Physicians Practice - March 2008 - (Page 44)

BILLING AND COLLECTIONS SOMEBODY’S WATCHING YOU Each ﬁscal year, the Ofﬁce of Inspector General for the Department of Health and Human Services publishes a work plan. Basically, it’s a list of items it will be paying special attention to on Medicare claims. Here are some of its focus areas for physicians in 2008, direct from the work plan. Watch your coding and billing for problems. Place-of-Service Errors: We will review physician coding of place of service on claims for services performed in ambulatory surgical centers and hospital outpatient departments. Evaluation and Management Services During Global Surgery Periods: We will review industry practices related to the number of E&M services provided by physicians and reimbursed as part of the global surgery fee. CMS’s “Medicare Claims Processing Manual,” Chapter 12, section 40, contains the criteria for the global surgery policy. Under the global surgery fee concept, physicians bill a single fee for all of their services usually associated with a surgical procedure and related E&M services provided during the global surgery period. Medicare Payments for Psychiatric Services: We will review Medicare payments for psychiatric services. Section 1862 (a)(1)(A) of the Social Security Act provides that Medicare will pay for items or services only if they are reasonable and medically necessary. We will determine whether claims submitted for psychiatric services were supported and billed in accordance with Medicare requirements. Medicare Payments for Selected Physician Services: We will review the appropriateness of Medicare Part B payments for selected physician services. … Section 1833(e) of the Social Security Act precludes payments to any provider of services unless the provider has furnished the information necessary to determine the amounts due such provider. We will review the appropriateness of Medicare payments for various types of physician services to determine whether these services were paid in accordance with Medicare requirements. Medicare “Incident to” Services: We will examine the Medicare services that selected physicians bill “incident to” their professional services and the qualiﬁcations and appropriateness of (Source: oig.hhs.gov/publications/workplan.html) FAQs B Y PA M E L A M O O R E , P H D , C P C Still stymied by particular coding problems? Maybe the answers to these common questions can help: LEARN ONLY WHAT YOU NEED the staff who perform them. This study will review medical necessity, documentation, and quality of care for “incident to” services. Assignment Rules by Medicare Providers: We will review whether Medicare providers are adhering to assignment rules in billing Medicare beneﬁciaries. Section 1866(2)(A) of the Social Security Act precludes participating physicians/suppliers from charging Medicare beneﬁciaries more than the deductible and coinsurance based upon the approved Medicare payment amount determination. Providers who accept assignment must accept Medicare’s payment and beneﬁciary copayment, referred to as the Medicare allowed amount, as payment in full for all covered services. Providers cannot “balance bill” beneﬁciaries for amounts in excess of the Medicare allowed amounts. Physician Reassignment of Beneﬁts: We will review the extent to which Medicare physicians reassign their beneﬁts to other entities. Section 1842(b)(6) of the Social Security Act prohibits physicians who provide services for Medicare beneﬁciaries from reassigning their right to Medicare payments to other entities, unless a speciﬁc exception applies. For example, physicians are permitted to reassign to other entities enrolled in Medicare when contractual arrangements exist between the physicians and the entities that meet certain program integrity safeguards or when payments are being made to the physicians’ employers. … Having a large number of reassignments may be indicative of fraudulent or abusive activity. We will examine a national sample of Medicare physicians to determine the extent to which they reassign their beneﬁts to other entities and the extent to which the physicians are aware of reassignments requested on their behalf. Q I am a physician and don’t have time to learn the every CPT code. I just want to get mine right. How do I learn what I need to know? A One of the most efﬁcient ways for physicians to learn about coding is to invite a coding consultant into their practices to review charts and tell them where they are making mistakes (whether in coding or documentation). It’s also absolutely worthwhile to invest an hour or two in reading the CPT manual for your areas of practice. The basics are all there. APPEALING DENIED MODIFIERS Q I've discovered that the majority of our denials come in response to modifier codes — specifically, modifiers 22, 57, and 59 — and are more from private insurers than Medicare. Any tips on how to proceed? Do we drop the use of modifiers for private payers due to the amount of time spent appealing? A It is very common to receive denials for these modiﬁers. Sadly, many carriers do not recognize them, unless the practice appeals them. I would analyze resources by modiﬁer. You'll need to do this analysis based on how much money is at stake and how many resources are expended to get that money. If you can send out a generic appeal letter to get the 22s paid, for example, it's worth your time. That said, be sure to establish boundaries for your staff. For example: • Appeal once over the phone for all denials; • Send a written appeal for denials of more than $25; • Send two written appeals for denials exceeding $100; and • Solicit physician involvement for denials of more than $500. These are just sample guidelines. Figure out your own based on your experience and practice needs. WWW.PHYSICIANSPRACTICE.COM 44 | PHYSICIANS PRACTICE | MARCH 2008 http://oig.hhs.gov/publications/workplan.html http://WWW.PHYSICIANSPRACTICE.COM

Table of Contents Feed for the Digital Edition of Physicians Practice - March 2008

Physicians Practice - March 2008 Contents The Bigger Picture: Try a Little Tenderness Second Opinion Letters Physicians Practice Pearls: The Value of First Impressions Noteworthy Cover Story: Your Complete Guide to Patient Service Billings & Collections: Rules to Code By The Administrators Desk: Selecting an EMR Technology: Learn to Love Your Nerd Ask The Experts Coding The Guide The Tech Doctor: All About Blogs The Great Practice Makeover: When Bad Things Happen to Good Practices Start It Up - NEW! The Law: Audits 101 In Practice: Do As I Say... Pretty Please? Healthonomics: Handling the Changes Wrought by Medicare D Classifieds Advertiser Index

Physicians Practice - March 2008

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