Basics of Internet-based PECOS for Physicians and Non-Physician Practitioners

Do you know how to use Internet-based PECOS to enroll in the Medicare Program?

A fact sheet produced by the Centers for Medicare and Medicaid Services (CMS) provides this information for physicians and non-physician practitioners

The fact sheet highlights the following:

• Submission Options on the Medicare Enrollment Application
• How to get started on the Internet-based PECOS
• Completing an Enrollment Action Using Internet-based PECOS
• Limitations of Internet-based PECOS
• How to use Internet-based PECOS (listed by group description)
• Medicare Enrollment Processing Time Frames
• Role of the Medicare Enrollment Contractor
• Who to contact if you run into problems
• Additional resources for the enrollment process

To download and view the fact sheet, please click the following link: Guide on PECOS

CMS-1500 Claim Form Instructions

Need help with your CMS-1500 Claim Forms?

Check out CMS-1500 Claim Form Instruction guide produced by NHIC highlighting the following:

• Instructions for Filling Out the Health Insurance Claim CMS Form-1500 
• Appendix A – Sample Wording For Authorization  & Appendix B - Place of Service Codes with Definitions 
• National Correct Coding Initiative (NCCI)
• Medically Unlikely Edits (MUEs)
• Limitation of Liability (Advance Beneficiary Notice)
• Local Coverage Determination (LCD) & National Coverage Determination (NCD) 
• Medicare Fraud and Abuse
• Recovery Audit Contractor (RACs)
• Comprehensive Error Rate Testing (CERT)
• Provider Enrollment Help Line/Provider Enrollment Status Inquiry Tool
• Mailing Address Directory
• Provider Services Portal (PSP)
• Durable Medical Equipment (DME)
• Reconsideration (Second Level of Appeal)
• Additional Resources to fill out your claim forms

To download and view the instruction guide, please click here: CMS-1500 Claim Form Billing Instructions

Correctly Using Modifier 33 and Modifier PT

Do you know the difference on when to use CPT® Modifier 33 and Modifier PT?

Modifier 33

• Developed by the American Medical Association (AMA)
• Modifier 33 is for services with US Preventive Services Task Force (USPSTF) A or B rating

Modifier PT

• Developed by the Centers for Medicare and Medicaid Services (CMS)
• Modifier PT is more specialized

An article published by Kareo, explains Modifier 33 & Modifier PT, as well as, addresses the following questions:

• What services have an A or B rating?
• What to do if you forget the modifier
• Should you use both Modifier PT and Modifier 33?

To go to the full article, please go to the following the link: Modifier 33 and Modifier PT

Coding Assistance with Quick Reference Coding Cards

Are you struggling to keep up-to-date with changing rules and requirements for coding?

To help, we created a handy pocket-sized "Quick Reference Coding Card" for Emergency Medicine, Internists, and Hospitalists:

An overview of the cards are listed by their specialty

Emergency Medicine:

• Explains Observation Guidelines/Key Procedures with appropriate codes
• Amount of Observation time required by Medicare and Medicaid
• Critical & Fracture Care Coding Guidelines with the appropriate codes
  

Office Visit Coding Card:

• Describes how to distinguish between new and established patients
• Explains time based codes, E/M levels and MDM (Medical Decision Making) criteria

Hospitalist Coding Card:

• Explains the difference between the Initial and Subsequent visits and the related codes used.
  

To download and view the quick reference card of your choice, please click the following link: Quick Reference Coding Cards

CPT® Modifier 33 for Preventive Services

Are you properly using Modifier 33 for Preventive Services?

An article published in the December 2010 issue of the CPT® Assistant highlights the correct usage of CPT® Modifier 33.

According to the American Medical Association (AMA) article:

• CPT® Modifier 33 has been created to allow providers to identify to insurance payers and providers that the service was preventive under applicable laws, and that patient cost-sharing does not apply.
• CPT® modifier 33 has been effective since January 1, 2011
• CPT® modifier 33 is applicable for the identification of preventive services without cost-sharing in four categories (The four categories are described in detail in the full article)
• Preventative services with a rating of an "A" or "B"  by the US Preventive Services Task Force (USPSTF) are services that are recommended to be offered or provided to the patient.
• The article also has a table highlighting the preventative services which are rated "A" or "B" with a description as well as the effective date.

To download and view the article published by the American Medical Association, please go to the following link: When to Use Modifier 33

Avoid Receiving Improper Payments Before and After Processing Your Claims

Do you know how to avoid receiving improper payments before & after processing your claims?

A how-to guide on Medicare Claim Review Programs was produced by The Centers for Medicare and Medicaid and highlights the following topics:

• Medicare Contractors and Their Responsibilities
• Medicare Prepayment and Postpayment Claim Review Programs
• National Correct Coding Initiatives (NCCI) Edits
• Performed by Affiliated Contractors (ACs) /Medicare Administrative Contractors (MACs)
• Medically Unlikely Edits (MUEs)
• Performed by ACs/MACs
•  FAQs on Medically Unlikely Edits
• AC/MAC MR Program performed by ACs/MACs
• Comprehensive Error Rate Testing (CERT) Program
•  Performed by CERT RC and CERT DC
•  CERT Error Rates
• Recovery Audit Program performed by Medicare FFS Recovery Auditors
• Summary of MR (AC/MAC Medical Review), NCCI Edits, MUEs, CERT, and Recovery Audit Program
• Supplementary website resources with more information on Medicare Claim Review Programs

To download and view the full fact guide, please go to the following link: Medicare Claim Review Program

The Medicare Overpayment Collection Process

Need guidelines on The Medicare Overpayment Collection Process?

The Centers for Medicare and Medicaid Services (CMS) produced a short fact sheet on "The Medicare Overpayment Collection Process" in July 2011.

According to the CMS, The definition of a Medicare Physician or Supplier Overpayment is:

"A payment that a physician or supplier has received in excess of amounts due and payable under Medicare statute and regulations. Once a determination of an overpayment has been made, the amount of the overpayment becomes a debt owed by the debtor to the Federal government. Federal law requires the Centers for Medicare & Medicaid Services (CMS) to seek the recovery of all identified overpayments."

In Medicare, physician or supplier overpayments occur due to: 

• Duplicate submission of the same service or claim;
• Payment to the incorrect payee;
• Payment for excluded or medically unnecessary services; or
• A pattern of furnishing and billing for excessive or non-covered services.

The Overpayment Collection Process

• Demand Letters
• Repayment Plans
• Rebuttals
• Appeals

Additionally there are links to external websites regarding Medicare Overpayments and the collection process.

To download and view the full fact sheet, please go to the following link: The Medicare Overpayment Collection Process Fact Sheet

Guidelines for Teaching Physicians, Interns, and Residents

Do you feel your residents are losing you money in documentation?

The Centers for Medicare and Medicaid Services (CMS) produced a short fact sheet with Guidelines for Teaching Physicians, Interns and Residents in December 2011.

Highlights of the Fact Sheet Include:

• Payment for Physician Services in Teaching Settings
• Services Furnished by an Intern or Resident Within the Scope of an Approved Training Program
• Services Furnished by an Intern or Resident Outside the Scope of an Approved Training Program (Moonlighting)
• Billing Requirements for Teaching Physicians
• General Documentation Guidelines
• Evaluation and Management Documentation Guidelines
• Evaluation and Management Documentation Provided by Students
• Exception for Evaluation and Management Services Furnished in Certain Primary Care Centers
• Glossary Highlighing Key Terms
• Resources Page with additional links to external websites with advice for Teaching Physicians, Interns, and Residents

To download and view the full fact sheet, please go to the following link:  Guidelines for Teaching Physicians, Interns and Residents

Medicare Physician Fee Schedule Fact Sheet

Need guidance on Medicare Physician Fee Schedules?

The Centers for Medicare and Medicaid Services (CMS) produced a short fact sheet on Medicare Physician Fee Schedules in December 2011.

Highlights of this fact sheet include:

• Pay rates for Physician Services 
• Pay rates for Therapy Services
• Medicare Physician Fee Schedule Payment Rates 
• The Medicare Physician Fee Schedule Payment Rates Formula (how to calculate payment rates for an individual service)
• Additional Web Resources on the Medicare Physician Fee Schedule

To download and view the complete fact sheet, please go to the following link: Medicare Physician Fee Schedule Fact Sheet

Proposed Medicare Physician Payment Act Will Repeal the SGR

The proposed bill: "Medicare Physician Payment Innovation Act of 2012" was introduced by U.S. Representatives Allyson Y. Schwartz (D-PA) and Joe Heck, D.O. (R-NV) on May 9, 2012. The proposed bill will repeal the Sustainable Growth Rate (SGR) as well as reform Medicare payments and delivery systems
Highlights of the bill include:

• Repeal the Sustainable Growth Rate (SGR) Permanently.
• Stabilize the current payment system
• Provide positive payment updates for all physicians.
• Institute interim measures to ensure access to care coordination and primary care services. 
• Aggressively test and evaluate new payment and delivery models. 
• Identify best practices and develop a menu of delivery model options.
• Provide alternative value-driver fee-for-service system 
• Establish a transition period.
• Reward clinicians for high-quality, high-value care while disincentivizing fragmented, volume-driven care.
• Ensure long term stability in the medicare physician payment system.

To download and view the full bill in detail, please go to the following link: Medicare Physician Payment Innovation Act of 2012

Ensure You're Billing Your Place of Service (POS) Codes Correctly

In medical coding and billing, place of service (POS) codes are two digit codes that specify where the patient received their treatment.  To ensure you are appropriately receiving payment, using the correct POS code is crucial.

According to the Centers for Medicare and Medicaid Services (CMS), incorrect billing of the POS code may result in over-payments to the physician and may also change the amount you are reimbursed by Medicare.

Billing the incorrect POS code may also cause your practice to face issues with the OIG (Office of Inspector General) as they have been reviewing correct POS coding in more detail over the past couple of years.

The following guideline, Place of Service Codes Guideline explains the POS codes and the descriptions for these codes as well as whether or not the pay rate is for a facility (F) or non-facility (NF).

To download and view the full guideline, please go to the following link: Place of Service Codes Guideline.

Evaluation & Management (E/M) Services - Proper Documentation

Proper documentation of your Evaluation and Management (E/M) Services is crucial when submitting claims to Medicare for your practice.

A short fact sheet was produced in April 2011 by the "Department of Health And Human Services - CMS" on proper E/M documentation. Topics addressed on this fact sheet include:

• Components of an Evaluation and Management (E/M) Service
• Tips on Documentation: ‘If It Wasn't Documented, It Wasn’t Done!’
• Determining the Correct Level of Code
• Links to Resources for: "1995 Documentation Guidelines for Evaluation and Management Services” and “1997 Documentation Guidelines for Evaluation and Management Services"

To download and view the full E/M documentation fact sheet published by the Department of Health And Human Services - Centers for Medicare & Medicaid Services, please go to the following link: Evaluation and Management (E/M) Services: Complying with Documentation Requirements

Modifier Billing Guide: Appropriately Bill Your Modifiers:

Modifiers used in medical billing and coding are the alpha or numeric character that coincides with the appropriate CPT code. 

If you do not use these modifiers appropriately, coding and billing errors will occur. Issues with fraud and compliance may also arise when you are billing and coding.

To be sure you are billing modifiers at the appropriate time, the below link will direct you to a Modifier billing guideline.

This guideline lists the modifiers by specialty and the appropriate time to bill the modifier with the specialty: Modifier Billing Guide

Third-Party Payers: Keeping Your Practice Up to Date & Optimizing Cash Flow

Enrollment with third-party payers is one of the most important pieces of your practice’s business foundation. 

If your enrollment or contractual information is outdated, you may not be collecting all the revenue available to you, your operations may be negatively impacted by delays in receiving payments. 
The incorrect information may also be reported to governmental entities in your name (i.e. the IRS) vs. the appropriate corporate entity.
You may be asking yourself the following questions regarding enrollment verification with third-party payers:

• How will you know that your practice information may be out of date?
• How do you ensure that the information about you and your practice are correct and how do you efficiently correct errors happen to you?

To answer these questions and more, follow the link below to download and view the guide:
Verifying Enrollment Data: A Step-by-Step Guide

Why Documentation is Critical in Medical Coding & Billing

Are you following the necessary steps to document your codes correctly?

• To ensure that you are coding and charging correctly, your documentation must be accurate.
• The coder must evaluate all of the physician's dictation and base their codes on that.
• If yourself or your physician does not document correctly, you may not be receiving appropriate reimbursement.

The following link will direct you to download and view a guideline where you can evaluate if you are following the necessary steps in order to document your codes correctly: ED E/M Documentation