Medicare Compliance & Reimbursement

Hint: Modifiers are key to collecting for screening-turned-diagnostic colonoscopy

Could your medical practice afford to leave several thousand dollars in your MAC's office each year? That's what some practices are doing by not coding and billing properly. Check out the following three questions and their answers, to determine whether you're collecting every dollar you're owed.

Question 1: Your physician discovers several polyps while performing a screening colonoscopy and removes them using the snare technique. Should you report the screening colonoscopy G code or the diagnostic colonoscopy 453xx code to collect for the screening-turned-diagnostic procedure?

Answer 1: In this case, you should report the colonoscopy with polyp removal via snare technique (such as 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s], by snare technique) with modifier PT (CRC screening test converted to diagnostic test or other procedure) appended to 45385.

Modifier PT tells the MAC that your procedure started off as a screening service (which would most likely have been billed with G0105 for this patient) but the physician found an abnormality and the procedure subsequently became diagnostic or therapeutic.

Revenue collected: If you had reported the screening code G0105 alone as a non-facility procedure, you'd collect about $395, but for 45385, you'll collect about $533. That means you'd surrender about $138 in rightful reimbursement if you erroneously reported the screening colonoscopy code for this procedure.

Question 2: Your MAC has denied every charge for your physician's 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 2: 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 you 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 (Chest x-ray, Professional component). The MAC denies your charge, which amounts to about $9.00. You write off several months' worth of these charges, but then when you add them up, you realize you've been writing off nearly $1,000 a year.

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

Revenue collected: Nearly $1,000 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 3: 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.

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.