Hey, everyone!
Long time browser, first time poster, hoping I can get some direction to some resources involving struggles I'm having both with insurances and coworkers. I've been doing hem/onc billing at outpatient practices for a few years now, but as we all know there's always something that comes along and futzes things up.
First, we're having difficulty with Medicare regarding pumps that patients take home and then return a day or two later. The patient receives deferoxamine (Desferal) in a portable pump. We send the claim to Medicare, however we're encountering a problem in how we bill the number of units. Desferal has an MUE of 12 for non-DME, so if we include the total number of units, we hit a denial for MUE. We can split the drugs, but then the question of how to split the drugs begins. Should we split it into each day's worth with a modifier, and if so a 59 or a 76? Do we just bill the max units for one day and then put what's left on another line with the modifier?
I've reached out to Noridian, and while I've been directed to very helpful guidelines for Part D billing, nothing for Part B.
Secondly, we're having a dispute amongst the staff involving provision of albuterol in an inhaler to patients receiving infusions or chemotherapy, or other times when a patient arrives for a visit and as part of the treatment the patient lets them take a puff off an inhaler. I've been arguing that there's a list online (https://med.noridianmedicare.com/web/jddme/claims-appeals/claim-submission/2018-jurisdiction-list) that clearly indicates that the inhaler should only be covered by part B if it's incident-to, which a nurse giving it to a patient having a reaction to the planned treatment wouldn't qualify as. Other people have argued that it's a separate service and needs to be billed, as the reaction is a new medical condition happening at that time and requires treatment. Others have stated "we've always billed it, it always gets paid," but I keep repeating that's not a solid argument.
Does anybody know if there's a definite definition or source I can cite to make sure we can stop billing this if it is incorrect or I can let my patients have a good "I told you so" if it is correct?
Thanks ahead of time for the assistance and for being such a great resource as I've continued learning new things every year!
Erik Bell
Long time browser, first time poster, hoping I can get some direction to some resources involving struggles I'm having both with insurances and coworkers. I've been doing hem/onc billing at outpatient practices for a few years now, but as we all know there's always something that comes along and futzes things up.
First, we're having difficulty with Medicare regarding pumps that patients take home and then return a day or two later. The patient receives deferoxamine (Desferal) in a portable pump. We send the claim to Medicare, however we're encountering a problem in how we bill the number of units. Desferal has an MUE of 12 for non-DME, so if we include the total number of units, we hit a denial for MUE. We can split the drugs, but then the question of how to split the drugs begins. Should we split it into each day's worth with a modifier, and if so a 59 or a 76? Do we just bill the max units for one day and then put what's left on another line with the modifier?
I've reached out to Noridian, and while I've been directed to very helpful guidelines for Part D billing, nothing for Part B.
Secondly, we're having a dispute amongst the staff involving provision of albuterol in an inhaler to patients receiving infusions or chemotherapy, or other times when a patient arrives for a visit and as part of the treatment the patient lets them take a puff off an inhaler. I've been arguing that there's a list online (https://med.noridianmedicare.com/web/jddme/claims-appeals/claim-submission/2018-jurisdiction-list) that clearly indicates that the inhaler should only be covered by part B if it's incident-to, which a nurse giving it to a patient having a reaction to the planned treatment wouldn't qualify as. Other people have argued that it's a separate service and needs to be billed, as the reaction is a new medical condition happening at that time and requires treatment. Others have stated "we've always billed it, it always gets paid," but I keep repeating that's not a solid argument.
Does anybody know if there's a definite definition or source I can cite to make sure we can stop billing this if it is incorrect or I can let my patients have a good "I told you so" if it is correct?
Thanks ahead of time for the assistance and for being such a great resource as I've continued learning new things every year!
Erik Bell