Cape Medical Billing: Providing Expert Medical Billing Solutions

Like Cape Medical Billing on Facebook

Call Today 888-MED-BILR

October 2010 Client Newsletter


On August 6th Humana announced they will be making a number of changes in billing and payment policies and procedures effective November 6, 2010. The most notable that we saw pertains to our PCP’s: Humana will include E&M services with the removal of impacted cerumen (69210). It is not clear from their letter whether they will allow modifiers to show when the 69210 was separate and distinct from E&M services.
HIghmark Medicare – 99204 & 99205 prepayment review

On September 20, Highmark Medicare announced that all 99204 & 99205 CPT codes will undergo prepayment review:

A recent widespread post payment audit performed by Highmark Medicare Services’ Medical Review Department revealed that 73% of new patient office or outpatient visits, procedure codes 99204 and 99205, were billed incorrectly. While the number one error was incorrectly coding the level of service, other issues were identified. The issues included:

· The lack of an accepted form of provider signature,
· The documentation did not support incident to guidelines as there was no evidence of the physician initiating the plan of care, and
· No documentation was received to support the services billed.

In order to bill a new patient office or outpatient visit, the patient must not have received any professional service from any physician in the group of the same specialty within the last three years.

As a result of these review findings, a prepayment edit will be implemented on procedure codes 99204 and 99205 for physicians and non-physician practitioners (NPP) of all specialties.

You can read the full article:

If you are asked for any medical records, you are welcome to ask us to review them for anything non-clinical. We strongly urge you not to respond without making sure that the signature is in an acceptable format. There are legitimate ways to make it acceptable. Be sure to respond within the required time frame and please notify us (faxing the letter is fine) so we know why payment is being delayed.

It is important that your medical records substantiate your services to avoid being placed on prepayment review for other services as well. Failure to respond at all may lead Medicare to review even more charges or cease paying entirely.

If you have any questions, please contact me.
2010 Client Newsletter Archive