Billing & Coding

Counseling vs Consultation: Different Words, Different Rules -- Part 1, Understanding Consultation

Although in common speech the words counseling and consultation are sometimes used interchangeably, in the reimbursement world they are two different terms, and getting paid for either may be tricky. The rules vary between payers, so much so that even when an insurance carrier covers it, many doctors do not even try to bill for it. This is a shame, because you could be leaving thousands of dollars on the table each year.

Quick Questions - Procedure Coding

When Billing for a "Fill in" Doctor

Question: 

Modifier Resources (Resource 343)

Modifiers proved a way for the practitioner to report or indicate that a procedure or service has been performed but has been altered by some specific circumstance. Modifiers are essential tools in the coding process. They are used to enhance a code narrative to describe the circumstances of each procedure or service and how it individually applies to the patient. The appropriate use of modifiers enable practitioners to effectively respond to payment policy requirements to payer policies.

Bill chronic care management (CCM) services on the last day of the calendar month the service was done. Therefore, if the service began in January, you would bill 99490 with the date of service as January 31. 

You cannot bill CCM for the care of a patient only due to having two chronic illnesses; to bill CCM, the chronic conditions must be showing significant risk of death, acute exacerbation, decompression or functional decline.

Definition

  • Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

Appropriate Usage

  • Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
  • Documentation indicates the services were provided during separate patient/provider encounter
  • Use Modifier XE with the Column 2 procedure code in the NCCI files
  • Use Modifier XE only when there is no other modifier to describe the situation

Inappropriate Usage

In an effort to improve quality of care in nursing home, CMS has been reviewing PQRS quality measures and offering provider training through a variety of mediums. Antipsychotic drug use is just one of the measures being reviewed. The MLN Connects Provider eNews for February 12, 2015 included the following notice about the trends in antipsychotic drug use and the results are promising:

Antipsychotic Drug use in Nursing Homes: Trend Update

Adaptive Behavior Coding

On July 1, 2014, 16 new codes (0359T through 0374T) were added for reporting adaptive behavior assessments/interventions services. These codes were included with the mid-year release of CPT Category III codes.

These new codes have been added to Section H-Procedure Coding in the Behavioral Health MultiBook. and may be used by any physician or other qualified licensed healthcare professional.

The June 2014 edition of CPT Assistant stated the following about these codes (emphasis added):

Of nearly 15,000 test claims received by the Centers for Medicare & Medicaid for the first round of end-to-end ICD-10 testing, 81 percent were accepted, according to statistics revealed by the agency Wednesday.

Fee Resources (Resource 171)

The establishment of appropriate fees for services is one of the greatest challenges in health care. You need to understand the following concepts:

Claims Processing (Resource 199)

A properly completed claim (whether paper or electronic) is a critical component of the reimbursement process. A clean claim is vital to the processing and payment of your claims. The "cleaner" the claim, the faster you will receive payment. It is the responsibility of the provider to understand what is needed and required by the carrier, then provide that information in the specified manner and time frame.

You need to understand the following concepts:

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