Anesthesia Coding Alert

Verify you’re handling these two situations correctly.

Medicare policies are never simple to comprehend, but some situations can lead to more confusion than others. Every dollar in your practice’s pocket counts, especially in uncertain financial times — so be sure you boost reimbursement by playing by the rules in these two common scenarios.

Stay Away From Multiple Claims Submissions

You might have to wait a while before hearing from your Medicare Administrative Contractor (MAC) about a claim — but don’t be tempted to resubmit the claim to be sure it wasn’t missed.

Here’s why: Simply resending a denied claim probably won’t solve the problem — and will almost certainly cost you more time and effort in the long run. “Don’t jump the gun and resend your claim. Wait to hear back from us,” advises Arlene Dunphy, CPC, of Part B MAC NGS Medicare in a webinar on duplicate billing.

Your MAC denied the claim for a reason during the first round of submission. If you don’t address that reason now, your claim will likely return to you as a denial again. What’s worse, once a payer has processed a claim for a date of service, they will detect the duplication in the date of service and CPT^® code(s) and deny the service(s) as a duplicate claim. Then you’re dealing with two denials.

If you know that you submitted a claim and you’re just seeking claim status, don’t resubmit the claim, counsels Caryanne Godfrey with Part B MAC Noridian Healthcare Solutions in a webinar. Instead, go to the MAC portal and check the status of the claim there.

Try this: After consulting with your MAC and using your online resources to investigate your claim, you might want to consider a reopening to fix minor claims problems like mathematical mistakes, clerical errors, or slight inaccuracies.

“A reopening must be requested within one year from the date of the initial determination. The contractor has discretion in determining what meets this definition and therefore, what could be corrected through a reopening,” reminds Part B MAC CGS Medicare in online guidance.

However, if you think the denial is unwarranted and not related to a minor issue, you may want to consider a redetermination — the first level of Medicare appeals.

Remember the Rules for Direct Supervision

Just because the physician and a nonphysician practitioner (NPP) are in contact over the phone — when in different buildings — doesn’t mean you can still bill incident to on Medicare claims.

Here’s why: Medicare stipulates an NPP must be working under “direct supervision” of a physician to bill incident to. The supervising physician cannot be across the street, three blocks away, or available via cell phone. If there is no physician physically present in the office suite during the time of the NPP service, the service must be billed to Medicare under the NPP’s name and NPI.

According to Medicare’s direct supervision guidelines, the supervising physician:

• Must be physically present in the office suite
• Need not be physically present in the treatment room
• Must be readily available to provide assistance and direction to the NPP
• Need not actually see the patient

“This means for the duration of the service if the supervising practitioner does not satisfy all requirements, the supervision component has not been met and should be billed with the NPP’s NPI. Expected reimbursement is 85 percent,” explains Kelly Loya, CPC-I, CHC, CPhT, CRMA, associate partner at Pinnacle Enterprise Risk Consulting Services LLC in Charlotte, North Carolina.

Documentation: As a best practice, the NPP should describe in the documentation that the supervising physician was in the suite at the time of the service. This will clearly illustrate that the supervision requirement has been met. “In the event this is not stated clearly, supervision must be supported in some other manner and consistently verifies the presence of the qualified physician to provide the necessary supervision,” Loya says.

Important: State laws sometimes lack clarity in supervision guidelines. However, CMS directly states that Medicare’s federal incident-to rules supersede any state’s rules — and the federal mandates are often more restrictive, experts say.

Some state boards may only require general supervision, or the physician be available by phone, in order to consider an NPP “directly” supervised. Don’t confuse this clinical practice guideline with the reimbursement guideline for services billed under the incident-to provision.