R A C

The RAC program has been established to identify and recover improper Medicare payments to providers that are under fee-for-service Medicare plans, including medical practices, hospitals and nursing homes.

Practices that bill Medicare may be subject to an audit to review inaccurate reimbursements and may be required to refund the money back to Medicare. There are four RACs, each pertaining to a region of the country. 

Types of government audits :

Medicaid Integrity Contractors (MICs) conduct audits of Medicaid claims instead of Medicare. Unlike RACs and Zone Program Integrity Contractors (ZPICs), whose appeal processes are determined by federal regulations, MIC appeals processes vary by state.

ZPIC audits look for cases of fraud by analyzing claims data.

Medicare Administrative Contractor (MAC) audits determine whether particular billed services are medically necessary and should be covered under Medicare.

Looking to eliminate Medicare overpayments to providers, the Centers for Medicare and Medicaid Services from 2005 until early 2008 conducted pilot tests of a new program to audit provider billings, called the Medicare Recovery Audit Contractor program.

Medicare started rolling out the RAC program nationwide during 2009. But 2010 was when its effects were widely felt by hospitals, with some health systems undergoing multiple RAC audits while others were notified they'll soon be up to bat. CMS intends to eventually audit all U.S. hospitals, and is now expanding the RAC program to physicians, laboratories, pharmacies and other providers.

There was no shortage of health care payer audit programs before RACs came around. Medicare already conducts audits under the Medicare Administrative Contractors program, state Medicaid agencies have audit programs, and so do commercial insurers and quality improvement organizations. And a proposed federal rule published in November 2010 has put the wheels in motion for establishment of Medicaid RAC programs.

Lately, commercial carriers are starting to copy RACs and that has really increased audits across the country.

RAC Audits :

There are two types of RAC audits-automated and complex. An automated review, also called a claims review, is a computerized analysis of a provider's Medicare claims based on algorithms that look for specific discrepancies in the claims. These include medical procedure that don't match the patient's age or gender, inpatient claims without a discharge disposition, or two or more units for a colonoscopy when only one unit can be billed a year.

Medicare has contracted with four companies to serve as the Recovery Audit Contractors in four regions that span the nation. These contractors can and do subcontract with other companies to conduct audits.

RACs can conduct an automated review anytime without notifying providers. Following an automated review that finds discrepancies, a RAC will send a "demand letter" to a provider organization identifying the overpayments found and stipulating reimbursement. RACs also are finding underpayments in favor of providers, but those account for about a fifth of the findings.

Under a complex audit, RACs can demand up to 300 medical charts from a hospital every 45 days, based on Medicare claims volume, for comprehensive review. These charts include any paper and electronic documentation that support a flagged encounter.

How RACs work :

The biggest difference with the RAC program compared with other payer audits is how contractors are reimbursed. Contractors for other audit programs get paid a fixed amount for doing their work. But RAC contractors get paid via contingency fees. They make money finding overpayments and underpayments, and the more they find the more money they make. So, RACs tend to be more aggressive than other audit programs.

The payment set-up for RACs has been perceived as bounty-hunting by many industry stakeholders.

Physician practices also fall under the RAC program. The number of records that can be demanded every 45 days for a complex review is based on the practice size and tops out at 50 for the largest practices. RAC auditors spent much of 2010 focused on automated reviews of hospital claims, which give quick results and cash in the door, with complex hospital reviews and physician audits starting to build toward year-end.

Following the receipt of a demand letter, a provider can appeal the findings and present documentation to support its position.

After a provider submits the requested medical records for a complex audit-with the RAC contractor, the contractor then has 60 days to review the records and inform the provider of findings.

Providers increasingly are using software specifically designed for the RAC program and embedded with the RAC rules to manage request fulfillment within 45 days, and generating supporting documentation to use during the appeals process.

ACOs In Practice

The accountable care organization ( ACO ) is a new model that has been proposed for health care reform.

The primary objectives of the ACO are to reduce costs, increase efficiency and improve the quality of patient care. The payer is basically aiming to reduce costs and at the same time improve quality of care. Since payers would give the ACO's a lump sum to cover all care, the ACO's would retain any savings that result from more efficient patient care. This is supposed to be the motive for physicians and hospitals to ensure that the patient is healthy and out of the hospitals and not do more procedures.

The ACO members will  share in the savings that results from their cooperation and coordination. Thus, ACOs can–theoretically–act as a reform tool by incentivizing more efficient and effective care. This would help to combat the current perverse incentives of overutilization and overbuilding of health care facilities and technology.

ACOs In Practice :

The ACO would have to be a legal organization that can receive shared savings, and would have to incorporate primary care physicians who solely practice under the ACO. Furthermore, there would have to be at least 5,000 beneficiaries in the ACO for it to be viable. The ACO would provide CMS with a list of their providers willing to participate in the ACO. The beneficiaries would be determined by, among other things, the patterns of patient referrals in the region. However, beneficiaries would not be “locked in” to a given provider. The ACO would receive savings if their risk-adjusted, per beneficiary spending levels were below their benchmark.

 

An Example :

An hypothetical independent practice association (IPA) teams up with a community hospital to create an ACO. Medicare determines a benchmark, that is, what it will cost to treat the average beneficiary in that geographic area per year–let’s say $10,000. The physicians submit their traditional claims to Medicare under the RBRVS system while the hospital submits its typical DRG-base claim. Thus, the traditional fee-for-service system remains in place. At the end of the year, Medicare determines if the ACO has provided care for less than $10,000. If they have, the ACO is entitled to share in the cost savings, and the savings are divided among the providers and hospital. Though simple in theory, ACOs become more difficult when attempting to construct payment models that will distribute the savings of the ACO to the individual providers.

ACO

The primary objectives of Accountable Care Organizations (ACO) are to reduce costs, increase efficiency, increase accountability and improve the quality of patient care.

The payer is basically aiming to reduce costs and at the same time improve quality of care. Since payers would give the ACO's a lump sum to cover all care, the ACO's would retain any savings that result from more efficient patient care. This is supposed to be the motive for physicians and hospitals to ensure that the patient is healthy and out of the hospitals and not do more procedures.

The patient is supposed to get better care and this model aims to provide a patient centric care plan. The physicians may need to do a lot of  screening procedures and wellness checkups ensuring that the patient is taking the right labs and medicines and staying healthy. So the clinical perspective would be that of being proactive and ensuring that the patient requires the right care ensuring that he is in good health, and that he makes as few visits to the Hospital as possible. This is to mean that the physician will proactively care for the patient, instead of the regular model of treating patients after a health event.

Challenges :

• ACO's would find it a challenge to construct a payment model that would distribute the savings of the ACO to its individual providers.
• The patient may feel  that he is being forced to see a small group of physicians in the ACO that he is participating.
• The patient may not perceive the quality of care that the ACO model proposes.
• Would patients continue to stay within their ACO ?
• Would patients see value in the ACO and support the ACO ?

ACO's have a lot of challenges ahead but it looks very viable and feasible considering the advantages is has over existing HMOs, but then again there are some physicians who feel that the ACO's are a little ahead of time, and now may not be the good time.

The ACO debate is endless but its success or failure will depend on how the patients perceive it. If the patients see value for themselves in the ACO than the patients would support the ACO and it will succeed, if the patients do not see any value from the ACO than it would be very difficult for the ACO to succeed.

"Incident to" Services

“Incident to” services are defined as services commonly furnished in a physician’s office, which are “incident to” the professional services of a physician or a Non-Physician Practitioner (NPP) and provided by auxiliary personnel.

"Incident to" is a Medicare billing provision that allows services provided by PAs in an office or clinic setting to be reimbursed at 100 percent of the physician fee schedule by billing using the physician's NPI. The Medicare Benefit Policy Manual defines "incident to," in part, as "services furnished as an integral although incidental part of a physician's personal professional service." This is limited to situations in which there is direct physician/non-physician personal supervision. This applies to auxiliary personnel under the supervision of the physician/non-physician, which includes, but is not limited to, nurses, technicians, therapists, NPPs, etc.

Requirements for “incident to” are:

• The services are commonly furnished in a physician’s office.
• The physician must perform the initial patient visit and ongoing services of a frequency that demonstrate active involvement of the physician in the patient’s care, thereby creating a physician service to which the non physician provider's services relate.
• There is direct personal supervision by the physician of auxiliary personnel, regardless of whether the individual is an employee, leased employee or independent contractor of the physician.
• A physician must be on the premises, but not necessarily in the room, when incident-to services are performed.
• Incident-to services cannot be performed in the hospital.

Direct supervision in the office setting does not mean the physician must be present in the same room with his aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.

Stark Law

Stark law, governs physician self-referral for Medicare and Medicaid patients. The law is named for United States Congressman Pete Stark, who sponsored the initial bill.

Physician self-referral is the practice of a physician referring a patient to a medical facility in which he has a financial interest, be it ownership, investment, or a structured compensation arrangement. Critics of the practice allege an inherent conflict of interest, given the physician's position to benefit from the referral. They suggest that such arrangements may encourage over-utilization of services, in turn driving up health care costs. In addition, they believe that it would create a captive referral system, which limits competition by other providers.
 

The physician referral law (section 1877 of the Social Security Act) prohibits a physician from referring patients to an entity for a designated health service (DHS), if the physician or a member of his or her immediate family has a financial relationship with the entity, unless an exception applies. (The exceptions are specified in 42 CFR Part 411, Subpart J.) The law also prohibits an entity from presenting a claim to Medicare or to any person or other entity for DHS provided under a prohibited referral. No Medicare payment may be made for DHS rendered as a result of a prohibited referral, and an entity must timely refund any amounts collected for DHS performed under a prohibited referral. Civil money penalties and other remedies may also apply under some circumstances.

Medicare Credentialing

Medicare credentialing is a complex process and is a very difficult task for most practices, doing it for the first time. It is very important that practices know the intricacies of Medicare credentialing, if they plan to do the credentialing themselves. For most practices, the majority of their reimbursements are from Medicare, also most insurances follow the same processes as Medicare. A proper understanding of Medicare's credentialing process is crucial to the success of every practice.

For most physician practices, Medicare requires three (3) basic applications which make up the 855 series,

1. 855I – Create or reactivate a physician’s individual number

This Medicare form is used to obtain a physician’s individual Medicare number from each state’s supplier. The physician must submit a copy of the medical school diploma and NPI letter with the individual NPI number with this form. Medicare requires an 855I application if any changes are made to the physician’s file. Also, Medicare will deactivate a Medicare number and require an 855I reactivation if a significant lapse occurs in billing or if no claims are submitted to the number issued.

2. 855B – Create or change a practice's group number

This Medicare application is used to obtain a group number for billing purposes. The physician must submit a copy of the IRS letter with this form. Groups already participating with Medicare use the form to make changes to physician listings, such as practice ownership, phone number, address, NPI group numbers, etc. You will be required to complete an 855B form if you make any changes to your practice, such as add a new physician for billing, change address, change billing, etc.

Ensure that the practice name, bank account details, contact person details are filled in accurately. Errors will delay the acceptance of your application.

3. 855R – Links the physician’s individual number to the group number

This Medicare form is used to reassign the benefits of the physician to the group. The group’s authorized official signs the form in addition to the individual being linked to the group. When reassigning the benefits of a physician to a group you may submit the 855R and 855I together if the provider's Medicare number needs to be reactivated e.t.c.

If the Medicare application is incomplete or incorrect, the Medicare process can take more time and in some cases the process can take about six months for approval.

Some points to note in the Medicare credentialing process,

• When reactivating physician billing privileges, the effective date will now be the later of either the date of filing the Medicare enrollment application (date stamped by Medicare), or the date the physician first began providing services at the new practice location
• When submitting the Medicare forms to a Medicare intermediary, ensure that the practice name is exactly as it appears on the Bank account, the IRS letter and the NPI letter

The Medicare credentialing process though complex can be managed by ensuring that the credentialing information on the 855 forms is accurate and consistent, so that Medicare is able to process the credentialing application without delay.

A B N Revised by CMS

CMS is notifying health care providers and suppliers that it has updated its Advance Beneficiary Notice of Noncoverage, or ABN form and made the revised form and information on how to use it available online.

Use of the revised ABN, which is issued to patients by physicians and other health care professionals, "in situations where Medicare payment is expected to be denied," will become mandatory on November 1, 2011. At that time, the old ABN form will be considered invalid, by CMS. 

Using the appropriate ABN form is critical to physicians getting paid, physicians would be well advised to start using the revised form before the deadline.

Physicians need to check the lower left hand corner of the document for the words "Form CMS-R-131" and the revised date "03/11" to ensure that they have the revised form in hand.

Practices must have a current and properly executed ABN, because if Medicare denies the services, the physician can't go back and collect payment from the patient. 

http://www.cms.gov/BNI/02_ABN.asp

Foot Care Coverage Guidelines

Covered foot care services

According to the Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 290, Medicare-covered foot care services only include medically necessary and reasonable foot care.

Exclusions from coverage 

Certain foot care related services are not generally covered by Medicare. Whether performed by a podiatrist, osteopath, or doctor of medicine and regardless of the difficulty or complexity of the procedure, the following services are not covered by Medicare:

• Treatment of flat foot
• Routine foot care
• Supportive devices for feet

Getting a DME License

Durable medical equipment (DME) is provided by home healthcare agencies, physicians or DME companies. DME is generally defined as medical equipment that is not disposable, is medically necessary and appropriate for home use.
The process for getting a DME license is as outlined below,

1. Apply for an Employer Identification Number (EIN). This number serves as your business identity for tax purposes.
2. Contact your state's department of health and obtain information regarding the state licensing application process and application. State laws vary greatly, from one state to the other, so what is required in one state may not be required in another.
3. Apply for a National Provider Identifier (NPI) from Centers for Medicare and Medicaid Services (CMS). This unique Physician identifier is a standard set by CMS and is required for reimbursement for products and services provided to patients.
4. Review the 26 Supplier Standards from the Medicare Enrollment Application and complete the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Medicare Enrollment Application. Once you are accepted as a DMEPOS supplier, you can bill Medicare for equipment provided to Medicare recipients.
5. Contact a DME accreditation program. An accreditation from a CMS-approved compliance program is needed in order to be accepted to the DMEPOS program. These compliance companies ensure that DME suppliers are following the 26 Supplier Standards. 
6. Submit the state application and prepare for inspection, if applicable. You may pay any applicable application and inspection fees alongwith your application.
7. Prepare for compliance inspection. The compliance company will send you items that they will inspect, but the list is not all-inclusive. Upon completion of the compliance inspection, you will receive the results and become accredited.
8. Submit DMEPOS application with all of the required documentation. Once your application is approved, you will receive your Medicare supplier number.
   

PQRI 2011

The Physician Quality Reporting Initiative (PQRI) is a program to improve the quality of reporting in the healthcare industry. The program is now considered to be permanent and therefore the program name has been amended to the Physician Quality Reporting System (PQRS). PQRS reporting is based on individual measures which are associated to a specific patient group by diagnosis, ailment, age, or clinical action taken by the reporting therapist. All Medicare Part B FFS (fee for service) patients are eligible, but must meet inclusion criteria for each measure. 

There are three methods of reporting your clinical data to CMS:  Claims, Registry and EHR-based.  Choosing your reporting method is very important in reaching your 1% incentive goal.  

Claims-based Reporting
With claims-based reporting, measures are tied to clinical practice reported on claims with CPT codes that link to measures.


To qualify for your 1% incentive, you must report on at least 3 measures ( atleast 3 individual measures or atleast 1 measure group ) and report on 50% of eligible patients (this is a reduction from the 80% requirement of 2010).

Advantages of claims-based reporting:

1. You are in control of your own data from completion to submission
2. Cost effective – no added cost
3. Only 50% reporting requirement
4. OK for smaller practice or if Medicare is a small portion of your payer mix

Disadvantages of claims-based reporting:

1. Must have someone in the clinic who will own this project: complete audits, know all the ins/outs of PQRS, keep record of the % completed
2. Auditing process can be tedious and potentially a productivity loss for an employee
3. We must complete and submit the proper forms in proper format for the eligible patients
4. Workload could be significant if large % of your patients are Medicare or part of a large clinic

Registry-based Reporting
With registry-based reporting, the eligible professional or group practice submits the data electronically to the registry, who then captures and stores the measure related data. The registry is then responsible for submitting the individual measure or measures group information to CMS on behalf of eligible professionals.  Registries provide CMS with calculated reporting and performance rates at the end of the reporting period.  Registries must pass stringent reporting method criteria annually and be qualified to participate.
 
To qualify for your 1% incentive, you must report on at least 3 measures ( atleast 3 individual measures or atleast 1 measure group ) and report on 80% of eligible patients or report.
 
Advantages of registry-based reporting:

1. Form creation and submission is done by registry
2. No need for auditing due to the EMR enforcing measure criteria and selecting eligible patients
3. Staff productivity maintained
4. Higher potential for meeting the reporting criteria and receiving your 1% incentive bonus
5. Using a EMR registry gives you added insight and assistance with choosing most appropriate measures
6. Measures are updated automatically each year as information is provided by CMS

Disadvantages of registry-based reporting: 

1. There is a cost involved; but it is nominal ( around 300 $ per provider ) and definitely provides an ROI when staff time, paper/office supplies, and decreased stress levels are calculated
2. 80% reporting requirement, but with the EMR in place, 100% data collection should be the expectation
3. Data collection enforcement with all eligible patients – no choice but to report on each patient

The 1% incentive may not seem like much, if you have to spend staff time and effort to get the proper codes into billing, complete audits to ensure your clinic is meeting its minimum criteria, and manually submitting claims to CMS. Although there is a cost associated with using a registry, the savings on staff time and maintaining productivity alone is substantial.

EHR-based Reporting
Eligible professionals who choose to report on EHR measures need to select at least three EHR measures to report on to be able to qualify to earn a PQRI incentive payment.To qualify for the incentive, the correct quality action or performance exclusion will need to be reported on at least 80 percent of the eligible cases identified for each selected measure.


A case is eligible for PQRI purposes when the codes match the denominator inclusion criteria and are listed as PFS covered services according to the PQRI EHR Measure Specifications. Each measure has a reporting frequency or timeframe requirement for each eligible patient seen during the reporting period for each individual eligible professional.

Ensure all patient-care and visit-related information are documented in your EHR system. Ensure you identify and capture all eligible cases per the measure denominator for each measure you choose to report. Review all the denominator codes that can affect EHR-based reporting to make sure the correct quality action is performed and reported for the eligible case.

Create the required reporting file, which would be uploaded from your EHR system. A PQRI-qualified EHR would have been programmed already to generate this file. Submit final EHR reporting files with quality measure data by the data submission deadline.
 

Advantages of EHR-based reporting:

1. Cost effective – no added cost
2. EHR enforces measure criteria and selects eligible patients
3. Staff productivity maintained
4. Measures are updated automatically each year by EHR as information is provided by CMS

Disadvantages of EHR-based reporting:

1. Must have adequate training on the EHR to manage the PQRI process
2. Must generate and submit the EHR-PQRI reporting files
3. 80% reporting requirement, but with the EMR in place, 100% data collection should be the expectation

Colonoscopy Billing Guidelines

A Colonoscopy is an exam that allows a doctor to closely look at the inside of the entire colon. The doctor is looking for polyps or signs of cancer. Polyps are small growths that over time can become cancer. The doctor uses a thin (about the thickness of a finger), flexible, hollow, lighted tube that has a tiny video camera. This tube is called a colonoscope.

Colonoscopy Codes

CPT Code
Description
45378
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)
45379
Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body
45380
Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
45381
Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance
45382
Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45383
Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45384
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45385
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45378 – Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without collection colon decompression (separate procedure).  Because this code is diagnostic and a separate procedure, it should never be reported with any other colonoscopy code.  Per the CPT manual, when a diagnostic endoscopy is followed by a surgical endoscopy, the diagnostic endoscopy is considered part of the surgical endoscopy and is not to be separately reported.  Only when the provider performs a diagnostic colonoscopy with brushings, washings and/or decompression and nothing else (no biopsies, excisions, etc.) should this code be reported.

45380 – Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple. The physician performs colonoscopy and obtains tissue samples.  This code can only be reported once regardless of the number of biopsies.  According to CPT Assistant, July 2004, this code is also used to describe polypectomy with cold biopsy forceps.  A cold biopsy with forceps is not the same as hot biopsy forceps and it is not a snare technique, therefore codes 45384 and 45385 would not be appropriate.  If the physician does remove a polyp or other lesion with a different technique and then takes a biopsy on a separate lesion, this code may be reported in addition with modifier -59. 

45381 – Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injections(s), any substance. The physician injects a substance into the submucosa, directed at specific areas through the scope while viewing the colon. (E.g. saline, India Ink).  This code is not to be used for injections used to control bleeding.  45381 may be reported in addition to other procedures with modifier -51 or -59. 

45382 – Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g. injections, laser, stapling, plasma coagulator).  This code is used when a physician controls bleeding in the colon due to a condition such as diverticulosis.  This code is not used to report control of bleeding caused by a procedure performed during the same encounter.  For example, there may be small amount of bleeding after a polyp is excised.   This would not be reported because control of bleeding is integral to therapeutic or surgical procedures.  However, if the physician treated a bleeding condition and then removed a polyp at a different location, the services may be reported together with modifier -59. 

45383 – Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amendable to removal by hot biopsy forceps, bipolar cuatery or snare technique.  This code is used when a physician ablates tumors, polyps or other lesions by laser or other method (e.g. fulguration).   

45384 – Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cuatery.  Hot biopsy forceps (also called monopolar cautery forceps) have “jaws” that are between 1 and 2 mm in size and can open up to about 1 cm wide to encompass a small polyp or lesion. The physician then applies cautery to ablate the base of the polyp (or other lesion) so it can be retrieved and sent to pathology for analysis. 

45385 – Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.  Snaring involves “lassoing” a polyp or lesion with a wire loop and shaving it off the bowel wall.  The snare may or may not be heated.  Any snare technique including cold snare, hot snare, and bipolar snare would be reported with this code.  The snare technique is the most often used technique and is best when removing both sessile polyps (those attached by a large base) and pedunculated polyps (those attached by a stalk).

Coding Multiple Procedures

When more than one procedure is performed using the same technique, report only one code.  For example, if the physician removes multiple polyps throughout the colon with snare technique, 45385 can be reported only once. 

However, if multiple polyps or lesions are removed with different techniques, you may report each separately.  For example, a physician removes a polyp with snare technique in the rectum and then biopsies a lesion in the transverse colon, you may report 45385 and 45380-59. 

In the absence of a CCI edit, always list the procedure with the highest RVU first.

Sigmoidoscopy Billing Guidelines

During a Sigmoidoscopy, a doctor closely looks at the lower parts of the colon, called the sigmoid colon and the rectum, for signs of cancer or polyps. Polyps are small growths which can over time become cancer. The doctor uses a thin (about the thickness of a finger), flexible, hollow, lighted tube that has a tiny video camera. This tube is called a sigmoidoscope.

The colon comprises three main parts: the ascending colon, the transverse colon, and the sigmoid colon—sometimes called the descending colon. The sigmoid colon is the last one-third of the colon. Flexible sigmoidoscopy enables the doctor to see only the sigmoid colon, whereas colonoscopy allows the doctor to see the entire colon. 

CPT Code
Description
45330
Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
45331
Sigmoidoscopy, flexible; with biopsy, single or multiple
45332
Sigmoidoscopy, flexible; with removal of foreign body
45333
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45334
Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45335
Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
45337
Sigmoidoscopy, flexible; with decompression of volvulus, any method
45338
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45339
Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45340
Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures
45341
Sigmoidoscopy, flexible; with endoscopic ultrasound examination
45342
Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
45345
Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)

Emergency vs Critical Care

Emergency Care

Emergency care, with respect to trauma or critical patients, is the recognition of the critical condition, then appropriate stabilization and initial management of these issues. Emergency care gets the patient who is almost dying to 'in critical condition', by correcting the immediate problems, and and managing it.

Emergency care deals with Disaster management (major role) primarily, and have to face a wide variety of patients with varied problems in an uncontrolled environment. Emergency care is confined to short term management of the patient's condition.

Critical Care 

Critical care is the long term management of these patients after they leave the Emergency care.

Critical care takes the patient in critical condition and gets them into stable condition where they can be managed on the general medical floor. They do this by taking hold of certain physiologic parameters and managing it. They also manage the life threatening conditions which take days to treat.

No coverage / Coverage terminated

Many times we come across the denial "Denied for No coverage or Coverage terminated", whenever we come across this denial we usually assume that the patient does not have coverage. This is not always true, let us review the following scenarios.

Scenario 1
The payor issued a new ID to the patient, while the claim was submitted with the old ID, hence the denial. So we need to call the payor or go online and search the patient. This way we can pull the patient's correct ID, update that in our records and have the claim resubmitted.

Scenario 2
The denial could be in error in which case we can verify this by calling the payor or checking online. We will also know by checking the claim history, if the payor has been paying claims before and after the date of service being denied by them, then it is obvious that this claim has been denied in error. A call to the payor will resolve this claim.

Scenario 3
The denial could be correct we can verify this by calling the payor. We need to call or check online and see whether we are able to pull up this patient, if we cannot find any information about the patient then we need to contact the patient. We can send a patient statement stating that the charges are being billed to the patient as the insurance has denied citing no coverage. If the patient has a new insurance, he would update us on receiving the statement. With the new insurance information the claim can be resubmitted.

PPOs

Most Americans who have health insurance through their employer (or who are self-insured) are enrolled in some type of a managed care plan - either an HMO or PPO. The most common types of managed care plans are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Less common are point-of-service (POS) plans that combine the features of an HMO and a PPO.

All managed care plans contract with doctors, hospitals, clinics, and other health care providers such as pharmacies, labs, x-ray centers, and medical equipment vendors. This group of contracted health care providers is known as the health plan's "network."

In some types of managed care plans, you may be required to receive all your health care services from a network provider. In other managed care plans, you may be able to receive care from providers who are not part of the network, but you will pay a larger share of the cost to receive those services. 

Preferred Provider Organizations (PPOs)

A preferred provider organization (PPO) is a health plan that has contracts with a network of "preferred" providers from which you can choose. You do not need to select a PCP and you do not need referrals to see other providers in the network.
If you receive your care from a doctor in the preferred network you will only be responsible for your annual deductable (a feature of some PPOs) and a copayment for your visit. If you get health services from a doctor or hospital that is not in the preferred network (known as going "out-of-network") you will pay a higher amount. And, you will need to pay the doctor directly and file a claim with the PPO to get reimbursed.

Features of PPOs

• You can choose doctors, hospitals, and other providers from the PPO network or from out-of-network. If you choose an out-of-network provider, you most likely will pay more.
• You can receive care from any doctor you choose. But remember, you will pay more if the doctors you choose are not "preferred" providers.
• You do not need a referral to see a specialist. However, some specialists will only see patients who are referred to them by a primary care doctor. And, some PPOs require that you get a prior approval for certain expensive services, such as MRIs.
• If you get your healthcare from a network provider you usually do not need to file a claim. However, if you go out of network for services you may have to pay the provider in full and then file a claim with the PPO to get reimbursed. The money you receive from the PPO will most likely be only part of the bill. You are responsible for any part of the doctor's fee that the PPO does not pay.
• In most PPO networks you will only be responsible for the copayment. Some PPOs do have an annual deductable for any services, in network or out of network.
• If you choose to go outside the PPO network for your care, you will need to pay the provider and then get reimbursed by the PPO. Most likely, you will have to pay an annual deductable and coinsurance. For example, if the out-of-network doctor charged you $100 for a visit, you are responsible for the full amount if you have not met your deductable. If you have met the deductable, the PPO may pay 60%, or $60 and you will pay 40%, or $40.

HMOs

 Most Americans who have health insurance through their employer (or who are self-insured) are enrolled in some type of a managed care plan - either an HMO or PPO. The most common types of managed care plans are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Less common are point-of-service (POS) plans that combine the features of an HMO and a PPO.

All managed care plans contract with doctors, hospitals, clinics, and other health care providers such as pharmacies, labs,  and medical equipment vendors. This group of contracted health care providers is known as the health plan's "network."

In some types of managed care plans, you may be required to receive all your health care services from a network provider. In other managed care plans, you may be able to receive care from providers who are not part of the network, but you will pay a larger share of the cost to receive those services.

Health Maintenance Organizations (HMOs)

If you are enrolled in a health maintenance organization (HMO) you will need to receive most or all of your health care from a network provider. HMOs require that you select a primary care physician (PCP) who is responsible for managing and coordinating all of your health care.
Your PCP will serve as your personal doctor to provide all of your basic healthcare services. PCPs include internal medicine physicians, family physicians, and in some HMOs, gynecologists who provide basic healthcare for women. For children, you can select a pediatrician or a family physician to be their PCP.
If you need care from a specialist in the network or a diagnostic service such as a lab test or x-ray, your primary care physician (PCP) will have to provide you with a referral. If you do not have a referral or you choose to go to a doctor outside of your HMO's network, you will most likely have to pay all or most of the cost for that care.

Features of HMOs

• You must choose doctors, hospitals, and other providers in the HMO network.
• The HMO will not provide coverage if you do not have a PCP.
• You will need a referral from your PCP to see a specialist (such as a cardiologist or surgeon) except in emergency situations. Your PCP also must refer you to a specialist who is in the HMO network.
• All of the providers in the HMO network are required to file a claim to get paid. You do not have to file a claim, and your provider may not charge you directly or send you a bill.
• The only charges you should incur for in-network services are copayments for doctor's visits and other services such as procedures and prescriptions.
• Except for certain types of care that may not be available from a network provider, you are not covered for any out-of-network services.

Billing Process

Tasks in Medical Billing

1. Insurance Verification
2. Patient Demographic Entry
3. CPT & ICD Coding
4. Charge Entry
5. Claim Submission
6. Payment Posting
7. A/R Follow-up
8. Denial management
9. Reporting
   

Insurance verification
Patient provides the insurance details to the Physician's front office. The Physician's front office verifies the patient's insurance details by calling the insurance company or through online verification.

Patient Demographic Entry
The Patient Demographic entry is the process of  capturing all the information of a patient such as his Name, Date of Birth, Sex, SSN, Address, Contact details e.t.c. in the practice management software.

CPT & ICD Coding
The Physician creates the progress note for the Patient encounter. From the progess notes the Coder picks the billable Dx / ICD codes  and the Procedure / CPT codes, in some practices the Physician themselves code the ICD and the CPT codes.

Charge Entry
The Charges are entered into the Practice management software and a Claim is generated.

Claim Submission
Once the Claim is generated the claims have to be sent electronically or thru paper depending upon the insurance company. The claims are checked for errors and then submitted to the clearinghouse for onward submission to the insurance companies.

Payment Posting
The payments received from the insurance companies are posted in the practice management software. The Explanation of Benefits received from the insurance companies are reconciled and the denials are also captured.

A/R Follow-up
The insurance companies are called with respect to each outstanding claim and the reason for the denial of the claims is ascertained.

Denial Management
Depending upon the status of each claim and the type of denial, different denial actions need to be taken to ensure that the claim is paid. Prompt and proper denial management will ensure that the Accounts receivable is under control.

Reporting
AR Reports, Aging reports and Collections reports indicate as to how the Accounts receivable is being managed and how the AR is faring across different collection buckets. The practice generates different reports to keep track of collections, performance and for analysis.