General / Hot Coding Topics

New Year, New Insurance = New Verification

Question:

How should I file a claim on a patient who has new coverage but has not received an insurance identification card yet? (South Carolina Subscriber)


Answer:

Ideally, when patients call to make appointments, you should have someone in your office confirm their insurance coverage and eligibility, especially if you know the patient is going to have new insurance.  Now is the time of year when benefits verification tends to be most useful. While verification is good practice all year long, January is the time when you’ll see more insurance changes – including payer, benefit, and deductible/copay changes – than at any other time during the year because most employers hold open enrollment in December.

Finding out about insurance changes before the appointment gives you time to check if you are a participating provider with the payer and verify coverage. If the patient doesn’t yet have an identification number with her new insurance company, ask for the name of the insurer and the policy number from the patient, or from the patient’s employer. Then, call the insurer and verify the coverage and the date of eligibility, and get the appropriate information to identify the patient on your claim.

Warning: The date of eligibility is an important question to ask the payer because many employers don’t make health insurance coverage immediately available to new workers. A patient with a new job and new insurance coverage may be in your office for a visit today, but his insurance isn’t effective for two months.

Alternative: Although verifying coverage in advance is preferable, many practices have patients confirm their insurance coverage and note any changes when they check in for their appointments. If you are unable to verify the insurance coverage, or you find that the patient is not eligible for coverage on...

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May 5, 2011
Coder's Cranium / modifier 58 / modifier 78 / modifier 79

Modifier 58, 78, 79 Tips to Get Postop Surgery Paid Correctly

Don’t miss out on extra pay when global period resets.

Just because you routinely append modifiers to your claims doesn’t mean you’re filing correctly and getting the most appropriate pay. Brush up on your modifier know-how with these tips for three of the trickiest choices: modifiers 58, 78, and 79.

Selecting between these modifiers can be carrier-specific in some situations, says Jacqui Jones, office manager for Benjamin F. Balme, MD, PC in Klamath Falls, Ore.

Remember All Possible Uses for 58

The descriptor for modifier 58 seems self-explanatory: Staged or related procedure by the same physician during the postoperative period. Coders sometimes trip, however, when they forget that modifier 58 actually applies to subsequent procedures that fall into one of three categories:

Planned or anticipated (staged):  A good example might be an infected hand that has to be debrided several times over the course of a couple of weeks. You won’t use a modifier on the first procedure, but will add modifier 58 on the subsequent procedures.

More extensive than the original procedure: The physician manipulates a patient’s ulnar fracture. An x-ray at the follow-up appointment shows that the reduction failed, so the physician completes pinning or an open reduction with internal fixation (ORIF). Code the procedure as needed (with 25545, Open treatment of ulnar shaft fracture, includes internal fixation, when performed, for example) and append modifier 58.

Therapy or treatment following a surgical or diagnostic procedure: This could apply to a soft tissue biopsy followed at a later date by malignant tumor excision.

You’ll only append modifier 58 to the second procedure if it occurs during the first procedure’s global period. The date of the second procedure resets the global period. You should expect 100 percent reimbursement for procedures you file with modifier 58.

Verify ‘Surprise’ Before Reporting 78...

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October 27, 2010
Coder's Cranium / Medicare / Oig

Nonphysician Providers and Incident-To: Your Coding Questions Answered

Here’s why you should keep your physicians’ work schedules on file. Correctly billing your nonphysician practitioners (NPPs) incident-to services means the difference between 85 and 100 percent reimbursement. But if you bill incident-to haphazardly, you’re just waving a red flag at auditors. And those auditors are jonesin’ to find incident to billing problems. Just check out this [...] Related articles:

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October 25, 2009