Prolonged Physician Service With Direct (Face-to-Face) Patient Contact
►Codes 99354-99357 are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting. This service is reported in addition to the designated evaluation and management services at any level and any other physician services provided at the same session as evaluation and management services. Appropriate codes should be selected for supplies provided or procedures performed in the care of the patient during this period.
Codes 99354-99355 are used to report the total duration of face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous. Codes 99356- 99357 are used to report the total duration of unit time spent by a physician on a given date providing prolonged services to a patient, even if the time spent by the physician on that date is not continuous
Code 99354 or 99356 is used to report the first hour of prolonged service on a given date, depending on the place of service.
Either code should be used only once per date, even if the time spent by the physician is not continuous on that date. Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes.
Code 99355 or 99357 is used…
The use of the time based add-on codes requires that the primary evaluation and management service have a
typical or specified time published in the CPT® codebook
The following examples illustrate the correct…
Total Duration of Prolonged Services Codes(s)
Less than 30 minutes (less than 1/2 hour) Not reported separately
30-74 minutes (1/2 hr. – 1 hr. 14 min.) 99354 X 1
75-104 (1 hr. 15 min. – 1 hr. 44 min.) 99354 X 1 AND 99355 X 1
►105 or more (1 hr. 45 min. or more) 99354 X 1 AND 99355 X 2
▲99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face)
patient contact beyond the usual service; first hour (List separately in addition to code for office or
other outpatient Evaluation and Management Service)
►(Use 99354 in conjunction with 99201-99215, 99241-99245, 99324-99337, 99341-99350,
90809, 90815)
+▲99355 each additional 30 minutes (List separately in addition to code for prolonged physician service)
(Use 99355 in conjunction with 99354)
+▲99356 Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual
service; first hour (List separately in addition to code for inpatient Evaluation and Management
service)
► (Use 99356 in conjunction with 99221-99233, 99251099255, 99304-99310, 90822, 90829)
▲99357 each additional 30 minutes (List separately in addition to code for prolonged physician service)
(Use 99357 in conjunction with 99356
Wednesday, May 15, 2013
Thursday, May 9, 2013
How to File a Void Request on a Paper Claim
Requirements for Filing a Void Request
A void request will be processed as a replacement to the original, incorrectly paid claim. When a claim is voided, the total payment for the original claim is deducted. There is no time limit on submitting a void. The provider can submit a paper void request on the remittance voucher, a legible photocopy of the
original claim, or an entirely new claim.
Voiding Claims on the Remittance Voucher
A claim can be voided by photocopying the remittance voucher and in black ink circling the claim to be voided. Write “void” on the side of the remittance voucher and briefly explain why the void is requested. Sign and date the remittance voucher in the margin. Only one claim can be voided per copy of the remittance voucher. Additional claims on the same remittance voucher must be voided by submitting additional photocopies of the remittance voucher. Each copy of the remittance voucher can only have one claim circled on it.
Voiding Claims on a Paper Claim Form
When requesting a void, the provider must:
· Resubmit a photocopy of the original claim or a new claim form;
· Enter the items listed on following page;
· Initial and date the form if it is a photocopy, or sign and date it if it is a new
form; and
· Mail the void request to the fiscal agent for processing to:
Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080
A void request will be processed as a replacement to the original, incorrectly paid claim. When a claim is voided, the total payment for the original claim is deducted. There is no time limit on submitting a void. The provider can submit a paper void request on the remittance voucher, a legible photocopy of the
original claim, or an entirely new claim.
Voiding Claims on the Remittance Voucher
A claim can be voided by photocopying the remittance voucher and in black ink circling the claim to be voided. Write “void” on the side of the remittance voucher and briefly explain why the void is requested. Sign and date the remittance voucher in the margin. Only one claim can be voided per copy of the remittance voucher. Additional claims on the same remittance voucher must be voided by submitting additional photocopies of the remittance voucher. Each copy of the remittance voucher can only have one claim circled on it.
Voiding Claims on a Paper Claim Form
When requesting a void, the provider must:
· Resubmit a photocopy of the original claim or a new claim form;
· Enter the items listed on following page;
· Initial and date the form if it is a photocopy, or sign and date it if it is a new
form; and
· Mail the void request to the fiscal agent for processing to:
Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080
Saturday, May 4, 2013
How to Resubmit a Denied Claim
Instructions
Check the remittance voucher before submitting a second request for payment. Claims may be resubmitted for one of the following reasons only:
· The claim has not appeared on a remittance voucher as paid, denied, or suspended for thirty days after it was submitted; or
· The claim was denied due to incorrect or missing information or lack of a required attachment.
Do not resubmit a claim denied because of Medicaid program limitations or policy regulations. Computer edits ensure that it will be denied again.
No Response Received
If the claim does not appear on a remittance voucher within 30 days of the day it was mailed, the provider should take the following steps:
· Check recently received remittance voucher dates. Look for gaps. A remittance voucher may have been mailed but lost in transit. If the provider believes this is the case, call ACS Provider Inquiry.
· If there is not a gap in the dates of remittance vouchers received, please call the Medicaid fiscal agent, Provider Inquiry. An associate will research the claim.
· If the fiscal agent advises that the claim was never received, please resubmit another claim immediately. See the Resubmission Checklist on the following page in this chapter.
Correcting a Denied Claim
If the claim has been denied for incorrect or missing information, correct the errors before resubmitting the claim.
Resubmission Checklist
Use the following checklist to ensure that resubmittals are completed correctly before submitting.
* Did you wait thirty days after the original submittal before resubmitting a missing claim?
* If using a photocopy of a claim, did you make sure it was legible and properly aligned?
* If you chose to fill out a new claim, did you type or print the form in black ink? Are all multi-part copies legible?
* If you have corrected or changed the original claim form, have strikeovers been corrected on each copy? (Do not use whiteout.)
* Have you clipped all required attachments and documentation to the claim form?
* Is the claim clean of all highlighting and whiteout?
* Do you have the correct P.O. Box Number and corresponding nine-digit zip code for mailing the resubmitted claim?
Check the remittance voucher before submitting a second request for payment. Claims may be resubmitted for one of the following reasons only:
· The claim has not appeared on a remittance voucher as paid, denied, or suspended for thirty days after it was submitted; or
· The claim was denied due to incorrect or missing information or lack of a required attachment.
Do not resubmit a claim denied because of Medicaid program limitations or policy regulations. Computer edits ensure that it will be denied again.
No Response Received
If the claim does not appear on a remittance voucher within 30 days of the day it was mailed, the provider should take the following steps:
· Check recently received remittance voucher dates. Look for gaps. A remittance voucher may have been mailed but lost in transit. If the provider believes this is the case, call ACS Provider Inquiry.
· If there is not a gap in the dates of remittance vouchers received, please call the Medicaid fiscal agent, Provider Inquiry. An associate will research the claim.
· If the fiscal agent advises that the claim was never received, please resubmit another claim immediately. See the Resubmission Checklist on the following page in this chapter.
Correcting a Denied Claim
If the claim has been denied for incorrect or missing information, correct the errors before resubmitting the claim.
Resubmission Checklist
Use the following checklist to ensure that resubmittals are completed correctly before submitting.
* Did you wait thirty days after the original submittal before resubmitting a missing claim?
* If using a photocopy of a claim, did you make sure it was legible and properly aligned?
* If you chose to fill out a new claim, did you type or print the form in black ink? Are all multi-part copies legible?
* If you have corrected or changed the original claim form, have strikeovers been corrected on each copy? (Do not use whiteout.)
* Have you clipped all required attachments and documentation to the claim form?
* Is the claim clean of all highlighting and whiteout?
* Do you have the correct P.O. Box Number and corresponding nine-digit zip code for mailing the resubmitted claim?
Monday, April 29, 2013
what is Remittance Voucher
Description
The remittance voucher displays the disposition of all claims processed during the claims cycle. A remittance voucher is mailed each week if the fiscal agent processed any claims or put any claims in “Suspend” status. If the provider receives payment by paper check, the check is mailed separately.
Role of the Remittance Voucher
The remittance voucher plays an important role in communications between the provider and Medicaid. It tells what happened to the claims submitted for payment–whether they were paid, suspended, or denied. It provides a record of transactions and assists the provider in resolving errors so that denied claims can be resubmitted.
The provider must reconcile the remittance voucher with the claim in order to determine if correct payment was received.
The remittance voucher contains one or more of the following sections, depending on the type of claims filed, the disposition of those claims, and any new billing or policy announcements:
· Remittance Voucher Banner Page Message
· Disposition Category by Groups
· Summary Section
Remittance Voucher Banner Page Message
When Medicaid or the fiscal agent discovers billing problems encountered by all or selected provider types, a remittance voucher banner message is printed as the first page of the voucher. Suggestions for avoiding problems, explanations of policy, and new or changed procedure codes are described. Training sessions
are also announced on the remittance voucher banner page.
Disposition Category by Groups
Claims are listed by disposition category (paid, denied, or suspended) in alphabetical order by the recipient’s last name. Voids and adjustments are also listed separately.
Suspend Status
All claims in the “Suspend” status are reported each week until adjudicated as “Paid” or “Denied.” If one line on a claim form suspends, then the entire claim will suspend until all of the claim lines can be adjudicated.
Summary Section
The remittance voucher summary section reports the number of claim transactions, and the total payment or check amount. If the account shows a prior negative balance, it will be carried forward weekly until eliminated.
The remittance voucher displays the disposition of all claims processed during the claims cycle. A remittance voucher is mailed each week if the fiscal agent processed any claims or put any claims in “Suspend” status. If the provider receives payment by paper check, the check is mailed separately.
Role of the Remittance Voucher
The remittance voucher plays an important role in communications between the provider and Medicaid. It tells what happened to the claims submitted for payment–whether they were paid, suspended, or denied. It provides a record of transactions and assists the provider in resolving errors so that denied claims can be resubmitted.
The provider must reconcile the remittance voucher with the claim in order to determine if correct payment was received.
The remittance voucher contains one or more of the following sections, depending on the type of claims filed, the disposition of those claims, and any new billing or policy announcements:
· Remittance Voucher Banner Page Message
· Disposition Category by Groups
· Summary Section
Remittance Voucher Banner Page Message
When Medicaid or the fiscal agent discovers billing problems encountered by all or selected provider types, a remittance voucher banner message is printed as the first page of the voucher. Suggestions for avoiding problems, explanations of policy, and new or changed procedure codes are described. Training sessions
are also announced on the remittance voucher banner page.
Disposition Category by Groups
Claims are listed by disposition category (paid, denied, or suspended) in alphabetical order by the recipient’s last name. Voids and adjustments are also listed separately.
Suspend Status
All claims in the “Suspend” status are reported each week until adjudicated as “Paid” or “Denied.” If one line on a claim form suspends, then the entire claim will suspend until all of the claim lines can be adjudicated.
Summary Section
The remittance voucher summary section reports the number of claim transactions, and the total payment or check amount. If the account shows a prior negative balance, it will be carried forward weekly until eliminated.
Tuesday, April 23, 2013
Insurance Claims Processing cycel - different stage
Paper Claim Handling
When the Medicaid fiscal agent receives a paper claim, it is screened for missing information and necessary attachments. If information or documentation is missing, the claim will not be entered into the Florida Medicaid Management Information System (FMMIS). It will be returned to the provider with a Return to Provider (RTP) letter that will state the reason the claim is being returned. The provider needs to correct the error, attach any missing documentation, and return the claim to the fiscal agent for processing.
Claim Entry
Data entry operators image and key into FMMIS each paper claim that passes initial screening. Electronic claims are loaded by batch into FMMIS by the fiscal agent’s data processing staff.
Claim Adjudication
FMMIS analyzes the claim information and determines the status or disposition of the claim. This process is known as claim adjudication.
Disposition of Claim
A claim disposition can be:
· Paid: payment is approved in accordance with program criteria.
· Suspended: the claim is put on “hold” so it can be analyzed in more detail by the fiscal agent or AHCA Medicaid.
· Denied: payment cannot be made because the information supplied indicates the claim does not meet program criteria, or information necessary for payment was either erroneous or missing.
Processing Time Frames
Claims are processed daily. Payments are made on a weekly basis. Under normal conditions a claim can be processed from receipt to payment within 7 to 30 days.
When the Medicaid fiscal agent receives a paper claim, it is screened for missing information and necessary attachments. If information or documentation is missing, the claim will not be entered into the Florida Medicaid Management Information System (FMMIS). It will be returned to the provider with a Return to Provider (RTP) letter that will state the reason the claim is being returned. The provider needs to correct the error, attach any missing documentation, and return the claim to the fiscal agent for processing.
Claim Entry
Data entry operators image and key into FMMIS each paper claim that passes initial screening. Electronic claims are loaded by batch into FMMIS by the fiscal agent’s data processing staff.
Claim Adjudication
FMMIS analyzes the claim information and determines the status or disposition of the claim. This process is known as claim adjudication.
Disposition of Claim
A claim disposition can be:
· Paid: payment is approved in accordance with program criteria.
· Suspended: the claim is put on “hold” so it can be analyzed in more detail by the fiscal agent or AHCA Medicaid.
· Denied: payment cannot be made because the information supplied indicates the claim does not meet program criteria, or information necessary for payment was either erroneous or missing.
Processing Time Frames
Claims are processed daily. Payments are made on a weekly basis. Under normal conditions a claim can be processed from receipt to payment within 7 to 30 days.
Medicare physician fee schedule - Quick overview
