusion or mix-up eventually due to your ignorance.

You also have to pass the coding certification examination to become finally eligible for the job. The test is very comprehensive and will test your knowledge on about the different protocols and procedures that you need to know to become a qualified medical coder. You will be asked about the current HCPCS procedures and also about ICD-9-CM to make sure that you understand properly the demands of the job.

Primary Care Physician Protocols

2011-09-03T19:53:00.000+05:30

If these Primary Care Physician Protocols differ from or conflict with other Protocols in connection with any matter pertaining to Evercare Institutional Customers, these Primary Care Physician Protocols will govern unless statutes and regulations dictate otherwise.

The Primary Care Physician will cooperate with and be bound by these additional protocols:

1. A ttend Primary Care Physician orientation session and annual Primary Care Physician meetings thereafter.
2. C onduct face-to-face initial and ongoing assessments of the medical needs of Evercare Institutional Customers, including all assessments mandated by regulatory requirements.
3. D eliver health care to Evercare Institutional Customers at their place of residence in collaboration with the Primary Care Team.
4. Family Care Conferences - Participate in formal and informal conferences with responsible parties, family and/or legal guardian of the Evercare Institutional Customer to discuss the Evercare Institutional Customer’s condition, care needs, overall plan of care and goals of care, including advance care planning.
5. Primary Care Team Collaboration and Coordination - Collaborate with other members of the Primary Care Team designated by Evercare and any other treating professionals to provide and arrange for the provision of covered services to Evercare Institutional Customers. This includes, but is not limited to, making joint visits with other Primary Care Team members to Evercare Institutional Customers and participating in formal and informal conferences with Primary Care Team members and/or other treating professionals following a scheduled Evercare Institutional Customer reassessment, significant change in plan of care and/or condition.
6. C ollaborate with Evercare when a change in the Primary Care Team is necessary.
7. Provide Evercare a minimum of forty-five (45) calendar days prior notice when discontinuing delivery of covered services at any facility where Evercare Institutional Customers reside.
8. When admitting an Evercare Institutional Customer to a hospital, notify Evercare or Payer immediately if the admission is for an emergency or for observation.

MENTAL DISORDERS & NERVOUS SYSTEM AND SENSE ORGANS DX code list

2011-08-30T23:21:00.000+05:30

MENTAL DISORDERS [290-319]
[290-299] Psychoses.
[290-294] Organic psychotic conditions.
[295-299] Other psychoses.
[300-316] Neurotic disorders, personality disorders, and other non-psychotic mental disorders.
[317-319] Mental retardation.

NERVOUS SYSTEM AND SENSE ORGANS [320-389]
[320-326] Inflammatory diseases of the central nervous system.
[330-337] Hereditary and degenerative diseases of the central nervous system.
[340-349] Other disorders of the central nervous system.
[350-359] Disorders of the peripheral nervous system.
[360-379] Disorders of the eye and adnexa.
[380-389] Diseases of the ear and mstoid process.

DISEASES OF THE CIRCULATORY SYSTEM [390-459]
[390-392] Acute rheumatic fever.
[393-398] Chronic rheumatic heart disease.
[401-405] Hypertensive disease.
[410-414] Ischemic heart disease.
[415-417] Diseases of pulmonary circulation.
[420-429] Other forms of heart disease.
[430-438] Cerebrovascular disease.
[440-448] Diseases of arteries, arterioles, and capillaries.
[451-459] Diseases of veins and lymphatics, and other diseases of circulatory system

Medical Billing Fraud & abuse

2011-08-29T19:49:00.001+05:30

Fraud, waste and abuse prevention & training

If you identify potential fraud, waste, or abuse, please report it to us immediately so that we can investigate and respond appropriately. Please see the How to Contact Us section of this guide for contact information. Please note UnitedHealthcare expressly prohibits retaliation if a report is made in good faith.

• Fraud Is a false statement, made or submitted by an individual or entity, who knows that the statement is false, and knows that the false statement could result in some otherwise unauthorized benefit to the individual or entity. These false statements could be verbal or written.

• Waste Generally means over-use of services, or other practices that result in unnecessary costs. In most cases, waste is not considered caused by reckless actions but rather the misuse of resources.

• Abuse Generally refers to provider, contractor or member practices that are inconsistent with sound business, financial or medical practices; and that cause unnecessary costs to the health care system.

Effective January 1, 2009, the Centers for Medicare & Medicaid Services (“CMS”) modified certain rules and regulations of the Medicare Advantage and the Part D programs. The rules state that a compliance plan must include training, education, and effective lines of communication between the compliance officer and the organization’s employees, managers, directors, as well as first tier, downstream and related entities. This change clarified that plan sponsors, such as UnitedHealthcare, need to apply these training and communication requirements to all entities they are partnering with to provide services in Medicare Advantage or Part D programs.

As a contracted provider for UnitedHealthcare’s Medicare Advantage programs, you are considered a first tier or downstream entity and are subject to this CMS requirement. It is our responsibility to ensure that your organization is provided with appropriate training for your employees and applicable subcontractors. To facilitate that, we will be providing your organization with training materials, which will be made available on UnitedHealthcareOnline.com.

Annually, your organization must administer the training materials to your employees and applicable subcontractors. This annual training can be done using our materials or you may use your existing training program and/or materials provided by another health plan as long as that training meets the CMS requirements. Please maintain records of the training (i.e. sign-in sheets, materials, etc). Documentation of the training may be requested by UnitedHealthcare, CMS, or an agent of CMS to verify the training was completed.

How To File an Adjustment Request on a Paper Claim

2011-08-29T18:41:00.000+05:30

Requirements for Filing an Adjustment

An adjustment request is processed as a replacement to the original, incorrectly paid claim. The original payment for the claim is completely deducted. All claim items on the request must be correctly completed. An adjustment must be for the entire amount, not just for remaining unpaid amounts or units.

A legible photocopy of the original claim or an entirely new claim can be used when submitting an adjustment.
The provider does not need to send an adjustment request for each claim line that paid incorrectly. All errors can be corrected with one adjustment request.

Adjustments must be received by the Medicaid fiscal agent within one year of the date of payment.

Partially Incorrect Claim Lines on a Claim Form

Use the following procedures when some claim lines on a claim form paid correctly and other lines did not pay correctly.

If some claim lines paid correctly and some lines denied, do not request an adjustment. Cross out the claim lines that were paid, change the total amount billed, correct the errors on the lines that denied, and resubmit the claim. If all the claim lines paid, but some paid incorrectly, request an adjustment.

Make needed corrections and circle the items to be corrected in black ink. Do not cross out the lines that paid correctly. Crossed-out lines are treated as voids and payment for these lines will be recouped.
If one claim line needs to be deleted from a claim that has other lines that paid correctly, request an adjustment not a void. If the request is marked as a void, all the claim lines will be recouped. To delete one line, mark the request an adjustment, circle the line to be deleted, and write “delete” to the side of the line.
You must use black ink.

Adjustment Instructions

When requesting an adjustment or void, the provider must:
· Resubmit a photocopy of the original claim or a new claim form;
· Enter the items listed below;
· Ensure that the items on the adjusted claim match the items on the original
claim, except for the corrections that are made and circled in black ink;
· Initial and date the form if it is a photocopy, or sign and date it if it is a new
form;
· Attach copies of the documents that were required for the original claim to
the adjustment request; and
· Mail the adjustment or void request to the fiscal agent for processing to:

Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080

Can we take Medical Insurance Biller and Coder as a job?

2011-08-25T11:34:00.001+05:30

A person working within the profession of medical insurance billers or medical insurance coder’s works in the administrative sector of the medical field, managing patient records and database information, following up on billing for insurance and book-keeping/accounting for the practice or healthcare facility. Insurance billers and coders that work in a front office utilize their expertise without having any direct interaction with patients.

A career in medical insurance billing and coding is ideal for a person looking for a job concerning the analysis of data with a focus on implementing a coding system that is used to identify and group various items. Whereas a medical biller implements a preset code, a medical coder focuses on allocating codes for the different procedures.

Each and every medical diagnosis and medical procedure used within a healthcare facility must have an appropriate code assignment. This allows the office to file a successful claim for settlement from an insurance company. Medical insurance billers and coders can work in doctor's practice, within a hospital, or even at a dedicated healthcare office. A fair amount of medical billers and coders choose to work for agencies that offer their resources to healthcare facilities on a freelance basis, outsourcing members of staff.

Medical insurance billing and coding is an exciting field of work that appeals to and suits people who have great attention to detail. Coders and billers must also be able to efficiently adapt to industry standards. Errors and inaccuracies within the profession can lead to mis-selling a particular service or under pricing a product, incorrect or incompatible coding, and even misplacement of claims and payments that more often than not contribute to loss of income in a medical practice.

Such is the requirement for efficient and error-free coding that a high value is placed on those who are very effective and proficient in their area of work. Medical insurance billers and coders find work in areas that include, but are by no means limited to doctor’s practices, billing agencies, medical care clinics and healthcare facilities. Many employers favor potential candidates with greater certifications or more advanced qualifications. Certifications can often help ensure that potential candidates have the right skills and as a consequence, secure a more successful job.

Certification for insurance billing and coding combined with work experience that is earned while working is something employers will use to determine potential candidates for advancing into managerial positions as well as bespoke posts within a company that call for specific skills and expertise.

Standard for Medical records - General Guidelines

2011-08-24T19:46:00.000+05:30

Medical record standards

Medical records will contain all information necessary and appropriate for quality improvement activities and to support claims for services submitted by you.

In providing care for UnitedHealthcare members, we expect that you have signed, written policies to address the following (critical elements appear in bold text in this section):

1. Maintain a single, permanent medical record that is current, detailed, organized and comprehensive for each
member and is available at each visit.

2. Protect member records, whether in paper or electronic form, against loss, destruction, tampering or
unauthorized use. For electronic medical records, you must establish security safeguards in order to prevent
unauthorized access or alteration of records without leaving an audit trail to identify the breach. Such safeguards must be programmed so that they cannot be overridden or turned off.

3. Maintain medical records in a confidential manner and provide periodic training to office staff
regarding confidentiality processes. Records storage must allow for easy retrieval, be secure and allow
access only by authorized personnel.

4. Maintain a mechanism for monitoring and handling missed appointments.

5. Demonstrate the office does not discriminate in the delivery of health care.

General documentation guidelines

We also expect you to follow these commonly accepted guidelines for medical record information and documentation:

• Date all entries, and identify the author and their credentials when applicable. For records generated by word processing software or electronic medical record software, the documentation should include all authors and their credentials. It should be apparent from the documentation which individual performed a given service.

• Clearly label or document subsequent changes to a medical record entry by including the author of the change and date of change. The provider must also maintain a copy of the original entry.
• Generate documentation at the time of service or shortly thereafter.

• Make entries legible.

• Cite medical conditions and significant illnesses on a problem list and document clinical findings and
evaluation for each visit.
• Documentation that is not reasonable and necessary for the diagnosis or treatment of an injury or illness or to
improve the function of a malformed body member (over documentation) should not be considered when selecting the appropriate level of an E&M service. Only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate E&M level.
• Give prominence to notes on medication allergies and adverse reactions. Also, note if the member has
no known allergies or adverse reactions.
• Make it easy to identify the medical history, and include chronic illnesses, accidents and operations.
• For medication records, include name of medication and dosages. Also, list over the counter drugs
taken by the member.
• Records reflect all services provided, ancillary services/tests ordered, and all diagnostic/therapeutic services referred by the physician/health care professional.
• Clearly label any documentation generated at a previous visit as previously obtained, if it is included in the
current record.

Document these important items:
• Tobacco habits, including advice to quit, alcohol use and substance abuse for members age eleven (11) and older
• Immunization record
• Family and social history
• Preventive screenings/services and risk screenings
• Screening for depression and evidence of coordination with behavioral health providers
• Blood pressure, height and weight, body mass index

Billing patient for non - covered service - consent form

2011-08-21T19:42:00.000+05:30

Charging members for non-covered services

For Commercial members, you may seek and collect payment from our member for services not covered under the applicable benefit plan, provided you first obtain the member’s written consent. Such consent must be signed and dated by the member prior to rendering the specific service(s) in question. Retain a copy of this consent in the member’s medical record. In those instances in which you know or have reason to know that the service may not be covered (as described below), the written consent also must: (a) include an estimate of the charges for that service; (b) include a statement of reason for your belief that the service may not be covered; and (c) in the case of a determination by us that planned services are not covered services, include a statement that UnitedHealthcare has determined that the service is not covered and that the member, with knowledge of UnitedHealthcare’s determination, agrees to be responsible for those charges.

For Medicare Advantage members, a Notice of Denial of Medical Coverage must be provided to the member advising them when a service is not covered.

You should know or have reason to know that a service may not be covered if:

•
We have provided general notice through an article in a newsletter or bulletin, or information provided on our Web site (UnitedHealthcareOnline.com), including clinical protocols, medical and drug policies, either that we will not cover a particular service or that a particular service will be covered only under certain circumstances not present with the member; or
• We have made a determination that planned services are not covered services and have communicated that
determination to you on this or a previous occasion.

You must not bill our member for non-covered services if you do not comply with this Protocol.

If you do not obtain written consent as specified above, the rendering provider must accept full financial liability for the cost of care. General agreements to pay, such as those signed by the member at any time (including at admission or upon the initial office visit), are not considered written consent under this Protocol.

NEOPLASMS, ENDOCRINE, BLOOD-FORMING ORGANS DX list

2011-08-20T23:20:00.000+05:30

NEOPLASMS [140-239]
[140-149] Malignant neoplasm of lip, oral cavity, and pharynx.
[150-159] Malignant neoplasm of digestive organs and peritoneum.
[160-165] Malignant neoplasm of respiratory and intrathoracic organs.
[170-176] Malignant neoplasm of bone, connective tissue, skin, and breast.
[179-189] Malignant neoplasm of genitourinary organs.
[190-199] Malignant neoplasm of other and unspecified sites.
[200-208] Malignant neoplasm of lymphatic and hematopoietic tissue.
[210-229] Benign neoplasms.
[230-234] Carcinoma in situ.
[235-238] Neoplasms of uncertain behavior.

ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES,AND IMMUNITY DISORDERS [240-279]
[240-246] Disorders of thyroid gland.
[250-259] Diseases of other endocrine glands.
[260-269] Nutritional deficiencies.
[270-279] Other metabolic and immunity disorders.

DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS [280-289]
[280-285] Anemias.
[286-287] Coagulation and hemorrhagic disorders.
[288-288] Diseases of white blood cells.
[289-289] Other diseases of blood and blood-forming organs.

Surgery CPT code list

2011-08-18T22:59:00.000+05:30

• CPT Codes listed by body system

Integumentary 10021 - 19499
Musculoskeletal 20000 - 29999
Respiratory 30000 - 32999
Cardiovascular 33010 - 37799
Hemic and Lymphatic 38100 - 38999
Mediastinum and Diaphragm 39000 - 39599
Digestive 40490 - 49999
Urinary 50010 - 53899
Male Genital 54000 - 55899
Intersex Surgery 55970 - 55980
Female Genital 56405 - 58999
Maternity Care and Delivery 59000 - 59899
Endocrine 60000 - 60699
Nervous 61000 - 64999
Eye and Ocular Adnexa 65091 - 68899
Auditory 69000 - 69979
Operating Microscope +69990

Affordable Medical Billing Services for Physicians

2011-08-16T11:27:00.000+05:30

Just like managing business accounts of any other company, medical billing comes with its own sets of rules and complexities. There are a lot of procedures to take care of and at the same time continue providing efficient, accurate and quality service. Then you also have to be worried about the insurance company which is sure to go over the billing system with a magnifying glass. One single mistake is going to cost you dearly and will leave a bad impact on the reputation of your medical facility irrespective of the quality of service you have provided to the patients. All in all, just like medical treatment should best be left to general physicians & specialist doctors, similarly the medical billing system of hospitals and clinics should be handed over to the professionals to manage.

Contrary to popular belief, outsourcing medical billing systems are not only for the big hospitals and treatment centers. Even medium sized medical facilities, diagnostic centers and healthcare clinics will be better off by investing in medical billing system to manage the collection of medical bills. The medical bills include everything ranging from consultation fee and cost of tests, right down to cost of treatments, operations and medicine. When you have found some company to handle the billing, you can get down to solving other administrative issues in your medical facility.

The best part about these medical billing companies is that they offer very affordable packages for everyone. The packages are so attractive that it is even affordable for a general physician to hire the company to handle the accounts in his small medical clinic. These companies have well-qualified and trained staff that can handle all your tasks including transcription services, claim submission, claim transmission, charge entry and audit, authorizations, payment posting, wellness checks, patient checks and denial resolutions among others. Not only this, but these companies will streamline your entire medical billing system to reduce time and effort required to manage the system. They will also help you in reducing the number of claim rejections for your medical facility.

Moreover once you have hired the right company you do not have to worry about complying with the laws and regulations of insurance companies and health regulatory authorities. Your hired company will make sure that everything goes according to the laws.

So what are you waiting for? Go online and find a medical billing service to outsource this job a reputed and experienced company.

Transplant Services CPT code list

2011-08-13T19:21:00.000+05:30

Request for transplant or transplant-related services prior to pre-treatment or evaluation,
including the following CPT Procedure Codes for Specifically Requested Transplantations:

BONE MARROW - Peripheral Stem Cell
38230 Bone marrow harvesting for transplantation
38240 Bone marrow or blood-derived peripheral stem cell transplantation; allogenic
38241 Bone marrow or blood-derived peripheral stem cell transplantation; autologous
38242 Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor
lymphocyte infusions

HEART / LUNG
33930 D onor cardiectomy-pneumonectomy, with preparation and maintenance of allograft
33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy
HEART
33940 D onor cardiectomy, with preparation and maintenance of allograft
33945 Heart transplant, with or without recipient cardiectomy
0051T I mplantation of a total replacement heart system (artificial heart) with recipient
cardiectomy
0052T Replacement or repair of thoracic unit of a total replacement heart system
(artificial heart)
0053T Replacement or repair of implantable component or components of total replacement
heart system (artificial heart), excluding thoracic unit

LUNG
32850 D onor pneumonectomy(ies) with preparation and maintenance of allograft (cadaver)
32851 L ung transplant, single; without cardiopulmonary bypass
32852 with cardiopulmonary bypass
32853 L ung transplant, double (bilateral sequential or en bloc); without cardiopulmonary
bypass
32854 with cardiopulmonary bypass

KIDNEY
50300 D onor nephrectomy, with preparation and maintenance of allograft, from cadaver donor,
unilateral or bilateral
50320 D onor nephrectomy, open from living donor (excluding preparation and maintenance of
allograft)
50340 Recipient nephrectomy
50360 Renal allotransplantation, implantation of graft; excluding donor and recipient
nephrectomy
50365 with recipient nephrectomy
50370 Removal of transplanted renal allograft
50380 Renal autotransplantation, reimplantation of kidney
50547 L aparoscopic donor nephrectomy from living donor (excluding preparation and
maintenance of allograft)

PANCREAS
48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or
pancreatic islet cells
48550 D onor pancreatectomy, with preparation and maintenance of allograft from cadaver
donor, with or without duodenal segment for transplantation
48554 Transplantation of pancreatic allograft
48556 Removal of transplanted pancreatic allograft
LIVER
47135 L iver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any
age
47136 heterotopic, partial or whole, from cadaver or living donor, any age
INTESTINE
44132 D onor enterectomy, open, with preparation and maintenance of allograft; from cadaver
donor
44133 partial, from living donor
44135 I ntestinal allotransplantation; from cadaver donor
44136 from living donor

INFECTIOUS AND PARASITIC DISEASES [001-139] - DX code

2011-08-10T23:19:00.000+05:30

[001-009] Intestinal infectious diseases.
[010-018] Tuberculosis.
[020-027] Zoonotic bacterial diseases.
[030-041] Other bacterial diseases.
[042-042] Human immunodeficiency virus (hiv) infection.
[045-049] Poliomyelitis and other non-arthropod-borne viral diseases of central nervous
system.
[050-057] Viral diseases accompanied by exam.
[060-066] Arthropod-borne viral disease.
[070-079] Other diseases due to viruses and chlamydia.
[080-088] Rickettsioses and other arthropod-borne diseases.
[090-099] Syphilis and other venereal diseases.
[100-104] Other spirochetal diseases.
[110-118] Mycoses.
[120-129] Helminthiases.
[130-136] Other infectious and parasitic diseases.
[137-139] Late effects of infectious and parasitic diseases.

Medicare supplement coverage plan responsibilities - Medicare select

2011-08-10T19:06:00.000+05:30

What Is Medicare Select?

Medicare Select is a Medicare Supplement product available only to AARP® members who reside within the service area of a hospital which participates in our Medicare Select network. It is a lower cost alternative to Standardized

Medicare Supplement coverage.

Responsibilities of Medicare Select members

To offer the plan at a lower premium, we require that Medicare Select members utilize a participating hospital for all inpatient and outpatient hospital services (except emergency care and services provided when members are outside of their service area).

Hospital responsibilities

Participating hospitals agree to a reduced/waived reimbursement of Medicare’s Part A In-Hospital deductible. Cost savings associated with hospitals’ reduction/waiver of Medicare’s Part A In-Hospital deductible are passed on to Medicare Select members in the form of lower premium cost.

To submit a Medicare Part A or Part B Intermediary claim for a Medicare Select insured, mail a copy of the standard

CMS billing form along with a Medicare Explanation of Benefits or Medicare Remittance Advice to:
AARP® Medicare Select
UnitedHealthcare Claim Division
P.O. Box 740819
Atlanta, GA 30374-0819

Note: Medicare Part B claims billed to a Medicare carrier are, in most cases, received electronically from the
Medicare carrier.

To promote timely processing on all claim submissions, follow standardized Medicare billing practices. Be sure to include the 11-digit AARP® Medicare Select member’s health care ID number on the standard CMS billing form.

What does Medicare Select cover in addition to Part A In-Hospital deductible?

• In-Hospital Part A coinsurance for days 61 through 90 in a Medicare Benefit Period.
• In-Hospital Part A coinsurance for days in which Lifetime Reserve days are used.
• Medicare Part A eligible expenses for a Lifetime Maximum of 365 days after all Medicare Part A benefits are exhausted.
• Medicare Part B coinsurance (generally 20% of Medicare’s approved amount).
• Medicare Part B deductible amount applied each calendar year.
• Skilled Nursing Facility stays - the daily coinsurance amount for days 21 to 100 for stays eligible under Medicare.
• Medicare Parts A and B Blood deductible: Charge incurred for the first three pints of unreplaced blood furnished in a calendar year.
• Foreign Travel Emergency.

Subrogation and Coordination of Benefits (COB) rules

2011-08-08T18:17:00.001+05:30

Our benefit plans are subject to subrogation and coordination of benefits (COB) rules.

1. Subrogation — To the extent permitted under applicable law and the applicable benefit plan, we reserve the right to recover benefits paid for a member’s health care services when a third party causes the member’s injury or illness.

2. Coordination of Benefits (COB) — COB is administered according to the member’s benefit plan and in
accordance with applicable law. UnitedHealthcare can accept secondary claims electronically. To learn more, go to UnitedHealthcareOnline.com  Claims & Payments  Electronic Claims Submission (EDI ), contact your EDI vendor, or call EDI support at (800) 842-1109.

Primary Plan --- Plan that pays benefits first --- Benefits under the primary plan will not be reduced due to benefits payable under other plans

Secondary Plan --- Plan will pay benefits after the primary plan --- Benefits under the secondary plan may be reduced due to benefits payable under other primary plans

Tertiary Plan --- Three or more group benefit plans may provide benefits for the same medical expense
Tertiary plans would offset the incurred expenses with the benefits paid by the primary and secondary carriers, and provide benefits for any remaining unreimbursed expenses

Note: When coordinating benefits with Medicare, all COB Types coordinate up to Medicare’s allowed amount when the provider accepts assignment. Medicare Secondary Payer (MSP) rules dictate when Medicare pays secondary.
3. Workers’ Compensation — In cases where an illness or injury is employment-related, workers’ compensation is primary. If notification is received that the workers’ compensation carrier has denied the claim, the provider should submit the claim to UnitedHealthcare, regardless of whether the case is being disputed. It is also helpful to send the other carrier’s denial statement with the claim.

How to Prevent Medical Billing Fraud

2011-08-07T11:25:00.004+05:30

Medical billing frauds are mostly related to medical insurances. In the US, such frauds may pertain to Medicare and Medicaid. Many people connected to health care sector may be involved in such frauds. The list of possible fraudsters includes beneficiaries, billing department personnel, recruiters, health care providers, and companies that offer medical services. Quite often invoices are raised for services that were not rendered to the beneficiary. Likewise, fraudulent bills may include medicines that are not prescribed for the beneficiary covered under medical insurance. Beneficiaries claim reimbursement of such bills, which might relate to somebody else's medication. Such inflated bills may also be raised to fleece the beneficiaries.

At times cost of treating ailments that are not covered under any medical insurance, or costs of other services related to health care that do not come under Medicare are recovered by beneficiary through invoices that mention other ailments that are covered. This defeats the purpose of having specific coverage in medical insurance policies and Medicare. Health care facility may raise separate bills for procedures that are already covered under some main billing item. The effect of such unbundling is that the invoices get inflated. Such frauds are obviously felony. They happen with connivance of some medical professionals, and other personnel in billing department of the health care facility. Since legal implications of such frauds are quite serious, health care facility needs to take necessary measures for preventing medical billing frauds.

For starters screening every employee at the time of recruitment is advisable. Background checking of the prospective candidate is a must. It is also necessary to verify the billing certificates produced by the candidate. In addition to this precaution, the health care facility can implement a foolproof system that requires compliance at different stages so that possibilities of medical billing fraud are remote. Somebody from administrative department should be given the responsibility of ensuring regular compliance with the system. This person should also have powers to deal severely with any fraud that may be detected. It is necessary to explain the entire procedure, and various checks integrated in them to every employee. The system should also ensure that an employee can report any abuse by superior without fearing any backlash.

In addition to above measures, the health care facility can ensure that all the rules and regulations stipulated under Health Insurance Portability and Accountability Act (HIPPA) are followed. HIPPA is a US law. It relates to health related information about a patient. It also has provisions relating to patient’s privacy and security of relevant information. HIPPA therefore stipulates that information about a patient such as the patient’s name, medical history, address, etc.. be protected. Passwords that guard such information should be kept a secret so that unscrupulous people do not learn about any patient’s case history. Placing fax machines in places that do not allow general public to access them is another way to prevent medical billing fraud. It is advisable to send encrypted mails relating to the patient rather than sending mails without any security precaution. A confidentiality agreement with severe consequences for breach can be entered into between the facility and the medical billing personnel. Such precautions are necessary even if a third party’s services are being availed for medical billing. Relevant clauses can then be incorporated in the contracts for such services.

HCPCS - Level 2 Codes

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Categories include:
Transportation Services Including Ambulance A0021 - A0999
Medical and Surgical Supplies A4206 - A7509
Administrative, Miscellaneous and Investigational A9150 - A9901
Enteral and Parenteral Therapy B4034- B9999
Temporary codes for use with Outpatient PPS C1010 - C9711
Dental Procedures D0120 - D9999
Durable Medical Equipment E0100 - E2101
Procedures/Professional Services (Temporary) G0001 - G9016
Rehabilitive Services H0001 - H2001
Drugs Administered Other Than Oral Method J0120 - J8999
Chemotherapy Drugs J9000 - J9999
K Codes Assigned to DMERC (Temporary) K0001 - K0597
Orthotic Procedures L0100 - L4398
Prosthetic Procedures L5000 - L9900
Medical Services M0064 - M0301
Pathology and Laboratory Services P2028 - P9615
Q Codes (Temporary) Q0035 - Q9940
Diagnostic Radiology Services R0070 - R0076
Temporary National Codes (non-medicare) S0009 - S9999
National T Codes for State Medicaid Agencies T1000 - T2007
Vision Services V2100 - V2799
Hearing Services V5008 - V5364

UHC overpayment - How to resolve?

2011-08-03T18:13:00.001+05:30

Overpayments

If you identify a claim for which you were overpaid by us, or if we inform you in writing or electronically of an overpaid claim that you do not dispute, you must send us the overpayment within thirty (30) calendar days (or as required by law), from the date of your identification of the overpayment or our request. We may also apply the overpayment against future claim payments to the extent permitted by your agreement with us and applicable law.

All refunds of overpayments in response to overpayment refund requests received from UnitedHealthcare, or one of our contracted recovery vendors, should be sent to the name and address of the entity outlined on the refund request letter. Refunds of any credit balances existing on your records should be sent to:

UnitedHealth Group Recovery Services
P.O. Box 740804
Atlanta, GA 30374-0804

Please include appropriate documentation that outlines the overpayment, including member’s name, health care ID number, date of service and amount paid. If possible, please also include a copy of the remittance advice that corresponds with the payment from UnitedHealthcare. If the refund is due as a result of coordination of benefits with another carrier, please provide a copy of the other carrier’s EOB with the refund.

When we determine that a claim was paid incorrectly, we may make claim reconsiderations without requesting
additional information from the network physician, health care professional, facility or ancillary provider. In the case of an overpayment, we will request a refund at least thirty (30) days prior to implementing a claim adjustment, or as provided by applicable law or contractual agreement. You will see the adjustment on the EOB or Provider Remittance

Advice (PRA). When additional or correct information is needed, we will ask you to provide it.
If you disagree with a claim reconsideration, our request for an overpayment refund or a recovery made to recoup the overpayment, you can appeal the determination (see Claim Appeals section of this Guide).

Selecting the Right Medical Billing Service - 5 Things to Consider

2011-07-30T11:23:00.000+05:30

Medical billing is crucial part of any health care facility even though it is not the main line of activity in such workplaces. There are many time consuming issues related to medical billing. Medical professionals are often overworked, and may not have time to attend to such issues. But ignoring this function may lead to severe repercussions such as drying up of funds, or even legal complications related to Medicare frauds. Therefore, this function deserves due respect.

One way to reduce medical billing procedures encroaching upon the health care functions is to off load the function to specialized medical billing services. Such offloading is advantageous even for smaller medical practices, as it leaves more time on hand for the professional work. There are many medical billing service providers. It becomes difficult to select the right one from these. In order to get the right medical billing company, following five points need to be considered.

1.    Where is the medical billing service located?
Location of such services is crucial because patients often have queries regarding their medical bills. Services of overseas medical billing companies are cheaper, but they may prove to be expensive for patients. In addition, there can be other issues such as accent or lack of familiarity with procedures in the country where health care facility is located.

2.    Is the medical billing company adequately experienced?

Experience is very important in this field. This is because terminology related to medical billing is quite different from other types of billing. In addition, billing is linked to medical reimbursements. Therefore, any such billing information should be accurate. It should also comply with all relevant legal stipulations.

3.    How efficient is the medical billing service in getting reimbursement?

Medical billing is a set of smaller functions like entering data, submitting claims for getting reimbursement, patient billing, payment posting, and follow up for reimbursement, and handling denial issues. The company that offers comprehensive service should be preferred over others. In addition, the company that systematically and regularly obtains the reimbursements in shorter time should be preferred.

4.    What sort of reports can the company generate, and how frequently?

Medical billing is not exclusively about generating bills, and obtaining reimbursements. It is also about generating different reports from the available data. Such reports should give the medical professional an idea about the financial health of the practice or health care facility as the case may be.

5.    Does the company guarantee data security?

There are legal stipulations relating to patient’s rights to privacy. Security of medical billing data is therefore important because information on it can lead to Medicare and other frauds, which could implicate the health care facility and lead to protracted legal battles.

what is complete claims?

2011-07-27T17:49:00.000+05:30

Complete claims

For proper payment and application of deductibles and coinsurance, it is important to accurately code all diagnoses and services (according to national coding guidelines). It is particularly important to accurately code because a member’s level of coverage under his or her benefit plan may vary for different services. You must submit a claim for your services, regardless of whether you have collected the copayment, deductible or coinsurance from the member at the time of service.

To assist you in understanding how your claims will be paid, UnitedHealthcare’s Claim Estimator includes a feature called Professional Claim Bundling Logic which helps you determine allowable bundling logic and other claims processing edits for a variety of CPT (CPT is a registered trademark of the American Medical Association) and HCPCS procedure codes. Note: Only bundling logic and other claims processing edits are available under this option.

Pricing and payment calculations are not included.

Allow enough time for your claims to process before sending second submissions or tracers, then check their status online at UnitedHealthcareOnline.com. If you do need to submit second submissions or tracers, be sure to submit them electronically no sooner than forty-five (45) days after original submission.

Complete claims include the information listed under the Complete Claims Requirements section of this Guide.
We may require additional information for particular types of services, or based on particular circumstances or
state requirements.

If you have questions about submitting claims to us, please contact Customer Care at the phone number listed on the member’s health care ID card. For questions specific to electronic submission of claims, please review the information at UnitedHealthcareOnline.com  Claims and Payments  Electronic Claims Submission (EDI ). If you need additional information on EDI , contact the EDI Support Line at (800) 842-1109, Option 3.

Learn about the many tools available to help you prepare, submit and manage your UnitedHealthcare claims at UnitedHealthcareOnline.com including: Claim Estimator with bundling logic and Real-Time Adjudication. Training tools and resources including Frequently Asked Questions (FAQs), Quick References, Step-by-Step Help and Tutorials are available by clicking “Help” at the top of any page.

Note: At the time of publication of this Guide, the Claim Estimator is not available for Medicare
products.

To order 1500 HIC F (CMS-1500) and UB-04 (CMS-1450) forms, contact the U.S. Government Printing Office, call (202) 512-0455, or visit their Web site at cms.hhs.gov/CMSForms.

5 tips for prompt claim processing

2011-07-25T17:35:00.000+05:30

Prompt claims processing

We know that you want your claims to be processed promptly for the covered services you provide to our members.

We work hard to process your claims timely and accurately. Here’s what you can do to help us:

1 Review the member’s eligibility at UnitedHealthcareOnline.com, using swipe card technology or keying
in the member’s information.

You can also check member eligibility by phone by calling the United Voice Portal at (877) 842-3210 or the
Customer Care number on the back of the member’s health care ID card.

Disclaimer: Eligibility & benefit information provided is not a guarantee of payment or coverage in any specific
amount. Actual reimbursement depends on various factors, including compliance with applicable administrative protocols, date(s) of services rendered and benefit plan terms and conditions.

2 Notify us in accordance with the Standard Notification Requirements list.

3 Prepare complete and accurate claims (see “Complete Claims” below).

4 Submit claims online at UnitedHealthcareOnline.com or use another electronic option.

a) Connectivity Director is a free direct connection for those who can create a claim file in the HIPAA 837
format. This Web-based application enables real-time and batch submissions direct to UnitedHealthcare.
Connectivity Director provides immediate response back to all transaction submissions (claims, eligibility, and
more). Additional information can be found at UnitedHealthcareCD. com, including a comprehensive User Guide and information on how to get started.

b) UnitedHealthcare Online All-Payer Gateway™ is a Web-based connectivity solution which links
UnitedHealthcare Online users to a leading clearinghouse vendor (Ingenix) that offers multi-payer health
transactions and services at preferred pricing. Using your current UnitedHealthcare Online User ID and
password, you can register with Ingenix to submit batch claims to many of your governmental and commercial
payers. For more information: UnitedHealthcareOnline.com  Claims and Payments  Electronic Claims
Submission  EDI Options.

c) EDI Gateway and Clearinghouse Connections – UnitedHealthcare’s preferred clearinghouse is Ingenix, but you can use any clearinghouse you prefer to submit claims to UnitedHealthcare. Both participating and nonparticipating physician, health care professional, facility and ancillary provider claims are accepted electronically using UnitedHealthcare’s payer ID 87726. Other UnitedHealthcare and affiliate payer ID s can be found on UnitedHealthCareOnline.com.

UnitedHealthcare contracts generally require you to conduct business with us electronically and contain requirements regarding electronic claim submission specifically. Please review your agreement with us and abide by its requirements. While some claims may require supporting information for initial review, UnitedHealthcare has reduced the need for paper attachments for referrals/notifications, progress notes, ER visits and more. We will request additional information when needed.

5 Receive Electronic Payments and Statements (EPS)

If you are enrolled with us for EPS, payments are electronically deposited into one or more checking
accounts which you designate. Take the next step by auto-posting the electronic 835/Electronic Remittance
Advice (ERA) that you receive from your clearinghouse, or obtain one free of charge from our Web site at
UnitedHealthcareOnline.com.

Explanations of Benefits (EOBs) that match each daily/weekly consolidated deposit are available on
UnitedHealthcareOnline.com, where you can review, store and print hard copies to use for manual posting.

EPS is UnitedHealthcare’s preferred method for receiving payments and statements and results in faster and easier payment to you. If you have not yet enrolled in this standard operating process, start receiving electronic payments and statements now by enrolling online at UnitedHealthcareOnline.com or by contacting us at (866) 842-3278, Option 5. Please note EPS is not available in all markets for our Medicare Advantage plans.

End Stage Renal Disease/ Dialysis Services CPT code and revenue code list

2011-07-23T19:39:00.000+05:30

Services for the treatment of End Stage Renal Disease (ESRD), including outpatient dialysis
services (as defined by, but not limited to, the revenue and CPT codes below), require
notification.

No notification is required for end stage renal disease when a Medicare member travels outside
of the service area.

Dialysis:
90935, 90937, 4052F, 4054F – hemodialysis
90945, 90947, 4055F – peritoneal
90963 – 90970 – ESRD
90989 – patient training, completed course
90993 – patient training, per session
90999 – unlisted dialysis procedure, inpatient or outpatient

Revenue Codes:
304 – Nonroutine Dialysis
800 – 804, 809 – Renal Dialysis
820 – 825, 829 – Hemo/op or home
830 – 835, 839 – Other outpatient/peritoneal dialysis
840 – 845, 849 – Capd/op or home
850 – 855, 859 – Ccpd/op or home
880 – 882, 889 – Dialysis / misc

For the most current listing of UnitedHealthcare contracted dialysis facilities, please refer to our
online provider directory at UnitedHealthcareOnline.com or call us at (877) 842-3210. In an
effort to maximize member benefit coverage and lifetime maximum limits, we ask that you refer to
UnitedHealthcare contracted dialysis facilities whenever possible. Note that your agreement with
us may include restrictions on referring members outside the UnitedHealthcare network.

LIST AND DEFINITION OF DUAL ELIGIBLES - Medicare and Medicaid

2011-07-22T14:44:00.001+05:30

Dual Eligibles - The following describes the various categories of individuals who, collectively, are known as dual eligibles. Medicare has two basic coverages: Part A, which pays for hospitalization costs; and Part B, which pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services. Dual eligibles are individuals who are entitled to Medicare Part A and/or
Part B and are eligible for some form of Medicaid benefit.

1. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) - These individuals are entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance for Medicare services provided by Medicare providers. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).

2. QMBs with full Medicaid (QMB Plus) - These individuals are entitled to Medicare Part A, have income of 100% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and
coinsurance, and provides full Medicaid benefits. FFP equals FMAP.

3. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) - These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid.

Medicaid pays their Medicare Part B premiums only. FFP equals FMAP.

4. SLMBs with full Medicaid (SLMB Plus) - These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not in exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part B premiums and provides full Medicaid benefits. FFP equals FMAP.

5. Qualified Disabled and Working Individuals (QDWIs) - These individuals lost their Medicare Part A benefits due to their return to work. They are eligible to purchase Medicare Part A benefits, have income of 200% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only. FFP equals FMAP.

6. Qualifying Individuals (1) (QI-1s) - This group is effective 1/1/98 - 12/31/02. There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have income of at least 120% FPL, but less than 135% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid.

Medicaid pays their Medicare Part B premiums only. FFP equals FMAP at 100%.

7. Qualifying Individuals (2) (QI-2s) - This group is effective 1/1/98 - 12/31/02. There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have income of at least 135% FPL, but less than 175% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays only a portion of their part B premiums ($2.23 in 1999). FFP equals FMAP at 100%.

8. Medicaid Only Dual Eligibles (Non QMB, SLMB, QDWI, QI-1, or QI-2) - These individuals are entitled to Medicare Part A and/or Part B and are eligible for full Medicaid benefits. They are not eligible for Medicaid as a QMB, SLMB, QDWI, QI-1, or QI-2. Typically, these individuals need to spend down to qualify for Medicaid or fall into a Medicaid eligibility poverty group that exceeds the limits listed above. Medicaid provides full Medicaid benefits and pays for Medicaid services provided by Medicaid
providers, but Medicaid will only pay for services also covered by Medicare if the Medicaid payment rate is higher than the amount paid by Medicare, and, within this limit, will only pay to the extent necessary to pay the beneficiary's Medicare costsharing liability. Payment by Medicaid of Medicare Part B premiums is a State option; however, States may not receive FFP for Medicaid services also covered by Medicare
Part B for certain individuals who could have been covered under Medicare Part B had they been enrolled. FFP equals FMAP.

Improve Medical Billing Collections - Billing Tips

2011-07-21T11:19:00.001+05:30

Any medical billing company would like to have on-time collections, of course. Although, it cannot be denied that there are issues that may hinder this from happening. To make sure that every billing is paid successfully, you have to work hard and to be organized. First, do not let a claim sit around for a long time. Once you have received it, process it immediately and inform the insurance company. If you take long in processing it, it would also take longer for the payment to arrive. Follow it up with the insurance company and get a specific answer about when payment will be sent so you could easily inform the patient in case they call or drop by.
Make good use of the available technology we have nowadays. Invest on electronic modes of payment and claims. This is not only convenient, it is also faster. This method is also more reliable because an electronic machine would easily detect entry errors and missed fields. It would immediately inform the patient or the insurance company about it so that it would be corrected right away.

It is necessary to follow-up with insurance companies in a timely manner. If a payment is expected today and it has not yet arrived, call them up. If they give another date, follow it up again on that particular date. If they do not reply at all, try calling them weekly. Regular follow-ups give the insurance company an impression that you are serious about collecting. Most insurance companies would do anything to avoid a payment. Make sure you point out to them that you will keep calling until the collection is sent.

As with other types of businesses, medical billing should document and record all conversations between them and the patient and between them and the insurance company. This way, when something fails and gets neglect, you can easily reference it. If an insurance company refuses to pay, you can inform them about certain conversations you have had or any promise they might have said. This will show them that there is no use for alibis as everything that went on between you is properly documented.

If none of this makes the insurance company pay, involve the patient. You will be surprised to know that patients are very willing to call their insurance companies and demand for payment. This is because if their insurance does not cover it, the bill might be charged to the patient. No patient would ever agree to this. If the patient is very busy or cannot able to contact their insurance company, ask them if you could write a letter or request on their behalf.

Update on Evaluation Management CPT codes - HighMark insurance

2011-07-19T14:16:00.000+05:30

Highmark Announces Adjustments to UCR and Premier Blue sm

Shield Reimbursement

As noted in the April 2011 issue of PRN, Highmark filed with, and has now received approval from, the Pennsylvania Insurance Department to implement a broad range of UCR Level II and Premier Blue Shield reimbursement adjustments.

The adjustments impact anesthesia, select surgical, diagnostic and evaluative services, including, but not limited to, musculoskeletal, eye, behavioral health, allergen immunotherapy and routine electroencephalography procedures.

• Increases in allowance will be implemented for dates of service beginning July 1, 2011.

• A minimum number of allowances will be decreased for dates of service on/after Sept. 26, 2011.

Highmark will also implement changes to its payment differential for evaluation and management procedure codes 99201 through 99215 when performed in the facility, compared to services performed in a non-facility setting. Effective Sept 26, 2011, Highmark will calculate payment for the facility service using Medicare's site-of-service differential, or at a predetermined cap, not to exceed a certain designated percentage. Currently, Highmark applies a 15 percent differential.

In addition, the allowances for CT studies of the abdomen and pelvis combined, procedure codes 74176, 74177 and 74178,will be increasing with this update. The allowances will be based upon additional data collection and analysis and have yet to be finalized.

Fees Available Via NaviNet

You may access the reimbursement adjustment information online in four convenient ways.

1. Visit our Provider Resource Center via NaviNet. Simply hover on Administrative Reference Materials, and click on Fee Updates to view the complete list of fee adjustments. (Fees are not published on the public

Provider Resource Center.)

When the adjustments are in effect (see effective dates above), you can also use the following online tools.

2. On NaviNet, hover on Allowance and then select Allowance Inquiry to determine pricing for specific procedure codes-by planrproduct type.

3. Also on NaviNet, you can hover on Allowance, and select Frequently Billed Codes. This function initiates a report request that provides you with a quicker means of retrieving the most frequently billed codes/procedure codes based on the specialty represented by the selected billing provider and plan.

4. Via NaviNet's Resource Center, you can download the full Premier Blue Shield fee schedule. Simply click on

Administrative Reference Materials.

Understanding CPT Code 28510 – Billing for Fracture Care Follow-Ups

2011-07-13T11:22:00.000+05:30

With regards to Standard Fracture Care, a patient’s fracture follow-up can be billed by the doctor. The doctor must make sure, however, that the appropriate procedure codes as well as the ICD-9 code is used. This pertains to the site of the fracture. The follow-up care for closed fracture sites are covered by the CPT code 28510. All, except those that involve the big toe. Due to the details enclosed in this code, the need to perform site manipulations is no longer required if you plan to bill a patient’s follow-up care. Because of the code 28510, it is immediately expected that a doctor will earn a hundred dollars for each patient.

A patient who comes in for a follow-up with regards to an injury such as a fracture is expected to spend time in a doctor’s clinic. There is also a big possibility for them to inform you about certain medical issues they might have that would not be related to their fracture. Doctors would not have to worry when this type of situation arises especially if they did not provide the fracture care initially. As long as you document the visit correctly, you would be able to bill for the fracture follow-up and the additional concerns separately. This is justified by the fact that the other concerns are not in any way related to the fracture. The doctor just has to be very detailed about the consultation with regards to the proper procedure codes and the injuries addressed.

If ever the situation involves a patient who has multiple fractures comes for a follow-up, you can bill for each type of fracture. For example, a patient has a fracture in his ribs, legs, and arms. You can bill each site separately. It is, however, crucial to document each fracture addressed and how long it took you to address it.

Most fractures are billed to insurance companies of patients. There are cases, however, wherein their fracture is work-related. With this situation, Worker’s Compensation and the Personal Injury Protection Policy are applied. The guidelines with this type of insurance may vary from state to state so it is important for a doctor to know about them before applying codes for the follow-up and any procedures done on the patient. The important thing here is that the doctor gets paid for the care he has provided for the patient even if the initial check was done by another doctor.

How to Buy Good Medical Billing Books

2011-07-11T11:17:00.001+05:30

There are an overwhelming number of medical billing books available in the market today. The electronic types, popularly known as eBooks are gaining more attention because it can easily be downloaded through the internet. No matter how interesting the title is or how cheap the book is, do not rely on these factors in purchasing medical billing books. There are things you must consider when choosing which one to purchase.
Do not just look at the title and the summary of a medical billing book. Though the text is smaller, the author is also an important factor to consider. If you really want to buy a good book about medical billing, research on the author. Look at their credentials as well as their accomplishments. Do not rely on their statements. Their record should speak for itself.

Not all medical books are the same. In fact, there are books that only tackle one specific part within the medical billing career. If you really want to learn all you need to learn, you could buy several books. This is, of course, not a practical thing to do. It is expensive and unnecessary. Research on each book with regards to the topics it tackles and the information it provides. The important topics that should be part of a really good medical billing book are: Claim Processing, Insurance (Primary, Secondary, Tertiary), Forms that are commonly used, Medicare, Medicaid, HMO, PPO, Explanation of Benefits (EOB), Patient Billing, Aging Reports, Account Receivables, Commonly used Terms, HIPAA, Training, ICD diagnosis and CPT procedure codes and their uses.

If you are planning on starting a medical billing business company or a home-based medical billing career, look for books written by authors who have experienced starting one up. First-hand experience is very important. Getting information from someone who has that experience would truly be beneficial. Some of the things you need to see in a book for medical billing business start-up books are: About medical billing contracts, expected income, what is needed when starting a medical billing business, rates and prices, medical billing software, electronic file claiming, and, of course, the business plan of medical billing.

You should also find a book that would help you market your medical billing business. Find a book that would help you on how to get a client, techniques on effective marketing, tips on how to talk to potential clients, and how to stand out in the growing world of medical businesses.

Service covered under Newborn Care

2011-07-10T14:56:00.000+05:30

Newborn Care

Provide the highest level of care for the newborn beginning immediately after birth. Such level of care shall include, but not be limited to, the following:

(1) Instilling of prophylactic eye medications into each eye of the newborn;
(2) When the mother is Rh negative, securing a cord blood sample for type Rh determination and direct Coombs test;
(3) Weighing and measuring of the newborn;
(4) Inspecting the newborn for abnormalities and/or complications;
(5) Administering one half (.5) milligram of vitamin K;
(6) APGAR scoring;
(7) Any other necessary and immediate need for referral in consultation from a specialty physician, such as the Healthy Start (postnatal) infant screen; and
(8) Any necessary newborn and infant hearing screenings (to be conducted by a licensed audiologist pursuant to Chapter 468, F.S., a licensed M.D. or D.O., or an individual who has completed documented training specifically for newborn hearing screenings and who is directly or indirectly supervised by a licensed physician or a licensed audiologist).

Postpartum Care
(1) Provide a postpartum examination for the enrollee within six (6) weeks after delivery;
(2) Provide for voluntary family planning, including a discussion of all methods of contraception,
as appropriate;
(3) Refer the newborn to a pediatrician for completion of CHCUP (Child Health Check Up)
screenings

Pregnancy service - prior authorization information

2011-07-07T14:49:00.000+05:30

Pregnancy

PCP’s or obstetricians are required to notify SHP of the first prenatal visit and/or positive pregnancy test within two (2) working days by completing the Pregnancy Notification Form (refer to the Forms Section), whether the pregnancy was identified through medical history, examination, testing or otherwise.

SHP will allow pregnant enrollees to choose in-network obstetricians as PCP’s if the obstetrician is willing to participate as a PCP.

If a pregnant member has not selected a PCP for her unborn child, SHP will assign a pediatrician for the care of their newborn babies no later than the beginning of the last trimester of gestation. If a provider treating a pregnant member for prenatal care decides to terminate the contract with the Plan, SHP will allow the member to continue care with that provider until completion of the postpartum care.

If the provider knows the recipient is pregnant and that her unborn child does not have a Medicaid ID number, the provider may have the newborn assigned a number by sending a CF-ES 2039, Medical Assistance Referral Form to the Department of Children and Families (DCF) regional office. The forms may be downloaded at http://www.dcf.state.fl.us/publications/eforms/es2039.pdf. Or the member may call the DCF to notify them of her pregnancy and obtain the Unborn ID Number and later call SHP Member Services with the number.

Finding Good Medical Billing Software - Question need to Ask yourself

2011-07-06T11:15:00.001+05:30

A medical billing business requires efficient software to be able to perform tasks related to medical insurance and benefits. There are several billing software available in the internet today, finding the right one, however, can be challenging. Below are some questions you can ask yourself to help you come up with a decision on which medical billing software to purchase.

Is it cost-effective? Our usual perception is that cheaper means less effective. This is not always true. Most expensive types come with a lot of extra features but you do not really need them. Purchase software that has all the things you need, nothing more.

Is it user-friendly? This question is asked not for computer illiterate employees. Most medical billers are tech savvy but the software should be easy enough to use so they could spend the extra effort in dealing with complex software in dealing with other important tasks instead.

Has the software been around for a long time? If it has, it is more likely to have encountered every bug and issues possible and a fix has already been applied. New software says that it is bug-free. It may be bug-free for now but it would surely encounter one in the future.

Is the medical billing software company experienced? A company that has been around for a long time is more reliable especially if they have a lot of employees. This ensures that there are experienced people to help you out in times of software trouble.

Is software training programs available? An online training should be available because it is more convenient and less costly. Vendors that require you to attend training seminars do not only save money, they do it at the expense of their customers.

Is there are technical support desk? A technical hotline should be available and reliable enough to help you out. Do not rely on companies that only offer email and fax contact numbers.

Is it integrated with Electronic Health Records software? This helps medical billers save time by entering data into only one system: the Electronic Health Records software integrated with the medical billing software.

Is it appropriate for your company’s type of practice? Purchasing software with tools that you do not really need is not only a waste of computer memory, but also a waste of your hard-earned money.

Can the software be tested before a purchase? A test run is necessary for you to be able to try out if the software is indeed easy to use and reliable. If possible, ask them for an online demonstration. If they have trial versions, that would be better.

Can the vendor provide you a list of their clients? Ask them for lists of offices that make use of the software you are interested. You can then approach each one and ask them about their experiences with the software. If the vendor is unable to provide you with references, find another one who could.

What is Second Medical Opinion service

2011-07-05T14:53:00.000+05:30

Requests for a Second Medical Opinion

Second Opinion is a consultation by a physician other than the member’s Primary Care Physician, whose specialty is appropriate to the need, and whose services are obtained when the member disputes the appropriateness or necessity of a surgical procedure, is subject to a serious injury or illness, including failure to respond to the current treatment plan.

The member will be advised to contact the Primary Care Physician (PCP) and request a consultation with the necessary specialty provider. The member may select a contracted provider listed in the provider directory supplied by SHP or a non-contracted provider in the Plan’s geographic area. The UM Coordinator will contact the member’s PCP, or admitting physician if the member is in the hospital if necessary to assist in the second opinion process.

SHP shall pay the amount of all charges which are usual, reasonable and customary in the community for second opinion services performed by a physician not under contract with SHP, but the member may be responsible for part of the bill. SHP’s physician’s professional judgment concerning the treatment of a member derived after review of a second medical/surgical opinion shall be controlling as to the treatment obligations of
SHP.

Treatment not authorized by SHP is at the member’s expense.

Any tests/procedures deemed necessary by a second opinion consultant, and/or non-contract physician, are to be performed by an SHP-contracted provider. The UM Department will coordinate the care between the provider and the member to ensure continuity of care. The Medical Director may choose to deny reimbursement rights granted as above in the event the member seeks in excess of three (3) such referrals per year if such subsequent referrals costs are deemed by SHP to be evidence that the member has unreasonably over-utilized the second opinion privilege. A member thus denied reimbursement under this section should have recourse to grievance procedures

Does Emergency Services require Authorization ?

2011-07-02T14:47:00.000+05:30

Emergency Services

Emergency services are not subject to prior authorization requirements and are available to our members 24 hours a day, seven days a week, 365 days a year.

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent lay person who possesses an average knowledge of health and medicine could reasonably
expect that the absence of immediate medical attention could reasonably be expect to result in any of the following:

* Serious jeopardy to the health of the member, including a pregnant woman or fetus
* Serious impairment to bodily functions
* Serious dysfunction of any bodily organ or part
* A pregnant woman having contractions

SHP shall not:
* Require prior authorization for an enrollee to receive pre-hospital transport or treatment or for emergency services and care;
* Deny payment for treatment obtained when a representative of the SHP instructs the enrollee to seek emergency services.
* Specify or imply that emergency services and care are covered by the Plan only if secured within a certain period of time;
* Use terms such as "life threatening" or "bona fide" to qualify the kind of emergency that is covered; or
* Deny payment based on a failure by the enrollee or the hospital to notify SHP before, or within a certain period of time after, emergency services and care were given.
* Deny claims for emergency services and care received at a hospital due to lack of parental consent.

Pre-hospital and hospital-based trauma services and emergency services and care will be authorized.

SHP shall cover all screenings, evaluations, and examinations that are reasonably calculated to assist the provider in arriving at the determination as to whether the member has an emergency medical condition. If the provider determines that an emergency medical condition does not exist, SHP is not required to cover services rendered subsequent to the provider's determination unless
authorized by the Plan.

If the provider determines that an emergency medical condition exists, and the enrollee notifies the hospital or the hospital emergency personnel otherwise have knowledge that the patient is an enrollee of SHP, the hospital must make a reasonable attempt to notify the enrollee's PCP, if known, or SHP, if the Plan has previously requested in writing that it be notified directly of the
existence of the emergency medical condition

If the hospital, or any of its affiliated providers, do not know the enrollee's PCP, or have been unable to contact the PCP, the hospital must notify SHP as soon as possible before discharging the enrollee from the emergency care area; or notify the Plan within twenty four (24) hours or on the next business day after the enrollee’s inpatient admission.

If the hospital is unable to notify SHP, the hospital must document its attempts to notify the Plan, or the circumstances that precluded the hospital's attempts to notify the Plan. SHP shall not deny coverage for emergency services and care based on a hospital's failure to comply with the notification requirements of this section.

SHP shall cover any medically necessary duration of stay in a non-contracted facility, which results from a medical emergency, until the Plan can safely transport the member to a participating facility. SHP may transfer the member, in accordance with state and federal law, to a
participating hospital that has the capability to treat the member’s emergency medical condition. The attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer, and that determination is binding.

List of procedure - Authorization required

2011-06-30T14:43:00.000+05:30

All of the following procedures and services require Prior Plan Notification and must be provided in a SHP participating facility*:

o Inpatient and Observation Admissions, as noted above
o Admission to any rehabilitation and skilled nursing facility
o All surgical procedures, inpatient or outpatient
o The following have special reporting requirements (refer to Forms Section):
* Abortions
* Hysterectomies
* Sterilization procedures
o Cosmetic or Reconstructive Surgery, including but not limited to:
* Breast reconstruction or reduction
* Blepharoplasty
* Venous procedures
* Sclerotherapy
o Services and items:
* Allergy (immunotherapy), exept for those services identified on the QAF
* Ambulance transportation (non emergent)
* Amniocentesis
* Cardiac and pulmonary rehabilitation programs
* Circumcisions after 12 weeks of age
* Court-ordered services
* Chemotherapy
* Dialysis
* DME, including apnea monitors and bili-blankets
* Upper endoscopies at colonoscopies at hospitals
* Genetic testing
* Gamma Knife, Cyberknife
* Hearing aids
* Home Health Services
* Hospice care
* Hyperbaric Oxygen Therapy (HBO)
* Investigational and experimental procedures and treatments
* IV Infusions
* Laboratory services in POS 22 and 24
* Lithotripsy
* Mental Health (See Mental Health Section)
* Nutritional counseling
* MRI’s, MRA’s
* Oral Surgery
* Oxygen therapy and equipment
* Out-of-Network Services
* Pain Management and or Pain Injections
* PET Scans
* Prenatal care
* Orthotics and Prosthetics, including Cranial Orthotics
* Physical, Occupational and Speech Therapy
* Radiation therapy
* SPECT scans
* Transplants and pre and post transplant evaluations
* Wound Care and wound vacuums
* Drugs that require pre-authorization
* Any services or procedures not listed on the Quick Authorization Form (QAF)

*Unless the service is only available in a non-participating facility.

Incentive Plans in Medical Billing - tips for success

2011-06-29T11:13:00.001+05:30

Incentive plans for medical billers are effective but it does not necessarily mean that it has to be expensive for it to work. There are more affordable options, which are as effective in inspiring and motivating medical billers. There are things you can do to ensure that the incentive plan will be successful.

First, you have to keep in mind that in a medical billing organization, there are different tasks being handled within and every task, when performed efficiently, will produce good results not only to one but also to everyone in the organization. You would have to set specific targets so that billers would know what they are aiming for. Divide the rewards by allotting half of it for team performance and the other half for individual performance.

Second, aim for cost-effective incentive plans. Employees are most likely to be motivated with cheap plans than those that require them to pay more than they prefer.

Third, invest in incentive plans that target different performances like speed, accuracy, delivery, and more. Study all these intensively to be able to determine which ones are much needed within the organization.

Fourth, if you have several accounts within a medical billing organization, make sure to take into consideration that not all accounts are the same. When providing incentives, make sure it is given to each account accordingly.

Fifth, when giving incentive payouts, distribute it as a part of the medical biller’s salary and make sure you adhere to this schedule. Provide them with a written statement of how much they earned and how much tax was deducted.

Sixth, make sure your employees understand the incentive plan. It would be difficult to achieve something when you do not know what you are aiming for. Post a chart of the incentive plan and post their progress as well. This way, every one of them is updated regularly.

Seventh, keep it simple. Do not offer huge rewards with complex incentive plans. Instead, make the plan easier with simple rewards. Employees appreciate a modest amount of reward than huge ones that are difficult to attain.

Eighth, make sure that each employee is informed. If possible, give out a detailed copy of the incentive plan to each employee so that it can be studied. Post on the wall and on your internal website to make everyone know that there is an ongoing incentive program.

Ninth, do an annual evaluation. Compare results each year to see which categories of performance are improving and which needs more attention. This way, you could modify your incentive plan to hit those goals that need more attention.

Last but not the least; offer various rewards aside from cash. To avoid making your employees dependent on money, offer other ways of rewarding them like vouchers or free tickets to the movies. This way, they would not think of a monetary incentive as a part of their salary. Besides, giving out freebies is just as motivating and inspiring.

Understand Prior Authorization - Full details

2011-06-27T14:35:00.000+05:30

Prior Authorizations:

Prior authorization (pre-service requests) allows for the use of quality, cost-efficient covered health care services and helps to ensure that effective transition of care planning is done so that members receive the most appropriate level of care within the most appropriate setting. Prior authorization must be obtained for all services not included on the Quick Authorization Form (QAF) for PCP’s (see section above) that require an authorization.

SHP’s UM Department evaluates requests for services/procedures and makes determinations based on medical necessity, covered benefits and appropriateness based on SHP’s approved utilization criteria (Interqual) and evidence-based, nationally recognized clinical guidelines. Only a Medical Director may issue an adverse determination, with the exception of denials due to benefit issues. No provider or any other individual or SHP employee or associate is rewarded for issuing denials of coverage or care. Financial incentives will NOT encourage decisions that would result in underutilization nor are incentives to create barriers to care and services.

Prior Authorization Requests are to be made through the SHP’s UM Pre-Certification Department.

Prior Authorization or Notification Process:

* Providers are to fax the Referral & Authorization Form (refer to Forms Section) to the SHP’s Utilization Management Pre-Certification Department at Fax number 1-800-283- 2114 or by calling the PreCertification Telephone Queue 1-800- 887-6888, ext 2271.

* Routine (NOT STAT/URGENT) requests are processed within fourteen (14)

calendar days of the Plan receiving the authorization request and having received all supporting clinical information.

STAT/URGENT requests are processed within seventy-two (72) hours of the Plan receiving the request and having received the supporting clinical information.

NOTE: STAT/URGENT Authorizations should be CALLED IN to the SHP Pre-Certification Authorization Telephone Queue and NOT faxed, and the caller should identify the request as “STAT/URGENT”. These requests should always meet the defined medical criteria for such which are:

STAT/URGENT: Any condition where failure to issue an immediate response may result in an IRREVERSIBLE SIGNIFICANT, ADVERSE outcome of health and/or function.

* Each Referral & Authorization Form received from the provider’s offices will be date and time- stamped, manually or electronically and is reviewed for completeness, eligibility, benefits, PCP and specialist network affiliation

* The Referral & Authorization Form must be accompanied by supporting clinical information for medical necessity determination

* An authorization number will be provided, via fax, to the PCP, specialist and other provider(s) that will provide services to the member, when the request is completed and approved

* All authorization requests and documentation of supporting clinical information will be entered and maintained within the SHP computer system for future reference and claims payment

When faxing a Prior Authorization Request, the SHP Referral & Authorizations Form must be completed. The requesting provider is reminded to include:

* Member demographic information (i.e. name, sex, DOB, SHP Member Number)
* Provider demographic information
* Requesting provider (i.e. name, SHP Provider Number, phone number, fax number, contact person)
* Referred-to specialist/facility (i.e. name, SHP Provider Number, address, phone number, fax number, date of service, and identification if PAR (Plan participating provider/facility) or Non-PAR (not a Plan participating
provider/facility)
* Diagnoses for authorization request, including ICD-9 Code(s)
* Procedure(s) for authorization request, including CPT/HCPCS Code(s)
* Number of visits requested, frequency and duration
* Pertinent medical history and treatment, laboratory and/or radiological data, physical examinations/referrals that support the medical necessity for the requested service(s)

Requests that do not meet medical necessity, based upon approved criteria are reviewed by the Medical Director for a final determination. The Medical Director may conduct a peer-to-peer discussion with the requesting provider, if indicated.

Medical Billing: An Introduction

2011-06-25T11:11:00.000+05:30

The need for well-experienced professionals in the health and medical industry increases every single day. The reason behind this is that the Healthcare industry is so large and it covers an extensive area of technological equipment and procedures. In fact, the medical technology we have nowadays may become outdated in just a few years time. The fast pace of advancement with medical procedures makes the need for a coding system to be created. This is to ensure that each medical procedure, diagnosis, as well as complaint is recognized by health insurance companies to be added with regards to medical professional compensation.

Medical billing is a process that covers different process within. It involves the filling up and completion of medical forms like insurance cards, patient profile and information, encounter forms, diagnosis sheet, treatment and surgeries performed, and more. All these are then collected and assessed to make sure that every necessary field is filled up accurately. After every form is verified, it is then processed for payment. Processing includes transferring all the collected data into an accounting software program.

Medical billers, just like other types of billing professionals, deal with a lot of paperwork as well as time-management to make sure every processing of payment is updated real-time. They should posses the skill to understand health insurance, payment processing, and benefits to be able to explain it to patients and doctors especially when there are claims for errors. It is also up to their discretion to decide on whether to charge or waive any balance not covered by their insurance. Their main goal, however, is to make sure that the attending physician as well as the medical facility is well compensated with regards to the services and procedures rendered on patients. The accounting software program where all the data was entered provides regular reports about profits and losses.

The increase of medical facilities and professionals is also increasing the need for medical billers. In fact, due to this increase, more and more people are focusing on careers that have to do with medical billing. They are trained to understand insurance and benefit enough to be able to explain them, bookkeeping duties, documentation, data-entry, and accounting. After completing these to make them eligible to handle medical billing tasks, they are then employed in hospitals and clinics. Some even set up their own home-based medical billing business while still affiliated with certain medical facilities and private clinics.

Quick Authorization Form (QAF) - whose responsibilty to get referral ?

2011-06-24T14:29:00.000+05:30

Referrals or Prior Notifications

A referral or prior notification is a request by a PCP or a participating specialist for a member to be evaluated and/or treated by a participating specialty physician and/or facility. SHP uses two types of forms and processes:

1. Quick Authorization Form (QAF)

For those services included on the SHP Quick Authorization Form (QAF) (see the Forms Section of this handbook) a referral is NOT required. Primary Care Physicians (PCP’s) can refer a member to a articipating specialist and to many frequently requested services and procedures at free-standing facilities with the Simply Healthcare Plans Quick Authorization Form (QAF) without contacting the health plan for prior authorization.

IMPORTANT NOTE: Communication with the Plan prior to the provision of care is not necessary when using the QAF; however, all inpatient services, outpatient hospital services (including diagnostics), and ASC services do require an authorization (see section below).

Prenatal care referrals are NOT to be made using the QAF.

**The QAF form is not valid for any inpatient or outpatient hospital services or for any consultations or procedures not listed on the form, or for out-of-network providers.

The PCP or specialist ordering the consultation or test is required to fax or mail a copy of the completed QAF to the participating provider or facility that will be providing the service(s), or to give a copy to the member so that it is presented at the time of the service.

Services that Do NOT Require Prior Authorization or QAF:

* Family Planning*
* Participating Office/free standing laboratory tests at labs consistent with CLIA guidelines
* Emergent transportation services
* Urgent or emergent care at participating Urgent Care centers or any Emergency Room
* County Health Departments (CHD), Federally Qualified Health Centers , Rural Health Clinics and
federally funded migrant health centers when providing:
* Vaccines
* STD diagnosis/treatment
* Rabies diagnosis/immunization
* Family planning services and related pharmaceuticals
* School health services and urgent services

*NOTE: If the member receives Family Planning Services from a non-network Medicaid provider, the Plan will reimburse the provider at the Medicaid reimbursement rate, unless another payment rate is negotiated.

what is Children Medical Services (CMS)?

2011-06-22T14:23:00.000+05:30

Children Medical Services (CMS)

Children with special health care needs are those children under age 21 whose serious or chronic physical or developmental conditions require extensive preventive and maintenance care beyond that required by typically healthy children. These Medicaid-eligible children with special health care needs have the option of enrolling with the Children’s Medical Services (CMS) Network. The CMS Network is administered by the Florida Department of Health.

The CMS Network provides a family centered, managed system of care for children with special health care needs. CMS offers a full range of care, which includes prevention and early intervention services; primary and specialty care; as well as long-term care for medically complex, fragile children. Examples of chronic conditions are short gut syndrome, leukemia, diabetes, etc. CMS determines the medical eligibility for the program. If you have a member who may benefit from CMS services please call us at the UM Department at 1-800-887-6888 ext. 2271, or contact CMS directly at 1-800-245-4200. You may find additional information at www.cms-kids.com.

Does Medicaid cover all vaccines?

2011-06-19T14:21:00.000+05:30

19 – 20 years

Those Medicaid members nineteen (19) through twenty (20) years of age may receive vaccines through their health care provider. SHP will reimburse the cost of the vaccine and the administration fee as per the provider’s contract.

For eligible members ages nineteen (19) through twenty (20) years of age who lack evidence of immunity (e.g., lack documentation of vaccination), or require the vaccinations, the following vaccines and combination vaccines are reimbursable:

Hepatitis A Meningococcal conjugate (MCV4)
Hepatitis B Meningococcal Polysaccharide (MPSV4)
HPV Pneumococcal Polysaccharide (PPV)
Influenza Td
MMR Varicella

21 and older

SHP covers immunizations services for members who are twenty-one (21) years of age or older only when medically necessary for the member’s health (not for travel or work-related).

Medical Billing as a Home-Based Business

2011-06-19T11:10:00.000+05:30

A medical billing business involves insurance claims filing and collection. A patient files a claim to their insurance company, you bill the procedures done on a patient to the insurance company, and you collect the payment from them. You have probably seen the billing section of a hospital. That is what medical billing is.

To become a medical biller, you would have to be familiar with insurance guidelines and regulations and back office work. Thanks to the technology we have today, medical billing has become much easier. But it would still require training, of course.

This career has become popular that there are those who have set up home-based medical billing businesses. You can too but first, you have to learn about a home-based medical billing business. So before you submit your resignation letter and decide to start one at home, learn more about it first. There is so much more to it than just filing and collecting.

A home-based medical billing business can not be handled by you alone. You would need a team to cover every task such as technical support and insurance claims filing. Each one should be trained well to be able to make them eligible enough to make the business successful. You would also need to have the right medical billing software necessary for creating a record of insurance claims and accounting payments and collections.
It should be reliable enough and easy to use. Forget about additional features if you would not need it for your business. This will only eat up computer memory and it might slow it down as well. Make sure you know your software and system well before actually starting the business.

Starting a medical business, even though it is home-based, would still require you to have the appropriate training in billing, coding, as well as medical terminology. Most training programs and medical billing software contain an index of medical terms. It is recommended, however, to go to a real medical billing business and ask if you could sit in and observe. Most medical billers allow this. This way, you get first hand lessons on medical billing.

Look for books on starting your home-based medical billing business or attend trainings or seminars to make you equipped and ready to take on a business such as this. It takes some time to be eligible enough to handle a career on medical billing. You have to learn about insurance companies and their guidelines and you should be familiar with processing claims and payments. With the right attitude, patience, and skills, you can make a home-based medical billing business a success.

Medicaid covered Immunizations and Federal Vaccine for Children (VFC) Program

2011-06-16T14:16:00.000+05:30

Immunizations

Providers are encouraged to review valuable immunization information on the Department of Health and Human Services, Center for Disease Control and Preventions website, which provides recommended vaccines and schedules for children at http://www.cdc.gov/vaccines/.

Birth – 18 years:

Medicaid eligible members from birth through eighteen (18) years of age are eligible to receive free vaccines through the Federal Vaccine for Children (VFC) Program. SHP will reimburse the provider the administration fee for the vaccine as per their contract. Providers must bill using the appropriate assigned HCPCS procedure code to the vaccine and a modifier code, as indicated.

The provider must enroll with the VFC Program of the Department of Health to receive the vaccines free of charge and have sufficient supplies of the vaccines. Information regarding the VFC Program is available by contacting the State of Florida Department of Health, Bureau of Immunizations, at (800) 4-VFC-KID or (800) 483-2543, HSDI 4052 Bald Cypress Way, BIN A11, Tallahassee, Fl 32399-1719, or visit the website and click on immunization services: www.immunizeflorida.org/vfc.

For eligible members from birth through eighteen (18) years of age, the following vaccines and combination vaccines are available free to the enrolled VFC provider through Florida’s VFC Program:

* Diphtheria-Tetanus-acellular Pertussis (DTaP)
* Haemophilus influenzae type b (HIB)
* Hepatitis B (pediatric and adult)
* Human Papillomavirus (HPV)
* Influenza
* Meningococcal Conjugate (MCV4)
* Measles-Mumps-Rubella (MMR)
* Pneumococcal Conjugate (PCV7)
* Polio (IPV)
* Rotavirus
* Tetanus-Diphtheria (Td)
* Varicella

The following vaccines are available by request or for high-risk areas only through the VCF program:

Diphtheria and Tetanus (DT-Pediatric), Pneumococcal Polysaccharide (PPV), Hepatitis A and Meningococcal Polysaccharide (MPSV4)

Child Health Check-Ups Program (CHCUP) Billing tips

2011-06-14T14:14:00.000+05:30

CHCUP (Child Health Check-up) is a Medicaid child health program of early and periodic screening, diagnosis and treatment services for beneficiaries under the age of 21. It used to be called EPSDT. All children of these ages who are SHP members should receive these examinations, including the required focus areas. The program ensures access to necessary health resources and assists parents and guardians in appropriately using those resources.

PCPs receive a list of eligible members at the beginning of each month who have chosen or been assigned to the PCP as of that date. It is the responsibility of the provider to contact members and encourage the member, or legal guardian, to be seen for the CHCUP. Each time a provider performs a CHCUP screening, the provider must submit an encounter form using the appropriate CPT and ICD codes.

The program provides for regular health check-ups that include:

* A comprehensive health and developmental history (including assessment of behavioral health status)
* A comprehensive physical exam
* Nutritional and developmental assessment
* Vision, hearing and dental screenings
* Lab tests, including testing for lead poisoning
* Appropriate immunizations
* Health education/anticipatory guidance
* Diagnosis and treatment
* Referral and follow-up, as needed
* Referral to a dentist begins at 3 years of age or earlier as medically necessary, with

subsequent examinations by a dentist every 6 months, or more frequently as prescribed by a dentist or other authorized provider

Eligible children and young adults should have health check-ups at:

* Birth
* 2 - 4 days for newborns discharged in less than 48 hours after delivery
* By 1 month , 2 months, 4 months, 6 months, and 9 months
* 12 months,15 months, and 18 months
* Once every year for ages 2 – 20 years
* Individuals may also request a Child Health Check-Up at other times if they think their child needs it

SHP - what are Primary Care Physician (PCP) Responsibilities ?

2011-06-12T14:09:00.000+05:30

Primary Care Physician (PCP) Responsibilities

The following is a summary of responsibilities that are required of PCP’s providing services to Simply Healthcare Plans members:

* Ensure 24/7/365 availability as outlined in the Access to Care section noted above

* Identify, coordinate, and supervise the delivery and transition of care needs/services to each SHP member

* Ensure newly enrolled members receive an initial office visit and health assessment within ninety (90) days of enrollment in the Plan and assignment to the PCP

* Maintain a ratio of members to full-time equivalent (FTE) health care providers, as follows:
One (1) FTE physician per 1,500 SimplyCaid members
One (1) Advanced Registered Nurse Practitioner (ARNP) or Physician Assistant
(PA) for every 750 SimplyCaid members above 1,500 members

* Ensure members utilize Plan participating network providers. If unable to locate a participating provider for services required, contact Utilization Management for assistance.

* Provide preventative healthcare screening services, as per nationally recognized guidelines/protocols – see links in Section 8 of this Handbook

* Have a procedure for non-compliant members: documentation and verbal or written notification to the member

* Provide regular appointments for adult healthcare, assessments and treatment, as indicated, or upon request for those members twenty-one (21) years of age and older

* Perform physical examinations within 72 hours or immediately if required for children taken into protective custody, emergency shelter or into the foster care program by the Department of Children and Families (DCF)

* Provide Child Health Check-Ups (CHCUP) as per the approved guidelines (Refer to CHCUP section below)

* Provide immunizations as per the approved guidelines

* Participate in the Vaccines for Children (VFC) program for members eighteen (18) years of age and younger (Refer to Children’s Vaccines section below)

* Providers will administer only VFC-supplied vaccinations for all members eighteen (18) years of age and younger that are supplied free to the provider through the VFC Program

* Provide immunization information to the Department of Children and Families (DCF) upon receipt of the member’s written permission and DCF’s request, for members requesting temporary cash assistance from the DCF

* Ensure members are aware of the availability of medical non-emergency transportation and/or public transportation, where available, by contacting Member Services for assistance

* Ensure translation services are available for those members requiring translation needs, including members requiring services for the deaf, by contacting Member Services for assistance

* Ensure members are aware of available community services/resources that are available to the member by contacting Member Services or a Care Manager

* Provide access to the Plan or its designee to examine thoroughly the Primary Care offices, books, records, and operations of any related organization or entity.

* Provide access to the Plan or its designee to conduct medical record audits, as per regulatory requirements or indicated

* Submit an encounter for each visit where the provider sees the member or the member receives a HEDIS® (Health Care Effectiveness Data and Information Set) service

* Submit encounters on a CMS 1500 Form

How to do Newborn Baby Enrollment

2011-06-10T14:07:00.001+05:30

Newborn Enrollment

Upon a SHP’s member delivery of a baby, the newborn is not automatically enrolled with the Plan. SHP will create a temporary newborn record within the system and work with the Department of Children and Families (DCF) to have an activation form completed. Once this is done, the newborn will become eligible/active with SHP.

* PCP’s are required to notify SHP within two (2) working days of the first prenatal visit and/or positive pregnancy test by completing the Pregnancy Notification Form (Refer to the Forms section at the end of the Handbook). Once this form is received, SHP will notify the designated DCF Customer Support of a member’s pregnancy.

* Hospitals are required to notify SHP when a pregnant member presents to the hospital for delivery. This notification is to be done as per the approved Plan process. Once notified, SHP will research if the newborn has an existing record on FMMIS that is waiting activation. Upon notification of a delivery, SHP will notify the Florida State Medicaid of the delivery.

* SHP will be responsible for payment of covered services for each enrolled newborn for up to the first (1st) three (3) months of life, provided the newborn was enrolled through the Unborn Activation Process. If it is determined that SHP was not notified of a member’s pregnancy and the first step of the Unborn Activation Process was not completed before the member presented to the hospital for delivery, the newborn will not be a member of SHP upon birth. As a result, SHP will not be responsible for payment of any services rendered to the newborn until such time that the newborn becomes a member of the Plan. If the Unborn Activation Process was not followed, SHP will not be responsible of covered services provided by the hospital, the pregnant member’s attending physician and the newborn’s attending or consulting physician. Providers will be required to file claims for services provided to the newborn through the Medicaid Fee-for-Service process.

Chiropractic services CPT code 98940, 98941, 98942

2011-06-09T10:51:00.000+05:30

Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.

Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient’s symptoms is expected and in order for payment for chiropractic services to continue, should be demonstrated within a time frame consistent with the patient’s clinical presentation. Failure of the patient’s symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner.

This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 chiropractic manipulations per month and 30 chiropractic manipulation services per beneficiary per year. Despite allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record.

Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:

Twelve (12) chiropractic manipulation treatments for Group A diagnoses.

Eighteen (18) chiropractic manipulation treatments for Group B diagnoses.

Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses.

Thirty (30) chiropractic manipulation treatments for Group D diagnoses.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules.

As published in CMS IOM, Pub. 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

Safe and effective.

Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).

Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
Furnished in a setting appropriate to the patient’s medical needs and condition.
Ordered and furnished by qualified personnel.
One that meets, but does not exceed, the patient’s medical need.
At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes

N/A

Revenue Codes

N/A

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
98940©	Chiropractic manipulation
98941©	Chiropractic manipulation
98942©	Chiropractic manipulation

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:

Primary Diagnosis Codes

Covered for:

739.0–739.5

Non-allopathic lesions, not elsewhere classified

Secondary Diagnosis Codes

Group A Diagnoses

Covered for:

307.81	Tension headache
719.48*	Pain in joint, other specified sites
	Note: When using 719.48*, you must specify spine as the site.
723.1	Cervicalgia
724.1–724.2	Other and unspecified disorders of back
724.5	Backache, unspecified
724.8	Other symptoms referable to back
728.85	Spasm of muscle
784.0	Headache

Group B Diagnoses

Covered for:

720.1	Spinal enthesopathy
721.0–721.2	Spondylosis and allied disorders (arthritis, osteoarthritis, spondyloarthritis)
721.6	Ankylosing vertebral hyperostosis
721.90–721.91	Spondylosis of unspecified site
724.79	Disorders of coccyx, coccygodynia
729.1	Myalgia and myositis, unspecified
729.4	Fasciitis, unspecified
846.0–846.3	Sprains and strains of sacroiliac region
846.8	Sprains and strains of other specified sites of sacroiliac region
847.0–847.4	Sprains and strains of other and unspecified parts of back

Group C Diagnoses

Covered for:

353.0–353.4	Nerve root and plexus disorders
353.8	Other nerve root and plexus disorders
722.91–722.93	Other and unspecified disc disorder
723.0	Spinal stenosis in cervical region
723.2–723.5	Other disorders of cervical region

Group D Diagnoses

Covered for:

721.3	Lumbosacral spondylosis without myelopathy
721.41–721.42	Lumbosacral spondylosis with myelopathy
721.7	Traumatic spondylopathy
722.0	Displacement of cervical intervertebral disc without myelopathy
722.10–722.11	Displacement of thoracic or lumbar intervertebral disc without myelopathy
722.4	Degeneration of cervical intervertebral disc
722.51–722.52	Degeneration of thoracic or lumbar intervertebral disc
722.6	Degeneration of intervertebral disc site unspecified
722.81–722.83	Postlaminectomy syndrome
724.01–724.03	Spinal stenosis, other than cervical
724.3–724.4	Other and unspecified disorders of back
724.6	Disorders of sacrum, ankylosis
738.4	Acquired spondylolisthesis
756.11–756.12	Anomalies of spine
839.01–839.08	Other, multiple and ill-defined dislocations, cervical vertebra,
839.20–839.21	Other, multiple and ill-defined dislocations, thoracic and lumbar vertebra, closed
839.41–839.42	Other, multiple and ill-defined dislocations, other vertebra, closed
953.0–953.4	Injury to nerve roots and spinal plexus

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses that Support Medical Necessity

N/A

ICD-9-CM Codes That DO NOT Support Medical Necessity

N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

Please see Medicare Benefit Manual sections referenced above for national documentation requirements for Medicare payment of chiropractic services.

Changes in The Field Medical Billing and Coding

2011-06-08T14:27:00.000+05:30

Medical coding specialists are professionals that transfer the information/data found in patients’ medical charts into codes used by billers to bill the insurance carrier and patients accordingly. Medical coding jobs are in high demand in the job market, but there is one risk to the coding field when it comes to coding specialists that work on-site and it is outsourcing.

There are two different types of coding specialists, inpatient and outpatient. Coders that work with inpatient medical charts will transfer the information within the chart from the patients that had an extended stay in the hospital. Coders that work with patients that undergo same-day surgery or other procedures that allow for the patient to leave after the procedure has been completed. Some coders will work for medical consulting companies that have hospital, clinics and other health care facilities. Some professional coders will make the choice to work from out of their home office.

Why do companies outsource coding services? What are the benefits?

When it comes to the coding service it is fast becoming a service that many in the healthcare industry are outsourcing. There are many advantages to these companies outsourcing coding services and even in some of the billing services. The reason behind the rise in outsourcing is because providers see that there is a rise in efficiency by medical staff. If the health care facility wants to ensure that claims are paid, then they have to hire coders that have an understanding of how to perform their job accurately and efficiently. Providers are finding that they can get the same benefit from outsourcing this type of task to billing and coding companies that specialize in strictly billing and coding.

Many larger health care facilities like and private facilities are using their staff currently hired for clinical duties and using them to perform the services that a professional coder would initially perform. So with having staff hired for patient care and working on coding can cause disorganization within the office which will then result in claims being filed incorrectly which will lead to claim rejections which is costly. Outsourcing has proven for a faster turnaround time of the clinical and office staff, the professionals at the coding companies the work has been has been outsourced to be able to focus solely on the coding process to get claims and the various treatments, diagnosis and diseases coded correctly and claims filled and sent in to the insurance companies in a timely fashion. So breaking down the benefits here is what providers see when it comes to outsourcing:

Cost, Precision and Dependability

Many providers have reported that they have seen savings of well over 50 percent by finding a qualified company to outsource to and get the required tasks completed. The main savings that providers see are in staffing, technology and set-up.

The companies that hire employees strictly for perform billing and coding duties will only hire those that are well knowledgeable and well trained in their field. The companies utilize top of the line technology to improve the accuracy of their specialist and to make their time more cost effectiveness. They also complete their work following the rules and regulations set forth by the Health Insurance Portability and Accountability Act (HIPAA).

In following the above benefits, this is also why many providers will choose to outsource with billing and coding specialists that choose to start their own home based businesses.

What changes should current on-site coders look into?

If you are among the many that are currently working on-site in the billing and coding field then one avenue you may wish to look into include becoming a home based coder or seeking employment with one of the medical billing companies that many hospitals and clinics are beginning to turn to.

About Author

Ceete Sheekels is a Certified Professional Coder (CPC) and a Certified Evaluation & Management Coder (CEMC) through the American Academy of Professional Coders (AAPC). She currently works as a Certified Professional Coder Instructor (CPC-I). Her years in the healthcare industry, CPC instructor certification training and her Bachelors in English and Literary arts makes her an ideal source for well written and well informed medical billing and coding specialist articles. If you plan on entering into the medical billing and coding field, you may wish to visit her website at AboutMedicalBillingAndCoding.Org so you can obtain the information needed to get you started on the right track in a high demand field. http://www.aboutmedicalbillingandcoding.org/

ICD 10 Reimbursement mapping

2011-06-03T17:49:00.002+05:30

What are the Reimbursement Mappings?

The Reimbursement Mappings were developed by CMS in response to non-Medicare industry requests for a “standard one-to-one reimbursement crosswalk,” which is a temporary mechanism for mapping ICD-10-CM/PCS codes submitted on or after October 1, 2013 back to “reimbursement equivalent” ICD-9-CM codes. In order to develop the Reimbursement Mappings, CMS used the GEMs as a starting point by selecting the best ICD-9-CM code that maps to each ICD-10 code based on Medicare data. The Reimbursement Mappings identify the best matching ICD-9-CM code that can be used for reimbursement purposes for each ICD-10 code. All ICD-10-CM/PCS codes are in the Reimbursement Mappings; however, all ICD-9-CM codes are not in the Reimbursement Mappings. Where an ICD-10-CM/PCS code
translates to more than one ICD-9-CM code, a single choice is required to create a functioning crosswalk. Inpatient hospital frequency data was used to aid in choosing a final ICD-9-CM translation in the crosswalk. If needed, the Reimbursement Mappings may be used to process ICD-10-CM/PCS-based claims received on or after October 1, 2013, with a legacy ICD-9-CM-based system as part of a planned transition period, until systems and processes are developed to process ICD-10-CM/PCS-based claims directly. The Reimbursement Mappings consist of two crosswalks:

* ICD-10-CM to ICD-9-CM for Diagnosis Codes; and
* ICD-10-PCS to ICD-9-CM for Procedure Codes.

CMS is not using the ICD-10 Reimbursement Mappings for any purpose. We are converting our systems and applications to accept ICD-10-CM/PCS codes directly.

Verifiying patient insurance eligibility details - Medical billing - important process

2011-06-01T18:08:00.001+05:30

VERIFICATION OF INSURANCE INFORMATION

During patient registration, it is important for front office staff to identify whether a beneficiary’s expenses should be covered by other insurance before, or in addition to, Medicare. This information helps the office determine who to bill and how to file claims with Medicare.

This is not an easy task. There are many insurance benefits a patient could have and many combinations of insurance coverage to consider before determining who pays and when. Depending on the type of additional insurance coverage a patient has (if any), Medicare may be the primary payer for a patient’s claims or be considered the secondary payer.

The office staff should:

* Copy the Medicare card and/or other insurance cards.

* Obtain essential patient information through use of completed medical information/history and insurance forms.

* Determine Medicare eligibility.

* Determine “other” insurance coverage, claim submission guidelines and limitations to coverage.

* Determine the proper order of claim submission, who is primary and who is secondary payer. Obtain appropriate information to allow the claim to be submitted to the appropriate insurance payer.

A good practice to incorporate into the patient screening process is to make copies of the patient’s insurance card(s).

COPYING THE MEDICARE CARD

Verification is important since the information from the Medicare card should be obtained during the patient’s initial visit. Medicare also recommends that office personnel periodically verify a beneficiary’s insurance information to determine if any changes have occurred. Rev. 9/2010 3 Patient Registration/Screening

Pay close attention to:

*Exact patient name.

* Claim number.

* Type of insurance coverage.

* Effective date of coverage.

Claim rejections or denials could occur if complete information is not obtained and supplied on the Medicare claim form submitted.

The accuracy and verification of the Medicare card information is extremely important because this information will be used on many claim forms and medical documentation materials throughout the patient’s history with the provider’s office.

Mistakes in patient information can carry over to Medicare claims, causing claim rejects, delays and even denials. These mistakes cause more work and can be quite costly for an office.

Many offices also collect information such as health status and previous condition/injury information, spouse and/or emergency contact information, and information about the events surrounding the accident or condition. The provider should also have the patient’s signature or the patient’s authorized representative on file to authorize the release of any medical or other information necessary to process claims submitted to Medicare.

Reminder: Item 12 or the electronic equivalent authorizes medical information to be released and Item 13 or the electronic equivalent authorizes the claim to be forwarded to a Medigap insurance plan.

Verification of correct patient information can also help protect providers from potential Medicare fraud in cases where individuals are attempting to falsely represent themselves as Medicare beneficiaries. Providers should always ask their patients if they have changed their address or legal name since they last visited their office. Many offices now ask for a valid photo ID when registering a new or established patient or in cases where the identity of a current patient is in question.

Something to consider with a Medicare patient: Just because the patient is carrying a red, white and blue Medicare card does not guarantee that the patient has Medicare Part B benefits. Under Medicare Part B, the patient must pay a premium to have Part B entitlement. If the patient chooses to discontinue the Part B Medicare coverage for whatever reason, they may still continue to carry the Medicare card. It is extremely important to verify the patient’s Medicare eligibility and never “assume” that possession of the card is proof of Medicare eligibility.

Need of General equivalence mapping - ICD 10

2011-05-31T17:46:00.000+05:30

Why Do We Need the General Equivalence Mappings?

* ICD-10 is much more specific:

For diagnoses, there are 14,025 ICD-9-CM codes and 68,069 ICD-10-CM codes; and
For procedures, there are 3,824 ICD-9-CM codes and 72,589 ICD-10-PCS codes (in the 2009 versions of
ICD-9-CM, ICD-10-CM, and ICD-10-PCS).

* One ICD-9-CM Diagnosis Code is represented by multiple ICD-10-CM codes:

82002 Fracture of midcervical section of femur, closed

— From S72031A Displaced midcervical fracture of right femur, initial encounter for closed fracture

— From S72031G Displaced midcervical fracture of right femur, subsequent encounter for closed fracture with delayed healing

— From S72032A Displaced midcervical fracture of left femur, initial encounter for closed fracture

— From S72032G Displaced midcervical fracture of left femur, subsequent encounter for closed fracture with delayed healing

— And other codes from the GEMs
* One ICD-10-CM Diagnosis Code is represented by multiple ICD-9-CM codes:

* E11341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy
with macular edema
* To ICD-9 cluster:

— 25050 Diabetes with ophthalmic manisfestations, type II or specified type, not
stated as uncontrolled
— 36206 Severe nonproliferative diabetic retinopathy
— 36207 Diabetic macular edema

* A few ICD-10-CM codes have no predecessor ICD-9-CM codes:

-- T500x6A Underdosing of mineralocorticoids and their antagonists, initial encounter
-- T501x6A Underdosing of loop [high-ceiling] diuretics, initial encounter
-- T502x6A Underdosing of carbonic-anhydrase inhibitors, benzothiadiazides and other
diuretics, initial encounter
-- T503x6A Underdosing of electrolytic, caloric and water-balance agents, initial
encounter
-- T504x6A Underdosing of drugs affecting uric acid metabolism, initial encounter-- And others found in the GEMs

* One ICD-9-CM Procedure Code captured by multiple ICD-10-PCS codes:
8659 Suture of Skin and Subcutaneous Tissue of Other Sites
— To 0JQ10ZZ Repair Face Subcutaneous Tissue and Fascia, Open Approach
— To 0JQ13ZZ Repair Face Subcutaneous Tissue and Fascia, Percutaneous Approach
— To 0JQ40ZZ Repair Anterior Neck Subcutaneous Tissue and Fascia, Open Approach
— To 0JQ43ZZ Repair Anterior Neck Subcutaneous Tissue and Fascia,
Percutaneous Approach
— And others found in the GEMs

General Equivalence Mappings of ICD 9 to ICD 10

2011-05-28T17:42:00.000+05:30

What are the General Equivalence Mappings?

The GEMs are a tool that can be used to convert data from ICD-9-CM to ICD-10-CM and PCS and vice versa. Mapping from ICD-10-CM and PCS codes back to ICD-9-CM codes is referred to as backward mapping. Mapping from ICD-9-CM codes to ICD-10-CM and PCS codes is referred to as forward mapping. The GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM-based data, including data for:

* Tracking quality;
* Recording morbidity/mortality;
* Calculating reimbursement; or
* Converting any ICD-9-CM-based application to ICD-10-CM/PCS.

The GEMs are complete in their description of all the mapping possibilities as well as when there are new concepts in ICD-10 that are not found in ICD-9-CM. All ICD-9-CM codes and all ICD-10-CM/PCS codes are included in the collective GEMs:

* All ICD-10-CM codes are in the ICD-10-CM to ICD-9-CM GEM;
* All ICD-9-CM Diagnosis Codes are in the ICD-9-CM to ICD-10-CM GEM;
* All ICD-10-PCS codes are in the ICD-10-PCS to ICD-9-CM GEM; and
* All ICD-9-CM Procedure Codes are in the ICD-9-CM to ICD-10-PCS GEM.

Getting Patient information - What information need to collect in front office

2011-05-26T18:07:00.000+05:30

INTRODUCTION

Patient screening is a vital step that is critical to every type of practice. Providers should establish a process to adequately screen all types of patients. There are several steps that need to be incorporated into the patient screening process. Some things to consider when initiating or updating existing office practices:

* Complete patient profile for the office files (name, address, insurance, etc.).

* Determination of primary insurance benefits.

* Office staff awareness of those insurance plans that the office “does not have provider/network participation.”

* Identify if the patient has a supplemental insurance plan.

* Identify any instances where the patient has an extenuating circumstance that could cause a change in the insurance currently on file (accident/injury)

* Eligibility information, deductible and coverage limitations.

* Special billing requirements based on where the patient resides (consolidated billing).

Front office staff plays a key role in the success of claims being filed correctly and timely, based on a few minutes spent up-front with the patient or the patient’s responsible party. These tasks that are handled by the front office personnel or person who receives initial patient information become vital to the efficiency and financial welfare of the health care organization to which they belong.

One of the first steps to consider during patient registration is to obtain important patient profile information for the office.

OBTAINING ESSENTIAL PATIENT INFORMATION

Office staff should obtain complete patient information when registering new patients. Usually this is accomplished by the patient completing a medical information/history and insurance information form.

Pay close attention to:

* Obtaining the patient’s full name directly from the card (use of nicknames on Medicare claims will cause unprocessable claim rejections).

* Patient address and phone number.

* Obtaining the name and identification number of other insurance (Medicare or other type of insurance plan involved).

* Date of birth.

* Emergency information.

* Patient’s signature.

o Item 12 of the CMS-1500 claim form or the electronic equivalent (Patient Signature Code – Loop 2300/CLM10 and Release of Information Code – Loop 2300/CLM09) must be signed if the patient authorizes the release of medical information to Medicare and payment of Medicare benefits to the provider. Loop 2300/CLM08 Condition or Response Code – “Y” or “N” to indicate assignment of benefits as “yes” or “no.”

o Item 13 of the CMS-1500 claim form or the electronic equivalent (Patient Signature Code – Loop 2300/Q104 and Benefits Assignment Certification Indicator – Loop 2320/Q103) must be signed by the patient if there is a Medigap insurance plan and the patient authorizes payment of benefits to the provider. Release of Information Code – Loop 2320/Q106 – “Y” indicates the provider has a signed statement.

*Previous medical information (if applicable).

It is also important to periodically review the existing patient’s profile to ensure that the information on file is still current. Patients may have changes to address or insurance information and inadvertently fail to notify office staff of those important changes.

Another important step is to determine the patient’s insurance information, which will be based on the information received on the medical information/history.

Understanding EFT enrollment process

2011-05-26T15:42:00.000+05:30

ELECTRONIC FUNDS TRANSFER (EFT)

Medicare offers all providers the option of having their Medicare Part B payments sent directly to their bank account via EFT.

There is no electronic claim submission or electronic remittance participation requirement to be eligible for EFT. It is a CMS goal to increase the utilization of EFT and reduce the number of checks printed and mailed. It is now a requirement to enroll in EFT for providers and suppliers initially enrolling in Medicare or who make changes to their enrollment information. EFT is a direct deposit into the provider’s bank account for payments on claims that have finalized and met the payment floor.

This option allows providers to be paid electronically on a daily basis for the claims that have finalized and met the payment floor. This eliminates manual handling of checks and mail time to receive payments.

How to Enroll in EFT
The EFT Authorization Agreement can be downloaded from:
http://www.trailblazerhealth.com/Electronic%20Data%20Interchange/Electronic%20Funds%20Transfer/

A link on the Web site will take providers to the CMS EFT Authorization Agreement. The EFT Authorization is a two-page form that must be signed in original ink by one of the authorized delegated officials on file with Provider Enrollment. It also must be returned to TrailBlazer with a permanent voided check or deposit slip. The EFT authorization should be mailed to:

TrailBlazer Health Enterprises, LLC Provider Enrollment P.O. Box 650544
Dallas, TX 75266-0544
Rev. 08/2009 11 EFT

EASY PRINT - ERA Medicare software

2011-05-26T15:41:00.000+05:30

Medicare Remit Easy Print
Since ERA 835 files are not suitable for viewing, CMS has approved a new software package called Medicare Remit Easy Print (MREP). MREP is user-friendly software that will allow the user to convert an 835 file into a readable Standard Paper Remittance (SPR). There are also reporting features that will summarize the ERA data.

Providers can take advantage of free MREP software now available for viewing and printing the Health Insurance Portability and Accountability Act (HIPAA)-compliant ERA. The MREP software gives providers and suppliers the following abilities:

• Easy navigation and viewing of the ERA using a personal computer.
• Printing of the ERA in the SPR format.
• Search capability that allows providers and suppliers the ability to find claims information easily.
• Print and export reports about ERAs including denied, adjusted and deductible-applied claims.
• Easy-to-use method to archive, restore and delete imported ERAs.
Providers and suppliers can view and print as many or as few claims as needed. This will be especially helpful when providers need to print only one claim from the remittance advice when forwarding the claim to a secondary payer. This free software can save time resolving Medicare claim issues. Take advantage of the MREP features unavailable with the SPR.
The software can be downloaded free from the TrailBlazer Web site at http://www.trailblazerhealth.com/Electronic%20Data%20Interchange/Electronic%20Remittance%20Advice/Default.aspx. CMS is trying to reduce the number of paper remittances that contractors print and mail. If a provider/submitter receives the electronic 835, there is no need for the paper copy. Medicare contractors are no longer allowed to print and mail the SPR 45 days after a provider has enrolled in ERA.

Reference Document
CMS provides a reference document entitled Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers. Anyone interested in learning more about ERA can visit the CMS Web site at:

http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf

ELECTRONIC REMITTANCE ADVICE (ERA) overview - basic tips

2011-05-23T15:39:00.000+05:30

What Is ERA?
All Medicare Part B providers are eligible and can take advantage of ERA.

• ERA files are produced daily and include all claims and adjustments for both electronic and paper claims.
• The GPNet communication platform is used to provide a direct mailbox system for ANSI X12 835. Providers will need a single analog telephone line, asynchronous modem and communication software that support X-modem, Y-modem, Z-modem or Kermit protocol.

• GPNet supports Medicare Part B electronic remittance in the ANSI X12 Versions 4010/A1.

• Providers can save time and money by using ERA to eliminate manual posting of claims payments. Medicare Part B payments can be posted to patient accounts automatically by programming an interface that will allow for the exchange of data.

• Electronic remittance files not downloaded remain in the mailbox for 14 days from the date of the file. Upon request, files can be reloaded into the mailbox as far back as 60 days.

How to Enroll in ERA

The ERA application can be downloaded from:
http://www.trailblazerhealth.com/Electronic%20Data%20Interchange/Electronic%20Remittance%20Advice/Default.aspx

A link to the ERA Receiver's Request form is on this page. This is a one-page form that can be completed and faxed to (469) 372-1045. After receipt of the ERA Receivers Request form, TrailBlazer will set up an electronic mailbox with a receiver number and password.

Different way of electronic claim submission EDI

2011-05-21T15:37:00.000+05:30

How Does It Work?

Providers have several alternatives for entering and electronically submitting claims data:

• Providers may work through a software vendor who can provide the level of practice management system support they need for their practice.

• Providers may submit their Medicare Part B claims directly to TrailBlazer Health Enterprises® or choose to submit claims through a clearinghouse.

Providers may choose to have a billing agent handle all or part of their Medicare billing.

• If the provider’s office has the required hardware, it may choose to use Medicare’s free billing software.

Welcome to the exciting world of electronic billing! If a provider is new to the concept of electronic claims submission or has never used a computer, the following tips and hints may make the transition to a computerized billing system easier.

• When buying or leasing a system, deal with a knowledgeable, established vendor. Avoid the temptation to base a buying decision solely on price. Ask for references from current users of the systems considered and check them. Providers should try to find another provider in their specialty that is using that particular software or someone who has billing practices similar to their office.

• A dedicated phone line is recommended; this will eliminate interrupted transmissions.

• Regularly make backups of all patient and claim data. Disaster-recovery procedures suggest two backup files be kept – one on-site and one off-site. Keep backups in a safe and protected place. In the event of fire or system problems, a current backup will enable a provider to reconstruct his office’s records.

• If the office is prone to power blackouts, brownouts or voltage surges, consider using an Uninterruptible Power Supply (UPS) with a built-in surge suppressor to protect equipment. During severe weather, disconnect the system’s modem from all phone connections to prevent damage.

• If the system has difficulty connecting, check the submitter number and password to be sure they are correct and are in uppercase letters. Most connection problems can be traced to invalid submitter numbers or passwords.

• If transmitting claims directly to TrailBlazerSM, always read the response file received. This report tells the provider what was received, when it was received and whether it was accepted. For questions about the report, contact the EDI Technology Support Center at (866) 749-4302. If filing claims through a clearinghouse, providers should contact their representative there for a copy of their response file.

• Changes in Medicare filing requirements are communicated in various newsletters and publications as well as listserv messages (if providers have signed up to receive EDI information via listserv). Read these carefully for advance notice of enhancements and changes for the electronic billing environment.

• Often, new computer systems can have issues that need to be resolved. Be patient and give it a chance; all change takes an adjustment period.

Electronic claim submission basic overview

2011-05-19T15:35:00.003+05:30

INTRODUCTION TO ELECTRONIC DATA INTERCHANGE (EDI)

EDI is the process of transacting business electronically. It includes submitting claims electronically, or “paperless” claims processing, as well as electronic remittance, Electronic Funds Transfer (EFT) and electronic inquiry for claim status and patient eligibility.

What Are the Benefits of EDI?

The benefits of EDI are as follows:

• Medicare Part B claims process faster and providers are reimbursed sooner, improving their cash flow. Payment for electronic claims may be released after 13 days; payment for paper claims can be released after 29 days.

• Mailing and administrative costs are significantly reduced.

• Because of GPNet editing, fewer claims are returned with development letters, saving staff time and effort (refer to the GPNet Edits Manual on Medicare’s Web site at http://www.trailblazerhealth.com/Publications/Training%20Manual/GPNetEditManual.pdf in the “EDI Publication” section for a list of GPNet edits).

• Better control over filed claims. The data providers enter into their system is sent directly to Medicare’s claims processing system exactly the way they sent it; there is no need for intermediate data entry. A response report lets providers know that Medicare’s computer system has received their claims.

• The patient account number appears on every Explanation of Medicare Benefits providers receive, which reduces staff time spent locating payment-posting information.

• Providers can further automate their office using Electronic Remittance Advice (ERA) and EFT.

• Providers have access to online inquiry, which allows access to claims status and patient eligibility information. This information is obtained through dial-up capabilities using software that is provided at no cost and is compatible with their IBM or IBM-compatible PC.

• Providers receive ongoing customer support through Medicare’s EDI Technology Support Center.

MISSING EFT ENHANCEMENT - Medicaid denial

2011-05-18T15:33:00.000+05:30

DESCRIPTION OF THE ISSUE

The Medicaid claims statuses states; the pay to provider is not eligible for direct payment.

CONCEPT

Any carrier should possess EFT enhancement during enrollment process inorder to obtain any claim status during verification.

SOLUTION

Upon verification with the Provider enrollment @ Medicare, the EFT Authorization form was submitted. Later the Billing Indicator was changed to "Yes" and the necessary billing information was updated. Finally all the claims were processed and paid

RAIL ROAD MEDICARE REQUESTS FOR PROVIDER’S PTAN#

2011-05-16T15:32:00.000+05:30

DESCRIPTION OF THE ISSUE

PTAN# was not issued for Dr. . Hence all the RR MCR claims were in pending for long duration.

CONCEPT

RRMCR requests for appropriate PTAN# for processing its claims.

SOLUTION

After regular follow-ups with the Insurance on request to issue PTAN#, we received the same after 60 business days and all the outstanding claims were processed and paid.

If Your Employer Doesn't Offer Health Insurance. What Do You Do?

2011-05-15T00:19:00.000+05:30

INCORRECT TIN# FILED FOR A CAPITATED CARRIER

2011-05-13T15:30:00.000+05:30

DESCRIPTION OF THE ISSUE

The claims of Wellcare were initially denied for “No Authorization on file”. {submitted with the Tax-Id# 123456789}.

CONCEPT

If a provider is capitated under a plan, we need to verify on all the information of the provider with the concerned Insurance records to avoid denials of missing/incorrect provider’s information.

SOLUTION

Upon verification with Wellcare we found Dr. had separate Tax-Id# 987654321 and was capitated with this plan. Hence all the claims were refiled and processed under capitation

PROVIDER INELIGIBLE TO FILE CPT 81001 - Denial reason

2011-05-11T15:29:00.000+05:30

DESCRIPTION OF THE ISSUE

We received denials for the CPT 81001 as “Provider is not certified eligible to perform this procedure” - CPT 81001 (Urinalysis with microscope)

CONCEPT

Any provider should be aware of his eligibility of the services to be performed for appropriate reimbursements.

SOLUTION

Per Coding Dept’s advice we changed CPT from 81001 to 81002 (Urinalysis without microscopy) and refiled all the denied claims for reprocessing. The refiled claims were paid successfully.

HOSPICE CLAIMS SUBMITTED DIRECTLY TO MCR INCORRECTLY

2011-05-09T15:28:00.000+05:30

DESCRIPTION OF THE ISSUE

Previously we had billed Hospice covered patient claims to Medicare with GW modifier to get quicker payments. Balance of 20% coinsurance was billed towards patients. Client raised an issue to file the claims to the concerned Hospice care itself instead of billing Medicare.

CONCEPT

Whenever we find patients with Hospice coverage for a particular service date, we must check with Hospice whether the patient was in Hospice for the specific DOS, if yes we must bill that concerned Hospice care and not Medicare, if not we could bill Medicare with GW modifier (which indicates the claim not related to Hospice).

Per Client - Incorrect filing of all claims towards MCR directly will cause a red flag for our provider in MCR system.

SOLUTION

On finding patients under Hospice coverage, we need to place a verification call towards Hospice care to inquire whether the patient was/is in Hospice for the specific DOS.

If incorrectly paid Hospice claim towards Medicare with GW would be refunded and the claims would be forwarded towards the concerned Hospice care, before that we need to confirm whether the GW modifier is removed from the claim

SECONDARY MEDICAID CLAIMS DENIED AS “MEDICARE COVERAGE IS PRESENT”

2011-05-08T15:27:00.000+05:30

DESCRIPTION OF THE ISSUE

Secondary Medicaid denied claims as Medicare coverage is present/ Crossover data missing at detail level. As per our conversation with Medicaid they do not cover the balance left from Primary Medicare HMOs.

CONCEPT

If patient have Medicare HMO as primary Insurance and Medicaid as secondary, such scenario claims have been denied like this.

SOLUTION

Before we bill claims to Secondary Medicaid we need to check the paid amount of the primary carrier with Medicaid fee schedule and if the amount greater than the Medicaid allowable we could waive the balance off

PSYCHIATRIC REDUCTION ON MEDICARE CLAIMS - PAYMENT REDUCED

2011-05-06T15:26:00.002+05:30

DESCRIPTION OF THE ISSUE

Whenever we use Psychiatric related diagnosis as primary one on a claim, this will cause a payment reduction from Medicare. The reduction has covered by some of the commercial secondary Insurances and if the patient does not have such, we could not bill the balance amount fully to the patient responsibility, we can only bill the 20% of the Medicare balance to patient not the reduced amount.

CONCEPT

If a patient treated for an Office/ Hospital visit based on the Psychiatric problem and if the patient needs specialty treatment, this would cause reduction on payment.

SOLUTION

Once we receive a claim with primary diagnosis related to Psychiatric (ICD Starts from the numeric 3) we need to check with Client Office whether there is any alternative primary Diagnosis. If reduction done by Medicare then we should correct primary ICD through Medicare IVR Telephone Clerical Reopening option

Health Plans, Can You Make Changes Anytime You Want?

2011-05-05T00:19:00.000+05:30

W9 FORM IS NOT REACHING THE CARRIER

2011-05-04T15:24:00.000+05:30

DESCRIPTION OF THE ISSUE

All the claims under Orlando Health care are awaiting for W9 form from the provider.

CONCEPT

Carriers request on any information should be submitted for the claims to be reimbursed.

REASON

Upon several submission of W9 form of the provider either through fax and despatch haven’t reached the carrier. We are in process of getting approval of receiving W9 form from the Carrier.

ADVANTRA CLAIMS WERE NOT REDIRECTED TO COVENTRY HEALTH CARE

2011-05-02T15:22:00.000+05:30

DESCRIPTION OF THE ISSUE

Advantra was undertaken by Coventry beginning of 2010. This was not noticed and the forwarded claims of Advantra were in pending for long duration. Upon notification and filing of claims towards Coventry resulted in TFL denials.

CONCEPT

Carrier updates should be carefully noticed and gathered from the Dr’s office by the Billing office.

SOLUTION

After a long follow up we started filing claims towards Coventry Healthcare which resulted in TFL denials. These

denied claims were appealed with appropriate proof and the claims were reimbursed by the carrier successfully