billing for rehabilitation services -...

1

7/7/2008Austin-Webster Group Ltd1

Billing for Rehabilitation Billing for Rehabilitation

ServicesServices

Julia R. Olson, CPCAustin-Webster Group, Ltd

[email protected](651) 430-1850

DisclaimerThe information contained in this booklet is designed to provide accurate information with regard to the subject matter. Every reasonable effort has been made to ensure the accuracy of the

information contained within this booklet. The definitive responsibility for accurate coding lies with the provider of services. Austin-Webster Group Ltd., their employees, and staff make no

warrantee, express or implied, that this document is error free or that the use of this course material will thwart disputes with Medicaid, Medicare or other third party payers and will bear no

liability for the outcome or consequences of its use.

These course notes have been compiled utilizing information from the Centers for Medicare and Medicaid Services, codes from the AMA's 2008 Physicians' Current Procedural Terminology,

Fourth Edition (CPT-4), HCPCS Level II codes and CPT Assistant.

CPT only © 2007 American Medical Association. All Rights Reserved. CPT five-digit codes, nomenclature and other data are copyright 2007 American Medical Association. All Rights

Reserved. The AMA assumes no liability for the data contained herein.

Copyright 2008, Austin-Webster Group Ltd. No part of this workbook may be reproduced in any manner without the expressed written consent of Austin-Webster Group Ltd.

Austin-Webster Group Ltd2

IntroductionIntroduction

� Processes to get paid for services provided

� Ensure claims get filed with correct information

� Private practice/group practice billing vs facility reporting

� Modifiers, NCCI Edits and MUEs

2


Steps to Payment For ServicesSteps to Payment For Services

1. Patient registration

2. Provision of services

3. Bill or submit claim

4. Claim follow-up / bill patient


Step 1: Patient RegistrationStep 1: Patient Registration

1. Trained personnel

2. Policies and procedures in place capture of patient information.

3. Clinic/practice has policies and procedures regarding collection of co-payments and deductibles.

3


Staff RoleStaff Role� At patient registration gather accurate

complete information used to set up medical record and bill and/or file claim(s) to payer source.– Call and pre-register new patients over the

telephone or make sure patients complete the information upon arrival for first clinic visit.

� Complete registration forms, assignment of benefits, HIPAA notification, release of information

� Copy insurance card (s) and identification

Co-

pay


Staff Role Staff Role

� Patient and health plan information is ACCURATELY entered into EMR or computer billing system.

� Call health plan(s) to verify coverage and benefits.

� Communicate clinic billing policy in writing and verbally to patients.

� When possible collect co-pays at time of the service.

Ins

Info

In-

network

ABN

4


Step 2: Deliver ServicesStep 2: Deliver Services

� Perform evaluation of the patient.

� Develop and begin carrying out the treatment plan.

– If requiring a physician order, order is obtained.

– Ordering physician certification of treatment plan dependent upon payer.

– Documentation must be completed and in the chart in a timely manner.

– Complete a charge tickets for services upon provision of services.

Bill

Pt

File

Claim


Step 3: BillingStep 3: Billing

1. Completion of charge ticket

2. Completion of coding, CPT, HCPCS II & ICD9CM

3. Enter charges into a billing system

4. Submit electronic and/or paper claims

5



Charge ticket completion:

� Charge tickets are accounted for based on the appointment schedule or the number of patients check in to see the PT/OT.– For each patient checked in for appointment

there is a completed charge ticket.

– If EMR each patient checked in will need to be checked out.

– It is important to have checks and balances.



Charge ticket is completed, now what do we do with it?

Completion of coding.

� Services are documented and coded on a charge ticket.

� Services are reviewed and any appropriate modifiers are applied to the procedure codes.

6


So Many Modifiers So Many Modifiers …………

� Modifiers are established to use by all different providers and specialties

– Some for evaluation and management services (physician visit codes)

– Surgical, diagnostic & radiology procedures

� Rehab providers will use only those that apply.


ModifiersModifiers

�-59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day.

Used when no other modifier applied in the situation.

7


ModifiersModifiers

-GO Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care

-GP Service delivered personally by a physical therapist or under outpatient physical therapy plan of care.

-LT Left side (used to identify procedures performed on the left side of the body)

-RT Right side (used to identify procedures performed on the right side of the body)Explaindetails


ModifiersModifiers

-GA Waiver of liability statement on file. Use to show that the provider/supplier expects Medicare to deny a service as not reasonable and necessary and they do have on file an Advance Beneficiary Notice signed by the patient.

�-GD Units of service exceeds medically unlikely edit value and represents reasonable and necessary services

8


Who applies the modifiers?Who applies the modifiers?� Therapy provider, billing staff, coder?

– Each therapy organization must determine what will work best for the process in their clinic.

� Ignorance is not bliss, therapy providers must have an understanding of why and when modifiers may be needed.

� Frequently used modifiers can be on the clinic charge ticket to prompt usage.


Who applies the modifiers?Who applies the modifiers?

� Modifier is indicated and entered for billing or

� In the case of facility billing, hard coded on to service

� Provider can indicate when a modifier needs to be applied to the service. OR

� Coding staff has knowledge of when modifiers are needed, checks the codes and applies modifiers when

9


National Correct Coding National Correct Coding

Initiative Initiative

� Edits developed by CMS to promote correct coding and ensure appropriate payment for Medicare services.

� In use since 1996, updated quarterly.

� One version for hospitals, one for physicians.

� Edits are also used by insurers other than Medicare.

� Published on the CMS website

– http://www.cms.hhs.gov/NationalCorrectCodInitEd/


Correct Coding InitiativeCorrect Coding Initiative

� Mutually Exclusive

Codes that would not logically

be performed together

� Comprehensive/Component (Column 1 / Column 2)Code combinations in which one code is a component of a more comprehensive code

10


National Correct Coding National Correct Coding

InitiativeInitiative

� What codes can not be billed on the same day for the same patient, same provider

� Quarterly updates published on CMS website

NCCI Edits - Physicianshttp://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/List.asp

NCCI Edits – Hospital Outpatient PPShttp://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEHOPPS/list.asp

#TopOfPage


ExampleExampleColumn1/Column 2 Edits (Comprehensive/Component)

Column 1 Column 2

* = In existence prior to

1996 Effective

Date

Deletion Date

*=no data

Modifier 0=not

allowed 1=allowed

9=not applicable

93000 93005 19960101 * 1 93000 93010 19960101 * 1 93000 93040 19960101 * 1 93000 93041 19960101 * 1 93000 93042 19960101 * 1 93005 93010 20051001 20051001 9 93005 93040 19960101 * 1 93005 93041 19960101 * 1 93005 93042 19960101 * 1 93010 93040 19960101 * 1 93010 93041 19960101 * 1 93010 93042 19960101 * 1

93012 93268 19970401 * 0

11


ExampleExampleMutually Exclusive Edits

Column 1 Column 2

* = In existence prior to 1996

Effective Date

Deletion Date

*=no data

Modifier 0=not allowed

1=allowed 9=not applicable

93012 G0015 19970101 20030331 1

93014 G0015 19970701 20020101 1

93014 93268 19970101 * 1

93014 93270 19970701 * 1

93040 93268 19960101 * 1

93042 92986 19960101 * 1

93042 93272 19970401 * 1

93201 93205 19960101 19970331 1

93204 93209 19960101 19970331 1

93208 93202 19960101 19970331 1


Appropriate Use of Appropriate Use of --59 Modifier59 Modifier

A different� Session or patient encounter, � Procedure or surgery, � Site or organ system, or

A separate� Incision/excision, � Lesion, or � Injury (or area of injury in extensive injuries)

Use when no other modifier applies to situation.

12


Example 1: Column 1 Code/Column 2 Code 97140/97530

· CPT Code 97140 Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

· CPT Code 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

Policy: Mutually exclusive procedures

Modifier "-59" is only appropriate if the two procedures are performed in distinctly different 15 minute intervals. The two codes cannot be reported together if performed during the same 15 minute time interval.

Example 2: Column 1 Code/Column 2 Code 98942/97112

· CPT Code 98942 Chiropractic manipulative treatment (CMT); spinal, five regions

· CPT Code 97112 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

Policy: Standards of medical/surgical practice

Modifier "-59" is only appropriate if the physical therapy service 97112 is performed in a different region than the CMT and the provider is eligible to report physical therapy codes under the Medicare program.


CMS CMS –– Medically Unlikely EditsMedically Unlikely Edits

� Developed to reduce the paid claims error rate for Part B claims.

� An MUE for a CPT/HCPCS code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

� All HCPCS/CPT codes do not have an MUE.

13


CMS CMS –– MUEsMUEs� Implemented January 1, 2007 and utilized

to adjudicate claims at Carriers, Fiscal Intermediaries, and DME MACs.

� MUEs are confidential and are for CMS and CMS Contractors' use only.

� MUE values for specific HCPCS/CPT codes cannot be released since CMS does not publish MUEs.

� Inquiries about a specific claim should be addressed to the claims processing contractor.


CMS CMS -- MUEsMUEs

� Fiscal intermediaries (FIs) and Part A/Part B Medicare Administrative Contractors (A/B MACs) processing claims with the Fiscal Intermediary Shared System (FISS), return to provider claim lines with units of service exceeding the MUE for the HCPCS/CPT code on the claim line. – The claim line is not denied. Therefore, no appeal

process exists for MUEs for claims processed by FISS.

� DMACs processing claims with the VMS system deny the entire claim line if the units of service on the claim line exceed the MUE for the HCPCS/CPT code on the claim line. Since claim lines are denied, the denial may be appealed.

14


CMS CMS -- MUEsMUEs

� Since each line of a claim is adjudicated separately against the MUE of the code on that line, the appropriate use of Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE.

� CPT modifiers such as -76 (repeat procedure by same physician), -77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), -91 (repeat clinical diagnostic laboratory test), and -59 (distinct procedural service) will accomplish this purpose. Modifier -59 should be utilized only if no other modifier describes the service.


Step 3: Billing ContinuedStep 3: Billing Continued

� Services are data entered into a billing system to facilitate claims submission and/or billing process.

� Staff member ACCURATELY keys charges into billing system

– Provider #s, NPI#

– HCPCS codes

– CPT, HCPCS II, modifiers and ICD9-CM

– Ordering physician name and NPI may be needed on the claim

15


Claim Form CompletionClaim Form Completion� CMS website claim form completion instructions

� Medicare contractors have manual information on their website for Medicare A & B providers to access

� Place of service codes

� Type of service codes

� NPI numbers

� Internet resources


Claim FilingClaim Filing

How often should claims be filed?

� Private practices

– Any where from 1-5 times a week depending on the volume of claims.

– The quicker claims are filed the faster the reimbursement can be received.

16


Claim FilingClaim Filing

� Hospitals

– Many hospitals submit claims only monthly.

– Claims should be submitted as often as possible.

– Medicare requires hospitals to file a repetitive service bill once a month with all services provided during the month.


Claim Filing Claim Filing –– Paper or ElectronicPaper or Electronic

� Medicare has offered software to submit electronic claims.

� New computer software offers electronic submission options, either direct to payers in your area or through a clearing house.

� Some claims do still require paper filing.

17


Billing Service Vs InBilling Service Vs In--house Billinghouse Billing

“Ignorance is not bliss”

� It is crucial for providers to have some knowledge of how claims are handled and receive feedback ongoing regarding claim submissions, payments and follow-up.

“The Good, The Bad and The Ugly”


Benefits of InBenefits of In--house Billinghouse Billing� Ability to monitor what is happening with

services billing, payment and follow-up and have greater control.

� Charge tickets, documentation and records do not have to be transferred between clinic and billing service.

� Ability to access reports directly because records are inhouse.

18


Negatives of InNegatives of In--house Billinghouse Billing� Additional expenses for computer,

software, salary, training.

� Fear of not finding qualified individual(s) to do the work.

� Either the therapy provider(s) or a trusted manager must over see processes and procedures.

� If staffing leaves employment, need to rehire individual(s) to handle billing.


Benefits of Contracting with a Benefits of Contracting with a

Billing ServiceBilling Service

� No need to hire staff to perform function

� No need to monitor staff and functions

� No need to incur expenses of equipment and software

19


Billing Service Billing Service -- NegativesNegatives

� Cost to practice– Per claim fee or percentage, some can be

quite high

� Billing service may not be knowledgeable of rehabilitation claims

� May not be delligent in following up on claims– Timely filing limits

– 120 day window for Medicare appeals


Negatives of Billing ServiceNegatives of Billing Service

� Fees for work: usually a percentage charge or a per claim charge for the work.

� Documents must be transferred back and forth from the billing service to accomplish the work.

� Can be a delay between provision of services and claim filing/billing.

� May not be able to get reports to show percentage of collections etc.

20


What to ask when considering a What to ask when considering a

billing service?billing service?1. Request references of organizations of

same type that billing is performed.2. How frequently will claims be filed to the

various payers in your area?3. When will unpaid claims be follow-up?4. What will the follow-up consist of?5. Will I receive regular reports of claim

denials and claim follow-up?6. How will claim appeals and denied claims

be handled?


Managing CollectionsManaging Collections

1. New patients should be informed verbally and in writing of the clinic payment policies.

2. Collect any per visit co-pays at the time of service if at all possible.

� It is costly to send a statement for a $20 copay.

� If two statements are sent to collect the $20 it is a significant expense to the practice.

21


Managing CollectionsManaging Collections

3. Patients should be billed for any balance that is owing after the insurance(s) pays as soon as possible.

� The longer the time since the date of service the smaller the percentage of payments the provider will receive.

4. Ongoing claims follow-up to find any problems with coverage, claim submissions and coordination of benefits to get claims paid and balance bill the patients as soon as possible.

� 30-45 days depending on the payer typical claim processing time.


Internet ResourcesInternet ResourcesAmerica Physical Therapy Association: www.apta.org

American Occupational Therapy Association: www.aota.org

CMS Claims Processing Manual Chapter 25, CMS 1450 UB-04 claim form completion instructions: http://www.cms.hhs.gov/manuals/downloads/clm104c25.pdf

CMS Claims Processing Manual Chapter 26, professional service CMS 1500 claim form completion instructions:

http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf

National Uniform Claim Committee 07/2008 revised CMS 1500 instructions:http://www.nucc.org/index.php?option=com_content&task=view&id=33&Itemid=42

CMS Internet Based Manuals: http://www.cms.hhs.gov/manuals/iom/list.asp

National Uniform Billing Committee, Handbook for Hospital Billing: http://www.nubc.org/guide.html

CMS Provider Enrollment: http://www.cms.hhs.gov/MedicareProviderSupEnroll/

Tips for completing the CMS 1450 UB-04 form: http://www.valueoptions.com/providers/Forms/Administrative/Tips_for_Completing_the_UB04.pdf

CMS MAC list for all states and toll free call center directory:http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip

22


If you have any questions I will be available for a time after the session.

Thank you