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TOMA Practice Management “Tips and Tricks to Getting Paid” WELCOME.

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Presentation on theme: "TOMA Practice Management “Tips and Tricks to Getting Paid” WELCOME."— Presentation transcript:

1 TOMA Practice Management “Tips and Tricks to Getting Paid” WELCOME

2 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 # 1

3 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 # 2

4 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 # 3

5 What is the penalty for NOT having an EHR by 2019? A: 1% B: 2% C: 3% D: 5% PRE-QUESTION # 4

6 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 PRE-QUESTION # 5

7  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

8  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. GETTING PAID

9 EMPLOYEE BONUSES

10  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) WELCOME TO MEDICARE PHYSICAL (IPPE EXAM)

11  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) INITIAL ANNUAL WELLNESS VISIT

12  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) SUBSEQUENT ANNUAL WELLNESS VISIT

13  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 OVERVIEW OF MEDICARE PHYSICALS

14  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) ADDITIONAL CODES FOR IPPE EXAM OR INITIAL AWV EXAM (OPTIONAL)

15 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. CODING ALERT !!!!!!!!!!!!!!!

16 HIGH – RISK FEMALE PATIENT VS LOW – RISK FEMALE PATIENT MEDICARE WELL WOMAN EXAM

17 What is considered High – Risk ?  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

18  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

19  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) MEDICARE - WELL WOMAN EXAM

20  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. INFLUENZA A & B SCREENING

21  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 PSYCHOTHERAPY MANAGEMENT CODE

22 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) POWER MOBILITY EVALUATION

23 20552 - Injection(s);single or multiple trigger point(s), 1 or 2 muscle(s) Key Words : Single or Multiple (can bill only one unit) TRIGGER POINT INJECTIONS

24 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. PR-22 MEDICARE DENIAL CODE

25 36415 – venipuncture 81002 – UA Aetna bundles these with office visit. If you will add a 25 modifier to Office visit, they will pay all. AETNA BUNDLING

26 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. INJECTION ADMINISTRATION

27 ** New requirements for 5010 Unit Measurement codes are: F2- International Unit GR- Gram ML- Milliliter UN – Unit ** www.Calculateme.comwww.Calculateme.com INJECTABLE MEDICATIONS

28 NDC numbers have to be converted from a 10 digit code to an 11 digit code: 4-4-2 *####-####-## (add zero in 1 st position) 5-3-2 #####-*###-## (add zero in 6 th position) 5-4-1 #####-####-*# (add zero in 10 position) NDC NUMBER CONVERSION

29  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 B COVERED VACCINES

30  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.mytransactrx.com  www.checkcoveragenow.com – Private insurance and Medicare Part D verification www.checkcoveragenow.com MEDICARE PART D VACCINES

31 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 PREVENTATIVE CARE CODES (INSURANCE)

32 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

33 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-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM7791.pdf) ANNUAL ALCOHOL SCREENING – MEDICARE

34  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) ) ALCOHOL/SUBSTANCE ABUSE INTERVENTION CODES

35  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) SMOKING CESSATION CODES

36 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

37  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 INTENSIVE BEHAVIORAL THERAPY FOR OBESITY

38 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/Medicare- Learning-Network- MLN/MLNMattersArticles/downloads/MM7637.pdf ANNUAL DEPRESSION SCREENING - MEDICARE

39  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 ANNUAL DEPRESSION SCREENING - MEDICARE

40 TEXAS MEDICAID CO-PAY CODES CP001 – Private HMO Copayment CP002 – Private PP0 Copayment CP003 – Medicare HMO Copayment CP004 – Medicare PPO Copayment Reimbursement $ 10.00

41 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 !! MEDICARE/MEDICAID PATIENTS

42 Are you having trouble getting paid for an Ingrown Toenail Removal? INGROWN TOENAIL

43 : TA Left foot, great toe FA Left hand, thumb T1 Left foot, second digit F1 Left hand, second digit T2 Left foot, third digit F2 Left hand, third digit T3 Left foot, fourth digit F3 Left hand, fourth digit T4 Left foot, fifth digit F4 Left hand, fifth digit T5 Right foot, great toe F5 Right hand, thumb T6 Right foot, second digit F6 Right hand, second digit T7 Right foot, third digit F7 Right hand, third digit T8 Right foot, fourth digit F8 Right hand, fourth digit T9 Right foot, fifth digit F9 Right hand, fifth digit INGROWN NAIL MODIFIERS

44  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. MODIFIERS

45  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

46  PQRS – (formally PRQI) Physician Quality Report System (2011 – 1%)  PCIP – Primary Care Incentive Program (10%) http://www.trailblazerhealth.com/Tools/PCIPEligibility.aspx http://www.trailblazerhealth.com/Tools/PCIPEligibility.aspx MEDICARE INCENTIVE PROGRAMS

47 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) E-RX NOTICE

48 First Year2011201220132014 201118,000-------------- ------------- 201212,00018,000--------------------------- 2013 8,00012,00015,000------------- 2014 4,000 8,00012,000 2015 2,000 4,000 8,000 2016 2,000 4,000 44,000 39,00024,000 EHR INCENTIVE PAYMENTS

49 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 EHR INCENTIVE PENALTIES

50 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 PQRS INCENTIVE BONUSES & PENALTIES

51 Claim Information  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)

52  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)

53 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)

54  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). INTERACTIVE VOICE RESPONSE (IVR)

55  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.comwww.practicefusion.com HELPFUL TOOLS

56 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 # 1

57 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 # 2

58 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 # 3

59 What is the penalty for NOT having an EHR by 2019? A: 1% B: 2% C: 3% D: 5% PRE-QUESTION # 4

60 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 PRE-QUESTION # 5

61 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 CONTACT INFORMATION


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