Billing Companion for Ob/Gyn

Billing Companion for Ob/Gyn

Contents Introduction... 1 Using the Billing Companion... 1 Structure of the Billing Companion... 2 Chapter 1. The Fundamentals of Billing... 5 Developing the Billing Process... 5 Coding... 6 Coverage Issues... 12 Medicare Participation... 16 Commercial Payer Participation... 18 Copayments, Coinsurance, and Deductibles... 18 Financial Hardships... 18 Free or Discounted Services... 19 Setting Fees... 20 Insurance Verification... 24 Preauthorization and Precertification... 25 Secondary Payer Guidelines... 25 Antikickback Statues and Self-Referrals... 41 Independent Diagnostic Testing Facility Issues... 43 Quality Initiatives... 49 Health Professional Shortage Area... 52 Physician Scarcity Area... 53 HIPAA and Billing... 54 Step-by-Step Claim Completion... 55 Items 1-13 Patient and Insured Information... 57 Items 14-33 Provider of Service or Supplier Information... 62 Information Regarding the Appropriate Method of Reporting Quality Indicators on the 1500 Claim Form... 75 Chapter 2. The Principles of Billing Ob/Gyn Services...77 Deductibles and Coinsurance... 77 Balance Billing... 78 Covered Services... 79 Modifiers... 82 Billing Evaluation and Management Services... 87 Billing Diagnostic and/or Therapeutic Procedural Services Surgery... 104 IUD Placement and Removal... 111 Pessary Insertion... 112 Multiple Procedures... 112 Ambulatory Surgery Center/Hospital Outpatient Surgery... 113 Billing Radiological Services... 114 Laboratory Services... 125 Limited License Providers... 127 Chapter 3. Remittance Advice: Friend and Foe... 141 Using Remittance Advice As a Billing Tool... 141 Claims Returned As Unprocessable... 142 Multiple Forms of an RA... 143 Electronic Remittance Advice... 143 Data Elements of an RA... 144 Posting Payments or Adjustments from the RA... 147 RA Review of Critical Information... 147 Reason Codes on the RA... 147 Third-Party Payers and the RA... 181 Appeals and Letters of Medical Necessity... 183 CMS Level of Appeals... 187 Expedited Determination Notices... 190 Chapter 4. Claim Submission Paper and Electronic... 193 Paper Claims... 194 Electronic Transactions... 195 Errors and Exclusions... 199 Compliance and Coverage Policy Denials... 202 Medicare... 204 National Correct Coding Initiative... 208 Medically Unlikely Edits... 212 Fraudulent Claims Concerns... 214 Appendix 1. E/M Guidelines... 215 Appendix 2. Claim Adjustment Reason Codes... 257 Appendix 3. Claim Status Codes... 263 Appendix 4. Remittance Advice Remark Codes... 275 Appendix 5. CMS-1500 to 837p Crosswalk... 299 Appendix 6. Place of Service Codes... 307 Appendix 7. State Licensing Boards... 311 Appendix 8. CPT Modifiers... 313 Appendix 9. HCPCS Modifiers... 329 Appendix 10. Examples of Commercial Claims Errors... 337 Glossary... 349 2009 Ingenix i

Billing Companion for Ob/Gyn CMS-1500 claim form. However, some ZIP code areas may have a mixture of eligible and ineligible areas for the HPSA/PSA bonus payment. An appropriate modifier may be needed to identify eligible services in an otherwise ineligible area. A list of qualifying areas, by ZIP code, may be found on the following websites: FOR MORE INFO Additional information on PSA/HPSA shortage areas can be found at http://bhpr.hrsa.gov. www.census.gov http://www.ffied.gov/default.htm http://hpsafind.hrsa.gov/ Note: For services provided in a patient s home, the PSA/HPSA bonus is based on the Medicare beneficiary s address. DEFINITIONS Health Insurance Portability and Accountability Act of 1996. Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, subtitle F, of HIPAA gives the Department of Health and Human Services the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. HIPAA and Billing The Health Insurance Portability and Accountability Act (HIPAA), signed into law in 1996, is multifaceted. This law affects the privacy of a patient s protected health care information but also the way claims are submitted and the very codes used on those claims. It is also important to remember that this regulation does not affect only Medicare claims, but those for other payers as well. Claims Completion and HIPAA HIPAA established transaction standards for the format of claim submission and communication. The administrative simplification provisions of HIPAA (Title II) require the Department of Health and Human Services to set national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. Implementation of these standards and expanded use of electronic data interchange (EDI) will improve the efficiency of the nation s health care system, reduce the administrative burden to providers and health care plans, and save more than $30 billion in the next decade, according to HHS estimates. Under HIPAA, every health care provider must use EDI standards for billing and other health care transactions, such as referrals and diagnosis reports. Health plans are required to accept these standard electronic claims. However, health plans are not prohibited from independently requiring the EDI standards for paper transactions as well. Some providers are exempt from the electronic claim submission requirement, including: Small providers (physician, practitioner, or supplier with fewer than 10 full-time employees) Dentists Participants in a Medicare demonstration project in which paper claim filing is required Providers who conduct mass immunizations, such as flu injections Providers who submit claims when more than one other payer is responsible for payment prior to Medicare Providers who furnish services only outside of the United States 54 2009 Ingenix

Billing Companion for Ob/Gyn E/M consultation services may be reported only once for an inpatient episode of care. Any requests for the patient to be evaluated again should be reported using subsequent care hospital codes. It is important to note that if the consultation services are considered bundled into other E/M codes for 2010 other non-medicare payers may still recognize these codes. Request for Surgical Clearance Due to the specialized nature of many gynecological practices, it is often customary to request a presurgical clearance from a patient s primary care physician. This is especially true with patients being managed for any chronic condition such as hypertension or diabetes that may put the patient at additional risk when general anesthesia is administered. A physician may report a consultation E/M code for his or her established patient when another medical practitioner or other appropriate source requested the presurgical consultation. All consultation criteria and documentation guidelines must be met to report these services. Inpatient Hospital Care General information For hospital care, the medical record should include specific documentation for the level of E/M services provided. The three key components must be documented and should include: Current and past medical, family, and social history Clinical findings Results of diagnostic tests Diagnostic assessment, including a statement regarding the primary reason for admission Therapy plan and rationale According to the hospital s conditions of participation, a complete history and physical (H&P) should be dictated or written within 48 hours of admission, including comprehensive documentation of the elements outlined above. KEY POINT Only one physician should bill for a hospital admission. If a payer receives multiple hospital admission claims for a single hospital stay, the subsequent claims are often denied. For scheduled admissions, if a complete H&P has been performed within one week before the hospital admission and there are no major changes in the patient s conditions, a repeat H&P need not be performed. A legible copy of the original H&P with additional documentation to update the record in the event of changes in the patient s condition should be filed in the medical record. If the current hospitalization is a readmission within 30 days for the same or related problems, an interval H&P documenting any changes in the patient s condition may substitute for a new, complete H&P as long as a legible copy of the original H&P is included with the interval H&P in the medical record for the current hospitalization. For subsequent hospital care, the medical record should include specific documentation for the level of E/M services provided. Documentation of reported services should include, but is not limited to, the following: 92 2009 Ingenix

Chapter 3. Remittance Advice: Friend and Foe Appeals and Letters of Medical Necessity An Ob/Gyn specialty practice may receive denials for non-covered services, failure to obtain prior authorization, or lack of medical necessity. These are all situations that should be sent for appeal. Medicare, as well as other third-party payers, have established processes for appeals. Commercial Payer Appeals Medical necessity denial: Review, appeal with notes, patient billing Noncovered services: Review for coding accuracy, possible appeal, patient billing Medical necessity: Medical necessity appeals may be the easiest type of denial to work with. In the majority of cases, an Ob/Gyn does not recommend unnecessary diagnostic testing or perform unnecessary procedures. If a service is denied for medical necessity, resubmitting a corrected claim or a written appeal may be the best recourse. A review of the medical record often reveals a more specific diagnosis or a different procedure code that should have been submitted on the intital claim. When submitting an appeal based on medical necessity, it is important to review the medical record documentation and any specific payer guidelines that may be available. If the payer does not have specific guidelines for appealing the procedure or service, the provider may simply be appealing to the payer s good nature or relying on common sense to obtain a favorable outcome. Once the provider has reviewed clinical documentation, he or she must decide whether an appeal is warranted. Filing an appeal is ill advised if the visit note or the operative report cannot support the previously billed services. Filing an appeal under these circumstances may invite an unwanted payer audit for other billed services. A corrected claim should be submitted immediately. QUICK TIP Most non-medicare payers have established appeal procedures that, if followed, can speed-up the appeals process. An appeal should be submitted after compiling every piece of documentation available that supports the specific case in explaining why the service should be covered. In addition to the visit note or operative report, include supporting documentation from specialty organizations (i.e., American College of Obstetrics and Gynecology, etc.) for a detailed explanation of the procedure performed. Compile the aforementioned documents along with a paper claim (provides all pertinent billing information) and a clear, concise letter stating the reason for the appeal. It is best to keep it brief, simple, and straightforward as this is an appeal based on facts and not emotion. For the most part, these first level appeals may be authored and submitted by ancillary staff. In some rare cases, a subsequent denial of a first level appeal may necessitate intervention from the physician and correspondence should be directed to the medical director of the specific payer/organization. This would only be in the case that the practice felt strongly enough that the service should be covered. Ncovered services: A denial for noncovered services is one of the most difficult to manage because of the considerable number of services that may fall into this category. Additionally, each payer has differing viewpoints on any given service or procedure. Any service denied as noncovered that has been identified on the remittance advice as provider responsibility should be appealed following the same criteria as a medical necessity denial. Otherwise, services that are denied and the payment for which the service is indicated are the patient s responsibility and should be transferred to self-pay. Patients may then choose to apply pressure on the payer to reconsider, which could result in an overturned denial. As a courtesy to the patient, the Ob/Gyn practice may file an appeal for a noncovered service. 2009 Ingenix 183