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May 2014 Client Newsletter





May 1, 2014





For practices treating children, when the child turns age 18, they are now considered an adult. That means the parents no longer have an automatic right to confidential patient information.  At that time, we STRONGLY recommend that the office ask the patient to complete their own Patient Information Form.  The new form needs to indicate who patient will release such information to and who balances should be billed to – the patient or parents/guardian?


As mentioned a few months ago, but worth repeating due to the potential loss of practice revenue, insurers are beginning to use a new tactic to avoid considering appeals (and thus, payment) by requiring the practice to have obtained patient approval to file appeals on their behalf.  Be sure your office New Patient Form includes a sentence giving the practice the authorization to file appeals on behalf of the patient. Chasing the patient after the service is time-consuming and often fruitless.




As a matter of policy, Medicare and most other insurers will not cover Cerumen removal (69210) when billed with an E&M code.  If billed with an E&M code, it will only be covered now if “instruments” were used to remove the ear wax and the OV had other unrelated diagnoses treated.  Lavage is not covered.


Note also that it is now specifically defined as “requiring instrumentation” and “unilateral.”  So if you do BOTH ears, we will bill with the correct modifier &/or units, depending on the insurance company’s policy.  If we need to appeal, the medical record needs to reflect the name of the specific “instruments” that were used to remove the cerumen – not irrigation.






Just a reminder that on September 23, 2013 the HIPAA Omnibus Rule became effective.  One of the provisions is that patients have the right to pay out-of-pocket and request that you not submit a claim to their insurer.  You in turn have the right to collect payment that day in return for not filing the claim.  We strongly advise that you require any patient electing to take advantage of this option to pay the bill in full before leaving the office.




Just a reminder that 2014 is the 2nd and final year for enhanced Medicaid primary care payments.

Under the enhanced payment policy, all Medicaid programs have been directed to pay the same as Medicare for certain primary care services. This policy is only in place for CY 2013 and CY 2014. After that it goes away unless Congress approves an extension. The cost for the enhanced payments is being fully paid by the federal government and comes with a pretty hefty price tag.

Also, as noted in an earlier Client Newsletter, the physicians (and only physicians) eligible for the enhanced payments are linked to either specific specialties (and subspecialties) OR based upon billing history. However, if a physician in a non-primary care specialty can demonstrate that 60% of his/her billing is for CPT codes identified by CMS as primary care, then that physician can qualify as well. The FAQs in the above links will give you the CPT codes that have been identified as "primary care" for purposes of the enhanced payments.

Here are the specialties that will be recognized:

  • Family Medicine,
  • General Internal Medicine, or
  • Pediatric Medicine.


The regulation specifies that specialists and subspecialists within those designations as recognized by the American Board of Medical Specialties (ABMS), the American Osteopathic Association (AOA), or the American Board of Physician Specialties (ABPS) also qualify for the enhanced payment.  Under the regulation, “general internal medicine” encompasses internal medicine and all subspecialties recognized by the ABMS, ABPS and AOA.




As you know, if a Referring provider is not in the PECOS system, you will not be paid.  To verify whether a provider is in that system:

  1. Check the CMS ordering/referring provider downloadable report which contains the NPI, first name, and last name of providers enrolled in PECOS. This report can be accessed on the CMS Web site at:
  2. Call the DME MAC A IVR at 866-419-9458 and select Option 8; enter the NPI, first and last name of the referring provider. The IVR will respond if the individual is, or is not, enrolled in PECOS.  This is available whether you are a DME provider or not.


Be aware that claims which are denied because they failed the ordering/referring edit do not expose a Medicare beneficiary to liability. Therefore, according to CMS, an Advance Beneficiary Notice of Non-coverage is not appropriate in this situation.


2014 Client Newsletter Archive