N T M C A
Medical Billing & Consulting
NTMCA
1505 W HOUSTON
SHERMAN, TX 75092
United States
ph: 903-892-6900
admin
CODERS CORNER NEWSLETTER
DID YOU KNOW?
WATCH AN INSIGHTFUL VIDEO ON HOW SOME HEALTH INSURANCE CARRIERS HANDLE MEDICAL CLAIMS. VIDEO
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Do you know the difference between a self-insured company and a fully-insured company?
A self-funded plan is one in which the employer assumes full financial risk of covering its employees, paying medical claims from its own resources. ERISA exempts self-funded plans from compliance with state laws and regulations.
A fully-insured plan is purchased from an insurance company or underwriter that assumes all financial risk for payment of medical claims. State laws and regulations apply to these policies. in addition to ERISA.
Understanding how to identify those companies and how they affect your claims payment revenue cycle is a vital element to the financial success of your practice.
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Modifier -25. When can you perform an E/M and a minor procedure on same day of service? You need to know how an auditor will extrapolate the clinical documentation for any exam appended with mod -25. They divide this into three parts:
1) Preoperative assessment
2) Intraoperative
3) Postoperative.
They look for any reference in the exam that applies to those three categories, then they look at what is left over to see if it is indeed "separately identifiable."
However, some carriers will not pay for an E/M service with modifier -25 without a review of clinical documentation. So, you have to know your carrier guidelines before billing with modifier -25.
Inappropriate use may trigger an audit.
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IOL Masters (92136) and A-Scans (76519) are bundled. But, when a dense cataract prevents you from getting a viable A-Scan result on one of the eyes, and you perform an IOL Master on that eye. ..the IOL Master is billable on that eye. You would bill as 92136-RT or LT for that eye only.
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When trying to determine if the procedure to be coded is a PRP (67228) or a Focal Laser (67210), correct documentation is essential. The main difference between the two: lesion -vs- vessels. The PRP seals the vessels in the retina so that they no longer leak. The focal laser is usually described as scattered destruction of lesion(s).
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Medicare has eliminated consultation codes; however, most other carriers continue to accept consultation codes.
http://www.trailblazerhealth.com/Publications/JobAid/2010ConsultationReferenceGuide.pdf
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CCI Edits bundle the OCT (92135) and the fundus photography (92250); however, it can be unblundled with mod-59. Make sure that before you unbundle these that you have documented medical necessity to support this. You should also notate on the bill that you have documentation on file to support the medical necessity. You would append mod -59 to the OCT. You should also have the patient sign an ABN just in case the carrier denies it. Use it, don't abuse it..MOD-59 is on the OIG watchlist!
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(92135) Was deleted on 1.01.2011 and replaced with:
(92132) 92132 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral
(92133) 92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
(92134).92134 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina
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Plaquenil Therapy Checks: First, did the exam find any ocular changes? Second, who is the carrier, Medicare or a Commercial carrier?
Medicare:
If no ocular changes, then: code to show the patient is on long term medication with V58.69, and code the systemic condition, such as rheumatoid arthritis 714.X as a secondary diagnosis.
If you do find ocular changes, then list that as your primary diagnosis and V58.69 as your secondary diagnosis.
Non-Medicare:
Use the V58.69 as the primary diagnosis, the ocular change as the secondary, and the systemic disease as the third diagnosis.
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This information should NOT be considered legal advice and receipt of it does not create an attorney-client relationship. NTMCA provides this information with the express understanding that 1) no attorney-client relationship exists, 2) neither NTMCA nor its attorneys are engaged in providing legal advice and 3) that the information is of a general character. Although NTMCA has attempted to present materials that are accurate and useful, NTMCA shall not be liable to anyone for any inaccuracy, error or omission, regardless of cause, or for any damages resulting therefrom. You should not rely on this information when dealing with personal legal matters; rather legal advice from retained legal counsel should be sought.
NOTEWORTHY NEWS
The number of legal cases continue to grow in the area of fraud and kickbacks. The legal fees and other costs involved in defense is daunting. But, did you know that the OIG offers to review prospective business arrangements between medical care providers. To learn more visit the OIG website HERE.
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Trailblazer loses the bid on Medicare J4 contract. READ
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Cigna buys HealthSpring Medicare Advantage Plan. READ
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Are you one of the physicians that will have to revalidate your provider enrollment in the Medicare program?
Click here to read the ARTICLE. If you are located in the J4 region (Texas, Oklahoma, New Mexico, or Colorodo) our company can assist you with this process. Contact us.
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NATIONAL 5010 TESTING
5010 external testing begins in April 2011. You must be compliant January 1st, 2012. CMS has stated that although you are still required to be compliant, they will temporarily waive fines and penalties. This waiver does not apply to any other carriers.
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National Health Insurance Report Card can be read here.
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Consumer search for Insurance Company profile here.
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E R X
You must report the ERX in 2011 to avoid the penalty. If you are not reporting or you are unsuccesfully reporting, then your 2012 - 2013 reimbursement will be reduced.
Exemptions: Optometrists, those qualifying for the hardship exception (G8642/G8643), and those that do not have prescribing privileges (G8644).
In 2011, you cannot claim both the EHR and the ERX. Those not exempted must report the ERX; however, they cannot report the EHR. If you report and get paid for the EHR, you will not get paid for the ERX and as a result, your 2012 - 2013 reimbursements will be penalized.
Recent proposals have been discussed to change requirements and penalties but have not been finalized as of 06/06/2011.
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E H R
If you have purchased or are considering the purchase of EHR you should know that the qualifications are staged and not all products qualify you for the CMS Incentive.
Cyndee Weston, President of AMBA, stresses the importance of knowing which EHR's will qualify. "There are 10 products that are 2011 CCHIT certified at this minute. You should expect that only a handful will eventually be offered and that if your vendor isn't 2011 certified, you may not want to jump off the deep end yet in making a purchase. There are 175 or so products that are certified or have a certified module, but they are not 2011 CCHIT certified, and that's going to be the type of product that will qualify you.
There are 25 objectives that a certified EHR product must have to qualify a
provider. An office must demonstrate meaningful use of these 25 objectives,
such as, 80% of patient labs, xrays, results must be ordered and received
electronically.
There is a LOT more to qualifying for the bonus than just buying an EHR
product. It must be a certified EHR system."
CMS TIP SHEET FOR INCENTIVE PROGRAMS
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IOM list of preventive services expected to boost women's health, article by:
By Doug Trapp, amednews staff. Posted Aug. 1, 2011.
"Private health plans with tens of millions of enrollees will remain exempt from the cost-sharing ban at first. Many health plans that existed when health reform was enacted in 2010 are grandfathered in when it comes to certain provisions of the law as long as the plans do not significantly change their cost or benefit structures. HHS estimated in July 2010 that 98 million people -- mostly in group health plans -- would remain exempt from the law in 2013."
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Bessie Stanley (adapted; erroneously attributed to Ralph Waldo Emerson):
Success
To laugh often and much;
To win the respect of intelligent people and the affection of children;
To earn the appreciation of honest critics and endure the betrayal of false friends;
To appreciate beauty, to find the best in others;
To leave the world a bit better, whether by a healthy child, a garden patch or a redeemed social condition;
To know even one life has breathed easier because you have lived.
This is to have succeeded.
Often attributed to Ralph Waldo Emerson, it is an adaptation of a poem published in 1905 by Bessie Stanley. No version of it has been found in Emerson's writings. For more information see http://www.transcendentalists.com/success.htm
OIG COMPLIANCE _____________
2012 OIG workplan. READ
OIG PHYSICIAN COMPLIANCE TRAINING VIDEOS ARE AVAILABLE. READ
OIG gives testimony to several US House of Representative Committess about Medicare fraud. STORY.
NEW FRAUD CASE IN THE NEWS SEEKING $150 MILLION IN DAMAGES AND PENALTIES UNDER THE FALSE CLAIM ACT.READ
2010 OIG SEMI-ANNUAL REPORT. The 2010 fiscal reporting period reports 552 criminal actions and 371 civil actions netting $3.2 billion in HHS and $570.2 milion in non-HHS receivables.
The 2009 OIG semi-annual report ending Sept. 30th, 2009, announced it would collect almost $21 Billion in FY 2009 due to fraud and waste.
During the FY 2009 there were 515 criminal and 387 civil actions against individuals and entities engaged in health care related offenses. These cases resulted in $3 billion in HHS and $985.7 million in non-HHS civil and administrative settlements and/or judgments related to Medicare, Medicaid, Federal, State, and other private health care programs.
They also excluded 2,556 individuals and entities from federal health care programs.
Included in the OIG 2010 work plan is billing for physician services during the global periods.
RAC auditors are paid a percentage fee based on the dollar amount they determine have been overpaid. Read the article here.
MAJOR FRAUD BUST 07.16.10 read story. .
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Dept. Of HHS proposes use of mystery shopper patients to compare primary care wait times. Read article.
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Texas Department of Insurance
February enforcement actions.
May enforcement actions.
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Texas Senate Bill No. 8 proposed to improve quality and efficiency in health care: www.legis.state.tx.us/tlodocs/82R/billtext/pdf/sb00008e.pdf)
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Medicare Supplement Insurance and Rate Guide READ.
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AMA, physician groups urge CMS to pay overdue reimbursements. read
CMS announces plans to issue reimbursements. read
CMS PUBLISHES: "ACA Claims Reprocessing: Questions And Answers (Q&As) for Providers" 5.17.11
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Read the "RED FLAGS" update. How does it affect your Practice? If you offer payment plans to your patients..then the rule will apply to you.
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The January 2, 2010, edition of ACP Internist contained an article by Stacey Butterfield, titled “Clinicians Crucial to Avoiding Coding Errors," really caught Medicare's attention.
Read the Medicare response.
MEMBER OF AAOE, AMBA, AAPC. All rights reserved.
NTMCA
1505 W HOUSTON
SHERMAN, TX 75092
United States
ph: 903-892-6900
admin
