Coding to the Highest Level of Specificity

Insurance carriers often deny claims for not being coded to the highest level of specificity. As many billers are not coders they often don’t understand what has gone wrong or how to fix it.

If a service line is denied for this reason they are saying that the diagnosis code needs to be more specific. Some diagnosis codes are only three or four digits but many are five digits. The diagnosis must be coded to the absolute highest level for that code, meaning the most number of digits for the code being used.

For example, the diagnosis for hypertension begins with 401. However if you submit a cliam with the diagnosis 401 it will be denied. The code 401 requires a 4th digit. 401.0 is malignant essential hypertension. 401.1 is benign essential hypertension. 401.9 is unspecified essential hypertension. So to bill a claim with a diagnosis of hypertension it must be either 401.0, 401.1, or 401.9.

Another example of a diagnosis needing to be billed to a higher level of specificity would be diabetes. 250.0 indicates diabetes however you neeed a 5th digit to specify what type of diabetes. 250.00 is diabetes mellitus type two, 250.01 is diabetes mellitus type one (juvenile type), and 250.02 is diabetes mellitus type one uncontrolled and so on.

As you can see in the above example just putting 250.0 does not indicate specifically what the problem is. Without the fifth digit the claim is lacking enough information to be processed and therefore will be denied.

If you are unsure if the diagnosis is coded to the highest level of specificity you can look it up in an ICD9 code book or on the web. There are several websites with current ICD9 codes available. They will indicate if the code is coded to the highest level.

Some practice management systems have scrubbers that will catch under coded diagnosis and give you a warning. Sometimes the biller may recognize a truncated diagnosis (or a diagnosis requiring an additional digit.)

In either case the biller should go back to the coder or provider and ask them to be more specific with the diagnosis code so the claim can be resubmitted.

New Mental Health Law Affects Benefits

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) signed by George Bush as part of the financial rescue package in October 2008 will take effect 1/1/2010. This law greatly affects mental health professionals and billers.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 made changes to the Mental Health Parity Act (MHPA) of 1996 which allowed for too many restrictions to mental health benefits. The problem with the 1996 act was that it allowed for too many loopholes and still encouraged discrimination against mental health benefits.

The 2008 Act closed up some of those loopholes. For example, the 1996 MHPA allowed employers to limit the number of visits for mental health treatment whereas the 2008 Act states that mental health benefits can be no more restrictive than medical benefits.

The new law attempts to make coverage for mental health benefits equivalent to medical service benefits. If a health plan allows for out of network benefits for medical services, they must now allow the same out of network benefits for mental health.

The major provisions for the new law are:

• Does not allow employers or insurers to place stricter limits on mental health services than they have on medical benefits. This means not allowing higher co-pays, deductibles or limiting the number of visits.
• If a policy allows for out of network benefits for medical benefits it must allow the same out of network benefits for mental health.
• If a policy allows benefits for substance abuse, both in and out of network, the limitations cannot be more restrictive than they are for medical or mental health benefits.
• Any state parity measures are left in place.

We currently see many policies paying only 50% of the allowable with the patient responsible for the remaining 50%. Under the new law this will no longer be possible unless the health plan pays only 50% of the allowable for medical benefits as well as mental health. We have even seen mental health plans that pay only $10 per visit.

The Act unfortunately does not cover all insured people. Employers with 50 or less employees are exempt from this Act. Also, the law does not require health insurance plans to cover mental health and substance abuse disorders. It only applies to plans that have coverage for mental health or substance abuse.

What does this mean to the mental health provider? Mental health providers will not see as much discrimination for their services. Patients will not be penalized for seeing mental health professionals and will receive equal benefits.

It’s not a perfect solution and doesn’t cover everyone, but it is definitely a step toward equal benefits.

Are You and Your Providers Breaking the Law

We have had a very hot topic on our forum lately regarding how medical billing services charge their providers. Most billers charge either a flat monthly fee, a per claim fee, or a percentage of the billing. But did you know that some states have laws on the books that prohibit physicians from entering into certain types of “fee splitting” arrangements?

It is very common for a medical billing service to charge a percentage of the money collected as a result of their efforts in billing the insurance claims but many billing services don’t realize that this practice is considered fee splitting and may be illegal. Several states have laws banning this practice and some have prosecuted doctors for paying this way.

The reason for fee splitting laws was not originally intended for medical billing services but does include billing services and providers including doctors, therapists and other health professionals. It was originally designed to prevent providers who had arrangements with other Medical providers to receive a kick back for referring patients for their services. But the way the law is written no one is allowed to share a percentage of the income of the provider except partners.

Many billers prefer charging a percentage as it provides a motivation for collecting all money due a provider and a selling point in marketing. It seems like an easy way to determine a reasonable fee and compare charges with other billing services.

Unfortunately it is the doctor or provider who gets in trouble for this practice. It is the provider who is splitting his or her fee.

The problem for the billing service is that the practice of fee splitting totally negates the contract with the provider. Although many billing services get away with charging a percentage in states where fee splitting is illegal, some states are starting to crack down on this practice.

If you are in a state which prohibits fee splitting or work with out of state providers who may reside in the fee splitting states it is a good idea to look at other options of charging for your work. Many billing services charge per claim, a flat fee, or at an hourly rate.

Many billing services who currently charge a percentage and learn about the fee splitting laws are reluctant to change. They have been using the percentage as a marketing technique and don’t know how to change to a different form of payment.

As Linda Walker points out on our forum, she uses not charging a percentage as a marketing technique. She asks the provider if they want to work with someone who would ask them to enter into an illegal contract.

If you are currently charging your providers a percentage in a fee splitting state there are several things you can do to change to a different method. Average out what the provider has been paying you for the last six months. Consider any unusual fluctuations in charges and come up with a flat monthly fee. You can also count the average number of claims each provider sends you in a month and come up with a per claim fee.

Yet another method would be to keep track of how much time you spend on each provider each week and multiply that times the dollar amount you would like to collect per hour. If you decide on the hourly rate make sure you allow for all your expenses not just your time.

The states which have fee splitting laws that we currently know of are N. Y., and Florida This does not mean other states do not have such laws. This list is just the ones we are aware of. Linda Walker has more information on the laws in various states on her website at www.billerswebsite.com. If you run a medical billing service make sure you are not breaking the law by charging your providers in this fashion.

How Mandatory Electronic Claims Submission Affects Us

Recently the state of Minnesota mandated that all medical claims are sent electronically by July 15, 2009. If you are not from Minnesota, you may not feel that this affects you, but it does. It affects us all.

Costs are definitely cut down with electronic billing. Both insurance companies and the government would like to see all claims sent electronically. If Minnesota is effective with instituting the electronic mandate, you can be sure that other states will follow. It is just a matter of time.

The real question is how will this affect the individual providers and billing services. A very small percentage of medical offices or billing services are capable of sending all their claims electronically. Many small insurance carriers are not yet capable of accepting claims electronically. So how will we accomplish this major undertaking?

The providers in the state of Minnesota will have to at the very least have a computer with internet access in the office or they will have to hire someone who can submit the claims on their behalf. Don’t laugh! We still find offices that don’t have a computer. They won’t have to purchase an expensive practice management system if they don’t want to. They may have a good way of tracking their claims on paper but hopefully they are tracking claims. Anyone who has been in this business for any length of time knows of the office that looses thousands of dollars or tens of thousands of dollars by not tracking claims to make sure they are paid.

The Trade Association of State HMO’s (The Minnesota Council of Health Plans) has contracted with an independent company who is building the software that will be available to medical offices and billing services in the state of Mn. to submit the claims online. The biller will go to the site and enter the claim information and send it to the insurance company. The only problem with this is that the information will have to be entered again for tracking purposes. If the office has a practice management system, any claims that had to be sent through this new system will also have to be entered into the practice management system.

We don’t know how this affects the smaller insurance companies in Minnesota who were not yet capable of receiving electronic claims submissions. I presume they are scrambling to get ready. Not only has Minnesota mandated that medical insurance claims be submitted electronically, but they have also mandated that all insurance carriers use ERAs or electronic remittance advices (electronic eobs). This is huge too. Electronic remittances make posting payments much quicker and easier if you have the means to post them automatically.

At any rate, it will be very interesting to see how this all works out. All eyes are on Minnesota. We would be interested in hearing from anyone in Minnesota and how it is affecting them.

Filing Medicare Claims

When submitting professional claims to Medicare part B, there are some things that Medicare requires that differ from other insurance carriers. If you do not follow these guidelines or rules, you will find that your claims will be rejected.

First of all, most Medicare carriers are requiring that claims be submitted electronically, even if Medicare is secondary. If you are not capable of submitting your claims electronically you can apply for a waiver. An office with less than 10 full time employees can obtain a waiver granting them permission to file on paper. The CMS requires you to obtain a waiver certificate “demonstrating extraordinary circumstances”. If accepted by Medicare, they can then file claims on paper. If you do not qualify for the waiver then you must find a method to submit your claims electronically.

If your software is not capable of electronic billing, which in this day and age would be unusual, or if you just do not want to go thru the expense or trouble, you can get a free software from your Medicare carrier. The biggest problem with using the free software is that it many times is cumbersome to use, and it requires double entry of the claims. However, if you do not submit a lot of Medicare claims it can be a viable option.

Another little quirk with Medicare is that they require you to enter the word “none” in box 11 (or the equivalent of box 11 if submitting electronically) on the CMS 1500 form. We have had many providers over the years contact us because “Medicare won’t pay!” when it was all just because they didn’t have the “none” in box 11.

Whenever we train a new employee that is one of the things we try to drill into their head! “Don’t forget the ‘NONE’!” There is nothing more annoying to me than getting a rejection to find that the only problem is that ‘none’ was missing. We are working with a company who is building a rules engine to prevent problems like this from getting thru. The claims scrubber will alert you to the missing word before you submit the claims!

Then of course there are the modifiers required only by Medicare such as the AT modifier for chiropractors or the GP modifier for physical therapists. These modifiers are not used by any of the other carriers, but without them Medicare will not pay.

Another thing Medicare requires is referring dr name and NPI number for simple in office services such as EKG’s. So if one of my doctors decides to do an EKG on one of his patients, I have to put HIS name and NPI number in as the referring doctor, even though he provided the service. Seems kind of ridiculous to submit a claim for Dr. Smith doing an EKG where Dr. Smith referred the patient to himself. But if I don’t put it in, the EKG is denied.

Another Medicare quirk is that many Medicare carriers (maybe all) require that you do not put the NPI number in box 24J if you are filing a claim for an individual provider who bills using just their individual NPI number. When the NPI number is in 24J for an individual provider, the claims are rejected. However, if you are filing a claim for a group, the individual NPI # must be listed in 24J and the group NPI# must be listed in box 33A.

When a claim is denied by Medicare or any other carrier, it is important to identify why the claim, or service, was denied. If the denial on the eob is not clear, call to get an explanation. If you do not agree with the reason for the denial ask what the process for appealing the denial is. If the claim was denied for something simple that you can fix easily, make the correction and resubmit the claim. If you do not understand the denial even after getting an explanation from a customer service rep, you can always Google it, or post a question on a good medical billing forum, like www.medicalbillinglive.com/members. The important thing is to take care of the denial and not to ignore it.

Most Medicare rules are consistent from carrier to carrier, but some are not. Rules change and you’ve got to be ready to change with them. Stay on top of the requirements, take care of any rejections, and attend any seminars you can. It is important to completely understand Medicare rules to do a good job at collecting the money due for the services rendered.

DME Suppliers Must Be Accredited by 9/30/2009

Medicare is mandating that all DME suppliers become accredited in order to continue to become reimbursed by Medicare DME carriers for supplies given to Medicare recipients. Accreditation is the process in which an independent organization evaluates a healthcare provider and certifies that the healthcare provider meets certain quality standards.

There are several accrediting organizations including the oldest which is Joint Commission on Accreditation of Healthcare Organizations (or JCAHO). Their process includes an evaluation of the healthcare provider’s clinical service as well as the provider’s administration process, personnel management and information management.

This mandatory accreditation is due to the Medicare Prescription and Drug Improvement and Modernization Act of 2003. Some areas in the country had to meet a deadline in the spring of 2007 to be accredited, but ALL (but those exempt) providers will have to meet the September 30 deadline. Any DME supplier who provides equipment and services to Medicare beneficiaries will have to become accredited if they want to continue to be reimbursed by Medicare for their services.

Those expept from this ruling are:

Suppliers providing drug and pharmaceuticals only
Physicians, including dentists
Audiologist
Optometrists
Orthotists
Prosthetists, including occularists
Opticians
Occupational Therapist
Physical Therapists

The accreditation process can take from 9 to 12 months. As we approach the deadline the demand on these accredting organizations will become greater and the process may take longer. Any provider needing to get accredited should decide which organization they want to go through and contact them as soon as possible.

The organization will inform them as to the process. Most likely they will review the current services, practices and policies to determine if they meet the standards. If the standards are not met, they will determine what changes need to be made and develop a plan for the provider including a time line for implementing the necessary changes.

Once this is complete, the provider submits an application for accreditation to the organization. The application can be submitted when the changes are being made. The accrediting organization will then review the application and any supporting documentation and determine whether the supplier is eligible for accreditation.

The cost of becoming accredited varies depending on the size and complexity of the provider applying. Prices include the cost of surveyor, travel expenses, hotel, etc. The best way to find out what it will cost is to contact one of the accrediting organizations and ask for an estimate.

GW Modifier for Care Unrelated to Hospice Terminal Care

Many billers think that if a patient is a Hospice patient that they cannot get reimbursed for services if they are not reimbursed by the Hospice carrier. But actually there is a modifier, GW, that indicates that the care is unrelated to the patient’s terminal condition. In order for a patient to receive Hospice services they must have a life expectancy of six months or less if the terminal illness or disease runs its normal course.

Many people mistakenly think that this means that the patient must be bed ridden or critically ill. However, that is not always the case. In fact, many hospices encourage the patients to continue with social and recreational activities as long as they are able. They try to make the patient’s last few months, or weeks as fulfilling as possible.

This in some cases means that the patient may need to see a medical provider for something that is not related to the terminal condition. For example, maybe the patient has low back pain and seeing a chiropractor gives the patient relief. Their terminal condition is an inoperable brain tumor, or an inoperable aortic aneurysm. The back pain is not related to the terminal condition. The patient receives relief from the chiropractic manipulation.

The chiropractor can still see the patient even though they are receiving hospice and the chiropractor doesn’t have to get hospice to agree to pay for the care. They can bill the patient’s insurance using the GW modifier to indicate “service not related to the hospice patient’s terminal condition”.

There are other examples of care that can be rendered that is not related to the terminal condition. Maybe the patient gets conjunctivitis and needs to see an ophthalmologist to get treatment. Again, the service is unrelated to the terminal condition, but you can’t just ignore the conjunctivitis.

For me the problem is that I use the GW modifier so infrequently that when I need it I can’t remember which modifier it is. So I decided to make it an entry in my rolodex so that when it comes up, I can find it easily! Hey, whatever works.

Submitting Out of Network Claims

If you are trying to submit claims for a provider who is out of network with the insurance carrier you will most likely run into some problems. For example, if you need to call on the claim you may find that the insurance carrier will not even speak to you since you are out of network. This makes following up on the claim difficult.

Some wonder why you would want to follow up on a claim that is out of network. Sometimes it is not the provider’s choice to be out of network. Or possibly they are trying to help the patient out. In our case, it was an inpatient drug rehab that just opened, still applying to be in network, but accepted the patient as an insurance patient. They had us submit the claim but they are waiting for the payment.

We submitted the claim and then called 2 weeks later to be advised the claim wasn’t on file. We then faxed them the claim and called again 1 week later. Now we were told the claim was received and was in process. Fortunately we didn’t rest on that information. We called again 1 week later to find that the claim was ‘lost’. Now I couldn’t figure out how it could be lost since we were told it was received and in process, but this new person was now telling me that she was sending it back for processing and ‘telling them where to find the claim”.

The funny thing was that we received a letter that day with the claim being returned stating that the type of bill was not a valid type of bill code. Isn’t it amazing that we were told such different information when we called? Well our type of bill certainly was valid, but it turns out that Blue Cross just requires a different type of bill. Now we’ve resubmitted the claim with the new type of bill and you can bet we will keep calling until payment is made.

There are other problems that you can run into when submitting out of network claims. In some cases patients have no out of network benefits which means no payment will be made on the services. Usually out of network claims are paid directly to the patient and this may not be a problem for you if you are just verifying if the claim was paid. If you are waiting for the payment then it can be helpful to know when the patient is receiving the money.

For those of us who are responsible for submitting out of network claims for providers we just have to be diligent in following up on the claims. It is not an easy task but if you just stay on top of it, it can be done.

ICD10 Codes – The Shocking Truth

October 2013 seems a long way away with little need to prepare now for the changes from ICD9 to ICD10 codes but I recently learned the shocking truth. The Healthcare Billing and Management Association held a conference in Boca Raton this month with a session attended by approximately 200 medical billers on the new ICD10 codes. Even though I have looked into the changes and even written on them, I was shocked to hear all that is really involved. We all need to start paying attention now.

My original questions revolved around whether all doctors will be expected to start using ICD10 codes on a specific day and will all the insurance companies be ready to accept them on that same day or will it be more of a transitional thing like the NPI numbers were.

My first surprise was that ICD10 codes are already in effect in all the rest of the world. Other countries have been using them for years. We are way behind the times with regard to the rest of the world.

My second surprise was that ICD9 codes are not just being expanded. ICD10 codes are totally different than ICD9 codes. We won’t just add another number and there aren’t just a few small changes. ICD10 codes will identify much more information about the visit than ICD9s do. ICD10 codes will contain an expansion of disease classification with greater specificity. They will be much more detailed and will help identify fraudulent billing practices. There will be no 1 to 1 crosswalk. This means that a 309.28 will not equal a A40258Z. You won’t take an ICD9 and turn it into an ICD10. They are completely different.

My next thought was how are my doctors going to learn all these codes? We bill many small specialty practices. Many of our chiropractors still do not understand the requirements by Medicare for the ICD9 codes. How are they ever going to get the ICD10 ones right? How are our psychiatrists, psychologists and social workers going to learn ICD10 coding? Most of these are single practitioners who work alone and do not hire a coder.

ICD10 coding will require more clinical information such as “did the patient use tobacco”, “did the patient use alcohol”, “which finger was cut”, “which part of the finger”, “was the nail damaged”. The new codes will contain alpha characters as well as numeric. The number 1 can mean 15 different things. It is estimated that it will require 24 – 40 hours of classroom education to understand the concepts of ICD10 coding.

Another consideration with the codes now using alpha characters as well as numeric is whether your software will allow you to use alpha characters. If you are using a web based software this won’t be a problem, but if you have a server based software, you will want to check with your vendor and make sure you will be able to submit alpha characters in diagnosis codes.

The speaker felt that unspecified codes may be a problem as insurance carriers have yet to tell us if they will pay on unspecified codes with the new changes. Pre-authorization policies will have to be rewritten. Workers comp is not subject to ICD10 changes so some companies say they will not process the ICD10 codes. For a period of time both ICD9 and ICD10 codes will be in effect. Does this sound confusing enough to the average biller yet?

Then came the bombshell. Insurance carriers are not ready for ICD10 codes and most of them won’t be ready. Many have announced that they will try to translate the ICD10 code back into an ICD9 code to pay the claim. This means doctors will be translating the ICD9 codes they are familiar with into a new unfamiliar ICD10 code and the insurance carriers will be translating this ICD10 code back into hopefully the same ICD9 code to pay the claim. I can only imagine the problems this will present.

As one of the speakers said “Hold onto your butts! It’s going to be a rough ride!”

Submitting Claims for Suboxone Therapy

Suboxone is a drug that is used in treating drug addiction. It is very effective and does not require inpatient treatment. Physicians must be certified to prescribe Suboxone and have other guidelines they must follow.

For example, on the first visit the patient must come in to their appointment in the early stages of withdrawal. The dr must document their condition and then give them the first dose of Suboxone in the office. Then they have to wait for the drug to begin to take effect. The patients condition is documented again and instructions are given.

The Suboxone works much like Opoids, but unlike Opoids the patient can be weaned down and in most cases completely off of the Suboxone. This can all be done with outpatient medical visits and eliminates the need for an inpatient stay.

Sounds good so far, the problem comes in when you submit the claims to the insurance carriers. Since the diagnosis begins with 30*.** the insurance carriers pick the claim up as mental health. Many carriers handle their mental health claims differently than their medical claims and some even subcontract their mental health to a different insurance carrier. Most mental health services require preauthorization. However, suboxone therapy is a medical service and is coded as a medical office visit.

Since Suboxone therapy is a fairly new treatment many insurance carriers do not know what to do with these claims. We are finding that we have to educate each carrier as to what Suboxone is and go thru a huge process with them in order to get the provider reimbursed properly for their services. One carrier in particular was telling us when we called that preauthorization was not required, but they were denying all claims stating no preauth was obtained. After 6 months of phone calls we finally got it straightened out. They had to make some adjustments to their system to allow the claims to process correctly but the provider got reimbursed for all visits.

We still have some insurance carriers not processing the claims correctly but most are starting to get the hang of it. We just keep plugging along and educating the carriers on what Suboxone therapy is. After all, in the long run it saves them money on the inpatient stay.