Pulmonology Coding Alert

Follow these keys to transition to Medicare smoothly.

If a new provider or coder is joining your pulmonology practice, they might not be familiar with the intricacies of the Medicare program. You can help make the transition easier by sharing a few of the basics to help them get up to speed quickly.

Check out these five tips that can steer you toward coding success.

1. Familiarize Yourself with the Medicare Process

The Centers for Medicare & Medicaid Services (CMS) states that Medicare pays about 80 percent of the allowed charges for a procedure or service, which leaves the patient responsible for the remaining 20 percent. In most cases, the patient’s deductible or coinsurance will apply to account for the remaining charges. For 2021, the Medicare Part B deductible is $203. This means the patient is responsible for the first $203 of approved charges for medical expenses.

Additionally, patients pay a monthly premium to have Medicare coverage, and the Part B monthly premium for 2021 is $148.50.

2. Realize Fees Can Change From Year to Year

While the Part B monthly premium and deductible are set for the current calendar year (CY), it’s very possible for the charges to change from year to year. This is due to the annual Physician Fee Schedule (PFS) Congress approves each year.

One year, the fees may increase for certain procedures, but fees can decrease as well for one reason or another. For example, the Consolidated Appropriations Act of 2021 (CAA) provided a one-time increase of 3.75 percent for CY 2021. But the CY 2022 Proposed Rule would reduce the conversion factor by 0.14 percent if the rule is finalized.

Important: Pay attention to the Final Rule every year to stay aware of upcoming fee changes.

3. Decide If Your Practice Will Participate with Medicare

Every year during the fall, CMS provides physicians with the chance to alter their participation status with Medicare — with an effective date of January 1 of the following year. Physicians can choose from a participation (PAR) agreement, non-participation (non-PAR), or to opt out and act as a private contracting physician (URL: www.ama-assn.org/system/files/2019-05/know-options-medicare-participation-guide.pdf).

Participating providers must accept assignment on all Medicare patients. This means they will accept the Medicare-approved charges and only collect the deductible and copayment amounts for covered Medicare services. Additionally, PAR physicians generally collect a higher amount of reimbursement and experience faster claims processing than non-PAR providers.

Non-participating providers can collect 95 percent of a fee schedule amount because they face a limiting charge. A non-PAR provider also has the option to accept or decline assignment for a claim on a claim-by-claim or patient-by-patient basis. Despite its title, the non-participation option is not an all-or-nothing decision, it allows providers to evaluate their Medicare revenues and how they relate to total revenues as PAR physicians.

4. Know What’s Included with an LCD

Regional Medicare Administrative Contractors (MACs) determine and publish the local coverage determinations (LCDs). The LCDs outline specific information that you’ll need to correctly submit a claim to Medicare. “[LCDs] are created by Medicare for a non-covered benefit, such as a specific diagnosis that may be a medical necessity later on,” says Najat Khoury, CPC in an AAPC webinar on local coverage determinations.

Each LCD covers a variety of criteria, including certain ICD-10-CM and HCPCS codes, which help determine if the service is covered, is considered necessary, or is not reasonable. If you are familiar with the LCDs of the services that your practices routinely, you’ll know what requirements to meet to submit a foolproof claim.

5. Understand That Payments May Take A Few Weeks

Receiving reimbursement for a Medicare claim isn’t as quick as splitting the dinner check with friends. Sometimes you’ll receive payment for your claims quickly, but other times it could take a few weeks. After submitting an electronic claim, your practice should receive an Electronic Data Interchange (EDI), which allows you to check a validation report to make sure your claims were received and accepted.

Additionally, it’s a good idea to check your software system to ensure that claims are not set to automatically rebill every 30 days. This will let you monitor your claims and allow enough time to elapse for reimbursement.