Email not displaying correctly? View it in your browser. Issue #14 — August 24, 2011
AAPC BillingInsider e-Newsletter

F R O M   T H E   F I E L D

Medicare and Workers' Compensation Settlements
By Luann Jenkins, CPC, CPMA, CEMC, CFPC

Have you ever received this denial from Medicare?

PR 201 Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC Medicare set aside arrangements or other agreement.

This denial happens when the Centers for Medicare & Medicaid Services (CMS) has been involved in the settlement of a Workers' Compensation case. CMS is required to review workers' compensation settlements if the worker involved is:

  • Currently a Medicare Beneficiary, and total settlement is over $25,000
  • Currently not a Medicare beneficiary but there is a reasonable expectation of Medicare enrollment within 30 months, and settlement is for $250,000 or more

From these reviews Medicare may require a Workers’ Compensation Medical Set-Aside Arrangement (WCMSA), whereby Medicare agrees to address future medical benefits. The WCMSA can be established as a structured arrangement, through which payments are made on a defined schedule to cover projected future expenses.

These agreements require a patient receiving medical services to pay from a fund that he or she personally controls, or that is managed by another entity. Patients are responsible to cover medical expenses until the funds are exhausted, after which Medicare will be responsible. The CMS website has further information.

G O O D   T I P S

Bill for Smoking Cessation

The smoking cessation codes have sparked a lot of attention lately. Yes, you really can bill for these services, but not every payer will reimburse you.

Let's look at the codes and descriptor requirements. Note that if you counsel the patient for fewer than three minutes, you would not report these codes. Be sure that the time spent counseling is specified in the medical record.

CPT® Codes
99406 - Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407 - intensive, greater than10 minutes

HCPCS Level II Codes
G0436 - Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes
G0437- intensive, greater than10 minutes

Payers who do not reimburse for these services may, nonetheless, apply the charges toward any unmet patient deductable. Other payers may bundle the services to any other E/M service on the same day. Check with your insurance plans for details, so that you are able to inform patients whether the service will be covered. Note that insurers may offer different plans with varying coverage. For example, Blue Cross/Blue Shield covers smoking cessation on some of their plans, but not on others.

F E A T U R E D   S T O R Y

Handle Non-Covered Services for Non-Medicare Patients
By Delly Parham, CPC

When a patient elects to receive a service deemed medically unnecessary or non-covered by his or her insurer, the patient is financially responsible for the charges. These services may be included in your participating agreement with the insurance carriers or they may be obtained from insurances. When your provider determines that a service is medically unnecessary, always advise your patients and consider these tactics to help preserve revenue:

  • Implement a financial policy for non-covered services that includes:
    • Non-covered services are to be paid at the time they are rendered.
    • The patient must sign a notice of non-covered service indicating his or her acceptance of financial responsibility.
    • Inform the patient that no coded receipt of the visit will be provided.
    • If the patient pays cash, a cash receipt will be provided (cash receipts can be obtained from a local office supply store).
    • No claim will be sent to the patient's insurance carrier at any time, now or in the future, unless the patient wants a denial for a flex plan or some specific coverage. For these patients, verify the coverage.
  • Do not allow your patients to dictate how and when your practice bills insurances for non-covered and/or medically unnecessary services. It is the provider's responsibility to make coverage determinations.
  • Do not misrepresent non-covered or medically unnecessary services as covered services to "help the patient get the service reimbursed by insurance." This might be fraudulent under the False Claims Act.

Warning: Providing patients with coded receipts (e.g., V50.9 and A9270) would allow the patient to submit the bill to the insurance carrier. The service could be considered by the carrier and may be covered for a low dollar amount. If you are contracted with the patient's insurance carrier and the patient gets a non-covered or medically unnecessary service covered and paid, your practice is obligated to refund the difference between the amount you collected at the time of service, and the amount the carrier paid, OR you should refund the insurance carrier with a letter stating that the service should not be covered because the provider has deemed the service "not medically necessary."

Remember to check payer contracts for hold harmless language. And remember it can be noncompliant to provide services to a patient and then refuse to bill with hopes of retaining the patient's payment.

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
Workers' Compensation
Bill for Smoking Cessation
Non-Covered Services

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