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.

AMAThe 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

77295 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.

AMAProcess 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”.

77280-77290A 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:

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.
 77293+ 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.
AMA 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.

77295 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 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:

billing news The 8 digit clinical trial number must be included in Box 19 (or the corresponding 837P electronic equivalent ) in this format: CT12345678.

 billing newsEither ICD-9 diagnosis V70.7 or ICD-10 diagnosis Z00.6 must be submitted as either the primary or secondary diagnosis.

billing news The appropriate modifier of Q0 or Q1 must be appended to the service charge.

denied claimsAny 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.

a christmas carolWhy 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.

ghost of christmas pastThe 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. 

hcfa 1500This 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. 

appointment schedulingWe 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!

santa claus ernieAs 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.

authorizationsAuthorizations: 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.

CCI editsDenials:  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.

uninsuredUninsured/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.

ghost of christmas futureHis 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. 

2014 ACA changesLet’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. 

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.

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?



Well if your wish list has some or all of these things, you don’t need Santa Claus, just Santa Ernie

santa claus ernie
Iridium Suite has:

Iridium suiteA built in ICD-9 to ICD-10 crosswalk

Iridium suiteCan be configured to import from numerous EMR systems via our Connectivity Clearinghouse

Iridium suiteUtilizes electronic data interchange functions for claims submission, ERA retrieval and auto-adjudication, and real-time eligibility.

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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 ForceCERT 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.

Comprehensive Error Rate TestingIn 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).  

CMS websiteFollow this link to the CMS CERT Program website.

MACs 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.
  MACsEducational 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.

CMS website 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.

CMS website Follow this link for access to all CMS published CERT reports.  By educating yourself, you can prevent billing errors that cause incorrect payments.