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Medicare's rules??

  1. #1
    Default Medicare's rules??
    Medical Coding Books
    I am recently employed in a physicians office for the first time doing the billing and coding. I am being told, what I think of as crazy things. For starters is it true that Medicare reduces payment 60% when diagnosis codes from the 300's are used (such as depression)? Second they are saying that you can't send in paper claims? So they won't bill an unlisted code because it won't pay, but
    I was under the understanding that if you had to use an unlisted code then you send in the claim on paper with the notes supporting the unlisted code? I have alot of other questions but this is a good start.

    Thanks to anyone who can help!

  2. #2
    Columbia, MO
    I am aware that in some areas to use a 300 level dx to indicate mental disease or process, the payer will down pay about 50% to the family practice or internal medicine, just because there is the availablity of mental health in your area. As far as paper claims you need to check with the payer regarding scanned information, if they do not allow scanned info then you must communicate that some claims must be submitted via paper, they truely must allow one or the other. If you run into the brick wall, then request the number for the CMS regional office and contact them for a solution. This office is there to help when the brick wall has been met.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    North Carolina
    Outpatient Mental Health Treatment Limitation

    Regardless of the actual expenses a beneficiary incurs for treatment of mental, psychoneurotic, and personality disorders while the beneficiary is not an inpatient of a hospital at the time such expenses are incurred, the amount of those expenses that may be recognized for Part B deductible and payment purposes is limited to 62.5 percent of the Medicare approved amount for these services. The limitation is called the outpatient mental health treatment limitation.

    Last edited by RebeccaWoodward*; 08-28-2009 at 06:31 AM.

  4. #4
    Tuscaloosa, AL
    Our Medicare carrier in Alabama (Cahaba GBA) requires an electronic submission of the unlisted procedure code. They will request documentation after it is in their system. You may have to work with your Medicare carrier's EDI department and/or your clearinghouse to get the unlisted code to go through. Good luck.


  5. #5
    Somers Point, NJ
    I worked for AARP for over a decade.

    Never use an unlisted code/DX. That is your last resort. You are just doing more work for yourself.

    It is true that in the case of psych codes that the payment is (used to be) 62.5% under cms from the approved amount.

    I do remember too, most provider of services DID NOT accept the medicare assignment.

    Example would be billed $300.00, Approved $100.00 x 62.5%=$37.50. You do not need to send the claims paper with a special report unless it is a unusual situation. If I remember right then the $37.50 is then calculated with the 80%. Not sure though.

    Thanks you have me thinking on this one.
    Last edited by tippee; 08-30-2009 at 12:44 AM. Reason: can not spell

  6. #6
    Columbia, MO
    I do not see how it is possible to never use an unspecified dx code... As in 401.9 for HTN . There are times when that is all you have, and the same is true for the procedure code, with new techniques and such there are times when the codes just do not keep pace. I agree with what Rebecca stated regarding the outpatient rule, however I did not know that applied to physician billing, I know in some areas when it can be proven there are no psych services available then the physician can get better reimbursement.
    I know also that some payers say to submit the unlisted via electronic and send doc only when requested. And that works when you have already set the precendent for your use of that code for that reason, also remember to put the disciption and compare to information in the gray line above the code using the ZZ qualifier. I hate working things on the back end and I would still try to find a way to get the payer to allow initial submission for unlisted procedures with the documentation.

    Debra A. Mitchell, MSPH, CPC-H

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