Dermatology Coding Alert

Published on Wed Mar 07, 2007 PDF

Question: One of our physicians is not yet credentialed with Medicare and our other carriers. We have a patient who needs surgery and doesn't want to wait. If this physician performs the surgery, how should we go about billing for the service?

Answer: When a new physician joins your practice, you not only have to give all of your carriers the new provider's information, but you also face the challenge of how to bill for the provider's services to both new and established patients who visit him at your practice.

"The only payers that usually let you back-bill and make the provider numbers retro are Medicare and public aid," says Sue Morrison, CCS-P, coding specialist with Physicians Billing Office, part of Sparta Community Hospital in Sparta, Illinois. Other payers give you an effective date for when you can start billing, Morrison adds. You cannot bill services under another provider while you're waiting for the new physician's credentialing completion.

Bill Medicare Retroactively

When a Medicare patient needs surgery before the physician is credentialed, you could take the private-pay route, if the patient is willing.

However, Medicare will allow you to place your physician's claims on hold from the date he files his Medicare provider number application and then file them once he receives his credentialing. You can do this for all of your surgeon's Medicare services while he remains without credentials.

Medicare will pay your claims retroactively from the date of the practice's new physician's NPI application. You should contact your carrier for details on how to do this.

Plan Ahead for Delays

Try this: In the future, you may want to allow your office more time when trying to credential a new physician.

The process can take 90 days or even longer, according to Medicare. Experts recommend that you initiate this process as far in advance of your new physician's starting date as you can (once you have all the necessary information such as the state license and DEA number)--two months ahead of time, if not more.

If you act early, you'll have the necessary credentials in place when the physician starts seeing patients and you won't have to hassle with delayed payments.

Don't Count On Private-Payer Payment

Although Medicare allows you to bill retroactively once a provider is credentialed, many carriers do not.

Tip: Try to arrange a new physician's starting date several months after his hire date to allow your billing office sufficient time to get everything in order.

Use Established Patient Codes for Followers

The problem: Whether to bill these visits as new or established patients is an on-going billing question.

Solution: Bill established patient codes for the new physician's patients who follow him to your practice. Billers often think they can bill a patient as new because the patient is new to their practice. But remember, the same physician already saw the patient - just in another location.