September 2018 Client Newsletter
Horizon Now Appear to be 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.
New examples since the August 1 Newsletter:
1. 99204-25 & G0439 (Horizon Medicare Blue).
2. 99214-25, 99396, & 20610. (Horizon)
3. 99214 & G0439. (Horizon)
Each had the ICD-10 codes properly linked to show they were separate and distinct.
We filed a complaint with Horizon's Medicare Complaints Department and have been told that the Medicare Advantage plan will be reprocessed and paid in September (tho they did not specify this Sept. or 2019!). But even if true, that does not address Horizon plans. We continue to work on this issue.
So, when seeing a any patient, and billing a level 4 office visit (new or established) 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.
ICD-10 Codes - Urgent
Just a reminder that Cape Billing has the capability to add up to 12 ICD-10 codes per claim. In these days of insurers using data analytic techniques to review claims, and to use that information to decide when to do audits, it is important to include all medically relevant diagnosis codes on each charge form. This provides a more accurate picture of the patient's health status to justify the level of E&M codes selected, and the procedures performed.
Ideally the codes should be "linked" (via a line on the charge form from each Dx to the CPT or HCPCS code) so the data entry staff knows which ICD-10 codes to attach each to each charge. This, along with good documentation of medical necessity, goes a long way toward avoiding audits.
Any questions, please give Rich a call.
GHI Policy Change Effective 10/30/18: Modifier 25 with Evaluation and Management Services Reported with Procedures
Modifier 25 is used to describe a significant, separately identifiable evaluation and management (E/M) service that was performed at the same time as a procedure.
Beginning October 30, 2018, our current coding policy will apply to GHI plans regarding E/M services billed with modifier 25 within 28 days of a previous face-to-face service. The E/M service will be denied when both of the following apply:
o The E/M service (92002-92004, 92012-92014, 99201-99380, 99441-99499) is billed with modifier 25 on the same day as a procedure with a 0-day, 10-day, or 90-day postoperative period.
o The patient has had a face-to-face service with the same provider for the same condition as the E/M service, and the 0-day, 10-day or 90-day procedure within the previous 28 days.
Face-to-face service codes included in this medical policy: 10021-36410, 36420-44680, 44800-69990, 90935-90993, 92002-92371, 92502-92504, 92511, 95831-95852, 96365-96379, 96405-96406, 96440, 96450, 96542-96999, 97597-97755, 97802-98943, 99100-99170, 99201-99285, 99291-99337, 99341-99357.
If a patient has Medicare & Medicaid, that group of patients is known as QMB's - Qualified Medicare Beneficiaries.
Even if you do not participate with Medicaid, those pts. cannot be balance billed under any circumstances. In those cases, your only option is to accept what is paid from Medicare or Medicaid or discharge them from your practice.
The following document is from CMS - see the 2nd paragraph under the "Executive Summary."
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).
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