Medicare provider based billing guidelines

The first option is that the hospital can provide a one-time notification to the CMS regional office, stating that they will be using "patient homes" in general as off-campus, provider-based clinics. This applies to every patient home that the hospital uses during the duration of the PHE. If they choose this, then every home is considered a "new" location, and the service will be paid at the PFS-equivalent rate. These claims get the -PN modifier. They also bill using the address of the hospital main campus on the claim. The notification to the CMS regional office is optional, but certainly a good practice to ensure that CMS is aware of your actions. When you submit a claim submit your usual fee. The carrier or MAC processes your claim based on the place of service you select. Be careful to select the correct place of service. It is important to know if the service is taking place in an outpatient department or physician office. Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch's career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti. This process is automatic. Your browser will redirect to your requested content shortly. CMS develops and publishes the Physician Fee Schedule in November of each year, as part of the Physician Fee Schedule Final Rule. With each CMS Town Hall call, I seem to learn a little bit more, and it makes me appreciate more the work of the CMS officials who could create such flexibilities in such a short time. In 1988, founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit Here is a link to a CMS MedLearn Matters article on the topic. The non-facility rate is the payment rate for services performed in the office. This rate is higher because the physician practice has overhead expenses for performing that service. (Place of service 11). And, if you need a refresher on RVUs and the fee schedule, see this CodingIntel article:. The fee schedule includes relative value units and payment indicators. Please turn JavaScript on and reload the page. Dear Resident, Do you Understand Relative Value Units (RVUs)?. Some codes may only be performed in one place or the other: for example, an initial hospital visit has only a facility fee, because it is never performed anywhere but a facility. Office visits, on the other hand, may be done in the office (non-facility) or in the outpatient department (facility.). Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do. Since you are establishing patients' homes as provider-based clinics, the conditions of participation for such clinics, located at 42 CFR 413.65, and 42 CFR 482.41, such as emergency power and fire safety plans, would normally have to be met. But CMS has waived those requirements as part of the PHE. That means that a hospital's ability to use patients' homes is contingent upon a formal waiver. Per instructions from CMS, as outlined in MLN Matters SE20011, the -DR condition code or -CR modifier should therefore be used. The use of the -DR or -CR is informational only, since the claim will appear as if the service was provided in person, and its absence should not result in a denial. RACMonitor: CMS Guidance Treating Patient Homes as Hospitals. xref 121 39 0000000016 00000 n 0000001567 00000 n 0000001726 00000 n 0000002230 00000 n 0000002344 00000 n 0000004115 00000 n 0000005810 00000 n 0000007441 00000 n 0000009007 00000 n 0000010819 00000 n 0000010960 00000 n 0000011544 00000 n 0000012053 00000 n 0000012165 00000 n 0000012192 00000 n 0000012676 00000 n 0000012951 00000 n 0000013449 00000 n 0000013721 00000 n 0000014309 00000 n 0000015913 00000 n 0000017560 00000 n 0000018865 00000 n 0000018935 00000 n 0000019035 00000 n 0000032775 00000 n 0000033061 00000 n 0000033423 00000 n 0000041895 00000 n 0000065605 00000 n 0000065729 00000 n 0000073149 00000 n 0000073188 00000 n 0000073266 00000 n 0000073525 00000 n 0000084770 00000 n 0000725403 00000 n 0000001395 00000 n 0000001097 00000 n trailer. The other option is to use the extraordinary circumstances policy in the second IFR to "relocate" a provider-based clinic temporarily to a patient's home individually. This would allow the hospital to be paid the OPPS rate for the services that are performed at that location. The hospital would use the -PO modifier to indicate that. But in this option, the hospital must notify the CMS regional office by email of their hospital's CCN; the address of the current provider-base department; the address(es) of the relocated departments (the patient home addresses); the date they began furnishing services at the new PBD(s); a brief justification for the relocation and the role of the relocation in the hospital's response to COVID-19; and an attestation that the relocation is not inconsistent with their state's emergency preparedness or pandemic plan. Interestingly, that information does not have to be sent until 120 days after starting to provide services at these locations, making operationalizing the process much easier. CMS must approve these relocations, and if the relocation is not approved, the care provided can be rebilled with the -PN modifier. Facility versus Non-Facility in the Physician Fee Schedule. There is continued confusion over the use of patient homes as off-campus, provider-based clinics for Medicare billing purposes. This is the provision in the Centers for Medicare & Medicaid Services' (CMS's) second recent Interim Final Rule (IFR) that allows hospitals to bill for services provided by employed hospital staff, such as therapists, dieticians, and counselors, who do not bill Medicare directly for their services (as they would in private practice). This provision also allows a hospital to bill a facility fee when one of their employed physicians performs a telehealth visit with a patient at a temporary location that is considered a provider-based clinic– including a patient's home. endobj 134 0 obj [147 0 R] endobj 135 0 obj stream. Like all of us, I am sure they will sleep well once the PHE has passed. The Medicare Physician Fee Schedule has values for some CPT codes that include both a facility and a non-facility fee. Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Provider contracted/negotiated rate expired or not on file. Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. Claim/service denied. Level of subluxation is missing or inadequate. Payment denied because only one visit or consultation per physician per day is covered. A therapy plan of care is developed either by the physician/NPP, or by the physical therapist who will provide the physical therapy services, or the occupational therapist who will provide the occupational therapy services, (only a physician may develop the plan of care in a CORF). The plan must be certified by a physician/NPP. Claim adjustment because the claim spans eligible and ineligible periods of coverage. Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Contracted funding agreement. Subscriber is employed by the provider of the services. Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. The date of birth follows the date of service. The procedure code is inconsistent with the provider type/specialty (taxonomy). State licensure requirements vary from state to state. However, in most states it is required that a physician interpreting a test hold a medical license in the state in which the test was administered. In the case of HSAT, the physician interpreting the test will typically be required to hold a license in the state where the patient was tested. Procedure code was incorrect. This payment reflects the correct code. can assist you in addressing these denials and recover the insurance reimbursement. For more information, feel free to call us at 888-552-1290 or write to us Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. CPT (Current Procedural Terminology) codes for massage therapy and related procedures– identifies the type of care or the procedure that is used in that care. The best way to know what codes the insurance company will accept is to call and ask them! You can not just bill whatever code that they accept. You have to bill what ever code you are trained in. Setting your fees for these codes are another issue. Just because you can get paid more for certain codes, you have to charge the same amount you charge cash clients (plus whatever additional billing fee there is) or else it is considered insurance fraud. These modalities apply to one or more areas treated per day (e.g. paraffin bath used for the left and right hand is billed as one unit). The G codes (G0398, G0399 and G0400), which describe home sleep apnea testing (HSAT) services, were added to the Healthcare Common Procedure Coding System (HCPCS) Level II codebook in 2008. For example, if 30 minutes of manual therapy techniques were provided to one or more regions, code 97140 would be reported two times, one for each 15-minute interval. Both services can be billed if the following conditions are met: both services are medically necessary; separate equipment is used for the ECG monitoring (PSG equipment with ECG lead and a holter monitor device); and separate interpretation and report is done for each procedure. The code for polysomnography is 95810 and the codes for holter monitoring are 93224-93227 (select code based on service provided). A patient undergoing polysomnography testing is also in the process of 24 hour electrocardiographic holter monitoring. Can these two procedures be coded separately? Which codes should be used? 29 N211 The time limit for filing has expired. You may not appeal this decision. Payment adjusted because rent/purchase guidelines were not met. Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. A1 N370 Oxygen equipment has exceeded the number of approved paid rentals. This (these) diagnosis(es) is (are) not covered, missing, or are invalid. Diagnosis codes (ICD codes-International Classification of Disease)- Diagnosis codes are often needed when billing even though we are not able to diagnose. This information should come from the referring physician. If the physician does not write the code on the prescription, call them directly to get the code. I highly recommend that you do not try to select your own code from the online code finder or the information below as each physician may code things differently. I am providing this information because physicians often write the code but they don't say what it means. How do home sleep apnea testing devices measure sleep time?. G47.30 (unspecified) G47.31 Primary central sleep apnea G47.32 High altitude periodic breathing G47.33 Obstructive sleep apnea (adult) (pediatric) G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation G47.35 Congenital central alveolar hypoventilation syndrome G47.36 Sleep related hypoventilation in conditions classified elsewhere G47.37 Central sleep apnea in conditions classified elsewhere G47.39 Other sleep apnea Diagnostic criteria for sleep apnea codes can be found in the International Classification of Sleep Disorders, 3rd Edition. Nursing Home Care vs. Home and Community Based Services..



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