Cape Medical Billing: Providing Expert Medical Billing Solutions

Like Cape Medical Billing on Facebook

Call Today 888-MED-BILR

December 2014 Client Newsletter



December 1, 2014

Holiday Hours

As is customary, CPB will be closed for Thanksgiving and the Friday after.  Any emergencies, just call my cell phone.  We will also be closed on Christmas Day, December 25th, closed from 1:00 – 5:00 on Monday, December 29th, and closed on New Year’s Day.  We wish everyone a Happy Holiday Season. 

Medicare Annual Deductible

The Medicare Annual Deductible for 2015 remains at $147.  Just a reminder, due to deductibles for many insurances starting on January 1 each year, there is usually a cash flow slow-down until March or April.  Be sure to check patient insurance eligibility when the appointment is made to remind patients to bring their co-pays & deductibles.  We also strongly urge clients to collect part of the deductible on the day of service if a substantial amount of it has not been met.

Billing An Annual Wellness Visit and Office Visit On The Same Day

Coventry Health Care has announced that whenever an Annual Wellness Visit (AWV) and Office visit are billed on the same day, they will apply “concurrency rules” and pay the AWV at 100% plus the office visit at 50%. 

CMS 2015  Chronic Care Management and EHR – New Revenue

Medicare continues to emphasize primary care by making payment for chronic care management (CCM) services – non-face-to-face services to Medicare beneficiaries who have multiple, significant, chronic conditions (two or more) – beginning in 2015. Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.

CMS has established a payment rate of $40.39 for CCM that can be billed up to once per month per qualified patient.  CMS is finalizing its proposal to allow greater flexibility in the supervision of clinical staff providing CCM services. The proposed application of the “incident to” supervision rules were widely supported by the commenters.

CMS proposed standards for electronic health records (EHR) – specifically, a 2014-certified EHR. In response to public comments indicating that very few practices have adopted a 2014-certified EHR at this time, CMS will require the version of the certified EHR that is in use on December 31 of the prior calendar year for the EHR Incentive Programs to bill for CCM services.

Medicare Psych Reduction

The Medicare Psych Reduction was finally phased out at the beginning of this year.  It didn't receive much fanfare but at least for Medicare there is no longer a change in reimbursement for a Psych Dx.  

Prior to 2010, Medicare’s payment liability for outpatient mental health services was limited to 62.5 percent of covered expenses incurred in any calendar year for an individual who was not an inpatient of a hospital at the time the expenses were incurred. Following the enactment of MIPPA, that limitation was gradually reduced over several years:  

  • From Jan. 1, 2010-Dec. 31, 2011, the outpatient mental health treatment limitation was 68.75 percent; Medicare paid 55 percent and the beneficiary paid 45 percent.
  • From Jan. 1, 2012-Dec. 31, 2012, the limitation was 75 percent; Medicare paid 60 percent and the beneficiary paid 40 percent.
  • From Jan. 1, 2013-Dec. 31, 2013, the limitation was 81.25 percent; Medicare paid 65 percent and the beneficiary paid 35 percent.
  • Beginning Jan. 1, 2014, the limitation will be 100 percent; Medicare will pay 80 percent and the beneficiary will pay 20 percent. 

With the end of the five-year phase-out of the mental health treatment limitation, Medicare will no longer lag behind private insurers in providing nondiscriminatory outpatient mental health coverage to millions of people across the cou

Bilateral Cerumen Removal (69210) - #2

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) has clarified use of code 69210 – Removal of impacted cerumen requiring instrumentation, unilateral.

The AAO-HNS defines cerumen as impacted if any one or more of the following conditions are present (and you should use these key words in the medical record, as appropriate):

• Cerumen impairs the examination of clinically significant portions of the external auditory canal, tympanc membrane, or middle ear condition;

• Extremely hard, dry, irritative cerumen causes symptoms such as pain, itching, hearing loss, etc.

• Cerumen is associated with foul odor, infection, or dermatitis; or

• Obstructive, copious cerumen cannot be removed without magnification and multiple instrumentations requiring physician skill.

Simply documenting “impacted cerumen” is not sufficient when medical records are submitted to support the service.

Another key factor in determining whether code 69210 should be reported is what instruments are utilized to remove the impacted earwax. In this context, instrumentation is defined as the use of an otoscope and other instruments such as wax curettes and wire loops, or an operating microscope and suction plus specific ear instruments (e.g., cup forceps, right ange forceps). Accompanying documentation should indicate the time, effort, and equipment to provide the service. Additionally, the descriptor of code 69210 has been clarified to reflect that code 69210 is an unilateral code (unfortunately at this point Medicare and many other insureres are only paying amount regardless of whether 1 or 2 units are billed, even if the bilateral modifier is used).

Other issues may also require consideration. Removing wax that is not impacted does not warrant the reporting code of 69210. Rather, that work would appropriately be reported with an evaluation and management (E/M) code regardless of how it is removed (e.g. lavage, irrigation, etc.

In the new 2014 fee schedule, CMS stated its opinion that the procedure will typically be done on both ears at the same encounter, because “the physiologic processes that create cerumen impaction likely would affect both ears.” CMS did not provide any evidence or citations to support this opinion. CMS went on to say, “Given this, we will continue to allow only one unit of CPT 69210 to be billed when furnished bilaterally.” Consequently, CMS elected to maintain the 2013 work value of 0.61 for CPT code 69210 when the service is furnished.

The bottom line is that Medicare will pay you the same amount for 69210 whether you do one ear or two, even though the CPT descriptor now says it is for one ear only. If other payers key off the Medicare fee schedule, they will pay the same way.

Compliance Question

Which of the following is true regarding the Federal False Claims Act?

a.) It is also known as Lincoln's Law dating back to 1863 passed to prevent defrauding the government during the Civil War.

b.) The Qui Tam provision allows a private citizen to file suit on behalf of the government (whistleblower) and receive a portion of the recovered damages. 

c.) A revision under PPACA states that overpayments must be reported and returned 60 days from discovery.

d.) A revision under PPACA states that claims submitted in violation of the anti-kickback statute are automatically considered false claims.

e.) All of the above are true

  (Answer: e)

CMS Proposal To Eliminate Surgery Global Periods

CMS proposed in the November "Final Rule" (apparently "final" doesn't yet mean final since there is a comment period) to eliminate the global periods for "10 day" global codes (in 2017) and "90 day global codes (in 2018)?  Stay tuned!





2014 Client Newsletter Archive