Surgical Global Periods

I am confident that all doctors have at least a basic understanding of the global package and what is expected of them during that time. However, what does and does not fall under the global period continues to be an issue for providers and medical billers alike.

Scenario #1: Provider performs pre-op visit and the subsequent surgery. Upon the follow -up visit, everything is found to be normal.

• Since the provider has already been reimbursed for the entire global period, there is no additional reimbursement. The provider should bill a 99024 to create a permanent record that the patient was seen for post-op evaluation.

Scenario #2: Provider performs pre-op visit and the subsequent surgery. Upon the follow-up visit, Provider finds a postoperative infection that needs additional care.

           

• The infection is unrelated to the diagnosis for which the surgical procedure was performed, therefore the provider should receive reimbursement for this encounter. The provider should code the encounter as they normally would for an office visit, but they must include a 24 modifier. Without the 24 modifier, the claim will be denied. 

A doctor can avoid a lot of denied claims by making sure that the biller includes the 24 modifier with claims such as in Scenario #2. If the modifier is not included, the claim will be denied and the biller will be left to try to figure out what caused the denial. The claim must then be appealed, where they will likely request chart notes. This requires an extensive amount of time and labor before the provider will receive reimbursement.

A good line of communication can avoid most of these denials on the front end.

Medical Billing Services & Solutions

2012 OIG WORK PLAN

The Office of Inspector General (OlG) has released its Work Plan for 2012.  The OIG sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities including CMS.

The OIG plans to initiate the following NEW activities related to physician services:

1)     High Cumulative Part B Payments – The OIG will review high cumulative Part B payments to determine if they are reasonable and necessary, adequately documented, and provided consistent with Federal Regulations.

2)     Incident-to-Services – The OIG will review whether “incident to” billing has a higher error rate than that for non-incident-to-services.

3)     E/M Services: Use of Modifiers during Global Surgery Period – The OIG will review the appropriateness of the use of certain claims modifier codes during the global surgery period to determine if Medicare payments were in accordance with Medicare requirements.

To avoid potential penalties in 2012, be sure that all providers in your practice are documenting exactly what they are billing out to Medicare.  Remember, if it isn't documented, it didnt happen!!!

For more information on this topic, visit http://oig.hhs.gov/reports-and-publications/workplan/index.asp

Medical Billing Services & Solutions

Medicare Payment Advisory Commission to Impose Pay Cut For Medicare Providers

The Medicare Payment Advisory Commission is charged with supervising $500 billion in Medicare cuts as a part of the Patient Protection and Affordable Care Act.  In September of 2011, MedPAC proposed that specialists will receive a 6% cut in their fees per year for three years followed by a 7 year freeze without any adjustment for inflation; general practitioners will face a 10 year freeze on their reimbursement fees, with no adjustment for inflation.  Despite overwhelming opposition from Medicare patients, Medicare providers, and many Health Organizations, they have recently gone ahead and voted to impose these drastic pay cuts on all doctors that accept Medicare as of January 1, 2012.

These cuts and pay freezes will equate to a 50% real pay cut for specialists and a 30% real pay cut for general practitioners over the next 10 years.  This assumes that inflation stays at a very low 3%.  Obviously, higher inflation would make the cuts in real pay even more drastic.

Consequences of this decision:

1)  Many physicians, and most specialists, will refuse to treat patients with Medicare as their primary insurance.  There are certain costs that physicians assume by practicing medicine and treating patients.  These include the obvious business overhead expenses, such as: rent, utilities, malpractice insurance, medical supplies, salaries of employees/nurses, etc.  Why would a physician want to treat a Medicare patient when they know that the reimbursement for treating that patient may not cover their expenses?

2)  More medical care will be turned over to nurses, nurse practitioners, and physician assistants.  Few people will ever get to see a doctor under the Medicare program.

3)  Medicaid will follow suit and cut their reimbursement fees as well.

4)  Many commercial insurance companies will also follow suit and cut reimbursement fees.

5)  The quality of health care in America will be drastically impacted because many students will choose to pursue careers in other fields.  The cost of medical school plus interest on student loans is always increasing.  Decreased future earnings to pay back these loans will prevent attending medical school from being a viable option.


If we do not take a stand, these cuts will drastically impact the health care industry in the United States.  I encourage you to write your Congressional Representatives and U.S. Senate Representatives to make your voice heard.

Denial Management 101

Every medical practice experiences denied claims, however some experience a far greater number of denials than others.  The best performing practices can have denial percentages as low as 5%.  Other practices are seeing claims denied 25-30% of the time.  It is key to understand that once a Medicare claim is denied and appealed correctly, it will take at least 1-3 months before the provider receives payment.  In tough economic times, this cash flow delay is unacceptable for most every practice.  Healthcare professionals are always looking for ways to improve their billing performance.  The best way to improve billing performance is to prevent many of these denied claims before they happen.

For those that have been involved in physician billing for over 20 years, we know that there was once a time when claims were submitted to the payers and we subsequently received payments.  It used to be much less sophisticated than it is today.  An individual claim processor manually reviewed, processed, and paid every single claim.  Over the last two decades, much of that work is now being done by a computer.  Programs are written to make sure that the medical practice/medical billing service is "dotting their i's and crossing their t's".  If there is any doubt, they deny it.  They assume that most medical practices will not go through the trouble of following up on denied claims.  This saves the payers money.

To ensure that you, as a provider, are not leaving money on the table, it is vital to be proactive as to what the root of the denials is.  Keep track of how many claims are denied every month, identify the reasons for denials, and track your denial performance over time.

1:  Determine your Denial Percentage at the end of every month.

1. Total # (and charge amount) of claims filed to a payer.
2. Number (and dollar value) of denied line items.
3. Calculate Percentage by dividing "number of denied line items" by the "total claims filed to payer"

This will enable you to track from month to month whether or not your practice is improving.  This should be tracked as a complete practice, as well as by individual provider, location, and by payer.  This will give you insight as to where and why problems may be occuring.

2:  Determine the main reasons for the claim denials.

• Registration error
• Charge entry error
• Lack of referrals & Pre-authorizations
• Insurance Company needs info from patient
• Duplicates
• Medical Necessity/CPT Code does not match ICD-9 Code
• Documentation
• Bundled/Non-covered  {ex)modifiers}
• Credentialing

This information will enable your practice to understand why claims are being denied, and where on the job training needs to take place.

3.  Track your denial performance over time.



The details about your claims denials will allow you to focus your energy on the most frequent reasons that claims are being denied.  The provider/practice management staff will know the most efficient ways to address the problem if they know the root cause of the why claims are being denied.  Every time you reduce your denial rate you bring more money to the bottom line of your practice.  Not only do you get paid correctly and timely, you have eliminated all the labor hours involved in reworking denied claims.

Medical Billing Services & Solutions