Answers to Frequently Asked Coding Questions
August 2008

Getting Paid for DMV Exams:
Getting Paid for Discharge Day Services:
Emergency Office Visits:
Billing for Care of the Hospice Patient:
Also ...
A New Medicare Carrier is Coming to California - Are You Ready?

Getting Paid for DMV Exams:

Q: We recently saw a patient for a physical exam requested by the Department of Motor Vehicles (DMV). The patient had Medicare and when we billed the exam, we used a diagnosis code of V70.0 (General Medical Exam). The patient, while elderly, is very healthy and had no other diagnosis. I used 99215 because I did a full physical exam and used a modifier -32 to indicate that the service was mandated. Medicare denied the claim, saying it was considered a "screening service."  How do I get paid for these exams when patients need to have them before their driver's licenses can be renewed?

A: Remember, Medicare rules require that services can only be paid for by Medicare if they are related to the treatment of illness or injury, except for those preventive services that have been specifically legislated for coverage. When you used the diagnosis code of V70.0, you were indicating to Medicare that this was a routine or screening service. In fact, most health plans would not pay for this service. You should code the service with a preventive medicine services code (CPT 99397 if 65 years old or older). You should also ensure that the patient is aware that Medicare will likely not cover this service and, therefore, will have to pay for the visit. If the visit doesn't meet the coding requirements of a preventive medicine service (i.e., complete history, complete physical exam) and your only option is to bill it with a CPT code such as 99215, then you should make sure your patient signs an Advanced Beneficiary Notice (ABN). Bill the service with the GA modifier to indicate the ABN is on file. (GA is the code that is appended to a coded service to signal to CMS that the provider has an ABN on file for the service performed.)Then, when Medicare denies the service because it is considered a screening service, you may bill the patient directly for the exam. An ABN form is available in both English and Spanish from:  www.cms.hhs.gov/cmsforms.

A third option for billing these types of services is to simply establish a financial protocol for health plan non-billable services such as a DMV exam. You don't need to assign a CPT code to the service and it should be known by all your patients that these services are billed directly to them (because insurance policies generally don't cover them).  When you establish your fee for such a service, remember to keep in mind you will likely be asked to complete some type of a form to document the service, and you will want to include the form completion in the fee for the service.

Getting Paid for Discharge Day Services:

Q: I saw a patient in the morning as part of my regular rounds and then later that afternoon I discharged the patient. How can I code and get paid for both visits?

A: You should use a hospital discharge day management code to report all services provided to a patient on the date of discharge. Use hospital discharge code 99238 if you spent a total of 30 minutes or less on the services; 99239 if you spent more than 30 minutes. Remember, the time is not required to be continuous. Include the time of the morning visit in the time spent performing the discharge activities later that day.  Discharge day management includes, as appropriate, the final examination, discussion of the hospital stay, instructions for continuing care for all caregivers, preparation of discharge records, prescriptions and completion of any referral forms. Because this is a time-based service, be sure to document the approximate time you spent rendering the services. 

Emergency Office Visits:

Q: Can you tell me when it would be appropriate to use the CPT 99058 (services provided on an emergency basis in the office)? Can we use that for our patients who call in the morning and request a same-day appointment?

A: It would not be appropriate to use this code simply for "same day" appointments.  CPT 99058 (defined by CPT as "service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service"), is an add-on code.  This means it is intended to compensate you for the interruption in your office schedule when you are taken from one patient to attend to or render emergent services to another patient.  Here's an example of how it might be used:

A 10-year-old asthmatic patient comes in for a scheduled appointment for follow-up on the asthma exacerbation.  While waiting in the reception area, he begins to wheeze profoundly.  His mother approaches the receptionist to alert her about the wheezing and the patient is immediately ushered to an exam room.  After a quick check by the nurse, the physician is interrupted from another patient and asked to immediately see the asthmatic patient.  Considerable time is spent with the patient before the physician can return to the patient visit from which she was pulled.  This disrupted the flow of other patients for the next couple of hours. 

You would code and bill for the asthmatic patient (established patient visit 99212-99215) based upon the level of care given plus CPT 99058 (emergency service).  Be sure to document the nature of the services you performed and the time required to handle the emergency.

Billing for Care of the Hospice Patient:

Q: I am sometimes asked to see a patient who has enrolled in a hospice program. When I try to bill for my services (usually either a hospital visit or a nursing home visit), I am never paid because this is a "hospice" patient.  Aren't I entitled to be paid for my services, too?

A: Just as the transition from curative to palliative care is important for therapeutic options, it also signals an important change in billing practices.  While those changes may be major, it can be easy to make a mistake and, given the nature of patients' illness, hard to recover payment if not properly submitted the first time.  Here's how the hospice benefit works:

Enrolling the Patient: You must first determine that your patient would be best served by enrolling in this program (administered through Medicare Part A).  Two physicians - the patient's primary care physician and the hospice medical director - must verify in writing that the patient is not expected to live more than six months.  The patient must also sign a statement agreeing to receive only palliative care in the future and discontinue all attempts to cure.

The original certification is good for 90 days and can be re-certified for 90 more days.  The benefit never expires.  If the patient lives longer than the initial six months, re-certification needs to occur every 60 days and only one physician has to sign the re-certification form.

How the Benefit Works:  Patients select a physician and hospice agency when they enroll for the program.  The benefit is capitated; the agency is paid for each day the patient lives and thus cannot collect or bill for other services during that time.  

Paying the Physicians:  If you are employed by the hospice, your payment is considered part of the hospice's capitated payment, and you cannot bill separately.  If you are not employed by the hospice agency, you can bill for palliative care using the same CPT codes normally used for non-hospice patients and appending the GV (attending physician, not hospice-employed) modifier to the CPT code(s).  Only the provider the patient selected during enrollment as the hospice physician - and one who is not an employee of the hospice agency - can bill for these services.

The patient may switch his/her hospice care to another physician, but only once per certification period and the patient must sign a form to do so.

Treating Hospice Patients for Issues not Related to the Terminal Illness:   You should be paid if the the proper modifier is used when billing for those services.  For services not related to the terminal illness, bill Medicare with the standard CPT code(s) for that service, but include the modifier GW (services unrelated to terminal condition).  Any physician treating the hospice patient for a condition unrelated to the terminal illness may bill with this modifier. 

Patients Improving or Choosing Curative Measures:  If the patient decides to pursue anything beyond palliative care, he/she should be removed from the Medicare hospice benefit program and returned to traditional Medicare.  Once that occurs, you should no longer use modifiers when billing for continued care.  In those cases, it is important to work with the hospice agency to transition care and ensure that future Medicare claims are paid. 

A New Medicare Carrier is Coming to California - Are You Ready?

As you probably know, the Centers for Medicare and Medicaid Services (CMS) will be transitioning Medicare Administrative Carriers.  By September 2, 2008, Palmetto GBA will replace NHIC as the Medicare Part B carrier.  In advance of this date, there are several important deadlines for signed agreements and applications that must be submitted to Palmetto GBA.  In order to prevent a delay of your Medicare payments and interruption of your claims processing, you must do several things as soon as possible:  

1. All providers who currently receive electronic funds are required to complete an EFT (Electronic Funds Transfer) agreement (CMS 588 form) with Palmetto GBA.  The deadline for completion of the EFT Agreement is currently August 15, 2008.  You should receive a letter of confirmation from Palmetto GBA indicating your agreement has been processed.   If you have not or do not receive a confirmation, contact Palmetto GBA to ensure they have received and processed your agreement
2. All providers who are direct submitters and currently transmit electronically are required to complete both the EDI (Electronic Data Interchange) application and EDI Enrollment/Agreement as soon as possible.  If you utilize a billing service or clearinghouse, follow-up with them to ensure they have completed the EDI Application.  Since they are considered the submitter, they are required to submit the EDI Application while you (the physician) are still responsible for submitting the EDI Enrollment/Agreement.  Once you receive confirmation and a password from Palmetto, you may participate in "early board" and begin submitting claims to them.  This process is highly recommended as a means to test your connections and file transmissions prior to the cut over on 9/2/2008. 

The EDI and EFT applications and agreements are available for download here: www.palmettogba.com/j1.  Their Web site also has a wealth of other useful information about the transition, including all the local coverage determination policies.

Palmetto GBA is sponsoring a number of transition webinars to address all changes to Medicare claims submission and processing.  Access the J1 Web site and select the "Learning and Education" link to see a list of topics, times and dates.    

Finally, every practice that bills Medicare should encourage their staffs to download the Transition Manual from the Web site; it contains all the specific details about changes to claims submission and processing. 

Mary Jean Sage has extensive experience in the healthcare field spanning a period of more than 20 years during which time she has managed diverse groups of professionals in delivering patient care.  A founding Principal and Senior Consultant with The Sage Associates, Mary Jean is a nationally-known speaker, consultant and educator. 

DISCLAIMER

The articles provided in Practice Management News are general.  They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney-client relationship.  Consult your attorney or other professional for advice in your particular situation.