3 rd Party Primer 3 rd party

3 rd Party Primer • 3 rd party basics to answer the questions… – – – – – Who are the insurers in Nebraska? How do I evaluate 3 rd Party Plans? Should I be a provider? How do I enroll? What exam procedures do insurers require? What services & materials do they pay for? What documentation is required? What is coding & how do I do it? How do I file a claim? Where can I go for help? 1

NOA 3 rd Party Primer • • • Please do not become distraught…. Complex Subject Overwhelming at times Extremely Important – How you get paid – How you stay out of trouble! 2

NOA 3 rd Party Primer • • Background Becoming a Provider Verification of Coverage Record Documentation Filing Claims References and Resources Evaluating Insurance Plans before Joining 3

Types of 3 rd Party Payers Routine Vision Care (prepaid care) Medical (health insurance coverage) Combo: Routine & Medical by same 3 rd party 4

Types of 3 rd Party Payers Routine (pre-paid) Care Cover Exam and materials Limits on frequency Limits on materials Does not pay for medical services (fields, gonioscopy, retinal photos) • Generally file over Internet or may use own claim forms • • 5

Types of 3 rd Party Payers • Routine examples: – VSP – Eye. Med (Eye Care Plan of America) – Optum Health (Spectera) – Medicaid (patients w/o medical diagnosis) 6

Types of 3 rd Party Payers Medical (health insurance coverage of eye Dx) • Medical diagnosis only (not refractive codes) • Pays for other medical services (fields, gonio) • Rarely pays for materials • File electronically using HIPAA approved format (5010 coming up), or • File on paper CMS-1500 forms • • Only okay if less than 10 FTE employees 5010 coming up 7

Types of 3 rd Party Payers • Medical examples – Blue Cross Blue Shield – Coventry – United Health Care – Medicaid medical coverage 8

Types of 3 rd Party Payers • • • Combination of Routine & Medical coverage If no medical diagnosis, routine care limitations apply If medical diagnosis only, medical insurance limitations apply If both refractive and medical services are provided, respective limitations apply. (varies, however) 9

Types of 3 rd Party Payers • Combination Examples – Conventional Medicaid – Optum Health (Spectera) Routine w/ United Health Care medical – BCBS medical w/ EYEMED routine – VSP routine w/ either CIGNA or BCBS medical – BCBS special policies that include routine care 10

NOA 3 rd Party Primer • • Background Becoming a Provider Authorization – Verification Documentation Filing Claims References and Resources Evaluating Insurance Plans before Joining 11

Should You Become a Provider Don’t have to be provider; rather can… • Give Patient “super-bill” or print a claim form • Patient pays your fee to you • Patient sends to Insurer • Insurer pays patient their allowable 12

Should You Become a Provider – Exception: Medicare • If you see a Medicare patient, you must file the claim for the patient. 13

Should You Become a Provider? Advantages of not being provider • Full fee • • Don’t file claims • • (Must file Medicare) No limit on services provided • • (Medicare has fee limitations on nonproviders) (except Medicare) Medicare: if you see ANY Medicare patients, you must follow ALL Medicare rules. 14

Should You Become a Provider Advantages of being provider • On provider list (strong patient resource) No $ collection problems • Patient happy • • Doesn’t have to file own claim Less $ out-of pocket Fees seem more reasonable than out-of-plan provider’s fees 15

Should You Become a Provider If you are not a provider for an insurer, but you are filing the claim for the patient, you have the choice of whether to Accept Assignment • If you Accept Assignment, you agree to accept what an insurer pays, and the insurer pays you directly. • If you do not Accept Assignment, the insurance payment goes to the patient, and the patient (hopefully) pays you. 16

Should You Become a Provider • If you have signed up to be a provider for a private insurer, you have agreed to accept what they pay, and payments will come directly to you. 17

Should You Become a Provider If you see ANY Medicare patients, you must follow ALL Medicare rules. You have a choice of Participating or not Participating Provider. 18

Should You Become a Provider Participating Providers are paid directly by Medicare using their “Par” fee schedule None-Participating Providers… • • • Medicare will pay the patient The patient will (hopefully) pay you. What you charge a Medicare patient is limited by Medicare’s “limiting charge”. 19

Should You Become a Provider Medicare Advantage (MA) • Privatization of Medicare • Medicare charges patient then pays insurance companies a capitation amount per patient • Claims are filed with these MA companies, not with traditional Medicare • Many patients do not understand they are no longer covered directly by Medicare 20

Should You Become a Provider Medicare Advantage • Cost to patient may be the same as for traditional Medicare, or there may be an additional charge over traditional Medicare • MA policies may have different co-pay amounts and deductibles than traditional Medicare • Some plans offer additional benefits (dental care, routine vision, drug coverage included) 21

Should You Become a Provider Medicare Advantage comes in a variety of types • HMO: Patients see only panel doctors; panel networks small; providers accept HMO’s fees • PPO: Panels more open; some out of panel coverage; providers agree to accept PPO fees • PFFS (Private Fee For Service)…next slide 22

Should You Become a Provider • Medicare Advantage comes in a variety of types PFFS (Private Fee For Service): No networks, More expensive to patients, Pays provider per its fee schedule, Provider does not sign up to be in network If you accept a PFFS MA patient, you are “deemed” to accept their fee schedule. • If in doubt, check on reimbursement before seeing patient. • • • 23

Becoming a Provider • A list of the Medicare Advantage plans found in Nebraska can be found at the Nebraska SHIIP web site, http: //www. doi. ne. gov/shiip/medsup/medadv. pdf • http: //nebraska. aoa. org/prebuilt/noa/2007_04%20 Newsletter. pdf 24

Becoming a Provider • • NPI (National Provider Identifier) Need before enrolling as any provider Need a separate NPI for – – – Each doctor (only one NPI for any doctor), Each office location, Each separate business entity (optical dispensary may need separate NPI if has a separate tax ID number) • http: //www. cms. hhs. gov/National. Prov. Ident. Stand/01_Overview. asp #Top. Of. Page 25

Becoming a Provider • NPI (National Provider Identifier) Exception: Sole Proprietor (Not a PC or partnership, etc. )… – Only one NPI total (represents both doctor and her/his practice). – Get specifics at http: //www. cms. hhs. gov/National. Prov. Ident. Stand/01_Overview. as p#Top. Of. Page 26

Becoming a Provider • Sole Proprietor – Single NPI includes Dr and Dispensary – Use Taxonomy codes to distinguish • • • Doctor Code 152 W 00000 X Optical Dispensary Code 332 H 00000 X Verify at Source: http: //www. wpc-edi. com/codes/taxonomy 27

Becoming a Provider NPI (National Provider Identifier) Information on NPI application must match information on • – Medicare B application (855 i and 855 b) Medicare DME application (855 s) IRS information (Employer ID number, etc) • NPI enrollment information found at – – • National Plan and Provider Enumeration System (NPPES) • https: //nppes. cms. hhs. gov/NPPES/NPIRegistry. Home. do 28

Becoming a Provider • Make sure you used correct entity type on NPI application – Entity type 1 for OD and for OD sole proprietor – Entity type 2 for PC and group practice (partnership) 29

Contacts to Become a Provider • Routine Care (July 2011) – Avesis http: //www. avesis. com/provider_benefits. html – Eye. Med (Eyecare Plan of America) http: //portal. eyemedvisioncare. com/wps/portal/emweb/providers/become_a_provider – Optum (Spectera) https: //www. optumhealthvision. com/providers/OH_Vision_Provi der. jsp – Vision Service Plan (VSP) https: //www. vsp. com/cms/provider-home. html 30

Contacts to Become a Provider Standard Medicaid • Via Nebraska Dept. of Health & Human Services • Both Routine & Medical • All patients age 65 & up • http: //www. hhs. state. ne. us/med/providerenrollment. ht m 31

Contacts to Become a Provider Medicaid Managed Care Plans • Covers all Medicaid patients that are not also covered by Medicare • Nebraska Medicaid has contracted with Coventry Nebraska and Share Advantage health plans to provide managed care in ten eastern Nebraska counties until mid-2012. • Cass • Dodge • Douglas • Gage • Lancaster • Otoe • Sarpy • Saunders • Seward • Washington Beginning Mid-2012, the entire state will be covered by managed care plans. 32

Contacts to Become a Provider Medicaid Managed Care Plans “Share Advantage” • Administered by United Health. Care • Contact: Jeremy Sand, at 402 -445 -5587, or [email protected] com. 33

Contacts to Become a Provider • Medicaid Managed Care Plans • “Coventry Of Nebraska, Inc. ” • Administered by Coventry Health Care • Coventry of Nebraska’s “contracting area” call 800 -471 -0240. 34

Contacts to Become a Provider Medicaid Managed Care Plans’ Routine Vision Care Block Vision • OD wishing to provide routine vision care to a Medicaid Managed Care client must enroll with Block Vision. • For Block Vision credentialing • Call Adrienne Bennett, VP, Operations at 800 -243 -1401 x 1067; • Email [email protected] com. 35

Contacts to Become a Provider Medical Coverage Blue Cross Blue Shield of Nebraska http: //www. bcbsne. com/Providers/Library/Credentialing. aspx Midlands Choice http: //www. midlandschoice. com/Provider/Credentialing/Index. html 36

Side Note BCBS Requires Special Form For Retroactive Reimbursement Apparently BCBS will pay claims retroactive to the date of application for enrollment, but only when their special form is completed. Credentialing web page at: http: //www. bcbsne. com/Providers/Library/Credentialing. aspx P. 9. January 2009

Contacts to Become a Provider Medical Coverage Coventry 800 865 -2673, press 6 for credentialing United Health. Care, 877/842 -3210, then using a fake tax ID # 471234567, follow their phone voice response. When given the choice, say Next choice Press 1 or say “Credentialing” Next choice Press 2 say “Medical” First choice, Press 5 or say “…Other” Next choice Press 2 or say “Join network” UHC convoluted web site found at: http: //www. uhc. com/physicians/join_our_network. htm 38

Contacts to Become a Provider Medicare – Medicare Part B http: //www. wpsmedicare. com/j 5 macpartb/departments/enrollment/ – Rail Road Medicare Part B 877/288 -7600 • http: //www. palmettogba. com/palmetto/Providers. nsf/docs. Cat/Providers~Railroad%20 Medicare~Resources~Provider%20 Enrollment? open – Medicare Durable Medical Equipment • • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Brochure [PDF, 87 KB] https: //www. noridianmedicare. com/dme/enroll/ 39

Becoming a Provider • Multiple page application forms with considerable documentation: copies of – – – – • Optometry Diploma State License NPI (National Provider Identifier) DEA Registration (need it) Proof of Malpractice Insurance Photo ID …plus more in some cases Turn-around time: weeks to months 40

Becoming a Provider • • Once Approved you will be given Provider number Manuals &/or other (Web) resources – Claim requirements – Explanation of various plans – Other important data • • Be sure to read these resources…ignorance is not an excuse for incorrect claims! Fraudulent filing is a Federal crime. 41

NOA 3 rd Party Primer • • Background Becoming a Provider Authorization – Verification Documentation Filing Claims References and Resources Evaluating Insurance Plans before Joining 42

Authorization – Verification Ø Ø Ø Need to obtain authorization before providing some services &/or materials Need to verify that the patient is indeed covered. Most patients are clueless about coverage • • • Coverage is via spouse’s employment Employers change coverage regularly Carry cards from previous years Employer HR may inadvertently misinform Concept of Routine vs. Medical care misunderstood 43

Authorization – Verification • • Receptionist who gets 3 rd Party Info from patient is possibly most important person in your office. Need to photocopy both sides of current cards – Routine Care if they have it – Medical Insurance if they have it 44

Authorization – Verification • • Some new patients will not believe they need to give you medical insurance info since “it doesn’t cover eyes” Explain that you will file a claim for them if they have any diagnosis where they would benefit from medical coverage. 45

Authorization – Verification Authorization for Routine Care: • • • Call-Fax-Online as directed on card or contract Sometimes time consuming Some offices start preliminary testing in the meantime • Authorized for exam, lenses, frame, CLs 46

Authorization – Verification Authorization for Medical Care: • Wise to contact to verify coverage. • “Authorization” not needed if you are on panel. – However, some ERISA policies do not cover ODs for medical diagnoses. 47

Authorization – Verification • Some offices get info ahead of time – Via phone when making appointment – Mail patient forms to complete and bring in with them • • Accuracy may be a problem since patient are not knowledgeable about new coverage. Too many re-dos? 48

NOA 3 rd Party Primer • • Background Becoming a Provider Authorization – Verification Documentation of patient encounter Filing Claims References and Resources Evaluating Insurance Plans before Joining 49

Encounter Documentation • • • Must document everything you do Must do everything you document 3 rd Party has right to request your records 50

Encounter Documentation • • Billing more than what was performed is fraud (If you didn’t document it, you didn’t do it) Altering records post-facto is fraud Insurance fraud is federal offense 51

Encounter Documentation • • • Civil fines up to $10, 000 per incorrect line Errors require payback way-back in time Criminal repercussions include federal prison 52

Encounter Documentation • Record Reviewers discriminate between – Errors (payback; education) – Abuse (payback; penalty; close monitoring; ejection) – Fraud (heavy fines; jail time) 53

Encounter Documentation • Routine documentation – Provider Manual describes examination expectations – Need to clearly document in records 54

Encounter Documentation • • • Medical CPT (Current Procedural Terminology) defines 92000 services (printed yearly) 1997 Evaluation & Management Guidelines define documentation in 99000 examinations Must document everything (remember Hx) 55

NOA 3 rd Party Primer • • Background Becoming a Provider Authorization – Verification Documentation Filing Claims References and Resources Evaluating Insurance Plans before Joining 56

Filing Claims • • • Basic concepts today Resources provided Additional education if desired 57

Filing Claims – Info provided • • Who (patient & insured) Why (diagnosis) What (service provided) When (date provided) How Much (fees) Where (provided) By Whom (provider) 58

Filing Claims –Format Used • Medical Insurance Claims – Electronic – – Currently 837 electronic form still accepted HIPAA 5010 beginning January 2012 – Paper – • CMS-1500 paper form (less than 10 FTE employees) Routine Care Claims – Proprietary paper forms – CMS-1500 paper form – Internet direct filing 59

CMS-1500 to Electronic Claims Crosswalk • • For those who file electronically, there is a WPS source that explains where to insert the CMS 1500 data items into which electronic claim data loop. This is referred to as the CMS-1500 Electronic Claim Crosswalk, and can be found at – http: //www. wpsic. com/edi/pdf/npi_1500_crosswalk. pdf 60

Current CMS-1500 See Forms Handout 61

TOP OF CMS-1500 Insurance Type 62

TOP OF CMS-1500 Patient Demographic data 63

TOP OF CMS-1500 Insured Person’s Data 64

TOP OF CMS-1500 Other Insured Person’s Data 65

TOP OF CMS-1500 Subrogation Data 66

TOP OF CMS-1500 Other Insurance 67

TOP OF CMS-1500 Patient Authorization to File Claim See Forms Handout 68

TOP OF CMS-1500 Patient Authorization to Pay to Provider (So Dr. can accept assignment) See Forms Handout 69

BOTTOM CMS-1500 Referring Dr. Data 70

BOTTOM CMS-1500 Qualifying Information Example: Date assumed + date relinquished post-op care + # Post-op care days. 71

BOTTOM CMS-1500 Diagnosis Data MORE TO COME ON THIS AREA…. 72

BOTTOM CMS-1500 Date of Service Data 73

BOTTOM CMS-1500 Service & Materials Supplied MORE TO COME ON THIS AREA…. 74

BOTTOM CMS-1500 Charges/Fee Data 75

BOTTOM CMS-1500 Group Practice: Providing Dr’s NPI 76

BOTTOM CMS-1500 Provider Data 77

Medicare Provider Manual Billing Instructions Including what data in which box • CMS Medicare Claims Processing Manual Website – (chapter 26) http: //www. cms. hhs. gov/manuals/downloads/clm 104 c 26. pdf 78

Medicare Provider Manual Billing Instructions Including what data in which box 79

Medicaid Provider Manual Billing Instructions What data in which box • Payments section: • http: //www. sos. ne. gov/rules-andregs/regsearch/Rules/Health_and_Human_Services_System/Title -471/Chapter-03. pdf • Form CMS-1500 Instructions – http: //www. hhs. state. ne. us/reg/appx/471 -000 -65. pdf 80

Routine Care Claims • • • Companies may still use proprietary claim forms (or on-line via Internet) Patient & Insured demographics Policy data Service provided Diagnosis (refractive ICD-9 -CM) Materials provided 81

NOA 3 rd Party Primer • • • Background Becoming a Provider Authorization – Verification Documentation Filing Claims – Diagnosis coding • • References and Resources Evaluating Insurance Plans before Joining 82

BOTTOM CMS-1500 Diagnosis Data 83

Diagnosis Codes • • • Don’t write “cataracts” or “presbyopia” Instead, use a standard code ICD-9 -CM is standard resource for diagnosis codes 84

Diagnosis Codes 1 st look up in alphabetical listing 85

Then refine in tabular listing 86

Diagnosis Codes • An ICD-9 -CM code for every eye disorders – Cataract, senile: 366. 10 • E-codes for external causes – E 960. 0 due to unarmed fight • V-codes for other situations – V 58. 69 observation due to use of toxic medication • Routine Care Claims – Use ICD-9 -CM Refractive codes 87

Diagnosis Codes • ICD-9 -CM is soon to be replaced by ICD 10 -CM • • • Completely different diagnosis coding system More comprehensive Defines disorders more explicitly Required on all claim by October, 2013 Quick Reference Guide at http: //www. cms. gov/ICD 10/Downloads/ICD-10 Quick. Refer. pdf • More information at http: //www. cms. gov/ICD 10/01_Overview. asp#Top. Of. Page 88

NOA 3 rd Party Primer • • • Background Becoming a Provider Authorization – Verification Documentation Filing Claims – Services and Procedures coding • • References and Resources Evaluating Insurance Plans before Joining 89

BOTTOM CMS-1500 Service & Materials Supplied 90

Coding the Services You Provided • • • Must correctly code the level of care provided Practitioner is ultimately responsible for correct coding Under-coding is as incorrect as overcoding 91

References 92

Medical Examination Coding • • • 92000 vs. 99000 20 years ago CPT had separate codes for every specialty (92000 for ophthalmology) Subsequently one set of universal codes (99000 E&M Codes) was created with equal payment for all types of physicians, specialty or not. Most specialty codes were discontinued; however, ophthalmology’s 92000 somewhat ambiguous codes remain 92000 codes need to be modernized and clarified; however, ther is concern that 92000 codes will be dropped altogether if tampered with. 93

Examination Coding • Medical Exam Coding: • Uses CPT coding…either the – – • 92000 Ophthalmology or 99000 Evaluation & Management Codes Routine Exam Coding: • Definitions unique to each routine 3 rd Party • Follow definitions & directions in Provider Manuals 94

Medical Examination Coding 92000 Ophthalmology Codes defined in CPT 95

Medical Examination Coding Ophthalmology Codes Intermediate 96

Medical Examination Coding Ophthalmology Codes Comprehensive 97

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See Forms Handout 99

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Final Code must be Reasonable and Necessary • • • Considering History Presenting Problem Clinical findings 104

NOA 3 rd Party Primer • • • Background Becoming a Provider Authorization – Verification Documentation Filing Claims – The 99000 Codes • • References and Resources Evaluating Insurance Plans before Joining 105

Evaluation and Management Coding 99000 Evaluation and Management Codes • There are three Key Components – History – Examination – Decision Making 106

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See Forms Handouts 108

See Forms 109

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58 min 111

Final Code must be Reasonable and Necessary • • • Considering History Presenting Problem Clinical findings 112

99000 vs. 92000 • • In general, the 99000 codes are more concrete, requiring less subjective judgment But these concrete requirements may necessitate tests or procedures not required by comparable 92000 comprehensive codes. (dilation) 113

99000 vs. 92000 • • The 92000 codes for a comprehensive exam require a “diagnostic and treatment program” while the 99000 codes do not. When following a patient chronic conditions that require • • • no billable diagnostic testing and no treatment, difficult to code comprehensive 92000 codes. 114

99000 vs. 92000 • • Maximum Medicare reimbursement for a 92000 comprehensive exam is higher in some cases than an equivalent 99000 exam. Any such advantage is dependent on your 92000 and 99000 fees. – Many OD’s 92000 exam fees are not near that Medicare maximum, and to them there seems no $$ advantage in using the 92000 fees. 115

99000 vs. 92000 But, if the OD’s 92000 examination fees are near or above Medicare’s maximum reimbursement level, then – Provider must charge all patients that same amount. – Cannot charge a non-covered patient less. • • • A discount for cash payment day of services by a selfpay patient is probably acceptable if it does not exceed 15% to 20%. Rationale: no billing, no insurance claim expenses. Always Bill based on the reasonable and necessary examination you performed and documented. Never examine and bill simply to maximize 116 reimbursement rates…to do so is fraudulent,

Exam Coding Modifiers http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ 117

BOTTOM CMS-1500 Service & Materials Supplied 118

http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ 119

Modifier 24 • Unrelated Evaluation & Management Service by the Same Physician During a Postoperative Period. http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Example: GLC follow-up exam and fields during cataract post-op period. • Cataracts 90 days Punctal plugs 10 days Foreign body 0 days • http: //www. cms. hhs. gov/pfslookup/02_PFSsearch. asp? agree= yes&next=Accept • • 120

Modifier 25 Significant, Separately Identifiable Evaluation & Management Service by the Same Physician on the Day of a procedure http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Example: Eyelash abrasion detected requiring epilation during a GLC follow-up exam. • Use on E&M (99000) code; • Documentation for E&M should be separate in record from procedure (each dated & initialed) • • Separately identifiable entry (different page? ) with separate signature 121

Modifier TC Technical Component http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Some codes can be broken down into a professional component and a technical component • Professional Component is done by the doctor • Technical Component is done by a technician • No need to break down if both doctor and technician are present when the service is provided. • Use breakdown if technician is testing when patient’s own doctor is not present (but there must be a doctor [associate] on the premises. ) 122

Modifier TC Technical Component • • Example: technician performing 92083 -TC while patient’s own OD is not on the premises OD and OMD codes that qualify Cannot charge Medicare if no doctors are on the premises Sensorimotor Exam 92060 TC Orthoptic/Pleoptic 92065 TC Visual Fields 92081, 2, 3 TC Scanning Laser 92135 TC Fundus Photos 92250 TC Color Vision 92283 TC Dark Adaptation 92284 TC External Photography 92285 TC 123

Modifier 26 • Professional Component http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Example: Doctor’s evaluation of 92083 -26 results done the day after technician performed fields (while a different doctor was on the premises). 124

Modifier 32 • • Mandated Service http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Example: driver license exam Not covered by Insurer…patient responsible 125

Modifier 50 Bilateral Procedure • • http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Some services are paid as binocular tests, some as monocular tests If a test is paid as monocular, but you do both eyes, the 50 modifier is used (with units of 1). 126

Modifier 50 Bilateral Procedure • http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ To determine whether a procedure is bilateral, go to http: //www. cms. hhs. gov/pfslookup/02_PFSsearch. asp? agree=yes&next=Accept • • Start Search -> Accept -> Click ‘Payment Policy Indicators’ Click ‘Single HCPCS code’ Enter Code you are inquiring about Select ‘All modifiers’ Submit -> Scroll Look at “Bilt Surg” column • • 0 means bill each eye separately – bilateral does not apply 1 means paid 100%, 50%, 25% for 1 st, 2 nd, 3 rd unit, respectively 2 means bill once for both eyes 3 means bill each eye separately https: //www. highmarkmedicareservices. com/partb/reimbursement/mfsdbhelp. html 127

Modifier 51 Multiple Procedures • • http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Example: multiple (four) foreign bodies in one eye. With four FBs in one eye – First FB filed without a modifer, 65222 – Balance would be filed with 51 modifer – 65222 -51 , and units of 3 in the units column in this case. Reimbursement diminishes with 51 s Medicare does not recommend using modifier 51, but simply increasing “units” instead (65222 with units of 4) 128

930. 0 No 65222 51 1 1 $ 3 x$ 1 3 65222 1 4 x $ 4 Reimbursement: 100%, 50%, 25% … 129

Modifier 52 Reduced Service http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ • Some services are paid as binocular tests, some as monocular tests If a test is paid as binocular, but you do only one eye, the 52 modifier could be used. 130

Modifier 53 Discontinued Procedure http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Example: Discontinued punctal plug insertion during the process because patient became ill. 131

Modifier 54 • Surgical Care Only http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Indicates post-op care done by another provider Example: Cataract surgery – used by surgeon only 132

Modifier 55 Postoperative Management Only • • http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Example: cataract post-op care Append to the procedure code that describes the surgical procedure. Example: 66984 RT 55 Surgery has a 10 or 90 -day postoperative period. The claim must show the date of surgery as the date of service. Indicate the date care assumed and date relinquished in Item 19 of the CMS-1500 claim form or the electronic equivalent. 133

Surgeon’s name Surgeons NPI Date assumed care; date relinquished care 366. 12 V 43. 1 01012009 2 68984 RT 55 Date of surgery 134

Modifier 59 • Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under these circumstances. http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Example: OCT and retinal photos on same day (OCT for GLC, photos for AMD. ) Normally denied when claimed together • Documentation indicates two separate procedures performed on the same day by the same physician • Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury) • Use Modifier 59 with the secondary, additional or lesser procedure of combinations listed in Correct Coding Initiative (CCI) edits. • Use Modifier 59 when there is NO other appropriate modifier. 135

Modifier GA • Used to indicate patient has signed an Advanced Beneficiary Notice (ABN) • http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ Used when it is expected Medicare will deny payment for the item as not reasonable and necessary. To collect fee from patient must have ABN signed by the beneficiary on file. 136

Forms http: //nebraska. aoa. org/prebuilt/noa/Final%20 Revised%20 ABN-English 3 -20 -08. rtf 137

Modifier GA • • In the ABN’s “reason” box, the provider should state why Medicare will most likely not cover the item: – Medicare will probably not cover this item due to your particular diagnosis or circumstance Medicare paperwork to patient, and your Remittance Advice, will then come back with patient responsible for payment. 138

Modifier GZ http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ The provider or supplier expects a medical necessity denial; however, did not provide an Advance Beneficiary Notice (ABN) to the patient. This will result in claim payment denial, and the patient can NOT be held responsible for payment (provider is out the fee). 139

Modifier GW http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ • • Used for Hospice Patient’s Claims for services not related to the hospice patient’s terminal condition. Otherwise Hospice Patient claims can be denied. 140

Modifier GY http: //www. wpsmedicare. com/j 5 macpartb/resources/modifiers/ • • • Used to indicate that the item or service is statutorily non-covered (not a Medicare Benefit). It is filed at the request of the patient or to instigate subsequent payment by another insurer. Example: refraction 92015 GY. 141

Modifier KX [Used for Durable Medical Equipment] https: //www. noridianmedicare. com/dme/news/docs/2007/06_jun/modifiers. html • • Item is covered under some circumstances (if ordered by a physician**). In this case it was ordered by the physician and is medically necessary. • You must document why in the patient’s record. • **Note: ODs are categorized as physicians under Medicare 142

Modifier EY [Used for Durable Medical Equipment] https: //www. noridianmedicare. com/dme/news/docs/2007/06_jun/modifiers. html • Item is covered under some circumstances (if ordered by a physician**). • In this case it was NOT ordered by the physician and is not medically necessary. Patient preference item Patient responsible for payment with this modifier • **Note: ODs are categorized as physicians under Medicare • • 143

http: //nebraska. aoa. org/prebuilt/NOA/2009 -08%203 RD%20 PARTY%20 NEWLSETTER. pdf EXAMPLE ITEMS (All are per lens charges) V-Code MODIFIER(S) DOCUMENTATION CLAIM REQUIREMENTS Deluxe frame extra charge V 2025 GY ABN for courtesy only (none-covered item) Must file on claim separate from claim containing medically necessary items ULV lens coating, medically necessary (non-polycarbonate lenses only) V 2755 KX Reason for medical necessity documented File on claim containing only medically necessary items ULV lens coating, Not medically necessary V 2755 EY & GA ABN Required Must file on claim separate from claim containing medically necessary items Photochromic tint, medically necessary V 2744 KX Reason for medical necessity documented File on claim containing only medically necessary items Photochromic tint, NOT medically necessary V 2744 EY & GA ABN Required Must file on claim separate from claim containing medically necessary items #1 or #2 rose tint, medically necessary V 2745 KX Reason for medical necessity documented File on claim containing only medically necessary items #1 or #2 rose tint, NOT medically necessary V 2745 EY & GA ABN Required Must file on claim separate from claim containing medically necessary items AR coating, medically necessary V 2750 KX Reason for medical necessity documented File on claim containing only medically necessary items AR coating, NOT medically necessary V 2750 EY & GA ABN Required Must file on claim separate from claim containing medically necessary items Anti-scratch coating V 2760 GY ABN for courtesy only (none-covered item) Must file on claim separate from claim containing medically necessary items Oversize, required by RX V 2780 KX Reason for medical necessity documented File on claim containing only medically necessary items Oversize, patient preference V 2780 EY & GA ABN Required Must file on claim separate from claim containing medically necessary items Progressive add extra charges V 2781 GY ABN for courtesy only (none-covered item) Must file on claim separate from claim containing medically necessary items 144

NOA 3 rd Party Primer • • Background Becoming a Provider Authorization – Verification Documentation Filing Claims References and Resources Evaluating Insurance Plans before Joining 145

References • CPT (Current Procedure Terminology) – Service Codes • • 92000 Ophthalmology 99000 Evaluation & Mgmt – Surgical Procedure Codes • • 65205 Removal of FB 67820 Epilation of Lashes 146

References • • CPT (Update yearly) Available from – AOA http: //www. aoa. org/x 12590. xml – – Combines multiple references Delivery later than some – AMA – • https: //catalog. amaassn. org/Catalog/; jsessionid =Q 3 YRMMKGBTFOLLA 0 MRPVX 5 Q? _requestid=1669537 – Amazon. com http: //www. amazon. com/ 147

References • ICD-9 -CM • International Classification of Diseases – – – Refractive Diagnosis Codes Disease Diagnosis Codes Injury Diagnosis Codes 148

References • • • ICD-9 -CM Update yearly before October 1 st Available from – AOA http: //www. aoa. org/x 12590. xml – – Combines multiple references Delivery later than some – AMA – https: //catalog. amaassn. org/Catalog/; jsessionid =Q 3 YRMMKGBTFOLLA 0 MRPVX 5 Q? _requesti d=1669537 – Amazon. com http: //www. amazon. com/ 149

Medicare Physician’s Guide • • It includes information on: Becoming a Medicare provider or supplier, Medicare payment policies, Medicare reimbursement, evaluation & management documentation, Inquiries, overpayments, and appeals. You can download it from: http: //www. cms. hhs. gov/MLNProducts/downloads/physicianguide. pdf 150

References Our Medicare B is Wisconsin Physician Services [WPS] Carrier’s Web Site http: //www. wpsmedicare. com/j 5 macpartb/index. shtml • Wealth of Information 151

http: //www. wpsmedicare. com/j 5 macpartb/index. shtml 152

Medicare B References – Local Coverage Determinations (LCDs) – • • http: //www. wpsmedicare. com/j 5 macpartb/policy/active/local/ Standardizes what Medicare considers “Reasonable and Necessary” Lists very specific coding requirements for those services & procedures that have a history or potential of abuse 153

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References WPS Medicare Communiqué • Medicare Carrier Monthly Newsletter • • • Changes in CMS policy Updates in coding requirements Updates on documentation needed FAQs Changes in contact information Changing in billing requirements 156

http: //www. wpsmedicare. com/j 5 macpartb/index. shtml 157

References Medicare Communiqué All Provider are legally responsible for reading and abiding by this document. 158

References CMS Publications Eventually will replace the Nebraska Medicare on-line publications Wealth of information and forms will be at this site. http: //www. cms. hhs. gov/ 159

References • 1997 Documentation Guidelines for Evaluation & Management Services – Explains how to code and document the 99000 codes – Includes information on single organ systems (such as eyes) 160

References • 1997 Documentation Guidelines for Evaluation and Management Services – Available at NOA web site – Available at CMS website: http: //www. cms. hhs. gov/MLNProducts/downloads/reference. II. pdf 161

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References Durable Medical Equipment DME MAC Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) Noridian Administrative Services, LLC https: //www. noridianmedicare. com/dme/index. html 164

References NAS DME Supplier Manual Noridian Administrative Services • Documentation required – Written order – Proof of Delivery – ABN – Supplier Standards • Claims Submission • V-codes • Pricing 165

166 https: //www. noridianmedicare. com/dme/

Noridian Policy on Refractive Lenses Policy Article Source: https: //www. noridianmedicare. com/dme/coverage/docs/lcds/current_articles/refractive_lenses. htm 167

Noridian LCD on Refractive Lenses LCD Source: 168 https: //www. noridianmedicare. com/dme/coverage/docs/lcds/current_lcds/refractive_lenses. htm

References DME Happenings DME Carrier newsletter • Changes in CMS policy • Updates in coding requirements • Updates on documentation needed • FAQs • Changes in contact information • Changes in Billing Requirements 169

References Medicaid Provider Manual Includes Visual Care Services • • • Covered and Non-Covered Services Examination Lenses Frames Contact Lenses Billing Requirements 170

References Medicaid Provider Manual – Vision http: //dhhs. ne. gov/med/phvis. htm Visual Care Services http: //www. sos. state. ne. us/rules-andregs/regsearch/Rules/Health_and_Human_Services_System/Title 471/Chapter-24. pdf Payment Rules http: //www. sos. ne. gov/rules-and- regs/regsearch/Rules/Health_and_Human_Services_System/Title-471/Chapter-03. pdf Fee Schedule http: //www. hhs. state. ne. us/reg/appx/471 -000 -524. pdf Billing Instructions http: //www. hhs. state. ne. us/reg/appx/471 -000 -65. pdf Bulletins http: //www. hhs. state. ne. us/med/PB/index. htm. O 171

References • • • NOA 3 rd Party Newsletters Changes in Carrier Policy LMRP Updates & Reminders Unique Coding in Nebraska Changes on the Horizon HIPAA Updates Q & A Page 172

References 173

References 174

Monthly Newsletter Mass Email: 175

References NOA 3 rd Party Web Page http: //nebraska. aoa. org/prebuilt/NOA/index. htm Index page with over 1000 links Past Newsletter Articles by title CMS, Medicare, Medicaid, BCBS, AOA, & other web sites Archived newsletters by date published HIPAA page, including HIPAA manual New Licensee page Previous 3 rd Party Presentations 176

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Internet Webinars Evaluating 3 rd Party Plans HIPAA • Privacy • Security • EDI Durable Medical Equipment (Medicare post-op prescription regulations)

CMS Education The Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals offers information on the Medicare Program…. • General Medicare information • Becoming A provider or supplier • Reimbursement • Payment policies • Evaluation & Management Svs • Protecting the Medicare trust fund • Inquiries • Overpayments • Fee-for-service appeals. Available at https: //www. cms. gov/mlnproducts/downloads/physicianguide. pdf P. 8. NOVEMBER

CMS Education CMS Quick Reference Charts The Quick Reference: Chart for All Medicare Providers includes a list of CMS web pages that ALL Medicare providers use most frequently, and can be found at http: //www. cms. hhs. gov/MLNProducts/downloads/Quick_Reference_All_Medicare_Providers. pdf The Quick Reference: New Medicare Provider Chart includes a list of CMS web pages that NEW Medicare providers use most frequently, and is available at http: //www. cms. hhs. gov/MLNProducts/downloads/Quick_Reference_New_Provider. pdf

CMS Education How To Use Medicare Coverage Database • The searchable Medicare Coverage Database contains a wealth of information. https: //www. cms. gov/MLNProducts/downloads/Medicare. Cvrge. Database_ICN 901 346. pdf Booklet on NPI-What You Need to Know • Information on the basics of the NPI http: //www. cms. gov/MLNProducts/downloads/NPIBooklet. pdf

CMS Education New Web-based Training On Medicare Fundamentals http: //www. cms. gov/MLNgeninfo/ (Look under Web Based Training Modules) CMS Form 1500 Diagnosis Coding: Using the ICD-9 -CM HIPAA EDI Standards Medicare Fraud and Abuse PQRI and EPrescribing Skilled Nursing Facility Consolidated Billing Understanding the Remittance Advice for Professional Providers World of Medicare Your Office in the World Of Medicare

Medicare Education NEW: How to Use the National Correct Coding Initiative (NCCI) Tools at https: //www. cms. gov/MLNProducts/downloads/How-To-Use-NCCI-Tools. pdf ---explains--Nationanl Correct Coding Initiative NCCI Program to reduce incorrect coding based on • Mutually exclusive codes (92083 & 92081) • Anatomic considerations (cataract extraction & enucleation). Medically Unlikely Edits (MUEs) • Program to reduce errors due to clerical entries and incorrect coding based on frequency of procedures on same day.

NOA 3 rd Party Consultation • Multiple Contact Methods – Email Schneider. [email protected] com – Cell Phone w/ Voicemail 402 -310 -2367 – Fax 402 464 -1214 (call cell first) • • Cover page: Contains PHI-for Dr. Schneider’s eyes only 24 hour turn-around time 189

That’s All Folks……… 190

Corrected to this point for 2011