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September 2012 Client Newsletter

MEDICARE ANNUAL WELLNESS VISITS AND EKG’S

G0402 Initial Preventive Physical Exam (IPPE) First 12 months of Medicare eligibility

G0403 Used only with G0402 to obtain a baseline EKG

G0438 First Annual Wellness Visit after 12 months of eligibility.

G0439 Subsequent years Annual Wellness visits. Must be 12 months since the previous year’s G0438 or G0439.

Medicare does not have a separate CPT code to bill an EKG on the same day as a Medicare Annual Wellness Visit (G0438 & G0439) like they do for an IPPE (G0402). Thus, to bill for an EKG - and get paid- with either a G0438 or G0439 you will need one of the pathologic diagnosis indications.

COLLECTING CO-PAYS

Reminder – only collect copays for office visits – not for Well Visits (99381-99397) or if the patient only received a procedure (no office visit). They almost always are overpayments resulting in refunds.

BILLING DRUGS

Some drugs are covered by insurers. Please not the following requirements:

• The NDC #, found on the product packaging, is required by NJ Medicaid and a few other insurers. Please be sure to send a copy of the label – large enough to be readable. Be sure to provide the unit measure given (Grams, mg, ml, etc.)

• The HCPCS (J”) code description specifies how it is to be billed – which often is very different than the way it is packaged. If it says “per mg” – and there are 10 mg/ml – then if you give 1 ml you will need to indicate 10 units (mg’s) on the charge form. Then you will get paid the correct amount. If you give 1 for “1 ml” – then you will not get paid in full.

Examples:

• 1 - description of drug is per 6 mg. 6 mg administered. Therefore - 1 unit is billed.

• 2 - description of drug is per 50 mg. 200 mg administered. Therefore - ◦ 4 units are billed.

• 3 - description of drug is per 1 mg. 10 mg vial of drug administered. Therefore - 10 units are billed

For Medicare, it is specifically stated that they will not cover an injection (96372) “if the provider is paid for any other physician fee schedule service (includes any office visit) furnished at the same time.” (August 29, 2012 Novitas Webinar.

Drug Waste:

• If the remainder of a vial must be discarded after being administered, the program covers the amount discarded as well as the amount administered.

• The amount ordered, administered, and the amount discarded must be documented in the

medical record.

• Coverage of discarded drugs applies only to single use vials. (CMS 100-02, Chapter 17, Section 40)

Let me know if we need to change your charge form.

RAPID STREP REIMBURSEMENT (2012)

Insurance Allowed Amount

Horizon $ 13.17

AmeriHealth $ 15.00

Aetna $ 9.29

CIGNA $ 10.94

Out-of-State Blue Shield $ 13.94

United Healthcare $ 7.70

In all cases, insurance paid the lab fee in full. Be sure the Dx code shows medical necessity.

EHR & PQRI Penalties

EHR penalties begin in 2015 at 1% based on 2013 performance for those that have successfully attested in a prior year and must use an EHR for a full year to comply. For those that are in their first year, they can use an EHR for 3 months in 2014 to avoid the 2015 penalty as long as they attest by July 2014.

The EHR penalties increase by 1% per year between 2015 and 2019 maxing out at 5%. By 2016 the PQRS penalties max out at 2%.

The total penalty assessment beginning in 2019 will be 7% of Medicare revenue.

AMBULANCE

Dizziness

Dizziness is covered if the patient has

• a Glasgow score of 15, or

• Transient symptoms of dizziness associated with neurologic or cardiovascular symptoms and/or signs, or abnormal vital signs (e.g., hypotension)

Be sure to document the additional signs & symptoms in order for dizziness to be covered.

Medicare Policy:

“Complaint or Symptom: Altered level of consciousness (non-traumatic)

Condition Requirement: Neurologic dysfunction in addition to any baseline abnormality


Examples of Systems and Findings Necessary for Coverage (and Documentation):  Acute condition with Glasgow Coma Scale <15 abnormal="abnormal" and="and" associated="associated" cardiovascular="cardiovascular" dizziness="dizziness" nbsp="nbsp" neurologic="neurologic" of="of" or="or" p="p" signs="signs" symptoms="symptoms" transient="transient" vital="vital" with="with">

Complaint or Symptom: Neurologic dysfunction

Condition Requirement: Acute or unexplained neurologic dysfunction in addition to any baseline abnormality.

Examples of Systems and Findings Necessary for Coverage (and Documentation): Signs include facial drooping, loss of vision without ophthalmologic explanation, aphasia, dysphasia, difficulty swallowing, numbness, tingling extremity, stupor, delirium, confusion, hallucinations, paralysis, paresis (focal weakness), abnormal movements, vertigo, unsteady gait/balance.”



glasgow score


The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person).

Best eye response (E)

There are four grades starting with the most severe:
  1. No eye opening
  2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
  3. Eye opening to speech. (Not to be confused with the awakening of a sleeping person; such patients receive a score of 4, not 3.)
  4. Eyes opening spontaneously

Best verbal response (V)

There are five grades starting with the most severe:
  1. No verbal response
  2. Incomprehensible sounds. (Moaning but no words.)
  3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
  4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
  5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

Best motor response (M)

There are six grades starting with the most severe:
  1. No motor response
  2. Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response)
  3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
  4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
  5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
  6. Obeys commands. (The patient does simple things as asked.)
2012 Client Newsletter Archive