Billing & Coding

In 2013, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated on the date of service. CMS subsequently discovered that some of the data used was incomplete. Since some of these recoveries might have been erroneous, CMS initiated refunds. Most of the incarcerated beneficiary erroneous overpayment refunds were issued before the end of December 2013, with some subsequent refunds on situations that had been appealed. The process CMS used to expedite the refunds precluded the issuance of a detailed remittance advice (RA).

After a claim has been submitted and a reimbursement decision has been made, you or your billing agent receive a Remittance Advice (RA). The RA is a notice of payments and adjustments that the MAC produces as a companion to claim payments or an explanation when there is no payment. It features valid codes and specific values that make up the claim payment.

Some of these codes may identify adjustments, which refer to any changes that relate to how a claim is paid differently from the original billing. There are seven general types of adjustments:

1. Denied claim;

Submitting the CMS-855 Enrollment Application and Billing Effective Date Changes

As of May 14, 2012, the billing effective date can be made retroactive as far back as 30 calendar days from the date the application was received in Medicare's office.

Provider offices must submit the CMS 855 form as soon as the provider begins seeing Medicare patients to ensure their services will be processed by Medicare. With CR7797, the CM-855 form can be now submitted up to 60 days in advance of the provider seeing Medicare patients.

Beware of the changes sneaking in as “money streams” in the name of EFT standards. Virtual Credit Cards are being used in provider’s offices as payments from payers; clearinghouses are starting to offer this service as well.

Enforcement Actions in FY 2013: the Department of Justice (DOJ) opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants. Federal prosecutors had 2,041 health care fraud criminal investigations pending, involving 3,535 potential defendants, and filed criminal charges in 480 cases involving 843 defendants. A total of 718 defendants were convicted of health care fraud-related crimes during the year.

A HIC number (HICN) is a Medicare beneficiary’s identification number. Also, remember when billing, ALWAYS use the name as it appears on the patient's Medicare card.

Both CMS and the Railroad Retirement Board (RRB) issue Medicare HIC numbers. The format of a HIC number issued by CMS is a Social Security number followed by an alpha or alphanumeric Beneficiary Identification Code (BIC).

RRB numbers issued before 1964 are six-digit numbers preceded by an alpha character.

Always read the full description of a CPT code.  For example, 20552 is reported for 1 or 2 muscle groups injected and 20553 is reported for 3 or more muscle groups injected.  

Do I Need Error and Omissions (E&O) Insurance for My Billing Company?

Having a billing company for the past 20 years, has been a great journey, 20 years ago it was called a Home-Based Business, today it is called a Corporation, more for protection and liability reasons. Over the years Medical billing has been considered low risk until now, and now has developed into a huge liability with HIPAA, E&O and Business Associate agreements to name a few. I have not had to consider whether to carry insurance on my small company until now.

Q. If a patient brings in x-rays from another provider, may I bill 76140, x-ray consultation?

 

A Laxative is considered a “Self Administered Drug” (SAD).   Insurance will usually pay for the care you provide but will only cover certain drugs in the outpatient setting such as drugs administered through an IV.  Therefore it would not be appropriate to report this under the Outpatient Prospective Payment System (OPPS).

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