Email not displaying correctly? View it in your browser. Issue #12 — June 22, 2011
AAPC BillingInsider e-Newsletter

F R O M   T H E   F I E L D

Can We Bill for That?
By LuAnn Jenkins, CPC, CPMA, CEMC, CFPC

When searching for the answers to tough billing questions, here are the resources I recommend:

  • Medicare Local Coverage Policies - Detail what is considered medically necessary, including the ICD-9-CM codes.
  • National Correct Coding Initiative (NCCI) - Contains a list of code combinations that cannot be billed and guidelines for each section that provide specifics about services that may be billed separately.
  • CPT® guidelines - The CPT® manual has section guidelines that provide additional coding assistance (CPT® is not a payer policy and not all payers follow CPT® rules).
  • Commercial Payer Coverage policies - Always check individual payers for their policies and guidance. Do not assume all follow Medicare.
  • AMA RBRVS Data Manager - Provides detail of resources used to determine RVUs. For example: how much time is allotted for pre-service evaluation, intraservice work and immediate post-service work; the number of post-operative days and the practice resources expected to be used (staff time, supplies, equipment, medications). This resource will apply to most payers that use RVUs as a basis for their fee schedules.

Billers and coders must be sure that the answers we give are based on documented information, and not an "opinion." Never assume that a denial from a payer is accurate unless we can confirm that it is based on documented policy. Our goal should be to optimize reimbursement by proving what can be billed, but also to protect our providers by understanding what cannot be billed based on the payer rules.

G O O D   T I P S

Are You Ready for Version 5010?

The 5010 standard for HIPAA transactions is effective January 1, 2012. Are you ready?

All HIPAA covered entities must make the transition. Failure to do so will prevent claims from being processed.

Providers, facilities, payers, Medicaid, EHR vendors, and other partners in the billing process have a chance to work out the bugs on August 24, 2011, the second of CMS' National Version 5010 Testing Days (the first was June 15th).

That doesn't mean you have to wait to test. You can contact your regional Medicare Administrative Contractor (MAC) and facilitate testing to gain a better understanding of MAC testing protocols and the transition. Successful testing is required before a "trading partner" may be "placed into production," says CMS.

The August 24th testing day also will give providers a chance to access real-time help desk support and direct access to their MACs.

For more information about the transition to 5010, go to your MAC or the CMS website.

F E A T U R E D   S T O R Y

Consultation Services and Medicare as Secondary Payer: Tips for Billing
By Delly Parham, CPC, AS

Medicare rule changes make staying on top of collections one of a practice's biggest challenges.

For example, with the exception of telemedicine, Medicare has eliminated payment for consultation codes, while many non-Medicare payers continue payment for consultations using the CPT® consultation codes [99241-99245 (office/outpatient) and 99251-99255 (inpatient visits)]. This creates confusion over how to bill when a non-Medicare carrier is the primary payer and Medicare is the secondary payer. Here are some tips:

  1. The consultation criteria must be met to report the consultation codes. The criteria include the "four Rs" (Request, Reason, Render, and Report).
  2. If the Primary payer follows Medicare's Consultation rules, providers must bill an appropriate E/M code for the services instead of CPT® consultation codes: for example, 99203 instead of 99243.
  3. If the primary payer continues to recognize consultation codes described in the CPT® manual, you must first determine the reimbursement rate for the consultation code vs. the reimbursement rate for the E/M code. You may choose either of the two options described below. The option you choose could affect the amount of reimbursement depending on the circumstances.

    Option 1:
    Bill the primary payer using the outpatient (99201-99215) or inpatient (99221-99233 Initial and Subsequent Hospital Care) E/M codes just as Medicare requires. Then report the amount actually paid by the primary payer along with the same E/M code to Medicare for determination of whether a payment is due.


    Option 2:
    Bill the primary payer using a consultation code that is appropriate for the service. Then report the amount actually paid by the primary payer along with an E/M code appropriate for the service to Medicare for determination of whether a payment is due as secondary payer.

FROM THE FIELD is thoughts and experiences from you the reader. If you have any tips, ideas, case studies, or just anecdotes please submit them to us for future editions.

In This Issue
Can We Bill for That?
Are You Ready for 5010?
Billing Consultations

Don't underestimate the importance of policies and procedures in the billing world.

Save time hunting down information for specific payer policies. We've compiled localized data from over 500 health plan's websites into an easy-to-use search tool.

Do you know a biller who might appreciate this newsletter?

The AAPC BillingInsider e-Newsletter is offered as a benefit to AAPC customers and we hope you find the information useful. If you'd rather not receive future BillingInsider e-Newsletters, please log in to your account and change your email preferences.

2233 S Presidents Dr., Suite F | Salt Lake City, UT 84120 | (801) 236-2200

Copyright © 2011 AAPC - All rights reserved. CPC®, CPC-H®, CPC-P®, CIRCC®, and CPMA® are registered trademarks of AAPC.

CPT® codes Copyright 2010 American Medical Association. All Rights Reserved. CPT® is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT®. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.