Wiki icd-10 placement with medicare

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sappingtonpa@gmail.com

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My Question: Any clue why the payments were different?

I compared two claims on two different patients.
Both Medicare, both office visit (11), both with same doctor, same DOS

#1 99213 (25) M2021
11720 (Q8) B351, E119

#2 99213 (25) M2040
11721 (Q8) E1151, B351

Looking at just the 99213

#1 paid $59.29
#2 paid $55.29

I called Medicare & the girl apparently has no clue. Her first response was the Diag placement (I explained there is only one dx code for both). Then she stated it must be the specificness of them (I explained they are the same - one is not Diabetic while the other hammertoe), she freaked out not knowing the answer & hung up.

I would love to hear what you think!
Sincerely,
Patricia
 
sappingtonpa@gmail.com said:
My Question: Any clue why the payments were different?

I compared two claims on two different patients.
Both Medicare, both office visit (11), both with same doctor, same DOS

#1 99213 (25) M2021
11720 (Q8) B351, E119

#2 99213 (25) M2040
11721 (Q8) E1151, B351

Looking at just the 99213

#1 paid $59.29
#2 paid $55.29

I called Medicare & the girl apparently has no clue. Her first response was the Diag placement (I explained there is only one dx code for both). Then she stated it must be the specificness of them (I explained they are the same - one is not Diabetic while the other hammertoe), she freaked out not knowing the answer & hung up.

I would love to hear what you think!
Sincerely,
Patricia
Click to expand...


The only thing I can think is that maybe patient 2 had a deductible remaining that was applied before Medicare paid ?? Are the amounts you listed the actual paid amounts? Or the allowed amounts?
 
I just looked up medcare, both patients had already satisfied their deductibles earlier in the year. Medicare is primary on both patients. Yes, that is the actual amount medicare paid on each claim.
 
Here is a thought. You used an unspecified code for the second example. It is possible the Medicare down coded the visit level due to unspecified.
 
Can we discuss this a little more? Because of the unspecified code and due to the reminders that we should not be using them unless absolutely necessary, MCR can go ahead and downcode the visit level? Am I understanding this right? Loss of revenue is always the great motivator to force the physician community to code to the new specifics! Thanks to the original poster for sharing this on the forum, and for Debra who always is in "observation status"!
 
I don't believe that Medicare contractors have the statutory authority to reduce physician fee schedule payment rates based on the diagnosis. We are seeing some denials because unspecified codes have been omitted from the newly published LCD policies, but not changes in payment rates. They should not be doing this unless they can point to a regulation or guideline that allows for it.
 
Since Medicare stated that the overarching criteria for a visit level is Medical necessity, then it is not too hard to believe that an unspecified diagnosis could result in a down coded level. If the documentation can not specify right or left side, then the visit could not have been at that intensity could be a way of thinking. I am not saying this is what happened only that it is a thought.
However I am curious as to why right or left could not be specified in the second scenario. This is something that if the visit was about the hammertoe then how is it that we don't know which foot?
 
I agree with Debra's line of thinking...that if a provider can't specify laterality, that maybe that would result in reduced payment. But wouldn't it be more likely that a payer would downcode the E/M itself--from 99213 to 99212 in this case? And not just reduce payment by a few dollars?

What about location? I'm assuming that both patients are seen under the same practice. But are both visits performed at the same location? There are geographical payment adjustments that would cause a small difference in reimbursement if, for example, one of those patients was seen at a satellite location that falls in a different region. I'm in Louisiana--we have 2 different regions in our state. Many states have more. Just another thought :confused::confused:
 
different patients, both Medicare as primary, both females, both seen at same location (office), both have met deductibles, same region within the state of VA. Actually I do agree with Debra & Meagan here. I think medicare does not like us using "unspecified" anything. therefore the 1st pt we used M2021 (right foot) & 2nd pt we used M2040 (unspecif) so they paid less when we did not state if the hammertoe was right or left foot ..... OMG this is stupid in my opinion, $4 to teach the dr a lesson on how to bill when all they need to be concerned with is how to treat his patients!!! Thanks everyone for your responses, they were greatly appreciated!
 
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....so the "take-away" here is that this may be a classic case scenario where we can advise our doctors that the use of unspecified codes (even though it may be easier for them to use), might ding their reimbursement! A few dollars here and there = a lot in the long run. This has has been very enlightening....
 
Medicare payers can make a reduction in payment when medical necessity doesn't support the billed code, but in that case there would be a remark code on the remittance explaining that this is what happened. They can't simply change the PFS payments arbitrarily without explanation. I'd recommend escalating this and insisting on an explanation - with this limited information, I really don't think any conclusions can be drawn about this being due to an ICD-10 unspecified code.
 
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