pathology modifiers

CPT Modifier 90

Reference Lab - Used to indicate a lab test sent to an outside lab. e.g., lab procedure performed by a party other than the treating or reporting laboratory. NOTE: Outside lab name, address and UPIN must be included on the claim. Section 20 must be marked "yes" and your actual cost for each test, net any discounts, must be included in the charges section.


CPT Modifier 26

Professional component only - Use to indicate that the physician component is reported separately from the technical component for the diagnostic procedure performed


CPT Modifier GH
Diagnostic mammogram converted from screening mammogram on the same day.


CPT Modifier QP
Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT
recognized panel other than automated profile codes


CPT Modifier QR
Repeat clinical diagnostic laboratory test performed on the same day to obtain subsequent reportable test value(s) (separate specimens taken in separate encounters)


CPT Modifier QW
CLIA waived test


CPT Modifier TC
Technical component only - Used to indicate that the technical component is reported separately from the professional component for the diagnostic procedure performed

use of 26 and TC modifiers

use of modifiers 26 and TC

Recently Palmetto GBA has noticed a number of diagnostic services being filed on the same day by different providers. In some of these instances one provider has filed for either the professional or the technical component while the other provider has filed a global charge. It is important to make sure you only file for the portion of the services you rendered.

If you are billing for the interpretation or the technical component of a diagnostic procedure, p lease ensure that you use the appropriate modifier. If you are performing the professional component of a service you should indicate this by using the 26 modifier. If you are performing the technical component of the service you will need to indicate this using the TC modifier. Please note that only one service for each component is appropriate per service and absence of a modifier indicates a global service and failure to utilize the appropriate modifier will result in an overpayment made to your office.

modifiers used with E/M codes (EVALUATION AND MANAGEMENT modifers)

CPT modifier 21

Prolonged evaluation and management services - Use only with highest level of care code for the category when the face-to-face or floor/unit service provided is prolonged or otherwise greater than that usually required for the highest level code.

CPT modifier 24

Unrelated E/M service during a post-op period - Use with E/M codes only to indicate that the E/M performed during a postoperative period for a reason(s) unrelated to the original procedure. Modifier 24 applies to unrelated E/M services for either a MAJOR or MINOR surgical procedure.- Failure to use modifier when appropriate may result in denial of the E/M service

CPT modifier 25

Separately identifiable service on same day as procedure - Use with E/M codes only to indicate that the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual pre- and postoperative care for the procedure performed- Failure to use modifier when appropriate may result in denial of the E/M service

CPT modifier 57

Decision for surgery - Use with E/M codes billed by the surgeon to indicate that the E/M service resulted in the decision for surgery (E/M visit was NOT usual pre-operative care). For E/M visits prior to MAJOR surgery (90 day post-op period) only.- Failure to use modifier when appropriate may result in denial of the E/M service.

collection agency

Some times patient may not be able to pay full payment of co-pay dues,
co-insurance dues, Deductible dues or any balance mentioned by insurance.
They would be ready to pay their dues in installments i.e. monthly fixed payments. Making the patient to come under Budget Payment System for paying their dues in installments is called as Budget Payment.

AR people have to discuss with their Supervisors and as per their discussion, they need to put the patient into monthly installment payment schemes.
They should clearly state that this arrangement to minimize the patient’s
burden and patient should not stop any monthly payments to the Doctors
Office.

We need to keep those patients in a separate Bill Cycle or in separate credit
status and a Control Log to be maintained all relevant patient details. If the patient does not pay their dues properly , then we need to inform the patient that their accounts would be moved to Collection Agency.

Moving Patients to Collection Agency

If the patient does not make any payment for his dues and not giving proper response for the calls, not attending calls, always stating that patient is not in the station and refusing to pay dues, then Billing office would be sending two bills to the patient and after 60 days, if there is no response, then thepatient account would be moved to Collection Agency.

After identifying the patient accounts which are to be moved to Collection agency, an excel spread should be prepared and sent to US office for approval. Once approval is received from US Office, then the patient account can be moved to internal collection agency or external collection
Agency. This process should be followed at the time of each and every patient is to be moved to collection agency.

There may be an internal collection agency or an external collection agency.
Their main function is to trace the patient and compel the patient to pay the dues or inform the patient that they may have to face legal action.

Internal Collection Agency would be setup by Billing office itself and they would send letters to patient requesting them to pay or there may be a legal action against them. There would not be any percentage or any share for the internal collection agency if they collect money from
patient. But in External Collection Agency, if they get payment from patient, then they would get approximately 35% of the collected money. The percentage is varies from collection agency to collection agency.

Normally Billing Office may not have their own Collection Agency. Because collection agency require more man power, need to spend more time, need to have people in various places and need to spend more money for searching patients, etc. So most of the billing offices hire the External Collection Agency and handover their accounts to them.

After handing over the accounts to Collection Agency, patients account balance would be changed as Zero and the balance would be moved to collection Account in the system. Once the payment is received then the balance would be retrieved in the patient account and payment would be
Applied.

capitation

A physician gets paid a specified dollar amount, for a given time period, to take care of the medical needs of a specified group of people.

Often used in Health Maintenance Organization (HMO) Insurance Plans and became prominent in the 1980s and 90s.

For example,

1. A physician is an HMO provider for a health plan paid at a capitation rate of $7.00 per member
2. People who have an HMO plan are required to select a primary care physician, by reviewing a list of physicians in a directory. This physician has been selected by 250 people to be their PCP
3. This physician gets paid $7.00 for each of the 250 members, or $1,750.00, each month
4. This physician is responsible for providing medical care to any of these 250 people with the $1,750.00 given
5. If the expenses are more than $1,750.00, the physician must cover the difference out of their own pocket

In other words, there is risk involved. The $1,750.00 capitated payment is the only amount the physician will receive from the health plan. Hypothetically, if each visit costs the physician an average of $110.00 (time, nursing, supplies, fixed costs, etc.), then the physician is able to see 16 of these 250 patients during a given month. If the physician sees more than 16 patients, then the physician is not able to cover the costs incurred for the month, and consequently, begins to lose money from this health plan contract.

Does this payment methodology encourage the physician to do less? Yes because they receive only a specified dollar amount each month to perform medical services to a group of people. Fee-for-service, on the other hand, continues to pay for each patient seen, without a specified limit. A physician may actually be encouraged to bill more to receive additional payments. (HMOs are often associated with Capitation, while PPOs commonly use the fee-for-service method).

medicare tips

Claim Status:

Wait for the 14 day electronic and 29 day paper payment floor before calling-use the IVR system.

Remittance Advice:

Group Code meanings to assist providers in reading remittance advices
Payment Calculation
Medicare payment at 80% of the allowable, minus deductibles for a participating provider. Example: Charge $120Allowed $100Medicare Paid (80%) $80Deductible/coinsurance amounts $20 (20%)

PR Patient Responsibility:

This signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary's behalf. The PR codes are used with the reason codes.· Patient deductible or coinsurance· Patient assumed financial responsibility for a service not considered reasonable· Cost of therapy or psychiatric services after the coverage limit has been reached· Charge denied because of the patient's failure to supply primary payer or other information· Patient is responsible for payment of excess non-assigned physician chargesCharges that have not been paid by Medicare and/or are not included in a PR group, such as a late filing penalty (Reason Code B4), excess charges on an assigned claim (Reason Code 42), services that are not reasonable and necessary for care (Reason Code 50 or 57), etc., are the liability of the provider. Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code.

CO Contractual Obligation:

This includes any amounts for which the provider is financially liable, such as participation agreement violations, assignment amount violations, excess charges by a managed care plan provider, late filing penalties, or medical necessity denials/reductions. The patient may not be billed for these amounts.

OA Other Adjustment:

This would only be used if neither PR nor CO applied. At least one PR, CO or OA group will appear on each remittance statement. Neither the patient nor the provider can be held responsible for any amount classified as an OA adjustment.

Consultation Code Update

UnitedHealthcare is aware of and has reviewed the Centers for Medicare and Medicaid Services’(CMS) decision as of January 1, 2010 to no longer reimburse physicians for CPT consultationcodes 99241-99245 or 99251-99255.

In summary, CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and managementcode (99201-99215 or 99381-99397) rather than a consultation code for Medicare claimsdepending on the status of the patient (new vs. established).

Per CMS, a physician who sees a patient in the hospital should bill an "initial hospital care" code(99221-99223) for the first visit for Medicare claims. The admitting physician will addmodifier AI to their initial hospital service allowing the Medicare Administrative Contractor (MAC)to differentiate between the admitting physician and other physicians providing care. Allphysicians should use the subsequent hospital care codes (99231-99233) for their follow-up care.

Likewise, per CMS, a physician who sees a patient in a skilled nursing facility should bill an “initialnursing facility care” code (99304-99306) for the first visit for Medicare claims. The admittingphysician will add modifier AI to their initial nursing facility care service, allowing the MAC toidentify the physician as the admitting physician of record who is overseeing the patient’s care.

All physicians should use the subsequent nursing facility care codes (99307-99310) for theirfollow-up care.

CPT codes 99241-99245 and CPT 99251-99255 have a status indicator of “I” in the January 2010National Physician Fee Schedule. The status indicator of “I” is defined as:

“I” = Not valid for Medicare purposes. Medicare uses another code for reporting of, and paymentfor, these services.

For UnitedHealthcare commercial plans, there will be no change in reimbursement for CPT codes 99241-99245 and 99251-99255 at this time. Physicians may continue to submit claims for these services, and will be reimbursed according to UnitedHealthcare payment policies.

For UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP®MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, theseplans will follow CMS regulations and implement the change, effective January 1, 2010. Thechange also includes the revalued relative-value units (RVUs) for E&M CPT codes and a newcoding edit, consistent with CMS, to deny the CPT consult code as a non-payable service.

For AmeriChoice Medicaid health plans, in state Medicaid plans that follow Medicare rules fortheir fee schedules, AmeriChoice will be aligning with CMS and implement the change, effectiveJanuary 1, 2010. For all other Medicaid states, AmeriChoice will follow the UnitedHealthcarecommercial position and continue to pay for the consult codes, until directed by each state topursue other strategies.

Medical coding Basic

When billing for a patient’s visit, codes are selected that best represent the services furnished during the visit. The two common sets of codes that are currently used are:

1. Diagnostic or International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) codes; and

2. Procedural or American Medical Association Current Procedural Terminology (CPT) codes.

These codes are organized into various categories and levels. It is the physician’s responsibility to ensure that documentation reflects the services furnished and that the codes selected reflect those services. The more work performed by the physician, the higher the level of code he or she may bill within the appropriate category. The billing specialist or alternate source reviews the physician’s documented services and assists with selecting codes that best reflect the extent of the physician’s personal work necessary to furnish the services.

ASC modifier - SG

Ambulatory Surgery Centers modifier - SG

Every ASC must file using the surgery code with the SG modifier. This identifies you are filing for the facility fee. If you file without the SG modi fier you may receive the fee schedule amount for the surgery instead of the payment from the group rate for the facility fee This is sometimes much lower than the facility fee and it will cause the surgeon ’ s claim to deny. You would have to file a first line appeal to have the SG modifier added and receive any additional payment due to you. You will only be paid for services that the Centers for Medicare and Medicaid (CMS) approved as an ASC service. These updates are published yearly as they are received from CMS. Code 69635SG allows $957.36 (Richland and Lexington Counties), but when filed without the SG (69635) it allows $826.74.


Please refer your local Medicare program since it was deleted modifier in some states.

ASC modifiers - AMBULATORY SURGICAL CENTER MODIFIERS

AMBULATORY SURGICAL CENTER MODIFIERS

73 - Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia
74 - Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia
SG - Ambulatory Surgical Center (ASC) Facility service

Medicare and its plans

Medicare advantage plan are run by private companies and approved by CMS. Usually employer provide these plan for more coverage than Medicare. In this scenrio all your claims covered by Medicare advantage plan. Medicare and Medigap will not pay your claims.
The only problem in the Medicare advantage plan is patient has to see the PCP before see other doctors. In other words referral will be integeral part here

List of Plans:

Medicare Health Maintenance Organization (HMOs)Preferred Provider

Organizations (PPO) Private Fee-for-Service Plans

Medigap and how does it work

Crossover insurance companies are insurers that provide secondary insurance plans and participate in the crossover program. Claims are automatically crossed over (for both participating and non-participating providers) when eligibility information is forwarded to Medicare from the plans that participate. There is nothing you need to indicate on the claim form. The Provider Remittance Notice will show a message that will tell you that the claim information has been forwarded to the secondary insurer.

The big advantage is we don't need to send the secondary claims.

A Medigap policy is an individual health benefit plan offered by a private insurance company to supplement Medicare. It provides reimbursement for charges not payable because of deductible, coinsurance or other limitations. For participating providers, Medicare will send payment information directly to Medigap insurers if the appropriate information is provided on the 1500 claim form.

There 12 different Medigap policies are available from A to L. Each policy has their own rules and benefits. Check the benefits of Patient Medigap policy before submitting the claims. Patient has to pay separate
premium for this insurance also.

Abbreviations used in Medical billing and coding

Abbreviations used in Medical billing and coding

EOB - Explanation of benefits
COB -Co-ordination of Benefits
MSP - Medicare as a Secondary Payer
POS - Place of service
TOS - Type of Service
DOS - Date of service
ICD - 9 -International Statistical Classification of Diseases and Related Health Problems
HCPCS - Healthcare Common Procedure Coding System
CPT - Current procedural Terminology
RBRVS - The Resource Based Relative Value Scale
RVU - Relating Value Unit
CHAMPUS - Civilian Health and Medical Program of the Uniformed Services
CHAMPVA - Civilian Health and Medical Program for the Veteran Administration
EIN - Employer Identification Number
ESRD - End-Stage Renal Disease
FICA - Federal Insurance Contributions Act
HICN - Health Insurance Claim Number
OBRA - The Omnibus Budget Reconciliation Act
CF - conversion factor
EGHP - Employer Group Health Plan
QMB - Qualified Medicare Beneficiaries
UCR - Usual, customary and reasonable
PCP - primary care physician
HMO - Health Maintenance Organization
PPO - Preferred Provider Organization
TPA - Third Party Administrators