Webinar
January 18, 2007
Topic:
2007 Medicare Updates
Questions & Answers
Question 1: Where can we find procedure codes
for Respiratory Therapists for BLS ambulance?
Answer 1 Please review your coding books and the Ambulance Billing Guide found on our website www.medicarenhic.com
Question 2: Are there new cardiac codes?
Answer
2:
Please check your CPT coding books for any coding changes.
Question
3:
When will there be a Webinar on how to complete the new 1500 claim form
with NPI?
Answer
3: There was a presentation done in October 2006 regarding this
topic. We hope to post an E-Learning on
this topic as well as conduct another webinar on the changes to the 1500
form. If you are not already on our
mailing list, please join so you can receive a notification as to when this
will be conducted.
Question
4: What are the revised fees for 2007?
Answer 4: The fee schedule can be found on our website; www.medicarenhic.com
Question 5: Can we use the NPI now?
Answer 5: Yes, you may enter the NPI number along with
your legacy number on an electronic claim at this time.
Question 6: How do we inform you of our NPI number for our
established providers?
Answer 6: You may bill us with your NPI number and your
legacy number.
Question 7: What is the start date of NPI usage?
Answer 7: You may begin using your NPI number now in
addition to your legacy number. You must be using NPI effective May 23, 2007.
Question 8: Do we have to have our NPI number to you prior to
billing so it matches your records?
Answer 8: If you have an NPI number currently, you may submit it
with your legacy number and we will cross reference.
Question 9: Is there going to be a cross reference site to check
the new NPI number against the old UPIN?
Answer 9: At this
time CMS is working on the Data Dissemination (UPIN registry, crosswalk etc)
process. Once finalized, this information will be published in the Federal
Registry. Continue to visit the
following link for updates http://www.cms.hhs.gov/NationalProvIdentStand/06_implementation.asp#TopOfPage
Question 10: Do we need to submit any forms with our NPI?
Answer 10: No, not unless you are submitting an
enrollment application, then you must submit the NPI notification letter.
Question 11: May physical therapists participate in the
PVRP?
Answer 11: The physician voluntary reporting is for
physician based services.
Question 12: Are there CEUs available for this webinar?
Answer 12: CEUs are not available.
Question 13:
Where do we put the NPI?
Answer 13: In items 17b, 24j, 32a, 33a of the newly revised
1500 claim form
Question 14:
When submitting the PIN and NPI should I put a slash in between? Example
xxxxx/xxxxxx?
Answer 14:
No, you should not use a slash if you are using NPI.
Question 15:
Can behavioral health providers participate in PVRP? In example psychiatrists
are MDs.
Answer 15: The PVRP is reserved for physician based
services. More information on the PVRP can be found at www.cms.hhs.gov/PQRI
Question 16: If we are currently participating, do we have to
resubmit a participating form by 2/14/2007?
Answer 16:
No, you do not need to complete a new participation agreement.
Question 17: Is it necessary to have all referring providers’ NPI
numbers on the claims?
Answer 17:
Yes, if the service requires it on or after May 23, 2007. You will need to
obtain all referring provider NPI numbers.
Question 18: Can you tell me about the bonus payment with label B
and R? I would like more information on how/what we need to do to get the bonus
payment for rural.
Answer 18:
If this is concerning ambulance claims the bonus payments are made
automatically by our system based upon the zip code you enter on your claim for
the point of pickup.
Question 19:
Is there extra reimbursement for PVRP?
Answer 19: Eligible professionals who participate in the 2007 PQRI program
and successfully report quality measure data on claims for services between
July 1 and December 31, 2007, will be eligible for a single consolidated
incentive payment in mid 2008. The bonus payment, subject to a cap, is the
equivalent of 1.5% of total allowed charges for covered physician fee schedule
services provided from July 1 through December 31, 2007. For additional
information: www.cms.hhs.gov/PQRI
.Question 20: Is there an upcoming
seminar on the DME MAC updates?
Answer 20:
Please refer to the DME MAC section of our website for any seminars that may be
available pertaining to DME.
Question 21:
How can a provider check the status of their NPI number after enrolling online?
Answer 21:
Fox Systems is the enumerator assigning NPIs to health care providers. Please
contact Fox Systems at 1-800-465-3203.
Question 22:
Does the cap not applicable outpatient hospital mean that if therapy is
performed in an OP setting at a hospital there is no deductible?
Answer 22:
No, the deductible is applicable. The therapy done in an OP setting is not
subject to the cap benefit of $1,780.00.
Question 23: Will we be required to obtain the NPI for
referring doctors for PT/OT/DME? Will these numbers be posted for us to obtain
or will we have to obtain by calling the referring doctor?
Answer 23: At this time there is no way to obtain a
referring providers’ NPI unless you contact them.
Question 24: When a patient reaches a cap and still
has a diagnosis code that may be covered we bill with the KX modifier?
Answer 24: Yes, that is correct. You bill with the
KX modifier when the cap has been reached. NHIC, Corp. will ask for any
additional documentation that may be needed to support use of the KX modifier.
Question 25: When are the new 1500 forms available and
required?
Answer 25:
The new 1500 form is available as of 1/1/2007 and required by everyone
to use when NPI is fully implemented.
Question 26: In
Answer 26: One is not scheduled at this time. You may log onto our website www.medicarenhic.com, choose Part B New
England then seminars then Interested in Sponsoring a Seminar? And you will
find an email address to submit your request.
Question 27: We were told we could not fax into NHIC
from
Answer 27: Yes, NCA can now fax in information.
Please review the EDI documentation
requirements at
www.medicarenhic.com/edi/download/caedidocumentation_1206.pdf
Question 28:
When is the UPIN for a physical therapist required? We were informed the
UPIN for a PT in private practice is not available to be disclosed. Does that
mean that we do not need UPIN for physical therapists?
Answer 28: UPINs are required for ordered or
referred services. A PT claim would require a UPIN of the physician that
referred or ordered the PT. The PT is not issued a UPIN and would not have any
reason to need one to be entered on the claim.
Question 29:
Where can I find special rules on Rheumatology practices?
Answer 29: Please consult the Internet Only Manual
found on the CMS website.
Question 30: For PT, do we still have to put the date
last seen?
Answer 30: The date last seen is has not been
required since June 6, 2005. Information for PT services/billing can be found
in the Physical and Occupational Therapy Billing Guide on our website at www.medicarenhic.com
Question 31: Are therapy caps applicable in the
hospital OP setting?
Answer 31: The therapy caps for 2007 have not
changed pertaining to OP hospital, therapy provided in a outpatient hospital
setting is not applied to the cap.
Question 32:
Are there any new or revised codes for Podiatry for 2007?
Answer 32: Please review your CPT coding book.
Question 33: Is
there a specific code to bill for a respiratory therapist or a nurse onboard an
ambulance, or is it not covered?
Answer 33:
No, there is no specific code. It is included in the base rate. See SCT
transports in the billing guide for ambulance.
Question 34: On
fecal occult tests, they are not billable until the patient brings the cards
back, right?
Answer 34:
Yes, that is correct.
Question 35: What diagnosis should be used for
screening guiac?
Answer 35: Please refer to the ICD-9 coding manual.
Question 36: Does the referring MD’s UPIN still need
to be in
Answer 36:
The referring physicians’ UPIN is entered in Item 17a and his name in
Item 17.
Question 37: Is there a modifier that we can use for a
clinician that has applied for, but not yet received their Medicare number?
Answer 37:
No, there is not. Claims can be billed when the number is received.
Question 38: Will we ever be able to access claim
status and eligibility online?
Answer 38: At this time there is no online
capabilities, please continue to use the IVR.
Question 39: Where do we get a list of procedure codes
subject to frequency of billing?
Answer 39: You may reference the LCDs and NCDs found
on our website.
Question 40:
What is the time limit for appeals?
Answer 40: 120
days from the date of the remittance advice
Question 41: If
an MD does a guiac in conjunction with a rectal exam is the 82272 covered?
Answer
41:
Yes, it should be covered. A
guiac is in additional to a rectal exam.
.Question
42: On an RA, what does the cc stand for?
Answer 42: It means that there has been a code change on
the claim.
Question 43:
How do we submit appeals?
Answer 43:
You would need to mail the appeal to the appropriate address for your state.
This information can be found in any of our Billing Guides and on our website
www.medicarenhic.com.
Question 44: What loop and segment are we supposed to use
for the legacy number and NPI on the 837 format?
Answer 44: Please contact the EDI department for your
state and/or your software vendor.
Question 45: Does the NPI have to be listed on each line
that is billed?
Answer 45: Yes, If you are completing 24j with the NPI
of the performing provider of service and the provider is a member of a group
practice.
Question 46:
What happens when a patient comes in for a colonoscopy screening, which would
not have a deductible, but the service turns into a polyp removal-is there
patient responsibility?
Answer 46:
If during a screening test a problem is discovered then it would be billed as a
diagnostic procedure and deductible and coinsurance would apply.
Question 47:
Where can we find a list of denial legends and explanations at the end of EOBs?
Answer 47:
On the Washington Publishing website - www.wpc-edi.com
Question 48: What
goes in
Answer 48: The Medicare legacy number prior to May 23,
2007. Leave them blank after this date.
Question 49:
Are the new anticoagulation management codes 99363-99364 reimbursable by Medicare?
Answer 49: Please review the Medicare Fee Schedule on our website..
Question 50: To
what procedures is the Medicare deductible applied?
Answer 50: The
deductible is applied to all services until it is met, unless the service is a
preventive service and is then exempt. The Preventive Services Guide can be
found at www.medicarenhic.com under
publications.
Question 51:
Once we submit a Redetermination will we be getting a written response or will
it come on an RA?
Answer 51: You will receive either a RA with payment or
a letter explaining the reason for denial.
Question 52:
On the slide Avoid Denials, it states not to resubmit lines already processed,
but sometimes this has to occur because when you bill particular types of
procedures they require that you have a CPT with a corresponding CPT (i/e Q
code application of cast and the MD professional application of the cast) what
should we do in those instances?
Answer 52: You will need to file a Redetermination.
Question 53:
My hardcopy 1500 claim form
Answer 53: No, it will not.
Question 54:
How long will we be using the HCFA 1500?
Answer 54:
The CMS 1500 (08-05) claim form has been updated to accommodate NPI. You may
begin using the new form, which will be required with the full implementation
of NPI.
Question 55:
A county is the legal entity, but the Health Department has numerous subparts. I
can’t find a taxonomy code that fits the county as a legal entity. Can you
advise?
Answer 55: Contact the NPI enumerator Fox Systems for instruction.
Question 56: Will electronic HCFA forms data specs
change?
Answer 56: Yes, the electronic version of the CMS
1500 requirements have changed. Please consult the EDI section of our website
for EDI information and work with your vendor/clearinghouse.
Question 57:
For G0107, is the effective date 1/1/7-for the date of service or date
of claim submission?
Answer 57: This is effective for date of service
1/1/7.
Question 58: I need a fee schedule for anesthesia
codes by line that I can hand access, but won’t have to retrieve.
Answer 58:
Please contact Customer Service.
Question 59: I just learned there is a Redetermination
form we have to use to appeal claims. Can I still use that to appeal claims
over 120 days?
Answer 59: You can use the form; however your appeal
rights will be dismissed if it is over 120 days from the date the claim was
processed.
Question 60: When is the next Webinar on how to
complete the 1500 claim form?
Answer 60: It is expected to take place in April
2007, please continue to check the website for updates.
Question 61: With the new cap rental issues, do we need
to send a letter to the patient and inform them it is now a rental converted to
purchase? Are they getting a letter from NHIC? Do we need to give them
anything-else?
Answer 61:
This is not a DME Webinar; please contact the DME customer service
department for assistance.
Question 62: For PT services; Are we still required to
enter any info in
Answer 62:. Information for PT services/billing can
be found in the Physical and Occupational Therapy Billing Guide found on our
website www.medicarenhic.com
Question 63:
Was area 18 fee schedule for professional services revised?
Answer 63:
Yes, the fee schedules were revised for 2007.
Question 64: When do we use the KX modifier? Only when
we know the patient has exceeded the cap? Do we have to wait for a denial?
Answer 64:
The KX modifier is applied to medically necessary services provided
after a beneficiary has met the cap. You do not need to wait for a claim to
deny.
Question 65: A
private practice in
Answer 65: The owner as an individual and the group
will need NPI numbers.
Question 66: Regarding the new 1500 form, is the date
a definitive calendar date for implementation or rollout or if I am rebilling
an old date of service from 2006 can I still utilize the old form?
Answer 66: On April 2, 2007 the new 1500 form is
mandatory on all claim submissions. To correct a claim that was previously
submitted you need to do a telephone review or Redetermination request. A
rebill of a claim may constitute a duplicate claim into our system and another
denial.
Question 67: Are SNF patients for MRI billing still billed
to the facility to submit to Part A?
Answer 67: SNF requirements have not changed.
Question 68: I have looked over the Medicare Fee
Schedule for 90732 and could not find it. Is it covered by Medicare?
Answer 68: It
is listed on the fee schedule after Influenza Administration Fees, Revised. The
next subheading is Allowance Limits for Part B Drugs. 90732 is reimbursable.
Question 69: An established patient is seen IP and an
EKG performed Are both the hospital visit and the EKG interpretation and report
billable?
Answer 69:
Yes, the EKG is not included in a regular hospital visit. If that physician interprets the EKG and
prepares the report, they may bill.
Question 70: On the new 1500 form do we still have to
fill out 17a after May?
Answer 70: No, you do not have to complete that field
after May.
Question 71: Will taxonomy codes be required in the
future along with the use of NPI?
Answer 71: Not on the claim form that we are aware
of at this time.
Question 72: Is there something in the Federal Register
that says providers are required to furnish us with their NPI number?
Answer 72: Yes CFR Part 162 Under Provision §
162.410 ( Implementation specifications): require each covered health care
provider to disclose its NPI, when requested, to any entity that needs the NPI
to identify that health care provider in a standard transaction.
Question 73: Can a MD that specializes in pain and
rehab bill for physical therapy?
Answer 73: An MD may bill for physical therapy.
Question 74: ER
department has a convenient care area open from 11:00am to 11:00pm for low
acuity level patients to be seen, may they still use the ED codes for the
providers? If a provider’s office also has urgent care center within the
building what is the policy on submitting POS for UCC versus POS office?
Answer 74: If the office provides urgent care it is
POS 11. An emergency department is defined as an organized hospital based
facility for the provision of unscheduled episodic services to patients who
present for immediate medical attention. The facility must be available
24 hours a day. Facilities open less than 24 hours a day should not use
the emergency department codes.
Question 75:
What modifier should be used for a physician to report 2 injections of
20552?
Answer 75: Multiple injections are reported based on
the number of units in the units’ field.
Question 76:
Where do we find re-evaluation PT codes?
Answer 76: Please review the 2007 CPT manual or the
Physical Therapy Billing Guide found on our website.
Question 77: I
get denials for duplicates when I do a corrected rebill. I was told to send the
entire claim too.
Answer 77: Please do not rebill an entire claim. If
one line remains unpaid, please utilize
the reopening or Redetermination process when appropriate.
Question 78: Does Medicare cover group nutrition
therapy (Registered Dietician services)?
Answer 78:
When provided by a certified MNT with a referral for services.
Question 79:
Can a MD who contracted (on salary) with a Chiropractor do physical
therapy and bill under the MD?
Answer 79: Physical therapy is not a covered service
when performed by a chiropractor, therefore incident to would not be allowed.
Question 80: We billed 90806 and 90853- same day
service with same provider…we received denial stating cannot bill same day/same
provider…but according to guidelines it states that 1 therapy service and 1
group can be billed if appropriate…why were we denied instead of documentation
asked for that corresponds to the service?
Answer 80: This may have occurred because part of
the service was billed incorrectly and that portion was rejected. We normally
split it off from the portion of the claim that has paid so it can be processed
on its own. You will want to contact customer service to conduct a telephone
review as we cannot access claim information during this Webinar.
Question 81: I cannot seem to find the fee for the new
codes for initiation of anticoagulation treatment and continuing
anticoagulation treatment. Have the fees been set?
Answer 81: The fee schedule is posted on the website
www.medicarenhic.com
Question 82: What happens when a SNF refuses to pay a
bill because they could have provided the service, can we bill the patient?
Answer 82: No, the services provided in the SNF
while under the SNFs care may not be billed to the patient. You can refer to
the Consolidated Billing information on the CMS website. Unfortunately Medicare
cannot mediate on this matter.
Question 83: Where can I find the Redetermination
form?
Answer 83: CMS 20027 is found on the CMS website www.cms.hhs.gov/ forms page.
Question 84: Is it new in 2007 that we have to send
the Redetermination form; does it apply to PT services?
Answer 84: The process is not new for 2007 and
applies to all services.
Question 85: So, we cannot just resubmit our claims?
Is this new?
Answer 85: A
resubmission of a claim constitutes a duplicate claim submission. If a change to the claim needs to be made and
you do not agree with the original decision you will need to appeal the claim
through the appeals process.
Question 86: When I appeal a claim and get a response
in 120 days, do you mean the date of the letter or the date you received it?
Answer 86: For the 1st level of appeal
the 120 days starts with the date of the remittance advice. For the 2nd
level of appeal the 6 months starts with the date of the Redetermination denial
letter.
Question 87: If we use two different billing software
products, can we use the same submitter number?
Answer 87: Please contact the EDI department for
your state to clarify what the products are you are using and if this is
possible.
Question 88: Do we need to put the date of MD
signature on the prescription or recertification?
Answer 88: Yes
Question 89: If I send in a secondary payer claim for a
co-pay and get back an EOB stating a deductible is owed, am I to assume that
Medicare thinks they are primary?
Answer 89: No, do not assume that. In cases like
this the beneficiary must meet the Medicare B deductible even when Medicare is
secondary.
Question 90: I own a private practice for physical
therapy and employ 3 physical therapists. Do I need to get an NPI for each
individual or the group?
Answer 90: Each practitioner and the group will need
an NPI number.
Question 91: We have claims that were sent for
Redetermination back I October 2006 that we are still being told are pending.
It is my understanding that we should have received a response within 60 days.
Answer 91: Yes, please call Customer Service for
assistance.
Question 92: For AAA do we need to put a referral with the claim or does it
just need to be noted in the IPPE on the patient’s chart?
Answer 92: Please do not send additional
documentation with your claims. If information is needed we will contact you to
request it.
Question 93: If I get an electronic denial for K24 no
number can I do a telephone reopening of an entire EOB?
Answer 93: If your entire claim file is “rejected”
and unprocessable you may correct and resubmit the file electronically.
Question 94: We are an ambulance company, what is the
rule in obtaining NPI? Is it required in the field for referring MDs? This will
be difficult. We are a 911 provider what are the NPI rules?
Answer 94: NPI replaces ALL current provider numbers
for all payers. Therefore the NPI will be reported in all appropriate fields
that require the current provider number. The NPI of a referring doctor is not
required on an ambulance claim.
Question 95: If a doctor does a test that is for the
TC and 26 modifier components, can we bill globally with no modifiers?
Answer 95: If you are performing both components of
a test in an office setting you can bill without a modifier.
Question 96: Currently we are still using date last
seen on PT claims and were told in a seminar to use it. We were just told this
is not correct, please clarify.
Answer 96: As of June 6, 2005 it is no longer
required unless the MD requires the patient return to their office or specifies
a frequency of visits back to their office.
Question 97:
Where can you find codes for mental health parity and nonparity codes?
Answer 97: Please review the Mental Health Billing
Guide and the CPT code book.
Question 98: Where do we find the fee paid under the
OPPS for a specific diagnostic imaging service?
Answer 98:
The fee schedule is posted under CAP
Payment Amount of Imaging Services on our website www.medicarenhic.com
Question 99: Is the physical therapy re-evaluation
code (97002) a timed code?
Answer 99: There is no time associated with the code
according to CPT.
Question 100: Do you have any preventive programs in
place for behavioral health/psychiatry that we can participate in (i/e suicide
prevention, prevent inpatient frequency, etc.)
Answer 100: Not at this time.
Question 101: What is the limit a patient can be seen
per day/week for mental health services? We find that at times a patient
requires more than 1 hour and really needs to be seen 1.5 hours or 2 hours for
a session.
Answer 101: Please review the Mental Health Services
Guide found on our website www.medicarenhic.com
and any LCDs or NCDs for your state.
Question 102:
The code 97002 is for re-evaluation however this code does not reimburse
when provided with treatment, is there anyway to get the 97002 paid?
Answer 102: Reassessments are considered a routine
aspect of intervention and are not billed separately from the charge for the
intervention. Please review the Physical and Occupational Billing Guide at
www.medicarenhic.com
Question 103: When the patient returns to the OR for a related procedure during
post-op period, how does Medicare base its reimbursement since the allowed
amount is lowered?
Answer 103: According to the inter-op percentage. You
can find it in the Medicare Fee Schedule Database.
Question 104: Who can I contact to initiate preventive
programs in the future for mental health?
Answer 104: Your local congressman or woman.
Question 105: My understanding is I can use modifier 59
for separate services. I have been told I need an individual modifier for each
and every service by an appeal person. Is this accurate?
Answer 105: The component code needs the 59 modifier.
Please refer to the following link - http://www.cms.hhs.gov/NationalCorrectCodiNitEd/01_overview.asp for
a complete overview of modifier -59 usage and the National Correct Coding
Initiative.
Question 106: In the HCPCS code book a modifier was
added for Medicare secondary payer, is this to be submitted on all secondary
claims?
Answer 106: It is not used by Medicare.
Question 107: Where is it noted that NPI is not
required on ambulance claims-Federal register?
Answer 107: It is not a claim requirement listed in
the Internet Only Manual published by CMS.
Question 108: My understanding about the PT cap is that
the $1780 is based on the Medicare allowed amount. Does this include the
patient’s deductible or do we start tracking the allowed amounts after the
patient’s deductible is met?
Answer 108: The $1780 includes the patient’s
deductible.
Question 109: What is the coverage for Zostavax vaccine?
Answer 109: This is not a Medicare covered vaccine.
Question 110: Is the Medicare Appeal form mandatory
before you appeal or will they accept handwritten or typed appeals?
Answer 110: No, the Appeals form is not mandatory but
it is best to use the form, to ensure all of the required information is included
with your request.
Question 111: Is there anywhere on CMS Manuals that
tells about lab codes and how many times we can bill? For example: 86332 we
bill three times with modifier 91. We do different tests, and I can’t find the
quantity.
Answer 111:
No, you
may also refer to the NCDs and LCDs for any frequency parameters. Otherwise,
this modifier may only be used for laboratory test(s) performed more than once on
same day on the same patient. This modifier may not be used when tests are
rerun to confirm initial results, due to testing problems with specimens or
equipment; or for any other reason when a normal, one-time, reportable result
is all that is required
Question 112: What
is the CMS website for final rule on NPI?
Answer 112: https://nppes.cms.hhs.gov
Question 113:
When we are asked for our NPI number by another doctor’s office, do we give out
individual doctor’s NPIs or the groups?
Answer 113:
The NPI for the individual should be supplied as the group number is a billing
entity and not an individual service provider.
Question 114:
Will appeals be dismissed if I already sent them without the form?
Answer 114:
Handwritten appeals are not dismissed.
Question 115: We
put the modifier KX on claims for exceptions and they deny as over cap. Are
there issues with the automatic exception?
Answer 115:
The exception for PT is still subject to any LCDs, if the condition does not
meet the LCD the service will be denied.
Question 116:
If we do 2 different injections with different CPTs, why do we get paid for
only one injection?
Answer 116:
Please review the correct coding guidelines. If you do not agree with the
determination that has been made on a claim the claim may have appeal rights.
You may discuss this with customer service.
Question 117:
Patient followed up with psychiatrist after hospitalization and while in a
rehab/nursing home claim was denied due to skilled nursing care clause. What if
the service was not offered in the rehab/nursing home as it was in this case?
Can we rebill in spite of Medicare making us refund the amount paid?
Answer 117:
Services provided to a patient in skilled nursing are normally considered
bundled in the consolidated payment made to the nursing home. Please contact customer service with the
particular claim so that research on the denial can be done.
Question 118:
If Medicare denies payment even though we have billed with KX modifier can the
patient be billed?
Answer 118:
If you suspected the claim would deny you could have had an ABN signed prior to
rendering the service and bill with the GA modifier.
Question 119:
For PT do we have to give a date of certification and recertification on a plan
of care?
Answer 119:
Yes, please refer to the Physical and Occupational Therapy Billing Guide found
on our website.
Question 120:
Is there any provision for processing paper claims when there is an electronic
failure?
Answer 120:
If there is an electronic failure you may want to wait a day or two and try
resubmitting as paper claims take 29 days to process. If you are unable to bill
electronically for an extended period of time you may contact EDI stating the
reason you need to submit your claims on paper.
Question 121:
When the Medicare deductible is taken from our payment are we able to get the
money from Medi-Medi patients?
Answer 121:
The claim crosses over to Medi-Cal and the deductible is paid by the program.
Question 122:
Is there a way to submit a claim for a clinician that is not billable to Medicare
due to their licensure level and receive a denial that states the clinician is
not billable? We currently get denials saying the claim cannot be processed due
to missing or invalid information.
Answer 122
You would have to write to written inquiries and request a manual denial.
Question 123: What is an ABN and GA modifier?
Answer 123:
ABN is Advanced Beneficiary Notice and the GA modifier is used to designate
that an ABN has been signed and the patient informed and agrees to pay for
denied services.
Question 124:
Does Medicare ever cross over claims to Banker’s Life? We enter the information
and it never seems to crossover.
Answer 124:
We no longer provide direct crossover of claims because CMS has contracted with
another vendor to provide that service. A claim would not crossover if the
secondary does not have a crossover agreement in place with that contractor
regardless of what you put on your claim to Medicare.
Question 125:
Does Medi-Cal always cover the deductible?
Answer 125:
That would depend on the coverage the beneficiary has.
Question 126:
Does Medicare accept a practice’s version of an ABN (with modifications) or
does it have to be Medicare’s formatted ABN?
Answer 126:
The CMS-R-131-L or CMS-R-131-G are the
only acceptable versions of the ABN for a Medicare patient.
Question 127:
If we have an ABN on file and forgot to bill with the GA modifier can we still
bill the patient?
Answer 127:
You would need to do a reopening and have the claim corrected.
Question 128:
Is Medi-Cal required to pay the entire Medicare deductible for approved
procedures or just the Medical rate if it is less?
Answer 128:
You would need to contact Medi-Cal for that information.
Question 129: I have not been able to locate any information
on the new HPV vaccine on the website, is there any coverage for this and where
can I locate it?
Answer 129: The HPV vaccine is not covered by Medicare.
Medicare covers Flu and pneumonia vaccines only.
Question 130:
Can we bill for a collection of a specimen?
Answer 130:
Yes, you can.
Question 131:
We have never received Medi-Cal secondary payments. Do we need to code
differently to receive reimbursement?
Answer 131:
You should not have to code the claim differently; you may want to speak with
Medi-Cal.
Question 132: If we are non par and do not accept assignment, do I
need ABNs signed on non-assigned claims?
Answer 132:
Yes, when you believe the service will not be covered you need to obtain an
ABN.
Question 133:
In conjunction with Zostavax injection, we were told in this seminar that it is
a vaccine not covered by Part B. Does that mean it would be covered by Part D?
Answer 133:
No, Part D covers prescriptions.
Question 134:
If Medicare denies a claim billed with the KX modifier we can’t bill the patient
if we do not have an ABN on file even if the patient has met their Medicare
cap. Is this correct?
Answer 134:
That would depend on the denial reason that you receive from Medicare.
Question 135:
Since we have begun electronic claims our claims are not crossing over for all
the secondary insurances. What can we do to streamline these claims?
Answer 135:
It may be a situation where the patients need to contact their secondary to
establish an automatic crossover.
Question 136: We
have an in-house lab; can we bill a technical component under the lab Id and
the professional under the clinic ID?
Answer 136:
Clinical laboratory services do not have a technical and professional
component.
Question 137:
If we took a hospice patient to the hospital, BLS ambulance service and got
denied for the claim, who can we collect the money from? Who would be
responsible for payment?
Answer 137:
Please refer to the Ambulance Guide regarding these services. If the transport is related to the hospice
condition you would bill the hospice, if not bill NHIC with the appropriate
modifier. If you are not a hospice provider, bill with modifier -GW.
Question 138:
Where on the Medicare website will I find a sample of the new 1500 claim form?
Answer 138: In
the 1500 Billing Guide on the NHIC website.
Question 139:
If the patient has no deductible coverage, can we recover that from the
patient?
Answer 139:
Please clarify what you mean by this question. Medicare beneficiaries have a
deductible each calendar year. Do you mean they may not have a secondary payer
that might cover their deductible? If that is the case, the beneficiary is
responsible for the payment.
Question 140:
I am signed up for a Medicare workshop on March 21, 2007 in
Answer 140:
Yes, items such as billing errors, NPI, provider enrollment, etc. will be
covered.
Question 141:
Will there be any seminars coming up that will relate to Mental Health billing?
Answer 141:
Question 142:
Where do we put the legacy and NPI in the 837 format? Need loop and segment.
Answer 142:
Please contact the EDI department for your state.
Question 143:
When will you send flyers for your Spring Medicare Fair in
Answer 143:
A flyer will be mailed to all active providers in the next few weeks.
Question 144:
I obtained 2 NPI numbers for a single provider that is incorporated. Is that
the correct process and do I need to report both numbers on the CMS 1500 form?
Answer 144:
Yes, type 1 will be in Item 24j and type 2 in
Item 33a.
Question 145:
Can an MD in clinic lab bill for the same test for the same patient on the same
date of service?
Answer 145:
Generally no, unless there is a medical reason for the test to be done on the
same day.
Question 146:
Can physicians’ offices provide medication to patients now?
Answer 146: Injections
can be provided and billed to NHIC. Oral medications can be provided free of
charge (such as samples),
Question 147:
Concerning the hearing, what is the lowest amount we can send for a hearing and
what date did this become effective?
Answer 147:
There is no longer an amount for reconsideration, this became effective 1/1/6.
Question 148:
Looking for a taxonomy code for the legal entity, a government agency (County).
Answer 148: Please
contact FOX Systems regarding taxonomy for NPI.
Question 149: Do I need a modifier when billing NP, PA services?
Answer 149:
Yes, you will need a modifier for specific services where the NP and PA are
rendering provider. Please refer to our Non-Physician
Practitioners billing guide for complete details.
Question 150: What if a patient’s share of cost exceeds
what was allowed by Medicare? Then can we bill the patient?
Answer 150: You may not bill the patient over the
limiting charge established by Medicare.
Question 151: Claims denied for a return to OR on the
same date of service, how can I individualize these claims that deny for
duplicate or global, past 120 days. How do we handle this problem?
Answer 151: You only have 120 days to file an appeal.
Question 152: Is it possible to bill Medicare if either
a LCSW or PHD refer their client to an outside Psychiatrist for pharmacological
management even though that Psychiatrist is not employed under our group
facility? This is for CPT code 90862.
Answer 152: NO.
The LCSW and PhD, who cannot perform medication management, cannot bill
for this even if it is done by a psychiatrist who IS employed in the group
facility. They cannot have anyone
working "incident to" them. So
this 90862 is NOT covered under these circumstances.
Question 153: Will there be a webinar covering ambulance
provider issues?
Answer 153: Not at this time, but we will consider it
as a topic.
Question 154: Where can we find if the patient has met
the PT maximum?
Answer 154: You may use the IVR or contact Customer
Service.
Question 155: Is the Telemedicine considered billable
even if the patient is outside the
Answer 155: We would need to know what CPT you are
billing with.
Question 156: We were told by Customer Service that we
could not give out therapy cap info, is this correct?
Answer 156: Yes, that is correct.
Question 157: Should the lab test be submitted under
the clinic ID or under the clinical lab ID?
Answer 157: It should be submitted under the ID number
for the entity performing the service/test.
Question 158: Can we send Q2A claims to the QIC if they
have not been settled-we are having issues with the Q2A.
Answer 158: You will want to contact the QIC for your
state.
3/01/2007