Pulmonology Coding Alert

Question: I've heard how practices can hold a physician's claims while waiting for Medicare to credential the doctor, and then the practice can later send in all that doctor's claims for retroactive payment after Medicare has credentialed him. Someone else told me that Medicare is planning to end the retroactive billing rule and allow us to bill only for services the physician provides after Medicare credentials him. Is this accurate?

Ohio Subscriber

Answer: Medicare did propose such a plan with an announcement in the July 7, 2008, Federal Register, says Robert B. Burleigh, CHBME, of Brandywine Healthcare Services in West Chester, Penn.

The Federal Register notes that currently, practitioners "may retroactively bill the Medicare program for services that were rendered up to 27 months prior to being enrolled to participate in the Medicare program."

CMS, however, solicited comments this past summer for a new system that would follow one of two plans:

• "The first approach would establish the initial enrollment date for physician and NPP organizations and for individual practitioners, including physician and NPPs, as the date of approval by a Medicare contractor," the Federal Register says. Under this plan, you would not be able to bill Medicare services retroactively --" instead, you could only bill for services performed after Medicare credentialed your physician.

• Under the second approach, the effective date would be the latter of either the filing date of the Medicare enrollment application that was subsequently approved by a fee-for-service (FFS) contractor, or the date an enrolled supplier first started rendering services at a new practice location.

What it means: Under the old plan, if an uncredentialed doctor saw a patient for an E/M service (such as 99213, Office or other outpatient visit ...) and later attained credentials, his services could be paid retroactively; but if the new system goes into effect, an equivalent E/M service would be reimbursed if the physician was recognized by Medicare.

"Many healthcare associations filed comments opposing CMS's proposed enrollment changes," Burleigh says. Although the comment period expired in August, CMS has not announced when it will determine whether to adopt one of these two proposed policies going forward.