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.

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.