May 2013 Client Newsletter
SEQUESTRATION
Now that sequestration has taken effect, what does that mean financially? Bottom line, you will see a 2% decrease in the 80% amount Medicare will pay.
The reduction applies to the amount Medicare will actually pay to the provider - AFTER - the appropriate deductible or copayment has been calculated. So, if the allowable is $100.00, the co-payment is 20% or $20. Medicare's payment was - pre-sequestration - $80.00 (80% of the allowable less any deductible).
NOW, post-sequestration, the $80.00 will be reduced by 2% ($1.60). So instead of the Medicare payment being $80.00, it will be $78.40. Unfortunately, providers are not authorized to collect the sequester related reduction from the patient. CPB handles this adjustment automatically for you. The patient (or secondary insurance) will still owe the full $20.00 (20%) co-insurance amount. If the pt has no 2% insurance, it can be collected during the office visit.
If anyone needs to know the monthly average amount of Medicare payments or has any questions, contact Rich.
Aetna has some plans that only pay for 1 Well Visit every 24 months (not 12 months) for members age 7 (yes, seven!) and older. You may want to check the member's plan before providing this service if the member is age 7 or older. If you are using our eligibility checking option in our Scheduler, you may find it there - if Aetna put it there.
How to Avoid PECOS Ordering Physician Denials
Medicare "blinked" again for "technical reasons." They will not turn the edits on effective May 1, 2013.
Transitional care management codes 99495 & 99496
So far, only Medicare & Horizon will pay. Aetna does not. Horizon & Medicare are allowing the same amount: 99495 = $176.73 & 99496 = $249.06.
FAQ's from CMS:
What date of service should be used on the claim?
The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The reported date of service should be the 30th day. Ex. Patient is discharged on April 5. DOS will be May 4th. The Place of Service is wherever the Face-to-Face service occurred (office, nursing home, etc.).
If a patient is discharged on Monday at 4:30, does Monday count as the first business day and then Tuesday as the second business day, meaning that the communication must occur by close of business on Tuesday? Or, would the provider have until the end of the day on Wednesday?
In the scenario described, the practitioner must communicate with the patient by the end of the day on Wednesday, the second business day following the day of discharge.
If the patient is readmitted in the 30-day period, can TCM still be reported?
Yes, TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge. CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.
Can we bill any services during the 30-day post discharge period? Yes. Second and subsequent E/M services after the initial bundled E/M service may be reported. Other diagnostic or therapeutic services may be billed.
Can TCM services be reported if the beneficiary dies prior to the 30th day following discharge?
Because the TCM codes describe 30 days of care, in cases when the beneficiary dies prior to the 30th day, practitioners should not report TCM services but may report any face-to-face visits that occurred under the appropriate evaluation and management (E/M) code.