Contractors hired by Medicare to audit the payment records of healthcare providers have a good track record spotting improper billing, the Department of Health and Human Services Inspector General concluded…
Physicians are very often so stressed out with seeing an increasing number of patients, providing medical services and appropriate follow-ups that they hardly get any time to see to the…
In an effort to control healthcare costs of the nation's oldest, poorest and often sickest patients, 34 states have implemented or are planning integration programs within the next two years…
In an effort to scale back use of high-priced imaging of questionable value in cancer treatment, Medicare has proposed ending reimbursement for post-treatment positron emission tomography scanning in prostate cancer…
The Centers for Medicare & Medicaid Services (CMS) Transmittal 1058, Change Request (CR) 7767 confirms a zero percent update for payments under the Medicare Physician Fee Schedule (MPFS) through year’s end.
Meaningful use expert Jim Tate has written that the Medicaid EHR incentive program reminds him of "zero entry" swimming pools: very easy to get into, with almost no barriers. Given…
Checklist Extra: The physician’s credentials have a role to play, too.
Your CPT® coding may be spick and span, but if you fail to fulfill your physician signature requirements, your claims could end up in hot waters because not following these rules can trigger audits and other compliance headaches. Getting your provider to sign your patient’s charts is a basic documentation prerequisite that calls for your relentless compliance.
Basic: The treating physician’s signature serves as a legible identifier for the provided/ordered services. Payers require that the signature must be present in the documentation that comes with your claim.
Check out the following Q&A and find out why stamped signatures just won’t do you any good.
Get to the Bottom line Of Handwritten vs. Electronic Signatures
Question 1: Some of our physicians use handwritten signatures on their charts and others prefer electronic signatures. Is either kind acceptable?
Answer 1: According to CMS,, “Medicare requires a legible identifier for services provided/ordered.” That “identifier” — or signature — can be electronic or handwritten, as long as the provider meets certain criteria. Legible first and last names, a legible first initial with last name, or even an illegible signature over a printed or typed name are acceptable. You’re also covered if the provider’s signature is illegible but is on a page with other information identifying the signer such as a typed name.
“Also be sure to include the provider’s credentials,” says Cindy Hinton, CPC, CCP, CHCC, founder of Advanced Coding Solutions in Franklin, Tenn. “The credentials themselves can be with the signature or they can be identified elsewhere on the note.”
Example: Pre-printed forms might include the physician’s name and credentials at the top, side, or...
Reporting modifier 78 for a staged procedure? Expect denials.
When it comes to appending CPT® modifiers to your codes, the rules can be daunting, and Medicare’s regulations only compound the confusion. But if you’re up to speed on these key modifier billing practices, you’ll be raking in deserved pay.
Check out the following five tips to ensure that you aren’t missing any opportunities.
1. Don’t Avoid Modifier 26.
If your physician provides an interpretation and report for an x-ray or other radiological service in the treatment of a patient, that’s not always just part of his E/M—in some cases, you can separately bill for the interpretation and report by appending modifier 26 (Professional component) to the CPT® code.
Typically, the technologist that performed the patient’s x-ray will bill the code — such as 71010 (Radiologic examination, chest; single view, frontal) — with modifier TC (Technical component) to indicate that he is billing for the equipment, room charge, film and radiologic technician, but not for the physician’s interpretation. If the physician who renders the interpretation is with a separate professional group and is not a hospital employee, you should report the service with modifier 26 to obtain his proper share of the reimbursement.
2. Know the Difference Between Modifiers 58 and 78.
Because both modifier 58 and 78 describe procedures performed during another surgery’s global period, it can be easy to confuse them. But differentiating between the two can mean the difference between collecting your due and filing endless appeals.
Key: You’ll report modifier 78 (Unplanned return to the operating room for a related procedure during the postoperative period) when conditions arising from the initial surgery (complications) rather than the patient’s condition...
Question: Eight days after an initial wart freezing, the patient returns, and the physician freezes another wart. Is the second procedure bundled into the first, or can we report it with a modifier? Answer: You may be able to report the second occurren...
Boost co-surgery, multiple surgery, and bilateral surgery pay for these select procedures
You’ll no longer have to eat the cost of your services if your physician acts as co-surgeon on spine revisions. Thanks to several Fee Schedule changes that CMS recently enacted. CMS had good news in MLN Matters article MM7430, which had an effective date of Jan. 1, 2011 and an implementation date of July 5, 2011.
Look for Potential Co-Surgery Payment for These Codes:
CMS will change the co-surgery indicator for spine revision codes 22212 and 22222 from “0” to “1”. Keep in mind that supporting documentation is required when billing for a co-surgeon with these procedures, so don’t forget to submit that with your claim or you’ll be looking at bad news.
Remember: If you’re billing for co-surgery, append modifier 62 (Two surgeons) to your procedure code. For modifier 62 claims, most payers pay an additional fee (generally 125 percent of the “usual” fee for the procedure, split evenly between the two surgeons). Avoid reimbursement problems by checking these claims carefully. To claim co-surgeons, each surgeon must perform a distinct portion of a single CPT procedure, and each surgeon must dictate and submit his own operative report for his portion of the surgery.
Benefit From Surgical Assist Changes:
Practices that perform sinus endoscopies will also get a potential boost from the fee schedule changes, now that you’ll see the assistant at surgery indicator change for codes 31233 and 31235 from “1” (Assistant at surgery may not be paid) to “0” (Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity).
You’ll append modifier 80 to the assistant’s surgical codes if the assisting surgeon is a physician. In cases when a non-physician assists at surgery on Medicare patients, append...
Beware of CPT® and Medicare differences when counting HPI elements.
Not accurately accounting for the history of presentillness (HPI) documented by your oncologist could result in missing appropriate opportunities to report level 4 or 5 E/M visits. Ensure you’re not missing higher paying possibilities by reviewing this guide to capturing HPI elements.
Brush Up on What Qualifies as an HPI Element
HPI is one of the three parts comprising an outpatient E/M history. It describes the patient’s present illness or problem, from the first sign/symptom to the current status, and typically drives a provider’s decisions about the physical examination and treatment. “The information gathered during the physical exam (PE) portion of a patient’s evaluation often only shows a very limited picture of the patient’s problem. However, speaking with a patient and gathering the history of the patient’s problem” can help fill out the picture, explains Amanda S. Stoltman, CCS-P, compliance coder at Urology Associates in Muncie, Ind.
Start counting:
HPI also will often determine the level of service you’ll report. You’ll count the HPI elements to help you determine which level of service you can report. There are seven or eight HPI elements, depending on which source you are following. For Medicare, the eight elements are as follows:
Medicare includes the above list in both the 1995 and 1997 E/M Documentation Guidelines, available at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.
In contrast: CPT® lists only seven HPI elements in the E/M Services Guidelines, with duration not making the list. Therefore, for Medicare and payers following its guidelines, you should consider duration and timing separately. With payers that follow AMA rules, however, be aware that they don’t consider duration and timing to be two separate elements. Rumor has it...
EMR signature pitfalls could be a daily challenge with which you often deal. Check your answers against our experts’ advice to verify your group’s signature compliance.
Question 1: Some of our physicians use handwritten signatures on their charts and others prefer electronic signatures. Is either kind acceptable?
Answer 1: According to CMS documents, Medicare requires a legible identifier for services provided or ordered. The identifier — or signature — can be electronic or handwritten, as long as the provider meets certain criteria. Legible first and last names, a legible first initial with last name, or even an illegible signature over a printed or typed name are acceptable. You’re also covered if the provider’s signature is illegible but is on a page with other information identifying the signer (letterhead, addressograph, etc.). Also be sure to include the provider’s credentials. The credentials themselves can be with the signature or they can be identified elsewhere on the note.
Pre-printed forms might include the physician’s name and credentials at the top, side, or end. All qualify as acceptable documentation as long as the coder or auditor can identify the provider’s credentials. You can also use a signature log to back up your physician’s documentation. The log should contain each provider’s printed or typed name and credentials, along with their signatures and initials. You can reference the signature log in order to verify a note that contains an otherwise unidentifiable signature. This is an important resource when providers are signing notes that do not include their typed or pre-printed name.
Make sure that you update signature logs at least once a year. Create separate logs by provider (physicians, CRNAs, AAs, residents, etc.) to help simplify tracking. Stamped signatures don’t meet the CMS requirements. Because a signature stamp can be used...
Make your physician’s job easier by letting the patient or nurse document the history.
If your physician glosses over a patient’s past, family, and social history (PFSH), you may be missing out on up to $69 per E/M. Accurately counting the number of PFSH items could result in more money for an encounter, because the top-level E/M codes require PFSH elements in addition to an extended history of present illness, and more than 1 system reviewed. Learn these three quick tips to ensure your physician is capturing, and you’re recognizing, every history component the patient mentions.
1. Determine the Level of PFSH
For coding purposes, the history portion of an E/M service requires all three elements — history of present illness (HPI), review of systems (ROS), and a past, family and social history (PFSH). Therefore, the PFSH helps determine patient history level, which has a great effect on the E/M level you can report. If you do not know the PFSH level, you may have to select a lower level of E/M service than might otherwise be warranted. There are three levels of PFSH: none, pertinent, and complete, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn.
Pertinent: To reach a detailed level of history for the encounter (in addition to an extended HPI and the review of 2-9 systems), you need a pertinent PFSH. According to Medicare’s Documentation Guidelines for E/M Services, you need at least one specific item from any of the three PFSH areas to achieve the pertinent level. When the physician asks only about one history area related to the main problem, this is a pertinent PFSH.
Complete: To reach a comprehensive level of history for the encounter (in addition to an extended HPI and the...
Get your system moving before June 30th or you’ll pay the price.
If you do not have an electronic prescribing (ePrescribing or eScribing) system yet in place, or have not integrated one into your electronic medical record (EMR) system, you better get a move on it. You only have until June 30, 2011 to submit at least ten claims to Medicare demonstrating that you are a successful eScriber for 2011. Otherwise, you are at risk of not only losing the bonus in 2011 but according to the rulemaking for 2011, also facing penalties assessed, reducing your Medicare fee schedule by 1 percent in 2012.
With limited time, it is smart to consider a stand-alone internet based system which you can implement relatively easy. You could get this system up and running right away, at a low cost, with simplified a implementation timeline and without depending on your electronic health record (EHR) selection and implementation which is both much more extensive, costly and more complicated to implement.
If you’re still asking, “Can our practice afford not to adopt ePrescribing?” Then, the answer is NO. Today you need to start doing something.
Background: eScribing is part of Centers for Medicare and Medicaid Services’ (CMS) incentive program called the Physician Quality Reporting System (PQRS). PQRS offers incentives to practices that meet CMS-set goals for the implementation and practice of electronic prescription on a regular basis. The system was designed with “a carrot and a stick”. While we have been enjoying the “carrot” for the past few years, the “stick is on the cusp of being implemented as of June 30th per the 2011 Rulemaking. CMS will pay you when you implement eScribing in 2011 (a 1 percent bonus), it will penalize you when you don’t put it into practice, a 1percent penalty...
Boost your bottom line by reporting new annual wellness visits correctly. If you want your annual visit claims to be picture perfect in 2011, then follow these five tips to avoid future denials and keep your physician’s claim on the fast track to success.
Background: The Affordable Care Act (ACA) extended preventive coverage to more than 88 million patients covered by health insurance, and Medicare has codified that benefit in the form of an annual wellness visit. Medicare valued the new annual wellness codes based on a level 4, problem-oriented new and established E/M service.
The two new codes are:
G0438 — Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit
G0439 — Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit.
Tip 1: Apply G0438 to Second Year of Coverage
Be wary of applying these codes to new Medicare patients coming in to your physician’s practice in 2011. The reason is that Medicare will only reimburse the initial visit (G0438) during the second year the patient is eligible for Medicare Part B. In other words, during the first year of the patient’s coverage, Medicare will only cover the Initial Preventive Physical Exam (IPPE), also known as the Welcome to Medicare exam.
Tip 2: CMS Limits G0438 to One Physician
If your FP sees the patient for the initial visit (G0438) and the patient sees a different physician for the next annual wellness visit, that second physician will only receive reimbursement for the subsequent visit (G0439), despite having never seen the patient before.
Here’s why: CMS has indicated that when a patient returns to the same or new physician in a third year, they might only pay for the subsequent visit, says Melanie Witt, RN, COBGC, MA, an...
Question: My doctors stand by for the cardiologists during a pacemaker placement in case they need to place epicardial leads. They want to report their time, and I have found 99360 for this. Do they need to dictate something in order for me to charge f...