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Medicare Compliance & Reimbursement

REIMBURSEMENT:

Don't Treat A Second-Hand Problem Like A New Development

Published on Tue Sep 18, 2007

Don't bill Medicare for routine pre-operative chest X-ray

A problem may be new to your doctor, but that doesn't make it "new" for payment purposes, warns Part B carrier Palmetto GBA.

A "new problem" is one that someone has identified but nobody has diagnosed, Palmetto says in a new Frequently Asked Questions (FAQ) answer on its Web site. A "new problem" may require an additional work-up to diagnose properly.

But if a patient shows up in your office with a problem that someone else has already diagnosed, that's not a "new problem." You should score that visit the same way you'd score a visit by a patient whom your doctor had already treated for that problem.

"For the purpose of scoring E/M documentation, a new problem is one that is new to the patient, not to the provider," Palmetto concludes.

Other recent FAQ answers from the carrier Web sites:

• You can't bill for cardiac catheterization using just a diagnosis of chest pain, says Mutual of Omaha Medicare. Instead, you should bill using the diagnosis that your physician arrived at after testing the patient, prior to the catheterization. For example: A patient has a stress test that indicates a diagnosis of myocardial infarction. You should use the code for myocardial infarction as the primary diagnosis code on the bill. The earlier diagnosis of chest pain isn't sufficient for coverage, Mutual warns.

• Non-physician practitioners can write orders, and participate in team conferences, in the Inpatient Rehabilitation Facility (IRF) setting, Mutual says. The only restrictions: they can't do anything their state licensure doesn't allow, and they can't "take the place of the physician." Medicare won't pay for IRF admission unless a physician with rehab training is available 24 hours a day, so the team that assesses the patient must include an actual physician.

• Just because you're in the Emergency Room doesn't mean administering Tylenol is risky, Palmetto cautions. You'd still consider the level of risk "low" under management options, "unless something unusual is going on with the patient," Palmetto notes. In that case, the medical record should show any unusual circumstances. "Tylenol is an over-the-counter drug regardless of where it is administered," Palmetto adds.

• You don't have to bill Medicare if you routinely provide a non-covered service. For example: One practice provides a chest x-ray to patients before surgery, but Medicare won't pay for it. In that case, you shouldn't bother to bill Medicare unless the patient requires a formal determination that this is a non-covered service. In that case, you can bill using modifier GY for statutorily excluded services, says WPS Medicare.

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