20 CSR 400-2.030 Group Coordination of Benefits

PURPOSE: This rule restricts the use of coordination of benefits provisions in group health insurance plans to those situations where they may be equitably applied

(1) Applicability. The purpose of this rule is to— (A) Permit, but not require, plans to include a coordination of benefits (COB) provision;

(B) Establish an order in which plans pay their claims; 

(C) Provide the authority for orderly transfer of information needed to pay claims promptly; 

(D) Reduce duplication of benefits by permitting a reduction of the benefits paid by a plan where the plan, pursuant to rules established by this rule, does not have to pay its benefits first; 

(E) Reduce claims payment delays; and 

(F) Make all contracts that contain a COB provision consistent with this rule.

(2) Definitions. The following words and terms, when used in this rule, shall have the following meanings unless the context clearly indicates otherwise: 

(A) Allowable or Allowable expense. 

1. Allowable or Allowable expense means the necessary, reasonable and customary item of expense for health care when the item of expense is covered at least in part under any of the plans involved, except where a statute requires a different definition. 

2. Notwithstanding this definition, items of expense under coverages, such as dental care, vision care, prescription drug or hearing- aid programs, may be excluded from the definition of allowable expense. A plan which provides benefits only for any of these items of expense may limit its definition of allowable expenses to like items of expense. 

3. When a plan provides benefits in the form of service, the reasonable cash value of each service will be considered as both an allowable expense and a benefit paid. 

4. The difference between the cost of a private hospital room and the cost of a semiprivate hospital room is not considered an allowable expense under this definition unless the patient’s stay in a private hospital room is medically necessary in terms of generally accepted medical practice. 

ABN (Advanced Beneficiary Notice)

In Medical Billing, we have our own language. Things such as EOBs, PPOs, HMOs, POSs, Catastrophic Cap, Deductibles and more can be very frightening if not understood. During training, medical coders and medical billers learn medical terminology. Medical Billing terminology is going to the next step to learn language medical billers face every day when interacting with patients, health benefits, and claims. There is a huge difference between otitis media and coordination of benefits (COB). Otitis Media is medical terminology. It is also a diagnosis that is converted by a coder from words to numbers that are recognized by an insurance company. COB is medical billing terminology, used by medical billers when interacting with multiple insurance policies carried by a patient. 

An ABN is a written notice from Medicare (standard government form CMS-R- 131), given to you before receiving certain items or services, notifying the patient:

• Medicare may deny payment for that specific procedure or treatment. 

• The patient will be personally responsible for full payment if Medicare denies payment.

An ABN gives the patient the opportunity to accept or refuse the items or services and protects the patient from unexpected financial liability in cases where Medicare denies payment. It also offers the patient the right to appeal Medicare's decision. You follow office policy on keeping the ABN form on file and you ad the modifier GA to the claim. Modifier GA informs Medicare of the ABN transaction. If you do not have the patient sign the ABN form and the claim is denied, then you cannot bill the patient for the denied claim.

The patient has the option to receive the items or services or to refuse them. In either case, the patient should choose one option on the form by checking the box provided, and then signing and dating it in the space provided.

When the patient signs an ABN and becomes liable for payment, the patient will have to pay for the item or service themselves, either out-of-pocket or by some other insurance coverage which they may have in addition to Medicare. Medicare fee schedule amounts and balance billing limits do not apply. The amount of the bill is a matter between the patient and provider. If this is a concern for the patient, they might want to ask for a cost estimate before they sign the ABN.

MALIGNANCIES

Lymphoma and other malignancies, some fatal, have been reported in children and adolescent patients treated with TNF blockers, including REMICADE®. Approximately half of these cases were lymphomas, including Hodgkin’s and non-Hodgkin’s lymphoma. The other cases represented a variety of malignancies, including rare malignancies that are usually associated with immunosuppression and malignancies that are not usually observed in children and adolescents. The malignancies occurred after a median of 30 months after the first dose of therapy. Most of the patients were receiving concomitant immunosuppressants.

Postmarketing cases of hepatosplenic T-cell lymphoma, a rare type of T-cell lymphoma, have been reported in patients treated with TNF blockers, including REMICADE®. These cases have had a very aggressive disease course and have been fatal. The majority of reported REMICADE® cases have occurred in patients with Crohn’s disease or ulcerative colitis and most were in adolescent and young adult males. Almost all of these patients had received treatment with azathioprine or 6-mercaptopurine concomitantly with REMICADE® at or prior to diagnosis. Carefully assess the risks and benefits of treatment with REMICADE®, especially in these patient types. In clinical trials of all TNF inhibitors, more cases of lymphoma were observed compared with controls and the expected rate in the general population. However, patients with Crohn’s disease, rheumatoid arthritis, or plaque psoriasis may be at higher risk for developing lymphoma. 

In clinical trials of some TNF inhibitors, including REMICADE®, more cases of other malignancies were observed compared with controls. The rate of these malignancies among patients treated with REMICADE® was similar to that expected in the general population whereas the rate in control patients was lower than expected. Cases of acute and chronic leukemia have been reported with postmarketing TNF-blocker use. As the potential role of TNF inhibitors in the development of malignancies is not known, caution should be exercised when considering treatment of patients with a current or a past history of malignancy or other risk factors such as chronic obstructive pulmonary disease (COPD). 

Melanoma and Merkel cell carcinoma have been reported in patients treated with TNF-blocker therapy, including REMICADE®. Periodic skin examination is recommended for all patients, particularly those with risk factors for skin cancer.

medical billing and coding

Skilled Nursing Facility​ - A nursing home or facility for convalescence. Provides a high level of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care. 

SOF​ - Signature on File.

Software As A Service (SAAS)​ - One of the medical billing terms for a software application that is hosted on a server and accessible over the Internet. SAAS relieves the user of software maintenance and support and the need to install and run an application on an individual local PC or server. Many medical billing applications are available as SAAS. 

Specialist​ - Pphysician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some health care plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist. 

Subscriber​ - Medical billing term to describe the employee for group policies. For individual policies the subscriber describes the policyholder. 

Superbill​ - One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms. 

Supplemental Insurance​ - Additional insurance policy that covers claims for deductibles and coinsurance. Frequently used to cover these expenses not covered by Medicare. 

TAR​ - Treatment Authorization Request. An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered. 

Taxonomy Code​ - Specialty standard codes used to indicate a provider's specialty sometimes required to process a claim. 

Term Date​ - Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible. 

Tertiary Insurance Claim​ - Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance covers gaps in coverage the primary and secondary insurance may not cover. 

Third Party Administrator (TPA)​ - An independent corporate entity or person (third party) who administers group benefits, claims and administration for a self-insured company or group. 

TIN​ - Tax Identification Number. Also known as Employer Identification Number (EIN). 

TOP​ - Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is also commonly referred to as a cafeteria plan. 

TOS​ - Type of Service. Description of the category of service performed. 

TRICARE​ - This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS. 

UB04​ - Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form. 

Unbundling​ - Submitting several CPT treatment codes when only one code is necessary. Untimely Submission​ - Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after this date are denied. 

Upcoding​ - An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the reimbursement from the insurance payor. UPIN​ - Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number. 

Usual Customary & Reasonable(UCR)​ - The allowable coverage limits (fee schedule) determined by the patient's insurance company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient. 

Utilization Limit​ - The limits that Medicare sets on how many times certain services can be provided within a year. The patient's claim can be denied if the services exceed this limit. 

Utilization Review (UR)​ - Review or audit conducted to reduce unnecessary inpatient or outpatient medical services or procedures. V-Codes​ - ICD-9-CM coding classification to identify health care for reasons other than injury or illness. 

Workers Comp​ - Insurance claim that results from a work related injury or illness. 

Write-off​ - Typically reference to the difference between what the physician charges and what the insurance plan contractually allows and the patient is not responsible for. May also be referred to as "not covered" in some glossary of billing terms. 

Medical Billing Terminology - U,V,W

U

UB04: A form used by providers for filing claims with insurance companies. The UB04 form has a format similar to that of the CMS 1500 form.

Unbundling: This term refers to the fraudulent practice of ascribing more than one code to a service or procedure on a superbill or claim form when only one is necessary.

Untimely Submission: Claims have a specific timeframe in which they can be sent off to an insurance company for processing. If a provider fails to file a claim with an insurance company in that timeframe, it is marked for untimely submission and will be denied by the company.

Upcoding: Upcoding is the fraudulent practice of ascribing a higher ICD-9 code to a healthcare procedure in an attempt to get more money than necessary from the insurance company or patient.

Unique Physician Identification Number (UPIN): A unique six-digit identification number given to physicians and other healthcare personnel, which has subsequently been replaced by a national provider identifier (NPI) number.

Usual Customary and Reasonable (UCR): The UCR is the amount of money stipulated in a contract that an insurance company agrees to pay for healthcare costs. After passing the UCR a patient is typically responsible for covering their healthcare costs.

Utilization Limit: The limit per year for coverage under certain available healthcare services for Medicare enrollees. Once a patient passes the utilization limit for a service, Medicare may no longer cover them.

Utilization Review (UR): An investigation or audit performed to optimize the number of inpatient and outpatient services a provider performs.

V

V-Codes: A codeset under ICD-9-CM used to organize healthcare services rendered for reasons other than illness or injury.

W

Worker’s Compensation: Worker’s compensation is paid by an employer when an employee becomes ill or injured while performing routine job duties. Most states have laws requiring that companies provide worker’s compensation.

Write-Off: This term refers to the discrepancy between a provider’s fee for healthcare services and the amount that an insurance company is willing to pay for those services that a patient is not responsible for. The write-off amount may be categorized as “not covered” amounts for billing purposes.

Medical Billing Terminology - R,S,T

R

Referral: This is when a provider recommends another provider to a patient to receive specialized treatment.

Remittance Advice (R/A): The R/A is also known as the EOB, which is the document attached to a processed claim that explains the information regarding coverage and payments on a claim.

Responsible Party: The person who pays for a patient’s medical expenses, also known as the guarantor.

Revenue Code: A three-digit code used on medical bills that explains the kind of facility in which a patient received treatment.

Relative Value Amount (RVA): The median amount Medicare will repay a provider for certain services and treatments.

S

Scrubbing: A process by which insurance claims are checked for errors before being sent to an insurance company for final processing. Providers scrub claims in an attempt to reduce the number of denied or rejected claims.

Self-Referral: When a patient does their own research to find a provider and acts outside of their primary care physician’s referral.

Self-Pay: Payment made by the patient for healthcare at the time they receive it at a provider’s facilities.

Secondary Insurance Claim: The claim filed with the secondary insurance company after the primary insurance company pays for their portion of healthcare costs.

Secondary Procedure: This is when provider performs another procedure on a patient covered by a CPT code after first performing a different CPT procedure on them.

Security Standard: The security standard serves as the guidelines for policies and practices necessary to reduce security risks within the healthcare system. The security standard policies work in concert with the security guidelines set in place with the passage of HIPAA.

Skilled Nursing Facility: These are facilities for the severely ill or elderly that provide specialized long-term care for recovering patients. Skilled nursing facilities are alternative healthcare establishments to extended hospital stays and may be covered by eligible patients’ insurance policies.

Signature on File (SOF): A patient’s official signature on file for the purpose of billing and claims processing.

Software as a Service (SAAS): Medical billing software hosted off site by another company and only accessible with Internet access. SAAS is useful for providers who don’t want to maintain and update in-house medical billing software.

Specialist: A physician or medical assistant with expertise in a specific area of medicine. Oncologists, pediatricians, and neurologists are among the many specialists in the medical field.

Subscriber: The subscriber is the individual covered under a group policy. For instance, an employee of a company with a group health policy would be one of many subscribers on that policy.

Superbill: A document used by healthcare staff and physicians to write down information about a patient receiving care. The superbill can contain demographic information, insurance information, and especially any diagnoses or healthcare plans written by the physician. A medical billing specialist inputs the information on a patient’s superbill into a claim.

Supplemental Insurance: Supplemental insurance can be a secondary policy or another insurance company that covers a patient’s healthcare costs after receiving coverage from their primary insurance. Supplemental insurance policies typically help patients cover expensive deductibles and copays.

T

Treatment Authorization Request (TAR): A unique number the insurance company gives the provider for billing purposes. A provider must receive the insurance company’s TAR number before administering healthcare to a patient covered by the company.

Taxonomy Code: Medical billing specialists utilize this unique codeset for identifying a healthcare provider’s specialty field.

Term Date: The end date for an insurance policy contract, or the date after which a person no longer receives or is no longer eligible for health insurance with company. Term dates are typically determined on a case-by-case basis.

Tertiary Insurance Claim: A claim filed by a provider after they have filed claims for primary and secondary health insurance coverage on behalf of a patient. Tertiary insurance claims often cover the remaining healthcare costs such as deductibles and co-pays left over after the primary and secondary claims have been processed.

Third Party Administrator (TPA): The name for the organization or individual that manages healthcare group benefits, claims, and administrative duties on behalf of a group plan or a company with a group plan.

Tax Identification Number (TIN): A unique number a patient or a company may have to produce for billing purposes in order to receive healthcare from a provider. The TIN is also known as the employment identification number (EIN).

Triple Option Plan (TOP): Also referred to as the cafeteria plan, this plan gives an enrolled individual the options to choose between an HMO, a PPO, or a traditional point of service plan for their health insurance. Some companies offer triple option plans to their employees to accommodate the needs of a diverse staff.

Type of Service (TOS): A field on a claim for describing what kind of healthcare services or procedures a provider administered.

TRICARE: TRICARE is the federal health insurance plan for active service members, retired service members, and their families, in addition to survivors of service members. TRICARE was previously known as CHAMPUS.

Medical Billing Terminology - N, O, P

N

Non-Covered Charge (N/C): N/Cs are procedures and services not covered by a person’s health insurance plan.

Not Elsewhere Classifiable (NEC): A term used to describe a procedure or service that can’t be described within the available code set.

Network Provider: A provider within a health insurance company’s network that has contracted with the company to provide discounted services to a patient covered under the company’s plan.

Non-participation: This is when a provider refuses to accept Medicare payments as a sufficient amount for the services rendered to a patient.

Not Otherwise Specified (NOS): This term is used in ICD-9 codes to describe conditions with unspecified diagnoses.

National Provider Identifier (NPI) Number: A unique 10-digit number ascribed to every healthcare provider in the U.S. as mandated by HIPAA.

O

Office of Inspector General (OIG): The organization responsible for establishing guidelines and investigating fraud and misinformation within the healthcare industry. The OIG is part of the Department of Health and Human Services.

Out-of-Network: Out-of-network refers to providers outside of an established network of providers who contract with an insurance company to offer patients healthcare at a discounted rate. People who go to out-of-network providers typically have to pay more money to receive care.

Outpatient: This term refers to healthcare treatment that doesn’t require an overnight hospital stay, including a routine visit to a primary care doctor or a non-invasive surgery.

P

Palmetto GBA: A MAC based in Columbia, South Carolina that is also a subsidiary of Blue Cross Blue Shield.

Patient Responsibility: This refers to the amount a patient owes a provider after an insurance company pays for their portion of the medical expenses.

Primary Care Physician (PCP): The physician who provides the basic healthcare services for a patient and recommends additional care for more serious treatments as necessary.

Point of Service Plans: A plan whereby patients with HMO membership may receive care at non-HMO providers in exchange for a referral and paying a higher deductible.

Place of Service Code: A two-digit code used on claims to explain what type of provider performed healthcare services on a patient.

Preferred Provider Organization (PPO): A plan similar to an HMO whereby a patient can receive healthcare from providers within an established network set up by an insurance company.

Practice Management Software: Software used for scheduling, billing, and recordkeeping at a provider’s office.

Preauthorization: Some insurance plans require that a patient receive preauthorization from the insurance company prior to receiving certain medical services to make sure the company will cover expenses associated with those services.

Pre-Certification: A process similar to preauthorization whereby patients must check with insurance companies to see if a desired healthcare treatment or service is deemed medically necessary (and thus covered) by the company.

Pre-determination: A maximum sum as explained in a healthcare plan an insurance company will pay for certain services or treatments.

Pre-existing Condition (PEC): PEC is a medical condition a patient had before receiving coverage from an insurance company. A person might become ineligible for certain healthcare plans depending on the severity and length of their PEC.

Pre-exisiting Condition Exclusion: The existence of a PEC denies a person certain coverage in some health insurance plans.

Premium: The sum a person pays to an insurance company on a regular (usually monthly or yearly) basis to receive health insurance.

Privacy Rule: Standards for privacy regarding a patient’s medical history and all related events, treatments, and data as outlined by HIPAA.

Provider: A provider is the healthcare facility that administered healthcare to an individual. Physicians, clinics, and hospitals are all considered providers.

Provider Transaction Access Number (PTAN): This refers to a provider’s current legacy provider number with Medicare.

Is your claim reimbursement in line with your contracted fees?

This type of analysis is invaluable to any medical practice.  Once you have signed on that dotted line with the payer, you are wise to ensure that you are receiving the proper reimbursement based on the agreed upon contractual rates.  In the daily whirlwind of activity in the medical office, office staff seldom has the time to comb over the detail of every paid line item.  

A monthly report that compares the payments received to the payer’s fee schedule will indicate payments that are below (as well as above) the payers contracted fees.  Payments that are below should immediately prompt a call the Provider Relations Department.  For payments above the contracted fees, research has to be done on the accuracy of the fee schedule you are using, for instance, perhaps the payer has updated its schedule and you have not.  

This type of report could also make you aware of overpayments. If those are pre-emptively refunded to the payer, it will show your practice to be following proper procedures in the eyes of the payer.

These two reports are just a small sampling of the extensive selection of practice management reporting options built into the Report Center module of Iridium Suite Medical Billing Software.

Be sure to watch for the upcoming publication of Part 3:  Temperature.

Check the Vital Signs of Your Medical Practice-Part 1

A Medical Practice is a unique business in many ways, but it is still a business and must be treated as such.  Checking the health of your practice is similar to checking the health of your patients.  In this three part series, we will look at these Vital Signs, pulse, blood pressure and temperature, to help you assess the financial well-being of your medical practice.

We will begin in Part 1 with the Pulse -     

How many new patients are you seeing each month?

By analyzing the trends month over month, you will be able to calculate your current growth rate and estimate the potential need for increased staffing and other infrastructure changes.  If close monitoring of your patient numbers shows a progressive decline or steep increase, it can give you the opportunity to research the reason why.  One reason could lie in the next item on our list, referrals.

Who is referring those patients to you?

With the almighty internet, physicians have been able to reach out much more easily and cost effectively to a wider range of patients.  While many people with basic medical needs may feel comfortable doctor-shopping online, there are many who have complicated issues.  These referrals generally come from colleagues and satisfied patients.  Know which providers in your area are referring patients to your office and always keep the lines of communication open in regards to those mutual patients.  

A happy, well-taken-care-of patient is the best advertising.  Many times less than stellar office staff can scare away patients who “love” their doctor, and those unpleasant episodes can make their way back to the referring colleague.  Watch for trends that would show a reduction in referrals from a particular source and take the time to reach out personally.   

These two reports are just a small sampling of the extensive selection of practice management reporting options built into the Report Center module of Iridium Suite Medical Billing Software.

Be sure to watch for the upcoming publication of Part 2:  Blood Pressure.

Inaccurate or non-specific diagnosis coding can adversely affect your reimbursement of medical claims.

Many categories of the ICD-9 contain codes that represent the non-specified site of a certain neoplasm. The are typically indicated with a “9” as the last digit of the code.

Even though all of these codes are viable, accepted diagnoses, many payers, especially Medicare, highly encourage the use of the more “site specific” codes. Failure to be specific can in some instances cause Medical Necessity denials as the non-specific codes may not be listed as acceptable in the payers' Medical Policies. 

Also, if audited, a discrepancy between the treating diagnosis in the medical chart and the diagnosis submitted on a claim, could cause payment reversals and money due back to the payer. 

In all medical specialties, the patient medical record should dictate what services are billed and the diagnoses used.

One specialty example is Radiation Oncology. The prescriptions for Radiation Therapy Treatment Courses are very site specific, so this information is one of the most helpful tools in proper diagnosis coding when used in conjunction with patient data the medical staff has entered into the medical record.

In any specialty, but quite frequently in Radiation Oncology, a patient can have numerous diagnoses that require treatment. In these instances, it is especially important to indicate the proper diagnosis priority on your services. The priority one diagnosis should always be the current treating diagnosis for the service you are billing.

Another frequent situation in Radiation Oncology billing arises when treating a patient for metastatic disease. The metastatic treatment site will be listed as the priority one diagnosis with the primary original site diagnosis listed as the second.

Other specialties would follow a similar scenario if they were treating a complication diagnosis, billed as priority one, from an initial diagnosis, billed as priority two.

Billing and coding software with comprehensive ICD -9 and ICD-10 code files, as well as an ICD 10 conversion crosswalk, such as Iridium Suite can assist your office in accurately billing the most specific diagnoses for the patients in your practice.

Electronic Health Record (EHR) and Medical Billing Systems

An EHR must not only record your patient data electronically, but should be certified for meaningful use by CMS. Once you select a certified system, this gives you the potential to earn financial incentives from CMS by providing the required proof of meaningful use.  

                                                                              

Integrating multiple systems can enhance your work environment and improve efficiency. Your billing and coding software should be able to directly import medical data such as patient demographics from your EHR. This type of integration will eliminate the need for re-entry of patient data into the billing system by office staff.

Iridium Suite medical billing software now comes with the Connectivity Clearinghouse enabling connections to multiple EHR systems. You can connect to your EHR as often as your office work flow dictates. With accurate and complete data entry in your EHR, you are able to bring in all the necessary information to bill and file your patient claims. 

The Connectivity Clearinghouse can use multiple protocols such as: LLP, HTTPS, and SFTP. It can also be extended to use multiple data formats such as: multiple versions of HL7, any well formed XML and delimited text.

The versatility of the Connectivity Clearinghouse in Iridium Suite practice billing software provides the foundation to integrate with your existing Electronic Health Record, saving your practice time and money.

Check the Vital Signs of Your Medical Practice-Part 2

A Medical Practice is a unique business in many ways, but it is still a business and must be treated as such.  Checking the health of your practice is similar to checking the health of your patients.  In this three part series, we will look at these Vital Signs, pulse, blood pressure and temperature, to help you assess the financial well-being of your medical practice.

In Part 1, we addressed the pulse of your practice: trends in new patient statistics and physician referrals.  If you missed Part 1, please select this link: Check the Vital Signs of Your Medical Practice-Part 1

For Part 2, let’s check that Blood Pressure-   

Are the numbers of services you bill increasing, decreasing, or staying the same?

Depending on your type of medical practice, you could expect to see one or two procedure codes billed per patient visit or for some specialties like Radiation Oncology, you may bill 10 procedure codes per visit.  In either case, reviewing reports that show month-to-month statistics can allow you to recognize anomalies in your billing patterns.  Sharp declines in a certain procedure may indicate forgotten or missed coding opportunities and therefore missed revenue.  

Many payers have time filing limits from the date of service.  They can range from 60 days to one year.  A regular review for missed charges will enable to meet those filing limits and collect on all of your rendered services.  If your report showed an unexpected procedure or an unusually high number of a certain procedure was billed, you will be able to audit the medical record(s) for appropriate documentation.  

If billing errors are discovered, you can get ahead of an insurance audit by quickly refunding any payments received for these non-provided services.  Keeping yourself in the good graces of your payers is always important.

The best way to keep your income stream flowing properly is to prevent claim denials.

cash flow

You should be aware of the following high volume denial reason codes and prepare a strategy to keep them to a minimum in your practice.

By utilizing an advanced Medical Practice Management Billing Software like Iridium Suite from Medical Business Systems, many of these types of denials will become a thing of the past.

duplicate claim18 - Duplicate claim/service.

Manual keying of services lends itself to duplicate entry of those services.   A configurable Claim Scrubber as found in Iridium Suite will check each service entered and alert the user immediately if the same service is already on record.

claim lacks information  16 - Claim/service lacks information which is needed for adjudication.

Some payers have specific claim rules that require “non-standard” 5010 format information be included on their claims.  An example is the rendering provider’s Taxonomy code in addition to the standard NPI.  Iridium Suite allows the user to include this specialized data on the claims to those individual payers as needed. 

payment included in another service97 - Payment is included in the allowance for another service/procedure.

Government payers, such as Medicare, as well as the larger Commercial payers have adopted the NCCI standard for “bundled” services.  The Iridium Suite Claim Scrubber comes standard with all current NCCI edits built in.  The Scrubber alerts the user when entering two or more procedures that are considered inclusive of each other.

Time filing limit has expired  29 - The time limit for filing has expired.

Payers each have their own time filing limits guidelines for claim submission.  It can be as short as 60 days, or the current Medicare limit is 12 months.  The sooner you submit your claims, the quicker. 

you will receive your payment and eliminate the risk of untimely filing denials. 

Connectivity Clearinghouse within Iridium Suite, you can import patient demographic and service data directly into the billing software from your EHR/EMR.  Your patient and charge entry process can be almost completely automated allowing for close to “real time” claims submission for your services.

non-covered service50 - These are non-covered services because this is not deemed a ‘medical necessity by the payer.  

The key to preventing these types of denials is being aware of your payers Medical Policies. These two Biller’s Blogs provide insight on both Commercial Payers and Medicare:

Reviewing Commercial Carrier Medical Policies

Understanding Medicare Fiscal Intermediaries LCD's

identification number and name do not match140 - Patient/Insured health identification number and name do not match.

By utilizing the Real Time Eligibility function in  

Iridium Suite, you can virtually eliminate denials 

like the one above or similarly “subscriber not  eligible

at time of service.”  You will be able to successfully 

submit charges to the correct active payer with the 

proper identification number and receive your  

appropriate claims reimbursement on the first submission. 

Absence of precertification197 - Payment adjusted for absence of precertification/authorization.

2013 Orthopedic Surgery CPT Code Changes and Additions

These are the highlights of the seven CPT code changes and a listing of numerous CPT code additions affecting Orthopedic Surgery billing in 2013.  Make sure you review the full CPT manual for complete details of all coding changes to insure you receive your optimum claim reimbursements.

Increased Claims Reimbursement

Spine CPT

Guideline Change: CPT codes 22633 and 22634 may be appropriately related as primary or index codes for spine bone grafts (20930–20938), instrumentation (22840–22844, 22848, 22845–22847), and intervertebral device (22851) codes. 

 Bone marrow aspirate

Clarification: Use of bone graft codes (20930–20938) related to bone marrow aspiration. CPT code 38220 defines the work associated with the harvest of bone marrow for bone grafting only. (Billing Note: Category III code 0232T should be used when bone marrow aspiration is performed for platelet-rich stem cell.)

Cervical Spinal Arthrodesis Guideline

Guidelines Added:  CPT codes 22554, 22585, 63075, and 63076; if the work associated with these procedures is performed during the same surgery by the same surgeon or by two separate surgeons/individuals during the same session, the correct codes are 22551 and 22552. (Billing Note: CPT codes 63075 and 22554 may not be unbundled and reported for the same patient, same session.)

Cast application

Guideline Change:  Refer to the section “Application and Strapping” for specific changes regarding the application of the first cast, its removal, coding by the individual who performs the initial service, and restorative management. (Billing Note: CPT code 29590 (Denis-Browne bar (splint) with manipulation and casting (eg, for metatarsus adductus, clubfoot) was deleted.)

Hip arthroscopy

Clarification: CPT code 29916 (Arthroscopic labral repair of a torn labrum) is considered inherent to CPT codes 29915, 29862, and 29863. (Billing Note:  CPT code 29916 should not be reported in addition to CPT codes 29915, 29862, or 29863 because the repair is already included in these codes, whether as a takedown and repair or a repair of an already torn labrum.)

Chemodenervation

Guideline Change:   CPT code 64614 (Chemodenervation of muscle(s); extremity and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis) may only be reported once per extremity. The parenthetical (s) was removed from extremity. (Billing Note:  CPT code 64614 states that modifier 50 should not be appended to this code. Check with your payers to determine specific rules to code submission.)

Intraoperative nerve monitoring

Clarification: Intraoperative nerve monitoring by the operating surgeon is included in the primary surgical service and is not separately reportable.

Update your medical billing system with the following new CPT codes for 2013: Spine

22586—Arthrodesis, pre-sacral inter-body technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace

0309T—Arthrodesis, pre-sacral inter-body technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (Billing Note: List 0309T separately in addition to code for the primary procedure 22586)

Shoulder Arthroplasty

23473 - Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component.

23474 - Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component.

Elbow Arthroplasty

24370 - Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component.

24371 - Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component.

Nerve Conduction

(Billing Note:  Guideline instructions related to the reporting of electromyograms (EMGs) and nerve conduction studies (NCS) are found in the beginning of their respective CPT sections.)

 CPT codes 95900–95904 were deleted and replaced by the following CPT codes: 

95907—Nerve conduction studies; 1–2 studies

95908—Nerve conduction studies; 3–4 studies

95909—Nerve conduction studies; 5–6 studies

95910—Nerve conduction studies; 7–8 studies

95911—Nerve conduction studies; 9–10 studies

95912—Nerve conduction studies; 11–12 studies

95913—Nerve conduction studies; 13 or more studies

Extracorporeal Shock Wave: Wound Healing

Two new Category III codes for extracorporeal shock wave for wound healing were introduced:

0299T—Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound

0300T—Each additional wound (Billing Note:  List separately in addition to code for primary procedure.)

With Iridium Suite practice management software, you can take the worry away from all of these changes. This medical billing software is loaded with all current CPT I, II, III and HCPCS Level II codes as well as the NCCI edits.  It also has the Claim Scrubber function, allowing you to create special billing rules so you don’t forget to bill those “companion” codes.

The Bundled Payments for Care Improvement Initiative

A medical billing software with the ability to indicate payers requiring authorization as well as track a multiple service/visit authorization as it is assigned to the performed procedures is crucial in assisting office staff with this issue.  Iridium Suite provides a specific area in the patient insurance information section to indicate authorization requirements and to record the authorization details. 

Before a claim can be submitted, it is scrubbed for authorization requirements and will warn the user if the authorization is missing. 

You are unable to submit the claim without the appropriate authorization.

not paid separately  B15 - Payment adjusted because this procedure/service is not paid separately.

This denial occurs when submitting a procedure code that is part of a “set” without the accompanying procedure.  A medical billing software, such as Iridium Suite, gives the user the ability to set up special code rules.  The system will warn the user if a particular code is being submitted without the “partner” code, allowing you to correct the claim before submission to the payer.

By being aware of the common denials your practice receives, you can develop the necessary processes to prevent them before they happen. 

Having the best medical practice billing software, Iridium Suite, can give you a head start with its many advanced functions.

Moving Forward: The Bundled Payments for Care Improvement Initiative

CMS has announced the participants for Models 2 through 4 of the Bundled Payments for Care Improvement Initiative (BPCI). 

Models 2 and 3 involve a retrospective bundled payment arrangement where actual expenditures are reconciled against a target price for an episode of care.   Model 4 involves a prospective bundled payment arrangement, where a lump sum payment is made to a provider for the entire episode of care. 

Over the course of the three-year initiative, CMS will work with participating organizations to assess whether the models being tested result in improved patient care and lower costs to Medicare. 

The implementation of these models has been broken down into two distinct phases:

Phase I:   Referred to as the “no-risk” preparation period has just begun and will continue until July 2013.  During this time, CMS and participants prepare for implementation and assumption of financial risk based on the provider’s final submitted list of their episodes.  Participants can select up to 48 different clinical condition episodes. 

Phase II:   Beginning in July 2013, the “risk-bearing” performance period starts for those participants from Phase I that are ultimately approved by CMS and decide to move forward with implementation and assumption of financial risk.

Model 2

Model 3

Model 4

Episode of Care

Inpatient stay at acute care hospital plus post-acute period for selected DRGs.

Selected DRG’s for an acute care hospital stay will trigger the episode to begin at initiation of post-acute care services with a participating skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency.

Inpatient stay at acute care hospital plus readmissions for selected DRGs.

Bundled Services

The bundle will include physicians’ services, care by post-acute providers, related readmissions, and other related Medicare Part B services included in the episode definition such as clinical laboratory services; durable medical equipment, prosthetics, orthotics and supplies; and Part B drugs.

The bundle will include physicians’ services, care by post-acute providers, related readmissions, and other related Medicare Part B services included in the episode definition such as clinical laboratory services; durable medical equipment, prosthetics, orthotics and supplies; and Part B drugs.

All Part non-hospice A and B services (including the hospital and physician) during initial inpatient stay and readmissions

Service Timeline

The episode will end either 30, 60, or 90 days after hospital discharge.

The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end   either a minimum of 30, 60, or 90 days after the initiation of the episode. 

Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount. 

Payment Calculation

Retrospective: A target price will be set that will be based on historical fee-for-service payments for the participant’s Medicare beneficiaries in the episode and will include a discount. Payments will be made at the usual fee-for-service payment rates, after which the aggregate Medicare payment for the episode will be reconciled against the target price. 

Any reduction in expenditures beyond the discount reflected in the target price will be paid to the participant and may be shared among their provider partners. Expenditures that are above the target price will be repaid to Medicare by the participant.

Retrospective: A target price will be set that will be based on historical fee-for-service payments for the participant’s Medicare beneficiaries in the episode and will include a discount. Payments will be made at the usual fee-for-service payment rates, after which the aggregate Medicare payment for the episode will be reconciled against the target price. 

Any reduction in expenditures beyond the discount reflected in the target price will be paid to the participant and may be shared among their provider partners. Expenditures that are above the target price will be repaid to Medicare by the participant.

Prospective: A single, prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit “no-pay” claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount.

Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners– allowing them to work closely together across all specialties and settings.

The Bundled Payments for Care Improvement initiative will test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of care for beneficiaries.