The Medicare/Insurance
Fundamentals
q 1. Are we following the 5 steps to q 12. Are we always using the
sticker that gets us $35 for an
ICD-10?
insurance company request for
more information?
q 2. Are our trading partners testing
HIPAA 5010?
q 13. Are we always requiring a
$350 payment for written
q 3. Are we prepared for RAC
narratives before sending them?
overpayments?
q 4. Have we established a “Red
Flag” program?
q 5. Are we reevaluating our
superbill for ICD-10 GEMS?
q 6. Are we violating the kickback
laws?
q 14. Do we always use the special
UCR letter whenever an
insurance company accuses us of
overcharging?
q 15. Are we handling a patient’s
resistance to pay by using the
proven comebacks numbered
19-42 on the collection audio CD?
q 7. Are we utilizing the ABN
appropriately with the GY, GA and q 16. Are all bills going out
allowing patients to pay by
GZ modifier?
credit card through the mail?
q 8. Are all insurance complaints
that go to the insurance company q 17. Are all accounts 30 or more
days past due getting a pink
including the Federal Ruling?
notice?
q 9. Are all insurance claims being
q 18. Has the entire staff been
filed with prompt payment
trained on Medicare coding?
wording?
q 10. Are we self auditing the audit q 19. Are attest sheets being used
for Medicare claims filing?
triggers?
q 11. Have we eliminated our
consultation codes correctly?
q 20. Are we appealing alleged
overpayments?
q 21. Are all Medicare claims
checked for clerical errors?
q 22. Is the correct primary
diagnosis being verified?
q 23. Is the R.B.R.V.S. guide being
used?
q 24. Are all ICD-9’s being coded
to the ultimate specificity?
q 25. Are all C.P.T. codes
crosschecked against the
current CCI edits?
q 26. Are we positive all
E&M codes match the chart
documentation?
q 27. Has the Medicare remittance
advice been checked over with a
fine-toothed comb?
q 28. Are all returned Medicare
claims being re-filed?
q 29. Are all accounts 60 days or
more past due being called before
they reach the 90 day mark?
q 30. Are the collection scripts
being utilized?
q 31. Are we listing the increased
practice income due to using this
checklist?
National Provider Compliance Corp.
Unauthorized reproduction will result
in immediate litigation
1st Edition Oct. 2002
Updated January 2010
© Copyright 2010
Table of Contents
Medicare Patient Information Form……...3 Modifiers………………………………..46
Medicare Primary vs. Secondary…………4 Advanced Beneficiary Notice…………..52
Assignment of Benefits Form……………5
Recovery Audit Contractors (RAC)…….53
Simple Agreement Form…………………6 Appealing Medicare Claims…………….54
Doctor Initiated Complaint Form………...7 Medicare Claim Attest Sheet……………58
Patient Initiated Complaint Form….……..8 Self Audit……………………………….59
Federal Rulings…………………………..9
HIPAA 5010…………………………….61
UCR Letter………….………….……….11 Compliance……………………………...62
Letter of Reconsideration……………….12 Healthcare Fraud Checklist……………..68
Fee Schedule Evaluation…………..……13 False Claims Act………………………..69
Internal Outcome Studies……………….14 Red Flag Rule…………………………...70
Practice Promotion Letters…………..….16 Patient Collections ……………………...72
$350 Narrative Report Letter…………...17 14 Hospital Hotspots……………………75
Recoupment Letters…………………….18
Therapy………………………………….77
Legal Rulings…………………………...21 Chiropractic……………………………..79
State Recoupment Limitations………….23 Glossary…………………………………80
123 Medicare Coding System ………….24 Follow Up Resources…………………...82
ICD–10 Descriptions……………………25 How To Get A Raise……………………83
General Equivalency Mapping…….……26 Stickers………………………………….84
5 Steps of ICD-10……………………….29
ICD-9 Narrow Band of Diagnosis………32
Establishing Medical Necessity…………33
CPT Coding……………………………..34
Evaluation and Management……………35
E&M Coding Charts…………………….37
E&M Glossary…………………………..40
National Provider Compliance Corporation
2
Medicare Patient Information Form
Name: _____________________________________________________________________________________
Home Phone:
Work Phone: _______________________ Cell Phone: ___________________
Email Address:______________________________________________________________________________
Zip Code:
Home Address:
City:
Spouse’s Name:
Work Phone:
Social Security #:
Date of Birth: _________________________________
Nearest relative not living with you:
Phone: ___________________
Nearest friend not living with you:
Phone: ___________________
Primary Care or Referring Physician:
Phone: _________________________
Dentist:
Phone: _____________________________________________
Whom may we contact in the case of an emergency?
Phone:
Whom may we thank for referring you to us?
Phone:
Who is responsible for this bill?
Did you sustain an injury at work?
Y
N
Are you covered under an employer or union policy? Y
N
Are your injuries accident related?
Y
N
Is your spouse or other family member employed?
Y
N
Are you currently employed?
Y
N
Do you have a secondary insurance policy?
Y
N
I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my
account for any professional services rendered. I have read all the information on both sides of this sheet and
have completed the above answers. I certify this information is true and correct to the best of my knowledge. I
will notify you of any changes in my status or the above information.
Signature
National Provider Compliance Corporation
Date
3
Medicare Primary vs. Secondary “Cheat Sheet”
No other insurance coverage
Medigap supplemental insurance
Employer group health plan (self or spouses)
Large Group Health Plan (self or spouses)
Working disabled w/ large group health plan
Accident related with liability
No Fault Auto Insurance
End stage renal disease w/ 30 month coordination
After 30 month coordination
Workers Compensation
Veterans’ Health Administration
Black Lung Program
United Mine Workers of America
Union policies
TriCare (Military insurance)
Medicare is primary carrier
Medicare is primary carrier
Medicare may be primary carrier
Medicare is secondary
Medicare is secondary
Medicare is secondary for charges relating to the
accident
Medicare is secondary for charges relating to the
accident.
Medicare is secondary
Medicare becomes primary
If a claim, or portion thereof, is denied by WC a
claim may be filed with Medicare on a primary
basis.
Medicare does not cover conditions or injuries
covered under VA benefits.
Medicare does not pay secondary to services
related to Black Lung. However, Medicare pays
primary to conditions not related to Black Lung.
Medicare never covers those covered by UMWA.
Medicare is secondary
Medicare is secondary
Employer Group Health Plan (EGHP)
A health insurance plan sponsored by the employer of either the patient or the patient’s spouse where a
single employer of 20 or more employees is the sponsor and/or contributor to the EGHP or two or more
employers are sponsors and/or contributors and at least one of them has 20 or more employees.
Large Group Health Plan (LGHP)
A health insurance plan sponsored by an employer or an employee organization (having 100 or more
employees) is the sponsor and/or contributor to a plan or a plan having at least one member who has at
least 100 employees.
National Provider Compliance Corporation
4
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Assignment of Benefits Form
<<< Practice Name
<<< Address
<<< City, State ZIP
<<< Phone Number
Patient: _____________________________________________________________________________________
Employer:___________________________________________________________________________________
Claim Group: ________________________________________________________________________________
SS# / ID#:___________________________________________________________________________________
I hereby instruct and direct
<<< Name
to pay by check made out and mailed to:
<<< Practice Name
<<< Practice Address
Or
If my current policy prohibits direct payment to Doctor, I hereby also instruct and direct you to make out the
check to me and mail it as follows:
<<< Patient Name
<<< C/O Patient Name
<<< Practice Address
for the professional or medical expense benefits allowable and otherwise payable to me under my current
insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT
ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my
indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said
professional service charges over and above this insurance payment.
A photocopy of this Assignment shall be considered as effective and valid as the original.
I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or
attorney involved in this case.
I authorize Doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
Dated at
this
day of
00
00:00 am/pm
Signature of Policyholder
National Provider Compliance Corporation
, 20
Month
YY
Witness
5
Simple Agreement Form
Patient authorizes the Doctor to deposit checks
received on Patient’s account when made out
to the Patient.
Signature:
Date: _______________________
National Provider Compliance Corporation
6
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Doctor Initiated Complaint Form
<<< Practice Name
<<< MM-DD-YYYY
<<< Address
<<< City, State ZIP
<<< Phone Number
We filed the attached claim form with
It has not been paid or denied.
< Ins. Comp. Name >
Please accept this letter as a formal written complaint against
on
< Month Day, Year >
< Ins. Comp. Name >
Doctors Signature
National Provider Compliance Corporation
7
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Patient Initiated Complaint Form
<<< Patient Name
<<< MM-DD-YYYY
<<< Address
<<< City, State ZIP
<<< Phone Number
I filed the attached claim form with with
< Ins. Comp. Name >
on
< Month Day,. Year
It >
has not been paid or denied.
Benefits were assigned to
<<< Patient Name
and as of today’s date, payment has not
been received. I am responsible for payment of this bill.
Please accept this letter as a formal written complaint against the
< Ins. Comp. Name >
Patient’s Signature
National Provider Compliance Corporation
8
Federal Ruling #1
DELAYED INSURANCE PAYMENTS
Quote from Judge Reafeedie in the federal court case of: Kanne
V. Connecticut General Ins. Co., 607 F. Supp. 899 (1985) on
upholding $750,000 in additional damages for unreasonable delay in
payment of medical claims:
“Repeated requests for payment of the bills were made
to the claims representative, and copies of the bills were in
defendant’s possession. Under these circumstances, it is
not proper for the insurer to sit back and delay payment of
the claims, under the pre-textual theory that the plaintiffs
have not dotted all the “i’s” and crossed all the “t’s”. On
the contrary, the insurer has the duty to see to it that the
promised protection is delivered when needed. It must act
to facilitate the claims instead of searching for reasons not
to do so.”
National Provider Compliance Corporation
9
Federal Ruling #2
DELAYED INSURANCE PAYMENTS
Quote from federal court case of: Alsobrook v. National Travelers Life Ins.
Co.: 852 P.2d 768 (Okla. Ct. App. 1993) for $100,000 in additional damages
for unreasonable delay in payment of medical claims:
“The essence of … bad faith is the insurer’s
unreasonable, bad faith conduct, including the unjustified
withholding of payment due under a policy.
The
obligation of an insurance company is not for the payment
of money only, it is the obligation to pay the policy amount
immediately upon receipt of proper proof of loss or to
defend in good faith and to deal fairly with its insured.
When the insurer unreasonably and in bad faith withholds
payment of the claim of its insured, it is subject to
liability.”
National Provider Compliance Corporation
10
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UCR Letter
<<< Insurance Company
<<< Address
<<< City, State ZIP
Dear
,
<<< Recepient
It has come to my attention that your company has taken the liberty to notify
certain patients, who are insured under your health plan; you feel my fees are above
the usual and customary or normal rate for this community. What I believe you
have the right to communicate to your policyholder is that your company, in its
adjudication policies, is unwilling or unable to pay for the standard of care freely
chosen by the patient.
I require, therefore, that you rephrase your communication to accurately
reflect your company’s ability to reimburse or cease and desist with your present
communications, which are inaccurate and intrusive in the doctor/patient
relationship.
Very truly yours,
Doctor Signature
CC:
Patient:
Insurance Commissioner, State of
<<< State
<<< Patient Name
National Provider Compliance Corporation
11
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Letter of Reconsideration
<<< Insurance Company
<<< Address
<<< City, State ZIP
To whom it may concern,
The attached claim had been previously submitted in good faith that
your determination would be fair and equitable for the services rendered.
The attached explanation of benefits does not support that level of
determination.
Since there is no system in place to accurately advise a patient as to the
UCR allowable amounts prior to services being rendered and billed, this
hardly seems fair. This reduction leaves a patient balance that is unfair and
inequitable, with no justification to support it. Please provide written
justification to support this UCR reduction as well as a copy of your dated
documentation and criteria utilized to implement your current UCR levels.
Also, please outline what accurate systems you provide to assist a
patient avoid this post-service reduction in the future.
I am requesting a reevaluation of this claim in full confidence that the
billed fees are supported by the level of service provided and are well within
range of what is reasonable, customary, usual and prevailing for the providing
area.
Thank you for your immediate consideration and redetermination.
Sincerely,
Doctor Signature
Cc: Insurance Commissioner State of
Patient:
National Provider Compliance Corporation
<<< State
<<< Patient Name
12
Fee Schedule Reevaluation
For MCP’s you are already accepted with:
Dear Provider Relations:
I have been a network provider for you for _____ year(s), and have had an excellent working
relationship with you and your client referrals. I have been very happy with your services, except for the
fact that I am being underpaid.
The UCR fee in my area for ______ services is $________. Currently you are paying me $_______
(including co-payment).
Because I am confident that I provide the highest quality counseling (please see my Outcomes Study in
my enclosed portfolio), in the briefest possible time frame, and I am committed to keeping clients
healthy, I believe my services are worth at least the UCR fees. The majority of Managed Care Plans I
am a provider for are paying this fee or higher.
I am requesting an increase to $_______. Thank you for your consideration and immediate response.
Sincerely,
Doctor
For new MCP’s with capitation/case fees:
Dear Provider Relations:
I am currently considering joining your network, and am examining your capitation/case fee offer. The
UCR fee for my area for ________ services is $_______, and my average number of sessions per
problem/episode is _______.
Because I am confident that I provide the highest quality service in the briefest possible time frame (see
my Outcomes Study in my enclosed portfolio), and I am committed to keeping clients healthy, I believe
my services are worth at least the UCR fee.
I would be happy to become a member of your provider panel, and would sign your contract today,
provided you could assure me $_______ per patient/per problem/episode. I also am requesting a stopclause after _______ sessions, at which time, if more sessions are required or desired, the client can
either pay my UCR fee of $________ per session or we can contract for an additional case fee.
Feel free to call me at __________ to discuss this further. I appreciate your consideration in this matter.
Sincerely,
Doctor
National Provider Compliance Corporation
13
Internal Outcomes Study
The “Internal Outcomes Study” is the single most important item you can give managed
care. This is a statistical analysis of your evaluations by your patients. You must be
able to show, through objective measures, that the vast majority of your patients are
satisfied with the services they received from you. Doctors often say they resist doing
their own evaluations because they feel their work speaks for itself.
The days of doctors as “Lone Rangers,” answerable to no one save their own
consciences, are over. Whether we like it or not, we are now accountable to whoever
pays the bill. It is absolutely critical to the survival of our practices that we become
accountable and develop a written method of demonstrating whether our treatment is
working or not. We must speak clearly to MCP’s and speak their language.
Doctors often ask “How will the MCP know I didn’t just make up the results of my
outcomes study?” If they have no prior experience with you, all they have to go on is
your written evaluation results. Your written word has a great deal of credibility to them
because:
A. Doctors in general are trustworthy;
B. 90% of an MCP’s decision to accept you as a provider and refer patients to you is
based on your written information.
National Provider Compliance Corporation
14
Sample Internal Outcomes Study
We appreciate you allowing us to
provide services to you. We are
interested in feedback from you, so
that we can evaluate our
effectiveness and improve our
services.
Comfort of reception waiting
area:
5
4
3
2
1 N/A
Quality of assistance from
answering service/machine:
5
4
3
2
1 N/A
Courtesy of office staff on the
phone:
5
4
3
2
1 N/A
Rate your general state of health
and functioning prior to
treatment:
5
4
3
2
1 N/A
We would very much appreciate
your completing this survey. Please
do not sign your name. This way Courtesy of office staff in the
you can feel free to be completely office:
honest.
5
4
3
2
1 N/A
You may return the survey to our Clear understanding of fees prior
office or simply attach a stamp and to treatment:
drop it in the mail.
5
4
3
2
1 N/A
Thank you for your assistance.
Promptness of your Doctor:
5
4
3
2
1 N/A
Name of your Doctor________
What type of service did you
receive?
? Initial Assessment
? Testing/Evaluation/X-Rays
? Routine Doctors Visit(s)
? Physical Exam (check up)
? Medication Evaluation
? Other__________________
Please rate the following services by
circling the appropriate number:
5 - Excellent
4 - Good
3 - Average
2 - Fair
1 - Unsatisfactory
N/A - Not Applicable
Prompt and helpful scheduling of
your initial appointment:
5
4
3
2
1 N/A
Location of our office:
5
4
3
2
1
N/A
Parking:
5
4
3
N/A
2
1
Cleanliness and pleasantness of
the Doctor’s office:
5
4
3
2
1 N/A
Your Doctor’s understanding of
your condition:
5
4
3
2
1 N/A
Your Doctor’s listening skills:
5
4
3
2
1 N/A
Clear understanding of goals and
treatment plan by you and your
Doctor:
5
4
3
2
1 N/A
Helpfulness of your treatment:
5
4
3
2
1 N/A
Rate your general state of health
and functioning after your initial
treatment:
5
4
3
2
1 N/A
Rate your general state of health
and functioning after your
treatment was completed:
5
4
3
2
1 N/A
Rate your likelihood of continuing
this treatment on a maintenance
plan:
5
4
3
2
1 N/A
Rate your ability to sustain any
positive strides you made in
treatment with this Doctor:
5
4
3
2
1 N/A
Rate your likelihood of continuing
or returning to treatment with
this Doctor:
5
4
3
2
1 N/A
Rate your likelihood of continuing
or returning to treatment with
this Doctor:
5
4
3
2
1 N/A
Assistance with filing insurance
claims:
5
4
3
2
1 N/A
Rate your likelihood of
recommending this Doctor to a
friend:
5
4
3
2
1 N/A
Helpfulness of staff with billing
questions:
5
4
3
2
1 N/A
Comments and Suggestions:
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
National Provider Compliance Corporation
15
Welcome to the Practice Letter
Dear Patient:
I would like to take the time to personally thank you for choosing me as your healthcare
provider. I hope I can help you in your journey towards improved health.
My foremost goal is patient satisfaction. Enclosed you will find a copy of my “Patient
Satisfaction Survey.” I would greatly appreciate it if you would please take a moment to fill it out and
return it to me. This is the best way I know to find out what my office and I are doing right, and what
skills we need to improve on. You do not need to put your name on it, so you can feel free to be honest.
Thanks!
Feel free to ask me any questions regarding your treatment or progress, and let me know if there
is a better way I can assist you.
Sincerely,
Doctor
Reactivation Letter
Dear Patient:
It’s been a while since I’ve seen you. I am writing this letter for several reasons. First, I hope
you are doing well.
Second, I want you to know I’ve made some changes at the office.
I.e. I am now i.e. My office now (Whatever information you can provide-new hours, new associate, etc)
(I hope this will help accommodate more patients).
(I hope this will serve our patients better).
Third, I would greatly appreciate it if you would take a few minutes to complete the enclosed
“Patient Satisfaction Survey.”
Please let me know if these changes can better accommodate your needs. This is the best way I know to
improve my skills and find out what I’m doing right. You do not have to put your name on it, so you
can feel free to be honest.
Again, I hope this letter finds you well.
Sincerely,
Doctor
National Provider Compliance Corporation
16
How to Get $350 for a Narrative Report
When an insurance company, attorney, or other entity requests a narrative report from the doctor,
regarding a patient, they should pay you a fair fee for your time and service. First, they MUST include a
legal and valid “Release of Information” signed by the patient or the patient’s guardian. Secondly, they
should include a check (always obtain payment prior to giving your report) for a minimum of $350.
This is a fair fee because:
A. Narrative reports take a great deal of the doctor’s time, uninterrupted concentration and
valuable time.
B. The time that it takes to write/dictate a narrative report is not a regularly scheduled
appointment; therefore, the doctor must work overtime.
C. Attorneys, insurance reviewers, or other medical experts may scrutinize the report, so the
doctor must be very careful how the report is worded. It is likely to become evidence in
court proceedings.
D. The report will require extra time/service of office personnel, i.e., filing, typing
photocopying, reviewing, etc. It also may involve other costs, i.e., medical transcribers,
word processors, etc.
NOTE: This procedure should be followed when an insurance company, attorney or any
other entity requests a copy of all medical records.
If the requesting party sends you a photocopy of a law that states you must provide
records for a fee of $35 (or any other amount), then simply explain why you believe
your fee is fair and tell them they can try to get “their” fee upheld in court. In the
meantime... you will need to receive your fee.
National Provider Compliance Corporation
17
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First Recoupment Request Letter
Dear Sir/Madam,
We have received your demand for the repayment of claim #
<<< Claim Number
I must respectfully decline your request until the following documentation has been presented to
establish your entitlement to the refund. Our records indicate, and your payment confirms, that
the patient was insured under your health care plan and covered for services rendered at the time
of treatment.
I will require:
1.
2.
3.
4.
5.
6.
7.
A copy of the claim.
A copy of the cancelled check.
A clearly stated reason for this reversal of payment.
An explanation as to why the claim was originally considered acceptable and is
now being denied.
The state statute of limitations in regard to refunds.
A copy of the appropriate section of your contract stating your entitlement of
this action.
Specific documentation of similar requests of other practices, which may have
fallen into this category.
I am entitled to this information in a timely manner. However, your demand of payment within
15 days is unrealistic. You will need time to gather the information and I will equally need time
to review it. Therefore your threat of reporting me to a collection agency is inappropriate,
unprofessional and illegal!
Upon arrival of the aforementioned documentation I will carefully review it and determine if I
feel a refund is appropriate.
Be advised that I DO NOT authorize an extraction from future payments to cover this.
I await your reply,
Doctors Signature
National Provider Compliance Corporation
18
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Second Recoupment Letter
Dear Sir/ Madam,
Upon review of your documentation we have reached the conclusion that our
participation followed the established guidelines for appropriate payment. We rendered
treatment following your established protocol.
We submitted an accurate claim and you accepted that claim as accurate and viable at the
time of treatment.
This error was entirely your responsibility, not ours. We did not induce the “overpayment”, you did. And we were not unjustly enriched by this payment but simply
brought even for services rendered.
It would be a disservice to our relationship with our patient to attempt to collect at this
late date. An attempt to do so would undoubtedly cause dissension to the relationship
and financial harm to the practice.
It will also be in your best interest to establish a better safeguard against this action in the
future.
From our perspective you had the last clear chance to avoid this situation. You failed to
do so at the appropriate time. Therefore, in regard to a refund, we respectfully decline.
Sincerely yours,
Doctor Signature
National Provider Compliance Corporation
19
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Contracted Provider Letter
Subscriber Name:
Patient Name:
Policy Number:
Claim Number:
Date of Service:
<<< Enter Subscriber Name
<<< Enter Patient Name
<<< Enter Policy Number
<<< Enter Claim Number
<<< Enter Date of Service
Dear Sir/Madam,
We are a contracted provider with your company. When we accepted payment for
the above claim, it was with the understanding all was just and proper.
If a mistake on your part now has you feeling the payment was in error, you will
have to take responsibility for it.
We made no misrepresentation inducing payment. We have not been unjustly
enriched by the services rendered or payment received.
Please accept this letter as formal notice of disputing your assertion of “overpayment.” Any attempt on your part to offset future payments will be met with stern
legal opposition.
Very Truly Yours,
Doctor Signature
National Provider Compliance Corporation
20
Legal Rulings
1.
City of Hope National Medical Center
Vs.
Superior Court of Los Angeles County
Western Life Insurance Company made payment on a
health insurance claim. They later deemed the treatment
experimental and therefore not covered. Western
demanded the money be refunded. The court refused,
stating:
“Stated plainly, if it’s your mistake, you get to pay for it unless
the recipient misled you or accepted the payment knowing you
didn’t owe it.”
2.
Federated Mutual Insurance Co.
Vs.
Good Samaritan Hospital
The Court ruled:
“To subject a hospital to possible refund liability if the insurer
later discovers a mistaken overpayment… would be to place an
undue burden of contingent liability on such institutions.”
National Provider Compliance Corporation
21
3.
National Benefit Administrators, Inc.
Vs.
Mississippi Methodist Hospital and Rehabilitation Center, Inc.
In this case, the patient’s father lied about the patient’s age and
status. In actuality, the patient was not covered as a dependant.
Even so, the court ruled:
“Restitution may not be had in cases in which the mistaken payment is
made to an innocent third party creditor, i.e., one who has made no
misrepresentation and has no knowledge of the mistake. This
exception derives from the fact that the element of unjust enrichment,
typically considered a prerequisite for restitution, is absent in such
cases…no unjust enrichment occurs because the creditor is actually
owed money it receives and has exchanged value for the right to
receive money.”
4.
Lincoln National Life Insurance, Co.
Vs.
Brown Schools, Inc.
In this case the insured’s policy had terminated. Nevertheless, the
court ruled:
“… Lincoln knew its own policy payment provisions, but failed to
notify (the provider) as to these provisions; and Lincoln alone made
the mistake of paying beyond its responsibility. (The provider) made
no misrepresentations, had no knowledge or notice of (Lincoln’s)
mistake, extended valuable services based on the assignment of
payment by the insured was not unjustly enriched, and simply had no
reason to suspect that any of the payments for services rendered were
in error. In the normal course of such business, the hospital has no
responsibility to determine if an insurance carrier is properly tending
to its business.”
National Provider Compliance Corporation
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State Limitation for Recoupment of Overpayment
The AMA guideline for the limitation for recoupment of overpayments is one year.
However, some states are still formulating their regulations.
In the case of fraud or misrepresentation, these limits may not apply. In the case of
contracted providers, limits may be based upon your individual contract.
AL
12 months
AR
18 months
AZ
12 months
CA
CO
12 months
12 months - Prohibits retroactive adjustment of claims based on eligibility for coverage if the
health care provider received eligibility verification within 2 business days prior to delivery of
service.
CT
5 years
DC
6 months – Except with COB; then 18 months
FL
30 months
GA
12 months
IN
2 years
IA
2 years
KY
2 years
LA
Same deadline as filing claims (either contract or prompt pay)
ME
18 months
MD
6 months – Except with COB; then 18 months
MA
12 months
MO
12 months
MT
12 months unless the plan limits time to file; then recoup limit is same as filing limit
NE
6 months
NH
18 months
NJ
12 months
NY
2 years
OH
2 years
OK
2 years
SC
180 days
TN
6 months
TX
180 days
UT
12 months
WA
18 months
WV
12 months unless limited time to file claim; then recoup limit is the same as filing limit
WY
18 months after the date of payment or 24 months after the date of service, whichever is sooner
National Provider Compliance Corporation
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The 1, 2, 3 System
...this makes Medicare Coding Easy!
1.
How to prevent clerical errors that cause
your claim to be returned unpaid.
A.
Train 3 people on Medicare claim
filing.
B.
Have each one triple check claims.
C.
Each one signs an attest sheet that
they have done so.
2.
ICD-9 coding to ultimate specificity.
A.
Attach a photocopy of relevant
pages of ICD-9 book to the chart.
B.
Attach a sticky note that says,
“Doc, pick one.”
C.
Yell “Fire” if you ever see 3 digits,
4 digits. .00, .8 or .9.
3.
4.
How to choose the correct primary
diagnosis.
A.
Look up $ value of each procedure
code in RBRVS Guide.
B.
Add up $ value of each procedure
set that flows from each particular
diagnosis.
C.
Code the most expensive diagnosis
first.
How to protect yourself legally when you
have any Medicare questions.
A.
Call Medicare carrier and ask your
question.
B.
Send them a memo concerning the
information.
C.
Tell them that you will code based
on their instructions unless they
give you contrary information in 30
days.
National Provider Compliance Corporation
5.
How to prevent incompatible CPT
coding.
A.
Get a copy of the incompatible
coding combinations from NTIS.
B.
Look up each code in the book for
incompatibility.
C.
Remove those codes from your
claim that are incompatible.
6.
How to match your chart documentation
to your choice of E&M code.
A.
Use the new updated patient chart.
B.
Have the Doctor select levels of
History, Physical Exam, and
Medical Decision-Making.
C.
Choose the appropriate E&M code
that corresponds with the #’s the
Doctor has circled pursuant to
Medicare guidelines.
7.
How to go through your Medicare
remittance advice with a fine tooth
comb.
A.
Notice the Medicare remittance
notice when it comes in.
B.
Sit down and analyze discrepancies
on what you billed for and what
they allowed.
C.
Look up return codes in red book to
decipher the discrepancies.
8.
Refiling returned Medicare claims.
A.
Check carefully for all upper/lower
portion mistakes.
B.
You must refile within 1 year of
date of treatment.
C.
Do not include correspondence with
refiled claims.
24
ICD-10 Descriptions
Approximate flag
GEM flag: turned on indicates that the entry is not considerer
equivalent.
Applied mapping
Reference mapping to conform to the needs of a particular
application (e.g., data quality, research).
Backward mapping
Searching from a newer code set to an older code set.
Choice list
Combination entries, a list of one or more codes in the target
system to chose from to satisfy the equivalent meaning of a
code in the source system.
Combination flag
GEM flag: When turned on indicates that more than one code
in the target system is required to satisfy the full equivalent
meaning of a code in the source system.
Combination entry
GEM entry: A code in the source system must be linked to
more than one code option in the target system to be a valid.
General Equivalence Map Reference mapping that attempts to include all valid
relationships between the codes in the ICD-9-CM and the
ICD-10-CM diagnosis classifications reference mapping that
attempts to include all valid relationships between the codes
in the ICD-9-CM and the ICD-10-CM diagnosis
classifications.
th
ICD-9-CM
International Classification of Diseases 9 Revision Clinical
Modification (I-9).
ICD-10-CM
International Classification of Diseases 10 Revision Clinical
Modification (I-10).
GEM flag: When turned on indicates that a code in the source
system is not linked to any code in the target system
Mapping that includes all possible valid relationships between
a source system and a target system.
Combination entry; a collection of codes from the target
system containing the necessary codes that when combined as
directed will satisfy the equivalent meaning of a code in the
source system.
GEM entry: A code in the source system linked to one code
option in the target system is a valid entry.
Origin mapping; the set being mapped ‘from’.
Destination mapping; the set being mapped ‘to’.
No Map Flag
Reference Mapping
Scenario
Single Entry
Source System
Target System
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GEMS
General Equivalency Mapping is a tool to facilitate the use of ICD-10 coding. GEMs are
not a crosswalk and will not replace the need to learn how to code ICD-10.
The most accurate and quickest method of coding to ICD-10 specificity in many cases
will be to code directly from the documentation in the medical record and selecting the
appropriate code(s) from the coding book or encoder system. The GE mappings are only
a tool and in most cases will only be effective in helping locate the broader category of
coding, but not the specific code applicable to an encounter. GEMs will be available for
the three years following the implementation of ICD-10 and then discontinued.
Three Steps should be taken when forward or backward mapping: FIND, ANALYZE,
and REFINE.
Step 1: FIND
All necessary code options starting with the broadest definition.
Step 2: ANALYZE
Any appropriate flags, terminology, combinations and choices.
Step 3: REFINE
Your selection to match the chart documentation.
There will be many changes in terminologies when becoming familiar with ICD-10
coding. A good example of terminology changes is the case of the “O” codes for
pregnancy and childbirth in the following chart. For these codes the terminology has
changed from episodes of care (ICD-9) to stages in pregnancy (ICD-10)
ICD-9
649.50 unspecified
episode of care
Forward GEM
ICD-10
64950 O26859 10000
O26.851 first trimester
649.51 delivered
64951 O26859 10000
O26.852 second
trimester
649.53 antepartum
64953 O26851 10000
64953 O26852 10000
64953 O26853 10000
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O26.853 third trimester
O26.859 unspecified trimester
26
Unspecified code 649.50 maps to an unspecified code 026.859 but the mapping is not an
exact match because the terminology has changed.
Delivered code 649.51 will also map to an unspecified code 026.859 since it is not
defined in the first, second, or third trimester for this particular code.
Antepartum code 649.53 maps to three choices:
O26.851 first trimester, O26.852 second trimester, O26.853 third trimester
Backward mapping codes 649.50, would look like this (there is no decimal point in
GEM):
O26851
O26852
O26853
O26859
64953 10000
64953 10000
64953 10000
64950 10000
This may look like a three column entity; but it is not.
The last series of 5 digits represents the “flag” criterion. A “1” in any column would
indicate a flag is “on”. A “0” would indicate that the flag is “off”.
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GEM FLAGS
ICD-9
Code
Description
ICD-10
Code
645.90
Unspecified 026.859
Description
unspecified
Approximate No
Flag
Map
1
0
Combination Scenario Choice List
Flag
flag
Flag
0
0
0
Column 1. Flag 1: Approximate mapping (if this map is “0” indicating “0ff”, that would
indicate an identical match. This is not going to appear very frequently.
Column 2. Flag 2: No mapping indicator. If it is turned “on”, there is no plausible
translation. A “0” would indicate there is at least one plausible translation.
Column 3. Flag 3: Is a combination flag meaning that if the flag is “on” a code maps to
more than one code. If the flag is “0ff”, it means that the code maps to a
single code.
Column 4. Field 4: There is a clinical variation, or scenario flag. If this flag were “on”,
it would indicate distinct clinical variations and each scenario must be linked
together to satisfy the meaning in the source code.
Column 5. Field 5: Choice list. For a combination flag (column 3) One or more codes in
the target system must be chosen to satisfy the equivalent meaning of the
code. The choice list contains one or more codes in the target system from
which one code must be chosen to satisfy the equivalent meaning of a code
in the source system
For the codes above;
1. The approximate flag is “on”, (column 1) indicating that there is no direct
match, but there is an approximate code.
2. The combination code flag is not “on” so it is not a combination code.
If a code has an identical match it would appear with 5 “0”’s in the flag criteria meaning
all flags are off. There would be only one cross code, as in the case of codes
I240 41181 00000
and
I241 4110 00000
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28
5 STEPS TO ICD-10
Practices need to have ICD-10 codes fully implemented by October 1, 2013. Meeting this
compliance date requires you to begin by analyzing your systems that you utilize for
ICD-9 and identifying the necessary operating, administrative and clinical, system that
will require updating. The following Guides will help formulate your internal and
external action plan.
5) Communicate
Communication with your trade partners is vital at an early stage of formation. Discuss
implementation plans and process with your
A. Practice management systems vendor
B. Clearinghouse or billing service
C. Payers
to verify their compliance plan for both HIPAA 5010 and ICD-10. Review your
contract(s) to determine any necessary changes as a result of implementation and if
updates are included in your maintenance or will there be additional fees. Make
absolutely sure that your vendors and their systems will accommodate the data format
changes for 5010 and ICD-10 and verify when their upgrading will begin and what the
expected date for complete compliance is. When will their system be ready for testing?
Warning: If your vendors, billing service, or clearinghouse is not going to transition
for ICD-10 in a manner that fulfills your needs you may need to purchase a new
system, or find different vendors.
4) Deadlines and Testing
Be aware of all deadlines and be prepared to test your systems with your trading
partners. Trading partners are organizations with which you exchange various
transactions. Testing your system will be the final step before going “live”. The testing
will involve sending ICD-10 coded claims in test transactions to see if they will be sent
successfully by your system and received successfully by your trading partner’s system.
Since the use of the ICD-10 codes is not allowed until October 1, 2013, all testing will be
done in a testing environment, not a live production environment. You should test with
the trading partners that make up the largest volume or largest revenue of your
transactions involving ICD-10.
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3) Training
Training will be a critical step in creating a knowledgeable and prepared staff. Nothing
can begin unless the staff is well trained.
A) Clinical staff will need to focus on documentation requirements. In coordinating
ICD9 to ICD-10, the level of documentation will greatly impact your coding, therefore,
your billing, and therefore, your payment.
B) Coding staff will need the most training to learn how to use the new code set and
correctly capture the correct codes.
C) Administrative staff will have their own training needs, verifying with partners,
vendors, overseeing contract negotiations, and implementing new policies.
2) Budget
Cost of implementation is a chief concern, but planning for the expense and utilizing
these guidelines will help you determine your projected costs. Keep in mind of the costs
not only involve updating your system, but also resource materials, training, workflow,
consultants etc. In order to avoid financial disaster, budgeting for the transition to ICD10 should have already begun; if you have not begun, begin today.
Many estimates have been completed regarding the potential cost associated with
implementation. Estimates range from roughly $84,000 for the average small physician
practice to $3 million dollars for large practices. The cost of implementation is going to
be high. It is going to be time sensitive and resource intensive. But when faced with the
alternatives the question health care professionals should be asking is: “How can we
afford not to implement ICD-10?”
Minimal budgeting should include:
A. Systems upgrades
B. Cost of training
C. Contract renegotiations
D. Impact of workflow
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1) Implement a system of self auditing your current systems
The increased specificity of the ICD-10 codes requires more detailed clinical
documentation in order to code the diagnosis to the highest level of specificity.
Documentation shows that ICD-9 is not currently being utilized to its full potential. That
is why YOU MUST SELF AUDIT FOR:
A) LACK OF SPECIFICITY. ICD-9 coding that lacks 4th or 5th digit is one of the most
common reasons claims are returned unpaid. Eliminate excessive use of .00, .8, and .9
when other more appropriate codes are available.
B) INCOMPATIBLE ICD-9 to the CPT code is another current reason for unpaid
claims.
C) LACK OF SUFFICIENT DOCUMENTATION to support submitted codes is the
primary reason for many CERT overpayments. These errors must be addressed, not only
for implementation, but also to avoid audit problems and potential overpayments. Verify
chart documentation matches your coding on every claim.
D) REVALUATE YOUR “SUPERBILL”. The specificity of ICD-10 will necessitate
usage of many more codes. If your superbill is already outdated or not specific to all
coding options, if you are not utilizing 4th and 5th digits appropriately, your claims may
already be an audit trigger for “narrow band of diagnosis". Utilizing a superbill, does not
excuse you from limited or incorrect coding. Your practice may consider eliminating a
superbill for learning purposes.
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ICD-9 Narrow Band of Diagnosis
Sample Point of Vulnerability
Arthritis - National Average
100
90
80
Frequency
70
60
50
40
30
20
10
0
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
38
40
42
44
46
48
50
36
38
40
42
44
46
48
50
Type
Arthritis - O u r Average
100
90
80
70
Frequency
60
50
40
30
20
10
0
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
Type
A Narrow Band of Diagnosis can trigger an audit of your ICD codes or delay payment of
your claims. It is caused by lack of specificity, and underuse of possible ICD codes.
This is created by:
1. Not billing to the 4th and 5th digit when applicable.
2. Overuse of .8 .9. 00 for the 4th or 5th digit ICD-9.
3. Billing from an outdated or limited superbill.
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Establishing Medical Necessity
1. List the primary diagnosis, condition, or other reason for medical procedure or service
in the first diagnosis position.
2. When describing the patient’s condition, illness, or disease, be as specific and
descriptive as possible, being able to define to the fifth digit if applicable.
3. Identify secondary diagnoses only when applicable. If someone has a history of
arthritis, but they come in for a sprained ankle and that is the only condition relevant to
the visit, do not list arthritis as a secondary diagnosis.
4. Documenting patient history (whether it be problem, family, or social) during an exam
is different than assigning it a diagnostic code for billing purposes.
5. This is especially important for potential preexisting conditions. Exercise extreme
caution when coding a preexisting condition. If the condition is preexisting but you’re not
treating it, don’t code it.
6. List additional factors that affect the patient’s health when indicated.
7. Identify the acute conditions of emergency situations such as coma, loss of
consciousness, hemorrhage, etc.
8. Distinguish between acute and chronic conditions where appropriate.
9. Avoid use of rule-out statements when a more applicable code exists.
11. For injury codes, identify how injuries occurred.
12. Documentation for any procedures must include any relevance to:
A. Functionality or lack of, if the condition is not treated.
B. Deterioration of the condition, if not treated.
C. Future potential cost, if the condition is not treated.
But services will not be deemed medically necessary if you have documented:
A. Cosmetic Value
B. Emotional Value
C. Quality of Life Value
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CPT Coding
Common CPT Audit Triggers
1. Unbundling of services inappropriately
http://www.cms.hhs.gov/NationalCorrectCodInitEd
NCCI edits are necessary to prevent improper billing of incorrect code combinations. NCCI contains
two tables of edits. The Column One/Column Two Correct Coding Edits table and the Mutually
Exclusive Edits table include code pairs that should not be reported together.
Column 1
(Comprehensive)
(Bundled)
21188
Column 2
(Component)
(Unbundled)
20902
20900
69990
Modifier Applicable
1
1
0
The 21188 code is a reconstruction code. 20900 and 20902 is a removal of bone with graft. They can
only be billed together if it is modifier applicable and the correct modifier is used. 69990 is a micro
surgical code and is not modifier applicable and will not be considered with code 21188.
2. Mutually Exclusive Edits: Two codes that cannot reasonably be performed together. Each edit
consists of a column 1 and column 2 code. If the same provider for the same beneficiary bills the two
codes of an edit for the same date of service without an appropriate modifier, they are mutually
exclusive. Unlike CCI edits, Mutually exclusive edits "column 1" code generally represents the
procedure or service with the lower RVU, and is the payable procedure or service when reported with
the column 2 code.
3.Medically Unlikely Edit (MUE): The maximum value units of service that a provider would expect
to report under most circumstances for a single beneficiary on a single date of service. To prevent fraud
some MUE values will be kept confidential.
4. Modifier: Use of modifiers is to explain circumstance where two services may be eligible that would
normally be inappropriate and prohibited according Correct Coding Initiatives edits. Providers are
responsible for correct and appropriate modifier use to support the codes they report. Inappropriate use
of modifiers not justified by the clinical circumstances constitutes fraud.
National Provider Compliance Corporation
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Evaluation and Management Codes
E/M (Evaluation/Management) coding is necessary for reimbursement of day-to-day
patient care and it is crucial to be precise and fully documented. E/M involves translating
the patient’s visit into categories, levels and components of correct E/M codes. There are
7 total billing components. We’ll split them into the three key components, and the 4
contributing components.
3 KEY COMPONENTS:
1. History: which can include history of present illness, family or social history
2. Physical examination
3. Medical decision-making
The level of coding is primarily based upon the 3 key components.
At least 2 out of 3 criteria must be provided for the level billed for ESTABLISHED
PATIENTS and subsequent care.
ALL 3 CRITERIA MUST BE PROVIDED FOR THE LEVEL BILLED FOR NEW
PATIENT AND INITIAL HOSPITAL CARE.
However, if more than 50 percent of the face-to-face, or floor time is spent providing
counseling or coordination of care, the duration of the visit may become a factor and the
four contributing factors are evaluated
4 CONTRIBUTING COMPONENTS:
1. Counseling
2. Coordination of care
3. Nature of the presenting problem
4. Time
A chief complaint is required for every E/M service submitted.
In order to establish medical necessity and compliant billing, documentation of all
components is mandatory.
National Provider Compliance Corporation
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4 LEVELS of EXAMINATION and HISTORY
There are four levels of examination and history. They are as follows:
1. Problem Focused
2. Expanded Problem Focused
3. Detailed
4. Comprehensive
The medical decision-making component involves gathering several elements before
deciding the complexity of the entire component such as:
• Number of diagnosis or management options
• Complexity of data reviewed
• Risk and complications
There are levels of these subcomponents: Minimum, Limited, Multiple, Moderate,
Extensive, and High to determine the…
4 LEVELS of MEDICAL DECISION MAKING
1. Straightforward
2. Low complexity
3. Moderate complexity
4. High complexity
Two of the three components must be met or exceeded to determine the overall level of
decision-making.
Most E/M codes are classified on performance location (inpatient hospital, or office) and
certain E/M services require the distinction be made as to whether the patient is new or
established. A new patient visit is allowed for a patient who has not received any
professional services, i.e., E/M service or other face-to-face service from the physician or
physician group practice (same physician specialty) within the previous 3 years.
After you have measured the complexity of each component as supported in the medical
record, compare your results with the requirements of each code in the appropriate chart.
Note that these are minimal qualifications. Instructions state that the key component must
meet or exceed the indicated level. Your assessment does not need to and probably won’t
match requirements as illustrated in the following chart.
National Provider Compliance Corporation
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Patient Name:
Date:
Referring Diagnosis / M.D. And NPI #
Date of Illness/ First Symptoms
Chief Complaint / Presenting Problem:
Review of Symptoms:
(1) Minimal
(1) Problem pertinent
(2) Self-limited or minor
(2) Extended (additional 2-9 additional systems)
(3) Low severity
(3) Complete (10 or more additional systems)
(4) Moderate severity
(5) High severity
History of present illness:
(1) Brief (1-3 elements)
(2) Extended (4 or more elements or the status of at least 3 chronic or inactive conditions)
Past History:
(1) Problem focused
(2) Expanded problem focused
(3) Detailed
(4) Comprehensive
Examinations:
(1) Problem focused
(2) Expanded problem focused
(3) Detailed
(4) Comprehensive
Tests Ordered / Reviewed:
Results (Date):
Findings / Decision Making:
(1) Straightforward
(2) Low
(3) Moderate
(4) High
Rx / Recommendations:
Total Time Spent:
Time Spent Counseling:
Start
Finish
Start
Finish
Family and /or Social History:
(1) Problem focused
(2) Expanded problem focused
(3) Detailed
(4) Comprehensive
Purpose of Counseling
I attest that all checked areas are fully documented in the record
Signature ______________________________________Date_________________
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3 KEY E&M FACTORS
Comprehensive
Detailed
Expanded
Problem Focused
Problem Focused
Chief complaint;
extended history of
illness; complete
system review;
complete past family
and/or social history.
Chief complaint;
extended history of
illness and extended
system review;
pertinent past family
and/or social history.
Chief complaint; brief
history of present
illness; problem
pertinent system
review.
Comprehensive
Complete single
system specialty exam
or complete multisystem exam.
Detailed
Extended exam of
affected area(s) and
other symptomatic or
related system(s).
Expanded
Problem Focused
Problem Focused
Exam extended to
other symptomatic or
related organ systems.
Exam limited to
affected body area
organ system
Chief complaint; brief
history of present
illness or problem.
Medical Decision Making
(Two subcomponents must be met or exceeded)
Number of Diagnosis
or Management
Options Mortality
Subcomponents
Amount and/or
Complexity of Data
Reviewed
Risk of
Complications and/or
Morbidity
Level
EXTENSIVE
EXTENSIVE
HIGH
High Complexity
MULTIPLE
MODERATE
MODERATE
Moderate
Complexity
LIMITED
LIMITED
LOW
Low Complexity
MINIMUM
MINIMUM
MINIMUM
Straightforward
National Provider Compliance Corporation
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E&M Factors (step chart)
Step 1: Chart your levels of service
Problem
Focused
History
Expanded Detailed Comprehensive
Prob. Focus
1
2
3
4
Physical
Exam
1
2
3
4
--------------------------------------------------------------------------Medical
Decision
1
2
3
4
Making
Straight
Low
Moderate
High
Forward
Step 2: New patient and initial patient care must meet or exceed all three
levels. Determine the appropriate code for established patients and subsequent
care, 2 of 3 levels must be met.
1
1
1
2
2
2
National Provider Compliance Corporation
3
3
3
4
4
4
5
4
4
4
39
E&M GLOSSARY
Care plan oversight:(CPO) is the physician supervision of a patient receiving complex and/or Multidisciplinary care as part of Medicare-covered services provided by a participating
home health agency or Medicare approved hospice.
Chief complaint:
(CC) is a concise statement describing the symptom, problem, or condition
usually stated in the patient’s words. It establishes and supports the medical
necessity and reasonableness for the services billed. A chief complaint is required
for every E/M service submitted. (also see presenting problem)
Examination:
Collecting diagnostic information through physical applications. The extent of the
examination performed is dependent on clinical judgment and on the nature of the
presenting problem. Documentation must contain up-to-date information
regarding the patient’s condition at the time of the exam, and should describe the
results and findings. Examination Documentation should include specific
abnormal and relevant negative findings of the affected or symptomatic body
area(s) or organ systems(s) should be documented. A notation of” abnormal”
without elaboration is insufficient. Abnormal or unexpected findings of the
examination of any unaffected or asymptomatic body area(s) or organ system(s)
should be described. A brief statement or notation indicating “negative” or
“normal” is sufficient to document normal findings related to unaffected areas(s)
or asymptomatic organ system(s).
Family history:
(FH) Medical events in the patient’s family that includes significant information
about: The health status or cause of death of parents, siblings, and children,
specific diseases related to problems identified in the CC or HPI, and/or ROS,
diseases of family members which may be hereditary or place the patient at risk.
History of present
illness:
(HPI) is a chronological description of the development of the patient’s present
illness from the first sign and/or symptom to the present.
Elements of an HPI include:
• Location: describes where on the body the symptom is occurring.
• Quality: the character of the symptom (burning, throbbing, tingling, stabbing, and
fullness).
• Severity: a rank of the symptom/pain on a scale of 1-10, or a term: Severe, slightly,
worst I’ve ever had.
• Duration: how long the symptoms/pain has been present or how long it lasts when
the patient has it.
• Timing when the pain/symptom occurs, number of occurrences or frequencies.
• Context: situation associated with the pain/symptom (dairy products, big meals, stair
climbing).
• Modifying factors: things done to make the symptom/pain worse or better.
• Associated signs and symptoms: symptom/pain and other things that happen when
this symptom/pain occurs .
National Provider Compliance Corporation
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Medical decision
making:
(MDM) The complexity of MDM should be fully documented accordingly and
not inferred or implied. The number of possible diagnoses, management options,
amount and/or complexity of data that must be obtained, reviewed and analyzed
be documented. Risk of significant complications, morbidity and/or mortality, as
well as comorbidities.
Past, family
(PFSH) Review of the patient’s past medical history, family health status, and
and social history: appropriate age-related social history. Subsequent hospital and nursing facility
care: “interval” history is sufficient. If the physician is unable to obtain a history
from the patient or other source, the record should describe the patient’s condition
or other circumstance, which precludes obtaining a history.
Past history:
(PH) Patient’s past experience with illnesses, injuries, and treatments that includes
significant information about:
• Prior illnesses and injuries • Allergies (e.g., drug, food)
• Prior operations
• Age appropriate immunization status
• Prior hospitalizations
• Age appropriate feeding/dietary status
• Current medications
Physicians in the same group practice who are in the same specialty must bill and be paid as though
they were a single physician unless the E&M services are for unrelated problems. The physicians should
select a level of service representative of the combined visits and submit the appropriate code for that
level. Physicians in a group practice /different specialty may bill and be paid without regard to their
membership in the same group.
Presenting problem:(PP) A disease, condition, illness, injury, symptom, finding, complaint, or other
reason for the encounter, with or without a diagnosis being established. Five types
of presenting problems that are defined:
• Minimal: A problem that may not require the presence of the physician, but
service is provided under the physician’s supervision.
• Self-limited or minor: A problem that runs a definite and prescribed course, is
transient in nature, and is not likely to permanently alter health status or has a
good prognosis with management/compliance.
• Low severity: A problem where the risk of morbidity without treatment is low;
there is little to no risk of mortality without treatment; full recovery without
functional impairment is expected.
• Moderate severity: A problem where the risk of morbidity without treatment is
moderate; there is moderate risk of mortality without treatment; uncertain
prognosis or increased probability of prolonged functional impairment.
• High severity: A problem where the risk of morbidity without treatment is high
to extreme; there is a moderate to high risk of mortality without treatment or high
probability of severe, prolonged functional impairment.
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Prolonged physician services include the office or other outpatient setting with direct face-toface patient contact which require one hour beyond the usual service are payable when billed
on the same day by the same physician or NPP as the companion evaluation and management
codes.
Review of Systems :
(ROS)
Inventory of body systems obtained through a series of questions seeking
to identify signs and/or symptoms that the patient may be experiencing or has
experienced. The ROS is what the patient is telling the provider, not what the
provider examines. Ancillary staff may record the ROS or it may be a form
completed by the patient; however, there must be documentation by the physician
supplementing or confirming the information recorded by others.
14 systems for review:
• Constitutional symptoms
• Cardiovascular
• Genitourinary
• Neurological
• Hematologic/lymphatic
• Eyes
• Ears, nose, mouth, throat
• Respiratory
• Gastrointestinal
• Musculoskeletal
• Integumentary (skin and/or breast)
• Psychiatric
• Endocrine
• Allergic/immunologic
The amount of detail obtained and documented determines the extent of the ROS.
3 levels of ROS:
• Problem pertinent: inquires about the 1 system directly related to the problem
identified by the HPI
• Extended: inquires about the system directly related to the problem(s) in the HPI and 29 additional systems
• Complete: inquires about the system(s) directly related to the problems(s) identified in
the HPI plus all additional body systems (10 or more)
At a minimum, the patient’s positive and pertinent negative responses should be documented.
For services that require a complete ROS at least 10 organ systems must be reviewed with
positive or pertinent negative responses individually documented. For the remaining systems, a
notation indicating, “all other systems are negative” is permissible. In the absence of such a
notation, at least 10 systems must be individually documented.
Social History (SH): Review of past, current activities, and significant information about: Marital
status, living arrangements, level of education, employment, sexual history, use of
drugs, alcohol and tobacco and other relevant social factors.
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Examples of Proper E/M Coding
Office or Other Outpatient Services
For new patients all three criteria must be met or exceeded. This is a patient who has not received
any professional services, i.e., E/M service or other face-to-face service from the physician or physician
group practice (same physician specialty) within the previous 3 years.
99201 Office or other outpatient service for the evaluation and management of a new patient
requires:
1. A problem focused history
2. A problem focused examination
3. Straightforward medical decision-making
Physician usually spends 10 minutes on a one-to-one basis with the patient and/or family. The
problem(s) are usually limited or minor.
99202 Office or outpatient visit for the evaluation and management of a new patient, which
requires:
1. An expanded problem focused history
2. An expanded problem focused examination
3. Straightforward medical decision-making
Physician usually spends 20 minutes on a one-to-one basis with a patient and/or family.
Problem(s) is usually of low to moderate severity.
99203 Office or other outpatient visit for evaluation and management of a new patient, which
requires these three key components:
1. A detailed history
2. A detailed examination and
3. Medical decision making of low complexity
Physicians usually spend 30 minutes on a one-to-one basis with the patient and/or family.
Problems are usually of moderate severity.
99204 Office or other outpatient visit for the evaluation and management of a new patient, which
requires:
1. A comprehensive history
2. A comprehensive examination and
3. Medical decision-making of moderate complexity
Physician usually spends 45 minutes on a one-to-one basis with the patient and/or family.
Problems are usually of moderate to high severity.
99205 Office or other outpatient visit for evaluation and management of a new patient, which
requires:
1. A comprehensive history
2. A comprehensive examination and
3. Medical decision making of high complexity
Physician usually spends 60 minutes on a one-to-one basis with the patient and/or family.
Problems are usually of moderate or high severity.
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The Elimination of Consultation Codes
1. Will impact your reimbursement
2. Will become an audit trigger
3. Will cause you to pay more attention to your initial visit codes
4. Will create coordination of benefit nightmares
Change Request 6740, issued December 14, 2009 has a proposed implementation date of
January 1, 2010.
This will delete the use of codes 99241-99245 and 99251-99255 to consult on a patient.
The dust on this issue will take time to settle and we are not offering a definitive solution to this
problem. However, we are being advised that you can now utilize:
Initial hospital care codes (99221 – 99223) to accommodate deleted codes. These codes will no longer
be limited to the admitting physician and more than one physician can report these codes. New policy
states: “In the inpatient hospital setting all physicians (and qualified non-physician practitioners where
permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223)”. A
possible crosswalk is outlined below:
99251- 99231
99252- 99232
99253- 99221
99254- 99222
99255- 99223
New modifier, “-AI” has been created and must be appended to the admitting physician’s initial
hospital care code
Office or other outpatient settings with dates of service on or after Jan. 1, 2010, physicians and
qualified non-physician practitioners could use:
99201-99205 for new patients
99211-99215 for established patients
Of course all codes must follow current E/M documentation guidelines.
Prolonged service codes may be utilized when appropriate.
Reminder: ALL THREE E&M KEY COMPONENTS MUST BE MET TO BILL AN
APPROPRIATE LEVEL FOR: new patient, initial hospital care, emergency department services,
initial nursing care facility, and domiciliary care.
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Prolonged Service Chart
Office/Outpatient and Consultation Codes
99354 and/or 99355
Code
99201
99202
99203
99204
99205
99212
99213
99214
99215
99324
99325
99326
99327
99328
99334
99335
99336
99337
99341
99342
99343
99344
99345
Typical
time
for code
Time
required
for code
99354
Time
required for
99354 and
99355
10
20
30
45
60
10
15
25
40
20
30
45
60
75
15
25
40
60
20
30
45
60
75
40
50
60
75
90
40
45
55
70
50
60
75
90
105
45
55
70
90
50
60
75
90
105
85
95
105
120
135
85
90
100
115
95
105
120
135
150
90
100
115
135
95
105
120
135
150
National Provider Compliance Corporation
Inpatient Setting Codes
99356 and/or 99357
Code
99221
99222
99223
99231
99232
99233
99304
99305
99306
99307
99308
99309
99310
99318
Time
Typical time required
for code
for code
99356
30
50
70
15
25
35
25
35
45
10
15
25
35
30
60
80
100
45
55
65
55
65
75
40
54
55
65
60
Time
required
for
99356 and
99357
105
125
145
90
100
110
100
110
120
85
90
100
110
105
45
Modifiers
DISCLAIMER:
Keeping in mind that rules constantly change, the use of modifiers may vary from Medicare to private
insurance and even in some cases, local coverage determinations vs. national coverage determinations.
This information is provided only as a guideline and is not to be considered coding advice. If you
detect any problems with the use of any modifier, you must refer to the guidelines of the specific
carrier. No one outside of your practice can tell you how to code your claims; that responsibility
ultimately rests with you.
Modifier -25 E&M services only
The most common cause for claim denial of an unrelated E/M service billed on the same day as another
procedure or during the post operative period for a non-surgery related reason is due to the omission of
modifier -25.
Patient condition requires a significant, separately identifiable E&M service above and beyond the
other services provided, or beyond the usual preoperative and postoperative care associated with
the procedure performed. Different diagnoses are not required for reporting of the E&M services on
the same day, but are not to be used to report an E&M service that resulted in a decision to perform
major surgery. Documentation to support the use of modifier –25 must be in the patient record.
Decision for minor surgery on the same day: Procedures with a 0 - 10 day follow-up period if the
decision is made during an E/M service the day of surgery. If the surgery is a major surgery, with a
longer follow up global period see modifier –57.
Inpatient Dialysis and Modifier –25: Separate payment can be made for initial hospital visits, initial
inpatient consultations, and hospital discharge when billed for the same date as an inpatient dialysis
service if billed with modifier –25 to indicate that they are significant and identifiable services and
documented in the patient chart.
Critical Care Visits and Modifier –25: In association with critical care visits (99291-99292)
performed during the global period, reimbursement can be made when:
1) The patient is critically ill and requires the constant attention of the physician; and
2) The critical care is above and beyond, and unrelated to the specific anatomic injury or general
surgical procedure performed.
Global Fees and Modifier –25 : A physician visit on the same day as a surgical procedure or
endoscopy procedure with 000 or 010 days postoperative period that are related to the standard
preoperative evaluation or recovery from the procedure is included in the global reimbursement for the
procedure. However, modifier –25 can be utilized if a significant separately identifiable service is
performed and is clearly documented in the patient’s chart.
Allowable Routine Physical Exams and Modifier –25: When a scheduled, Medicare eligible, routine
physical exam or screening visit determines a significant problem or condition that required a higher
level of E&M code, modifier –25 can be utilized.
Code 99211 and Modifier – 25: Medicare will pay for medically necessary office/outpatient visits
billed on the same day as a drug administration service when billed with modifier –25. The modifier
indicates that a separately identifiable evaluation and management service was performed that meets a
higher complexity level of care than a service represented by CPT code 99211.
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Modifier –59 Distinct Procedural Services:
Secondary to modifier –25, modifier –59 is also the cause for many under evaluated claims. It is
an important National Correct Coding Initiative (NCCI) associated modifier that is often used
incorrectly. Physicians may indicate that a procedure or service was distinct or independent
from other services performed on the same day utilizing modifier –59 to identify
procedures/services that are not normally reported together but are appropriate under certain
circumstances.
This may represent:
a) Different session or patient encounter
b) Different procedure or surgery
c) Different site or organ system
d) Separate incision
e) Separate lesion
f) Separate injury (or area of injury in extensive injuries) not normally encountered or performed on the
same day by the same physician.
However, when another already established modifier is appropriate, it should be used rather than
modifier –59. It is important to verify whether the services are bundled through the NCCI edits.
Procedure codes that are billed to Medicare and denied due to NCCI may not be billed to the patient.
21 – Prolonged Evaluation and Management Services When face-to-face or floor/unit service(s)
provided are prolonged or greater than usually required for the highest level of E&M service. This is
classified as an “informational only” modifier and no additional reimbursement is allowed.
22 – Increased procedural services: For a service that is substantially greater than typically required.
Documentation must support the additional work and, reason for the additional work and any
contributing factors: increased intensity, time, and technical difficulty of procedure. Normally applies to
those procedures that have global periods of 0, 10, or 90 days and includes services usually classified as
therapeutic or diagnostic and not to be used with E&M codes.
23 – Unusual Anesthesia: For a procedure which usually requires either no anesthesia or local
anesthesia, because of unusual circumstances must be done under general anesthesia.
24 – Unrelated E&M by the same physician during the postoperative period unrelated to the
original major or minor surgery. It is not to be used for medical management of a patient by the
surgeon following surgery.
26 – Professional component: Certain procedures are a combination of physician component and a
technical component. Modifier –26 is utilized to report the physician component separately.
32 – Mandated Services: This modifier is not used by Medicare.
47 – Anesthesia by surgeon: Regional or general anesthesia provided by the surgeon. This does not
include local anesthesia or minimal sedation. Effective October 1, 2007: If a physician performing the
procedure also provides moderate sedation; payment may be made for conscious sedation.
50 – Bilateral diagnostic, radiological, and surgical procedures. (Medicare guidelines for modifier
–50 differ from those in the CPT manual and many third-party payers’ accepted protocol.) FOR
MEDICARE: Bilateral procedures should only be reported with one procedure code appended with
modifier -50. This should as a single line item with the number of Days/Units “1”.
51 – Multiple procedures: When services other than E/M services, physical medicine, rehabilitation
services, or provision of supplies, are performed at the same session by the same provider, the primary
procedure or service may be reported as listed. The additional procedure(s) or service(s) may be
identified by appending modifier –51 to the additional procedure or service code(s).
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52, 53, 73, 74 – Reduced, discontinued, terminated procedures: Due to extenuating circumstances or
to circumstances that threatened the well being of the patient. Elective cancellation of a procedure
should not be reported.
52 – Partial reduction or discontinuation of radiology procedures and other services that do not
require anesthesia
53 – Discontinuation of physician services.
73 – Facility modifier (outpatient hospital or ambulatory surgical center) to report surgical
or diagnostic procedures terminated or discontinued after the patient had been prepared for
the procedure, and taken to the room where the procedure is to performed but prior to
administration of anesthesia. Will be paid at 50 percent of the full OPPS payment amount
74 – Facility modifier (outpatient hospital or ambulatory surgical center) a surgical or
diagnostic procedure requiring anesthesia was terminated after the induction of anesthesia or
after the procedure was started..
Modifiers –73, –74 are not used to indicate discontinued radiology procedures (see modifier –52).The
patient has to be taken to the room where the procedure is to be performed in order to report modifier
–73 or –74.
54, 55, 56 - Separate billing for global surgical procedures: When different physicians perform
portions of a global service, for surgical procedure codes having a 90 day postoperative period,
modifiers should be used to indicate what portion of the service was performed by each provider. Each
provider may be reimbursed a percentage of the global fee.
54 – Surgery only
55 – Postoperative care only
56 – Preoperative care only (not valid for Medicare)
57 – E&M resulted in decision to perform surgery: Is only used with E&M services performed within
24 hours of a major procedure since the global period includes the day before, the day of, and the 90
days immediately following the procedure.
58 – Staged procedures: Staged or related procedure or service by the same physician during the
postoperative period that may have been planned or more extensive, than the original procedure.
62 –Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s)
of a procedure, each surgeon should report his/her distinct operative work by adding modifier –62 to the
procedure code and any associated add-on codes(s) for that procedure. Two physicians, performing a
different procedure during the operative session: each physician would bill independently for only the
procedure he/she actually performed, even if the procedures are performed through the same incision.
Multiple surgery rules would not apply unless one or both of the surgeons actually performed multiple
procedures.
66 – (Surgical Team): Highly complex procedures (requiring the services of several physicians,
different specialties, highly skilled specialty trained personnel, various types of complex equipment)
76, 77, 78, 79 Repeat Procedures:
76–Repeat procedure or service by the same physician subsequent to the original procedure or
service.
77 – Repeat Procedure by another physician: An explanation of the medical necessity may be
entered in item 19 of the paper claim or the comment field of the electronic version.
78 – Unplanned return to the operating/procedure room by the same physician following an
initial procedure for a related procedure during the postoperative period:
79 – Unrelated service or procedure by the same physician during the postoperative period:
A different diagnosis would generally be reported. The use of RT and LT modifiers, or other
descriptive modifiers when the diagnosis is the same, should be used following modifier –79.
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80, 81, 82, AS – Assistant surgery modifiers:
AS – PA, NP or CNS served as the assistant at surgery. Modifier 80, 81 or 82 must also be
billed when modifier AS is billed to indicate that a physician served as the assistant at surgery.
80 – Assistant surgeon
81 – Minimum assistant surgeon
82 – Qualified resident surgeon not available
90, 91 – Laboratory:
90 – Outside laboratory. Use modifier 90 for venipuncture. Laboratory work performed in the
physician’s office includes reimbursement for the drawing of blood
91 – Repeat clinical diagnostic laboratory test: repeat the same laboratory test on the same day
to obtain subsequent (multiple) test results
92 Alternative Laboratory Platform Testing: When testing is being performed using a kit or
transportable instrument that wholly of in part consists of a single use, disposable analytical chamber.
99 – Multiple modifiers
HCPCS Modifiers
1P –Performance Measure Exclusion Modifier due to Medical Reasons (PQRI)
(Allergic to medicine etc.)
2P- Performance Measure Exclusion Modifier used due to Patient Reason (PQRI)
3P- Performance Measure Exclusion Modifier used due to System Reason (PQRI)
8P Performance Measure Reporting Modifier – action not performed, reason not otherwise specified
(PQRI)
A1 – Admitting physician modifier applied to initial hospital code. For admitting
physicians only.
AH – Clinical psychologist therapeutic service(s) reported was personally performed by a clinical
psychologist
AJ – Clinical social worker therapeutic service(s) reported was personally performed by a clinical
social worker
AP – Determination of refractive state was not performed in the course of diagnostic ophthalmologic
examination
LS FDA – monitored intraocular lens implant
VP – Aphakic patient. Informational only
E1 – Upper left eyelid
E2 – Lower left eyelid
E3 – Upper right eyelid
E4 – Lower right eyelid
AQ – Physician providing a service in an unlisted Health Professional Shortage Area
AR – Physician provider services in a Physician Scarcity Area
AT - Acute treatment: Chiropractic treatment codes for acute treatment. It should not
be used when the treatment is maintenance in nature. Only submit with CPT codes
98940, 98941, and 98942. (CPT code
98943 is not reimbursed by Medicare.) See Chiropractic information.
EJ – Subsequent claim for a defined course of ESA ESRD therapy. Informational only
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JA – Administered intravenously. Informational only
JA – Administered intravenously. Informational only
JB – Administered subcutaneously. Informational only
EA –Erythropoetic stimulating agent (ESA) administered to treat anemia due to anticancer
chemotherapy
EB – Erythropoetic stimulating agent (ESA) administered to treat anemia due to anticancer radiotherapy
EC – Erythropoetic stimulating agent (ESA) administered to treat anemia due to anticancer radiotherapy
or anticancer chemotherapy
FA – Left hand, thumb
F1 – Left hand, second digit
F2 – Left hand, third digit
F3 – Left hand, fourth digit
F4 – Left hand, fifth digit
F5 – Right hand, thumb
F6 – Right hand, second digit
F7 – Right hand, third digit
F8 – Right hand, fourth digit
F9 – Right hand, fifth digit
FB – ASC facilities to indicate an item provided without cost to provider, supplier or practitioner, or
full credit received for replaced device (examples, but not limited to, covered under warranty, replaced
due to defect, free samples)
FC – ASC facilities to indicate partial credit received for replaced device.
Modifiers GA, GY, and GZ are ABN modifiers. Whenever a service or supply is not eligible
or may not be eligible, the practice / supplier must make the patient aware of the possible ineligibility of
the service or supply and have an ABN on file and the appropriate modifier utilized when filing the
claim.
GA – Item or service may be denied as not reasonable and necessary ABN on file. Patient will be
liable for the unpaid service or supply if the ABN was utilized
GY – Item or services statutorily excluded. (Meaning it is NOT and eligible service or supply)
GZ – Item or service expected to be denied as not reasonable and necessary. NO ABN ON FILE.
The service is not statutorily excluded, but deemed ineligible by the carrier as not medically necessarily.
The patient will not be liable for unpaid service or supply if the ABN is not on file.
GC – service performed in part by a resident under the direction of a teaching physician
GE – service performed by a resident without the presence of a teaching physician under the primary
care exception. Informational and may only be submitted with procedure codes included in the “primary
care exception”
GG – Performance and payment of a screening mammogram and diagnostic mammogram on the same
patient, same day as the screening test. For tracking purposes only
GJ – “Opt Out” physician or practitioner provided emergency or urgent service
GM – Multiple patients on one ambulance trip
GN – Service delivered under an outpatient speech language pathology plan of care
GO – Service delivered under an outpatient occupational therapy plan of care
GP – Service delivered under an outpatient physical therapy plan of care
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KX – Outpatient speech language, physical, occupational therapy Services above the maximum cap
but still medically necessary and the service qualifies as an exception
(See physical therapy)
GQ – Via asynchronous telecommunications systems
GT – Via interactive audio and video telecommunications systems
GV – Attending physician not employed or paid under arrangement by the patient's hospice provider
GW – Service not related to the hospice patients terminal condition
LT – Left side (used to identify procedures performed on the left side of the body
RT – Right side (used to identify procedures performed on the right side of the body
LC – Left circumflex coronary artery
LD – Left anterior descending coronary artery
RC – Right coronary artery
Q0 – Clinical research code that replaced QA and QR Investigational clinical service provided in a
clinical research study that is in an approved clinical
Q1 – clinical research code that replaced QV. Routine clinical service provided in a clinical research
study that is in an approved clinical research study
Foot care in vascularly compromised patients
Q7 – Class A finding. Nontraumatic amputation of the foot or integral skeletal portion thereof
Q8 – Class B finding: Absent posterior tibial pulse,-advanced trophic changes; three of the
following are required:
hair growth, nail changes, pigmentary changes, skin texture, skin color
Q9 – Class C finding: Absent dorsalis pedis pulse-claudication, temperature changes, edemaparesthesia –burning
TA – Left foot, great toe
T1 – Left foot, second digit
T2 – Left foot, third digit
T3 – Left foot, fourth digit
T4 – Left foot, fifth digit
T5 – Right foot, great toe
T6 – Right foot, second digit
T7 – Right foot, third digit
T8 – Right foot, fourth digit
T9 – Right foot, fifth digit
QW – CLIA test waived
AA – performed personally by anesthesiologist
KD – Drug or biological infused through DME
SG – Ambulatory Surgical Center (ASC) facility service
TC – Technical component alone
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Advanced Beneficiary Notice (ABN)
This is a sample only. You must use the Medicare approved version. It can be
downloaded free at cms.hhs.gov/bni/02_ABNGABNL.asp
(A) Business name, address and telephone number:_________________________________
(B) Patient name:____________________________________________________________
(C) Medicare ID #:___________________________________________________________
Note: If Medicare doesn’t pay for (D) (item, test, service, procedure, supply, etc) listed
below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have
good reason to think you need. We expect Medicare may not pay for (D) below.
(D) Service or supply__________________________________________________________
(E) Reason Medicare may not pay________________________________________________
(F) Estimated cost:___________________________________________________________
What you need to do now:
• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
• Choose an option below about whether to receive the (D) listed above.
Note: If you choose option 1 or 2, we may help you to use any other insurance that you
might have, but Medicare cannot require us to do this.
(G) OPTIONS: Check only one box. We cannot choose a box for you.
Option 1: I want the (D) listed above. You may ask to be paid now, but I also want
Medicare to be billed for an official decision on payment, which is sent to me on a Medicare
Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for
payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does
pay, you will refund any payments I made to you, less co-pays or deductibles.
Option 2: I want the (D) listed above, but do not bill Medicare. You may ask to be paid
now as I am responsible for payment. I cannot appeal if Medicare is not billed.
Option 3: I do not want the (D) listed above. I understand with this choice I am not
responsible for payment, and I cannot appeal to see if Medicare would pay.
(H) Additional Information: This notice gives our opinion, not an official Medicare decision. If you
have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-6334227/TTY: 1-877-486-2048).
Signing below indicates that you have received and understand this notice. You also receive a
copy.
Signature:_______________________________________________________________
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5 Most Common RAC Overpayments
Recovery audit contractors will be paid a percentage of overpayment monies recouped
from providers. It is in their best interest to find you guilty of overcoding and miscoding.
In just one year of their demonstration phase, RAC recovered approximately $20.97
billion in alleged overpayments. The most common causes are:
1. Lack of medical necessity; file documentation not supporting the medical necessity
for services billed
2. Incorrectly coded claims; file documentation not supporting the codes used and the
level of services billed
3. Failure to submit documentation; worse than submitting incomplete documentation
is to submit no documentation
4. Duplicate claims; even though many claims can be denied as a duplicate, when you
know the claim had not been paid; the same is true for duplicate claim
overpayments; you have to verify that the claim was paid twice to be a legitimate
overpayment.
5. Medicare Secondary Payer; determining correct order of determination requires
asking the right questions of your patients and verifying that Medicare is or is not
their primary carrier. You cannot count on your patients knowing who their
primary carrier should or should not be.
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RAC Limitations
1) LIMITATION OF FILE REQUESTS:
A) Inpatient Hospital, IRF, SNF, Hospice; 10% of average monthly Medicare claims (max of
200) per 45 days.
B) Other Part A Billers (Outpatient Hospital, HHA)
1. 1% of average monthly Medicare services (max of 200) per 45 days
C) Physicians
1. Solo Practitioner; 10 medical records per 45 days
2. Partnership of 2-5 individuals; 20 medical records per 45 days
3. Group of 6-15 individuals; 30 medical records per 45 days
4. Large Group (16+ individuals); 50 medical records per 45 days
D) Other Part B Billers (DME, Lab)
1. 1% of average monthly Medicare services per 45 days
2) SUBSEQUENT THREE YEAR RULE: Refers to the fourth year after the payment was
made. It limits the recoupment of an overpayment to the subsequent third year following the year in
which notice of payment was made, unless the provider is found to be “at fault”. The provider is
normally considered “without fault" unless there is evidence to the contrary, such as a pattern of billing
errors.
Only the year of the payment, and the year it was found to be an overpayment are entered into the
determination of the subsequent three year rule. The day and the month of the service or payment are
irrelevant. With respect to payments made in 2000, the third calendar year thereafter is 2003 and the
subsequent year would be 2004.
3) APPEAL OF OVERPAYMENTS: Prior to the MMA, when an appeal was filed for an
alleged overpayment, extraction process began regardless of the appeal process. However, Section
1893(f)(2) Limitation on Recoupment requires that if a provider seeks an appropriate FIRST LEVEL
OR SECOND LEVEL (QIC reconsideration) appeal for an overpayment determination, CMS and its
Medicare contractors may not recoup the overpayment until the decision on the reconsideration has been
rendered.
APPEALS MUST BE FILED PROMPTLY TO AVOID EXTRACTION.
A) 120 days to file an appeal for a first level claim reconsideration
B) 30 days to file a response to a notice of overpayment determination to stop extraction of
benefits
C) ONE DAY RULE: APPEAL IMMEDIATELY WHEN NOTIFIED OF AN
APPEALABLE OVERPAYMENT TO VERIFY THAT THE CONTRACTOR WILL
HAVE PLENTY OF TIME TO NOTIFY RAC OF THE PENDING APPEAL.
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5 Levels of Appeal
Reopening is not an appeal: Minor errors, clerical errors or omissions in an initial determination may
be corrected with the reopening or resubmitting process. Unprocessable claims being submitted with
required or corrected information are not eligible for an appeal since it is not a denied claim.
1. Redetermination:
•
•
•
•
•
Must be filed within 120 days from date of receipt of the notice initial claims determination
Medicare remittance advice will provide the addresses necessary to submit the appeal
No monetary limits for this level of appeal
An extension for filing may be granted for special circumstances
Medicare contractors must complete 100% of redeterminations within 60 days
2. Reconsideration:
•
•
•
•
Must be filed within 180 days from date of receipt of the redetermination
Medicare remittance advice will provide the QIC addresses necessary to submit the appeal
No monetary limits for this level of appeal
Contractors must complete review within 60 days
3. Administrative Law Judge (ALJ) Hearing:
•
•
•
•
Must be filed within 60 days from the date of the reconsideration
$120.00 minimum monetary limit remains in controversy
Determination notice from the QIC will provide address to submit third level appeal
90 day limit to complete review
4. Departmental Appeals Board (DAB) Review/Appeals Council
•
•
•
Must be filed within 60 days from the date of receipt of the ALJ hearing decision
90 day limit to complete review
Review request may be declined
5. Federal Court Review
•
•
Must be filed within 60 days from date of receipt of the Appeals Council decision or declination
of review by DAB
$1,220 minimum monetary limit remains in controversy
National Provider Compliance Corporation
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Please fill out all the fields. The [PRINT] button will remove the headers,
footer and the visable buttons so they will not print. Don't forget to sign
the form!
Print
Reset
Medicare Redetermination Request
Date:
Carrier name and address:
Beneficiary Name:
Health Insurance Claim #:
Date of Initial Determination:
Date(s) of Service:
Service being appealed:
Diagnosis or injury:
Y
N
Copy of EOMB (attached)
Additional Supporting Documentation (attached)
Signature of the claimant attached
Signature:
I am requesting a redetermination of the attached claim because:
National Provider Compliance Corporation
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Please fill out all the fields. The [PRINT] button will remove the headers,
footer and the visable buttons so they will not print. Don't forget to sign
the form!
Print
Reset
Medicare Reconsideration Request
Date:
Contractor that processed redetermination:
Beneficiary Name:
Health Insurance Claim #:
Date of Initial Determination:
Date(s) of Service:
Service being appealed:
Diagnosis or injury:
Y
N
Copy of MRN (attached)
Additional Supporting Documentation (attached)
Signature of the claimant (attached)
Signature:
The redetermination of this claim was unsatisfactory because:
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Medicare Claim Attest Sheet
I, the undersigned, do hereby attest under penalty of perjury that I have triple checked Claim
#
________________ for the following:
Initials
_________ 1. Clerical Errors
_________ 2. The Correct Primary Diagnosis
_________ 3. ICD-9 Coding to the Ultimate Specificity
_________ 4. Incompatible CPT Codes
_________ 5. E&M codes that match the chart documentation
I understand my legal liability for fraudulent coding under the False Claims Act and hereby
attest to the validity of the above numbered claim.
Date: ___________________
Signed: ____________________________________
Witness: ____________________________________
National Provider Compliance Corporation
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Most Frequently Found Coding Errors
Date: __________
Area of
Awareness
Code
Code
Code
Code
Code
Clerical
Primary
Diagnosis
ICD-9
Incompatible
Codes
E&M
Modifiers
MSP
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E/M Errors Found
Errors
11
10
9
8
7
6
5
4
3
2
1
Wk1
Wk2
Wk3
Wk4
Wk5
Wk6
Wk7
Wk8
Wk9
Wk10
Date
ICD, Modifier, CCI, Primary Diagnosis,
Copy and create a separate chart for each criterion.
Errors
11
10
9
8
7
6
5
4
3
2
1
Wk1
Wk2
Wk3
Wk4
Wk5
Wk6
Wk7
Wk8
Wk9
Wk10
Date
National Provider Compliance Corporation
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HIPAA 5010
HIPAA 5010 will replace Version 4010/4010A1. Version 5010 includes structural, front matter,
technical, and data content improvements. The updated versions are more specific in requiring the data
that is needed, collected, and transmitted in a transaction, so their adoption would reduce ambiguities.
Version 5010 will also address a variety of currently unmet business needs, including an indicator for
conditions that were “present on admission” on institutional claims. Version 5010 would also
accommodate the use of the International Classification of Diseases, Tenth Revision (ICD-10) code sets,
which are not supported by Version 4010/4010A1.
Effective, Testing and Compliance Dates
The effective date is the date that the final rule takes effect, and new policies are considered officially
adopted.
The compliance date is the date that all covered entities must be in compliance with the standards in the
final rule.
Dual use of standards between the effective date and compliance date is recommended so that either
Version 4010/4010A1 or Version 5010, and either Version 5.1 or D.0, may be used.
Subject to trading partner agreement.
March 17, 2009:
Effective date for all of the standards except the Medicaid pharmacy subrogation
transaction.
January 1, 2010:
Effective date for the Medicaid pharmacy subrogation transaction standard.
January 2009:
Begin Level 1 testing. Internal readiness testing period activities (gap analysis,
design, development, internal testing) for Versions 5010 and D.0. between a
covered entity and the trading partner.
January 2010:
Begin internal testing for Versions 5010 and D.0.
December 31, 2010: Completed Level 1 Compliance (Covered entities have completed internal testing
and can send and receive compliant transactions) for Versions 5010 and D.0.
Level 2 Testing:
Preparations to reach full production readiness with all trading partners. A
covered entity is in compliance with Level 2, when it has completed end-to-end
testing with each of its trading partners, and is able to operate with the new
versions of the standards by the end of that period and can successfully exchange
(accept and/or send) standard transactions and as appropriate, be able to process
them successfully.”
January 2011:
Begin Level 2 testing period activities.
January 1, 2012:
Covered entities will have reached Level 2 compliance, and must be fully
compliant in using Versions 5010 and D.0 exclusively.
January 1, 2012:
Is the compliance date for all covered entities, with only one exception.
January 1. 2013:
Is the compliance date for small health plans to comply with the Medicaid
pharmacy subrogation standard.
No Contingency Plan will be authorized, as it would have a direct impact on the implementation of
ICD-10. Civil penalties may be filed against covered entities that are not in compliance. Prepare
now, to incorporate effective planning, collaboration and testing in the implementation strategies and to
identify any problems long before the deadline.
National Provider Compliance Corporation
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Compliance
Hiring, training, and maintaining a successful staff
Compliance is not merely a matter of adhering to guidelines. Practices that establish compliance
systems are more successful than practices that do not. Compliant practices are more profitable
and maintain a loyal staff. Compliant practices can hire a new employee and have them trained
quickly and efficiently on their system.
This section is designed to be a simplified version of the HIPAA Compliance Plan for medical practices.
It is not designed to include micro-details but simply to assist you in setting up and maintaining a
compliance plan.
HIPAA applies to medical providers, hospitals, medical centers, and any outside businesses partners,
i.e., insurance companies, pharmacies, other medical providers, labs, marketing companies, billing
agencies etc.
Fundamentally, the goal of HIPAA is to never violate patient confidentiality and to protect your
computer resources from malicious or unintentional damage. A secondary goal is to ensure you can
prove your vigilance in protecting patient confidentiality for at least six years.
A compliance plan is simply a written plan to show that you have the suggested “Seven Elements” of
privacy and security in place and that you are monitoring it on an ongoing basis.
This material is not legal advice.
The goals of these materials are simple:
1.
To ensure you have the capability to be right legally, morally and ethically.
2.
To be able to prove through self-monitoring and documentation that you are right.
Under ordinary circumstances, your lack of vigilance will cost you money in extraction of
overpayments, but it can also lead to violation fines and under negligent circumstances jail
sentencing.
A Compliance Plan is a structure for the fulfillment of your integrity. You are honest, right? Ok, lets
structuralize that honesty so foolish mistakes don’t occur and your office is doing everything in your power to
avoid violating a patient’s constitutional right to privacy?
How long should it take your office to discover privacy violations, security breeches or disclosure
errors?
If a staff member mysteriously quit, and you discovered bad checks, bad credit card slips and unfiled
insurance claims in their drawer 6 months old, would that be acceptable to you? This can occur when
you don’t have a “monitoring system” in place.
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7 SUGGESTED COMPLIANCE ELEMENTS
1)
Establish a Compliance Officer
This can be the same person as your security or privacy administrator
The Compliance Officer should have the authority to determine:
A. Who will be trained
B. How they will be trained
C. The extent of training
2)
Have established open lines of communication to and from the Compliance Officer. People
need a safe place to communicate violations. They need to know their first concern is integrity.
3)
Conduct regular and adequate training of your personnel on compliance issues.
A minimum one-hour a week should be set aside for training. External website, newsletter
updates such as: www.cms.hhs.gov or your MAC website. Internal information such as patient
satisfaction survey reviews returned Medicare claims, error charts.
4)
Established standards of conduct. Don’t tolerate a “wing it” approach from a staff member.
5)
Establish methods to monitor compliance with the standards of conduct in regards to
compliance. If you have violations it’s best to find them internally rather than through an audit.
6)
Establish systems to quickly respond to compliance mistakes.
7)
Establish written standardized disciplinary measures that you follow when transgressions
occur. The purpose behind standards is to identify weakness and remedy them quickly.
Your systems should enhance your ability to:
1.
2.
3.
Identify your points of vulnerability and audit triggers though the use of:
A. Checklists: to ensure nothing is dropped out
B. Graphs: to show you if you are improving or not
C. Attest sheets: to allow you to sleep at night knowing the system is being followed.
Identify your own billing patterns.
Determine how well you can prove everything you are doing is in compliance.
Some areas of special concern may be: documentation requirements, what to do if errors are noted,
penalties for violating patient privacy, use of internal forms to report violations, how to report
statistics and read graphs, record retention policies.
“That which is measured tends to improve.”
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Compliance Plan Elements
We as a Professional Group _____________ agree to adhere and commit to the following steps:
Step 1
Develop a “Code of Conduct” for all employees.
Step 2
Analyze your risk of exposure and specifically work on your most vulnerable
areas.
Step 3
Prepare for court now -- even before you learn of any such necessity.
Step 4
Make it safe for employees to point out trouble spots. If you overcharged
Medicare, then get legal advice on how to report and repay the mistaken
charges.
Step 5
Conduct training sessions on Medicare coding and charting compliance.
Step 6
Monitor and audit compliance with your “Code of Conduct.”
Step 7
Discipline violators in a standardized and consistent manner.
Step 8
Make sure high level executives are responsible and attentive to the
liabilities you are exposed to.
Initials________________
National Provider Compliance Corporation
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Sample Code of Conduct
We, the staff at _________________________, have been and continue to be
committed to the highest of ethical standards in the conduct of our healthcare and
business operations.
We demand of ourselves full compliance with all Federal, State, and local laws.
We are committed to preventing, detecting, and disciplining any unethical behavior.
We thrive and prosper on our quality medical treatment and outstanding
reputation for professional conduct. We create systems and controls to keep ourselves
dedicated to these standards.
We are partners in defining the leading edge of vigilance in protecting the rights of
all those with whom we deal.
Signature____________________________
National Provider Compliance Corporation
Date________________
65
Disciplinary Measures
Consequences for compliance violations must be known and enforced. A doctor thrown
out of Medicare because of “staff non-compliance” becomes a cab driver who knows a
lot about medicine.
Assuming you have well trained staff that is adequately supported, compliance violations
should be rare. You must have written standardized disciplinary actions ready and
waiting for those who wish to play games with your livelihood and freedom.
First violation: Call to attention verbally; retrain as necessary, written records
kept.
Second violation: Written reprimand. Retrain as necessary. Sign agreement to
not repeat violation. Written record kept.
Third violation: Ten-day suspension without pay. Retrain. Inform next
violation equals dismissal. Written record kept.
Fourth violation: Dismissal. Possible legal action.
You can choose what you deem appropriate punishments. The key is that they be
standardized, and used. Turning a blind eye to violations is simply asking to be standing
in front of a Federal Judge explaining why you didn’t take any real action to solve your
compliance problem.
You can find out if the person you are thinking of hiring (or hired) has already been
blacklisted by the Government. The O.I.G. and G.S.A. list individuals banned. Over
fifteen thousand individuals are currently banned and you can view their names on the
OIG website.
National Provider Compliance Corporation
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SAMPLE NOTICE OF PRIVACY
PRACTICES
This is not legal advice. You should give this information to your lawyer to assist them in covering all the
bases. Let them draft the final wording.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.
Our commitment here at
(Name of Practice)
is to serve our customers with
professionalism and caring, being sure at all times to protect the privacy and security of
all Protected Health Information.
During the course of serving your interests it may be necessary to share
information with other health care providers or business sssociates. The following are
examples of instances where information may be shared:
• During treatment, we may find it necessary to acquire a laboratory analysis.
• For payment purposes, we may use the services of a billing service.
• During health care operations, we may need a second opinion.
(Include any other examples of situations where Protected Health Information may be
shared.)
We here at
(Name of Practice)
are committed to obeying all Federal,
State and Local laws and regulations regarding Privacy Practices. If any other uses or
disclosures than the ones listed above are needed, information will only be released with
the written authorization of the individual in question. This written authorization may be
revoked at any time by the individual, as provided for by law.
If you have any questions or comments regarding your Protected Health
Information, feel free to contact our Compliance Officer
(Name)
at
(Phone # ) .
I have read and understand the above Notice of Privacy Practices.
Signed_______________________________________ Date_______________________
(Patient or Legal Guardian)
National Provider Compliance Corporation
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Health Care Fraud Checklist
1. Billing for services not rendered is inexcusable fraud.
2. MEDICAL NECESSITY: Not established in the chart. The documentation does
not support the services rendered.
3. DUPLICATE CLAIMS: Delaying review of EOMS (…..) and recent patterns have
made this an audit trigger.
4. MODIFIERS: Misuse and overuse. No chart documentation to support the
modifier.
5. UPCODING: Billing for services that are not fully documented in the chart. Billing
for more costly services that the services rendered.
6. UNBUNDLING: Billing for segments of a procedure that should have been
combined.
Not referencing current CCI (Correct Coding Initiative) Edits at
http://www.cms.hhs.gov/NationalCorrectCodInitEd/
7. KICKBACKS: Providing and accepting monetary incentives for referrals. Waiving
patient deductibles, coinsurance or co-payments.
Kickback Section 1128A of the ACT 42 U.S.C. 1320a-7a
EXCEPTION to the prohibition of waiving Medicare cost sharing amounts for financial
hardship.
a.) The waiver is not offered as part of any advertisement or solicitation.
b.) The party offering the waiver does not routinely waive cost share amounts.
c.) The party waives the cost sharing amounts after determining in good faith that the
beneficiary is in financial need and reasonable collection efforts have failed.
National Provider Compliance Corporation
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False Claims Act
(a) Liability for Certain Acts. — Any person who —
(1) Knowingly presents, or causes to be presented, to an officer or employee of the United States Government or a member of
the Armed Forces of the United States a false or fraudulent claim for payment or approval;
(2) Knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or
approved by the Government;
(3) Conspires to defraud the Government by getting a false or fraudulent claim allowed or paid;
(4) Has possession, custody, or control of property or money used, or to be used, by the Government and, intending to
defraud the Government or willfully to conceal the property, delivers, or causes to be delivered, less property than the amount
for which the person receives a certificate or receipt;
(5) Authorized to make or deliver a document certifying receipt of property used, or to be used, by the Government and,
intending to defraud the Government, makes or delivers the receipt without completely knowing that the information on the
receipt is true;
(6) Knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the
Government, or a member of the Armed Forces, who lawfully may not sell or pledge the property; or
(7) Knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an
obligation to pay or transmit money or property to the Government,
is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times
the amount of damages which the Government sustains because of the act of that person, except that if the court finds that —
(A) The person committing the violation of this subsection furnished officials of the United States responsible for
investigating false claims violations with all information known to such person about the violation within 30 days
after the date on which the defendant first obtained the information;
(B) Such person fully cooperated with any Government investigation of such violation; and
(C) At the time such person furnished the United States with the information about the violation, no criminal
prosecution, civil action, or administrative action had commenced under this title with respect to such violation, and
the person did not have actual knowledge of the existence of an investigation into such violation; the court may
assess not less than 2 times the amount of damages which the Government sustains because of the act of the person.
A person violating this subsection shall also be liable to the United States Government for the costs of a civil action
brought to recover any such penalty or damages.
(b) Knowing and Knowingly Defined. — For purposes of this section, the terms “knowing” and “knowingly” mean that a
person, with respect to information —
(1) has actual knowledge of the information;
(2) acts in deliberate ignorance of the truth or falsity of the information; or
(3) acts in reckless disregard of the truth or falsity of the information,
and no proof of specific intent to defraud is required.
(c) Claim Defined. — For purposes of this section, “claim” includes any request or demand, whether under a contract or
otherwise, for money or property which is made to a contractor, grantee, or other recipient if the United States Government
provides any portion of the money or property which is requested or demanded, or if the Government will reimburse such
contractor, guarantee, or other recipient for any portion of the money or property which is requested or demanded.
National Provider Compliance Corporation
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Red Flag Rule
Effective date: November 1, 2009:
The Federal Trade Commission (FTC) verified that November 1, 2009 is the effective date for compliance with the identity
theft prevention red flags rule. The final rules implement sections 114 and 315 of the Fair and Accurate Credit Transactions
Act of 2003.
Healthcare providers that extend delayed payment plans to patients are deemed “creditors” under
the red flags rule.
“Surveys conducted by the Federal Trade Commission (FTC) found that close to 5% of identity theft victims have
experienced some form of medical identity theft. Victims may find their benefits exhausted or face potentially lifethreatening consequences due to inaccuracies in their medical records. The cost to health care providers — left with unpaid
bills racked up by scam artists — can be staggering, too.”
The law defines “creditor” to include any entity that regularly defers payments for goods or services or arranges for the
extension of credit. For example, you are a creditor if you regularly bill patients after the completion of services,
including for the remainder of medical fees not reimbursed by insurance. Similarly, health care providers who regularly
allow patients to set up payment plans after services have been rendered are creditors under the Rule. Health care providers
are also considered creditors if they help patients get credit from other sources — for example, if they distribute and process
applications for credit accounts tailored to the health care industry.
Health care providers who require payment before or at the time of service are not creditors under the Red Flags Rule.
Simply accepting credit cards as a form of payment at the time of service does not make you a creditor under the Rule.
If you’re a creditor or financial institution with covered accounts, you must develop and implement a written Identity Theft
Prevention Program.
Your Program must:
One – Identify relevant red flags of identity theft you’re likely to come across in your business.
Two – Detect red flags. Set up procedures to detect those red flags in your day-to-day operations.
Three – Prevent and mitigate identity theft. If you spot the red flags you’ve identified, respond appropriately to prevent and
mitigate the harm done.
Four – Update your Program. The risks of identity theft can change rapidly, so it’s important to keep your Program current and
educate your staff.
Healthcare providers who bill patients and accept credit card payments may not experience widespread identity theft
however, even if theft isn’t a big risk in your business, complying with the Rule is mandatory and should be simple and
straightforward, with only a few red flags. For example, where the risk of identity theft is low, your program might focus
on how to respond if you are notified by a consumer or through processing systems that there are any suspicions of identity
misuse at your business. Low-risk businesses need to have a written program that is approved either by its board of directors
or an appropriate senior employee. However, because risks change, you must assess your program periodically to keep it
current.
National Provider Compliance Corporation
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Red Flag Program
We, the staff of ___________________________________________________
are committed to awareness and vigilance regarding any possible occurrences of identity theft.
We are committed to training and implementation of the following compliance program.
One –Identify Relevant Red Flag Risk Factors
1. Employees opening or managing accounts, those with access to personal information, billing customers, providing
customer service, or collecting debts.
2. Outsourced service providers and their access to patient and billing information..
3. Patients seeking health care using someone else’s name or insurance information
4. A patient providing altered or suspicious identification documents
Two – Detect Red Flags
1. The photograph or physical description on the ID inconsistent with what the patient looks like?
2. Employees accessing information unrelated to their job description or unassigned task.
3. Being aware of mail returned as undeliverable, even though the patient still shows up for appointments?
4. A patient complains about receiving a bill for a service that he or she didn’t get?
5. Inconsistency between a physical examination or medical history reported by the patient and the treatment records?
Three – Prevent and mitigate If red flags are identified, we are prepared to respond appropriately to prevent and
mitigate the harm done.
1. Require picture identification of persons seeking services or paying for services.
2. Training staff to carefully examine any questionable forms of identification, and ask for secondary identification.
3. Add provisions to our outsourced contracted providers that they have procedures in place to detect red flags and
either report them or respond appropriately to prevent or mitigate the crime themselves.
4. Be Vigilant in heeding the warnings from others that identity theft may be ongoing such as website and association
newsletters and bulletins
Four – Update our Program.
1. Keep our program current.
2. Provide ongoing education and training.
3. Provide annual report of instances, and actions taken.
Signed____________________________________ Date__________
National Provider Compliance Corporation
71
PATIENT SIGN-IN SHEET
Patient’s Initials
Doctor
National Provider Compliance Corporation
TODAYS DATE__________
Appointment
Time
I Will Be Paying Today By:
(Please check box)
Cash
Check
Credit Card
72
Collection Scripts
“Okay, Mrs. Jones, the fee for today's
services is $200. You can handle that today by
cash, check or credit card today, whichever
works best for you today.”
Phone Collection Script
May I speak to
(patient)
please? This
is
with
. There is
a balance on your account of
.
Do you have a credit card there handy and we
will just go ahead and take care of this?
National Provider Compliance Corporation
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Billing Notice Checklist
The following is a list of helpful hints to accelerate payments.
q 1. Size—Statement should be at least 8 ½” x 11”.
q 2. Color—Preferably red or pink.
q 3. Graphics—“PLEASE PAY TODAY” printed large and in red.
q 4. Statement—“Pay today by Credit Card.” Include insignia of credit cards you
accept, place for account number, expiration date, and signature.
q 5. Response Vehicle—Enclose a self addressed envelope. No need for postage.
q 6. Outside Envelope—Print “DO NOT FOLD” across the front. Return address
only, omit the doctor’s office name.
National Provider Compliance Corporation
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14 Hospital “Hot Spots”
FATHOM (First Look Analysis Tool for Hospitals Outlier Monitoring) was established by the
Texas Medical Foundation to compare Medicare claims from each hospital in a Quality Improvement
Organization area.
CMS can use this data to recoup erroneous payments or investigate hospitals for problems. CMS
also gave approval for this information to be available to hospitals for their own self auditing efforts.
The Program for Evaluating Payment Patterns Electronic Report (PEPPER) pulls data down from
FATHOM and compares it to state level statistics.
YOU NEED TO BE AWARE OF THE 14 HOT
SPOT PROCEDURES THAT MAY PUT YOU AT
RISK. ARE YOU:
Hot Spot
Above the 75th percentile or below the 10th percentile?
Problem
Cure in the works
No problem
1. One day stays excluding
transfers
c
c
c
2. One day stay transfers
c
c
c
3. DRG-127 (heart failure and
shock) one day stays
c
c
c
4. DRG-143 (chest pain) one
day stays
c
c
c
5. DRG-182 and 183
(esophagitis, gastroenteritis
and other miscellaneous
digestive disorders) one day
stays
c
c
c
6. DRG’s 296 and 297
(nutritional and
miscellaneous metabolic
disorders) one day stays
c
c
c
7. DRG 014 (intracranial
hemorrhage and stroke with
infarct)
c
c
c
National Provider Compliance Corporation
75
Hot Spot
Above the 75th percentile or below the 10th percentile?
Problem
Cure in the works
No problem
8. DRG’s 079/080 (complex
pneumonia)
c
c
c
9. DRG’s 239, 243, and 253
(pathological fractures and
musculoskeletal and
connective tissue
malignancy; medical back
problems; fracture, sprain
and other)
c
c
c
10. DRG 416 (septicemia)
c
c
c
11. DRG 475 (respiratory system
diagnosis with ventilator
support)
c
c
c
12. Seven day readmit to same
facility or elsewhere
(reporting on the first
admission)
c
c
c
13. Same day readmit elsewhere
(reporting on the first
admission)
c
c
c
14. Same day readmit to same
facility (reporting on the
first admission)
c
c
c
National Provider Compliance Corporation
76
Most Common Therapy Questions - Answered
Physical Therapy and Speech Language Pathology will have a combined maximum of $1860.00.
Occupational Therapy will have an incurred maximum cap of $1860.00 separately.
Limits apply to outpatient Part B therapy services from all settings except outpatient hospital and
hospital emergency room.
Maximums are based on incurred expenses and include applicable deductible and coinsurances.
Exceptions to caps due to medical necessity apply only when the exceptions process is in effect. When
in effect: All covered and medically necessary services may qualify for exceptions.
a) All requests for exception are in the form of a KX modifier added to claim line.
b) Use of the exception modifier increases the responsibility of the provider/supplier to fully
document that services are appropriate/ medically necessary, even though the documentation
does not need to be submitted with the claim. Lack of documentation may lead to a future
overpayment.
c) Use of the automatic process for exception does not exempt services from medical review
processes and use of the modifier above the expected normalcy may trigger an audit.
d) Only utilize the KX modifier when there is reason to believe that the cap is being exceeded,
not as a blanket modifier for all service, this also may trigger investigation.
Evaluation codes may also be exempted from caps after the therapy caps are reached when the
evaluation is necessary to determine future care and treatment.
Utilize the most relevant diagnostic code that best relates to the reason for the treatment. Codes
representing the medical condition that caused the treatment may be used when there is no code
representing the treatment itself.
Services that exceed therapy caps and do not meet Medicare criteria for medically necessary services are
not payable even when clinicians recommend and furnish services.
Providers/suppliers must notify beneficiaries of the therapy financial limitations at the first therapy
encounter and inform them that beneficiaries are responsible for 100 percent of the costs of therapy
services above the therapy limit, unless the outpatient care is furnished directly or under arrangements
by a hospital. Also if services may be questionable regarding eligibility, the patient must be advised. At t
he time of the communication, providers should have the ABN completed.
“Untimed” service units are reported with a “1” in the units field since determination is based on the
number of times the procedure is performed, and not the time involved in providing the procedure.
“Timed” codes specify the direct (one on one) time spent in patient contact and is normally represented
in 15 minutes segments. These codes report services delivered on any single calendar day using the
appropriate number of 15 minute units of service. A one-hour service would be 4 units of that service.
If only one service is provided in a day, providers should not bill for services less than 8 minutes. For
services that do not fall exactly on the 15-minute billable time frame the example of unites to time is:
1 unit: = 8 minutes through 22 minutes
2 units: = 23 minutes through 37 minutes
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3 units: = 38 minutes through 52 minutes
4 units: = 53 minutes through 67 minutes
Example:
24 minutes of neuromuscular reeducation, code 97112,
23 minutes of therapeutic exercise, code 97110,
Total timed code treatment time was 47 minutes.
Since 47 minutes falls within the range for 3 units, billing for 47 minutes is only 3 timed units. Each of
the codes is performed for more than 15 minutes, so each shall be billed for at least 1 unit. The correct
coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service
that took the most time
Modifiers to distinguish discipline of care are necessary for all therapy services related to:
GN Services delivered under an outpatient speech-language pathology plan of care;
GO Services delivered under an outpatient occupational therapy plan of care; or,
GP Services delivered under an outpatient physical therapy plan of care.
Reminder: CMS has updated the therapy code list with the “Sometimes Therapy” code 92520. This code always represents therapy services when performed by a
therapist and requires a therapy modifier.
Code 95992 has been deleted.
National Provider Compliance Corporation
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Top Chiropractic Myths Revealed
1) There are NO Medicare caps or limits for covered Chiropractic Services. Caps or limits are not
allowed.
2) Chiropractors have the highest provider compliance error rate in Medicare.
3) Medicare will pay for items or services that are determined to be “reasonable and necessary”.
4) All Medicare Covered Services MUST be billed to Medicare, whether you are a participating
provider or not. If you do not bill Medicare, the provider could face penalties.
5) Participating and Non-Participating providers must comply with the same guidelines, standards and
documentation requirements.
6)
Being non-participating does not exclude you from Medicare Audits.
7) Opting-Out of Medicare and being Non-Participating is not the same.
Chiropractors can decide to be participating or Non-participating but they cannot opt-out.
8) An ABN (Advanced Beneficiary Notice) is only utilized when you have good reason to expect that
Medicare will not pay for a particular service on a specific occasion due to non-eligibility of the
service as in the case of lack of medical necessity. In this case the patient should sign the ABN
acknowledging their financial liability for the service. You must then submit the claim to Medicare
even though you expect the claim to be denied.
9) You may keep an ABN on file for the same service to the same patient for one year.
10) Although Spinal manipulation is a covered service, and maintenance care is not excluded from
coverage, maintenance care is not considered medically reasonable and necessary and not payable by
Medicare.
11) Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and
prolong and enhance the quality of life; or therapy that is performed to maintain or prevent
deterioration of a chronic condition. When further clinical improvement cannot reasonably be
expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather
than corrective in nature, the treatment is then considered maintenance therapy.
12) Every chiropractic claim (those containing HCPCS code 98940, 98941 and/or 98942) must include
the Acute Treatment (AT) modifier if active/corrective treatment is being performed.
13) No modifier if maintenance therapy is being performed.
14) If a chiropractor orders, takes, or interprets an x-ray or other diagnostic procedure to demonstrate a
subluxation of the spine, the x-ray can be used for documentation. However, there is no coverage or
payment for these services or for any other diagnostic or therapeutic service ordered or furnished by
the chiropractor.
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Glossary
ABN:
ALJ:
ANSI:
ASC:
CABS:
CAFM:
CAH:
CAPS:
CCI:
CCN:
CCP:
CERT:
CMD:
CMS:
COB:
COBRA:
CPT:
CPT-4:
CWF:
DCS:
DHHS:
DME:
DOJ:
DRG:
E/M:
EDI:
EFTS:
EOB:
EOMB:
EPHI:
ERRP:
FFS:
GAO:
HAVEN:
HCFA:
HCPCS:
HDI:
HHPPS:
HIPAA:
HMO:
Advanced Beneficiary Notice
Administrative Law Judge
American National Standards Institute
Ambulatory Surgical/Surgery Center
Contractor Administrative Budget & Cost Reporting System
Contractor Accounting Financial Management System
Critical Access Hospital
Claims Automated Processing System
Correct Coding Initiative
Claim Control Number
Comprehensive Compliance Program
Comprehensive Error Rate Testing
Contractor Medical Director
Centers for Medicare and Medicaid Services (HCFA Prior to Jul. 1, 2001)
Coordination of Benefit
Consolidated Omnibus Budget Reconciliation Act (of 1985)
Current Procedural Terminology
Current Procedural Terminology, Version 4
Common Working File
Diversified Collections Services (The California MSP RAC)
Department of Health and Human Services
Durable Medical Equipment
Department of Justice
Diagnostic Related Group (patients with similar illness)
Evaluation & Management
Electronic Data Interchange
Electronic Funds Transfer System
Explanation of Benefits
Explanation of Medical Benefits
Electronic Protected Health Information
Error Rate Reduction Plan
Fee-for Service
General Accounting Office
Home Assessment Validation & Entry System
Health Care Financing Administration
Healthcare Common Procedure Coding System
Health Data Insights
Home Health Prospective Payment System
Health Insurance Portability & Accountability Act of 1996
Health Maintenance Organization
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IRF:
LCD:
MAC:
MMA:
MSP:
NAIC:
NCD:
NDNH:
NEC:
NOS:
NTIS:
OASIS:
OCE:
OIG:
OMB:
OPPS:
Part A:
Part B:
PECOS:
PHI:
PRG:
PSC:
QIC:
QIO:
RAC:
RBRVS:
RFP:
RVC:
RVU:
SCHIP:
SNF:
TRHCA:
U&C:
UCR:
VDSA:
WHO:
Inpatient Rehabilitation Facility
Local Coverage Determination
Medicare Administrative Contractor
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
Medicare Secondary Payer
National Association of Insurance Commissioners
National Center for Health Statistics
National Database of New Hires
"Not elsewhere classifiable" other specified
"Not otherwise specified" unspecified
National Technical Information Service (NBS, DOC)
Outcome & Assessment Information Set
Outpatient Code Editor (System)
Office of the Inspector General
Office of Management and Budget
Outpatient Prospective Payment System
Medicare Hospital Insurance
Medicare Supplementary Medical Insurance
Provider Enrollment, Chain and Ownership System
Protected Health Information
PRG-Schultz (The California and Arizona Claim RAC)
Program Safeguard Contractor
Qualified Independent Contractor
Quality Improvement Organization
Recovery Audit Contractor
Resource Based Relative Value Scale
Request for proposals
RAC Validation Contractor
Relative Value Unit
State Child Health Insurance Program
Skilled Nursing Facility
Tax Relief and Healthcare Act of 2006
Usual and Customary
Usual, Customary and Reasonable
Voluntary Data Sharing Agreements
World Health Organization
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Follow-up Resources
Office of the Inspector General
www.hhs.gov/org
Health and Human Services
www.hhs.gov
Centers for Medicare and Medicaid Services
www.cms.hhs.gov
Listing of Government Websites
www.firstgov.gov
American Medical Association
www.ama-assn.org
American Chiropractic Association
www.amerchiro.org
American Dental Association
www.ada.org
American Pediatric Association
www.aap.org
Skilled Nursing Facility Updates
www.cms.hhs.gov/center/snf.asp
Home Health Agency Updates
www.cms.hhs.gov/center/hha.asp
Ambulatory Surgical Center Updates
www.cms.hhs.gov/center/asc.asp
Physical, Occupational, Speech Language
http://www.cms.hhs.gov/TherapyServices
Medicare Updates
http://www.cms.hhs.gov/MLNGenInfo/
Comprehensive Error Rate Testing
www.certprovider.org
Quality Improvement Organization
www.qnetexchange.org
Washington Publishing Company
www.wpc-edi.com/codes
Remittance Advice Remark Codes
www.wpc-edi.com/codes
Claim Adjustment Reason Codes
www.wpc-edi.com/codes
Claim Status Codes
www.wpc-edi.com/codes
Correct Coding Initiative Products
www.wpc-edi.com/codes
National Association of Insurance Commissioners
www.naic.org
Bonus Incentives
PQRI – Physician Quality Reporting
www.cms.hhs.gov/pqri
E – Scripting
www.cms.hhs.gov/erxincentive/
National Provider Compliance Corporation
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How To Get A Raise
Step 1 Create two (2) Daysheets. Utilize Daysheet #1 for all money coming into the practice. Utilize
Daysheet #2 for any additional money coming into the practice as a direct result of using the National
Provider Compliance Corporation System.
Items for Daysheet #2:
1. Any time you get an insurance company to pay the practice, especially when they have gone beyond
the 30 day limit, then list that income on Daysheet #2.
2. Any time you receive a new check when they sent the money to the patient.
3. Any time you receive $35 for more information.
4. Any time you receive more money as a direct result of using the UCR letter.
5. Any time you receive $350 for a written narrative.
6. Any time you re-file a returned Medicare claim and receive payment.
7. Any time you correctly code the Primary Diagnosis resulting in higher lawful reimbursement.
8. Any time you collect any past due bills through the mail or phone that are paid with a credit card.
9. All other additional money you create as a direct result of actually implementing the seminar material.
Step 2 Itemize improvements that are difficult to quantify.
Examples:
1. Track the average days outstanding of insurance payments. Notate the faster payments.
2. Track the average days outstanding of the patient portions of bills.
3. Track the percentages of billings collected at the time of treatment.
4. Track the number of bad credit cards and checks that you have followed-up on.
5. Track the number of coding mistakes that could have resulted in fraud accusations that you have
caught in time.
Step 3 Add all the additional income you have created by implementing the changes over the next 90
days, then go to the Doctor and say, “Doc, how about a raise?”
Additional Revenue Generated
Dollars
3500
3000
3500
3000
2500
2000
1500
1000
500
0
Wk1
Wk2
Wk3
Wk4
National Provider Compliance Corporation
Wk5
Date
Wk6
Wk7
Wk8
Wk9
Wk10
83
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
National Provider Compliance Corporation
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
Unless this claim is paid or denied within 30 days,
we will file a formal written complaint with the
Insurance Commissioner.
84
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
National Provider Compliance Corporation
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
We will be happy to send you the additional
information you requested upon the receipt of
$___________________
85
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
National Provider Compliance Corporation
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
We charge a minimum of $35.00 for a request for
additional information. Please contact our office
for the exact charge. We will be happy to provide
you with any information you request upon the
receipt of those fees.
86
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
Name_________________________________
Acc#__________________ Exp. Date_______
Signature______________________________
National Provider Compliance Corporation
87