Medicare Compliance & Reimbursement

Tip: Know the rules on NPP prolonged service codes.

As costs continue to rise, it’s essential that you collect the pay you deserve. That includes billing for items and services that you may not realize are legitimately billable to Medicare.

Read on for five of the most common services that you should be billing.

1. Should we collect copays and deductibles for every Medicare patient?

Yes, you should — and can get into legal hot water if you don’t. Although there are some rare instances when you can write off a patient’s copay or deductible, as a rule you should be collecting these. Financial arrangements that differ from the billing obligations laid out in your contract with government or third-party payers can result in fraud charges, penalties, and loss of carrier contracts.

According to the HHS Office of Inspector General (OIG), “the routine waiver of Medicare coinsurance and deductibles can violate the federal Anti-Kickback Statute if one purpose of the waiver is to generate business payable by a federal health care program.” In addition, offering inducements like cost-sharing waivers to influence a patient’s provider selection can violate other statutes, the OIG says.

Best bet: If you ever encounter a situation in which you think a waiver or discount of fees is legally and ethically appropriate, contact your payer or a health care attorney to ensure that the arrangement would be in compliance with the payer’s contracts and policies.

2019 money matters: “Traditional Medicare pays 80 percent of the allowed charges, and the patient makes a 20 percent copayment,” advised NGS Medicare’s Arlene Dunphy, CPC in a webinar from Part B Medicare Administrative Contractor (MAC). A deductible and coinsurance apply in most cases, and patients pay a monthly premium.

Next year, the Medicare Part B deductible will be $185; therefore, the first $185 of approved charges for medical expenses are the patient’s responsibility. In 2019, the Medicare Part A deductible will be $1,364.

Check out the MLN Matters release on Medicare Deductible, Coinsurance and Premium Rates for 2019 at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11025.pdf.

2. Can we recoup the cost of casting materials?

Yes, you can. Although cast application coding can vary, you have one simple rule to remember for cast and splint supplies: they are always separately billable, assuming you incurred the expense for supplies.

Look to HCPCS for all your cast supply codes. Make your selection based on the patient’s age, type of cast/splint, and the type of cast material, but typically you’ll report codes Q4001-Q4051. These cover the gamut of cast supplies and application types. Each Q-code fee includes the cast material, padding, and stockinette.

3. How do we charge for more complicated procedures?

With appropriate documentation and judicious application, you can append modifier 22 (Increased procedural services) and yield increased payment for especially difficult or time-consuming procedures.

No payer will allow additional payment for a procedure unless you can provide convincing evidence that the service/procedure the physician provided was truly out of the ordinary or significantly more difficult or time-consuming than usual. The time to append modifier 22 is when the service(s) the physician provided was “substantially greater than typically required,” according to Appendix A of the CPT® manual.

Details: CMS guidelines stipulate that you should apply modifier 22 to indicate an increment of work infrequently encountered with a particular procedure and not described by another code. These could include situations involving excessive blood loss or trauma, in addition to other scenarios.

The documentation should clearly identify additional diagnoses, pre-existing conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure, as well as the special circumstances of the additional time and/or effort necessary.

Include a physician’s letter that explains the unusual nature of the procedure with the claim, so the payer can see that more than a typical service was performed. Also, let the payer know how much extra reimbursement you believe you deserve.

Scenario: For instance, if a procedure took 20 percent longer than it typically should, you might ask for an extra 20 percent over the normal fee.

4. Can we bill for extra time spent with patients at office/outpatient E/M visits?

Yes, you certainly can use prolonged services codes with the proper documentation. CPT^® includes add-on codes you can report along with your E/M code to describe prolonged services with direct patient contact.

When a practitioner spends at least 30 minutes or more time beyond the typical time for a particular E/M code, you will report prolonged services in the outpatient setting or office with +99354 (Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service) for the first hour (actually, 30-74 minutes) of prolonged service. You can report every additional 30 minutes of direct patient contact with +99355 (… each additional 30 minutes (List separately in addition to code for prolonged service).

While reporting the encounter, make sure to document all the details regarding the total time spent by the physician for the encounter, the actual time of the visit spent in counseling/coordination of care, and what topics were discussed.

NPP options: CPT^® code +99415 (Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service) and +99416 (… each additional 30 minutes (List separately in addition to code for prolonged service) are specifically for non-physician providers (NPPs).

Critical: “The difference between these two sets of codes for prolonged services would definitely be who provided the service,” explains Manny Oliverez, CPC, CEO of Capture Billing & Consulting Inc., in South Riding, Virginia.

“Codes +99354 and +99355 are for prolonged services by a physician or other qualified healthcare provider — such as a nurse practitioner or physician assistant,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Codes +99415-/+99416 are for clinical staff — such as a registered nurse [RN] or a licensed practical nurse [LPN]. One other difference is that +99354/+99355 include both prolonged E/M and psychotherapy, whereas +99415/+99416 only reference E/M.”

5. Are we allowed to charge fees for no-shows?

Yes, you can set up a policy that charges patients who fail to reschedule an appointment. Although some practices are still hesitant to bill for missed appointments, these holes in your day have an impact on the physician’s schedule and availability to other patients, and cost your practice real dollars. In some cases, charging patients a fee when they miss a visit will help you offset the lost time and money the open appointment time cost.

Your first step in evaluating whether to charge a fee to patients who do not show up for appointments is to check with your MAC. Medicare allows charging for no-shows as long as it is the office policy and done universally to all patients (except Medicaid, which doesn’t allow no-show fees).

Key: Even if your contract allows you to bill for no-show visits, that doesn’t mean you can bill the payer. You need to bill the patient for the missed appointment. You should tell all of your patients about the policy and have them sign the policy with their other annual financial documents.

Your no-show policy should spell out exactly what fee you will charge for a missed appointment. Some may charge a fixed amount of $25 or $50, which won’t cover the missed reimbursement. Others may charge the actual amount of the missed visit; for example, a behavioral health professional may charge their normal fee for a one-hour counseling appointment.