ANSWERS TO YOUR BILLING, CODING QUESTIONS

by Elizabeth W. Woodcock, MBA, FACMPE, CPC

Gaining a comprehensive understanding of capricious coding and compliance issues is vital to a healthy bottom line. Here is a look at some of the common questions practices face, along with answers that will help keep you on the right side of payer policies and, ultimately, optimize reimbursement.

QUESTION: Is it acceptable for us to charge patients who don’t show up for their appointments?

ANSWER: No-shows are undoubtedly a drain on productivity and profitability. And it is understandable that practices want to recoup their losses. But whether or not you can charge patients when they fail to keep their appointment depends on the payer, and the contractual relationship you have with that particular insurance company.

If you don’t participate with an insurance company, you are free to charge what you want. If you do participate, however, you’ll want to review your contract carefully. Some expressly prohibit these charges, but the majority deals with the topic less directly. To get to the bottom of the issue, you’ll need to review the insurer’s definition of “covered” and “non-covered” services.

Typically, no-show charges, interest on overdue accounts, and fees for procedures like cosmetic services are considered non-covered services, unless your contract says otherwise. Under these circumstances, the decision about whether or not to charge no-show fees is yours.

If the contract is not clear, consider negotiating for a more detailed definition of what’s covered by the contract and what’s not. Your negotiated definition should support your interest in charging beneficiaries fees for not having the courtesy to show up for their appointments without cancelling.

National Medicare policy allows practices to bill no-shows – provided the patient knows that this will happen ahead of time. This means you must post and distribute your no-show policy so that all patients are informed.

Most practices that have instituted no-show policies charge a flat fee of $20 to $50 for a missed appointment. Be sure to clearly define the amount of the no-show charge and under what circumstances the fee will be levied in your patient brochure.

QUESTION: I’ve heard that you can be paid extra for treating patients after hours. Is that true?

ANSWER: Yes, in some cases. There is a procedure code for after-hours care – 99050 – which can be used for services provided in the office at times other than regularly scheduled office hours, or on days when the office is normally closed.

You will report this code in addition to the appropriate evaluation and management code (e.g., 99213) that describes the services rendered.

Of course, billing a procedure code for after-hours care does not always mean you’ll be paid. In fact, most insurance companies do not offer reimbursement for this service. If after-hours care is considered a non-covered service, however, you can pass the charge along to the patient.

CPT offers a second code – 99051 – that you can use when you hold regular office hours during the evening, weekend or on holidays for the convenience of your patients. This, too, is rarely paid, but you could bill the patient if you choose, so long as the insurer classifies it as a non-covered service.

QUESTION: I’ve thought about turning my practice into a “concierge practice,” but heard that it’s illegal to charge an annual concierge fee. Is that true?

ANSWER: No, that is not true. The General Accounting Office (GAO) authored a report - “Concierge Care Characteristics and Considerations for Medicare” - in 2005 which revealed that concierge fees are fine as long as they are not applied to “covered” services.

Concierge care is an approach to medical practice in which physicians charge their patients a membership fee in return for enhanced services or amenities. The GAO report shows these fees range from $60 to $15,000 per year – although most fall into the $1,500 – $2,000 range. The most often reported features of concierge care programs included same- or next-day appointments for non-urgent care, 24-hour telephone access, and periodic preventive care examinations, the GAO study says.

While these conveniences are acceptable, other services might not be. If you market your concierge fee as inclusive of timely test results notification and appointment access, for example, you’ll not meet the criteria – because these are considered services that should be included in what the insurance companies, including Medicare, already pay you for.

Click here if you’d like to review the GAO report.

QUESTION: I’ve heard that there are some changes in diagnosis codes for 2007. Where can I find out about them?

ANSWER: That’s correct – there have been recent changes to ICD-9 codes and it’s vital you remain current with all revisions. Ensuring that your claims include the correct diagnosis code is essential for payment. Diagnosis codes support – or undermine – every medical claim you file. The ICD-9 code is what justifies charges submitted because it confirms the medical necessity of the services provided.

The Centers for Medicare and Medicaid Services (CMS) now update ICD-9 codes twice a year, with revisions, deletions and additions going into effect each October and April. Click here to ensure you’re using the right diagnosis codes in 2007. Visit the CMS website (www.cms.hhs.gov) periodically to make sure you’re prepared for the next round of changes effective April 1, 2007.

Elizabeth Woodcock is the founder and principal of Woodcock & Associates, with 15 years experience in medical group operations and revenue cycle management. A speaker, trainer and author, Ms. Woodcock has led educational sessions for the Medical Group Management Association, the American College of Obstetricians & Gynecologists, and the American Medical Association, and has consulted for clients as diverse as a solo orthopedic surgeon in rural Georgia to The Mayo Clinic. She is author of Mastering Patient Flow to Increase Efficiency and Earnings, and co-author of The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid and Operating Policies and Procedures Manual for Medical Practices.

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