Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)
CRITICAL CARE SERVICES (CODES 99291-99292)
Use of Critical Care Codes
Pay for services reported with CPT codes 99291 and 99292 when all the criteria for critical care and critical care services are met. Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.
Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.
Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.
Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.
Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.
Consult the American Medical Association (AMA) CPT Manual for the applicable codes
and guidance for critical care services provided to neonates, infants and children.
Wednesday, June 30, 2010
Critical Care Services and Medical Necessity
Critical care services must be medically necessary and reasonable. Services provided that do not meet critical care services or services provided for a patient who is not critically ill or injured in accordance with the above definitions and criteria but who happens to be in a critical care, intensive care, or other specialized care unit should be reported using another appropriate E/M code (e.g., subsequent hospital care, CPT codes 99231 - 99233).
As described in Section A, critical care services encompass both treatment of “vital organ failure” and “prevention of further life threatening deterioration of the patient’s condition.” Therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient’s bedside emergently, this is not a requirement for providing critical care service. The treatment and management of the patient’s condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration (i.e., the patient shall be critically ill or injured at the time of the
physician’s visit).
What is critical care services
Critical Care Services and Full Attention of the Physician
The duration of critical care services to be reported is the time the physician spent evaluating, providing care and managing the critically ill or injured patient's care. That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient.
For example, time spent reviewing laboratory test results or discussing the critically ill patient's care with other medical staff in the unit or at the nursing station on the floor may be reported as critical care, even when it does not occur at the bedside, if this time represents the physician’s full attention to the management of the critically ill/injured patient.
For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.
Critical Care Services and Qualified Non-Physician Practitioners (NPP)
Critical care services may be provided by qualified NPPs and reported for payment under the NPP’s National Provider Identifier (NPI) when the services meet the definition and requirements of critical care services in Sections A and B. The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified NPP practices and provides the service(s). Collaboration, physician supervision and billing requirements must also be met. A physician assistant shall meet the general physician supervision requirements.
The duration of critical care services to be reported is the time the physician spent evaluating, providing care and managing the critically ill or injured patient's care. That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient.
For example, time spent reviewing laboratory test results or discussing the critically ill patient's care with other medical staff in the unit or at the nursing station on the floor may be reported as critical care, even when it does not occur at the bedside, if this time represents the physician’s full attention to the management of the critically ill/injured patient.
For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.
Critical Care Services and Qualified Non-Physician Practitioners (NPP)
Critical care services may be provided by qualified NPPs and reported for payment under the NPP’s National Provider Identifier (NPI) when the services meet the definition and requirements of critical care services in Sections A and B. The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified NPP practices and provides the service(s). Collaboration, physician supervision and billing requirements must also be met. A physician assistant shall meet the general physician supervision requirements.
Critical care services CPT 99291 - 99292
Critical Care Services and Physician Time
Critical care is a time- based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided. More than one physician can provide critical care at another time and be paid if the service meets critical care, is medically necessary and is not duplicative care.
Concurrent care by more than one physician (generally representing different physician specialties) is payable if these requirements are met.
The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous.
Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5).
1. Off the Unit/Floor
Time spent in activities (excluding those identified previously in Section C) that occur outside of the unit or off the floor (i.e., telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care because the physician is not immediately available to the patient. This time is regarded as pre- and post service work bundled in evaluation and management services.
2. Split/Shared Service
A split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time.
Unlike other E/M services where a split/shared service is allowed the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified non physician practitioner and shall not be representative of a combined service
between a physician and a qualified NPP.
When CPT code time requirements for both 99291 and 99292 and critical care criteria are met for a medically necessary visit by a qualified NPP the service shall be billed using the appropriate individual NPI number. Medically necessary visit(s) that do not meet these requirements shall be
reported as subsequent hospital care services.
3. Unbundled Procedures
Time involved performing procedures that are not bundled into critical care (i.e., billed and paid separately) may not be included and counted toward critical care time. The physician's progress note(s) in the medical record should document that time involved in the performance of separately
billable procedures was not counted toward critical care time.
4. Family Counseling/Discussions
Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service. However, time involved with family members or other surrogate decision makers, whether to obtain a history or
to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met:
a) The patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and
b) The discussion is necessary for determining treatment decisions.
For family discussions, the physician should document:
a. The patient is unable or incompetent to participate in giving history and/or making treatment decisions
b. The necessity to have the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment
options with the family",
c. Medically necessary treatment decisions for which the discussion was needed, and
d. A summary in the medical record that supports the medical necessity of the discussion
All other family discussions, no matter how lengthy, may not be additionally counted towards critical care. Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, but only if they meet the same criteria as described in the aforementioned paragraph.
5. Inappropriate Use of Time for Payment of Critical Care Services.
Time involved in activities that do not directly contribute to the treatment of the critically ill or injured patient may not be counted towards the critical care time, even when they are performed in the critical care unit at a patient's bedside (e.g., review of literature, and teaching sessions with
physician residents whether conducted on hospital rounds or in other venues).
Critical care is a time- based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided. More than one physician can provide critical care at another time and be paid if the service meets critical care, is medically necessary and is not duplicative care.
Concurrent care by more than one physician (generally representing different physician specialties) is payable if these requirements are met.
The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous.
Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5).
1. Off the Unit/Floor
Time spent in activities (excluding those identified previously in Section C) that occur outside of the unit or off the floor (i.e., telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care because the physician is not immediately available to the patient. This time is regarded as pre- and post service work bundled in evaluation and management services.
2. Split/Shared Service
A split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time.
Unlike other E/M services where a split/shared service is allowed the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified non physician practitioner and shall not be representative of a combined service
between a physician and a qualified NPP.
When CPT code time requirements for both 99291 and 99292 and critical care criteria are met for a medically necessary visit by a qualified NPP the service shall be billed using the appropriate individual NPI number. Medically necessary visit(s) that do not meet these requirements shall be
reported as subsequent hospital care services.
3. Unbundled Procedures
Time involved performing procedures that are not bundled into critical care (i.e., billed and paid separately) may not be included and counted toward critical care time. The physician's progress note(s) in the medical record should document that time involved in the performance of separately
billable procedures was not counted toward critical care time.
4. Family Counseling/Discussions
Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service. However, time involved with family members or other surrogate decision makers, whether to obtain a history or
to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met:
a) The patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and
b) The discussion is necessary for determining treatment decisions.
For family discussions, the physician should document:
a. The patient is unable or incompetent to participate in giving history and/or making treatment decisions
b. The necessity to have the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment
options with the family",
c. Medically necessary treatment decisions for which the discussion was needed, and
d. A summary in the medical record that supports the medical necessity of the discussion
All other family discussions, no matter how lengthy, may not be additionally counted towards critical care. Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, but only if they meet the same criteria as described in the aforementioned paragraph.
5. Inappropriate Use of Time for Payment of Critical Care Services.
Time involved in activities that do not directly contribute to the treatment of the critically ill or injured patient may not be counted towards the critical care time, even when they are performed in the critical care unit at a patient's bedside (e.g., review of literature, and teaching sessions with
physician residents whether conducted on hospital rounds or in other venues).
How to submit clinical information - healthnet
Submission of Clinical Information
Health Net of California does not routinely require or request clinical information at the time of claim submission.
Health Net of California does reserve the right to request clinical records before or after claim payment to identify possible fraudulent or abusive billing practices, as well as any other inappropriate billing practice not consistent or compliant with AMA CPT codes or guidelines, provided there is ample evidence such an investigation is warranted.
Health Net of California, Inc.'s Medi-Cal State Health Programs does not routinely require or request clinical information at the time of claim submission.
Health Net of California, Inc.'s Medi-Cal State Health Programs reserves the right to request clinical records before or after claim payment to identify possible fraudulent or abusive billing practices, as well as any other inappropriate billing practice not consistent or compliant with the AMA CPT codes or guidelines, provided there is evidence such an investigation is warranted
Health Net of California does not routinely require or request clinical information at the time of claim submission.
Health Net of California does reserve the right to request clinical records before or after claim payment to identify possible fraudulent or abusive billing practices, as well as any other inappropriate billing practice not consistent or compliant with AMA CPT codes or guidelines, provided there is ample evidence such an investigation is warranted.
Health Net of California, Inc.'s Medi-Cal State Health Programs does not routinely require or request clinical information at the time of claim submission.
Health Net of California, Inc.'s Medi-Cal State Health Programs reserves the right to request clinical records before or after claim payment to identify possible fraudulent or abusive billing practices, as well as any other inappropriate billing practice not consistent or compliant with the AMA CPT codes or guidelines, provided there is evidence such an investigation is warranted
Medicare Recovery Audit Contractors (RAC) - working methodology
Medicare Recovery Audit Contractors (RAC) - What is it and How will it work
The Centers for Medicare and Medicaid Services (CMS) devised the Medicare Recovery Audit Contractor (RAC) program to identify coding errors and issues of proper documentation to support medical necessity and other requirements.
CMS will choose four independent contractors to run this new program that was initially intended to commence in September 2008. However, due to issues regarding the process for choosing the contractors, this program will be delayed.
Contractors will earn 2% of the money collected from the audits. Audits will only encompass claims paid after October 1, 2007.
The expansion of this program was based on a 3 year demonstration project based on the success of the initial project that recouped Medicare overpayments, mostly from hospitals. Based on this pilot program, CMS believes there are about $1 billion in overpayments in six states including Arizona, California, Florida, Massachusetts, New York and California.
There will be two types of audits conducted.
• Claims Reviews- Utilizing data mining they will identify obvious coding errors
• Complex Reviews – Upon complete review of medical records, a determination will be made to ascertain whether proper documentation was provided to support medical necessity or other requirements.
Providers will have 45 days to provide the records or request an extension. RAC will have 60 days to review the medical records. Records can be submitted by postal mail, fax or a CD or DVD.
Hospitals can appeal RAC’s findings providing additional information and records. The appeal will go to the local fiscal intermediary that administers Medicare for the state.
CMS is reducing the number of fiscal intermediaries from 51 to 15 chosen by competitive bidding.
If appeals are lost providers will have to pay back overpayments through deductions in future Medicare reimbursements.
The Centers for Medicare and Medicaid Services (CMS) devised the Medicare Recovery Audit Contractor (RAC) program to identify coding errors and issues of proper documentation to support medical necessity and other requirements.
CMS will choose four independent contractors to run this new program that was initially intended to commence in September 2008. However, due to issues regarding the process for choosing the contractors, this program will be delayed.
Contractors will earn 2% of the money collected from the audits. Audits will only encompass claims paid after October 1, 2007.
The expansion of this program was based on a 3 year demonstration project based on the success of the initial project that recouped Medicare overpayments, mostly from hospitals. Based on this pilot program, CMS believes there are about $1 billion in overpayments in six states including Arizona, California, Florida, Massachusetts, New York and California.
There will be two types of audits conducted.
• Claims Reviews- Utilizing data mining they will identify obvious coding errors
• Complex Reviews – Upon complete review of medical records, a determination will be made to ascertain whether proper documentation was provided to support medical necessity or other requirements.
Providers will have 45 days to provide the records or request an extension. RAC will have 60 days to review the medical records. Records can be submitted by postal mail, fax or a CD or DVD.
Hospitals can appeal RAC’s findings providing additional information and records. The appeal will go to the local fiscal intermediary that administers Medicare for the state.
CMS is reducing the number of fiscal intermediaries from 51 to 15 chosen by competitive bidding.
If appeals are lost providers will have to pay back overpayments through deductions in future Medicare reimbursements.
Tuesday, June 29, 2010
CMS Final Rule Announces a 21.2% Medicare Physician Payment Cut
CMS Final Rule Announces a 21.2% Medicare Physician Payment Cut for 2010
Medicare’s final 2010 payment rule confirms that in 60 days physicians face steep cuts of 21.2% — the largest payment cut since Congress adopted the Medicare physician payment formula.
The difference is due to the use of the most recently available data on CMS spending for physicians’ services.
Medicare’s payment rule also includes refinements that will increase payment rates for primary care services.
Taking all changes in the final rule-with-comment period into account, the CMS projects that payments to general practitioners, family physicians, internists and geriatric specialists will increase by between 5% and 8%, prior to application of the negative update required by the SGR.
The final rule with comment will appear in the Nov. 25, 2009 Federal Register. CMS will accept comments on designated provisions of the final rule with comment period until Dec. 29, 2009, and will respond to all comments at a later date. Unless otherwise specified, the new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after Jan. 1, 2010.
Jonathan Blum, Director of CMS, Center for Medicare Management, indicated the Administration tried to avert the pending fee schedule cut in the FY 2010 budget proposal that it submitted to Congress, and remains committed to repealing the SGR (Sustainable Growth Rate).
CMS is currently finalizing its proposal to remove physician-administered drugs from the definition of ‘physicians’ services’ for purposes of computing the physician fee schedule update. While this decision will not affect payments for services during CY 2010, the CMS projects it will have a positive effect on future payment updates.
While the CMS had proposed to use information about physician practice costs from the Physician Practice Information Survey (PPIS), the agency will now phase in the information during a 4-year period.
In addition, the CMS will continue to uses specialty supplemental survey data — not information from the PPIS — to determine practice expenses for medical oncology.
Other provisions in the rule make changes to the Physician Quality Reporting Initiative and the Electronic Prescribing Incentive Program. These changes include providing participants with more reporting options and implementing a new method for practices to be considered successful e-prescribers.
Medicare’s final 2010 payment rule confirms that in 60 days physicians face steep cuts of 21.2% — the largest payment cut since Congress adopted the Medicare physician payment formula.
The difference is due to the use of the most recently available data on CMS spending for physicians’ services.
Medicare’s payment rule also includes refinements that will increase payment rates for primary care services.
Taking all changes in the final rule-with-comment period into account, the CMS projects that payments to general practitioners, family physicians, internists and geriatric specialists will increase by between 5% and 8%, prior to application of the negative update required by the SGR.
The final rule with comment will appear in the Nov. 25, 2009 Federal Register. CMS will accept comments on designated provisions of the final rule with comment period until Dec. 29, 2009, and will respond to all comments at a later date. Unless otherwise specified, the new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after Jan. 1, 2010.
Jonathan Blum, Director of CMS, Center for Medicare Management, indicated the Administration tried to avert the pending fee schedule cut in the FY 2010 budget proposal that it submitted to Congress, and remains committed to repealing the SGR (Sustainable Growth Rate).
CMS is currently finalizing its proposal to remove physician-administered drugs from the definition of ‘physicians’ services’ for purposes of computing the physician fee schedule update. While this decision will not affect payments for services during CY 2010, the CMS projects it will have a positive effect on future payment updates.
While the CMS had proposed to use information about physician practice costs from the Physician Practice Information Survey (PPIS), the agency will now phase in the information during a 4-year period.
In addition, the CMS will continue to uses specialty supplemental survey data — not information from the PPIS — to determine practice expenses for medical oncology.
Other provisions in the rule make changes to the Physician Quality Reporting Initiative and the Electronic Prescribing Incentive Program. These changes include providing participants with more reporting options and implementing a new method for practices to be considered successful e-prescribers.
Interest, late and overpayment of Medicare
Interest on Late Payment of Claims
The late payment on a complete HMO, POS, AIM, Healthy Families Program, or Medi-Cal claim for emergency room (ER) services that is neither contested nor denied automatically includes the greater of $15 for each 12-month period or portion thereof on a non-prorated basis, or interest at 15 percent per year for the period of time that the payment is late.
Late payments on all other complete HMO, POS, AIM, and Healthy Families Program claims that are neither contested nor denied automatically include interest at the rate of 15 percent per year for the period of time that the payment is late.
If Health Net does not automatically include the interest fee with a late-paid complete HMO, POS, AIM, Healthy Families Program, or Medi-Cal claim, an additional $10 is sent to the provider of service.
The late payment on a complete PPO, EPO or Flex Net claim for ER services that is neither contested nor denied automatically includes the greater of $15 per year or interest at the rate of 10 percent per year beginning with the first calendar day after the 30-working-day period.
Late payments on all other complete PPO, EPO or Flex Net claims that are neither contested nor denied automatically include interest at the rate of 10 percent per year beginning with the first calendar day after the 30-working-day period subject to exceptions pursuant to applicable state law including fraud, misrepresentation, eligibility determinations, or instances in which the carrier has not been granted reasonable access to information under a provider's control.
If Health Net fails to notify the provider of service in writing of a denied or contested claim, or portion thereof, and ultimately pays the claim in whole or in part, computation of the interest begins on the first calendar day after the applicable time period for denying or contesting claims has expired.
Overpayment of Claims
If Health Net determines that an overpayment has occurred, Health Net notifies the provider of service in writing within 365 days of the date of payment on the overpaid claim through a separate notice that includes the following information:
• Member name
• Claim ID number
• Date of service
• Clear explanation of why Health Net believes the claim was overpaid
• The amount of overpayment, including interest and penalties
The 365-day time period does not apply to overpayments caused in whole or in part by fraud or misrepresentation on the part of the provider.
The provider of service has 30 working days to submit a written dispute to Health Net if the provider does not believe an overpayment has occurred. In this case, Health Net treats the claim overpayment issue as a provider dispute.
If the provider does not dispute the overpayment, the provider of service must reimburse Health Net within 30 working days from the receipt of Health Net's notice or, as permitted by law, interest begins to accrue at the rate of 10 percent per year beginning with the first day after the 30-working-day period.
Health Net may recoup uncontested overpayments by offsetting overpayments from payments for a provider's current claims for services as permitted under the Fair Claims Settlement Practices Regulations (in section 2695.11 of title 10, of the California Code of Regulations (CCR)).
A written notification is sent to the provider of service if an overpayment is recouped through offsets to claim payments. The notification identifies the specific overpayment and the claim ID number.
The late payment on a complete HMO, POS, AIM, Healthy Families Program, or Medi-Cal claim for emergency room (ER) services that is neither contested nor denied automatically includes the greater of $15 for each 12-month period or portion thereof on a non-prorated basis, or interest at 15 percent per year for the period of time that the payment is late.
Late payments on all other complete HMO, POS, AIM, and Healthy Families Program claims that are neither contested nor denied automatically include interest at the rate of 15 percent per year for the period of time that the payment is late.
If Health Net does not automatically include the interest fee with a late-paid complete HMO, POS, AIM, Healthy Families Program, or Medi-Cal claim, an additional $10 is sent to the provider of service.
The late payment on a complete PPO, EPO or Flex Net claim for ER services that is neither contested nor denied automatically includes the greater of $15 per year or interest at the rate of 10 percent per year beginning with the first calendar day after the 30-working-day period.
Late payments on all other complete PPO, EPO or Flex Net claims that are neither contested nor denied automatically include interest at the rate of 10 percent per year beginning with the first calendar day after the 30-working-day period subject to exceptions pursuant to applicable state law including fraud, misrepresentation, eligibility determinations, or instances in which the carrier has not been granted reasonable access to information under a provider's control.
If Health Net fails to notify the provider of service in writing of a denied or contested claim, or portion thereof, and ultimately pays the claim in whole or in part, computation of the interest begins on the first calendar day after the applicable time period for denying or contesting claims has expired.
Overpayment of Claims
If Health Net determines that an overpayment has occurred, Health Net notifies the provider of service in writing within 365 days of the date of payment on the overpaid claim through a separate notice that includes the following information:
• Member name
• Claim ID number
• Date of service
• Clear explanation of why Health Net believes the claim was overpaid
• The amount of overpayment, including interest and penalties
The 365-day time period does not apply to overpayments caused in whole or in part by fraud or misrepresentation on the part of the provider.
The provider of service has 30 working days to submit a written dispute to Health Net if the provider does not believe an overpayment has occurred. In this case, Health Net treats the claim overpayment issue as a provider dispute.
If the provider does not dispute the overpayment, the provider of service must reimburse Health Net within 30 working days from the receipt of Health Net's notice or, as permitted by law, interest begins to accrue at the rate of 10 percent per year beginning with the first day after the 30-working-day period.
Health Net may recoup uncontested overpayments by offsetting overpayments from payments for a provider's current claims for services as permitted under the Fair Claims Settlement Practices Regulations (in section 2695.11 of title 10, of the California Code of Regulations (CCR)).
A written notification is sent to the provider of service if an overpayment is recouped through offsets to claim payments. The notification identifies the specific overpayment and the claim ID number.
Prepare Materials for the Venipuncture Procedure
How to Prepare Materials for the Venipuncture Procedure
Venipuncture is the extraction or collection of blood from the vein of a person. The antecubital fossa at the bend of the arm is the ideal site of collection. Other sites are wrist and ankle veins.
It is a relatively painless procedure in the hands of a skilled phlebotomist. Preparing the materials needed is essential in the proper performance of the procedure. How and what are the materials needed for this procedure?
Step 1
Bring out all materials needed for the procedure; a vacutainer tube or a disposable syringe with needle, wet and dry cotton, 70 % isopropyl alcohol, a test tube (if vacutainer method is not used), test tube rack.
Step 2
Check the syringe with the needle on it by pulling and pushing the plunger. If the barrel gets stuck, slowly rotate while pulling simultaneously. If you could not pull and push the plunger, check the needle for clogs. If you remove the needle and it still refuses to move, discard it.
Step 3
Examine the needle for any factory defect like bent or crooked shaft and deformed bevel. If any of these is present it. Discard the needle. While examining the needle, do not expose it unnecessarily. Infectious agents would contaminate it. A second or two would do. Cover immediately. If the cap is transparent, you can examine it through the cap.
Step 4
Make sure the cotton the dry and wet are sterile. One main source of contamination is unsterile cotton. They should be in sterile separate containers.
Step 5
Arrange all materials in such a way that they are within arm's reach of the phlebotomist but not too near the patient, especially if the patient is a child.
Tips
Prepare the material before you call in the patient. The patient will feel anxious looking at all the strange and unfamiliar objects before him.
Arrange the materials in the order that you will use them. Avoid cluttering your work area. This reflects unprofessionalism. Make sure you label your specimen right after collection.
Make sure your puncture-resistant sharps container is at hand. Ascertain what test to perform before preparing. Certain tests need special equipment and additional apparatus.
After collection, never recap needles but dispose of them immediately and properly in the sharps container.
The successful performance of the procedure begins with the first step - the preparation of materials. Prepare your materials properly and succeed in your venipuncture procedure.
Venipuncture is the extraction or collection of blood from the vein of a person. The antecubital fossa at the bend of the arm is the ideal site of collection. Other sites are wrist and ankle veins.
It is a relatively painless procedure in the hands of a skilled phlebotomist. Preparing the materials needed is essential in the proper performance of the procedure. How and what are the materials needed for this procedure?
Step 1
Bring out all materials needed for the procedure; a vacutainer tube or a disposable syringe with needle, wet and dry cotton, 70 % isopropyl alcohol, a test tube (if vacutainer method is not used), test tube rack.
Step 2
Check the syringe with the needle on it by pulling and pushing the plunger. If the barrel gets stuck, slowly rotate while pulling simultaneously. If you could not pull and push the plunger, check the needle for clogs. If you remove the needle and it still refuses to move, discard it.
Step 3
Examine the needle for any factory defect like bent or crooked shaft and deformed bevel. If any of these is present it. Discard the needle. While examining the needle, do not expose it unnecessarily. Infectious agents would contaminate it. A second or two would do. Cover immediately. If the cap is transparent, you can examine it through the cap.
Step 4
Make sure the cotton the dry and wet are sterile. One main source of contamination is unsterile cotton. They should be in sterile separate containers.
Step 5
Arrange all materials in such a way that they are within arm's reach of the phlebotomist but not too near the patient, especially if the patient is a child.
Tips
Prepare the material before you call in the patient. The patient will feel anxious looking at all the strange and unfamiliar objects before him.
Arrange the materials in the order that you will use them. Avoid cluttering your work area. This reflects unprofessionalism. Make sure you label your specimen right after collection.
Make sure your puncture-resistant sharps container is at hand. Ascertain what test to perform before preparing. Certain tests need special equipment and additional apparatus.
After collection, never recap needles but dispose of them immediately and properly in the sharps container.
The successful performance of the procedure begins with the first step - the preparation of materials. Prepare your materials properly and succeed in your venipuncture procedure.
Monday, June 28, 2010
Billing CPT 80061 and 36415
New Jersey Service Wide Lipid Panel and Venipuncture Probe Results
New Jersey Claim Review on HCPC 80061 and 36415
In an effort to safeguard the Medicare Trust Fund by lowering the Comprehensive Error Rate Testing (CERT) paid claims error rate, Highmark Medicare Services’ Medical Review Department performs reviews and provides education based on data analysis performed to identify problem areas. The CERT program is the driver of this data analysis. The Centers for Medicare and Medicaid Services (CMS) and Highmark Medicare Services uses the information from the CERT error rate findings to determine the underlying reasons for claim errors and develops appropriate action plans to improve compliance in payment, claims processing, and provider billing practices.
Recent CERT data analysis indicated that there were claim errors in New Jersey for procedure code 80061 Lipid Panel and 36415 Venipuncture. As a result of this data analysis, Highmark Medicare Services’ Medical Review Department conducted a widespread post payment review in New Jersey on procedure code 80061 and 36415.
Our findings indicated that approximately 46% of the claims sampled were lacking supporting documentation.
The majority of the reductions/denials were based on the following:
• Physician order/referral information was missing from supporting documentation
• Submitted documentation did not support the billed diagnosis
• Requested documentation was not received in a timely manner
Please refer to the following publication for information on billing procedure codes 80061 and 36415:
• Medicare National Coverage Determination (NCD) 190.23 – Lipid Testing
As a result of these findings, and to assist in the reduction of the overall claims payment error rate, a prepayment review will be implemented on procedure code 80061 and 36415, for New Jersey providers.
Medical records will be requested to verify that services billed were rendered, medically necessary, adequately documented, and billed appropriately to the Medicare program. Please, do not send in documentation until requested by the Additional Documentation Request (ADR) process. If the requested medical record documentation is not made available upon request to support services billed, the service may be denied.
New Jersey Claim Review on HCPC 80061 and 36415
In an effort to safeguard the Medicare Trust Fund by lowering the Comprehensive Error Rate Testing (CERT) paid claims error rate, Highmark Medicare Services’ Medical Review Department performs reviews and provides education based on data analysis performed to identify problem areas. The CERT program is the driver of this data analysis. The Centers for Medicare and Medicaid Services (CMS) and Highmark Medicare Services uses the information from the CERT error rate findings to determine the underlying reasons for claim errors and develops appropriate action plans to improve compliance in payment, claims processing, and provider billing practices.
Recent CERT data analysis indicated that there were claim errors in New Jersey for procedure code 80061 Lipid Panel and 36415 Venipuncture. As a result of this data analysis, Highmark Medicare Services’ Medical Review Department conducted a widespread post payment review in New Jersey on procedure code 80061 and 36415.
Our findings indicated that approximately 46% of the claims sampled were lacking supporting documentation.
The majority of the reductions/denials were based on the following:
• Physician order/referral information was missing from supporting documentation
• Submitted documentation did not support the billed diagnosis
• Requested documentation was not received in a timely manner
Please refer to the following publication for information on billing procedure codes 80061 and 36415:
• Medicare National Coverage Determination (NCD) 190.23 – Lipid Testing
As a result of these findings, and to assist in the reduction of the overall claims payment error rate, a prepayment review will be implemented on procedure code 80061 and 36415, for New Jersey providers.
Medical records will be requested to verify that services billed were rendered, medically necessary, adequately documented, and billed appropriately to the Medicare program. Please, do not send in documentation until requested by the Additional Documentation Request (ADR) process. If the requested medical record documentation is not made available upon request to support services billed, the service may be denied.
CERT Error Relating to Billing of Venipuncture (36415)
CERT Error Relating to Billing of Venipuncture (36415)
The CERT error report has identified CPT® 36415, the collection of venous blood by venipuncture, being submitted as a covered service when the associated lab service is submitted as non-covered. If a provider chooses to submit a lab service with non-covered charges, the associated venipuncture code must also be submitted as non-covered for proper claim processing. In addition, if the same provider completes the venipuncture and lab service, the charges must be combined on the same claim.
Frequently, providers draw a lab specimen, but send the specimen to another facility for processing of the specimen. It is important the provider drawing the lab specimen review the Medicare coverage for the lab service. If Medicare will not cover the lab service, the provider drawing the lab specimen should submit the venipuncture charge as a non-covered service.
An understanding of CERT is critical to providers. While billing errors result in a partial or full denial of payment for procedures and services, the impact of CERT on providers extends beyond potential errors. Additional data may be collected on CERT-identified errors, resulting in possible implementation of focused reviews. Also, referrals may be made to other agencies or NAS departments for recovery, education or review.
Applies to the states: AK, ID, MN, ND, OR, UT & WA
The CERT error report has identified CPT® 36415, the collection of venous blood by venipuncture, being submitted as a covered service when the associated lab service is submitted as non-covered. If a provider chooses to submit a lab service with non-covered charges, the associated venipuncture code must also be submitted as non-covered for proper claim processing. In addition, if the same provider completes the venipuncture and lab service, the charges must be combined on the same claim.
Frequently, providers draw a lab specimen, but send the specimen to another facility for processing of the specimen. It is important the provider drawing the lab specimen review the Medicare coverage for the lab service. If Medicare will not cover the lab service, the provider drawing the lab specimen should submit the venipuncture charge as a non-covered service.
An understanding of CERT is critical to providers. While billing errors result in a partial or full denial of payment for procedures and services, the impact of CERT on providers extends beyond potential errors. Additional data may be collected on CERT-identified errors, resulting in possible implementation of focused reviews. Also, referrals may be made to other agencies or NAS departments for recovery, education or review.
Applies to the states: AK, ID, MN, ND, OR, UT & WA
CPT venipuncture - 36415 - Not seperately paid
Venipuncture
When blood is drawn to be sent to a reference lab, use code 36415 for the venipuncture. HCPCS Code G0001 was deleted in 2005. The most appropriate current code for G0001 is 36415 and the current fee for this is $3.00.
• CPT 36415 will not be separately reimbursed when submitted with the following CPT codes:
80048 82247 82728 83655 84450 85651
80050 82306 82784 83891 84460 85652
80051 82310 82785 84132 84550 86003
80053 82378 82947 84144 84702 86038
80055 82465 82948 84146 84703 86304
80061 82533 82950 84153 85007 86308
80069 82550 82951 84402 85013 86592
80074 82565 82962 84403 85014 86677
80076 82575 83001 84432 85018 86703
82040 82607 83036 84436 85025 86706
82105 82627 83516 84439 85027 86787
82150 82670 83540 84443 85610
• CPT 36416 will not be separately reimbursed when submitted with the following CPT codes:
80061 82947 83036 85014 85027
82247 82948 83655 85018 85610
82465 82962 85013 85025
When blood is drawn to be sent to a reference lab, use code 36415 for the venipuncture. HCPCS Code G0001 was deleted in 2005. The most appropriate current code for G0001 is 36415 and the current fee for this is $3.00.
• CPT 36415 will not be separately reimbursed when submitted with the following CPT codes:
80048 82247 82728 83655 84450 85651
80050 82306 82784 83891 84460 85652
80051 82310 82785 84132 84550 86003
80053 82378 82947 84144 84702 86038
80055 82465 82948 84146 84703 86304
80061 82533 82950 84153 85007 86308
80069 82550 82951 84402 85013 86592
80074 82565 82962 84403 85014 86677
80076 82575 83001 84432 85018 86703
82040 82607 83036 84436 85025 86706
82105 82627 83516 84439 85027 86787
82150 82670 83540 84443 85610
• CPT 36416 will not be separately reimbursed when submitted with the following CPT codes:
80061 82947 83036 85014 85027
82247 82948 83655 85018 85610
82465 82962 85013 85025
Enrolling part D - The correct time
Enroll in Part D when you are eligible
The best time to enroll in a Part D prescription drug plan is when you first become eligible. Often, a Medicare beneficiary may mistakenly believe that they can save some money by not enrolling in a Part D Plan because they are prescribed little or no medications.
Don’t fall into this trap. You could end up with higher costs due to the late enrollment penalty. Also, it’s called insurance for a reason. Even though you are on little or no prescription medicine, that is not an indicator as to what may happen in the future.
Here are some tips from the publication “Medicare and You”
Here are a few ways to avoid paying a penalty:
Join a Medicare drug plan when you’re first eligible.
You won’t have to pay a penalty, even if you’ve never had prescription drug coverage before. Don’t go for more than 63 days in a row without a Medicare drug plan
Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, or the Department of Veterans Affairs. Your plan will tell you each year if your drug coverage is creditable coverage. Keep this information, because you may need it if you join a Medicare drug plan later. Let your Medicare drug plan know if you had other creditable coverage.
When you join a plan, you may get a letter asking if you have creditable coverage. Complete the form they send you. If you don’t tell the plan about your creditable coverage, you may have to pay a penalty
The best time to enroll in a Part D prescription drug plan is when you first become eligible. Often, a Medicare beneficiary may mistakenly believe that they can save some money by not enrolling in a Part D Plan because they are prescribed little or no medications.
Don’t fall into this trap. You could end up with higher costs due to the late enrollment penalty. Also, it’s called insurance for a reason. Even though you are on little or no prescription medicine, that is not an indicator as to what may happen in the future.
Here are some tips from the publication “Medicare and You”
Here are a few ways to avoid paying a penalty:
Join a Medicare drug plan when you’re first eligible.
You won’t have to pay a penalty, even if you’ve never had prescription drug coverage before. Don’t go for more than 63 days in a row without a Medicare drug plan
Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, or the Department of Veterans Affairs. Your plan will tell you each year if your drug coverage is creditable coverage. Keep this information, because you may need it if you join a Medicare drug plan later. Let your Medicare drug plan know if you had other creditable coverage.
When you join a plan, you may get a letter asking if you have creditable coverage. Complete the form they send you. If you don’t tell the plan about your creditable coverage, you may have to pay a penalty
Thursday, June 24, 2010
Evaluating Medicare Part D Plans
Evaluating Medicare Part D Plans
Many people make the mistake of only looking at the monthly premium and then assume that the lowest premium is the best value. But there are several factors to consider beyond the monthly premium for Medicare Part D Plans. Other factors that you should consider include:- The Plans co-pays. Co-pays can vary from one Part D Plan to another. These differences can make a difference in your overall annual costs.
- Whether or not there is an annual deductible. Medicare Part D Plans can include an annual deductible up to $310 for 2010.
- Which tier your individual prescriptions are in. Having a low monthly premium and having some of your prescriptions listed in a higher more expense tier than another Medicare part D Plan may cost you more over the course of the year.
- Whether or not all your drugs are included in the plan’s formulary. If a drug is not in the formulary, you will be paying for it out of pocket.
- Is there some coverage in the coverage gap (donut hole)? Several plans include some level of coverage in the donut hole. These plans will normally have a little higher premium, but it may be worth the higher cost if you know that you will more than likely reach the donut hole.
Also, evaluate the Medicare Part D Plan that is included in a Medicare Advantage Plan. If your prescriptions are a large part of you annual health care cost, you should evaluate the Part D plan in an Advantage Plan just as you would a stand alone Medicare Part D Plan.
Medicare Advantage Plans (Part - C) include the following:
Medicare Advantage Plans (Part - C) include the following:
■ Health Maintenance Organization (HMO) Plans.
■ Preferred Provider Organization (PPO) Plans.
■ Private Fee-for-Service (PFFS) Plans.
■Medical Savings Account (MSA) Plans.
■ Special Needs Plans (SNP).
There are other less common types of Medicare Advantage Plans that may be available:
■ Point of Service (POS) Plans—Similar to HMOs, but you may be able to get some services out-of-network for a higher cost.
■ Provider Sponsored Organizations (PSOs)—Plans run by a provider or group of providers. In a PSO, you usually get your health care from the providers who are part of the plan.
Not all Medicare Advantage Plans work the same way, so before you join, find out the plan’s rules, what your costs will be, and whether the plan will meet your needs.
■ Health Maintenance Organization (HMO) Plans.
■ Preferred Provider Organization (PPO) Plans.
■ Private Fee-for-Service (PFFS) Plans.
■Medical Savings Account (MSA) Plans.
■ Special Needs Plans (SNP).
There are other less common types of Medicare Advantage Plans that may be available:
■ Point of Service (POS) Plans—Similar to HMOs, but you may be able to get some services out-of-network for a higher cost.
■ Provider Sponsored Organizations (PSOs)—Plans run by a provider or group of providers. In a PSO, you usually get your health care from the providers who are part of the plan.
Not all Medicare Advantage Plans work the same way, so before you join, find out the plan’s rules, what your costs will be, and whether the plan will meet your needs.
Electronic Health record
What is Electronic Health Records (EHR)
An Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports The EHR automates access to information and has the potential to streamline the clinician's workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.
EHRs are the inevitable next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians. The data, and the timeliness and availability of it, will enable providers to make better decisions and provide better care.
For example, the EHR can improve patient care by:
An Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports The EHR automates access to information and has the potential to streamline the clinician's workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.
EHRs are the inevitable next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians. The data, and the timeliness and availability of it, will enable providers to make better decisions and provide better care.
For example, the EHR can improve patient care by:
- Reducing the incidence of medical error by improving the accuracy and clarity of medical records.
- Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.
- Reducing medical error by improving the accuracy and clarity of medical records.
Claims Data for PHRs - Blue Button Initiative
In January 2010 the Centers for Medicaid & Medicare Services (CMS) and the Department of Veterans Affairs (VA) were invited to attend a meeting with the Markle Consumer Engagement Workgroup. Discussion at the face-to-face meeting focused on how best to provide consumers with electronic access to data and to incent market innovators to create health information technology solutions using the data, to expand its usefulness for individuals. The workgroup expressed a strong desire for CMS and VA as "data holders" to participate in follow up discussions on the breakthrough idea of a download button (i.e. a "blue button" in the portal) that would enable individuals to download their electronic health data. Subsequent discussions on the potential for a demonstration project included a request for the creation and public availability of sample data sets from CMS and VA as a way to 1) advance understanding of the available data and 2) to begin to enable the identification and development of applications using the data to support consumer engagement.
Currently, Medicare beneficiaries can access their claims data on MyMedicare.gov, and can add personal information into that site as well. They can then create and print a report called the "On-the-Go report" to share with their caregivers and providers. At this time, beneficiaries cannot download their own data into their own computers. CMS is interested in enabling beneficiaries to use their data with other health management tools, and may be conducting a project called "the BlueButton" through which beneficiaries can test their computer's ability to download their claims information in a simple file format, which can then be uploaded into a unique Personal Health Record application of their choice.
Today Veterans can create and maintain a web-based Personal Health Record (PHR) with VA's My HealtheVet. My HealtheVet is intended to improve the delivery of health care services to Veterans, to promote health and wellness, and to engage Veterans as more active participants in their health care. The My HealtheVet portal enables Veterans to create and maintain a web-based PHR that provides access to patient health education information and resources, a comprehensive personal health journal, and electronic services such as online VA prescription refill requests and secure messaging. Veterans can visit the My HealtheVet website and self-register to create an account, although registration is not required to view the professionally-sponsored health education resources, including topics of special interest to the Veteran population. Once registered, Veterans can create a customized PHR that is accessible from any computer with Internet access.
On May 10, 2010, CMS and VA co-hosted a web-based meeting on increasing consumer access to data through the use of Personal Health Record (PHR) applications. CMS and VA are working together because of our mutual interest in improving services to constituents, including PHR-related services. This meeting was intended as a dialogue and exchange of ideas to foster innovation, not just for CMS and VA beneficiaries, but also as an exercise for the PHR industry to gain experience in using data from external entities. We hope this meeting will support industry innovation and enable industry stakeholders to provide feedback for future initiatives to better serve citizens. Interested parties learned about the sample data sets available to test PHR functionality and related health information technology applications and services. To access the sample data files, go to the Related Links Inside CMS section below. This is part of the government's ongoing efforts to support ehealth initiatives and open government principles.
Currently, Medicare beneficiaries can access their claims data on MyMedicare.gov, and can add personal information into that site as well. They can then create and print a report called the "On-the-Go report" to share with their caregivers and providers. At this time, beneficiaries cannot download their own data into their own computers. CMS is interested in enabling beneficiaries to use their data with other health management tools, and may be conducting a project called "the BlueButton" through which beneficiaries can test their computer's ability to download their claims information in a simple file format, which can then be uploaded into a unique Personal Health Record application of their choice.
Today Veterans can create and maintain a web-based Personal Health Record (PHR) with VA's My HealtheVet. My HealtheVet is intended to improve the delivery of health care services to Veterans, to promote health and wellness, and to engage Veterans as more active participants in their health care. The My HealtheVet portal enables Veterans to create and maintain a web-based PHR that provides access to patient health education information and resources, a comprehensive personal health journal, and electronic services such as online VA prescription refill requests and secure messaging. Veterans can visit the My HealtheVet website and self-register to create an account, although registration is not required to view the professionally-sponsored health education resources, including topics of special interest to the Veteran population. Once registered, Veterans can create a customized PHR that is accessible from any computer with Internet access.
On May 10, 2010, CMS and VA co-hosted a web-based meeting on increasing consumer access to data through the use of Personal Health Record (PHR) applications. CMS and VA are working together because of our mutual interest in improving services to constituents, including PHR-related services. This meeting was intended as a dialogue and exchange of ideas to foster innovation, not just for CMS and VA beneficiaries, but also as an exercise for the PHR industry to gain experience in using data from external entities. We hope this meeting will support industry innovation and enable industry stakeholders to provide feedback for future initiatives to better serve citizens. Interested parties learned about the sample data sets available to test PHR functionality and related health information technology applications and services. To access the sample data files, go to the Related Links Inside CMS section below. This is part of the government's ongoing efforts to support ehealth initiatives and open government principles.
Tuesday, June 22, 2010
Medicare HIC Prefixes and Suffixe code and explanation
Medicare HIC Prefixes and Suffixes
HIC Suffix Sex Explanation
A M or F PRIMARY CLAIMANT
B F AGED WIFE, AGE 62 OR OVER (FIRST CLAIMANT)
B1 M AGED HUSBAND, AGE 62 OR OVER (FIRST CLAIMANT)
B2 F YOUNG WIFE, WITH A CHILD IN HER CARE (FIRST CLAIMANT)
B3 F AGED WIFE (SECOND CLAIMANT)
B4 M AGED HUSBAND (SECOND CLAIMANT)
B5 F YOUNG WIFE (SECOND CLAIMANT)
B6 F DIVORCED WIFE, AGE 62 OR OVER (FIRST CLAIMANT)
B7 F YOUNG WIFE (THIRD CLAIMANT)
B8 F AGED WIFE (THIRD CLAIMANT)
B9 F DIVORCED WIFE (SECOND CLAIMANT)
BA F AGED WIFE (FOURTH CLAIMANT)
BD F AGED WIFE (FIFTH CLAIMANT)
BG M AGED HUSBAND (THIRD CLAIMANT)
BH M AGED HUSBAND (FOURTH CLAIMANT)
BJ M AGED HUSBAND (FIFTH CLAIMANT)
BK F YOUNG WIFE (FOURTH CLAIMANT)
BL F YOUNG WIFE (FIFTH CLAIMANT)
BN F DIVORCED WIFE (THIRD CLAIMANT)
BP F DIVORCED WIFE (FOURTH CLAIMANT)
BQ F DIVORCED WIFE (FIFTH CLAIMANT)
BR M DIVORCED HUSBAND (FIRST CLAIMANT)
BT M DIVORCED HUSBAND (SECOND CLAIMANT)
BW M YOUNG HUSBAND (SECOND CLAIMANT)
BY M YOUNG HUSBAND (FIRST CLAIMANT)
C1-C9, CA-CZ M or F CHILD (INCLUDES MINOR, STUDENT OR DISABLED CHILD)
D F AGED WIDOW, 60 OR OVER (FIRST CLAIMANT)
D1 M AGED WIDOWER, AGE 60 OR OVER (FIRST CLAIMANT)
D2 F AGED WIDOW (SECOND CLAIMANT)
D3 M AGED WIDOWER (SECOND CLAIMANT)
D4 F WIDOW (REMARRIED AFTER ATTAINMENT OF AGE 60) (FIRST CLAIMANT)
D5 M WIDOWER (REMARRIED AFTER ATTAINMENT OF AGE 60) (FIRST CLAIMANT)
D6 F SURVIVING DIVORCED WIFE, AGE 60 OR OVER (FIRST CLAIMANT)
D7 F SURVIVING DIVORCED WIFE (SECOND CLAIMANT)
D8 F AGED WIDOW (THIRD CLAIMANT)
D9 F REMARRIED WIDOW (SECOND CLAIMANT)
DA F REMARRIED WIDOW (THIRD CLAIMANT)
DC M SURVIVING DIVORCED HUSBAND (FIRST CLAIMANT)
DD F AGED WIDOW (FOURTH CLAIMANT)
DG F AGED WIDOW (FIFTH CLAIMANT)
DH M AGED WIDOWER (THIRD CLAIMANT)
DJ M AGED WIDOWER (FOURTH CLAIMANT)
DK M AGED WIDOWER (FIFTH CLAIMANT)
DL F REMARRIED WIDOW (FOURTH CLAIMANT)
DM M SURVIVING DIVORCED HUSBAND (SECOND CLAIMANT)
DN F REMARRIED WIDOW (FIFTH CLAIMANT)
DP M REMARRIED WIDOWER (SECOND CLAIMANT)
DQ M REMARRIED WIDOWER (THIRD CLAIMANT)
DR M REMARRIED WIDOWER (FOURTH CLAIMANT)
DS M SURVIVING DIVORCED HUSBAND (THIRD CLAIMANT)
DT M REMARRIED WIDOWER (FIFTH CLAIMANT)
DV F SURVIVING DIVORCED WIFE (THIRD CLAIMANT)
DW F SURVIVING DIVORCED WIFE (FOURTH CLAIMANT)
DX M SURVIVING DIVORCED HUSBAND (FOURTH CLAIMANT)
DY F SURVIVING DIVORCED WIFE (FIFTH CLAIMANT)
DZ M SURVIVING DIVORCED HUSBAND (FIFTH CLAIMANT)
E F MOTHER (WIDOW) (FIRST CLAIMANT)
E1 F SURVIVING DIVORCED MOTHER (FIRST CLAIMANT)
E2 F MOTHER (WIDOW) (SECOND CLAIMANT)
E3 F SURVIVING DIVORCED MOTHER (SECOND CLAIMANT)
E4 M FATHER (WIDOWER) (FIRST CLAIMANT)
E5 M SURVIVING DIVORCED FATHER (WIDOWER) (FIRST CLAIMANT)
E6 M FATHER (WIDOWER) (SECOND CLAIMANT)
E7 F MOTHER (WIDOW) (THIRD CLAIMANT)
E8 F MOTHER (WIDOW) (FOURTH CLAIMANT)
E9 M SURVIVING DIVORCED FATHER (WIDOWER) (SECOND CLAIMANT)
EA F MOTHER (WIDOW) (FIFTH CLAIMANT)
EB F SURVIVING DIVORCED MOTHER (THIRD CLAIMANT)
EC F SURVIVING DIVORCED MOTHER (FOURTH CLAIMANT)
ED F SURVIVING DIVORCED MOTHER (FIFTH CLAIMANT
EF M FATHER (WIDOWER) (THIRD CLAIMANT)
EG M FATHER (WIDOWER) (FOURTH CLAIMANT)
EH M FATHER (WIDOWER) (FIFTH CLAIMANT)
EJ M SURVIVING DIVORCED FATHER (THIRD CLAIMANT)
EK M SURVIVING DIVORCED FATHER (FOURTH CLAIMANT)
EM M SURVIVING DIVORCED FATHER (FIFTH CLAIMANT)
F1 M FATHER
F2 F MOTHER
F3 M STEPFATHER
F4 F STEPMOTHER
F5 M ADOPTING FATHER
F6 F ADOPTING MOTHER
F7 M SECOND ALLEGED FATHER
F8 F SECOND ALLEGED MOTHER
J1 M or F PRIMARY PROUTY ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND)
J2 M or F PRIMARY PROUTY ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND)
J3 M or F PRIMARY PROUTY NOT ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND)
J4 M or F PRIMARY PROUTY NOT ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND)
K1 F PROUTY WIFE ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (FIRST CLAIMANT)
K2 F PROUTY WIFE ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (FIRST CLAIMANT)
K3 F PROUTY WIFE NOT ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (FIRST CLAIMANT)
K4 F PROUTY WIFE NOT ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (FIRST CLAIMANT)
K5 F PROUTY WIFE ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (SECOND CLAIMANT)
K6 F PROUTY WIFE ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (SECOND CLAIMANT)
K7 F PROUTY WIFE NOT ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (SECOND CLAIMANT)
K8 F PROUTY WIFE NOT ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (SECOND CLAIMANT)
K9 F PROUTY WIFE ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (THIRD CLAIMANT)
KA F PROUTY WIFE ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (THIRD CLAIMANT)
KB F PROUTY WIFE NOT ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (THIRD CLAIMANT)
KC F PROUTY WIFE NOT ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (THIRD CLAIMANT)
KD F PROUTY WIFE ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (FOURTH CLAIMANT)
KE F PROUTY WIFE ENTITLED TO HIB (OVER 2 Q.C (FOURTH CLAIMANT)
KF F PROUTY WIFE NOT ENTITLED TO HIB (LESS THAN 3 Q.C.)(FOURTH CLAIMANT)
KG F PROUTY WIFE NOT ENTITLED TO HIB (OVER 2 Q.C.)(FOURTH CLAIMANT)
KH F PROUTY WIFE ENTITLED TO HIB (LESS THAN 3 Q.C.)(FIFTH CLAIMANT)
KJ F PROUTY WIFE ENTITLED TO HIB (OVER 2 Q.C.) (FIFTH CLAIMANT)
KL F PROUTY WIFE NOT ENTITLED TO HIB (LESS THAN 3 Q.C.)(FIFTH CLAIMANT)
KM F PROUTY WIFE NOT ENTITLED TO HIB (OVER 2 Q.C.) (FIFTH CLAIMANT)
T M or F UNINSURED-ENTITLED TO HIB UNDER DEEMED OR RENAL PROVISIONS
TA M or F MQGE (PRIMARY CLAIMANT)
TB M or F MQGE AGED SPOUSE (FIRST CLAIMANT)
TC M or F MQGE DISABLED ADULT CHILD (FIRST CLAIMANT)
TD M or F MQGE AGED WIDOW(ER) (FIRST CLAIMANT)
TE M or F MQGE YOUNG WIDOW(ER) (FIRST CLAIMANT)
TF M MQGE PARENT (MALE)
TG M or F MQGE AGED SPOUSE (SECOND CLAIMANT)
TH M or F MQGE AGED SPOUSE (THIRD CLAIMANT)
TJ M or F MQGE AGED SPOUSE (FOURTH CLAIMANT)
TK M or F MQGE AGED SPOUSE (FIFTH CLAIMANT)
TL M or F MQGE AGED WIDOW(ER) (SECOND CLAIMANT)
TM M or F MQGE AGED WIDOW(ER) (THIRD CLAIMANT)
TN M or F MQGE AGED WIDOW(ER) (FOURTH CLAIMANT)
TP M or F MQGE AGED WIDOW(ER) (FIFTH CLAIMANT)
TQ F MQGE PARENT (FEMALE)
TR M or F MQGE YOUNG WIDOW(ER) (SECOND CLAIMANT)
TS M or F MQGE YOUNG WIDOW(ER) (THIRD CLAIMANT)
TT M or F MQGE YOUNG WIDOW(ER) (FOURTH CLAIMANT)
TU M or F MQGE YOUNG WIDOW(ER) (FIFTH CLAIMANT)
TV M or F MQGE DISABLED WIDOW(ER) FIFTH CLAIMANT
TW M or F MQGE DISABLED WIDOW(ER) FIRST CLAIMANT
TX M or F MQGE DISABLED WIDOW(ER) SECOND CLAIMANT
TY M or F MQGE DISABLED WIDOW(ER) THIRD CLAIMANT
TZ M or F MQGE DISABLED WIDOW(ER) FOURTH CLAIMANT
T2-T9 M or F DISABLED CHILD (SECOND TO NINTH CLAIMANT)
W F DISABLED WIDOW, AGE 50 OR OVER (FIRST CLAIMANT)
W1 M DISABLED WIDOWER, AGE 50 OR OVER (FIRST CLAIMANT)
W2 F DISABLED WIDOW (SECOND CLAIMANT)
W3 M DISABLED WIDOWER (SECOND CLAIMANT)
W4 F DISABLED WIDOW (THIRD CLAIMANT)
W5 M DISABLED WIDOWER (THIRD CLAIMANT)
W6 F DISABLED SURVIVING DIVORCED WIFE (FIRST CLAIMANT)
W7 F DISABLED SURVIVING DIVORCED WIFE (SECOND CLAIMANT)
W8 F DISABLED SURVIVING DIVORCED WIFE (THIRD CLAIMANT)
W9 F DISABLED WIDOW (FOURTH CLAIMANT)
WB M DISABLED WIDOWER (FOURTH CLAIMANT)
WC F DISABLED SURVIVING DIVORCED WIFE (FOURTH CLAIMANT)
WF F DISABLED WIDOW (FIFTH CLAIMANT)
WG M DISABLED WIDOWER (FIFTH CLAIMANT)
WJ F DISABLED SURVIVING DIVORCED WIFE (FIFTH CLAIMANT)
WR M DISABLED SURVIVING DIVORCED HUSBAND (FIRST CLAIMANT)
WT M DISABLED SURVIVING DIVORCED HUSBAND (SECOND CLAIMANT)
How to bill bilateral procedure and get paid
Payment of Bilateral Procedures in a Method II Critical Access Hospital (CAH)
BackgroundThe Social Security Act (Section 1834(g)(2)(B); see http://www.ssa.gov/OP_Home/ssact/title18/1834.htm on the Internet) states that professional services included within outpatient Critical Access Hospital (CAH) services, will be paid 115 percent of such amounts as would otherwise be paid under this part if such services were not included in the outpatient CAH services. The Centers for Medicare & Medicaid Services (CMS) establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. See 42 CFR 414.40 at http://edocket.access.gpo.gov/cfr_2007/octqtr/pdf/42cfr414.42.pdf on the Internet. This includes the use of the 50 modifier (bilateral procedure).
Physicians and non-physician practitioners billing on type of bill (TOB) 85X for professional services rendered in a Method II CAH have the option of reassigning their billing rights to the CAH. When the billing rights are reassigned to the Method II CAH, payment is made to the CAH for professional services (revenue codes (RC) 96X, 97X or 98X).
Bilateral procedures are procedures performed on both sides of the body during the same operative session. Medicare makes payment for bilateral procedures based on lesser of the actual charges or 150 percent of the Medicare Physician Fee Schedule (MPFS) amount when the procedure is authorized as a bilateral procedure. CR 6526 implements the 150 percent payment adjustment for bilateral procedures. Medicare contractors use payment policy indicators associated with certain procedures in the MPFS in processing claims and determining payment.
Bilateral procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is authorized as a bilateral procedure and is billed on TOB 85X with revenue code (RC) 96X, 97X or 98X and the 50 modifier (bilateral procedure). Modifier 50 applies to bilateral procedures performed on both sides of the body during the same operative session. When a procedure is identified by the terminology as bilateral or unilateral or bilateral, the 50 modifier is not reported.
If a procedure is authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator 1), the procedure should be reported on a single line item with the 50 modifier and one service unit. Whenever the 50 modifier is appended, the appropriate number of service units is one.
Modifiers LT (left side) and RT (right side) are not to be reported when the 50 modifier applies. Claims with the LT and RT modifiers will be returned to the provider (RTP) when modifier 50 applies. See the Medicare Claims Processing Manual, Chapter 4, section 20.6 at http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf on the CMS website for more information on the use of the 50, LT and RT modifiers.
If a procedure can be billed as bilateral but is not authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator 3), the procedure is to be reported on a single line item with the 50 modifier and one service unit. Payment is made based on the lesser of the actual charges or 100% of the MPFS amount for each side of the body.
The January 2010 Integrated Outpatient Code Editor (IOCE) specifications will include a change to edit 74 (units greater than one for bilateral procedures billed with modifier 50). At that time, claims submitted on TOB 85X with revenue code (RC) 96X, 97X or 98X , a Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code with a bilateral indicator of ‘1’ or ‘3’, modifier 50 and more than one service unit on the same line will be returned to the provider.
Medicare uses the bilateral surgery payment policy indicators on the MPFS to determine if the 150 percent payment adjustment is payable for a specific HCPCS/CPT code. The MPFS database is located at http://www.cms.hhs.gov/apps/ama/license.asp?file=/pfslookup/02_PFSsearch.asp on the CMS website. Medicare contractors have access to the payment policy indicators via the Physician Fee Schedule Payment Policy Indicator File in their claims processing systems.
BackgroundThe Social Security Act (Section 1834(g)(2)(B); see http://www.ssa.gov/OP_Home/ssact/title18/1834.htm on the Internet) states that professional services included within outpatient Critical Access Hospital (CAH) services, will be paid 115 percent of such amounts as would otherwise be paid under this part if such services were not included in the outpatient CAH services. The Centers for Medicare & Medicaid Services (CMS) establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. See 42 CFR 414.40 at http://edocket.access.gpo.gov/cfr_2007/octqtr/pdf/42cfr414.42.pdf on the Internet. This includes the use of the 50 modifier (bilateral procedure).
Physicians and non-physician practitioners billing on type of bill (TOB) 85X for professional services rendered in a Method II CAH have the option of reassigning their billing rights to the CAH. When the billing rights are reassigned to the Method II CAH, payment is made to the CAH for professional services (revenue codes (RC) 96X, 97X or 98X).
Bilateral procedures are procedures performed on both sides of the body during the same operative session. Medicare makes payment for bilateral procedures based on lesser of the actual charges or 150 percent of the Medicare Physician Fee Schedule (MPFS) amount when the procedure is authorized as a bilateral procedure. CR 6526 implements the 150 percent payment adjustment for bilateral procedures. Medicare contractors use payment policy indicators associated with certain procedures in the MPFS in processing claims and determining payment.
Bilateral procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is authorized as a bilateral procedure and is billed on TOB 85X with revenue code (RC) 96X, 97X or 98X and the 50 modifier (bilateral procedure). Modifier 50 applies to bilateral procedures performed on both sides of the body during the same operative session. When a procedure is identified by the terminology as bilateral or unilateral or bilateral, the 50 modifier is not reported.
If a procedure is authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator 1), the procedure should be reported on a single line item with the 50 modifier and one service unit. Whenever the 50 modifier is appended, the appropriate number of service units is one.
Modifiers LT (left side) and RT (right side) are not to be reported when the 50 modifier applies. Claims with the LT and RT modifiers will be returned to the provider (RTP) when modifier 50 applies. See the Medicare Claims Processing Manual, Chapter 4, section 20.6 at http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf on the CMS website for more information on the use of the 50, LT and RT modifiers.
If a procedure can be billed as bilateral but is not authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator 3), the procedure is to be reported on a single line item with the 50 modifier and one service unit. Payment is made based on the lesser of the actual charges or 100% of the MPFS amount for each side of the body.
The January 2010 Integrated Outpatient Code Editor (IOCE) specifications will include a change to edit 74 (units greater than one for bilateral procedures billed with modifier 50). At that time, claims submitted on TOB 85X with revenue code (RC) 96X, 97X or 98X , a Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code with a bilateral indicator of ‘1’ or ‘3’, modifier 50 and more than one service unit on the same line will be returned to the provider.
Medicare uses the bilateral surgery payment policy indicators on the MPFS to determine if the 150 percent payment adjustment is payable for a specific HCPCS/CPT code. The MPFS database is located at http://www.cms.hhs.gov/apps/ama/license.asp?file=/pfslookup/02_PFSsearch.asp on the CMS website. Medicare contractors have access to the payment policy indicators via the Physician Fee Schedule Payment Policy Indicator File in their claims processing systems.
Personal Health Records (PHR)
What is Personal Health Records (PHR)
The Centers for Medicare & Medicaid Services (CMS) has been engaged in a number of pilot projects to encourage Medicare beneficiaries to take advantage of Personal Health Records (PHRs). These tools, usually available through the internet, can help people track their health care services and better communicate with their providers. The type of Personal Health Records CMS has been testing are populated with health information from Medicare claims data. In the future, these records may be able to get information from a provider's electronic health record system, and some providers may begin to allow patients to see the information directly from those electronic records.
In general, a Personal Health Record (PHR) is controlled by the individual, and can be shared with others, including caregivers, family members and providers. This is different from a provider's electronic health record, which is controlled by the provider just as paper medical records are today. Ideally, a Personal Health Record will have a fairly complete summary of an individual's health and medical history based on data from many sources, including information entered by the individual (allergies, over the counter medications, family history, etc).
Today, Personal Health Records are available from a number of sources: by many health plans for their members, by providers for their patients, and by independent vendors who are given permission by the individual to receive and store information from health plans, providers, pharmacies, labs, etc.
The Centers for Medicare & Medicaid Services (CMS) has been engaged in a number of pilot projects to encourage Medicare beneficiaries to take advantage of Personal Health Records (PHRs). These tools, usually available through the internet, can help people track their health care services and better communicate with their providers. The type of Personal Health Records CMS has been testing are populated with health information from Medicare claims data. In the future, these records may be able to get information from a provider's electronic health record system, and some providers may begin to allow patients to see the information directly from those electronic records.
In general, a Personal Health Record (PHR) is controlled by the individual, and can be shared with others, including caregivers, family members and providers. This is different from a provider's electronic health record, which is controlled by the provider just as paper medical records are today. Ideally, a Personal Health Record will have a fairly complete summary of an individual's health and medical history based on data from many sources, including information entered by the individual (allergies, over the counter medications, family history, etc).
Today, Personal Health Records are available from a number of sources: by many health plans for their members, by providers for their patients, and by independent vendors who are given permission by the individual to receive and store information from health plans, providers, pharmacies, labs, etc.
Payment of Bilateral Procedures - 150% of allowed amount
Payment of Bilateral Procedures in a Method II Critical Access Hospital (CAH)
Part A Providers
Provider Types Affected Method II Critical Access Hospitals (CAH) submitting claims to Medicare contractors (Fiscal Intermediaries (FIs) and/or A/B Medicare Administrative Contractors (A/B MACs)) for bilateral procedure services provided to Medicare beneficiaries.
Impact to You This article is based on Change Request (CR) 6526 which implements payment for bilateral procedures performed in Method II Critical Access Hospitals (CAHs), in cases where the physician reassigns billing rights to the Method II CAH.
What You Need to Know Bilateral procedures are procedures performed on both sides of the body during the same operative session. Medicare makes payment for bilateral procedures based on the lesser of the actual charges or 150 percent of the Medicare Physician Fee Schedule (MPFS) amount when the procedure is authorized as a bilateral procedure. Modifier 50 is used for bilateral procedures and this article provides information on claims submission for these procedures. CR 6526 implements the 150 percent payment adjustment for bilateral procedures.
What You Need to Do See the Background and Additional Information Sections of this article for further details regarding these changes.
Part A Providers
Provider Types Affected Method II Critical Access Hospitals (CAH) submitting claims to Medicare contractors (Fiscal Intermediaries (FIs) and/or A/B Medicare Administrative Contractors (A/B MACs)) for bilateral procedure services provided to Medicare beneficiaries.
Impact to You This article is based on Change Request (CR) 6526 which implements payment for bilateral procedures performed in Method II Critical Access Hospitals (CAHs), in cases where the physician reassigns billing rights to the Method II CAH.
What You Need to Know Bilateral procedures are procedures performed on both sides of the body during the same operative session. Medicare makes payment for bilateral procedures based on the lesser of the actual charges or 150 percent of the Medicare Physician Fee Schedule (MPFS) amount when the procedure is authorized as a bilateral procedure. Modifier 50 is used for bilateral procedures and this article provides information on claims submission for these procedures. CR 6526 implements the 150 percent payment adjustment for bilateral procedures.
What You Need to Do See the Background and Additional Information Sections of this article for further details regarding these changes.
Monday, June 21, 2010
How to Coding - E- prescribing with example
Medicare E-prescribing Bonus Payment – Coding Scenario Examples
Example for G8443; All Medications Prescribed Electronically
Mr. Johnson sees Dr. Smith regularly for treatment of his hypertension and hyperlipidemia. Dr. Smith e-prescribes the renewal of Mr. Johnson’s medication. Dr. Smith bills CPT code 99214 for the established patient office visit and reports the HCPCS code G8443 to indicate that all prescriptions generated during the visit were electronically prescribed. Dr. Smith lists ICD-9 code 401.1 to indicate Mr. Johnson’s benign hypertension as the primary reason for the encounter.
Example for G8445, No Medications Prescribed
Mrs. Jones, who is new to Medicare, comes to see Dr. Smith because of her acute, mild respiratory symptoms. Dr. Smith determines that Mrs. Jones has a cold and recommends an over the counter medication. Dr. Smith bills CPT code 99202 for the new patient office visit and reports the HCPCS code G8445 to indicate that there were no prescriptions associated with the visit. Dr. Smith lists ICD-9 code 460, acute nasopharyngitis, as the reason for the encounter.
Example for G8446, One or More of Medications Not Prescribed Electronically
Mrs. Green, who regularly visits Dr. Smith for multiple chronic conditions, sees Dr.Smith for extreme pain associated with her severe arthritis that is compounded by her osteoporosis. Dr. Smith prescribes a controlled substance, which cannot be prescribed electronically, for her pain in addition to renewing other prescriptions. Dr. Smith bills CPT code 99215 for the established patient office visit and reports the HCPCS code G8446 to indicate that one or more of medications were not e-prescribed. Dr. Smith lists ICD-9 code 715.09 to indicate Mrs. Green’s generalized osteoarthritis in multiple sites is the primary reason for the encounter.
Example for G8443; All Medications Prescribed Electronically
Mr. Johnson sees Dr. Smith regularly for treatment of his hypertension and hyperlipidemia. Dr. Smith e-prescribes the renewal of Mr. Johnson’s medication. Dr. Smith bills CPT code 99214 for the established patient office visit and reports the HCPCS code G8443 to indicate that all prescriptions generated during the visit were electronically prescribed. Dr. Smith lists ICD-9 code 401.1 to indicate Mr. Johnson’s benign hypertension as the primary reason for the encounter.
Example for G8445, No Medications Prescribed
Mrs. Jones, who is new to Medicare, comes to see Dr. Smith because of her acute, mild respiratory symptoms. Dr. Smith determines that Mrs. Jones has a cold and recommends an over the counter medication. Dr. Smith bills CPT code 99202 for the new patient office visit and reports the HCPCS code G8445 to indicate that there were no prescriptions associated with the visit. Dr. Smith lists ICD-9 code 460, acute nasopharyngitis, as the reason for the encounter.
Example for G8446, One or More of Medications Not Prescribed Electronically
Mrs. Green, who regularly visits Dr. Smith for multiple chronic conditions, sees Dr.Smith for extreme pain associated with her severe arthritis that is compounded by her osteoporosis. Dr. Smith prescribes a controlled substance, which cannot be prescribed electronically, for her pain in addition to renewing other prescriptions. Dr. Smith bills CPT code 99215 for the established patient office visit and reports the HCPCS code G8446 to indicate that one or more of medications were not e-prescribed. Dr. Smith lists ICD-9 code 715.09 to indicate Mrs. Green’s generalized osteoarthritis in multiple sites is the primary reason for the encounter.
AARP Medicare Rx Plan Enrollment Information
AARP Medicare Rx Plan Enrollment Information
Open enrollment is between November 15th and December 31st of each year.
You will need to compare plans to see which will meet your individual needs. If you are currently an AARP Medicare Plan beneficiary, your membership will be renewed automatically; however, you may use the open enrollment period to make any needed changes to your plan.
How Do I Prepare for Enrollment?
First, you need to check to see if you qualify for financial assistance. Based on your income and resources, you may be eligible for assistance to help offset or completely pay additional out-of pocket expenses (costs not covered by your insurance plan). Pre-planning is important, and it may take up to eight weeks for financial assistance to be processed and approved. Don't delay. You don't want to miss the enrollment period (Nov 15 - Dec 31).
Next, you will need to gather all your information on health care or drug coverage you may have. You will also need to make a complete list of the names, dosage, and refill information for any prescription drugs you currently take. This information will help you to compare plans and make the best choice.
The final step is to compare several Medicare Part D Plans in your area. There are several things you should consider in order to accurately compare plans. You will need to find out what the monthly premiums are, and if there is a deductible. Also, ask the following questions: What is the company's reputation? What drugs are covered? Is there a co-pay amount?
Once you have completed these steps, it is time to select the option that will provide you with the coverage you require, and enroll in the plan you have chosen. With the costs of prescription drugs on the rise, this program can help you get the medications you need when you need them.
Open enrollment is between November 15th and December 31st of each year.
You will need to compare plans to see which will meet your individual needs. If you are currently an AARP Medicare Plan beneficiary, your membership will be renewed automatically; however, you may use the open enrollment period to make any needed changes to your plan.
How Do I Prepare for Enrollment?
First, you need to check to see if you qualify for financial assistance. Based on your income and resources, you may be eligible for assistance to help offset or completely pay additional out-of pocket expenses (costs not covered by your insurance plan). Pre-planning is important, and it may take up to eight weeks for financial assistance to be processed and approved. Don't delay. You don't want to miss the enrollment period (Nov 15 - Dec 31).
Next, you will need to gather all your information on health care or drug coverage you may have. You will also need to make a complete list of the names, dosage, and refill information for any prescription drugs you currently take. This information will help you to compare plans and make the best choice.
The final step is to compare several Medicare Part D Plans in your area. There are several things you should consider in order to accurately compare plans. You will need to find out what the monthly premiums are, and if there is a deductible. Also, ask the following questions: What is the company's reputation? What drugs are covered? Is there a co-pay amount?
Once you have completed these steps, it is time to select the option that will provide you with the coverage you require, and enroll in the plan you have chosen. With the costs of prescription drugs on the rise, this program can help you get the medications you need when you need them.
Medicare Rx Plans Does AARP Offer?
What Medicare Rx Plans Does AARP Offer?
Three prescription drug plans will be offered in 2007. They are AARP Medicare Rx Plan, AARP Medicare Rx Plan - Enhanced, and AARP Medicare Rx Plan - Saver. Each plan may have one or more of the four tiers (co-pay/co-insurance coverage levels) offered for you to choose from.
Description of Tiers and Co-Pay
* Tier 1 - This has the lowest co-pay and includes most generic drugs.
* Tier 2 - This has the medium co-pay and includes preferred brand name drugs.
* Tier 3 - This has higher co-pay and includes non-preferred drugs.
* Specialty Tier - This is the highest cost co-insurance.
Each of the three plan options is unique. Listed below are the items covered by each plan.
AARP Medicare Rx Plan
* Includes 100% of the drugs covered by Medicare Part D
* Mid-priced premium
* Flat and simple co-pays
* No deductible
* Over 60,000 participating network pharmacies
AARP Medicare Rx Plan - Enhanced
* Includes 100% of the drugs covered by Medicare Part D
* Tier 1 generic drug coverage (w/in coverage gap)
* Bonus drug list (drugs not covered by Medicare Part D)
* Flat and simple co-pays
* No deductible
* Over 60,000 participating network pharmacies
AARP Medicare Rx Plan - Saver
* Low monthly premiums
* Low co-pays
* Annual deductible ($265)
* Includes 100% of the drugs covered by Medicare Part D
Three prescription drug plans will be offered in 2007. They are AARP Medicare Rx Plan, AARP Medicare Rx Plan - Enhanced, and AARP Medicare Rx Plan - Saver. Each plan may have one or more of the four tiers (co-pay/co-insurance coverage levels) offered for you to choose from.
Description of Tiers and Co-Pay
* Tier 1 - This has the lowest co-pay and includes most generic drugs.
* Tier 2 - This has the medium co-pay and includes preferred brand name drugs.
* Tier 3 - This has higher co-pay and includes non-preferred drugs.
* Specialty Tier - This is the highest cost co-insurance.
Each of the three plan options is unique. Listed below are the items covered by each plan.
AARP Medicare Rx Plan
* Includes 100% of the drugs covered by Medicare Part D
* Mid-priced premium
* Flat and simple co-pays
* No deductible
* Over 60,000 participating network pharmacies
AARP Medicare Rx Plan - Enhanced
* Includes 100% of the drugs covered by Medicare Part D
* Tier 1 generic drug coverage (w/in coverage gap)
* Bonus drug list (drugs not covered by Medicare Part D)
* Flat and simple co-pays
* No deductible
* Over 60,000 participating network pharmacies
AARP Medicare Rx Plan - Saver
* Low monthly premiums
* Low co-pays
* Annual deductible ($265)
* Includes 100% of the drugs covered by Medicare Part D
AARP Medicare Rx Plan
A Quick Overview of the AARP Medicare Rx Plan
AARP is a Medicare approved organization you can trust. It offers three different drug plans for you to choose from. AARP designed these drug plans to provide prescription drugs to Medicare beneficiaries at lower costs. You can't afford not to enroll if you are eligible. When the need arises for prescription drugs, you'll have peace of mind knowing that a majority of your medication costs will be covered. Read below to learn more about this popular program.
What Can I Expect from an AARP Medicare Rx Plan?
When choosing an AARP Medicare Rx Plan, you can expect affordable and flat co-pays and three plan options (two have no annual deductibles). Drug coverage will include every brand name prescription drug or its generic brand that is covered by Medicare Part D with over 60,000 participating pharmacies.
AARP is a Medicare approved organization you can trust. It offers three different drug plans for you to choose from. AARP designed these drug plans to provide prescription drugs to Medicare beneficiaries at lower costs. You can't afford not to enroll if you are eligible. When the need arises for prescription drugs, you'll have peace of mind knowing that a majority of your medication costs will be covered. Read below to learn more about this popular program.
What Can I Expect from an AARP Medicare Rx Plan?
When choosing an AARP Medicare Rx Plan, you can expect affordable and flat co-pays and three plan options (two have no annual deductibles). Drug coverage will include every brand name prescription drug or its generic brand that is covered by Medicare Part D with over 60,000 participating pharmacies.
Medicare prescription coverage.
Eligibility for Part C
If you join Part C, you will still be in the Medicare Program and will have complete Part A and B coverage. You will continue to have Medicare rights and protection and in most cases, you will have prescription drug coverage (Part D) included as well.
You can join Part C if you reside in the service area where you wish to join, if you already have Medicare Part A and B, and if you do not have End-Stage Renal Disease (with minor exceptions).
Part C is really not that complicated once you understand it all. Before you decide to get health care insurance, it is a good idea to make sure you have a clear understanding of the coverage and premiums. This is not guesswork; don't be afraid to ask questions. A Medicare representative can help you find the answers
Do You Need Prescription Drug Coverage?
Most Part C plans already include prescription drug coverage (Part D). If your plan offers drug coverage, you have to take it. If you have a stand-alone drug plan, and your Medicare Advantage Plan already has one, you will not be able to keep the Part C coverage. If you already have a prescription drug coverage, then you may choose a plan that does not have the drug plan included.
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If you join Part C, you will still be in the Medicare Program and will have complete Part A and B coverage. You will continue to have Medicare rights and protection and in most cases, you will have prescription drug coverage (Part D) included as well.
You can join Part C if you reside in the service area where you wish to join, if you already have Medicare Part A and B, and if you do not have End-Stage Renal Disease (with minor exceptions).
Part C is really not that complicated once you understand it all. Before you decide to get health care insurance, it is a good idea to make sure you have a clear understanding of the coverage and premiums. This is not guesswork; don't be afraid to ask questions. A Medicare representative can help you find the answers
Do You Need Prescription Drug Coverage?
Most Part C plans already include prescription drug coverage (Part D). If your plan offers drug coverage, you have to take it. If you have a stand-alone drug plan, and your Medicare Advantage Plan already has one, you will not be able to keep the Part C coverage. If you already have a prescription drug coverage, then you may choose a plan that does not have the drug plan included.
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Saturday, June 19, 2010
How to Report the E-prescribing Incentive Program Measure
To obtain the incentive in 2009, you have to report on the e-prescribing quality
measure for 50% of applicable cases. The e-prescribing measure has two basic elements: (1) a reporting denominator consisting of a specified set of service codes that defines the circumstances when the measure is reportable; and (2) a reporting numerator consisting of a set of specific “G” -codes, one of which must be reported for successful reporting.
When you have an applicable case (defined by engaging in one of the service codes listed in Step 1 below for a Medicare Part B Fee-For-Service beneficiary), you report on the e-prescribing measure with two steps:
Step 1. Bill on one of the following service denominator codes:
| 90801 | 92004 | 99201 | 99215 |
| 90802 | 92012 | 99202 | 99241 |
| 90804 | 92014 | 99203 | 99242 |
| 90805 | 96150 | 99204 | 99243 |
| 90806 | 96151 | 99205 | 99244 |
| 90807 | 96152 | 99211 | 99245 |
| 90808 | 99212 | G0101 | |
| 90809 | 99213 | G0108 | |
| 92002 | 99214 | G0109 |
*Codes in bold typically billed by internists.
Step 2. Report one of the three G-codes listed below on more than 50% of applicable
cases for the numerator. All three codes (even the code for not generating prescriptions)
count toward the e-prescribing incentive. One of the G codes must be reported on the
same claim as the denominator billing code.
E-prescribing Incentive Program Quick Reference: G -Codes
| If You... | Report |
| Used a qualified e-prescribing system for all of the prescriptions | G8443 |
| Had a qualified e-prescribing system, but didn’t generate any prescriptions during this encounter | G8445 |
| Had a qualified e-prescribing system, but could not electronically submit one or more of the generated prescriptions because: • The prescription was for narcotics or other controlled substances. • State or Federal law required you to phone in or print the prescriptions. • The patient asked that you phone in or print the prescriptions. • The pharmacy system was unable to receive an electronic transmission. | G8446 |
*** Work Flow Suggestion—Add the three e-prescribing measure numerator G-Codes to your superbill.
Medicare Changes to 2010 CPT Inpatient Consultation Codes
Prevent 99251-99245 denials in 2010 with this checklist.
Multiple physicians using the same hospital codes sounds like a recipe for denials, but that’s what Medicare is instructing physician inpatient consultants and care coordinators to do.
Whether carriers will kick out these submissions as coordination of care or inpatient admit limiting admit edits is contractor specific, Charles E. Haley, MD, MS, FACP, Medicare medical director for Trailblazer Health Enterprises, LLC, told the audience during the E/M session at the 2010 CPT symposium. “If come January you’re getting denials, work out the issues with your specific contractor.”
You can, however, prevent many rejections from Medicare’s invalidation of 99251-99245 by following this checklist.
√ Use Initial Hospital Day Codes on Day 1
If a physician consults a patient on his first day in the hospital, you should use an initial hospital code (99221-99223), according to Medicare’s new consultation guidelines for 2010. “Stop thinking of these codes as admit codes,” cautioned Peter A. Hollmann, MD, the AMA CPT Editorial Panel, Vice Chair. They are for initial hospital care. “We should say ‘admitting physician’ when we mean just that.
More than one physician can use an initial hospital care code for the same patient. If two physicians from different specialties are both consulting on a patient, both physicians use the initial code. Next, what’s up with modifier AI?
√ Designate Admitter With Modifier
Surgery coders will have to educate primary care physicians who perform the majority of admissions on attaching an appendage to indicate his role as the admitting doctor. “The physician of record will use the initial code with a modifier,” stressed Kenneth B. Simon, MD, MBA, CMS senior medical officer, in “Medicare Physician Payment Schedule 2010 Changes and Beyond” at the AMA CPT and RBRVS 2010 Annual Symposium in Chicago. All other same...
What Medicare Advantage (Part C) Plans are available?
There are several plans available for Medicare Advantage. The Part C plans include the following:
*Medicare Preferred Provider Organization (PPO) - You are able to see any doctor or specialist that you choose. If they are not in your PPO network, your cost will increase. You usually can see a specialist without a referral.
*Medicare Health Maintenance Organizations (HMO) - You are able to visit doctors in the HMO network only. In most cases, you will be required to have a referral to visit a specialist.
*Medicare Private Fee-for-Service (PFFS) - You are able to see any doctor or specialist, but they must be willing to accept the PFFS's fees, terms, and conditions. You do not have to have a referral to see a specialist.
*Medicare Special Needs - These plans are designed for people with certain chronic diseases or other special health needs. These plans must include Part A, Part B, and Part D coverage.
*Medicare Medical Savings Account (MSA) - There are two parts to this plan:
(1) A high-deductible plan with which coverage won't begin until the annual deductible is met.
(2) A savings account plan where Medicare deposits money for you to use for health care costs.
Medicare part C - what it is
Explanation of Medicare Part C
When considering your Medicare options, it is easy to get confused and overwhelmed. Relax and take one section at a time to gain an overall understanding. Knowing what Medicare is and how it works will help you to make the best decision. One option is called Part C, or Medicare Advantage Plan (like HMO or PPO).
What is Part C?
Medicare Part C combines your Part A and Part B options and must cover all medically needed services. The difference is that private insurance companies that are approved by Medicare provide this type of coverage. In most cases, Part C is a lower-cost alternative to the Original Medicare Plan, and providers usually offer extra benefits and include prescription drug coverage (Part D).
Part C plans often have networks, and you must use the doctors or hospitals that belong to the plan. These plans help you coordinate and manage your overall care. Part C includes specialized care for people who need a large amount of health care services. If you find yourself needing medical attention while traveling out of your plan coverage area, you will still be covered for emergency or urgent care services.
Thursday, June 17, 2010
Why patient need to get enrolled in Medicare -
Disadvantages of NOT Enrolling in Medicare Part B
Applies only if you are covered for Medicare Part A, but not enrolled in Medicare Part B, and have a medical plan:
- If you decide not to purchase Medicare Part B when you become eligible, your plan will not coordinate coverage for Medicare Part B services. That means you’ll continue to pay for those services and equipment as you did before you become eligible for Medicare. For example, under the Anthem Blue Cross Plan II, a doctor’s office visit will be covered at 80 percent after your deductible. You would be responsible for the remaining 20 percent.
- Without Medicare Part B, you would continue to incur these costs until you hit your out-of-pocket maximum on Anthem Blue Cross Plan II ($2,500 per calendar year, including deductible). If you have Anthem Blue Cross Plan I or Prudent Buyer Plan, you will continue to incur the costs into the future because there is no out-of-pocket maximum.
- You are subject to the one (1) million dollar Lifetime Maximum coverage for the Anthem Blue Cross Plans I, II, and Prudent Buyer Plan, alone or combined. “Combined” means any benefits paid under a prior LACERA-administered Anthem Blue Cross plan will reduce any maximum amounts eligible for the current Anthem Blue Cross plan.
- Without Medicare Part B, you are ineligible to enroll in a LACERA-administered Medicare plan. Thus, you are disqualified from participating in the County’s Medicare Part B Premium Reimbursement Program.
- If you are eligible, but are not enrolled in Medicare Part B and have a HMO plan, you may pay a higher premium.
- Finally, if you decide not to enroll in Medicare Part B when you become eligible at age 65, and later decide to enroll, you will be charged a penalty of 10 percent for each year you were eligible and chose to decline coverage. If you are a late enrollee in Medicare Part B and pick one of the plans eligible for reimbursement, the County will not reimburse the penalty portion of the Part B premium.
Ultimately, the decision is yours. It is worth considering enrolling in Medicare Part B as soon as you are eligible to avoid penalties for late enrollment. Additionally, enrolling in Medicare Parts A and B and a Medicare plan will qualify you for the County’s Medicare Part B Premium Reimbursement Program and coordination of benefits with Medicare, providing the following conditions are met:
- You are paying for your Medicare Part B premium yourself.
- You are not being reimbursed for your Medicare Part B Premium by another agency, for example: other employer, State.
NOTE: Some benefit information mentioned above may be subject to future changes.
Advantages of Enrollment in Medicare Part B
Advantages of Enrollment in Medicare Part B
If you are enrolled in Medicare Parts A and B, and Non-Medicare plan:
- Suppose you have Part B and are enrolled in Anthem Blue Cross Prudent Buyer or Anthem Blue Cross I, II Plan; Medicare and Anthem Blue Cross will coordinate coverage for services. That means when you visit your doctor, once you’ve met your deductible, Medicare Part B will pay 80 percent of eligible services and Anthem Blue Cross will pay a portion of the remaining balance of eligible services, according to each plan design. That leaves you with a small out-of-pocket expense. Over time, Medicare Part B may help reduce your overall health care spending depending how often you use the covered services.
- You are subject to the Lifetime Benefit Maximum of one (1) million dollars coverage for Anthem Blue Cross Plans I, II, and Prudent Buyer Plan, alone or combined. “Combined” means any benefits paid under a prior Anthem Blue Cross plan will reduce any maximum amounts eligible for the current Anthem Blue Cross plan. With Part B coverage paying most of your eligible medical services, it will help you reach your Maximum Lifetime Benefit at a slower pace.
- If you have a Non-Medicare HMO plan, you agree to receive covered services from the plan; and in most situations there is no coordination of coverage between your Medicare and the HMO plan
If you are enrolled in Medicare Parts A and B, and a LACERA-administered Medicare plan:
- Suppose you have both Medicare Part B and Anthem Blue Cross III Plan; Medicare and Anthem Blue Cross will coordinate coverage for services. That means when you visit your doctor, Medicare Part B will pay 80 percent of eligible services and the Anthem Blue Cross III Plan will pick up the remaining 20 percent of eligible services. That leaves little or nothing for you to pay out-of-pocket. Over time, Medicare Part B may help reduce your overall health care spending. In addition, you are not subject to the Lifetime Benefit Maximum of one (1) million dollars that applies to the other Anthem Blue Cross plans.
- If you have a LACERA-administered Medicare Advantage Prescription Drug Plan (MA-PD) such as Kaiser Senior Advantage, you assign Medicare Parts A, B, and D to your medical plan, and must receive all covered services directly from the plan.
- Currently, the County reimburses the 2008 Medicare Part B standard rate of $96.40 for all Medicare Plan enrollees, subject to annual review and approval by the Board of Supervisors.
Medicare physician fee schedule - Quick overview
