THe JOuRNaL OF THe HeaLTHCaRe BILLINg aND maNagemeNT assOCIaTION 35 for 2014 CODING CORNeR but also the most error-prone, modifier available. modifier 59 is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. This modifier indicates that the ordinarily bundled code represents a service performed at a different anatomic site or at a different session on the same date. The procedure report must indicate that the procedures were separate and distinct. It is critical to have documentation that supports a separate, distinct procedure before appending modifier 59 to a code. This modifier allows the code to bypass edits in many payor systems, so appropriate documentation must be present in the record. use modifier 59 only if another modifier does not describe the procedure or service more accurately. NUMBER 5: MODIFIER 25. a provider seeing a patient for a separate visit and minor procedure on the same day does not automatically indicate that it is appropriate to report an evaluation and management (e/m) service. e/m services on the same date of service as the minor surgical procedure are included in the payment for that procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an e/m service. However, a significant and separately identifiable e/m service, unrelated to the decision to perform the minor surgical procedure, is separately reportable with modifier 25. If there is always an e/m service billed on the same day as a procedure, this raises a red flag to investigate for appropriateness. NUMBER 4: E/M LEVELS. e/m codes have been around for decades and their definitions have not really changed very much; however, there seems to be a renewed focus by Cms and other external organizations on external audits of assigned e/m levels. Just because a physician is a specialist, it does not automatically mean that all of their patient visits will qualify for level 4 or level 5 e/m codes. Documentation is key, but so is medical necessity. many payors consider medical necessity an overriding factor in the assignment of an e/m level regardless of the amount of documented history and physical exam. It is critical to ensure that your clients’ documentation sufficiently supports the e/m levels that are being billed. NUMBER 3: INCIDENT-TO. given the number and type of compliance problems that are typically seen in this area, I could make an argument that incident-to is one of the most misunderstood (or alternatively, blatantly ignored) billing practices currently allowed by Cms. In the HBma Billing september–October 2012 issue, this column’s topic was solely focused on incident-to services, so you can go back and review this information to ensure you are billing correctly. There are several important aspects to remember when considering billing non-physician services as incident-to. Incident-to is a Cms concept, and most other payors do not allow incident-to services. They expect the services to be billed in the name of the credentialed provider. If a payor will not credential non-physician providers, you must obtain written guidance on how to appropriately submit claims for their services, which may mean you cannot bill for their services. It is important that you ask your clients the correct questions to assist them in properly billing for true incident-to services. NUMBER 2: EMRs. One of my takeaways from the HBma 2013 Fall Conference in Las Vegas was a quote from our lobbyist, Bill Finerfrock, that emR (electronic medical record) does not stand for “electronic magic record.” unfortunately, there are a lot of physician practices that believe that their emR is a magic bullet that will solve any and all documentation, coding, and billing problems. There are some great emRs available, but there are also some less-than-great ones as well. some emRs can generate cloned notes, inappropriate templates, and other documentation concerns that can create compliance nightmares with the potential for fraud and abuse. The Office of Inspector general (OIg) specifically listed emRs and cloned notes as a target of concern in its 2013 work plan. It is on their radar that
Billing_JanFeb14
To see the actual publication please follow the link above