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September 2016 Client Newsletter

Use of 25 Modifier - Reminder
When we receive charges with an E&M code and a procedure, if there are multiple diagnoses with at least one not related to the procedure, we use that as an indication they are unrelated.  That makes use of the 25 modifier appropriate.  If that is not going to be the case, please call me directly so we can find a clear way to when to use the -25 modifier. 
 Insurers Requesting Refunds
 In New Jersey insurers (other than federal programs like Medicare, Medicaid and TriCare) cannot request a refund more than 18 months from the date payment was received (absent fraud, of course).  So if you receive such a request, forward to Cape Medical Billing to review and we will advise you whether it is required.  However, once identified, the refund is required to be made within 60 days. 
From MGMA:  "Three hospitals within the Mount Sinai Health System agreed to pay nearly $3 million to settle a whistleblower lawsuit alleging they held onto Medicare and Medicaid overpayments after the 60-day repayment window. This is the first settlement coming from the final 60-day repayment rule issued by the Centers for Medicare & Medicaid Services (CMS), which requires all overpayments to be reported and returned within 60 days of identification. Under the final rule, "identified" is defined as when the person has, or should have through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment. More cases and settlements are expected."
 Deductible Payment Policy
 We are beginning to see some denials for non-specific ICD-10 codes - and are being advised by our professional association that we should expect to see all insurers require the most specific ICD-10 codes for each condition no later than October 1st.  Examples:
  • For injuries - location on the body & how did it happen?
  • Which side of the body - left?  Right?
  • Wounds - sizes.
 We will be notifying clients of the ICD-10 code changes by mid-September. 
Deductible Payment Policy
 Unless your provider agreement specifically states that you cannot collect deductibles until the EOB comes back, then you have every right to demand payment in full up-front, or to whatever standard is your office policy. (Note, if a provider agreement does specify you must wait until the EOB comes back and only then seek payment from the patient, good luck. That's a provision that needs to be negotiated out of the contract.) 

Will the guy who rebuilds your car's transmission accept partial payment now, do the work, and give you your car with the hope of collecting the balance later? No way. It's cash, check, credit card! Arrangements of some sort must be made for guaranteed payment in full before services are rendered or the car picked up.
Verify your EIDM account status to prepare for forthcoming quality program reports.
CMS is expected to release the 2015 PQRS Feedback Reports and 2015 Annual Quality and Resource Use Reports (QRURs) early this fall. These reports will include insight into group's 2015 results for the PQRS and Value-Based Payment Modifier programs, including details about bonus or penalty amounts, which will impact Medicare Part B reimbursements beginning Jan. 1.
To access both reports, physicians and their representatives must have active Enterprise Identity Management (EIDM) accounts. There are numerous steps involved in creating and maintaining EIDM accounts, we encourage practice executives to confirm their account is active or establish a new account now in order to avoid delays in retrieving forthcoming quality reporting feedback.
For detailed instructions on setting up EIDM accounts, you can access the CMS EIDM User Guide. For questions, contact the QualityNet Help Desk at 1-866-288-8912 or  
 Telemedicine is becoming a "hot topic" and insurers are beginning to reimburse for those services.  However, before you consider telemedicine, be advised that whether you are paid depends on whether your specialty is eligible and whether the patient's insurer covers telemedicine. 
Much depends upon the patient's insurance. Each carrier has their own rules on telemedicine. If the patient has Medicare Part B, click here to link to the Medicare Learning Network (MLN) guidance form for TeleHealth. Not all specialties are permitted.   

Click here for a MLN article that was updated January 18, 2013 has details on many of the codes that can be used for TeleHealth.

When dealing with TeleHealth, first you need to determine if the patient has a TeleHealth benefit as part of their coverage, then determine if you are eligible to be paid for TeleHealth services.
2016 Client Newsletter Archive