Ask the Contractor Teleconference

July 22, 2005

Topic: Small Providers

Questions & Answers

QUESTION:   Would you explain LMRP , what is it?  How do I access LMRP? When I asked questions to my specialty meetings, I'm told to always check with my local LMRP , how do I do that?

ANSWER: LMRP stands for Local Medical Review Policy.  LMRPs are currently being replaced by Local Coverage Determinations, or LCDs.  LCDs are established by the Carrier when no national policy exists.  These local policies are usually developed to identify when an item/service is covered and under what clinical circumstances it is covered.  Local policies can also be developed as a program integrity tool to help curb abuse of the Medicare program.  For example, an LCD may be developed if our reports indicate a sharp increase in the use of a certain CPT code.  You can find a list of these policies on our website: www.medicarenhic.com and clicking on LCD/ LMRPs .

QUESTION: In talking to many Podiatry offices, it seems we keep being denied for exceeding the frequency limitation.  We see a patient, count 1 the following day, and see the patient on day 60.  Why are we receiving these denials?

ANSWER: This question is a little difficult to answer without the patient's information in front of me.  The best th ing to do is call customer service and have them tell you the last date of service Medicare paid for routine foot care for that patient.  The clock will start ticking from that service date, and the patient is eligible for routine foot care every 60 calendar days.

QUESTION: How do you bill for 93000 for rural billing?

ANSWER: Only the technical component of EKGs performed in the RHC (POS 72) can be billed to NHIC.  The professional component is a RHC service if performed by a RHC physician or non physician practitioner.  Global tests which include the technical and professional component will deny.  93000 is a global code; therefore, it will always deny when billed to NHIC with POS 72.  NHIC-will only make payment only when the technical (tracing only) code (93005) is billed.  Billing information can be found in the Internet only manual on the CMS website. Specifically, refer to Publication 100-2, Chapter 13, Section 30.  If the term “rural” is referring to Health Professional Shortage Area or HPSA, you must bill the technical and professional components separately, because only the professional component is eligible for the bonus payment.  For more information, refer to Medlearn Matters Article SE0449  on the www.cms.hhs.gov/medlearn/matters .

QUESTION: I'm an Internist licensed in CA and am starting a new practice in Fullerton, CA.  I am anxious to start seeing patients in my office.  Until now, I was employed by Kaiser Permanente and had been providing care to Medicare and Medicaid members.  I have a UPIN and Medi-Cal provider numbers.  I have registered and obtained an NPI number as well.  I have filled out and sent Medicare CMS 855 I and new Medi-Cal application.  What are your suggestions for me?

ANSWER: My suggestions to you are: 1) Go ahead and start seeing Medicare patients.  Medicare cannot issue you a provider number until your doors are open and you are seeing patients.  We will back date your effective date to the date your first Medicare patient was seen. 2) Download the Medicare billing made easy guide online to familiarize yourself with the claim form and general billing information.

QUESTION: I have been getting conflicting answers and handling of patients with an HMO which is primary to Medicare.  In both cases, the spouse of the disabled patient enrolled the family in an HMO to which I do not belong.  The patient understood that the HMO would deny my claim, which would then be sent to Medicare, which would pay their amount on the mental health claim.  This all went well for several years until late last year when Medicare began to deny a patient's claims stating that if she went outside her primary insurance's HMO, Medicare would no longer pay for any of her mental health care at all.  I could not find this statement in the Medicare policies and called again, this time about the other patient, whose claims continued to be paid by Medicare.  Despite both patients having filled all the appropriate paperwork and Medicare having all the primary information, a patient's claims are denied.  Can you clarify this?  If it is true that patients who sign up for an HMO as the primary insurance, will also have their Medicare claims denied if they go outside the plan, has this been communicated clearly to patients in the Medicare & You booklets or other information?

ANSWER: Federal Regulations stated that a beneficiary that is enrolled in group health plan (HMO) that is primary to Medicare must use the provider who is a member of the HMO.  Many beneficiaries believe they can go outside their HMO plan and Medicare will pay as the primary payer.  This is incorrect.  However, Federal Policy allows Medicare to make primary payment on a claim if we believe the beneficiary did not understand the HMO policy.  When we receive a claim denied by the HMO as non authorized, Medicare will make primary payment on this claim and send a warning to the beneficiary on their MSN.  They are warned they must use providers who are member of their HMO and Medicare will no longer make primary payment on claims after the warning date.  This information is published in the CMS online Manual, Publication 100-5, Section 40.1.2 and 40.1.2.1.

QUESTION: I have a provider that has dual responsibility.  She is a primary care physician and a Nephrologist who receives a lot of consults.  Where can I locate the billing requirements and limitations on coverage for consultations?  Is there a limit on how to process the billing (CPT Codes 99241 – 99245) monthly?

ANSWER: There is no monthly limit; however, if two consults are billed on the same day, one will pay and one will duplicate.  For billing requirements, please consult the CMS Internet only manual, Publication 100-2, Chapter 15, Section 30.1.  Also, because you indicated you are a California provider, we have a billing article on our website regarding consultations which applies to you.  Just type “consultations” in the search box and you will be able to view the article. 

QUESTION: We have a Medicare Provider Number, but we are being paid at the Non-participant physician's rate.  Do I have to wait until November to file at a Participating Provider or can I fix that now?

ANSWER: You have to wait until November to enroll as a Participating Provider.

QUESTION: I have our EOB in front of me that comes out to us every Monday. On the EOB, all my Medicare patients that we bill on for July 13, 2005, all of their procedure codes were both of them were denied.  They were denied because they were invalid procedure codes.  One of those would be 97110 –which is 15 minutes of therapeutic exercise which we billed for ages.  Do you know if that's an invalid code?

ANSWER:  I would call Customer Service and have them look at your specific claim to see what the problem is because that code is a valid code.  We haven't had any changes with the code itself.

QUESTION: I have our EOB in front of me that comes out to us every Monday. On the EOB, all my Medicare patients that we bill on for July 13, 2005, all of their procedure codes were both of them were denied.  They were denied because they were invalid procedure codes.  One of those would be 97110 –which is 15 minutes of therapeutic exercise which we billed for ages.  Do you know if that's an invalid code?

ANSWER:  I would call Customer Service and have them look at your specific claim to see what the problem is because that code is a valid code.  We haven't had any changes with the code itself.

Caller: Because the code (when it gives you why it was/wasn't paid is CO B18) which is payment denied because this procedure code modifier was invalid on the date of service or claim submission.   

Answer: Did you bill with a Modifier?

Caller: No.

Answer: Physical Therapy codes require a Modifier to identify a plan of treatment.  Check our website for an article on Physical Therapy or Physical Medicine for the appropriate Modifiers to use.  

QUESTION:  Our office is a chiropractic office which unfortunately closed December 31 st 2004.  Previously to that, we started our electronic billing in September, 2003 and ran into problem after problem after problem with it.  I want to know, especially now that they're closed, if I can re-bill any of the claims or if there's even a cut-off date going back where I can re-bill on the paper HCFA 1500 form to get any kind of reimbursement. 

ANSWER:  You do have the option of billing as far back as 10/01/03 dates of service until December 31, 2005.  However, any claims billed after a year from the date of service will get a 10% reduction. 

QUESTION: Calling to request that you would repeat the web address in obtaining an NPI.

ANSWER: https://NPPES.cms.hhs.gov

QUESTION: Question on the Automated Voice Response System to check claim status.  Before you installed the new claim status check, we used to be able to just “key-in” our responses.  Is that function still available to us now in the new system cause we have a problem with some of the accents we have in our office, in that it doesn't recognize our voices.?

ANSWER: The ability to key-in the information is there.  There still are some problems with it which we are working through; but for the most part, it does work for everything you would need. 

QUESTION: Question in regards to intermediate repairs (repair code 12032 and 12034).  12032 is the smaller code but it's reimbursed at higher rate than 12034.  Is that intentional or is that a mistake?

ANSWER: You have to go back to the Relative Value Unit that has been assigned to each of those codes along with all the other factors that go into calculating the allowable charge.  The fees are set by CMS and not the Carriers. 

Caller: 12032 was up to 7.5 centimeters and 12034 is 7.6 to 12.  It's quite a bit larger but it's reimbursable at a lesser amount. 

Answer: You can check the RVU for each of these codes along with the other factors that are used in calculating the allowances.  And if you have concerns about it, you can work through your association or you can write directly to CMS.  They do have a review panel that meets on a regular basis for the annual updates.

Caller: How do we contact them?

Answer: You can go out to the CMS website for addresses to send inquiries.

QUESTION:   We have an Osteopath clinic and we do Physical Therapy.  I'm calling to see if Osteopathic aids can do the therapy or even if a massage therapist can do it, incident to the Osteopath.

ANSWER: Whoever actually performs the therapy needs to have the skills and qualifications (other than licensing) of a physical therapist in order to bill incident to an osteopath.

QUESTION: Question regarding a patient who had Medicare, then changed their Medicare into an HMO plan and they want to be treated in our office; but, because we don't take HMOs.  Can the patient turn around and change their plan back to Medicare?

ANSWER: They would have to go through Social Security to change their actual plan.  (I don't know if they have a specific enrollment period which they can do that or not).  They would have to call Social Security and inquire if they can do that. 

QUESTION:   Also can I answer a question that somebody had regarding physical therapy with therapeutic exercises -  the code 97110? The Modifier that we use is 59 and we get paid on those. 

ANSWER (by Michele): We'd like to respond a little bit on the inquiry regarding the 97110.   59 is a Modifier that is used to say that “this is separately identifiable service from the item that is being bundled with."  I don't think your denials are because of bundling.  I believe your denials are because you're not using physical therapy plan of treatment modifier.  So you need to look for the plan of treatment modifier  and you also need to be very careful in using Modifier 59 that your medical records do reflect that they are significant separately identifiable services or that they may meet other requirements of different time of day or different body area. 

QUESTION: How can we find out what ICD-9 diagnoses code used with what CPT code that would go along with that certain diagnosis.  Is there a way we can research it on internet or site?

ANSWER: You can look it up on our website which will then redirect you to CMS website to see if there's a policy on the codes which you are billing for.  Our policies do have procedure codes and diagnoses information.

QUESTION: Question on NPI.  We're a very small office.  We do not do electronic billing.  Is that an identifier for electronic billers or this can be for everyone?

ANSWER: The Medicare numbers are being replaced by the NPI.  So the Medicare billing number that you currently use will need to be replaced.

Caller: You mean the UPIN number?

Answer: The UPIN number and your Provider I.D. number will be replaced by NPI in  2007. 

Caller: So whether we do electronic or just a regular paper, we have to have this change?

Answer: Yes

QUESTION: We have a small chiropractic office, and this is in reference to the 97110 code, as a chiropractic office, we have tried billing this code with the modifier and we keep being denied on it. 

ANSWER: Chiropractors can only bill for manipulations.  That code will not be covered for Chiropractors. 

QUESTION: Question on the CMS-1500 form.  Is it in effect now on the diagnosis line you only put one diagnosis, now you can't put three or four like before for each procedure code?

ANSWER: That's correct. Our system will only pick up the first number that you've pointed to in item 24E. So if you're putting 1, 2, 3, 4, we're only picking up the first one; however, if there's a policy on that procedure that you're billing which requires more than one diagnosis, we have access to go back and look at the additional diagnosis codes. However, we're looking for only one number in 24E, which is the primary diagnosis for that line. 

Caller: Just recently, we would do 45 minute therapy sessions on a patient and bill it as a three unit and now you're saying it's been paid, and others are saying it's too much service or seems excessive, and again we're doing that service, and I'm wondering (if possibly) you're looking at that one diagnosis and not the other three or the other two or whatever?

Answer: No, if we need to look at the additional diagnosis code on the claim, we do have the ability to do that. 

Caller: What about electronic?

Answer: The same rules apply.  We're going to look at the first diagnosis code that you referenced. 

Caller: Would you still have the ability to look at the other codes electronically?

Answer: Yes.

Caller: And where is 24E on the claim form?

Answer:   Item 24 E is right next to where you put your procedure code (to the right of it)

QUESTION: Question regarding using Medicare as their Secondary Insurance.  What's the percentage of coverage that Medicare is liable for in that case.  I know Medicare as primary they pay 80%, what if they're secondary?

ANSWER:  Medicare calculates the full allowable charge under Medicare and then determines what would pay as primary and generally pays the difference.  It just depends on how much it paid from the primary.

NOTE: We received some additional comments from chiropractors expressing dissatisfaction with coverage and reimbursement rates.  We do understand your frustrations; however, NHIC does not have authority over whether or not Medicare will pay for a service, or how much we will reimburse. If you are affiliated with an association, they can assist with lobbying for change. You could also notify your congressman of your concerns. 

9/29/2005