August 2018 Client Newsletter
Horizon Reneging on Paying Well Visits With Office Visits on the Same Date of Service
Horizon has now started to use the McKesson CCI guidelines which is resulting in a MUCH stricter interpretation than the national CCI guidelines. According to a written denial dated June 25, 2018 received for one of our PCP's:
"Please be advised that after further investigation, we have determined that the initial denial is correct. According to McKesson guidelines, when multiple E&M services are reported on the same date of service, only the most clinically intense E&M service will be recommended for reimbursement. If more than one E&M (face-to-face) service is provided on the same day to the same patient by the same physician...only one E&M service may be reported unless the E&M services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Therefore, procedure 99387 is not recommended for separate reimbursement when submitted with procedure 99205."
This is a radical departure from the past 5 or so years when both a Well visit and an Office visit could be provided on the same date of service and paid as long as there were 2 separate services. When billed, we used the appropriate modifier in accordance with CCI guidelines. In this case, the diagnoses were appropriately linked - well visit ICD-10 on the 99387 & and 6 unrelated, non-well codes on the 99205.
I spoke with Horizon's Coding Manager and was told this is only an issue with 99205 and a New patient Well code (99381-99387). Horizon feels that 99205 has enough complexity built in to cover the Well visit.
So, when seeing a new patient, you will need decide whether the patient also requires a Well visit service on the same day, or whether it could be performed at a future visit.
Benefit Plan Administrators - in Receivership
This insurance is in Receivership. Strongly advise NOT seeing a patient with this insurance unless you treat them as "CASH" patients. They are not insured.
Billing G0444 with an Annual Wellness Visit
The G0444 (Annual Depression Screening) is NOT covered by insurers when performed on the same day as a Well Visit (G0402, G0438, G0439, 99381-87, 99391-97).
Just an FYI, Clover is having difficulty processing DME claims and some procedures due to "system" problems. They are not expecting a "fix" until mid-August. You may want to consider this as Clover patients present in your office.
Horizon Self-Funded Plan That Does NOT Allow Appeals!
We have a Horizon Medicare Blue Advantage patient who was denied payment for an office visit performed with an x-ray. The diagnoses are properly linked with unrelated Dx’s on each. When we sent the formal appeal, Horizon sent a letter that said the patient “is enrolled in a Self-Funded Health Plan (ASC/ASO) account, which is exempt from HCAPPA law’s applicability and therefore, cannot be addressed under the HCAPPA Claims Appeals process.”
What an incentive to deny claims!
Effective August 18th dates of service, UHC for Commercial plans is going to pay 99051 as an “Add-on” fee when a patient is seen during “scheduled evening, weekend or holiday office hours.” The 99051 would be billed in addition to the usual visit codes. So if you normally would bill 99213 for a visit, you would bill 999213 & 99051.
Effective July 1st, UHC will reimburse:
- 99173 - Visual Acuity Screen, quantitative, bilateral. Cannot be billed with 99174 or 99177.
- 99174 - Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral, with remote analysis & report. Cannot be billed with 99173 or 99177.
- 99177 - Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral, with on-site analysis. Cannot be billed with 99173 or 99174.
New Medicare ID Numbers
Just FYI, Medicare updated their new Medicare cards release dates:
- Newly enrolled, are mailed as enrolled.
- New Jersey & New York - Are now being mailed. Please remind your staff to begin asking for them.
- Massachusetts - “After June 2018”
- New Mexico - “After June 2018”
If you want to review the full list:
As we have written many times, the CURRENT STANDARD is to verify insurance every time a patient makes an appointment and every time they arrive for an appointment. For those with electronic verification in your EHR, be sure to use it. For those using the Healthpac Scheduler, be sure to use when making the appointment and when the patient arrives (in case the insurance changed after the appointment was made).
E&M Codes and Diagnoses
With MIPS and other billing, be sure to include ALL diagnoses that you treat and which affect your treatment to support the level of service you are billing. For instance, if a patient has diabetes, COPD, or other similar diagnoses which are part of the consideration for your treatment, be sure to include those Dx’s also. Insurers are looking to see how sick or injured a patient is when paying E&M codes - the better you describe that “picture” thru the use of all relevant diagnosis codes the less likely they will want to review charts.
For example, the Cost component for MIPS is based ultimately on how 'sick' a providers' patients are determined to be and how much care was actually rendered. If a patient has been reported (through claims submission) as only having 'heart failure' but also has 'COPD' and 'obesity', that patient will appear much healthier to a computer system, and the allocated Member Spending Per Beneficiary (MSPB) will be lower for patients that are recognized as being 'healthier', thus their providers could be viewed as 'high cost' if their patients are not documented as 'high cost' patients through their diagnoses.
If you are not participating in MIPS, CPC+, or other CMS programs, it is still important to provide the full “picture” of the patient’s health when billing E&M codes in particular, including for certain procedures. We can add up to 12 diagnosis codes to each charge.
This is true also for EMS patients in order to “paint the picture” as CMS likes to refer to it.