Anesthesia Coding Alert

Tip: Go back to basics and build from there.

Slogging your way through Medicare claims has never been simple but can get especially tricky with the current pandemic affecting many practices’ bottom lines. That makes it an ideal time to remind yourself of some Medicare billing basics, in hopes of keeping your own bottom line intact.

Reminder 1: Provider NPIs Follow Them

Each Medicare provider is assigned a national provider identifier (NPI). This was mandated in 2004 under the NPI rule to align with HIPAA and simplify electronic transactions. An NPI consists of a 10-digit numeric identifier and is specifically for HIPAA-covered healthcare providers.

NPIs don’t “carry information about you, such as the State where you practice, your provider type, or your specialization,” Medicare guidance says. And that’s why “your NPI will not change, even if your name, address, taxonomy, or other information changes,” notes the MLN booklet, “NPI: What You Need to Know.”

Reminder 2: Don’t Resubmit Claims Before MAC Responds

If you don’t hear back from your Medicare Administrative Contractor (MAC) on a claim, it can sometimes be tempting to resubmit the claim until the carrier responds. But don’t let yourself give into the temptation.

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 particular 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, says 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.

Best bet: 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.

Reminder 3: Return to Medicare Basics

Many patients are covered by Medicare, but also by other insurance. That’s why it’s incredibly important to ask the right questions and update patients’ coverage information at every visit. From an anesthesia perspective, this primarily pertains to patients your providers might see on a routine basis, such as for pain management services.

Pay attention: The term “Medicare Secondary Payer” refers to situations where another payer has primary payment responsibility for care provided to a Medicare beneficiary.

Several factors determine whether Medicare is primary or secondary, such as the patient’s age or employment status, as well as diagnoses such as end stage renal disease (ESRD). For instance, if the patient has Medicare as well as group coverage through a large employer, the private (employer-backed) payer would usually be primary and Medicare would be secondary.

So, determining which payer is secondary or primary comes down to who the other payer is. If the patient has Medicare and Tricare, you should submit the claim to Medicare first, and then the balance bill can go to Tricare.

Reminder 4: Understand How Direct Supervision Ties to Incident To

Medicare stipulates a nonphysician practitioner (NPP) must be working under “direct supervision” of a physician to bill incident to for office services such as those provided by a pain management specialist.

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.

Breakdown: 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.

As a best practice, the NPP should describe in the documentation 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 feds’ mandates are often more restrictive, experts say.