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: We received a credentialing packet for a health plan I’ve never heard of. Should I fill it out?

ANSWER: No way! Some unscrupulous health plans are using the National Provider Identifier (NPI) implementation to sign physicians on as participating providers. These plans fax or mail requests for you to “update” their records by sending your new NPI – or ask you to complete an entire set of credentialing forms. Read the fine pint: If you sign the forms, you agree to become a network provider and accept their discounted fees.

QUESTION: We do a pretty good job of collecting co-payments from patients at the time of service, but we don’t pursue other outstanding balances. Is it worth the investment of time and effort?

ANSWER: Without a doubt. Co-payment collection is just a start. You’ll want to add collections of all outstanding balances (one-day-old, or months past due) and non-covered services in order to improve collections and save statement costs. For uninsured patients, collect the full fee for the service rendered or set a minimum “deposit,” such as $100.

Review your contracts to determine what you can collect at the time of service from insured patients. Although some contracts disallow these efforts, many encourage collections of co-insurance and unmet deductibles.

Before you start these efforts, you’ll need to make sure you give your staff the information and tools to collect these – the allowances for each service by health plan, and how to determine and calculate the amount due. If it’s too complicated to collect these for all services, at the minimum you should make sure you do so for pre-scheduled surgeries and procedures.

QUESTION: Do I need to have a separate note if I bill a service with a -25 modifier?

ANSWER: It’s not necessary to create a separate note for a service billed with a -25 modifier. The American Medical Association definition of the -25 modifier states: “A significant, separately identifiable evaluation and management services is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.” In other words, although a separate note isn’t required, your documentation must support both services billed.

QUESTION: Can we get paid for a pulse ox?

ANSWER: If you perform the pulse ox during an office visit, you will not be paid. The Centers for Medicare and Medicaid Services (CMS) has declared that pulse oximetry, 94760, is a “B” or “bundled” status code. It is not separately payable when performed with another service, such as an office visit. Most private payers follow Medicare’s guidance.

QUESTION: How do I code a well-woman visit for a Medicare patient?

ANSWER: Medicare does not pay for most preventive care, so you’ll need to get an advanced beneficiary notice (ABN) signed. Code the service as a 99397 and add a –GY modifier to indicate that the ABN was signed.

The patient will owe you for these visits – but there are some services and situations where Medicare will reimburse you. These include cervical or vaginal cancer screenings, and pelvic and clinical breast exams if the patient qualifies (every two years for low-risk patients and every year for high-risk). Use G0101 to code for these services. Medicare will also pay for a screening Papanicolaou smear under the same criteria. Use Q0091 to bill for the Pap smear.

In sum, a Medicare well-woman check should be coded as such: 99397-GY, G0101, and Q0091.

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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