As Flu Season Continues Review Claim Reimbursement for Vaccinations

If your office is administering Influenza Virus and Pneumococcal vaccinations, you should review the following information to insure you are submitting the correct diagnosis and procedure codes to receive the proper claim reimbursement. The vaccine procedure code should be chosen based on the description of the drug and the age of the patient. Each vaccine code should be billed with the appropriate administration code as well.

                                                                    

The following procedure and diagnosis codes are used for influenza virus vaccinations:

CPT/HCPCS Code	Description
90654	Influenza virus vaccine, split virus, preservative free, for intradermal use
90655	Influenza virus vaccine, split virus, preservative free, for children 6-25 months of age, for intramuscular use
90656	Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use
90657	Influenza virus vaccine, split virus, for children 6-25 months of age, for intramuscular use
90660	Influenza vaccine, live, for intranasal use
90662	Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use. (High Dose)
Q2034	Influenza virus vaccine, split virus, for intramuscular use (Agriflu)
Q2035	Influenza virus vaccine, split virus, when administered to individuals 3 years of age and above, for intramuscular use (Afluria)
Q2036	Influenza virus vaccine, split virus, when administered to individuals 3 years of age and above, for intramuscular use (Fluluval)
Q2037	Influenza virus vaccine, split virus, when administered to individuals 3 years of age and above, for intramuscular use (Fluvirin)
Q2038	Influenza virus vaccine, split virus, when administered to individuals 3 years of age and above, for intramuscular use (Fluzone)
G0008	Administration of influenza virus vaccine

Diagnosis Code	Description
V04.81	Influenza vaccination with dates of service 10/1/2003 and later
V06.6	Influenza and pneumococcal vaccination (Report this code when the purpose of the visit was to receive both vaccinations during the same visit)

The following procedure and diagnosis codes are used for pneumococcal vaccinations:

CPT/HCPCS Code	Description
90669	Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, for intramuscular use
90670	Pneumococcal conjugate vaccine, 13-valent, for intramuscular use
90732	Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use
G0009	Administration of the pneumococcal vaccine when no physician fee schedule service on the same day

Diagnosis Code	Description
V03.82	Pneumococcal vaccination
V06.6	Pneumococcal and influenza vaccination (Report this code when the purpose of the visit was to receive both vaccinations during the same visit)

CMS has available on it's website numerous resources to assist providers:

Facts on Influenza, Pneumococcal, and Hepatitis B Immunizations: http://www.cms.gov/Medicare/Prevention/Immunizations/index.html?redirect=/Immunizations/

The 2012- 2013 Immunizers’ Question & Answer Guide : http://www.cms.gov/Medicare/Prevention/Immunizations/Downloads/2012-2013_Flu_Guide.pdf

Current pricing information: http://www.cms.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp#TopOfPage

The best way to keep your income stream flowing properly is to prevent claim denials.

You should be aware of the following high volume denial reason codes and prepare a strategy to keep them to a minimum in your practice.

By utilizing an advanced Medical Practice Management Billing Software like Iridium Suite from Medical Business Systems, many of these types of denials will become a thing of the past.

18 - Duplicate claim/service.

Manual keying of services lends itself to duplicate entry of those services.   A configurable Claim Scrubber as found in Iridium Suite will check each service entered and alert the user immediately if the same service is already on record.

    16 - Claim/service lacks information which is needed for
                                  adjudication.

Some payers have specific claim rules that require “non-standard” 5010 format information be included on their claims.  An example is the rendering provider’s Taxonomy code in addition to the standard NPI.  Iridium Suite allows the user to include this specialized data on the claims to those individual payers as needed. 

97 - Payment is included in the allowance for another
                              service/procedure.

Government payers, such as Medicare, as well as the larger Commercial payers have adopted the NCCI standard for “bundled” services.  The Iridium Suite Claim Scrubber comes standard with all current NCCI edits built in.  The Scrubber alerts the user when entering two or more procedures that are considered inclusive of each other.

   29 - The time limit for filing has expired.

Payers each have their own time filing limits guidelines for claim submission.  It can be as short as 60 days, or the current Medicare limit is 12 months.  The sooner you submit your claims, the quicker you will receive your payment and eliminate the risk of untimely filing denials.  With the Connectivity Clearinghouse within Iridium Suite, you can import patient demographic and service data directly into the billing software from your EHR/EMR.  Your patient and charge entry process can be almost completely automated allowing for close to “real time” claims submission for your services.

  50 - These are non-covered services because this is not
                                deemed a ‘medical necessity by the payer.  

                      The key to preventing these types of denials is being aware

                      of your payers Medical Policies. These two Biller’s Blogs 

                      provide insight on both Commercial Payers and Medicare:

Reviewing Commercial Carrier Medical Policies

Understanding Medicare Fiscal Intermediaries LCD's

  140 - Patient/Insured health identification number and
                                  name do not match.

    By utilizing the Real Time Eligibility function in  

    Iridium Suite, you can virtually eliminate denials 

    like the one above or similarly “subscriber not  eligible

    at time of service.”  You will be able to successfully 

    submit charges to the correct active payer with the 

    proper identification number and receive your 

    appropriate claims reimbursement on the first 

    submission.

197 - Payment adjusted for absence of
                                precertification/authorization.

A medical billing software with the ability to indicate payers requiring authorization as well as track a multiple service/visit authorization as it is assigned to the performed procedures is crucial in assisting office staff with this issue.  Iridium Suite provides a specific area in the patient insurance information section to indicate authorization requirements and to record the authorization details.  Before a claim can be submitted, it is scrubbed for authorization requirements and will warn the user if the authorization is missing.  You are unable to submit the claim without the appropriate authorization.

   B15 - Payment adjusted because this procedure/service is
                                   not paid separately.

This denial occurs when submitting a procedure code that is part of a “set” without the accompanying procedure.  A medical billing software, such as Iridium Suite, gives the user the ability to set up special code rules.  The system will warn the user if a particular code is being submitted without the “partner” code, allowing you to correct the claim before submission to the payer.

By being aware of the common denials your practice receives, you can develop the necessary processes to prevent them before they happen. 

Having the best medical practice billing software, Iridium Suite, can give you a head start with its many advanced functions.

                                                                                 

Moving Forward: The Bundled Payments for Care Improvement Initiative

CMS has announced the participants for Models 2 through 4 of the Bundled Payments for Care Improvement Initiative (BPCI). 

Models 2 and 3 involve a retrospective bundled payment arrangement where actual expenditures are reconciled against a target price for an episode of care.   Model 4 involves a prospective bundled payment arrangement, where a lump sum payment is made to a provider for the entire episode of care. 

Over the course of the three-year initiative, CMS will work with participating organizations to assess whether the models being tested result in improved patient care and lower costs to Medicare. 

The implementation of these models has been broken down into two distinct phases:

Phase I:   Referred to as the “no-risk” preparation period has just begun and will continue until July 2013.  During this time, CMS and participants prepare for implementation and assumption of financial risk based on the provider’s final submitted list of their episodes.  Participants can select up to 48 different clinical condition episodes. 

Phase II:   Beginning in July 2013, the “risk-bearing” performance period starts for those participants from Phase I that are ultimately approved by CMS and decide to move forward with implementation and assumption of financial risk.

	Model 2	Model 3	Model 4
Episode of Care	Inpatient stay at acute care hospital plus post-acute period for selected DRGs.	Selected DRG’s for an acute care hospital stay will trigger the episode to begin at initiation of post-acute care services with a participating skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency	Inpatient stay at acute care hospital plus readmissions for selected DRGs.
Bundled Services	The bundle will include physicians’ services, care by post-acute providers, related readmissions, and other related Medicare Part B services included in the episode definition such as clinical laboratory services; durable medical equipment, prosthetics, orthotics and supplies; and Part B drugs.	The bundle will include physicians’ services, care by post-acute providers, related readmissions, and other related Medicare Part B services included in the episode definition such as clinical laboratory services; durable medical equipment, prosthetics, orthotics and supplies; and Part B drugs.	All Part non-hospice A and B services (including the hospital and physician) during initial inpatient stay and readmissions
Service Timeline	The episode will end either 30, 60, or 90 days after hospital discharge.	The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end   either a minimum of 30, 60, or 90 days after the initiation of the episode.	Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount.
Payment Calculation	Retrospective: A target price will be set that will be based on historical fee-for-service payments for the participant’s Medicare beneficiaries in the episode and will include a discount. Payments will be made at the usual fee-for-service payment rates, after which the aggregate Medicare payment for the episode will be reconciled against the target price. Any reduction in expenditures beyond the discount reflected in the target price will be paid to the participant and may be shared among their provider partners. Expenditures that are above the target price will be repaid to Medicare by the participant.	Retrospective: A target price will be set that will be based on historical fee-for-service payments for the participant’s Medicare beneficiaries in the episode and will include a discount. Payments will be made at the usual fee-for-service payment rates, after which the aggregate Medicare payment for the episode will be reconciled against the target price. Any reduction in expenditures beyond the discount reflected in the target price will be paid to the participant and may be shared among their provider partners. Expenditures that are above the target price will be repaid to Medicare by the participant.	Prospective: A single, prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit “no-pay” claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount.

Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners– allowing them to work closely together across all specialties and settings.

The Bundled Payments for Care Improvement initiative will test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of care for beneficiaries.

2013 Orthopedic Surgery CPT Code Changes and Additions

These are the highlights of the seven CPT code changes and a listing of numerous CPT code additions affecting Orthopedic Surgery billing in 2013.  Make sure you review the full CPT manual for complete details of all coding changes to insure you receive your optimum claim reimbursements.
                                                         
Spine CPT

Guideline Change: CPT codes 22633 and 22634 may be appropriately related as primary or index codes for spine bone grafts (20930–20938), instrumentation (22840–22844, 22848, 22845–22847), and intervertebral device (22851) codes. 

 Bone marrow aspirate

Clarification: Use of bone graft codes (20930–20938) related to bone marrow aspiration. CPT code 38220 defines the work associated with the harvest of bone marrow for bone grafting only. (Billing Note: Category III code 0232T should be used when bone marrow aspiration is performed for platelet-rich stem cell.)

Cervical Spinal Arthrodesis Guideline

Guidelines Added:  CPT codes 22554, 22585, 63075, and 63076; if the work associated with these procedures is performed during the same surgery by the same surgeon or by two separate surgeons/individuals during the same session, the correct codes are 22551 and 22552. (Billing Note: CPT codes 63075 and 22554 may not be unbundled and reported for the same patient, same session.)

Cast application

Guideline Change:  Refer to the section “Application and Strapping” for specific changes regarding the application of the first cast, its removal, coding by the individual who performs the initial service, and restorative management. (Billing Note: CPT code 29590 (Denis-Browne bar (splint) with manipulation and casting (eg, for metatarsus adductus, clubfoot) was deleted.)

Hip arthroscopy

Clarification: CPT code 29916 (Arthroscopic labral repair of a torn labrum) is considered inherent to CPT codes 29915, 29862, and 29863. (Billing Note:  CPT code 29916 should not be reported in addition to CPT codes 29915, 29862, or 29863 because the repair is already included in these codes, whether as a takedown and repair or a repair of an already torn labrum.)

Chemodenervation

Guideline Change:   CPT code 64614 (Chemodenervation of muscle(s); extremity and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis) may only be reported once per extremity. The parenthetical (s) was removed from extremity. (Billing Note:  CPT code 64614 states that modifier 50 should not be appended to this code. Check with your payers to determine specific rules to code submission.)

Intraoperative nerve monitoring

Clarification: Intraoperative nerve monitoring by the operating surgeon is included in the primary surgical service and is not separately reportable.

Update your medical billing system with the following new CPT codes for 2013:
Spine

22586—Arthrodesis, pre-sacral inter-body technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace

0309T—Arthrodesis, pre-sacral inter-body technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (Billing Note: List 0309T separately in addition to code for the primary procedure 22586)

Shoulder Arthroplasty

23473 - Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component.

23474 - Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component.

Elbow Arthroplasty

24370 - Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component.

24371 - Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component.

Nerve Conduction

(Billing Note:  Guideline instructions related to the reporting of electromyograms (EMGs) and nerve conduction studies (NCS) are found in the beginning of their respective CPT sections.)

 CPT codes 95900–95904 were deleted and replaced by the following CPT codes: 

95907—Nerve conduction studies; 1–2 studies

95908—Nerve conduction studies; 3–4 studies

95909—Nerve conduction studies; 5–6 studies

95910—Nerve conduction studies; 7–8 studies

95911—Nerve conduction studies; 9–10 studies

95912—Nerve conduction studies; 11–12 studies

95913—Nerve conduction studies; 13 or more studies

Extracorporeal Shock Wave: Wound Healing

Two new Category III codes for extracorporeal shock wave for wound healing were introduced:

0299T—Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound

0300T—Each additional wound (Billing Note:  List separately in addition to code for primary procedure.)

With Iridium Suite practice management software, you can take the worry away from all of these changes.   This medical billing software is loaded with all current CPT I, II, III and HCPCS Level II codes as well as the NCCI edits.  It also has the Claim Scrubber function, allowing you to create special billing rules so you don’t forget to bill those “companion” codes.

                                                                                      

Electronic Health Record (EHR) and Medical Billing Systems

An EHR must not only record your patient data electronically, but should be certified for meaningful use by CMS. Once you select a certified system, this gives you the potential to earn financial incentives from CMS by providing the required proof of meaningful use.

                                                                                  

Integrating multiple systems can enhance your work environment and improve efficiency. Your billing and coding software should be able to directly import medical data such as patient demographics from your EHR. This type of integration will eliminate the need for re-entry of patient data into the billing system by office staff.

Iridium Suite medical billing software now comes with the Connectivity Clearinghouse enabling connections to multiple EHR systems. You can connect to your EHR as often as your office work flow dictates. With accurate and complete data entry in your EHR, you are able to bring in all the necessary information to bill and file your patient claims. 

The Connectivity Clearinghouse can use multiple protocols such as: LLP, HTTPS, and SFTP. It can also be extended to use multiple data formats such as: multiple versions of HL7, any well formed XML and delimited text.

The versatility of the Connectivity Clearinghouse in Iridium Suite practice billing software provides the foundation to integrate with your existing Electronic Health Record, saving your practice time and money.