Billing Training
04/1 and 2/2015
Pamela Pully
Professional Insurances Consultants
Disclaimer
This information is accurate as of March 30, 2015 and is
designed to offer basic information for coding and
billing. All information is based on experience, training
and has been researched, interpreted and carefully
reviewed by this trainer. Medical compliance/coding
and billing information changes quickly. This can
become outdated . This is training is intended to be an
educational guide and should not be considered as legal
or consulting opinion.
Disclaimer cont.
 CPT, HCPCS, ICD-9 and NCCI edits books and web-sites




were used for coding information.
Rules used come from AMA, ICD-9,CMS, final rule, WPS,
CMS and others.
HIPAA and PPACA laws considered.
Any questions on information I am presenting, please ask. I
will give you the source document I used.
It is important to me to give the best and most up to date
information I can.
Medicaid for behavior health
 Need to make sure you review the cost per code
list and qualification lists often.
 They can be found at www.michigan.gov watch
you dates for valid information.
 Let review where this is at.
 You also must follow all rules in the Medicaid
manual.
 Don’t forget the DCH-OIG looks to insure you
are following all these rules.
Medicare “incident to”






www.wpsmedicare.com
WPS PSY014 and 12
CMS L30489 and L30715
Private office and clinic rules are different.
J-code rules under “incident to”
Modifier to help with when there is no provider
on site no “incident to” . When to use modifier
RD.
NCCI EDITS
 http://www.cms.gov/Medicare/Coding/NationalCorrectC




odInitEd/NCCI-Coding-Edits.html
Need to understand how to read the chart
First you need to make sure you are in the right quarter.
They change the first of every yearly quarter.
Look for your primary code then second code your billing
for same billing provider/same group provider.You may have
to look both ways.
If the code is present you can not bill together. If there is an
*/1 that means maybe you can bill if you have a proper
modifier. There can be many to choose from.
Modifiers commonly used for proper
explanation of same day services
 Modifier 25-Most over used and effective modifier, when
used under the definition: Significant, separately identifiable
evaluation and management service by the same physician or
other qualified health care professional on the same day of
the procedure or other service.
 Modifier-59 Also over used and effective, when used under
the definition: Distinct procedural service.
 Modifier 59 now has defined even more.
Modifier-59 is Expanding
 XE (Separate Encounter). A service that is distinct because it
occurred during a separate encounter.
 XS (Separate Structure). A service that is distinct because it
was preformed on a separate organ/structure.
 XP (Separate Practitioner). A service that is distinct because
it was preformed by a different practitioner.
 XU (unusual Non-Overlapping Service). The use if a service
that is distinct because it does not overlap usual components
of the main service.
Different rules different carriers
 We need to keep in mind carriers can set different rules.
 We need to follow the rules of the carrier because they hold




the money.
Most carries follow the CMS/AMA and ICD-9 rules. This
includes fee for service Medicaid and the Medicaid health
plans.
The PIHP and the carve out of behavior health services are a
big exception.
Review the cost per code chart and qualification chart.
Review of modifier and how they may mean something
different.
Codes for RN billing
 RN’s can provide and bill many services. They can be billed
to Medicare under the “incident to” rule. To Medicaid under
the providing doctor or clinic’s NPI. To BCBSM under the
doctor who set the plan. Other commercials have the same
rules. RN’s can bill following provider of plans rules, goal
and care.
 RN’s have extra service they can bill under Medicaid rules
due to the Medicaid T-codes and PIHP qualification chart.
 Keep in mind you can not just use these codes when it gives
you better reimbursement. You must follow coding rules and
their must be medical necessity.
Codes for RN billing
 The number one billing rules for coding these: Always code




CPT before HCPCS codes.
Great example RN visit in the office setting. 99211 not
T1002….explain
RN assessment no CPT code only HCPCS code T1001.
Because it is a T code it is only billable to Medicaid.
Nutritional education and diabetes training can be codes to
use depending on the carrier.
Lets look at the cost per code chart and what Medicaid
allows as they are the most generous with RN services.
Audit the E/M visit
 You need to follow all the rule from the morning
session.
 The key document is the CMS E/M site.
https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/eval_mgmt_se
rv_guide-ICN006764.pdf
Trouble shooting rejections
Most common Medicare rejection
50 -Medical necessity
1. This usually lies with the diagnosis. Good example is a
rejection for RD services when not billed with the only
covered diagnoses codes under Medicare.
2. Can happen when there is no change in the diagnosis code
over time.
3. Can happen when the documentation reveals no medical
necessity.
Trouble shooting rejections
 If you get rejected from the primary carrier
there is a possibility you can not bill/use
Medicaid funds.
 Example: RD for Medicare they reject due to
diagnosis medical necessity. You can bill that and
use Medicaid funds. They reject because you are
not credentialed with the carrier you can not
bill or use Medicaid funds.
Medical Billing Questions