Webinar
9/22/05
Topic: Appeals
Questions & Answers
Question 1: Is there an updated list of the pairing of CPT codes
that require certain diagnosis codes? I
have one from a couple of years ago.
Answer 1: You
can check the local or national coverage determinations for updates. They are located on the CMS website: www.cms.hhs.gov. You could also visit the NHIC website, which
is www.medicarenhic.com, click on
either
Question 2: How
are the ALJ hearings conducted? Are they
done in person, in writing or via telephone, and do we have a choice?
Answer 2: The
ALJs determine what type of ALJ hearing to
conduct. The types of hearings are on-the-record, telephone, in-person
and (new) videoconference.
Question 3: When
multiple doctors see the patient during the same time period for concurrent
care during a hospital stay, we received a denial stating they need
to know exactly why the doctor is visiting.
Why is that?
Answer 3: When
you have multiple physicians of the same specialty, seeing the physician on the
same day, only one of them is going to be paid initially. The others would have to be appealed with enough
documentation to support as to why two physicians of the same/similar specialty
had to see the patient. And we look at
specialties of General Practice, Family Practice and Internal Medicine as being similar.
Question 4: Can
you please explain Modifier 25?
Answer 4: Modifier
25 is used to indicate that a separately identifiable evaluation &
management service was performed on the same day as a procedure.
Question 5: Would
that be used for radiation oncology?
Let’s say a patient has a consultation and a radiation treatment on the
same day.
Answer 5: Most
of the services are bundled into the radiation therapy. The Evaluation and Management (E/M) of that patient
and other services are considered to be included in the therapy.
Question 6: In the past, if we found if we billed the service date
incorrectly on a claim, we resubmitted it with a stamp stating “corrected
claim”. But it’s being ignored and the claim
is being paid twice. How would you
suggest we re-bill those corrected claims?
Answer 6: What
you should do is have the claim re-opened and have the date of service corrected
on that original claim and we can go back on that original claim and adjust it.
You can call Customer Service to have that done.
Question 7: What
are we going to
be able to do on a telephone line after
January 1, 2006?
Answer 7: You
will be able to do re-openings over the telephone and not
re-determinations.
Question 8: I’ve
been receiving denials regarding Home Health consolidated billing. Is there
anything, besides asking the patient, or anything that
we can do to prevent this?
Answer 8: You
have to make sure that you are aware of all the codes that are included in the consolidated
billing. You can go to the CMS website
and look under consolidated billing and look at all the codes that are going to
be included that way you will know in advance if your services are going to be
subject to that. You can find out also
through Customer Service if a patient is currently in a Home Health episode.
Question 9: If
we do that and the patient is stating that they are not receiving any type of
Home Health, yet we’re still getting denials for Home Health consolidated billing. Is there anything further that we can submit,
such as a discharge summary, to get that appealed?
Answer 9: Our
system would have to be updated to show that the Home Health episode is no
longer in effect, so the Home Health Agency would need to take care of that
first.
Question 10: We
do physical therapy billing and back to the Modifier 25 for the E/M, are we
able to do that modifier when we’re doing the E/M and procedures on the same
date of service?
Answer 10: The
Modifier 25 is only used for Evaluation and Management services. It doesn’t apply to therapy services.
Question 11: I’m getting denials on CPT code 82270.
Answer 11: There
are several lab national coverage determinations that are out there in the CMS
website. You may want to check out the
CMS website relating to Lab National Coverage determination.
Question 12: If
a patient comes in and has several procedures; e.g. Vitamin B-12 injection and
we had the same diagnosis for the office visit.
Is the Office visit payable with the Modifier 25 even though it has the
same diagnosis code?
Answer 12: You
would not need a modifier with an injection.
The only time you would need Modifier 25 if its significantly separately
identifiable services performed in conjunction with a procedure. And for the most part, procedures are
classified in the Surgical section of the CPT
book. Although there a few in some of
the other sections.
Question 13: When
hearing process changes in January to the new reconsideration, will those two
be available via phone or will it be only in writing?
Answer 13: Only
on the record. No telephone, no
in-person.
Question 14: Is
there a way to stop a claim that you submitted?
There are times we know we made an error in submitting a claim and we
would like to stop it before it actually results in payments.
Answer 14: There
is no way to stop a claim once it comes into our system.
Question 15: Are incorrect dates of service or incorrect provider
number considered clerical errors?
Answer 15: An
incorrect provider number is handled as a reopening. Incorrect dates of service
are handled as reopenings if the claim has paid and payment is not going to
change. If the claim was denied due to
date of service, and by changing the date of service it becomes an allowed
service, it must be appealed.
Question 16: We
have multiple group provider numbers.
Can you aggregate claims with different group numbers to get to the $100
minimum for a hearing?
Answer 16: No,
the $100 aggregate must be under the same group provider number.
Question 17: My client’s claim was billed to Medi-Cal
and paid. Later, we found out that the
client has Medicare. Should we pay Medi-Cal back in full and rebill?
Answer 17: Yes.
Question 18: I’m receiving a PR-22 denial. The patient has a PPO as primary. How do I appeal to Medicare for payment?
Answer 18: Confirm your patient’s insurance status to determine
which insurance plan is primary. The
patient’s records may need to be updated by contact the Coordination of
Benefits (COB) Contractor. MSP claims do
not have appeal rights.
11/10/05