Priority Management Group – CHC Billing Experts

Our state recently told us that we can’t bill a 99211 done by an RN unless a midlevel or a Dr. is onsite.  We hadn’t heard this before.  Have you heard this?  We commonly bill a 99211 if the client is seen by an RN and the client is already established.

Assuming (and this is dangerous) the state is following the federal “incident to” guidelines (set forth initially in 1992) they require physical presence (and Medicare has clarified this to mean “within shouting distance”) of the provider under whose name the claim will be billed, therefore on-site. It is overlooked (ignored) by scores (I daresay thousands) of practices across the country as the 99211 is for most simply the code used for a non-billable provider visit; i.e., covers any multitude of services from conversation about diagnostic outcomes, simple walk-in issues not requiring a billable clinician, brief educational sessions, etc.  However, in the end, if following these federal rules, the billable provider must be on-site.

To your question, please remember that the “incident to” guidelines pertain only to Medicare in the fee-for-service (FFS) world in terms of using a different NPI. In a FQHC, Medicare is payable via the encounter rate which is based on face-to-face encounter between a patient and a “core provider.” The core provider can be a physician or a “non-physician practitioner” (NPP).  A NPP is defined as a Nurse Practitioner, Physician Assistant, or Certified Nurse Mid-wife. There is no reduction in payment (as in the FFS world) world when being compensated for “encounter rate.” Further, the restrictive “incident to” guidelines are Medicare FFS only which means you should not automatically apply these to Managed Medicaid, encounter rate (PPS) Medicaid, or other commercial plans unless you determine, in writing, that they follow Medicare’s explicit statutes.  However, since the Medicare “incident to” guidelines are quite conservative, it is a very safe way to interpret how to bill a NPP under a doctor’s NPI.

As most of you are aware, Medicare postponed implementation of edits to deny claims when/if the ordering/referring provider is either not enrolled in Medicare and/or does not have a current PECOS record.  There were a great many questions as to why this was required for FQHC providers as they are reimbursed at the all-inclusive rate and do not require individual provider enrollment applications.

CMS has now published guidance for those providers that ‘infrequently receive reimbursement from the Medicare program.’  One of the specific provider types mentioned is those employed at an FQHC.   They have abbreviated the application process but it indicates that it must be completed on paper and include a letter to advise that it is for the sole purpose of ordering/referring services for Medicare beneficiaries and CANNOT be reimbursed for services performed. 

While it sounds like they were being sensitive to the facts, it does not eliminate the need to complete the full 855I and R to capture payment for any services that are carved out of the FQHC Medicare contract. 

Here is the link and there are a few included in the document that you may want to check out.  I haven’t read through them all but will do so.  I also haven’t seen when the edit will be put into place as a final rule but we need to get ahead of the curve, just in case.

http://www3.cms.gov/MedicareProviderSupEnroll/Downloads/SpecialEnrollmentFactsheetInfrequentPhysicianReimbursement.pdf

By: Kristie Sell Viveiros, CPC, VP of Billing Operations Priority Management Group, Inc

We have a question – v72.40 – pregnancy unconfirmed, v72.41 pregnancy negative test, v72.42 pregnancy, positive test

Patients come in and wants to know if they are pregnant. We do the pregnancy test (HCG) this test will either read out negative or positive – we have used the above dx codes v72.41(Neg) or v72.42(Pos).  If a provider does this test and then wants to confirm the test by doing a venipucture and sends out to lab then we use the v72.40.

I have read in the coders desk reference that you would only use the above dx codes if there was absence of a symptom. I have also been told that we should be using v72.40 for every HCG test as these test are not fully accurate and most generally the provider will request a venipucture to have a confirmed dx of pregnancy.

I feel that the HCG is a test and we would be ok using v72.41 if test result is negative and v72.42 if test result is positive and if provider sends out the venipucture I would use v72.40.  If the pt came in and had symptoms then I would code symptoms for the HCG test.   

Can you give me your opinion on when we should and should not be using these dx codes?

Thanks for the note. In short, it is either positive or negative, period. This supports ACOG which says the “unconfirmed” option should be rarely used. In the family planning world, it is used to delay a confirmation to a third party payer or due to a need (desire) for ultrasound confirmation. However, the urine PT is pretty solid diagnostic evidence and patients either are, or are not, pregnant.

In a CHC wouldn’t the post partum be included in the delivery billing code since we billed the 59410 which is vaginal delivery with post partum care?

In short, yes. HOWEVER, if FQHC and the post partum occurs at the clinic site for Medicaid, they will normally want the T1015 for the postpartum so… would recommend billing 59409 for FQHC unless the state Medicaid program has more exacting instructions stating otherwise. Assuming we are not billing this for Medicare BUT could happen for SSI patient so in that case definitely use the 59409 and the UGS/NGS encounter rate would work for the office based post-partum encounter.

I have a question, can you bill for a visit to a family practice physician and a psychiatrist on the same day?

For UGS/NGS Medicare on a UB-04 claim the psych visit uses a 900 series revenue code with the appropriate behavioral health HCPCS (e.g., CPT code 90406) while the family practice doctor uses revenue code 521 with the appropriate medical service HCPCS (e.g., CPT code 99212). Full encounter rate payment is eligible less variable co-payments; i.e., the behavioral health component is near 50% while the medical is the standard 20% of charges.

Medicaid is similar to Medicare in this scenario, in nearly all states, except no co-payment. Commercial payers would also allow both to be paid due to two distinct provider specialties based on national board certification.

I have a question on billing out Nursing Visits (re: dressing changes, suture removals, etc) currently we enter these types of visits in our system but do not bill them to insurance companies.  As a FQHC can we bill these types of services to Medicare and Medicaid and if so, can you advise us on how what the guidelines would be as to who/what needs to be recorded in patients chart and if we would bill using the revenue code for Medicare or bill to NHIC, with Medicaid the T1015 or fee for service?

Thanks for the note. To be clear, there is distinction between Medicare and Medicaid on this topic. UGS/NGS Medicare payment is NOT available for nurse visits. This is incontrovertible. However, certain states (e.g., Vermont and Connecticut), have language within the Medicaid FQHC manuals which clearly affords payment opportunity for services rendered “incident to” a core provider.  The language for each state is unique so take a look yourself via the following URL. The T101, not fee for service, would be appropriate as this is what triggers encounter rate payment.

http://www.hrsa.gov/reimbursement/states/Vermont-Medicaid-Covered-Services.htm

According to CMS regulations, under Chapter 13 in the Medicare Benefit Policy Manual, 60.1, would fetal non-stress tests performed in the office setting fall under Incidental and Integral part of physician’s professional services, making it necessary for the physician to be on site in order to bill for the service?

In short, don’t think so.   CMS recognizes three levels of supervision: general, direct, and personal. General supervision means the billing.provider does not even need to be on-site; e.g., lab, ultrasound.  Direct means the billing provider needs to be in the office suite “within shouting distance;” e.g., residency supervision or “incident to” billing. Personal supervision means in the exam room with the patient; e.g., personal oversight of surgical resident if wanting to bill as attending. Thinking fetal stress testing (like ultrasound) falls under “general supervision” not requiring physical presence of the billing doctor.  

With exception of SSI patients, questioning how many OB services are rendered to Medicare patients.  Can research whether fetal stress tests definitely fall under “general” supervision, or not, if desired.

By Robert Skeffington, Partner, PMG, Inc.

Now that the celebrations have ended and the confetti has been cleared, it’s time to consider how the Patient Protection and Affordable Care Act will impact Federally Qualified Health Centers (FQHCs).

As one of the most effective federal programs, FQHCs are poised to continue their prominence. Nearly everyone agrees that covering more individuals with health insurance is a positive step forward, as is substantially growing the FQHC program. But what, if anything, will change in the revenue and/or billing process as a result of the new law? Patient revenues from Medicaid, Medicare and other payers make up more than 50 percent of an FQHC’s revenue. As such, this question requires further examination.But what, if anything, will change in the revenue and/or billing process as a result of the new law? Billing is more than half of the average FQHC’s annual revenue, so this question requires a closer look.

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Pawtucket, R.I., May 19, 2010 — Priority Management Group, Inc. (PMG), a leading national supplier of revenue cycle management and consulting services to community health centers, announced today it has entered into an agreement to serve East Liberty Family Health Care (ELFHC) of Pittsburgh, Penn.

The contractual arrangement calls for PMG to deliver a comprehensive suite of services in the back-end billing staffing, denial management and clearinghouse areas. PMG also will provide consulting services, including a full onsite operational assessment, to improve the effectiveness and efficiency of front-end billing processes along with semi-annual in-service training sessions to ensure appropriate coding by physicians.

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