John F. Bishop, PA, CPC, CPMA, CGSC, CPRC
President John Bishop and Associates, LLC
Physician, Provider Coding, Auditing Compliance
and
Reimbursement Consulting
Tampa, FL
John F. Bishop, PA, CPC, CPMA, CGSC, CPRC
AAPA National Chair Reimbursement Work Group
Principle, John Bishop and Associates, LLC
Private Consultant
Tampa, Florida
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Get managed care and private carrier companies to
recognize and pay for NPPs services
Bill properly for a shared visit
Supervision requirements
Identify what physician supervision rules apply to
NPPs performing diagnostic tests
List the modifiers to use for NPPs
Discover whether NPPs can perform consults
“Incident to” – one more time!
Skilled Nursing Facility billing for NPP’s
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If you didn’t write it down-you didn’t do it
If you did write it down but incorrectly-you didn’t do it
If you can’t produce a dictated copy of whatever you
said you did (OR, ER,ASC)-you didn’t do it
If you didn’t do it, don’t bill it. That’s called FRAUD!!
If you can’t justify the medical necessity of what you
dictated or wrote down-you didn’t do it
If you code it incorrectly-you still didn’t do it
If you did code it correctly-just maybe you’ll get paid!
If you did get paid, doesn’t mean you get to keep it!!
If you did get paid, be prepared to give it back!!
OIG
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http://oig.hhs.gov/fraud/fugitives/index.asp
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Physician-owned distributors of spinal
implants
Physicians: Place of service errors in ASC
and outpatient locations
Evaluation and Management Services:
Trends in Coding of Claims
◦ We will review E&M claims to identify trends in
coding of E&M services from 2000-2009
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E&M services during Global Surgery periods
E&M services: Use of modifiers during
global surgical periods*****
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E&M services:
◦ We will review multiple E&M services for the same
providers and beneficiaries to identify EHR
documentation practices associated with
potentially improper payments. Medicare
contractors have noted an increased frequency of
medical records with identical documentation
across all services, Medicare requires providers to
select the code for the service based upon the
content of the services and have documentation
to support the level of service reported.
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“Incident to” Services-medical necessity, documentation, quality
of care. Determine whether payment for such services had a
higher error rate than that for non-incident to services. We will
also assess CMS’s ability to monitor services billed as “incident
to.” Medicare Part B pays for certain services billed by physicians
that are performed by nonphysicians incident-to a physician
office visit. They found that over half of services in 24 hours were
being performed by nonphysicians. Also found unqualified
nonphysicians performed 21% of the services that physician did
not perform personally. Incident-to services represent a program
vulnerability in that they do not appear in claims data and can be
identified only by reviewing the medical record.
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Excessive dosages…monitoring high volume, high cost
drugs for acceptable therapeutic levels for patient
condition
Wound Care Services
“Incident to” Services-medical necessity, documentation,
quality of care
Physical Therapy and OT providers
Place of Service Errors-services provided in ASC and
outpatient locations
E/M during global surgery periods
Consults
Home Calls
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Services by Social Workers
Medicare payments for Interventional Pain Management
procedures
Geographic areas with high utilization of Ultrasound
services
Geographic areas with high density of Independent
Diagnostic Testing Facilities
Psychiatric Services – inpatient setting
Polysomnography reimbursement –
◦ Medical necessity
Violation of assignment rules-improper balance billing
Business relationships with Advance Imaging Service in
Physician office
10. Debridement Coding - Errors in coding surgical
debridement versus active wound care management.
9. Duplicate Billing - Filing claims more than once for the same
service.
8. Stark Violations - Physicians referring patient to services in
which they have a financial interest or in which a family
member has a financial interest.
7. Pharmaceutical Coding in Physician Offices - Incorrect use of
codes or units in billing of injections.
6. Social Work Services in Facilities - Some clinical social
worker services provided to inpatients in hospitals or skilled
nursing facilities cannot be billed under Part B.
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5. Psychiatric Services - Over utilization of psychiatric services
provided in outpatient setting.
4. Medical Necessity - Documentation not supporting the level
of service provided in the outpatient setting.
3. E/M Billed During Global Periods - Use of modifier -24 in
billing
services that should have been included in the global package.
2. Place of Service Errors - Physicians performing services in
ASCs or outpatient facilities but when billing applying a place
of service code indicating the service was performed in the
physician office.
1. Incident-to Errors - Physician assistants and nurse
practitioners performing services for a physician but not
following billing-specific guidelines related to the physician's
relationship to the patient and the physician's presence in the
office.
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Allowed by state and federal laws to
provide physician services and procedures
and direct bill (Medicare/Medicaid/Tricare)
Physician Assistants-PA’s
Nurse Practitioners-NP’s
Clinical Nurse Specialists-CNS’s
CRNA’s
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The “other” group
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RNFA’s
Physical Therapists-PT
Occupational Therapists-OT
Speech/Audiology Therapists
Surgical Techs-CST
Psychologists
LCSW
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Medicare usually defers to state laws Scope
of Practice
Hospitals CANNOT bill for those
considered auxilliary personnel services
(on payroll)
Require UPIN/PIN
File CMS form # 855-Medicare Part B
Services must be considered Physician
Services
Hospital based NPP’s charges may be billed
IF NOT INCLUDED ON THE COST REPORT
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Must have national certification/license
Must have state license/registration
Must have hospital (s) privileges
If employed by hospital, must still have a
supervising physician of record (most states)
◦ PA’s tied to physicians by law
◦ NP’s may be independent in some states
Reimbursement is totally dependent upon
carrier discretion and interpretation!!
Must be considered Revenue generators****
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NPP’s can get reimbursed for seeing patients in the
office
Physician must be in Office suite
MD must maintain direct supervision
MD does not have to see patient
NPP can see established, (not new patient or new
problem) for “incident to”
Bill in MD’s PIN number-100% reimbursed
If No MD—NPP bills 85% with NPP PIN
NPP can see new patient or new problem-just bill
under NPP NPI number
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Only Medicare Part B
Not commercial carriers or Medicaid
Bill at 100% of physician fee schedule in
physician’s provider number
Must be established patient
Service must be within Physician’s plan of care(not a new problem)
Physician must be in office suite
ARNP/PA must be employee/leased back to
practice
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The physician was directly involved in the
patients care
Services were provided in an office setting
The patient was not new, nor had new
conditions
You expect 100% of the allowed fee schedule
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There was general supervision (physician NOT
in office)
The patient had a new or exacerbated
condition (NPP deviated from plan of care)
Expect to receive 85% of the allowed fee
schedule
Think of NPPs as Revenue Generators!!
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Medicare usually defers to state laws Scope
of Practice
Hospitals CANNOT bill for those considered
auxilliary personnel services (on payroll)
Require UPIN/PIN/NPI
File CMS form # 855-Medicare Part B
Services must be considered Physician
Services
Hospital based NPP’s charges may be billed
IF NOT INCLUDED ON THE COST REPORT
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CMS defines 3 levels
◦ General (level 1) – procedure is furnished under
physician’s overall direction and control (ie, is
available by telephone or beeper)-does NOT need to
be present
◦ Direct** (level 2) – physician must be physically
present in office suite (laboratory suite) and
immediately available to furnish assistance and
direction throughout the performance of the
procedure
◦ Personal supervision** (level 3) - physician must be in
attendance in the room during procedure
** Apply equally to all places of service (office/clinic and
hospital facility)
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Level 1 - Most diagnostic pulmonary function
tests require general supervision
Level 2 – Direct supervision involves
◦ administering an inhaled medication
 94060, 94070, 94664
◦ Breathing unusual gas mixture-carbon dioxide
 94400
 Low percentage oxygen-94450, 94452, 94453
 And exercise 94621, 94680, 94681
◦ Pulmonary stress testing 94620 only requires level 1
supervision
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Office/Clinic when physician is not on site-85% of physician’s
fee schedule
All services PA is legally authorized to provide that would
have been covered if provided personally by a physician in
Office/Clinic when physician is on site
Physician must be in the suite of offices for 100% of
physician’s fee schedule
Home visit/ House Call- 85% of physician’s fee schedule
Skilled Nursing Facility & Nursing Facility
◦ 85% of physician’s fee schedule
Hospital-85% of physician’s fee schedule
First assisting at surgery in all settings- 85% of physician’s
first assist fee schedule
Federally Certified Rural Health Clinics- Cost-based
reimbursement.
HMO- Reimbursement is on capitation basis. All services
contracted for as part of an HMO contract Using carrier
guidelines for "incident to" services.
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“Direct” Supervision
Doctor must see all
new Medicare patients
and established
patients with
exacerbations or new
conditions
100% of physician fee
schedule
Must indicate point of
doctor’s involvement
Doctor should sign all
notes
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“General” Supervision
Doctor doesn’t have to
see new patients or
exacerbated or new
conditions
85% of physician fee
schedule
Not required
Not required
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Indirectly-MD time is freed up for other
uses-office, surgery, hospital rounds, golf
course, home, family/children, exercise,
reading
MD efficiency, accuracy and skills 
MD bill all carriers for NPP services
MD can set a base salary plus give
performance bonus based on either
productivity, percentage of their monthly
A/R or overall practice A/R
Prescription writing (DEA)
Work for your practice (not Hospital)
NPPs are Revenue Generators
PAs
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Cardiology $109,030
Dermatology $107,727
ED $103,489
Surgery $102,760
Hospital based $97,680
House Calls $94,383
Orthopaedics $91,491
Family Practice $90,528
Pediatrics $86,894
Oncology $85,851
Academia $95,215
NPs
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Oncology $98,327 $90,574
ED - $104,549
Hospital - $93,943
Surg. Specialties - $91,511
Women’s Health- $76,483
Gerontology-$93,668
Cardiology-$100,881
Int. Med-$88,287
Family Practice- $86,518
Academia- $80,400
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Burn Wound Dressing changes under anesthesia
1st Assist in the OR
VAC changes
Compartment measurements-Wick catheter
ALL Central lines, Triple lumens, A-line, Hickman’s,
Ports, Use of US and Fluoro w/interp
I&D’s, NG tubes under guidance, Intubation, Trach’s
Consults
Admission H&P
Daily subsequent visits (not related to Burn injury)
Counseling and Coordination of care
Joint injections/aspirations
Discharge summaries
$$$
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99406 Smoking and tobacco use cessation
counseling visit; intermediate, greater than 3
minutes up to 10 minutes
99407 intensive , greater than 10 minutes
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INCLUDES: Administration and analysis of a health risk assessment (99420)
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Face-to-face services for new and established patients based on time
increments of 15 to 60 minutes
Issues such as a healthy diet, exercise, alcohol and drug abuse
Services provided by a physician or other qualified healthcare professional
for the purpose of promoting health and reducing illness and injury
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EXCLUDES: Counseling and risk factor reduction
interventions included in preventive medicine
services (99381-99397)
Counseling services provided to patient groups
with existing symptoms or illness (99078)
Code also distinct evaluation and management
services when performed in addition
Do not report with heath and behavioral services
provided on the same day (96150-96155)
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Surgery Day-Surgical Assisting
◦ THR (27130) x 3=37.70 x 36.07=$4271.07
 4271.07 x 13.6% = $580.87****
◦ TKR (27447) x 2=40.38 x36.07=$3051.62
 3051.62 x 13.6% = $415.02****
◦ Arthroscopy, knee
 Menisectomy 29881x3:16.38 x 36.07=$1834.50
 1834.50 x 13.6% = $249.49****
 TOTAL generated $ 9157.19
 TOTAL paid $1,244.88
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Office Day-Dr. in office (“Incident To”)
◦ PA schedule 40 patients
 30 follow-up = 99213=1.70 x 36.07=$1813.50
 10 new pt/new problems=99204=3.93 x
36.07=$1203.18 (85%)
 5 Trigger points injected= 20550=1.49 x
36.07=$273.30
 3 Large joint injections=20610=1.94 x
36.07=$211.65
 2 Med. Joints injected=20605=1.50 x 36.07=$109.12
 TOTAL $3610.75
◦ ALL charges go under supervising physician’s
billing number except new patients. Then they go
under PA’s NPI number (expect 85% return)
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If more than 50% of visit is spent in
counseling the patient
Document total visit and counseling time
Document what was discussed
Can use time as overriding factor on those
categories where time is a factor
Must make sense for the diagnosis/reason
for visit
Do Not Use Alone – Add-on Code**
 Prolonged
◦ Office
Services
99354
30 minutes to 1 hour additional time
(above the time designated for the “base”
visit code)
99355
each additional 30 minutes additional
time (above the time designated for the
“base” visit code and after the first hour of
additional time (99354)
Do Not Use Alone – Add-on Code**
 Prolonged
◦ Hospital
Services
99356
30 minutes to 1 hour additional time
(above the time designated for the “base”
visit code)
99357
each additional 30 minutes additional
time (above the time designated for the
“base” visit code and after the first hour of
additional time (99356)
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NPPs are highly educated licensed
health care providers
Federal and State agencies do not find
it credible that an NPP would refrain
from providing health care services or
making their own observations to
solely report the work of a physician
NPPs can (and should) be better
utilized!!
They are revenue generators!!!
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Medicare only allows coverage for services
and items which are “medically reasonable
and necessary” for treatment/diagnosis of
a patient.
◦ Medical necessity may be determined according
to several factors including the following:
 Items or services provided to the patient must be
appropriate for that patient’s treatment/diagnosis
 Documentation (When identified as required or when
requested) supports the medical need.
 The frequency of service or dispensing of an item is
within the accepted standards of medical practice.
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Working diagnosis must match the ICD-9
description
Close doesn’t count
Do not up-codeFraud
Do not down-codeFraud
Do not not code-????
Don’t code from the index
Always verify and check the book!
Then run it through your CCI and NCCI
edits
60-70% of first denials come from
wrong/not specific/ ICD-9
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Fracture coding in ICD-10-CM requires:
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documentation of site,
laterality,
type of fracture,
whether it is displaced or nondisplaced,
and the stage of healing (or encounter), which
includes open fracture classification.
This resource is to assist in the
understanding of the classification system
utilized in ICD-10-CM for open fractures.
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The procedure for evaluation and
management of open fractures is basically a
set of principles that involve initial
management and subsequent surgical
interventions. The purpose of any fracture
classification system in the clinical setting is
to allow communication that infers fracture
morphology and treatment parameters.
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Grade I:
• wound less than 1 cm with minimal soft tissue injury;
• wound bed is clean;
• bone injury is simple with minimal comminution;
• with intramedullary nailing, average time to union is 21–28 weeks
Grade II:
• wound is greater than 1 cm with moderate soft tissue injury;
• wound bed is moderately contaminated;
• fracture contains moderate comminution;
• with intramedullary nailing, average time to union is 26–28 weeks
Grade III:
The following fracture types automatically results in classification as type III:
• segmental fracture with displacement
• fracture with diaphyseal segmental loss;
• fracture with associated vascular injury requiring repair;
• farmyard injuries or highly contaminated wounds;
• high velocity gun shot wound;
• fracture caused by crushing force from fast moving vehicle;
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Grade IIIA fracture:
• wound less than 10 cm with crushed tissue and contamination;
• soft tissue coverage of bone is usually possible;
• with intramedullary nailing, average time to union is 30–35
weeks;
Grade IIIB fracture:
• wound greater than 10 cm with crushed tissue and
contamination;
• soft tissue is inadequate and requires regional or free flap;
• with intramedullary nailing, average time to union is 30–35
weeks;
It is important to educate providers on the use of this scale for
the specific documentation necessary in ICD-10-CM.
This will ensure that proper code assignment can be made
without multiple queries to the provider.
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715.16 Primary
localized osteoarthrosis,
lower leg
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715.00 Generalized
osteoarthrosis,
unspecified site
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M17.0 Bilateral primary
osteoarthritis of knee
M17.10 Unilateral primary
osteoarthritis, unspecified
knee
M17.11 Unilateral primary
osteoarthritis, right knee
M17.12Unilateral primary
osteoarthritis, left knee
M15.0 arthritis of multiple
sites
bilateral involvement of
single joint (M16-M19)
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ICD-9-CM
719.47 - Pain in joint; ankle and foot, Ankle
joint, Digits [toes], Metatarsus, Phalanges, foot,
Tarsus, Other joints in foot
ICD-10-CM
M25.571 Pain in right ankle
M25.572 Pain in left ankle
M25.579 Pain in unspecified ankle
M79.671 Pain in right foot
M79.672 Pain in left foot
M79.673 Pain in unspecified foot
M79.674 Pain in right toe(s)
M79.675 Pain in left toe(s)
M79.676 Pain in unspecified toe(s)
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ICD-9-CM
726.12 - Bicipital tenosynovitis
ICD-10-CM
M65.811 Other synovitis and tenosynovitis, right shoulder
M65.812 Other synovitis and tenosynovitis, left shoulder
M65.819 Other synovitis and tenosynovitis, unspecified shoulder
ICD-9-CM
729.5 - Pain in limb
ICD-10-CM
M79.601 Pain in right arm
M79.602 Pain in left arm
M79.603 Pain in arm, unspecified
M79.604 Pain in right leg
M79.605 Pain in left leg
M79.606 Pain in leg, unspecified
M79.609 Pain in unspecified limb
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Chapter 19 Injury, Poisoning and certain
other consequences of External causes
What ICD-9 looked like: 945.39
What ICD-10 looks like: T24.309Aunspecified site
T24.312-D-left thigh, subsequent visit
T24.321A-right knee
T24.332S-sequela left lower leg
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Physician bills 25% of CPT
Medicare-PA’s can charge . 85% x 16% =
13.6% of surgeon’s fee
Medicaid-same
3rd party-either 100%75%
Reimbursement depends on IF a surgeon
assistant is required/allowed and NO
Resident is available
Check each carrier reimbursement schedule
for all reimbursable cases
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If physician-modifier-80
Minimal assistance-modifier-81
In teaching institution-modifier-82 (Resident
not available)
Medicare-PA/NP-modifier AS
Blue Cross/Blue Shield doesn’t recognize Nonphysician PIN codes-state specific
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If physician-modifier-80
Minimal assistance-modifier-81
In teaching institution-modifier-82 (Resident
not available)
Medicare-PA/NP-modifier AS
Blue Cross/Blue Shield doesn’t recognize
Non-physician PIN codes-state specific
Carrier
Reimburse
Bill under
MD
1st Assist
Modifier
Aetna
100%
Yes
12%
80-81
Assurant
Health
100%
Yes
20%
80-81
BC/BS
100%
Yes
13.6%
AS
Cigna
100%
Yes
13.6%
AS
GHI
100%
Yes
13%
AS
Humana
100%
Yes
10-20%
AS
School
Insurance of
FL
100%
Yes
Pasco
Co-13.6%
AS or 80
United
Healthcare
100%
Yes
14%
AS
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The PA and the physician must work for the
same employer.
The regulation applies only to E/M services
delivered in the hospital and not to
procedures.
The physician must provide some face-to-face
portion of the E/M services on same day.
Simply reviewing or signing the patient’s chart
is not sufficient.
“Incident to” billing has never applied to the
hospital setting – and still does not apply
Bill 100% under physician PIN
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97802-97804Medical Nutrition Therapy
96040Medical Genetics/Counseling Services
98960-98962Education/training for Self management
established pts using standardized guidelines (CHF,
Coumadin, Genetics, Immune, Transplant Svc)
99341-99350Home Services (E&M)
99500-99600Home Health procedures (Postnatal,
Resp. Tx, Hemodialysis
99401-99429Preventive Medicine-Counseling, Risk
factor reduction
99241-99245, 99251-99255 with modifier –GT to
signify Teleconsultation via interactive video/audio
98966-98968→ Non face-to-face Telephone E&M
98969→ Online (email) E&M assessment and
management
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CPT code G0447, a 15-minute face-to-face behavioral counseling for obesity, has
been assigned total non-facility RVUs of 0.74. The 2011 conversion factor is
$33.9764.
Screening and counseling coverage is effective as of the decision date, so when
contractors are ready to process the claims, physicians will be able to submit
claims for service back to the date of coverage, according to the spokeswoman.
Patients with Medicare will not be charged for the screening or counseling,
according to CMS. Screening for obesity and counseling for eligible
beneficiaries by primary care providers are covered under this new benefit. For
a beneficiary who screens positive for obesity with a body mass index greater
than 30, the benefit includes one face-to-face counseling visit each week for 1
month and one face-to-face counseling visit every other week for an additional 5
months, according to CMS.
The beneficiary may receive one face-to-face counseling visit every month for an
additional 6 months (for a total of 12 months of counseling) if he or she has
achieved a weight reduction of at least 6.6 pounds during the first 6 months of
counseling.
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Why is the patient being seen?
Does the level of visit make sense?
Does the documentation support the level
indicated?
Could it support a different (higher or lower) level
of E&M?
Too much, too little or just right?
Has Medical Necessity been met?
Is this visit justifiable?
Is this visit defensible from an outside audit or
worse, an ALJ hearing?
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Teach your doctors, PA’s and other providers
to understand what medical necessity is from
the payer’s perspective, NOT the provider’s
Teach them what is required for documentation
per payer
Teach them to dictate/write the proper
justification-OP note, procedure note,
lab/radiology orders, etc….
Finally, don’t bill it, if it’s not documented and
justifiable.
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NPP’s very cost effective
NPP’s accepted just about every clinical
environment
NPP’s billing and reimbursement has
improved significantly
NPP’s will be around for quite a while!
Reimbursement is totally dependent upon
carrier discretion and interpretation!!
Must be considered Revenue
generators****
Learn how to get them reimbursed!!
email:
bishopjf@aol.com