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EDITOR’S VOICE:

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Sivakumar V., CPCP, CMRS

Since the evolution of human kind on earth, 2 things have been of utmost importance, Food & Health. Caring for health has been an evergreen point of thought and discussion for the humans, which resulted in continuous research and innovation in this field.

United States has played a vital role in developing healthcare industry to the present day scenario by adding insurance component to the healthcare. Though, Germany has adapted to healthcare insurance much prior to USA, it has not gained much prominence due to its socialist policies when compared to US Healthcare.

American Medical Association (AMA) is one of the oldest medical associations (first being Royal Medical Society of UK) formed in 1847 and incorporated in 1897, has played a role that reflected dual-standards, first by opposing participation in HMOs during Great Depression in 1930s, again during 1950-1965 opposing Medicare, and then reversing their stand and now playing an important role in CMS policy making.

While the words of Florence Nightingale influenced Jacques Bertillon to document “Bertillon Classification of Causes of Death,” which took the shape of current days International Classification of Disease (ICD), it is AMA’s lead role that helped in developing Current Procedural Terminology (CPT) and HCPCS.

While talking about health insurance, it is worthy to quote the name of Blue Cross dating back to 1929, which later merged with Blue Shield to become BCBS in 1982 and is one of the biggest Healthcare Insurance companies in USA rendering services to over 110 million US Citizens. Blue Cross has been vital in implementing Medicare and thus partnered with Federal Government Health Policies.

With the advent of information technology and outsourcing of Medical Coding & Billing across the globe, the concern for “confidentiality of the patient information” has grown to the extent that HIPAA has been enacted by US Federal Government.

All in all, US healthcare industry has not only provided a basis for better healthcare management model for other countries, it has also provided employment opportunities for people in some developing countries.


About The Editor: The Editor is in to US Healthcare industry for the past 18 years with end-to-end experience and is a blogger of various Healthcare Coding and Billing Forums & Blogs.

Likes: Driving long distances to explore nature and has driven cross-country covering all most all of India twice in the past 24 years.

Favorite Songs:
1. Smiling Faces Sometimes – Temptations
2. In The Living Years – Mike & Mechanics

Favorite Author: Irving Wallace - The Seventh Secret

Favorite Move: The Guns of Navarone


TWO NEW E/M CODES THAT CAN GENERATE EXTRA REVENUE FOR PHYSICIANS IN 2016

In 2016, two new E/M Codes are introduced for reporting Prolonged Office or Outpatient Observation Services that too without direct face-to-face contact with the physician, but clinical staff should provide the observation under physician’s supervision. (This is unlike 9954 and 99355).

+ 99415 Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)

+ 99416 each additional 30 minutes (List separately in addition to code for prolonged service)

Remember, these are Add-on Codes only and cannot be reported independently. The total time of the primary service is used to determine when the prolonged service time begins.

QUALIFYING CRITERIA

  1. The place of service must be in an office or outpatient setting.
  2. Face-to-face time with the clinical staff must be beyond the typical face-to-face time of the E/M service on a given date (Note: Time does not have to be continuous).
  3. The physician or qualified healthcare professional must be present to provide direct supervision of the clinical staff.
  4. +99415 is for the first hour of prolonged clinical staff service on a given date (Note: A service of less than 45 minutes total is not reported separately).
  5. +99415 is for each additional 30 minutes.
  6. +99415, +99416 may not be reported for more than two simultaneous patients.

DENIALS – NON-COVERED SERVICES

“Non-Covered Services” has a wide range of meaning when it comes to Denials. Broadly, these can be divided into THREE parts:

  1. Patient’s Health Insurance Policy Does Not Cover the Service.
  2. Provider Contractual Agreement related.
  3. NCCI Edits or Coding related.

An AR Caller should be wise and quick enough to question the Insurance Carrier Representative on call “whether the Denial is because of Patient Policy Coverage Issue or the other TWO issues.

  • If the patient does not qualify for getting the services that were provided by the Physician due to the limitations of the patient’s Health Insurance Policy then the Biller can straight away Bill to Patient along with the copy of the EOB and mentioning the reason why the balance is being billed as Patient Responsibility.
  • If the denial is because of the contractual agreement between the Insurance Carrier and the Provider then update the Physician of this information and tell him to not provide such services in future to any patient as this would result in outright denial of the claims.

The Third Scenario is in fact the frequently faced one by all most all the Billers and this can again be broadly classified as:

  1. Wrong CPT code selected for the service rendered.
  2. Wrong Primary Diagnosis Code selected.
  3. Primary Diagnosis Code selected does not go with the LCD/NCD of the Payor
  4. Primary Diagnosis Code selected does not establish the medical necessity.

(Since the 3rd scenario is a vast subject, we will continue discussing this over the next 2 editions of the journal.)

BILLING UPDATES - DMEPOS – 2016
NEW CODES DELETED CODES REPLACEMENT CODES
A4337 E0450 E0465 Replaced by E0450
E1012 E0460 E0463 Replaced by E0466
E0465 E0461  
L8607 E0464  
E0466 E0463 E0466 replaces E0460, E0461, and E0464.

MEDICARE – CONSULTATION CODES – CROSSWALK

Effective January 1, 2010, Medicare stopped recognizing Outpatient/Inpatient Consultation Codes (CPT 99241-99245 & 99251-99255).

The Coder/Biller will have to use E/M CPT Codes:

  1. 99201-99215 for Office/Outpatient consults.
  2. 99221-99223 for Inpatient consults.
  3. 99304-99306 for Nursing Facility consults.

The below coding crosswalk Table may be of some use.

OFFICE/OUT-PT CONSULT CODE CROSSWALK E/M CPT CODE (NEW PATIENT) CROSSWALK E/M CPT CODE (ESTB PATIENT)
99241 99201 99212
99242 99202 99213
99243 99203 99214
99244 99204 99214
99245 99205 99215
INPATIENT CONSULT CODE CROSSWALK TO INPATIENT E/M CROSSWALK TO NURSING HOME E/M
99251 99221 99304
99252 99221 99304
99253 99221 99304
99254 99222 99305
99255 99223 99306

One more important aspect of this scenario is that the Admitting Physician or the physician whoever does the Admission History & Physical should append Modifier “AI – Principal Physician of Record” for their initial hospital and nursing home visits (99221-99223).

AI modifier identifies the physician as the principal physician who oversees the patient's care, separately from all other providers who may be providing patient care.

If the principal physician's claim for initial hospital or nursing home visits does not include HCPCS modifier AI, claims for other E/M services rendered on the same date may not be paid.

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