Billing modifiers 62 , 66 , 73 & 74 - 2014

Medicare Part B modifiers - 62

Two surgeons: Under certain circumstances the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Under such circumstances the separate services may be identified by adding the modifier 62 to the procedure number used by each surgeon for reporting his services.

Under some circumstances the individual skills of two surgeons are required to

perform surgery on the same patient during the same operative session. This

may be required because of the complex nature of the procedure(s) and /or the patient’s condition.

If two surgeons, usually with different skills, are required to perform a single

surgical procedure, each surgeon bills for the procedure with modifier 62. Cosurgery also refers to single surgical procedures involving two surgeons performing the parts of the procedure simultaneously, e.g., heart transplant or bilateral knee replacements. Documentation of the medical necessity for two surgeons is required for certain services identified by Centers for Medicare & Medicaid Services (CMS).

Medicare Part B modifiers - 66

Surgical Team: Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances may be identified by each participating physician with the addition of the modifier 66 to the basic procedure number used for reporting services.

All claims for team surgeons must contain sufficient information i.e., operative reports, to allow pricing “by report”.

Medicare Part B modifiers - 73

Discontinued out-patient hospital/ambulatory surgical center (ASC) procedure prior to the administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be preformed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the modifier 73.

Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

Modifiers 76 , 77 Overview - 2014

Medicare Part B modifiers - 76

Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the modifier 76 to the repeated service.

Note: When it is medically necessary to repeat a service, the first service should be reported in the usual manner. The repeat service should be reported on the next line with modifier 76 appended to the procedure code. In the event it is medically necessary to repeat a procedure more than twice, report the second line with the 76 modifier and the appropriate number of units in the units field. If a service is repeated more than once, additional documentation should be provided in the narrative field of the claim to support the medical
necessity of the repeat services. The patient’s medical records must always document the medical necessity of performing repeat procedures and be available to the carrier upon request.

Remittance Advice

Wait for the 14 day electronic and 29 day paper payment floor before calling-use the IVR system

Remittance Advice

Group Code meanings to assist providers in reading remittance advices

Payment Calculation

Medicare payment at 80% of the allowable, minus deductibles for a participating provider. Example: Charge $120
Allowed $100
Medicare Paid (80%) $80
Deductible/coinsurance amounts $20 (20%)

PR Patient Responsibility

UB 04 or (UB 92) billing instruction - 2014

UB form Feilds and Descriptions

Box : 39-41
Field :Value Codes
Description : For Medicare Part A and B claims, enter the appropriate value code(s) for Medicare
Coinsurance and Deductible when Medicare is the primary payer. When Medicare coverage is
present, it will normally be reported as "Payer A" on the UB-04. Value codes are then reported as follows:
• A1 (Deductible Payer A) - For the Part A or Part B
deductible amount
• A2 (Coinsurance Payer A) - For Part A or Part B
coinsurance amounts.
However, in situations where Medicare is "Payer B",
use Value Codes "B1" and "B2" to report Medicare
coinsurance and deductible.
Failure to correctly report the Medicare deductible
may result in incorrect payment, suspended claims, or
denied claims.

PR - Patient Responsibility

An ANSI Group Code is always shown with each ANSI reason code to indicate when you may or may not, bill a beneficiary for the non-paid balance of the services or equipment you furnished. Group codes are not used with Medicare Reference (REF) or Medicare Outpatient Adjudication (MOA) remark code entries.

PR - Patient Responsibility

A PR group code signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary’s behalf. For example, PR would be used with the reason code for patient deductible or coinsurance, if the patient assumed financial responsibility for a service not considered reasonable and necessary, for the cost of therapy or psychiatric services after the coverage limit had been reached, for a charge denied as result of the patient’s failure to supply primary payer or other information, or where a patient is responsible for payment of excess non-assigned physician charges. Charges that have not been paid by Medicare and/or are not included in a PR group, such as a late filing penalty (reason code B4), excess charges on an assigned claim (reason code 42), excess charges attributable to rebundled services (reason code B15), charges denied as result of the failure to submit necessary information by a provider who accepts assignment, or services that are not reasonable and necessary for care (reason code 50 or 57) for which there are no indemnification agreements are the liability of the provider. Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code.

Procedure code G0108 & G0109 - 2014

Medicare provides coverage of diabetes self-management training (DSMT) services for beneficiaries who have been recently diagnosed with diabetes, determined to be at risk for complications from diabetes, or were previously diagnosed with diabetes before meeting Medicare eligibility requirements and have since become eligible for coverage under the Medicare Program

A qualified DSMT program includes the following services:

* Instructions in self-monitoring of blood glucose,

* Education about diet and exercise,

* An insulin treatment plan developed specifically for insulin dependent patients, and

* Motivation for patients to use the skills for self-management.

DSMT services are aimed toward individuals with Medicare who have recently been impacted in any of the following situations by diabetes:

*Problems controlling blood sugar,

*Beginning diabetes medication, or switching from oral diabetes medication to insulin,

*Diagnosed with eye disease related to diabetes,

*Lack of feeling in feet or other foot problems such as ulcers or deformities, or an amputation hasbeen performed,

*Treated in an emergency room or have stayed overnight in a hospital because of diabetes, or

Diagnosed with kidney disease related to diabetes.``

Coverage Information

Medicare provides coverage of DSMT services only if the treating physician or treating qualifiednon-physician practitioner managing the beneficiary’s diabetic condition certifies that DSMT services are needed. The referring physician or qualified non-physician practitioner must maintain a plan of care in the beneficiary’s medical record and documentation substantiating the need for training on an individual basis when group training is typically covered, if ordered. The order must also include a statement signed by the physician or qualified non-physician practitioner that the service is needed as well as thefollowing information:

*The number of initial or follow-up hours ordered (the physician can order less than 10 hours, but cannot exceed 10 hours of training),

*The topics to be covered in training (initial training hours can be used to pay for the full initial *training program or specific areas, such as nutrition or insulin training), and

A determination if the beneficiary should receive individual or group training.

CPT 99212, 99213 visit history

The only difference between the history requirements for a 99212 and a 99213 is the review of systems.

For a level-II visit, you need one point to meet the data requirement, which is considered minimal. You can earn one point by ordering or reviewing lab, radiology or procedure reports, or simply by obtaining old records about the patient or obtaining history from someone other than the patient (e.g., a family member or caregiver). The data for a level-III visit is considered limited and requires a total of two points. You can earn two points by reviewing or ordering two different types of tests (e.g., a complete blood count and a chest X-ray). You can also earn two points by summarizing old records or discussing the case with another health care provider. 

MEDICARE TIPS

Wait for the 14 day electronic and 29 day paper payment floor before calling-use the IVR system

Remittance Advice

Group Code meanings to assist providers in reading remittance advices

Payment Calculation

Medicare payment at 80% of the allowable, minus deductibles for a participating provider. Example: Charge $120
Allowed $100
Medicare Paid (80%) $80
Deductible/coinsurance amounts $20 (20%)

PR Patient Responsibility

This signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary's behalf. The PR codes are used with the reason codes.
· Patient deductible or coinsurance

UB Form Billing - Field descriptions -2014

Valid claim formats

DMAP only accepts commercially-available “red form” versions of the UB-04 claim form. We will return claims submitted on the UB-92 form, black-and-white copies of the UB-04 form, Turn-Around Document (TAD) or Extended Care Invoice (DHS 1039) with a request to resubmit the claim on the correct form.

DMAP processes hardcopy claims using Optical Character Recognition (OCR) scanning. To avoid processing delays, make sure information is left-aligned in the following fields:

4 - Type of Bill
6 - Statement From and Through Dates
8b - Patient Name

If your forms are not to scale, or if the fields on your form are not correctly aligned, DMAP will manually enter your claim, which may delay processing of the claim.
Box : 3a
Field :Patient Control No.
Description : If a patient account number is provided in this box, DMAP will print it on the Remittance Advice (RA).

Box : 4 
Field :Type of BillDescription : Enter the appropriate three (3)-digit code that identifies the type of service you are billing for.
See the “Type of Bill Codes” section of the Appendix for specific codes by provider type, or refer to the provider guidelines for your program.