Why am I being Charged for my “FREE” physical? Saturday, Sep 1 2012 

Due to the Patient Protection and Affordable Care Act (PPACA), or commonly called “Obamacare”, Health Plans are starting to cover Preventive Medicine services at 100% with no copays, coinsurance or deductible. Unfortunately, insurance companies are not informing patients that dealing with medical issues during these preventive medicine visits will result in an out-of-pocket charge that could result in a co-payment, or a substantial out-of-pocket expense if they have not met their deductible. Insurance companies require all services to be itemized and coded appropriately. One of the primary reasons is to prevent the health plans from paying for services that are not covered. Providers cannot code problem visits as preventive because this would be insurance fraud and could result in the insurance company denying the claim, dropping the physician from their network, and/or, if a government plan, the physician can face imprisonment and fines.

This has resulted in patients becoming angry with their doctor’s offices. Many practices are trying to figure out how to deal with this issue. At my practice, we notify patients before their preventive visit by posting signs on the exam room walls and the medical assistant provides a written notification for the patient to sign that they understand the billing policy. We are also trying to have the physician alert the patient, during the preventive medicine visit, when their concerns become a medical visit and may result in an out-of-pocket expense to the patient. Depending on the severity of the patient’s concern, the physician may be obligated to address the medical issue because, if he didn’t, it could result in a bad outcome for the patient. For example, if the patient states that they have been dizzy and having terrible headaches, this could mean that the patient may have a brain tumor or other significant medical issue. If the physician ignored this complaint, it would harm the patient or could harm others if the patient were driving a vehicle and had an episode. In addition, this would easily become a malpractice lawsuit against the physician.

Some physicians have chosen not to do both a preventive medicine visit and a problem visit on the same day. If the patient is scheduled for a wellness visit and a problem comes up, the physician would either make the decision to change the visit to a problem-oriented visit and reschedule the preventive if the problem is high risk; or have the patient return to deal with the problem issue at a later date if the problem is a low risk. This method keeps the appointments separate and easier for the patient to understand the difference. The downside is that it requires the patient to come back for a second visit, taking additional time off work, to deal with something that could have been handled during one visit.

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FOBT (Fecal Occult Blood Testing) Coding Fact Sheet Sunday, Aug 12 2012 

Erica Schwalm graciously allowed me to post her coding fact sheet for Fecal Occult Blood Testing. Thank you, Erica!

“My office was having a lot of billing errors related to billing for FOBTs so I made this coding fact sheet to help everyone (physicians and coders) out!  Perhaps it will be of some use to some of you as well.  82270 can NOT be billed for FOBT done via DRE, but 82272 can…  I was seeing a lot of providers trying to bill 82270 with wellness visits when they shouldn’t have been and then, on the other hand, I found many “problem” FOBT’s (82272) that were never billed for when they should’ve been.”

Erica D. Schwalm, CPC, CPC-GENSG, CMRS

http://www.ericacodes.com

FOBT (Fecal Occult Blood Testing) Coding Fact Sheet 

There are two types of FOBT – Screening (82270) & Diagnostic (82272)

1.  The SCREENING test is covered yearly for those aged 50 and over.  This is a preventive test done in the absence of any signs or symptoms.

The patient is given “Stool Cards” to take home and collect three consecutive specimens.  When complete, the pt sends the cards in for testing.  Once testing is complete, then we can bill for CPT code 82270Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection).

We cannot bill for the test when the pt is given the cards, only once they are returned and interpreted.

We cannot bill for screening FOBT when done during a rectal exam because only one sample is tested.  This does not meet the qualification for the code.  This method is considered to be included in the payment for the office visit.

The only acceptable diagnosis for this is V76.51 (Screening for colorectal cancer)

 

2.  The DIAGNOSTIC test is covered when medically necessary for signs & symptoms without regard to patient age or frequency limitations.

The patient may be given “Stool Cards” to take home and collect 1 – 3 specimens.  When complete, the pt sends the cards in for testing. Once testing is complete, then we can bill for CPT code 82272Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening.

In some situations, the physician may perform the test during a rectal exam (e.g. pt comes in c/o abdominal pain and tarry stools, physician would need to know immediately if there is active GI bleed).  Unlike code 82270, this one CAN be billed even when only one specimen is tested.

Do not use a v-code.  Use the sign or symptom(s) that prompted the test (e.g. rectal bleed, abdominal pain, etc.)

Never forget your medication information again! Monday, Jul 2 2012 

Most people have phones with cameras now-a-days. To help remember your medications in an Emergency situation, or even simply when you go to your physicians office, take a close-up picture of the prescription bottle! Try to get the medication name, strength, dosage, and prescribing physician in the picture. In addition, it is helpful to know the pharmacy name, pharmacy telephone number and your prescription number. You can also take pictures of your vitamins, supplements and any over-the counter medications that you take.

Many Smart phones allow you to create files, similar to a computer, where you can create a file called “My Prescriptions” and file each picture of your medication into that file.

HHS PROPOSES ONE-YEAR DELAY OF ICD-10 COMPLIANCE DATE Monday, Apr 9 2012 

For Immediate Release: Monday, April 09, 2012
Contact: CMS Office of Public Affairs
202-690-6145

HHS PROPOSES ONE-YEAR DELAY OF ICD-10 COMPLIANCE DATE

(CMS-0040-P)

Action

The Department of Health and Human Services (HHS) today announced a proposed rule that would delay, from October 1, 2013 to October 1, 2014, the compliance date for the International Classification of Diseases, 10th Edition diagnosis and   procedure codes (ICD-10).

The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement.   The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish adopt standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).   OESS is part of the Centers for Medicare & Medicaid Services (CMS).

Background

On January 16, 2009, HHS published a final rule to adopt ICD-10 as the HIPAA standard code sets to replace the previously adopted ICD–9–codes for diagnosis and procedure codes (see HIPAA Administrative Simplification;  Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS,  74 FR 3328). The compliance date set by the final rule was October 1, 2013.

Implementation of ICD-10 will accommodate new procedures and diagnoses unaccounted for in the ICD-9 code set and allow for greater specificity of diagnosis-related groups and preventive services.  This transition will lead to improved accuracy in reimbursement for medical services, fraud detection, and historical claims and diagnoses analysis for the health care system.  Many researchers have published articles on the far-reaching positive effects of ICD-10 on quality issues, including use of specific reasons for patient non-compliance and detailed procedure information by degree of difficulty, among other benefits.

Some provider groups have expressed serious concerns about their ability to meet the October 1, 2013 compliance date.   Their concerns about the ICD-10 compliance date are based, in part, on implementation issues they have experienced meeting HHS’ compliance deadline for the Associated Standard Committee’s (ASC) X12 Version 5010 standards (Version 5010) for electronic health care transactions.  Compliance with Version 5010 is necessary prior to implementation of ICD-10.

All covered entities must transition to ICD-10 at the same time to ensure a smooth transition to the updated medical data code sets.   Failure of any one industry segment to achieve compliance with ICD-10 would negatively impact all other industry segments and result in rejected claims and provider payment delays.   HHS believes the change in the compliance date for ICD-10, as proposed in this rule, would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition among all industry segments.

Provisions of the proposed rule announced today

HHS is proposing to change the ICD-10 compliance date to October 1, 2014.

As stated, the ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement.

Standards compliance date

HHS proposes that covered entities must be in compliance with ICD-10 on October 1, 2014.

The proposed rule, CMS-0040-P, may be viewed at www.ofr.gov/inspection.aspx.

A news release on the proposed rule may be viewed at http://www.hhs.gov/news.

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Congress approves measure averting 27 percent physician cut through 2012 Friday, Feb 17 2012 

Special Edition: SGR Update

Congress approves measure averting 27 percent physician cut through 2012

A House-Senate Conference Committee tasked with identifying a compromise to avoid the pending 27.4 percent Medicare physician payment cut reached a 10-month deal that would maintain current physician payment rates through the end of the year. The measure was approved this afternoon by both the House and Senate. The measure now goes to President Obama for his signature. The President is expected to sign the bill.

HHS announces intent to delay ICD-10 compliance date Friday, Feb 17 2012 

News Release
FOR IMMEDIATE RELEASE
February 16, 2012

Contact: CMS Public Affairs
(202) 690-6145

HHS announces intent to delay ICD-10 compliance date
As part of President Obama’s commitment to reducing regulatory burden, Health and Human Services Secretary Kathleen G. Sebelius today announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).

The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013 – a delay of two years from the compliance date initially specified in the 2008 proposed rule. HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our health care system,” said HHS Secretary Kathleen Sebelius. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our health care data with that of the rest of the world that has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

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I’d rather buy a month’s worth of Starbucks than…pay my doctor bill Wednesday, Jul 6 2011 

One of the biggest frustrations we have in the health care industry is due to patients not understanding their own health insurance benefits. Oftentimes, patients think that just because they carry insurance, that means that everything is covered and they don’t have to pay anything. Patients receive health care service and a month later they discover that their insurance doesn’t cover that particular service; however, instead of accepting the responsibility of paying, many patients fight, demand, and threaten the physician’s office staff to make the balance go away.

This phenomenon has gotten worse in the past twenty years or so. I subscribe to the theory that much of this mentality is due to the inception of HMO’s. In the beginning, HMO’s had either zero patient financial responsibility, or an exceptionally low out-of-pocket cost. People have been conditioned in thinking that health care is an entitlement. After about a decade, due to insurance companies (and employer groups) not being able to withstand the expense of higher utilization of “free” health care, they began to make the consumer more responsible by charging higher co-pays and not covering certain services. Unfortunately, most Americans expect the same Cadillac coverage without any additional expense (beyond their insurance premium and co-pay).

A major challenge in physician practices is to help their patient’s understand their insurance company’s reimbursement policies, all the while maintaining good will. Physicians are finding themselves having to develop various financial informed consent forms to assure that the patient understands that they may be responsible for some of the cost. Medicare has required this, in the form of Advanced Beneficiary Notices (ABN), for years.  Even so, we often hear patients state, “I signed it but didn’t read it.”  Or, “I was afraid if I didn’t sign it that I wouldn’t get the service.” Perhaps the days of accountability are long gone.

One of the biggest threats we hear from patients is that they will leave our practice if we don’t write off their balance. Not much that you can do about that. Health care is a business and we cannot pay the bills with altruism. In addition, it is fraud to bill the insurance company for services and write off the patient’s responsibility. Aside from financial hardship cases, routine adjustments of patient responsibility can get a physician excluded and/or fined by the government when it is a government program such as Medicare or Medicaid. Worst case scenario for commercial insurance is the insurance company dropping the physician from their network.

With lower reimbursements, practices really need to devote more energy in collecting all revenues due. The average overhead for a primary care physician practice is reaching 60%. There are no government subsidies for physicians, other than rural health care, community health care centers and native american health centers. More and more physicians are closing their offices, retiring early, selling their practices to hospitals, transitioning to concierge medicine, or going to cash only practices. This is devastating to primary care because of the physician shortage; however, many specialists are also getting hit hard as well.

Burn Coding/Rule of Nines Monday, Apr 18 2011 

There are several CPT codes related to burn coding that I want to share with you to enhance your coding and reimbursement. These codes refer to local treatment of burned surface area only. When using these burns codes, remember to document percentage of body surface involved and depth of burn. Remember your “Rule of Nines” in calculating Total Body Surface Area!

  • 16000 Initial Treatment, first degree burn, when no more than local treatment is required.
  • 16020 Dressings AND/OR Debridement of partial thickness burns, Initial OR Subsequent; small (less than 5% total body surface area)
  • 16025 Dressings AND/OR Debridement of partial thickness burns, Initial OR Subsequent; medium (e.g. whole face or whole extremity, or 5% to 10% of total body surface area)
  • 16030 Dressings AND/OR Debridement of partial thickness burns, Initial OR Subsequent; large (e.g. more than one extremity, or greater than 10% of total body surface area)

 

These codes can be used in addition to an office visit; however, the office visit must be medically necessary and a modifier -25 must be appended to the office visit. An example of a medically necessary office visit would be to prescribe medications (such as antibiotics and/or pain medication, for example).

Rule of Nines Burn Chart for Adults

Rule of Nines Burn Chart for Infant

Well Child Visit vs. School/Sports/Camp Form completion Tuesday, Feb 22 2011 

Most insurance companies will cover a well-child physical; however, the vast majority will NOT cover a “sport”, “school”, “camp” (etc.) physical.  There are several ways that this can be handled:

1)  If it is time for a well-child physical, perform the normal well-child physical and complete any paperwork during that visit.  The well-child visit should be coded using CPT 9938x-8839x series along with V20.2 diagnosis code.  If the child is eligible for this benefit, the claim should be paid.  Most health plans have a limit of one well-child visit per year.

2)  If the child recently had a well-child check and, if it is possible to complete the form using the information from the recent well-child check, go ahead and complete the form using that information.  This can be done free of charge.

3)  The last option is to have the child come to the office for a visit to complete the form and charge a CPT 9920x-9921x series code with a diagnosis code of V70.3.  The insurance company will NOT pay for this and the visit should be considered “Time of Service”.  The parent should be informed of this fact prior to the visit.

 

AZZ Cardfile Saturday, Jan 1 2011 

Happy New Year!   Many of us make new year’s resolutions and one such resolution that is often made is to get more organized.  I wanted to recommend a helpful computer program that can assist you in creating a database of useful information and to provide easy access to information that you regularly use, both professionally and personally.

Let  me introduce you to AZZ Cardfile:

http://www.azzcardfile.com/

You can download a trial of this program for free and see how other people have used it by looking at collections that have been submitted:

http://www.azzcardfile.com/collections/

There are so many ways that this program can be used and one is only limited by their imagination.  The collections provide some ideas and may be useful to others.  Many people use this program for recipes (ethnic dishes, beverages, desserts, etc.) or a way to create a database of gift ideas.  One thing that I use this program for is to organize my professional letter and form templates for easy reference.

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