(per Partners and Health Update, October, 2010)
POS members, like HMO members, must choose a primary care physician. However, POS members have the option of seeing a specialist who is either in or out of network. When POS members seek specialty services, they must receive a referral from their PCP to receive maximum benefit levels. If they choose to ‘self-refer’, the patient will be responsible for additional out-of-pocket expenses. This applies both to in and out of network providers.
POS member may also need preauthorization for some services. When you request preauthorization through NaviNet, you will be asked “has the member been referred by the PCP for treatment?” PER IBC, It is very important to answer YES, IF your office has a referral on file for the member to receive the highest benefit. Please check the members chart for a referral or verify that an electronic referral is ‘on file’ through NaviNet.
If you incorrectly answer NO, the system will automatically process the claim as self-referred and the member may be responsible for erroneous out of pocket expenses. In addition, you may receive the following message due to the difference in preauthorization requirements:
“This member’s benefits program does not require pre-authorization for the procedure(s) requested based upon the information provide.” Claims will be denied for lack of preauthorization!
POS members seeking services from OB/GYN providers are not required to have a referral. For correct payment, answer the above mentioned question “YES”. This will ensure the member’s benefits are managed correctly.
If you have further questions, regarding POS preauthorization, per IBC, please contact your Network Provider.read more
Effective January 1, 2011, there will be two new components for precertification:
To view the dosing policies go to: www.ibx.com/medicalpolicy, select Accept and Go to Medical Policy Online, then click on the Policy notification box.read more
Beginning January 1, 2011, IBC will no longer provide payment or reimbursement on any ESWT claims for musculoskeletal conditions. ESWT has been studies in the treatment of conditions including: plantar fasciitis, tennis or golfers elbow, rotator cuff bursitis and other overuse injuries. IBC has determined this treatment for these injuries is investigational.read more
Upon renewal of plans to existing employer groups, the following changes will take place due to the federal health care reform acts. As required by the act, beginning with renewals from October 1, 2010 there will be no member cost-sharing (i.e. $0 copayment) for certain Preventative Services, which include the list of applicable preventative service codes. The policy will be available on Navinet or www.ibx.com/medpolicy.
As it is expected, per IBC, to take several years for this change to be phased in, you must continually check Navinet and ID cards for member benefit information.
Preventative care $0 capitation rates – your capitation rates will increase to account for this benefits change for members with a new $0 copayment benefits plan for preventative care services. The benefit and rate of capitation payment change is effective October 1, 2010, for certain commercial HMO and POS benefit plans and January 1, 2011 for all Medicare Advantage plans.
The capitation payment rates have been increased to account for the actuarial value of preventative care copayments currently collected under these benefits.
For members with commercial plans and Medicare Advantage plans whose benefits are note changing, the current rates will be continued to be paid.read more
Depending on the procedure, the global period assigned to CPT codes can range from 0 to 90 days. The count actually begins the day after the procedure is performed. There are two different views on what is included in the global period.
CPT/AMA rules, which most commercial carriers use, state the global period includes the following:
Note “Typical” in the sense refers to the care that is usually part of the surgical service, such as looking at the healing process, bandage changes when necessary etc.
You should bill and separately report complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring services. This means, any diagnosis that is not the reason you took the patient to surgery.
Medicare differs slightly. From their prospective the global period includes the following services when completed by the physician who performs the surgery:
Services NOT included in Medicare’s global fee definition include:
Modifier ‘24’ – unrelated E/M service by the same physician in a post-operative period is used to report services during the 90 day global. Your choice of diagnosis code (ICD-9) will verify the need for the service.
Understanding the rules and educating ourselves allows us to use the rules for their intended purpose and improve our bottom line.
Source: Medicare www.cms.hhs.gov/manuals/14_car/3b4820.asp#_1_2
CPT/AMA –as quoted in Orthopedic Coding Alert Extra by Alice Marie Reybitz, RN, BA, CPC, CPC-H
Hip arthroscopy codes:
2011 brings additional observation codes for ‘subsequent’ care while a patient is in observation status in the hospital.
Historically, patients admitted to observation in the hospital were either discharged or admitted as an inpatient within 24 hours. Consequently, the old codes defined exactly that – codes 99234-99236 when the service took place, admit and discharge within the same calendar day and 99218-99220 for the admission and 99217 for the discharge when the service spanned midnight.
In recent years, physicians have been keeping patients in observation status for multiple days (not just initial care and discharge) which has lead to CPT adding codes for the ‘in-between’ dates of service.
99224 subsequent care, problem focused, patient is stable, recovering or improving – provider usually spends 15 minutes in total at the bedside and on the floor/unit
99225 subsequent care, expanded problem, moderate complexity, patient is responding inadequately to therapy or has developed a minor complication – provider time spent 25 minutes in total at the bedside and on the unit/floor
99226 subsequent care, high complexity, patient is unstable or has developed a significant complication or new significant problem. Provider will spend 35 minutes typically in total at the bedside and on the floor/unit.
Patient still in observation status Wednesday – 99224-99226
Patient discharged from observation Thursday – 99217
CMS requires that you document clearly in the medical record any drug waste. The policy states: “It is expected that the medical record will contain the name of the drug, dosage, and route of administration, time and date given. When a portion of the drug is discarded, the medical record must clearly document the amount administered and the amount wasted.”
Please insure your documentation is clear and appropriate when you are administering drugs.read more
Medicare Administrative Contractors are getting ready to review transforaminal epidural injections (64479, 64480, 64483 and 64484) so get prepared for documentation requests, pre and post payment.
The reason? The OIG has reviewed these services that were performed in 2007 and was not pleased with the findings. They state that 34% of the services reported should not have been paid resulting in overpayments to physicians in the amount of $45 million and $23 million for facilities.
Highmark Medicare LCD (local policy) for transforaminal epidural, paravertebral facet and SI injections states that “due to the inherent risk with transforaminal epidural injections (specifically with the cervical procedures and risk of inadvertent arterial injection and L1 and L2 procedures and the risk of inadvertent injections into the artery of Adamkiewicz), physicians performing this procedure should have substantial and specific experience with transforaminal epidural injections and a clear understanding of the patient risks involved.”
The biggest errors found were documentation errors. In many instances the records didn’t have a description of the service or the service performed was not documented at all. Medical necessity accounted for another $19 million in overpayments.
As a result of these findings, the OIG wants CMS to instruct MACs to take the following steps:
CMS has agreed to all recommendations, except number 3. The individual MAC determines whether or not it will develop a local policy. Bottom line, expect audits.
The OIG target list for 2011 includes (but probably not limited to):
The scenario: You have nurse shadowing you during rounds and recording patient vitals, labs and possibly your exam in the progress notes, who signs the note?
Medicare states that “the situation should be clearly indicated so the reviewer can identify the provider who performed the service and both parties, the scribe and the physician, should sign the record, clearly indicating which signature belongs to whom.”
Remember that earlier this year Medicare issued stricter guidelines for signatures, please use them, including the attestation statement when necessary.read more