How to Bill for After Hours Care

CPT 99050 may be billed for services provided in the providers office during evening, weekend, or holiday office hours that are in addition to the regularly scheduled office hours.

Documentation must appear on the claim and be recorded in the patient medical record that includes the time the service was rendered and regularly scheduled office hours for that day in box 19 of the CMS 1500 claim form

  • Example: patient seen 5:45pm, office hours: 8am-5pm
  • Example: patient seen 5:45pm, office hours: None (Weekend)
  • Example: patient seen 5:45pm, office hours: None (Holiday)

The special circumstances that required the use of this code must be recorded in the patient medical record as well. 

 

OIG Work Plan (Audits)

OIG (Office of Inspector General) mission is to protect the integrity of the Department of Health and Human Services (HHS) programs as well as the health and welfare of program beneficiaries. This includes audits of healthcare professionals to make sure they are acting in accordance with the regulations and guidelines in place. The audits are areas that are considered high risk are listed in the OIG work plan. The work plan is continuously updated and added. The OIG determines what will be on its work plan by evaluating the risks in HHS programs and operations to identify areas that need attention.  

For example, in 2017 the Office of Inspector General is also doing a review of Medicare payments for telehealth services covered under Part B expenses, see below for more information.

“Medicare Part B covers expenses for telehealth services on the telehealth list when those services are delivered via an interactive telecommunications system, provided certain conditions are met (42 CFR § 410.78(b)). To support rural access to care, Medicare pays for telehealth services provided through live, interactive videoconferencing between a beneficiary located at a rural originating site and a practitioner located at a distant site. An eligible originating site must be the practitioner's office or a specified medical facility, not a beneficiary's home or office. We will review Medicare claims paid for telehealth services provided at distant sites that do not have corresponding claims from originating sites to determine whether those services met Medicare requirements.”

The OIG website has a plethora of information needed to keep track of regulations and upcoming changes that could affect your practice. Since the work plan is constantly updated and changed its a good idea to review it.

There is also an online searchable database for providers that are excluded from Medicare and Medicaid due to fraud/abuse.

Resources

For a complete list of the OIG work plan active items:

https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp

 

2017 Work Plan PDF

https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/hhs%20oig%20work%20plan%202017.pdf

 

MIPS Hardship Exemption

What is MIPS? MIPS started on January 1 2017 and is an acronym that stands for Merit-based Incentive Payment System. This program determines what Medicare payment adjustments are by using a composite performance score. Eligible clinicians may receive payment penalty, no payment adjustment or they can receive a payment bonus.

The Composite Performance Score is based on four performance categories:

  • Quality (50% PQRS or Value Based)
  • Resource use (10%)
  • Clinical practice improvement activities (15%)
  • Meaningful use of certified electronic health records (EHR) technology (25%)

A MIPS-eligible clinician or group may submit a Quality Payment Program Hardship Exception Application, citing one of the following specific reasons for review and approval:

  • Insufficient Internet Connectivity

  • Extreme and Uncontrollable Circumstances

  • Lack of Control over the availability of CEHRT

The significant hardship exemption.

Clinicians facing a significant hardship, such as insufficient internet access or extreme and uncontrollable circumstances (e.g., a natural disaster that destroys the EHR system) can apply for CMS to reweight their ACI (Advanced Care Information) score.

Certain types of MIPS eligible clinicians are exempt from ACI in 2017.

CMS will automatically exempt the following types of clinician: Hospital-based clinicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists. However, if they do submit any ACI data, they will effectively have opted back in—they will receive an ACI score and their MIPS final score will be calculated in the standard way.

 2018 Eligible Professional (EP) Hardship Form

The deadline for Eligible Professionals (EPs) to submit Hardship forms for the 2018 payment adjustment, based on the 2016 EHR reporting period was July 01, 2017.

 2018 Eligible Hospital Hardship Form

The deadline for Eligible Hospitals to submit Hardship forms for the 2018 payment adjustment, based on the 2016 EHR reporting period was July 01, 2017.

 2016 Critical Access Hospitals (CAHs) Hardship Form

The deadline for Critical Access Hospitals (CAHs) to submit Hardship forms for the 2016 payment adjustment, based on the 2016 EHR reporting period is November 30, 2017.

Additional Sources

http://www.aafp.org/practice-management/payment/medicare-payment/mips/aci.html

https://qpp.cms.gov/mips/advancing-care-information/hardship-exception

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/PaymentAdj_Hardship.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-Quality-Payment-Program-webinar-slides-10-26-16.pdf

 

Consult Codes

99241-99245 (new) and 99251-99255 (established)

A consultation as defined by the current CPT manual as a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.

As of January 2010, Medicare no longer accepts consultation codes for the fee for service Medicare plan. For the most part other commercial payers still reimburse for consult codes however as of October 1, 2017 Unitedhealthcare is changing their policy and will no longer accept consult codes. Providers will need to utilize the appropriate E/M code instead of consult codes.

As a sidenote, a consultation that is requested by the patient should not be billed using a consult code no matter who the payer is, if the patient requests the consultation then use the appropriate E/M code.

Modifiers

There are times that you will need to append the appropriate modifier for reimbursement or reporting purposes, the following information pertains to the use of modifiers and consultation codes.

For Inpatient consults, there could be a time when both the admitting physician and the consulting physician both report an initial inpatient visit, when this happens if the AI modifier is not appended the claims will deny as a duplicate. Modifier AI is used by the admitting or attending physician only.

If the consult is mandated by a third party payer then modifier 32 should also be reported, even though most payers  do not  typically reimburse when modifier 32 is appended.

Documentation

Documentation of the written or verbal request for the consult from the requesting physician must be in the patient’s medical record and provided on the encounter form.  The requesting physician’s name must be referenced on the CMS 1500 claim form.

The physician must also report their findings and any services that were ordered or performed will also need to be documented in the patient’s medical record and must be communicated by written report to the requesting physician or other appropriate source and recorded in the chart note.

 

Additional information:

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/June-Interactive-Network-Bulletin-2017.pdf

 

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6740.pdf

 

https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/bundling_guidelines.pdf

 

https://www.aapc.com/blog/25415-how-to-get-medicare-to-pay-for-consults/

Blue Cross of NC New CEO

On August 8, 2017 BCBSNC announced that its Board of Trustees have elected a new President and CEO to lead the company. The current CEO J. Bradley Wilson has been leading the company since 2010 and will be retiring. The new CEO and President Dr. Patrick Conway will start his new role effective October 1, 2017. Conway is currently the Deputy Administrator for Innovation and Quality for CMS and the Director of the Center for Medicare and Medicaid Innovation (CMM). Conway is also a major proponent of the national movement to value based care with healthcare payments being tied directly to quality and innovation. Conway is a practicing Pediatrician with gives him a unique perspective, as he not only knows the business aspect of leading a healthcare organization but also the clinical aspect.

BCBS of North Carolina is typically one of the major payers for providers in the state, let's hope that the new leadership at BCBS of NC will do its part to help small and medium sized practices not only to sustain but to thrive and grow.  

 

Additional Resources:

BCBS of North Carolina Media Announcement of new CEO:

http://mediacenter.bcbsnc.com/news/blue-cross-nc-board-of-trustees-elects-dr-patrick-conway-as-new-president-ceo

-The Paradox of Size: How Small, Independent Practices Can Thrive in Value-Based Care by Farzad Mostashari, MD:     https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709149/

LME MCO Change

Effective July 1, 2017 Trillium Health Resources started servicing Nash County residents. Previously Nash County was serviced by EastPointe Behavioral Health. There have been several articles in the local papers about the strained relationship between Nash County and Eastpointe and the legal battle that has followed, feel free to do a quick google search for more background information on the split. So far the transition seems seamless, I have not heard of any problems with Nash County residents having trouble getting the service they need.

Trillium Health Resources now services the following counties: Brunswick, Carteret, Nash, New Hanover, Onslow, Pender, Beaufort, Bertie, Camden, Chowan, Craven, Currituck, Dare, Gates, Hertford, Hyde, Jones, Martin, Northampton, Pamlico, Pasquotank, Perquimans, Pitt, Tyrrell, and Washington. While Eastpointe now services Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Robeson, Sampson, Scotland, Wayne and Wilson counties.

My past interactions with Eastpointe have not been favorable, I found them to be difficult to work with and their website was extremely difficult to navigate. I often hit a brick wall when trying to get a provider through the credentialing process, attempting to get any clear and concise information was a struggle.

However, they seem to be cleaning up their act, the website has improved and now has a clean and user friendly interface, the staff that I have come in contact with are easier to get along with and have been extrememly helpful. I will provide an update as I move through the credentialing process with Eastpointe.

New Medicare Cards and New ID Number Format

Starting April 1 2018 CMS will start issuing new cards to its beneficiaries. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 requires that CMS remove Social Security Numbers from all Medicare cards. CMS is also required to issue new cards and assign new ID numbers that will be known as MBI (Medicare Beneficiary Identifier).

The transition period for this major change will start April 1, 2018 and end on January 1, 2020 (21 months).

The new MBI will be 11 characters in length and be made up of numbers, uppercase letters and no special characters. The new ID numbers won't have any special meanings, just randomly selected letters and numbers.

CMS will start mailing new cards to beneficiaries by April 2018 and by April 2019 all cards should be replaced.

In order to get ready for this change offices should check with their EHR and clearinghouse providers to make sure they are able to handle to new 11 alphanumeric MBI's that will be issued by CMS. This needs to happen by April 2018. Providers will still be able to bill and file healthcare claims using the patients old HICN during the 21 month transition period.

Of course as with any major change there will be some challenges that we will have to face. You will need to commuicate with your patients to let them know to be expecting a new ID card from Medicare and for them to open all correspondence from Medicare in the coming months. Patients will need to present your office with the new card so that the new id number can be on file in your office.

Currently, CMS has not issued a sample of what the new id cards will look like, as soon as I come across one I will send that information out.

Below are the links to some very helpful informaiton about the upcoming changes.

Talk to your patients:

https://www.cms.gov/Medicare/New-Medicare-Card/New-Medicare-Card-Messaging-Guidelines-July-2017.pdf

The New Medicare Card:

https://www.cms.gov/medicare/new-medicare-card/nmc-home.html

Provider Drop-In Article

https://www.cms.gov/Medicare/New-Medicare-Card/5-Things-What-to-do-Now-Drop-In-English.pdf

Authenticity

In business we are often faced with tough decisions and we have to make tough calls. I strive to remain true to my core values and to not allow monetary desires dictate how I am treated. Simply put no business owner should take clients based purely on the money involved. Doing so can have you in some pretty high stress and underpaid situations. It is imperative that we do our due diligence when selecting clients. If personality styles do not match then it will make a rocky and maybe even chaotic working relationship. As someone who is an aspiring minimalist, I am de-cluttering my material possessions and realizing that I may also have to de-clutter my business world as well. Living a simplistic life with the least amount of stress is ideal. Most of us become business owners due to the allure of doing what we love while receiving compensation for it. Being our own boss and escaping the hustle and bustle of a 9-5. Never forget the reasons you wanted to become a business owner, let those reasons be your guiding principles. If a situation or client becomes a threat to those things, it may be time to reevaluate yourself and your business. 

The Past, The Present, The Future

In my first blog post of many to come I would like to share my journey and what led me to create Billing Solutions Unlimited and how I combined my passion for business with my knowledge of revenue management.

For over a decade I have been fascinated with revenue management in healthcare. Professionally I have worked for some of the bigger names in the Healthcare industry in North Carolina. My first experience was with a company that Humana outsourced their Medicare Part D claims (Prescription Drug Plan) to, after a few years I was ready to learn more about health insurance. That led me to Blue Cross Blue Shield of North Carolina. This is where I learned the ins and outs of health insurance, claims processing systems as well as medical policies regarding how BCBSNC pays and processes their claims.

I have always had a passion for business, it was during my time at BCBSNC that I completed a Bachelors of Business Administration with an academic focus on management. After a few years at BCBSNC I was ready to move on and learn things from the providers perspective.  This led me to an opportunity to work as a Professional Billing Specialist at Duke University Health Systems in Durham NC. In this role I received exposure to various specialties within healthcare, from Inpatient to Outpatient, Ambulatory, clinics, and physician billing.

However as life changes I yearned to work and utilize my skills in a smaller setting where I could have a larger impact. In my search I found a small Critical Access Hospital and I was given the opportunity to assist in running the day to day operations of the business office, specifically Patient Accounting. In this role I was able to combine my passion for business and my knowledge of the healthcare industry and make outstanding changes that led to significant growth in revenues for that organization. It was during this time that I decided that I should combine my passion and my career which brings us to Billing Solutions Unlimited. 

It is with Billing Solutions Unlimited that I created the perfect career for myself. With my passion for business and my hands on experience in health care revenue management I have found the ideal balance. I look forward to sharing more of my journey as I continue to learn in this ever changing industry, I also look forward to sharing the experiences of our staff and guest contributors. Until next time.....

Kenya Batts

 

Skyla Jenkins wrote 1 year ago

It is no surprise to me that Kenya Batts has launched a successful business in healthcare account management. Kenya has the experience & knowledge to handle all aspects of revenue related to patient accounts. She has an extensive background with respecting patient confidentiality and following all applicable privacy laws. Kenya is thorough, detail-oriented, and an excellent problem solver; that will make her an asset to any company/client.

Francisca Harper wrote 1 year ago

Congratulation's Kenya on your creation of Billing Solutions Unlimited. Under your supervision, guidance, and training I learned and gained knowledge of Healthcare Revenue Management which landed me my current position as a Lead Professional Billing Specialist. Therefore, I know first hand that Billing Solutions Unlimited will be a valuable asset to any medical provider seeking to outsource their billing. Please feel free to contact me if I can be of any assistance to you on your road to success.

Fran Harper
Lead Professional Billing Specialist