Insurance & Reimbursement

What To Do When Your Claim Is Lost

What to Do When Your Claim Is Lost

by Tom Necela, DC, CPC, CPMA
January 2010

Medicare Improper Payment Report for Behavioral Health Services

The following information is from the 2014 Medicare Improper Payments Report by the Department of Health and Human Services.

This table shows the Improper Payment Rates by Provider Type and Type of Error for Medicare Part B claims:

    Provider Type

    Improper Payment Rate

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):

Consumer Directed Health Plans

Establish Patient Financial Responsibility (Resource 149)

Financial responsibility (insurance, cash, etc) should be established as soon as possible, preferably before the patient comes in for the first visit. Both provider and patient need to understand who is responsible for payment of services. The patient needs to understand what they are responsible for versus what the insurance plan or company will or will not pay. Consider the following:

Medicare Definition of Timed Codes

Many procedure codes are considered "timed codes," that is, the number of units are determined by the amount of time spent performing the service. To clarify questions about this, the Medicare Claims Processing Manual, Chapter 5 - Part B Outpatient Rehabilitation and CORF/OPT Services, states the following (emphasis added):

20.2 - Reporting of Service Units With HCPCS
(Rev. 3367, 10-07-15))

Healthcare Reform

Even though the health care system in the United States is one of the most expensive per capita in the world, we have a dismally low quality of care ranking. Healthcare reform (HCR) in its simplest terms is addressing these shortcomings in order to improve healthcare coverage, delivery, policies, or payment. According to Wikipedia, "healthcare reform typically attempts to:

The law requires that a physician must document that a physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. The encounter must occur within the 6 months before the order is written for the DME.

 by Aimee Wilcox, MA, CST, CCS-P

Have you ever wondered when it is appropriate to document a comprehensive past medical, family and social history (PFSH) or if the necessity of doing so will be questioned during an audit?

Well, providers are concerned about how their documentation will hold up in an audit and since most haven’t been formerly trained in medical coding, their concerns over a potential audit are valid. 

Q: When is it appropriate to document a comprehensive past medical, family and social history?

CLICK HERE for a copy of an ABN Form in Spanish.


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