WELCOME
TOMA Practice Management
“Tips and Tricks to Getting Paid”
PRE-QUESTION # 1
Can you bill Medicare for the DX of
Obesity?
A. Yes
B. No
C. Only if the patient’s BMI is greater than 30 kg/m2
D. Only if you document that the patient is obese
PRE-QUESTION # 2
What modifier do you use if you
perform a toenail removal on Left
Great Toe?
A: T5
B: TA
C: F5
D: FA
PRE-QUESTION # 3
If you have two procedures with an office visit
on the same day, which procedure do you add the
59 modifier (Procedure or service was distinct or
independent from other services performed on
the same day.) ?
A: Least Paid Procedure
B: Both Procedures
C: On the office visit
D: Most Expensive Procedure
PRE-QUESTION # 4
What is the penalty for NOT having an EHR by 2019?
A: 1%
B: 2%
C: 3%
D: 5%
PRE-QUESTION # 5
If you started the EHR Incentive Program in 2012, you
no longer have to use G8553 on your claims to show
you sent an electronic prescription since the E-Rx Bonus
is included in the EHR bonus.
A. True
B. False
GETTING PAID
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File Claims on a daily basis
Correct Rejections on a daily basis
Keep electronic deposits posted
Work Insurance A/R weekly to avoid missing
deadlines
 Collect copays and Co-insurance at time of service
GETTING PAID
 Collect past due balances before the patient is
seen. Let patient know that payment is
expected when appointment is made.
 Keep logs of Injections given and Labs done
so they can be checked monthly for missed
charges.
 Audit 20 to 30 charts a month for billing
accuracy.
EMPLOYEE BONUSES
WELCOME TO MEDICARE
PHYSICAL (IPPE EXAM)
 Must be done within the first 12 months of Medicare
effective date
 Can only be billed ONCE in a lifetime
 Code is G0402
 Reimbursement is $ 149.03 for a Participating
Physician in Locality of 99 (Rest of Texas)
INITIAL ANNUAL WELLNESS VISIT
 Can only be billing ONCE in a lifetime
 Cannot be billed the same year as the IPPE Exam
 If Eligible for IPPE, must do IPPE not AWV.
 Code is G0438
 Reimbursement is $ 158.65 for a Participating
Physician in the Locality of 99 (Rest of Texas)
SUBSEQUENT ANNUAL
WELLNESS VISIT
 Can be billed EVERY year after the Initial Annual
Wellness Visit (Must be 12 months)
 Code is G0439
 Reimbursement is $ 105.59 for a participating
Physician in the Locality of 99 (Rest of Texas)
OVERVIEW OF MEDICARE
PHYSICALS
 G0402 – IPPE Exam - $ 149.03
 G0438 – Initial AWV - $ 158.65
 G0439 – Subsq AWV - $ 105.59
** Co-Payment/Co-Insurance or Deductible are waived.
** Based on 2011 Medicare Fee Schedule – Rest of Texas – Participating Provider
ADDITIONAL CODES FOR IPPE EXAM
OR INITIAL AWV EXAM
(OPTIONAL)
 G0403 – ECG
$17.82
 G0404 – ECG Tracing $ 9.59
 G0405 – ECG Interpret & Report $ 8.23
 Pap Smear and Prostate exam should be
scheduled for a different day (not
included in this physical)
CODING ALERT !!!!!!!!!!!!!!!
If you are seeing the patient for another Dx
NOT related to the Medicare Physical Code, you
may bill and office visit code (99201-99205 or
99211-99215) in addition to their IPPE or AWV
code. Your office visit code will need a 25
modifier and a different DX code attached to it.
MEDICARE WELL WOMAN EXAM
HIGH – RISK FEMALE
PATIENT
VS
LOW – RISK FEMALE
PATIENT
MEDICARE - WELL WOMAN EXAM
What is considered High – Risk ?
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Early onset of sexual activity
Multiple sex partners ( 5 or more in lifetime)
History of STD
DES exposed daughters of women who took DES during
pregnancy
MEDICARE - WELL WOMAN EXAM
 HIGH RISK Patient – Every year ( 11
months)
 Dx code – V15.89
 G0101 – Screening Pelvic & Breast Exam
 Q0091 – Obtaining Smear for pap
 You may bill an office visit with 25 modifier if
you are seeing the patient for another dx. (ex:
hypertension, diabetes, CHF, COPD, etc)
MEDICARE - WELL WOMAN EXAM





Low risk patient – every 2 years (24 months)
DX Code - V76.2
G0101 – Screening Pelvic & Breast Exam
Q0091 – Obtaining Smear for pap
You may bill an office visit with 25 modifier if
you are seeing the patient for another dx. (ex:
hypertension, diabetes, CHF, COPD, etc)
INFLUENZA A & B SCREENING
 When screening for Influenza A & B you must Use a
59 or 91 modifier to get paid for both.
 CLIA waived tests must still have a QW modifier in
addition to the 59 or 91

Ex: 87804 QW

87804 QW 59
 ** Medicaid claims use modifier 91 instead of 59 &
most insurances will accept either.
PSYCHOTHERAPY MANAGEMENT
CODE
 DX Codes – ADD, ADHD, Anxiety, Depression, Etc.
 90862 – Pharmacologic management, including prescription,
use, and review of medication with no more than minimal
medical psychotherapy.
 Most insurance companies including Medicaid pay more than a
99213
POWER MOBILITY EVALUATION
G0372 – Power Mobility Evaluation
Reimbursement for 2012……….$ 9.17
(You may also bill an office visit in addition to G0372 and no modifier is
needed)
TRIGGER POINT INJECTIONS
20552 - Injection(s);single or multiple trigger
point(s), 1 or 2 muscle(s)
Key Words : Single or Multiple (can bill only one
unit)
PR-22 MEDICARE DENIAL CODE
Definition: Payment adjusted because this care
may be covered by another payer per
Coordination of Benefits.
What does this mean???
Medicare is the secondary payer.
AETNA BUNDLING
36415 – venipuncture
81002 – UA
Aetna bundles these with office visit. If you will
add a 25 modifier to Office visit, they will pay all.
INJECTION ADMINISTRATION
96372 – Injection administration
 You can bill for a E/M code with a 25
modifier in addition to the 96372 code.
 ** New requirements for 5010…..the unit and
NDC number must be on the medication.
INJECTABLE MEDICATIONS
** New requirements for 5010
Unit Measurement codes are:
F2- International Unit
GR- Gram
ML- Milliliter
UN – Unit
** www.Calculateme.com
NDC NUMBER CONVERSION
NDC numbers have to be converted from a 10 digit code to an 11 digit code:
4-4-2 *####-####-## (add zero in 1st position)
5-3-2 #####-*###-## (add zero in 6th position)
5-4-1 #####-####-*# (add zero in 10 position)
MEDICARE PART B COVERED
VACCINES
 Pneumonia Vaccine (V03.82)
Admin Code (G0009)
 Influenza Vaccine (V04.81)
Admin Code (G0008)
(If Pneumonia and Influenza is given on same visits, you must use V06.6 for
dx code)
 Hepatitis B vaccine (high risk only - ex: exposed to Hepatitis B) (V05.3)
Admin Code (G0010)
 Other vaccines (ex: tetanus toxoid) when directly related to the treatment
of an injury or direct exposure to a disease or condition)
MEDICARE PART D VACCINES
 Zostavax ( for shingles) – This is a Medicare Part D
vaccine. You will not be reimbursed in the office
without filing the claim thru this website.
Go to :
 www.mytransactrx.com – Merck can set your practice
up with a login to file the claim
 www.checkcoveragenow.com – Private insurance and
Medicare Part D verification
PREVENTATIVE CARE CODES
(INSURANCE)
99401 is for 15 minutes of preventative care
99402 is for 30 minutes of preventative care
99403 is for 45 minutes of preventative care
99404 is for 60 minutes of preventative care
Examples of counseling would be:
Use condoms, buckle up, adjust water temp, lift with
your legs, lose weight
ANNUAL ALCOHOL SCREENING –
MEDICARE
Effective for dates of service on or after October 14,
2011, CMS will cover annual alcohol screening, and for
those that screen positive, up to four brief, face-to-face
behavioral counseling interventions annually for
Medicare beneficiaries, including pregnant women.
Medicare coinsurance and Part B deductible are waived
ANNUAL ALCOHOL SCREENING –
MEDICARE
G0443 - brief face-to-face behavioral counseling for alcohol
misuse, 15 minutes - $24.21
G0442 - Annual alcohol misuse screening, 15 minutes
- $ 16.34
(http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7791.pdf)
ALCOHOL/SUBSTANCE ABUSE
INTERVENTION CODES
 G0396 (99408) Alcohol and/or substance (other than tobacco)
abuse structured assessment (e.g., AUDIT, DAST) and brief
intervention, 15 to 30 minutes. ($ 33.16)
 G0397 (99409) Alcohol and/or substance (other than tobacco)
abuse structured assessment (e.g., AUDIT, DAST) and
intervention greater than 30 minutes. ($65.39)
( Reimbursement based on Medicare Fee Schedule of a
participating physicians in locality 99 (Rest of Texas) )
SMOKING CESSATION CODES
 G0436 ($13.10)– Smoking/Tobacco cessation counseling visit 3 to 10
minutes.
 G0437 –($27.16) - Smoking/Tobacco cessation
counseling visit 10 minutes or greater.
 ** Use dx codes: 305.1 or V15.82
 ** 2 cessation attempts per year; 8 sessions in a 12 month period. (Copays,
Co-Ins and Ded are waived)
INTENSIVE BEHAVIORAL
THERAPY FOR OBESITY
Medicare beneficiaries with obesity, defined as Body Mass Index (BMI) equal
to or greater than 30 kg/m2, who are competent and alert at the time that
counseling is provided and whose counseling is furnished by a qualified
primary care physician or other primary care practitioner in a primary care
setting, are eligible for:
 One face-to-face visit every week for the 1 st Month
 One face-to-face visit every other week for Months 2 – 6
 One face-to-face visit every month for Months 7-12, IF the Medicare
Patient meets the 6.6 lbs weight loss requirement during 1 st Six months
INTENSIVE BEHAVIORAL
THERAPY FOR OBESITY
 G0447 – Face-to-Face behavioral counseling for
obesity (15 minutes)
 Reimbursement is $ 24.21 for Participating Medicare
Provider in Locality 99 (Rest of Texas)
 DX codes: 278.00 or 278.01
 Medicare coinsurance and Part B deductible are
waived
 Office Visit may be billed if you are seeing patient
for another DX. If so, add 25 modifier to OV
ANNUAL DEPRESSION
SCREENING - MEDICARE
Effective October 14, 2011, Medicare covers annual
depression screening for adults in the primary care setting
that has staff-assisted depression care supports in place to
assure accurate diagnosis, effective treatment and follow-up.
 Medicare co-insurance and deductibles are waived
http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/downloads/MM7637.pdf
ANNUAL DEPRESSION
SCREENING - MEDICARE
 G0444 – Annual Depression Screening (15 minutes)
Type of Service is 1
 Reimbursement - $ 16.34 for Participating Physicians
in Locality 99 (Rest of Texas)
 Office Visit may be billed if you are seeing patient
for another DX. If so, add 25 modifier to OV
TEXAS MEDICAID CO-PAY CODES
CP001 – Private HMO Copayment
CP002 – Private PP0 Copayment
CP003 – Medicare HMO Copayment
CP004 – Medicare PPO Copayment
Reimbursement $ 10.00
MEDICARE/MEDICAID PATIENTS
As of January 1, 2012, Texas Medicaid will
no longer pay the 20 % co-insurance
approved by Medicare. Medicaid will only
pay the Medicaid rate on the deductible
amount. CANNOT bill patient !!
INGROWN TOENAIL
Are you having trouble getting paid
for an Ingrown Toenail Removal?
INGROWN NAIL MODIFIERS
:
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
FA Left hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, 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
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
MODIFIERS
 24 - Unrelated E/M service during a post op period.
 25 - Evaluation and Management service by the same physician on the
same day as the procedure
 50 – Bilateral Procedure
 59 - Procedure or service was distinct or independent from other services
performed on the same day. (Least paid procedure)
 79 - Unrelated surgery/Procedure during postop period
 GW - Service not related to the hospice patient's terminal condition.
 GV - Physician not employed or paid under agreement by the patient's
hospice provider.
MEDICARE INCENTIVE
PROGRAMS
 EHR - $ 44,000
 E-Rx – Now included in the EHR Incentive.
 QIP – End Stage Renal Disease Incentive.
 HPSA – Shortage Area Bonus (10 %)
 HSIP – Surgeries ( 10-day and 90-day Globals)
in a shortage area (extra 10%)
MEDICARE INCENTIVE
PROGRAMS
 PQRS – (formally PRQI) Physician Quality Report System (2011 – 1%)
 PCIP – Primary Care Incentive Program (10%)
http://www.trailblazerhealth.com/Tools/PCIPEligibility.aspx
E-RX NOTICE
G8553- At least one prescription created during the encounter
was generated and transmitted electronically using a qualified eRx
system.
This code must be included on at least 10 claims before June 30,
2012 or Medicare will PENALIZE your 2013 Medicare payments
by 1.5%
(E-Rx Bonus is included in EHR Bonus)
EHR INCENTIVE PAYMENTS
First Year
2011
2012
2013
2014
2011
18,000
--------------
--------------
-------------
2012
12,000
18,000
--------------
-------------
2013
8,000
12,000
15,000
-------------
2014
4,000
8,000
12,000
12,000
2015
2,000
4,000
8,000
8,000
2,000
4,000
4,000
44,000
39,000
24,000
2016
44,000
EHR INCENTIVE PENALTIES
2015 – 1% of the allowed amount
2016 – 2 % of the allowed amount
2017 – 3 % of the allowed amount
2018 – 4% of the allowed amount
2019 – 5% of the allowed amount
PQRS INCENTIVE BONUSES &
PENALTIES
2012 – 0.5 % Bonus
2013 – 0.5 % Bonus
2014 – 0.5 % Bonus
2015 – 1.5 % Penalty
2016 – 2.0 % Penalty
2017 – 2.0 % Penalty
All other years 2.0 % Penalty
INTERACTIVE VOICE RESPONSE
(IVR)
Claim Information
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
Pending and processed claim information.
Coinsurance amount (Part A only).
Amount paid.
Order a duplicate remittance notice (Part B paid remittances only).
Overlapping/duplicate claim lookup .
INTERACTIVE VOICE RESPONSE
(IVR)
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Eligibility and Benefits Information
Part A and Part B effective and termination dates.
Amount of Part B deductible remaining to be met for the current year.
Amount of Part B deductible remaining to be met for the prior year.
Amount of physical and speech-language pathology cap remaining to be met
the for current year.
Amount of occupational therapy cap remaining to be met for the current year.
Medicare Advantage Plans.
Medicare Secondary Payer (MSP) information.
Benefits under a different Medicare number.
Hospice enrollment.
Home health enrollment.
Capability of verifying preventive services available for patient.
INTERACTIVE VOICE RESPONSE
(IVR)
Financial Information
 Information on the last five checks (up to 25), which includes the issue
date, check number, check amount and status of the check (Part B).
 The number of claims approved to pay and the approved-to-pay amount
(Part B only).
 Check status by check number (Part B only).
 Number of pending claims and the pending claims amount (Part B only).
INTERACTIVE VOICE RESPONSE
(IVR)
 Provider Enrollment
 PECOS status (Part B only).
 Application status (Part B only).
 Duplicate Remittance
 Request a duplicate copy of a remittance (Part B paid remittances only).
HELPFUL TOOLS
 LCD – Local Coverage Determination
http://www.trailblazerhealth.com/Tools/LCDs.aspx?DomainID=1
 Part B IVR - (877) 567-9230
 Denial Reason Code Search –
http://www.trailblazerhealth.com/Tools/ReasonCodeSearch.aspx?ProgramID=2
 FREE EHR PROGRAM – www.practicefusion.com
PRE-QUESTION # 1
Can you bill Medicare for the DX of
Obesity?
A. Yes
B. No
C. Only if the patient’s BMI is greater than 30 kg/m2
D. Only if you document that the patient is obese
PRE-QUESTION # 2
What modifier do you use if you
perform a toenail removal on Left
Great Toe?
A: T5
B: TA
C: F5
D: FA
PRE-QUESTION # 3
If you have two procedures with an office visit
on the same day, which procedure do you add the
59 modifier (Procedure or service was distinct or
independent from other services performed on
the same day.) ?
A: Least Paid Procedure
B: Both Procedures
C: On the office visit
D: Most Expensive Procedure
PRE-QUESTION # 4
What is the penalty for NOT having an EHR by 2019?
A: 1%
B: 2%
C: 3%
D: 5%
PRE-QUESTION # 5
If you started the EHR Incentive Program in 2012, you
no longer have to use G8553 on your claims to show
you sent an electronic prescription since the E-Rx Bonus
is included in the EHR bonus.
A. True
B. False
CONTACT INFORMATION
Skinner Medical Billing &
Consulting
Kelly Skinner, CMM, CPC, CFPC
P.O. Box 1521
Eastland, Texas 76448
254-631-1012 – cell
254-629-2747 – office
skinnermedicalbilling@gmail.com