Medicare Compliance & Reimbursement

Hint: Detailed notes help you prove medical necessity to appeal denials.

With the high cost of practicing medicine today, can you really afford to throw thousands away? Unfortunately, some practices do that every day by not coding and billing properly. Check out these three questions and their answers, which highlight the income you could be putting in your pocket.

Question 1: You often see patients during the global period of surgeries, but many times the E/M services are for reasons unrelated to the surgeries. Most of the time, you include the visits in the global period. Should you keep billing this way, or can you sometimes report these E/M visits?

Answer: If the E/M visit takes place during the global period but is truly unrelated to the surgery, you should append modifier 24 (Unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period) to the E/M code.

Modifier 24 tells the payer that the surgeon is seeing the patient after the surgery for a problem unrelated to it. Therefore, the MAC should not include the E/M service in the previous procedure’s global surgical package.

Modifier 24 is only for use on E/M codes provided during the post-operative period (10 days or 90 days), experts say. The very definition of the modifier states it plainly: “unrelated evaluation and management service.”

Revenue collected: If you see one patient a week for a visit unrelated to the surgery and write off a level-three established patient E/M code — 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components …) — rather than appending modifier 24 to it each time, you’re missing out on about $74 for each visit. Over the course of the year, this would add up to almost $3,850.

Question 2: Your MAC has denied every charge for the medically necessary chest x-ray interpretations that you’ve submitted this year. Your office has a policy indicating that you shouldn’t bother appealing any denial for charges lower than $10.00, so should you write them all off?

Answer: When you analyze your denials, determine how many of those low-dollar amount charges you wrote off over the past year and add them up. Do they amount to a decent-sized sum? If so, it’s worth your while to appeal the denials. If you know you’ve appropriately documented and billed a claim and deserve your $10.00, you should capture it.

Example: Your physician routinely reads chest x-rays and writes the interpretive report for the radiology documentation, but you get denials when you report 71010-26 (Radiologic examination, chest; single view, frontal, Professional component). The MAC denies your charge, which amounts to a little over $9.30. You write off several months’ worth of these charges, but then when you add them up, you realize you’ve been writing off nearly $1,100 a year.

Solution: Appeal these claims with documentation showing the medical necessity of your interpretations of these x-rays.

Revenue collected: Nearly $1,100 annually.

Question 3: You have at least one no-show a week and it ends up costing your practice money because you could have filled that appointment with another patient, but you’re reluctant to institute a missed appointment fee because you’ve heard that Medicare payers frown upon those. Is that accurate?

Answer: You cannot bill your Medicare payer for no-shows, but you can bill the patient. Ever since 2007, Medicare has allowed you to charge patients fees for missed appointments. The only stipulation is that your no-show charge policy must apply to both your Medicare and non-Medicare patients — you cannot discriminate against your Medicare patients by only charging them for missed appointments. Plus, you should bill all your patients the same amount for no-shows.

Good idea: Ask all of your patients to sign your missed appointment policy when they sign your HIPAA and financial policy forms, so they know the fee ahead of time.

Revenue collected: If you institute a $25 missed appointment fee that you charge once per week to absentee patients, you’ll collect $1,300 annually.