Ask the Contractor Teleconference
August 25, 2005
Topic: Open
Forum
Questions & Answers
Question: When transporting a patient by ambulance
who in enrolled in a SNF to and from an IDTF, how can I determine the patient's
longevity of the Part A stay?
Answer: Medicare Part B cannot verify Skilled
Nursing information. The Medicare Part A intermediary would need to be
contacted.
Question: We are a
Answer: The 59 modifier indicates that a therapeutic
service was distinct or independent from other services performed on the same
day. The 59 modifier identifies services that are not normally performed
together. This may represent a different session, patient encounter,
procedure or surgery.
Question: We are a participating provider of
mental health. Our provider is an MD who bills CPT code 90862 for
medication management. At the short visit he will write a script for
medication. Up to a week and half later after the patient has tried to
obtain medication, their insurance will request that a prior authorization for
medication is done. The paper work and phone calls can take up to 45
minutes. May we bill the patient for this work or is it part of the CPT
code 90862?
Answer: No. Any paper work and phone calls that
stem from the service are not billable separately, to Medicare or the
patient.
Question: Is there any way (other than having the
patient directly talk to Medicare) to find out how it got reported to Medicare
that a patient is in a SNF? If it was reported in error, is there
anything a clinic can do to fix it?
Answer: Medicare Part B does not handle the
reporting of Skilled Nursing information. You would need to contact the
Medicare Part A intermediary for this information and
if it would be possible for a clinic to correct the information if it has been
reported in error.
Question: Once a non-physician practitioner has
their own provider number and we bill for their services, is there a physician
presence requirement for their service?
Answer: No, a physician presence is not required for their own service. Billing for services independent of a physician's direct
supervision can only be done within the limits of general Medicare coverage guidelines
and the restrictions of applicable State law. The rendering non-physician
practitioner must obtain and use a Medicare Provider Identification Number ( PIN ) for billing
purposes, and this must be identified on the claim. In a group setting, this
number will report in item 24k of the CMS 1500 claim form (or the Rendering
Provider field for electronic media claims). In a private practice setting, the
practitioner's PIN would be entered in item 33. NP and CNS claims may be
paid to the rendering practitioner directly, or to their employing group (whichever applies).
Medicare reimbursement will be based on 85% of the physician's fee schedule
rate for that locality.
Question: If a Medicare patient has been discharged from
physical therapy and wishes to return to our clinic for sessions with our
personal trainer, must will bill for that service? What about for pilates?
Answer: No. Since it is never a covered benefit with
Medicare, you are not required to bill us for the service. You may bill
the patient upfront for the charges.
Question: When we bill with CPT code 99354, we get a
request for a report. But when we originally submit the claim with a
report, we receive a letter stating that we need to submit a report. Why
is that?
Answer: With a development letter, you are
always required to reply to the letter even if you have already done so.
Question: When billing for CPT code 99214, it is being
reduced down to 99213 or 99212 stating you looked at our medical records, yet
we've never submitted document records with these claims.
Answer: The 99214 along with the 99215 is a higher
level evaluation & management code which is over billed quiet
frequently. If you disagree with the down coding, please go through the
appeals department and supply documentation to warrant the higher level
code.
Question: How does Medicare's COB department work
when we call the IVR for eligibility?
Answer: Medicare's file coordinates with the
common working file which is updated every day by the Coordination of Benefits
department. There are instants when information comes to the common
working file after processing claims, and claims will have to be reprocessed
with the new information. Unfortunately, the specific date range of
another insurance being primary to Medicare cannot be released by Medicare to a
provider. The best course of action is to refer the patient to the
Coordination of Benefits if there is a possible discrepancy.
Question: When we bill for spinal cord stimulator trials, and two leads are implanted. We bill one lead,
but the second one is always denied as a duplicate which we bill with a 51
modifier. How should we bill this because we use the same CPT code for
the two leads?
Answer: Since you are using the same CPT code for the
two leads, it should be billed on one line item with a quantity billed of two
and state in the extra narrative the requirement for two leads.
Questions: Can claim corrects be sent to Written
Inquiries?
Answers: If the claim denies you may submit it to
Written Inquiries, but if the claim is rejected it will have to be resubmitted
as a new claim.
Question: We submitted claims into the
redetermination department and received the entire stack back.
Answer: All requests to the redetermination
department must be signed. If the request is sent without a signature
from someone in the office, it will be returned.
Question: I saw a patient who was admitted into
the hospital after having an allergic reaction to the pain patch her doctor had
prescribed for her. After she was released from the hospital, she
received a visit from a home health agency. In the mean time, she came
into my office and we saw her. We submitted the claims into Medicare and
they were denied stating the patient was enrolled in a home health. Who's
responsible for paying for this bill?
Answer: When a patient is enrolled in a home
health agency, it is the home health's responsibility to cover outpatient
physical therapy.
Question: How do we correct home health
information? We have patients who have been dismissed from home health
but are having their claims deny.
Answer: It is usually a timing issue from when
the home health agency discharges the patient and then submits the discharge to
Medicare Part A. When the information is corrected, you may contact
Medicare Part B's customer service and we will reprocess your denied claims for
you.
Question : With the NPI, I
have been unable to find a lot of information on it. Is there a website I
could go to for further information?
Answer : Please check out https://nppes.cms.hhs.gov for information
on the NPI number.
Question: When a patient first comes in for out patient
physical therapy, does the recertification have to be signed by the provider
after 30 days?
Answer : Along with the initial treatment
window changing from 60 days to 30 days, CR 3648 now allows for the patient to
no longer be physically seen by their referring provider every recertification
period.
Question:
Is it true that every time a patient is discharged from an inpatient hospital
stay, the patient is automatically enrolled into a home health?
Answer: Correct. It is part of the umbrella of a
part A stay. The physician may decide that the
home health is not needed and have the patient disenrolled
from the home health before 60 days.
10/13/2005