Thursday, December 19, 2013
Tuesday, December 17, 2013
Take a Look at What is Coming for Radiation Oncology Billing in 2014
In Radiation Oncology, technology usually evolves faster than the
billing codes that represent the services. Below you will find coding
changes slated to take effect January 1, 2014.
77295 is a perfect example of coding lagging behind technology. It was originally lumped in with the actual “hands-on” patient physical simulation codes, 77280-77290. Those of us that have been billing in radiation oncology have just “overlooked” its misplacement for many years. We are aware that this code represents the “behind the scenes” work performed by the physics and dosimetry staff in conjunction with the physicians in planning a 3D treatment course.
The AMA
has decided that 77295 will be officially moved to the Medical
Radiation, Physics, Dosimetry, Treatment Devices and Special Services
subsection of the CPT book (CPT codes 77300–77370). The descriptor has
been revised to reflect this change:
Note: This change should have no effect on the circumstances of when this code should be billed.
Other
revisions have been done to all the other established simulation codes
77280-77290. This is also is keeping with the ever changing technology
of radiation therapy.
Process
changes made in the performance of simulations required redefining the
levels of complexity in ways that reflect the real added work performed
by radiation oncologists. Also the references to ports, blocks, etc.
have been removed. Now the level of coding is based on the number of
“Treatment Areas”.
A
treatment area is a contiguous anatomic location, such as primary tumor
organ or the resection bed and applicable lymph nodes that will be
treated with radiation therapy.
The descriptors have been revised to reflect this change:
Note: This change also bundles the CT Simulation, so the technical charge of acquiring the CT (CPT code 77014 TC) will no longer be reported separately for simulation.
CPT code +77293, a new add-on code was created. This new code describes
the physician work and resources involved in acquiring a respiratory
correlated or ‘4-D’ CT simulation study for conformal planning. The plus
(+) symbol in front of the code number indicates that this is an add-on
code. Add-on codes are never performed independently and must be
reported in addition to the primary procedure.
Note: This code must always be billed in conjunction with either CPT code 77295 or 77301 and on the same date of service (even if the actual work was performed over several other days).
Medicare billing news for Clinical Trials:
January 2014 is the implementation date for the mandatory reporting of
clinical trial services. To ensure processing, your outpatient
professional claims must include the following:
The
8 digit clinical trial number must be included in Box 19 (or the
corresponding 837P electronic equivalent ) in this format: CT12345678.
Either ICD-9 diagnosis V70.7 or ICD-10 diagnosis Z00.6 must be submitted as either the primary or secondary diagnosis.
The appropriate modifier of Q0 or Q1 must be appended to the service charge.
Any claims received without the required items will be returned as unprocessable.
Further details on changes to clinical trials billing can be found on the CMS website by searching for MLN Article #MM8401.
77295 is a perfect example of coding lagging behind technology. It was originally lumped in with the actual “hands-on” patient physical simulation codes, 77280-77290. Those of us that have been billing in radiation oncology have just “overlooked” its misplacement for many years. We are aware that this code represents the “behind the scenes” work performed by the physics and dosimetry staff in conjunction with the physicians in planning a 3D treatment course.
The AMA
has decided that 77295 will be officially moved to the Medical
Radiation, Physics, Dosimetry, Treatment Devices and Special Services
subsection of the CPT book (CPT codes 77300–77370). The descriptor has
been revised to reflect this change:
Previous descriptor: therapeutic radiology simulation-aided field setting; 3-dimensional
Updated descriptor: three-dimensional radiotherapy plan, including dose-volume histograms
Note: This change should have no effect on the circumstances of when this code should be billed. Process
changes made in the performance of simulations required redefining the
levels of complexity in ways that reflect the real added work performed
by radiation oncologists. Also the references to ports, blocks, etc.
have been removed. Now the level of coding is based on the number of
“Treatment Areas”.A
treatment area is a contiguous anatomic location, such as primary tumor
organ or the resection bed and applicable lymph nodes that will be
treated with radiation therapy.
Previous descriptors:
77280 Therapeutic radiology simulation-aided field setting; simple. Simulation of a single treatment area with either a single port or parallel opposed ports. Simple or not blocking.
77285 Therapeutic radiology simulation-aided field setting; intermediate. Simulation of 3 or more converging ports, two separate treatment areas, multiple blocks.
77290 Therapeutic radiology simulation-aided field setting; complex. Simulation
of tangential portals, 3 or more treatment areas, rotation or arc
therapy, complex blocking, custom shielding blocks, brachytherapy source
verification, hyperthermia probe verification, any use of contrast
materials.
Updated descriptors:
77280 Therapeutic radiology simulation-aided field setting; simple. Simulation of a single treatment area.
77285 Therapeutic radiology simulation-aided field setting; intermediate. Simulation of two separate treatment areas.
77290 Therapeutic radiology simulation-aided field setting; complex. Simulation of 4 separate fields. Simulation
of 3 or more treatment areas or any number of treatment areas if any of
the following are involved: particle, rotation or arc therapy, complex
blocking, custom shielding blocks, brachytherapy source verification,
hyperthermia probe verification, any use of contrast materials.
Note: This change also bundles the CT Simulation, so the technical charge of acquiring the CT (CPT code 77014 TC) will no longer be reported separately for simulation.
CPT code +77293, a new add-on code was created. This new code describes
the physician work and resources involved in acquiring a respiratory
correlated or ‘4-D’ CT simulation study for conformal planning. The plus
(+) symbol in front of the code number indicates that this is an add-on
code. Add-on codes are never performed independently and must be
reported in addition to the primary procedure. Note: This code must always be billed in conjunction with either CPT code 77295 or 77301 and on the same date of service (even if the actual work was performed over several other days). Medicare billing news for Clinical Trials:
January 2014 is the implementation date for the mandatory reporting of
clinical trial services. To ensure processing, your outpatient
professional claims must include the following: The
8 digit clinical trial number must be included in Box 19 (or the
corresponding 837P electronic equivalent ) in this format: CT12345678.Either ICD-9 diagnosis V70.7 or ICD-10 diagnosis Z00.6 must be submitted as either the primary or secondary diagnosis. The appropriate modifier of Q0 or Q1 must be appended to the service charge.Any claims received without the required items will be returned as unprocessable.Further details on changes to clinical trials billing can be found on the CMS website by searching for MLN Article #MM8401.
Wednesday, December 11, 2013
Medical Billing: Past, Present and Future
It is the holiday season, and I can’t help myself. Get ready for
another “Christmas themed” posting. In the less than 7 days since
Thanksgiving, I have come across on the television 3 showings of various
iterations of A Christmas Carol, By Charles Dickens. This
could possibly be one of the most re-made holiday films in history as
well as a “recycled” theme for numerous other films, usually those sappy
romantic comedies.
Why
do we love it? It is a tale of introspection, realization and
redemption. When confronted with the true reality of his life, Scrooge
transforms himself “overnight”. That is why we love it!
Well, we all know that in the “life” of medical billing, an overnight transformation of any sort is completely impossible. The deadlines for “mandatory” claims rules like 5010 and ICD-10 are pushed back over and over again. A 100% paperless medical office, I haven’t seen one of those yet.
Even though it has not happened overnight, significant changes have been made and are on the horizon in the medical billing world.
So follow along as we reminisce about the “old days”. (Notice I did not say “Good old days”. I think things have gotten much better. I hope you agree.) We will take stock of our current situation and wax hopeful or commiserate about the upcoming 2014 and beyond.
The
visit by the “Ghost of Christmas Past” demonstrates the hardships and
heartbreak suffered by Scrooge in his much earlier years. My medical
billing memories might not go back in time quite as far and would
qualify as neither true hardships nor heartbreak. I will confess there
was a real sense of nuisance and inconvenience.
This
typewriter had a small amount of built in memory and the ability to be
programmed slightly for some formatting requirements. It also was able
to save a “created” document onto a 3” memory disk. I managed to utilize
these functions to calculate the proper spacing for completing the
necessary fields in the claim form and store this information.
We
used those same cards to enter the insurance and patient payments as
they were received. If you have been around a medical office for a long
time, then you know exactly the ones I am talking about. We also
worked with those old “pegboard” payment receipts and a calendar year
appointment book. A “quick search” for the next available appointment
meant flipping from page to page!
As the clock stuck two, Scrooge moved from Christmas past to Christmas present, so now we will also.
Authorizations:
This process of obtaining approval from the payer or a third party
reviewer for requested procedures and services can be quite time
consuming and frustrating. Although many can be performed via online
sites, often times the submission and review of medical records is still
required. The timeline on the review can be as much as 7 – 10 business
days. These types of delays are very stressful for patients and the
office staff that have the unfortunate responsibility to communicate the
authorization status to those patients.
Denials:
This is the #1 enemy of the Accounts Receivables manager. I do believe
it is unlikely that payers have blanket policies to automatically deny a
claim, but there are rules that must be followed. Those rules include CCI
and MUE edits, NCDs and LCDs, and payer medical policies. If you
ignore those, you are asking for denials. Education and information are
the best tools in prevention and sometimes, you are right, those don’t
even work. As most claims are processed electronically these days,
denials can simply be a “computer glitch”, so taking time to truly
investigate the denial reason codes will provide the proper strategy for
your appeal.
Uninsured/under
insured/patient collections: No one enjoys asking sick people for
money. I am sure this falls to the bottom of many “to do” lists and I
cannot blame you. In 2009 it was estimated that 48.6 million people in
the US were uninsured. There are also those who can only afford such
limited coverage that many medical services end up being their full
financial responsibility.
His
next visitor, the “Ghost of Christmas Future” presented to Scrooge his
fate, a lonesome and celebrated death, if he failed to adjust his path
and change his ways. That is a pretty harsh reality to face.
Let’s see the changes that are in our near future and those that are looming a little further off in the distance.
So, just as Scrooge was not already
doomed, I do not think we are either. I do believe in evaluation of
your current path and making the right choices for the success of your
medical practice. I do believe making bad choices, can in time, doom a
medical practice. Therefore, we must learn from the past, appreciate the
present and embrace the future as best we can.
Why
do we love it? It is a tale of introspection, realization and
redemption. When confronted with the true reality of his life, Scrooge
transforms himself “overnight”. That is why we love it!Well, we all know that in the “life” of medical billing, an overnight transformation of any sort is completely impossible. The deadlines for “mandatory” claims rules like 5010 and ICD-10 are pushed back over and over again. A 100% paperless medical office, I haven’t seen one of those yet.
Even though it has not happened overnight, significant changes have been made and are on the horizon in the medical billing world.
So follow along as we reminisce about the “old days”. (Notice I did not say “Good old days”. I think things have gotten much better. I hope you agree.) We will take stock of our current situation and wax hopeful or commiserate about the upcoming 2014 and beyond.
The
visit by the “Ghost of Christmas Past” demonstrates the hardships and
heartbreak suffered by Scrooge in his much earlier years. My medical
billing memories might not go back in time quite as far and would
qualify as neither true hardships nor heartbreak. I will confess there
was a real sense of nuisance and inconvenience.
Before
the advent of medical billing software, medical office staffs in
offices around the country were forced to manually complete claim forms
for submission to payers. I guess I could have been thankful the
physician who owned the practice forked up the money for a “word
processing” style electric typewriter.
This
typewriter had a small amount of built in memory and the ability to be
programmed slightly for some formatting requirements. It also was able
to save a “created” document onto a 3” memory disk. I managed to utilize
these functions to calculate the proper spacing for completing the
necessary fields in the claim form and store this information.
Each
month, I would take the previous month’s “form” for patient “A”, update
the dates of service and services rendered, put a form in the
typewriter and print it. One patient down, and who knew how many left
to go. Oh and where did I get the charge information? It was written
on those old- style hand written ledger cards.
We
used those same cards to enter the insurance and patient payments as
they were received. If you have been around a medical office for a long
time, then you know exactly the ones I am talking about. We also
worked with those old “pegboard” payment receipts and a calendar year
appointment book. A “quick search” for the next available appointment
meant flipping from page to page!
Far
less traumatizing than Scrooge’s situation, however the refusal of the
physician to change with the times and get a computerized billing
system, made me leave that job!
As the clock stuck two, Scrooge moved from Christmas past to Christmas present, so now we will also.
Thankfully, we currently have medical billing software, with automated payment posting, electronic claims submission, real time eligibility and appointment scheduling. All of these are very common in today’s medical billing world and represent some of good things we encounter in our day.
But
in keeping with the grim nature of the visions experienced by Scrooge,
we should mention the less than positive experiences a medical biller
can be subjected to.
Authorizations:
This process of obtaining approval from the payer or a third party
reviewer for requested procedures and services can be quite time
consuming and frustrating. Although many can be performed via online
sites, often times the submission and review of medical records is still
required. The timeline on the review can be as much as 7 – 10 business
days. These types of delays are very stressful for patients and the
office staff that have the unfortunate responsibility to communicate the
authorization status to those patients.
It gets even worse when a
request is denied. A stressed patient can quickly become irate and
“blame” the messenger. Most authorization departments do follow
standard medical guidelines and protocols, but we all know a patient can
have a unique set of circumstances that may not fall neatly into a
protocol. Keeping a cool head and learning to work with the payers is a
crucial skill required by today’s medical office staff.
Denials:
This is the #1 enemy of the Accounts Receivables manager. I do believe
it is unlikely that payers have blanket policies to automatically deny a
claim, but there are rules that must be followed. Those rules include CCI
and MUE edits, NCDs and LCDs, and payer medical policies. If you
ignore those, you are asking for denials. Education and information are
the best tools in prevention and sometimes, you are right, those don’t
even work. As most claims are processed electronically these days,
denials can simply be a “computer glitch”, so taking time to truly
investigate the denial reason codes will provide the proper strategy for
your appeal.Uninsured/under
insured/patient collections: No one enjoys asking sick people for
money. I am sure this falls to the bottom of many “to do” lists and I
cannot blame you. In 2009 it was estimated that 48.6 million people in
the US were uninsured. There are also those who can only afford such
limited coverage that many medical services end up being their full
financial responsibility.
One such
situation I have seen is a “Hospital only” policy. It will cover
inpatient treatment, but all outpatient services are the patient’s
responsibility. Think about how many services are provided as
outpatient: chemotherapy, radiation therapy, physical therapy, many
surgical services, those are a lot of very expensive exclusions. It is a
tough situation, but I feel it is best dealt with openly with the
patient. Discuss the costs up front and make a plan for payment. I
know of no doctor who turns away a patient for inability to pay, it is
our very tough job to try to walk that fine line.
When
confronted with these real life difficulties, keeping a positive
attitude like hopeful Tiny Tim, can allow us all to be calm and
persevere.
His
next visitor, the “Ghost of Christmas Future” presented to Scrooge his
fate, a lonesome and celebrated death, if he failed to adjust his path
and change his ways. That is a pretty harsh reality to face.
The
harsh reality in medical billing is things change, sometimes for better
and sometimes for worse and we are unable to do anything to stop it. We
are not like Scrooge; we are not in complete control of our path in
medical billing. There are numerous outside forces: government
regulations, payer policies, physician needs, and the ever present
patient factor.
Let’s see the changes that are in our near future and those that are looming a little further off in the distance.
January
2014 will see the initial implementation of the new HCFA 1500 claim
form that has been updated to accommodate up to 12 diagnosis codes. CMS
has set an April 1, 2014 deadline for its mandatory use. It does seem
most large payers are following the same timeline, but as we all know,
some payers may not yet be “ready” for the new forms. ICD-10 becomes mandatory October 1, 2014 so any straggler payers will have no more excuses at that point.
In
regards to the ICD-10 mandate, we have all had many years to get ready,
yet I fear few feel really confident about the change. ICD-10 is not
really new; it has been utilized in countries around the world for years
and does provide a more thorough “picture” of the patient’s condition.
Physicians evaluate the whole patient, now billers and coders will do
the same thing.
Tied to the use of
ICD-10 is the concept of potentially transitioning to a “flat rate” type
of medical reimbursement, instead of our current fee for service
model. As this concept is also tied to a “Value Based” care delivery
system, I see the advantages. Standardizing the reimbursement could
standardize the level of care patients receive. It could eliminate the
variations due to socio-economic status, geographical location, etc. We
would emphasize optimum patient care at the center, which in the long
run has proven to lower costs. This is a scary concept for US
physicians and certainly not anything that will happen overnight, but I
feel no one can disagree that better care for lower cost is a win-win
situation for all involved.
Tuesday, December 10, 2013
Monday, December 9, 2013
Free eBook: The Journey to Understanding Medicare Billing
This eBook contains valuable information on the following topics:
Section 1: Appeals
Section 2: Duplicate Claim Rules
Section 3: HER and PQRS Incentives
Section 4: Incident to Services
Section 5: Local Coverage Determinations (LCDs)
Section 6: Medically Unlikely Edits (MUEs)
Section 7: National Provider Identifier (NPI)
Section 8: Prepayment Review of Evaluation and Management
Services
Section 9: Remittance Advice Terms
Section 10: Sequestration
Section 11: The Global Surgical Package
Wednesday, December 4, 2013
A Letter to Santa from a Medical Biller
Thanksgiving has passed and most of us feel as stuffed as the turkey
that was on our table. Malls far and wide have hailed the arrival of
Santa. Our banks accounts are approaching $0 as our credit card balances
rise exponentially.
Yes that time of year is upon us, when lots of children scurry furiously around the house to find paper and pencil, pen or crayon so they can begin their “Dear Santa” wish list. From the younger ones, there may be dolls and cars, bikes and trains, toy ovens and baseball mitts on those lists. As the authors’ ages increase, the technology certainly must begin to creep in: video games, cellular phones, and maybe even tablet computers (kids are growing up so fast these days).
As I was surrounded by the spirit of the season, the smell of pine trees and baked goods, my mind wandered to this idea, if a medical biller wrote their wish list to Santa, what would be on that list?
A built in ICD-9 to ICD-10 crosswalk
Can be configured to import from numerous EMR systems via our Connectivity Clearinghouse
Utilizes electronic data interchange functions for claims submission, ERA retrieval and auto-adjudication, and real-time eligibility.
Yes that time of year is upon us, when lots of children scurry furiously around the house to find paper and pencil, pen or crayon so they can begin their “Dear Santa” wish list. From the younger ones, there may be dolls and cars, bikes and trains, toy ovens and baseball mitts on those lists. As the authors’ ages increase, the technology certainly must begin to creep in: video games, cellular phones, and maybe even tablet computers (kids are growing up so fast these days).
As I was surrounded by the spirit of the season, the smell of pine trees and baked goods, my mind wandered to this idea, if a medical biller wrote their wish list to Santa, what would be on that list?
Well if your wish list has some or all of these things, you don’t need Santa Claus, just Santa Ernie
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Tuesday, December 3, 2013
Get Ready For the CERT Task Force
When you hear the words joint “Task Force”, I am sure you assume like
I do FBI/DEA or CIA/NSA hunting down terrorists or criminals. Usually
it is two or more entities that typically work alone but join together
for a common goal.
The type of task force I am going to speak about is: The CERT A/B Contractor Task Force. CERT stands for the Comprehensive Error Rate Testing program and the A/B contractor refers to the Medicare Administrative Contractors (MACs) for Parts A and B.
In case you are currently unfamiliar with the CERT program here is a brief overview:
Follow this link to the CMS CERT Program website.
See below for the listing of current MACs and their corresponding jurisdictions:
Since, the purpose of the CERT program is not to identify fraud; it utilizes the error rate findings to educate providers in the prevention of inaccurate claims for services that result in incorrect payments. The Task Force is simply an extension of this goal, bringing together all the MACs to collaborate on mutual issues.
Educational
activity by the CERT A/B Contractor Task Force will be provided in
addition to the existing materials offered by CMS, the Medicare Learning
Network (MLN®), and the MACs within their jurisdictions.
Educational materials from the CERT A/B Contractor Task Force will include this logo:
The Plan:
The Task Force will focus on one to four key subjects per year.
There will be periodic publications with detailed “coding scenarios” providing guidelines on preventing the applicable common errors.
Each MAC provides a dedicated page on their website for the CERT A/B Contractor Task Force and its communications.
Watch for future announcements regarding upcoming activities from the CERT A/B Contractor Task Force.
Follow this link for access to all CMS published CERT reports. By educating yourself, you can prevent billing errors that cause incorrect payments.
The type of task force I am going to speak about is: The CERT A/B Contractor Task Force. CERT stands for the Comprehensive Error Rate Testing program and the A/B contractor refers to the Medicare Administrative Contractors (MACs) for Parts A and B.
In case you are currently unfamiliar with the CERT program here is a brief overview:- Measures improper payments in the Medicare Fee-for-Service (FFS) program.
- Selects a stratified random sample of approximately 40,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs).
- Claims are reviewed by an independent medical review contractor to determine if they were paid properly under Medicare coverage, coding, and billing rules.
- If these criteria are not met or the provider fails to submit medical records to support the claim billed, the claim is counted as either a total or partial improper payment and the improper payment may be recouped (for overpayments) or reimbursed (for underpayments).
- Based on the findings from the claim review process, the annual Medicare FFS improper payment rate is calculated which is published in the Health and Human Services (HHS) Agency Financial Report (AFR).
Follow this link to the CMS CERT Program website. See below for the listing of current MACs and their corresponding jurisdictions:- Cahaba Government Benefit Administrators, LLC/J10
- CGS Administrators, LLC/J15
- First Coast Service Options, Inc. /J9
- National Government Services, Inc./J6 & JK
- NHIC, Corp/J14
- Noridian Healthcare Solutions, LLC/JF
- Novitas Solutions, Inc./JL & JH
- Palmetto GBA/J1 & J11
- Wisconsin Physicians Service Insurance Corporation/J5, J8, & T18
Since, the purpose of the CERT program is not to identify fraud; it utilizes the error rate findings to educate providers in the prevention of inaccurate claims for services that result in incorrect payments. The Task Force is simply an extension of this goal, bringing together all the MACs to collaborate on mutual issues.
Educational
activity by the CERT A/B Contractor Task Force will be provided in
addition to the existing materials offered by CMS, the Medicare Learning
Network (MLN®), and the MACs within their jurisdictions.Educational materials from the CERT A/B Contractor Task Force will include this logo:The Plan: There will be periodic publications with detailed “coding scenarios” providing guidelines on preventing the applicable common errors.
Each MAC provides a dedicated page on their website for the CERT A/B Contractor Task Force and its communications. Watch for future announcements regarding upcoming activities from the CERT A/B Contractor Task Force. Follow this link for access to all CMS published CERT reports. By educating yourself, you can prevent billing errors that cause incorrect payments.Monday, December 2, 2013
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