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Welcome to PMI’sWebinar Presentation

Brought to you by:Practice Management Institute®

pmiMD.com

On the topic:

Master Challenging Billing Hurdles

Meet the Presenter…

Lisa Maciejewski-West, CMC, CMIS, CMOM, CPCO

Welcome to Practice Management Institute’s Webinar and Audio

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MASTER CHALLENGING BILLING HURDLES

Presented By Lisa Maciejewski-West, CMC CMIS CMOM CPCO

FACULTY: Practice Management Institute

THE DREADED DENIALS

CO-50 CO-4 CO-97 CO-11

CO-16 CO-29 CO-96 and ON and ON and ON…….

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Practice Management Institutewww.pmiMD.com

Webinar/Audio ConferenceSeptember 05, 2019

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TOUCH A CLAIM ONCE

• DENIALS COST MONEY…even if the claim eventuallygets paid

• Increased Practice Overhead

• Time Constraints “I just don’t have time to follow up on these denials”

• Miss the timely rebill/appeal window

• Chasing unpaid claims can put current claims on hold; miss timely filing

• Staff members who are not trained on proper billing and follow up get unfavorable response on appeal

• Provider frustration leads to burnout, less productivity

GET IT RIGHT THE FIRST TIME

• Vet the codes

• Accurate demographics

• Accurate eligibility checks

• Preauthorizations/Predeterminations obtained (if applicable)

• Spend more time on the billing, less time on the follow up

• Don’t be afraid to hold a claim back; don’t let claims with errors leave the building

• Keep an eye on your time (timely filing)

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UNDERSTANDING DENIALS

• Learning how to “read” an EOB/Remit is the key to proceeding with efficient denial management.

• The denial/reduction code will tell you what the issue is, and if there is anything you can, or should do about it.

• If you don’t understand what the denial/reduction code means, or it’s not clear on the remit, CALL the payer for guidance.

CARC/RARC CODES

• CAGC – Claim Adjustment Group Code

• CARC – Claim Adjustment Reason Code

• RARC – Remittance Advice Remark Code

All these code sets and more can be found on the Washington Publishing Company website http://www.wpc-edi.com/reference/ These code sets are used by Medicare/Medicaid and most commercial payers to describe activity of a claim.

The lists are maintained by the Centers for Medicare and Medicaid Services (CMS), The National Uniform Claim Committee (NUCC), and committees that meet during standing X12 meetings.1

1http://www.wpc-edi.com/reference/

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Claim Adjustment Group CodesDid you receive a code from a health plan, such as: PR32? The "PR" is a Claim Adjustment Group Code and the description for "32" is to the left. The Claim Adjustment Group Codes are internal to the X12 standard. These codes generally assign responsibility for the adjustment amounts. The format is always two alpha characters. For convenience, the values and explanations are below:2

CO Contractual Obligation

CR Corrections and ReversalNote: This value is not to be used with 005010 and up.

OA Other Adjustment

PI Payer Initiated Reductions

PR Patient Responsibility

2http://www.x12.org/codes/claim-adjustment-reason-codes/

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COMMON DENIALSCO-50 “NOT MEDICALLY NECESSARY”

Not Medically Necessary “by the payer” is the key to understanding this denial – this means that the payer has defined medical necessity in the form of a guideline or white paper. Find the guideline for clues to the denial. The majority of the time CO-50 denials are due to diagnosis coding issues.

PARTIAL LIST

EXAMPLE – Trigger Point Injections. Excerpts of Payer guideline from BCBS IL

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EXAMPLE – Trigger Point and Tendon Sheath Injections. Excerpts of Payer guideline from BCBS IL

CO-50, CO-55

CO151 Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

COMMON DENIALSCO-4 “MODIFIER ERROR”

Modifier Errors: Most answers to Modifier errors can be found under the National Correct Coding Initiative Edits (NCCI). NCCI edits help determine if a pair of codes requires a modifier on one or both codes. Sometimes informational modifiers are missing, ie: -RT –LT. Sometimes payers have “local” edits that require you to use a modifier with code pairs that are not in the NCCI edits.

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Understanding what the payer wants is half the battle. Always check with your payers to find out whether they follow standard billing and coding rules, or whether they have “local” edits that supercede NCCI

Example from BCBS TX

DOES “CO” MEAN WRITE IT OFF?

• NO!

• A “CO” – Contractual Obligation beside a CARC code means that the provider is required to take action. Sometimes the action would be a write off, i.e., CO-45, Adjusted amount due to legislated/negotiated fee schedule.

• Sometimes a CO + CARC means a rebill or an appeal

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REBILLS – DO I AUTOMATICALLY FILE A CORRECTED CLAIM?

• NO! The payer determines how claims are to be appealed and/or rebilled.

• Understand the difference between a REJECTED claim and a DENIED claim

• A rejected claim is a claim with billing or submission errors that has prevented it from being accepted by the payer. Rejected claims can be fixed and reprocessed CO-16.

• A denied claim is a claim that was accepted for adjudication by the payer, but was not billed according to the correct guidelines, or not billed in a timely manner. Contact payer for instructions on how to file corrected claims or appeal a denial.

TIMELY FILING DENIALS- ARE THEY WORTH FIGHTING? CO-29

• Payers will usually provide guidance on what would overturn a timely filing denial.

• Make sure you know what the timely filing and appeal guidelines are for each payer you do business with.

• In most cases, a claim that has been REJECTED is considered to never have been filed. Until the rejected claim is fixed and rebilled, you are on the hook for TF.

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E X C E R P T F RO M

B C B S T X O N T F

A P P E A L S

BILLING CHALLENGE - GLOBAL BILLING

• Global Billing has its own set of billing and coding challenges.

• Global Billing is driven by Procedure/Diagnosis and Time

• A certain procedure for a certain dx will be under a global billing rule for a certain amount of time

• Any services relating to the procedure and dx during the Global period will not be separately reimbursable.

• Certain Specialties/Procedures deal with Global Billing more than others

• OB/GYN

• Surgical Procedures

• Make sure you understand the global billing rules for the various services and procedures you perform.

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WHAT IF I NEED TO BILL FOR SOMETHING DIFFERENT DURING A

GLOBAL PERIOD?

• You must show the payer that the service/item you are billing for is NOT RELATED to the service/item covered under the Global/Postoperative period.

• May need to indicate a DIFFERENT dx (Bill E/M with Mod -24)

• Sometimes a service provided under the Global relates to the Global procedure but is over and above the normal services provided under the Global package.

• EXAMPLE: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period (Bill Procedure with Mod -78)

• Global Surgery Modifiers 24,25,57,58,59,78,79

BILLING CHALLENGE – BILLING FOR MID LEVEL PROVIDERS

• BIGGEST CHALLENGE IS KNOWING WHEN YOU SHOULD OR SHOULD NOT USE THE MID LEVEL PROVIDER’S NPI AS THE RENDERING PROVIDER IN BOX 24J OF THE CMS-1500 CLAIM FORM

• Most of the time you will use the mid-level (NP/PA) NPI in box 24J. Exception would be under the MEDICARE incident-to rules, which state that you may use the SUPERVISING PHYSICIAN’S NPI in 24J for certain procedures/E-M Services. BUT the S.P. must be IN THE BUILDING. If S.P.’s NPI is used, Medicare will pay at 100% of the Medicare Fee Schedule. If Mid Level’s NPI is used, Medicare will reimburse at 85%.

• SOME Commercial Payers will follow the Medicare Incident-to rules, but not all. Check payer guidelines.

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BILLING CHALLENGE – BILLING FOR LOCUM TENENS (COVER DOCTOR)

What does locum tenens mean?

• A locum is a person who temporarily fulfills the duties of another.

• EXAMPLE: a locum physician is a physician who works in the place of the regular physician when that physician is absent, or when a hospital/practice is short-staffed. These professionals are still governed by their respective regulatory bodies, despite the transient nature of their positions.

• The Centers for Medicare and Medicaid Services (CMS) has stated that a locum tenens physician can provide services to Medicare patients over a continuous period of no longer than 60 days. The only exception given was if the regular physician was called for active duty in the Armed Forces.

• Locum Tenens billing guidelines are only applicable to Medicare. You must check with your commercial payers to see if they have adopted those guidelines.


• LOCUM TENENS BILLING is allowed if:

• The regular physician or physical therapist is unavailable to provide the service.

• The Medicare beneficiary has arranged or seeks to receive the services from the regular physician or physical therapist.

• The regular physician or physical therapist pays the substitute for his/her services on a per diem or similar fee-for-time basis.

• The substitute physician or physical therapist does not provide the services to Medicare patients over a continuous period of longer than 60 days. The only exception is when the regular physician is called for active duty in the Armed forces.

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• The 60-day count would start on the first day the locum tenens physician sees a patient and not when the regular physician took their absence.

• Modifier Q6 (service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area) is appended after the CPT code

• If the only services a locum physician performs in connection with an operation are postoperative services furnished during the period covered by the global fee, these services need not be identified on the claim as services furnished by a substitute physician.

• The absent provider may return to the practice for a brief period of time, which would reset the 60-day window and allow you to reuse the same locum tenens physician or contract for a new locum tenens physician for an additional 60-day engagement. (This process can be repeated for as long as necessary.)

LOCUM TENENS – BEYOND 60 DAYS

• Sometimes you know that the Locum relationship will have to extend past 60 days.

• Upon acquisition of a locum tenens provider, begin enrolling him/her in the organization’s contracted payer mix (Medicare, Medicaid, commercial payers, etc.) prior to their start date or as soon as possible upon starting. At the end of the Medicare 60-day window, you would then bill under the locum tenens physician NPI number as if they were a permanent physician.

• Try to have the absent provider return for a few days. That will reset the 60-day clock.

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THANK YOU FOR YOUR PARTICIPATION!

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