Modifiers 52 & 53

The usage of Modifiers 52 & 53 is very clear and straightforward but still many claims have these modifiers applied incorrectly opening up the possibility of a recoupment later on.

52 Modifier - Reduced Services.

In many instances a procedure or service is reduced at the discretion of  a physician.

We need to apply the 52 modifier to that CPT code, when the physician is performing a reduced procedure rather than the entire procedure, as denoted by the CPT code and when that reduced procedure does not have a specific CPT code for billing. The 52 modifier should not be applied to a CPT code, when the procedure that was planned had to be discontinued / terminated for any reason whatsoever. In these instances we need to use modifier 53 to indicate that the procedure was discontinued.

If the reduced procedure is surgical, the claim needs to submitted with an Operative report and a separate report detailing how the reduced procedure differs from the normal procedure.

For procedures that are non-surgical, a report detailing how the reduced procedure differs from the normal procedure needs to be sent alongwith the claim.

Example :

The provider is planning on performing pure tone audiometry, air only, for a patient on only one ear. There is no CPT code for this test when performed on one ear, while we have CPT code 92552 pure tone audiometry (threshold), air only, for both ears ( bilateral procedure ). 

In this instance since the provider plans to perform the test for one ear only, this becomes a reduced procedure. Hence we need to append modifier 52 to CPT code 92552.

53 Modifier - Discontinued Procedure.

In many instances a surgical or diagnostic procedure may need to be terminated / discontinued due to various reasons.

A procedure that was initiated may need to be terminated / discontinued due to various reasons, in such cases we need to apply Modifier 53 to the CPT code. A procedure may be discontinued / terminated due to various reasons, such as the patient not being able to tolerate the procedure. The 53 modifier basically indicates that the procedure was initiated but not completed.

If the discontinued procedure is surgical then a Operative report needs to be sent alongwith the claim. 

For procedures that are non-surgical, a report detailing how the discontinued procedure differs from the normal procedure needs to be sent alongwith the claim.

The 53 modifier cannot be used, if a Procedure is discontinued by the Physician before administering anesthesia or surgical preparation in the operating room.

Example :

Colonoscopy was initiated on a patient. Polyps were removed by hot biopsy from the descending colon. The provider then attempted to move the colonoscope past the splenic flexure but due to a tortuous colon / blockage the colonoscope could not advance past the splenic flexure. The procedure was hence discontinued.

In this instance the physician had initiated a Colonoscopy by Hot biopsy CPT 45384, but the procedure was discontinued as the colonoscope could not move past the splenic flexure. Hence we need to append mofifier 53 to CPT code 45384.

Hemodialysis & E & M visits

In general when Hemodialysis is billed alongwith an E&M procedure, the Hemodialysis procedure alone is paid while the E&M procedure is denied.

This is because the Hemodialysis procedure has an E&M component built into it and hence the additional E&M procedure is denied. The Evaluation and Management services related to dialysis treatment for ESRD are included in the Dialysis codes and so are not separately reimbursable.

However an E&M can be billed if it is for a separate and distinct service.

For example if a Physician treats a separate and unrelated condition, than the E&M code can be billed with modifier 25, the important point to note is that the documentation should substantiate that the E&M is for a separate and identifiable service apart from the Dialysis procedure on the same day.

Services that are generally included into the Dialysis code are the Physician's evaluation, treatment plan, phone calls, counselling, physician laboratory visits and overall management of the patient.

Key Indicators

Knowing whether your practice is doing well financially is important for the successful running of any practice. Many practices flounder and go bankrupt because they were not monitored properly, leading to their financial ruin.

There are some key indicators which would guide us to make major course corrections where necessary, to bring the practice back on track. Monitoring these key indicators on a regular basis, will ensure that your practice remains financially healthy and continues to run smoothly.

Visits :
The number of Patient visits per month is a straightforward indicator, that is directly proportional to the monthly revenue.

New Patients :
Practices need to ensure that the percentage of New Patients to the total monthly visits is on the increase or steady, on a monthly basis, this would ensure that Old Patients dropping out are compensated by the New Patients, otherwise we would see a drop in the monthly revenue of the practice. When we see the percentage of New Patients decreasing on a monthly basis, this should serve as a warning for us to make course corrections in our practice.

Payor Mix :
An analysis of the Payorwise monthly collections will help us to identify which Payors contribute the most to the revenue of the practice and which payors will significantly impact the practice when their reimbursements change.

Days in AR :
Practices need to know how many days it takes, for them to collect one days charges. The days in AR reflect how quickly and efficiently the practice is able to work the AR and get paid. Higher the Days in AR could be due to a whole host of problems such as Charge / Demographic entry errors, Coding errors,  delayed claim submission, not working the clearing house reports, improper handling of denials and poor AR management. Practices should aim to keep the days in AR under 40.

AR aging :
The AR bucketwise aging is an indicator of how the AR is distributed across different buckets. We can have upto 70% AR (70% of Average monthly charges) in the 0-30 day bucket, upto 15% AR in 30-60 day bucket, upto 10% AR in the 60-90 day bucket, upto 5% AR in the 90-120 day bucket and upto 25% AR in the 120+ days bucket. High AR in the 0-30 day bucket could be due to Charge entry errors, Demographic entry errors, Coding errors or delays in claim submission, high AR in the later buckets could point to improper denial / AR management.

Gross Collection Rate :
The ratio of Actual Collections to Total Charges for a month would be a good indicator of how well we are collecting against the total charges billed. But this ratio needs to be reviewed based on your contractual adjustments. So if you are overbilling your allowed amount by 180 % then a Gross Collection Ratio of 45-50 % is fine.

Net Collection Rate :
The ratio of Actual Collections to Net Charges (Total Charges Less Adjustments) for a month would be a more accurate indicator, than the Gross Collection Rate, of how well the practice is collecting its receivables, since this ratio measures Actual Collections against Actual Collectables, practices should aim for a ratio of 95% or higher.

Preventive Services

Medicare has been reimbursing certain Preventive Services such as Annual Wellness Visits, Cardiovascular Disease Screenings, Diabetes Screening Tests, Screening Pelvic Exam, Glaucoma Screening, Smoking and Tobacco Cessation Counseling e.t.c for some time now.

Recently Medicare has started covering for Screening and Behavioral Counseling to reduce Alcohol misuse and Face-to-Face Behavioral Counseling for Obesity.

Alcohol misuse :

Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women.

Obesity Therapy :

Effective for claims with dates of service on or after November 29, 2011, CMS will allow coverage for Face-to-Face Behavioral Counseling for Obesity, 15 minutes, G0447, along with 1 of the ICD-9 codes for BMI 30.0-BMI 70 (V85.30- V85.39 and V85.41- V85.45), only when submitted with one of the following place of service (POS) codes: 11 – Physician’s Office, 22 – Outpatient Hospital, 49 – Independent Clinic or 71 - State or Local Public Health Clinic.

For more information on Medicare preventive services, visit http://www.cms.gov/PrevntionGenInfo on the CMS website.
For more information on Medicare Learning Network® (MLN) preventive services educational products, visit  http://www.cms.gov/MLNProducts/35_PreventiveServices.asp on the CMS website.

Source CMS

Referral vs Authorization

A Referral is not the same as an Authorization. 

In general a referral is required when a PCP refers a patient to a specialist in-network provider for consultation, while an Authorization also known as Prior Authorization, is approval from the Insurance plan for the performance of certain specific medical procedures and services, based on medical necessity.

A typical scenario would be a PCP referring a patient to a in-network Nephrologist. A referral would be required without which the Insurance plan will not pay. If the Nephrologist performs only an evaluation, the referral alone would suffice, but if the Nephrologist chooses to administer a Procrit injection, than this procedure ( which is on the Prior authorization list of the Insurance plan ) would require a Prior authorization for the Insurance plan to make payment.

Referral :

• A referral is required when a PCP refers a patient to a specialist
• HMO Plans in general require a referral while PPO plans do not require a referral
• A referral is valid for a certain period and for a certain number of visits
• A referral is not required for Emergency services
• A referral is not required for Routine / Preventive services
• Without a referral the insurance plan will not pay

Prior Authorization :

• A Prior authorization is required when a provider plans on performing a procedure which is on the Prior authorization list of the Insurance plan
• A Prior authorization needs to be obtained from the Insurance plan before the performance of the medical procedure
• A Prior authorization is provided by the Insurance plan when they are satisfied as to the medical necessity of the procedure
• A Prior authorization is not required for Emergency services
• Without a Prior authorization the Insurance plan will not pay for procedures that are on its Prior authorization list 

Annual Wellness Visit

From January 1, 2011 Medicare has initiated the Annual Wellness Visits. Medicare uses the codes  G0438 and G0439 for these wellness visits.

G0438 Initial visit 

Annual wellness visit, consisting of  a personalized prevention plan of service (PPPS), first visit.

G0439 Subsequent visit

Annual Wellness visit, consisting of  a personalized prevention plan of service (PPPS), subsequent visit.

Annual Wellness Visits can be for both new or established patients. The initial AWV, G0438, is used for patients enrolled with Medicare for more than a year.

A patient becomes eligible for their subsequent AWV, G0439, a year after the initial visit. During the first year a patient has enrolled with Medicare the patient is eligible for the Welcome to Medicare visit or IPPE, Initial Preventive Physical Exam. This visit is billed using HCPCS code G0402. The Annual wellness code of G0438 should not be used in this scenario  and will be denied since the patient is eligible for the Welcome to Medicare visit G0402 during the first year.

Initial Annual wellness visit consists of,

– Medical and family history

– List of current  providers

– Height, weight, BMI, BP and other parameters

– Detection of cognitive impairment

– Review risk factors

– Review of functional ability

– Establish a written screening schedule for next 5-10 years

– Establish list of risk factors

– Provide advice and referrals to health education and preventive counseling services

– Other elements as determined by the Secretary of Health and Human Services

The above list is just a summary. Check out http://www.cms.gov/MLNMattersArticles/downloads/MM7079.pdf for additional information and links to other Medicare resources on services that must be provided at the AWV and subsequent AWV.

5010

The U.S. Department of Health and Human Services has issued a final rule to transition to the next generation of HIPAA electronic transaction standards (5010) by January 1, 2012.


January 1, 2012: Any healthcare entity that submiting electronic claims must comply with HIPAA 5010 by January 1, 2012. After January 1, version 4010A will no longer be valid.
Payors will reject any electronic claims that are not HIPAA 5010 compliant. This will impact claim payments. The new HIPAA 5010 standards has improved functionality and fully support NPI and the new International Classification of Diseases, Tenth Revision (ICD-10) code sets. 

Why 5010 ?

The current format, is unable to meet some important new developments in health care such as supporting the ICD-10 code set and pay for performance. Other changes in the 5010 version will streamline reimbursements. Most of the changes are technical and geared toward improved standardization and uniformity. Many of these can be handled by your vendor and clearinghouse. However, it is important that you understand your own responsibilities in order to become 5010 compliant.

Billing Provider Address

With 5010, the Billing Provider Address you use on claims must be a physical address?  Once 5010 is implemented, you can no longer use PO Box and lock box addresses as a billing provider address.  This rule applies to both professional and institutional claim formats. However, you can still use a PO Box or lock box address as your location for payments and correspondence from payers as long as you report this location as a pay-to address. The pay-to- provider address is only needed if it is different than that of the billing provider. Work with your software vendor to ensure the correct addresses are captured and inserted in the necessary locations on your claim submission.

Nine Digit Zip Codes

In 5010, providers must submit a full 9-digit ZIP code when reporting billing provider and service facility locations? An easy way to determine the 4-digit extension to your standard ZIP code is to look it up on the U.S. Postal Service’s ZIP Code Lookup Tool. Work with your software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses.

Anesthesia Claims

In 5010, you must report anesthesia services in minutes rather than units if the procedure code does not define a specific time period? However, if the procedure code has minutes in its description, then you can continue to report those charges in units. 
When you need to manually calculate the time period, you can only use minutes for the time measurement. For example, if the total time of anesthesia services is one hour and thirty minutes, services should be submitted as 90 minutes.
Anesthesia providers should verify that their systems can manage this change.

Subscriber vs. Patient Clarification

With 5010, the insurance plan subscriber/patient hierarchy has been clarified. Two possible situations can occur:

1. If the patient has a unique member identifier assigned by the payer, then the patient is considered to be the plan subscriber and is sent as the subscriber. There is no need to also enter their information in the patient section on the claim.
2. If the patient is a dependant of the plan subscriber and does not have their own unique member identifier, then both the subscriber and patient information will be required on the claim.

Providers must check the patient’s insurance card and/or check patient eligibility to ensure the information is appropriately documented for accurate submission in 5010.

Drug Reporting

In 5010, professional claims for injectable medications must include additional drug information and qualifiers, such as National Drug Code (NDC), quantity, composite unit of measure and prescription number.
Currently providers must submit a HCPCS code as the service-line procedure along with the total charge and units of service. In 5010, you will now be required to also submit the NDC Drug Quantity and Composite unit of measure.  Providers who submit service-line drug charges must work with their software vendor to ensure that the drug quantity and unit of measure can be submitted. Claims that do not include this information may be rejected.
Providers should work with their software vendors to determine if the product supports these and other drug entry changes.

Compound Drug Claims

The 4010 standards made it difficult to select a single HCPCS code for a compound injectable medication because each ingredient pointed to a different HCPCS code. In 5010, all ingredients that make up a compound prescription must be identified on the claim, and a unique HCPCS must be assigned to each ingredient. The provider will be required to enter separate lines of service for each HCPCS.  As with single ingredient drugs, the provider must also include their service line charge for each ingredient, the service line associated units, the NDC number, the NDC Drug Quantity, and the Composite unit of measure.   
Providers should work with their software vendors to determine if the product supports these and other drug entry changes.

Durable Medical Equipment

The Durable Medical Equipment (DME) Service segment (2400 SV5) is used when it is required to report both the rental and purchase price information for durable medical equipment at the service line level. In 4010, only the procedure code, unit of measurement and quantity were required for this entry. In 5010, the DME Rental Price, DME Purchase Price and Rental Unit Price Indicator will also be required. If all three of these fields do not contain a valid value, the claim will be rejected.
Some claims may also require the DME Condition Indicator segment (2400 CRC) for a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), a DMERC Information Form (DIF), or an Oxygen Therapy Certification.  In 4010, you could repeat the segment more than once, but 5010 limits you to one DMERC condition indicator segment per service line. The number of condition indicator codes for this segment has also been reduced from five possible codes in 4010 to only two codes in 5010. If invalid indicator codes are used, the claim will be rejected.

Ambulance Claims

In 5010, ambulance suppliers who submit medical transportation claims will be required to report the pick-up and drop-off locations for ambulance transport. Previously, there were no dedicated fields for this information, but now it can be reported at the claim level (5010 loops: 2310E and 2310F) and service line level (5010 loops: 2420G and 2420H). 5010 also added another new segment (2400 QTY) that will be required to report the number of patients transported in the same vehicle for ambulance or non-emergency transportation services.
Additionally, CMS currently does not require ambulance suppliers to submit a diagnosis code on claims for payment. However, in 5010, a diagnosis code must be present on all professional electronic claims, including ambulance claims.
Your billing systems will need to be able to capture and report this information on your electronic claims to avoid rejection.

Line Item Control Number

While some practices have been entering a unique line item control number for each line of service for each patient, it will now be required to be unique in 5010. The line item control number segment is not required but if it is sent it will need to be unique to each line of service. In addition, payers are required to return the line item control number in the electronic remittance advice (ERA) transaction when the provider includes it in the original electronic claim or when they have split the claim or line item. This change is helpful because receiving the unique line item control number within the ERA gives you the capability to automatically post by service line.
If providers send a line item control number they should work with their software vendors to verify that their systems can create a unique line item control for each line of service.

Health Care Diagnosis Codes for Professional Claims

One of the main purposes of 5010 is to support the upcoming change to ICD-10 diagnosis and procedure codes – a change providers must make by October 1, 2013. To help prepare for ICD-10, 5010 now requires a Diagnosis Code on all claims, and the maximum number of Diagnosis Codes was increased from eight in 4010 to 12 in 5010. Although you can report 12 diagnosis codes at the claim level, you can only point or link four codes to a specific service at the service line level.
You need to work with your software vendor to ensure you have the ability to report the number of required diagnosis codes.

Primary Identification Code Qualifiers

Previously, you were allowed to report an Employer’s Identification Number (Tax ID) or Social Security Number (SSN) as a primary identifier for the billing provider. In 5010, you are only allowed to report a National Provider Identifier (NPI) as a primary identifier (ANSI loop 2010AA NM108/NM109). If the billing provider does not qualify for an NPI number, such as an Atypical provider, then only the Tax ID or SSN would be allowed in the REF segment of the billing provider loop.
In addition, 5010 standards have eliminated the use of payer-specific provider numbers in favor of NPI and Tax ID numbers.