Coding Strategy

Plus: Look for an increase in your DEXA scan reimbursement.

The bad news: Your carrier won’t be paying your claims using the conversion factor of $36.0846 anymore.

The good news: CMS is only changing the conversion factor by less than a penny, making it $36.0791, according to CMS Transmittal 700, issued on May 10. MACs will use this 2010 conversion factor to calculate your payments, but keep in mind that after May 31, you’re still due to face a 21 percent pay cut unless Congress intervenes. Keep an eye on the Insider for more information on whether Congress steps in to avert that reimbursement drop.

The CMS transmittal also announces …

… increased payment for dual-energy x-ray absorptiometry (DEXA) scan imaging, making the new non-facility total RVU 2.70, whereas the original 2010 fee schedule listed the transitioned non-facility total RVU for this code as 1.71.

When combined with the conversion factor of $36.0791, that makes DEXA pay about $97.00, a $36.00 increase over the previous payment of approximately $61.00.

Keep in mind: DEXA payment is subject to frequency rules. In some cases, you may notknow when the patient last had a DEXA scan. In these cases, “I would, along with the patient, make the call to Medicare to see if we could find out if or when there was a previous DEXA,” says Kim French, CIRCC, with Crouse Radiology Associates in Syracuse, N.Y.

“It’s worth the extra effort for good patient care (you can then obtain the previous results for comparison) and public relations. These days, there is a lot of competition and with reimbursement decreasing, little things like this are critical for survival.”

If you cannot locate the date of the previous DEXA scan, you’ll want to ask the patient to sign an advance beneficiary notice (ABN), says Barbara J. Cobuzzi, MBA, CPC, CPCH,CPC-P, CENTC, CHCC, with CRN Healthcare Solutions in Tinton Falls, NJ.

Plus: CMS corrected several “technical errors” published in the 2010 Fee Schedule, and thanks to these corrections, Medicare will increase payment for several cardiology-related testing codes, including codes 75571-75574 (Heart CT) and 78451-78454 (Heart muscle SPECT imaging).

For instance, you’ll find a 28 percent increase in pay for code 78451 (SPECT image, heart muscle), from $222 to $312, based on an analysis featured on the American College of Cardiology’s Web site.

For more information on DEXA payment and the conversion factor, subscribe to the Part B Insider. Editor: Torrey Kim, CPC

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Save this option for when other collection methods have failed.

You’ve offered discounts, payment plans, and more,but you still haven’t received payment from a patient. You may be forced to do a write-off at this point, says Steve Verno, CMMC, CMMB, NREMT-P, a medical billing consultant and educator in Orlando, Fla. Your practice is justified in writing off a patient’s balance in the following situations:

1. The cost of collecting a balance is more than what the patient owes. For example: A patient’s balance due is $3 after all insurance payments. The administrative cost to bill and collect is at least $15 per statement. “You don’t spend $15 to collect $3,” Verno says.

2. The provider uses all available methods to try to collect, including submitting the account to a collection agency.

3. The patient files for bankruptcy. This does not automatically initiate a write-off, however. The court could discharge the debt or establish a payment plan based on available assets. If you do receive a discharge of debtor notice, you can then write off the debt.

4. If the patient has Medicare, but there is no signed Advanced Beneficiary Notice of Non-Coverage (ABN) form on file for the specific date of service, and thus there is no GA (Waiver of liability statement on file) modifier on the claim, you will not be allowed to balance bill. So if Medicare won’t pay the claim due to medical necessity, you will be forced to write off the charges.

5. If the terms of your contract with the insurance company state that you cannot balance bill the patient if a claim is denied. The process may follow a similar outcome as in bullet point 4, resulting in a write-off.

6. The patient proves financial hardship, using the criteria mentioned in part one of “Don’t Let Patients’ Financial Hardship Become Yours” in the Vol. 10, No. 2 issue of Medical Office Billing & Collections Alert. Editor: Joshua Thines.

Sign up for the upcoming on-demand Webinar, 5 Steps to Optimize Your Office’s Coding & Billing Practices, or order the CD/transcripts.

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Decipher what column 1/column 2 means in this neurosurgery bundle example.

Question: Would you explain what the differences are between mutually exclusive and “column 1/column 2″ edits that come from the Correct Coding Initiative (CCI)?

Florida Subscriber

Answer: Mutually exclusive edits pair procedures are services that the physician could not reasonably perform at the same session on the same beneficiary.

For example, CCI lists 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) as mutually exclusive of 61313 (… intracerebral). The payer would not expect that the neurosurgeon would perform both types of craniectomy on the same date for the same patient because they describe different, exclusive procedures.

Bottom line: If you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser-valued of the two procedures (in the case of 61312 and 61313, the payer would reimburse only 61312).

Column 1/column 2 edits describe “bundled” procedures. That is, CMS considers the procedure code listed in column 2 as the “lesser” service, which is included as a component of the more extensive,-column 1 procedure code.

Example: The CCI contains an edit bundling 61535 (Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue [separate procedure]) with 61320 (Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial).

In this case, 61320 is the more extensive procedure which includes the “lesser” procedure 61535. In theory, removing the electrode array is not significant enough to warrant separate payment when it’s done at the same time as the abscess drainage.

Bottom line: If you were to report bundled (column 1/column 2) procedures for the same patient during the same session, Medicare would reimburse only for the higher-valued of the two procedures (in the case of 61320 and 61535, the payer would reimburse only 61320).

@ Neurosurgery Coding Alert, Editor: Leigh DeLozier, CPC

Want to know more about neurosurgery? You can attend (or order a transcript/CD of) Marvel Hammer’s Understanding Spinal Cord Stimulator Coding Changes for 2010 – Don’t Leave Money on the Table.

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A revised GA and new GX hope to clarify some of Medicare’s non-coverage policies.

At least one aspect of dealing with Advance Beneficiary Notice of Non-Coverage (ABN) forms is about to get a little simpler, thanks to two modifiers.

CMS is now giving you two HCPCS level 2 modifiers to distinguish between voluntary and required uses of liability codes, according to release CR6563.

Know when you need an ABN with this expert advice:

Background: When your physician provides a service that Medicare does not cover, your practice must provide an ABN to the patient. The patient should then examine and complete the form before your providers administer that service or procedure.

When you have a patient sign an ABN, you also need to append the appropriate modifiers on your claim. ABN modifiers tell the Medicare carrier that you have an ABN on file for services that won’t be covered.

Luckily, modifiers GA (Waiver of liability on file) and GX (Notice of liability issued, voluntary under payer policy) should add more tools to your belt that will help you fend off denials.

Good practice: “It is in the provider’s best interest to discover which procedures need ABNs in their offices, and flag accounts prior to the patient coming in,” says Melinda Brown, CMBS, insurance biller with H. Matt Smith, MD in Kennewick, Wash.

Don’t Waver on Modifier GA Use

CMS redefined modifier GA to be a “waiver of liability statement.” You should only use modifier GA “to report when a required ABN was issued for a service, and should not be reported in association with any other liability-related modifier and should continue to be submitted with covered charges,” CMS says.

Simply put, “the GA indicates that you have a signed ABN on file,” Brown explains.

Unfortunately, using GA does not mean you’ll get automatic reimbursement. According to the CMS guidelines, a GA modifier indicates the possibility that a service may be denied for medical necessity only, and that the physician may bill the patient after the claim is denied.

Example: A patient presents for lesion destruction (freezing) of seborheic keratosis(es). In this case, you would bill 17000 (Destruction [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [eg, actinic keratoses; first lesion) and 17003 (second through 14 lesions, each) times three units of service, for four total lesions with a diagnosis code of 702.19 (Other seborrheic keratosis). You’ll need to obtain an ABN from the patient and then use modifier GA since Medicare may deny 17000 with any diagnosis except 702.0 (actinic keratosis), for medical necessity, says Brown.

Use GX for a Voluntary ABN

When your practice issues a voluntary ABN for a particular service, you’ll instead turn to modifier GX. CMS defines modifier GX as “notice of liability issued, voluntary under payer policy.” You will use modifier GX when you need a denial remittance advice to submit for secondary insurance, when Medicare does not pay as primary, but the secondary insurance does pay with a denial explanation of benefits (EOB).

Old way: Before CMS revised the ABN last year, you would have used a Notice of Exclusion of Medicare Benefits (NEMB) form for these cases. CMS eliminated the NEMB, however, so modifier GX helps you tell the payer you have a voluntary ABN on file.

You might also use the ABN for a never covered service if a patient does not believe the service is not covered and insists that you submit the claim to Medicare. You would have the patient sign the ABN and submit the service to Medicare with a GX modifier so that the patient receives the denial remittance advice.

Watch for: If you append GX on the same line as many liability-related modifiers, including EY (No doctor’s order on file), GA, GL (Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN), and others, Medicare will likely deny your claim.

Example: A patient needs a hearing aid, which Medicare never covers, but the patient has secondary insurance that will pay. The patient signs an ABN. You should submit the claim to Medicare with a GX modifier. Your practice may then submit to the secondary insurance, which will pay for a part of the hearing aid based on the denial from Medicare.

@ Medical Office Billing & Compliance Alert

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Assigning an ICD-9 code merely to get your claim paid could land you in legal hot water.

Medical coders face a lot of questions each day in the course of their work, but one question you should not be asking is “which diagnosis code should I put on this claim if I want to collect?”

When the Insider solicited subscribers’ questions last week, the overwhelming majority asked questions such as, “We performed xyz procedure — can you tell me which diagnosis codes we can report to Medicare to get this claim paid?”

But this type of ICD-9 coding is backward, experts say. Instead, you should be coding based on the documentation — not based on which codes your MAC will reimburse.

“I do not feel that we as coders should be coding based on getting the claim paid,” says Michelle Jubeck, CPC, CEMC, CPMA, coding compliance analyst with Monroe Clinic in Monroe, Wis.

Jubeck points to the ICD-9-CM guidelines, which state, “The entire record should be reviewed to determine the specific reason for the encounter and conditions treated.”

Keep in mind: “It is illegal to just assign an ICD-9 code that will get your claim paid — you have to report the codes documented in the record,” says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. Any diagnosis that you report on a claim must be clearly documented in the patient’s chart — not selected because it’s a covered diagnosis.

ABN use: “If you want to know what will justify the medical necessity of the service the physician performed so you know when to get an advance beneficiary notice (ABN) signed, you need to look at your local coverage decisions (LCDs),” Cobuzzi says.

Tip: In some cases, an LCD will list a very general or unspecified diagnosis code as being payable, whereas your physician has documented a more specific diagnosis which isn’t in the LCD. “In these cases, you should still report the documented diagnosis, but if the MAC denies the claim, appeal it by saying ‘If the unspecified code is payable, then why isn’t the more specific condition considered medically necessary?’” Cobuzzi advises.

Bottom line: “We need to have a good rapport with our physicians — let them know that documentation (accurate and complete) begins and ends with them,” Jubeck says.

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