Facility Billing

Billing for facilities is much different than professional billing, or billing for individual doctors or groups of doctors.  Facilities include drug and alcohol rehab, eating disorder clinics, and much more. Billing for facilities is usually done on UB04 forms rather than CMS 1500 forms.  UB04 forms are entirely different than CMS 1500 forms and require different information than CMS forms.

UB04 forms require REV codes, type of bill, source of admission, condition codes and more.  If you are currently billing for primary care doctors and for specialties like physical therapy or mental health, you will have a lot to learn in order to bill for a facility.  UB04 forms in themselves can be a bear to complete properly, but besides that, individual insurance carriers will often insist that claims to their company be billed differently.

They may require a different REV code than the norm.  They may require that services be billed as HCPCs codes on a CMS 1500 form instead of as REV codes on a UB04.  Each carrier may have a completely different set of billing guidelines.  Because of this facility billing tends to be a lot more involved than professional billing.  The important thing is to develop communication with each insurance carrier, find out their requirements and be diligent to get the claims filed in the manner that is required.

The Business of Medical Billing

This industry is such a balancing act in many respects.  When we are first starting our businesses we can’t find enough providers who hire us.  As we grow, we find we have more work than we can get done and we need to hire and train someone.  Once you start hiring and training people it can be difficult to know when you need to hire the next person.  Is there enough work to justify another person?  Is there enough income to cover the additional costs of hiring another person?  Who will train the next person and how will that affect their work load?  We find we are often questioning if we are ready to hire another person.  Is this just a busy time frame due to a few projects or do we need another full time person?

Last month we tried something new.  We hired a person to fill a position we had never hired for previously.  We found that as we grew we found new needs.  We bill for over 50 offices.  We assign certain accounts to each worker.  We also cross train all accounts so if someone is out or they leave someone else can take over that account.  Then we also have one person who continuously works aging reports so each provider’s aging is completed every 4 – 6 weeks.

Over the years as we added accounts and insurance carriers offered ERAs or electronic remittance advice we found that it was taking a lot of time just to download all these ERAs and take care of the denials on the reports.  We tried having one person do the reports on Monday and Wednesday and another on Tuesday and Thursday and a third person on Friday.  This worked, but it entailed problems too.  We found we had to keep rearranging who could do which accounts because so much time was being spent on the ERA downloads.

Last month we had someone approach us asking if we were hiring.  We were not looking for someone, but thought what if this person could learn just the ERA downloads.  She wanted to work only part time as she has a special needs child.  The downloads took a little less than 4 hours most days.  It was a difficult job for her to learn, but now 4 weeks later it is working great.  It has freed up three other workers to spend more time on their own accounts and take on a little more work.  We filled a position that we were not aware was a need.  Keep your eyes open to such possibilities.  Sometimes we are so used to doing things one way we are unable to see a better way.

Update on 59 Modifier

Barbara Griswold researched and wrote an article about the new CPT code changes for mental health effective January 1, 2017 and graciously allowed us to reprint her article which you can read here.

Since then a kind reader sent us more information on her experience with using the 59 modifier.  She states that they have had good experience getting paid using the modifier XE in place of the 59 modifier when billing the CPT code 90847 along with 90832, 90833, 90834, 90836, and 90837 and 90838.

I checked back with Barbara and she researched further and sent me the following information.

The 59 hasn’t been deleted but I found that some codes that have come out that should be used instead since they are more specific, most notably XE in the case we are talking about when a therapist does a couples and individual session in the same day.  I’m not sure if this is just Medicare, or if private plans will accept this,  but a few websites seemed to verify this.  Here is one of them that explains it well.

Thanks for clarification Barbara

Author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance — And Whether You Should” www.theinsurancemaze.com

New CPT Codes for Mental Health

Barbara Griswold researched and wrote the following article about the new CPT code changes for mental health effective January 1, 2017 and graciously allowed us to reprint her article.

While you may know that psychotherapy CPT codes underwent radical changes in 2013, on January 1, 2017, more changes quietly went into effect.  According to the American Psychological Association, in the American Medical Association’s new 2017 CPT manual the following was clarified:

·         The descriptions of codes 90846 (couple/family therapy without patient present) and 90847 (couples/family therapy with patient present) have been changed so they now have stated time lengths of 50 minutes.  These codes should be used when providing family or couples therapy, with a minimum of 26 minutes.

·         Psychotherapy codes (90832, 90834, and 90837) are now for individual therapy only.  The description “psychotherapy with patient and/or family member” has now been changed to simply “psychotherapy with patient.”  Yes, the AMA says these sessions may occasionally involve “informants” such as family and caregivers, but these codes are to be used when the therapist is primarily providing individual counseling, and the patient is present for the majority of the session.

·         Codes 90832, 90833, 90834, 90836, 90837, 90838 can be reported on the same day as 90846 or 90847.  Include modifier 59 to emphasize the services were separate and distinct.  (Note: this doesn’t mean the insurance plan will cover them both, but this is how to code them).

by Barbara Griswold, LMFT, Author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance — And Whether You Should” www.theinsurancemaze.com

Telemedicine changes

We received the following article from Barbara Griswold and she graciously allowed us to reprint it.

The CPT manual also introduced a new CPT modifier, 95, for “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.”  While this will cover video sessions, you’ll notice this description doesn’t apply to phone sessions.  This modifier follows the code for the service provided — ex. If you provided 60 minutes of telemedicine, you would code 90837 with modifier 95. (Note: Many clients don’t have coverage for telehealth.  Also, payers have previously asked providers to use the GT modifier to indicate a telehealth session, so it is a good idea to check with plans before billing).

In addition, the manual clarified that the only codes appropriate for telemedicine are 90832, 90834, 90837, 90845, 90846, and 90847.

What is the Place of Service Code for Telehealth? The APA article suggests when recording the Place of Service code for telehealth sessions that you use the originating code for where the provider is located (typically 11 for office).  However, since the article was written, a new Place of Service Code, 02, took effect (January 1, 2017) to identify “The location where…services are provided or received, through a telecommunication system.”   As always, it is a good idea to check with the insurance plan to see which should be used.   For a complete list of Place of Service codes, click here.

by Barbara Griswold, LMFT, Author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance — And Whether You Should” www.theinsurancemaze.com


What is Fee-splitting

Fee-splitting laws were enacted many years ago in several states including NY to protect patients from unscrupulous physicians.  Fee-splitting occurs when a physician splits part of the professional fee he earns with someone else.  It was enacted to prevent harm from a small minority of physicians who were looking to strictly line their pockets.  It was meant to keep doctors from referring services to another doctor who was getting paid for the referrals.

In the strictest sense of this law, it also pertains to doctors who take credit cards as a form of payment as the credit card companies are charging a percentage to the doctors.

Medicaid admits that charging a provider a percentage is very common but still illegal.  Most medical professionals prefer to pay a percentage as it is easier for them to compare to other services.  All are now required to find another method of payment or risk losing their medical license.

NY Medicaid demands repayment of Millions of Dollars

NY Medicaid has been sending letters to physicians in New York State demanding providers pay back huge amounts of money.  These demands are not for any overpayments or errors in billing.  The Medicaid Fraud Control Unit has found a new way to take millions of dollars away from doctors based on an article in Volume 16 Number 3 of a Medicaid update issued in March of 2001.

The article states that billing agents are prohibited from charging Medicaid providers a percentage of the amount claimed or collected.  They state it is prohibited by the antiquated fee splitting laws.

They go on to state that they understand that these practices are very common but it is not acceptable under the Medicaid program.

The letter then goes on to state that during the period of 1/1/2010 to present time Medicaid paid out $XXXXXXXX to the provider, and that the provider paid the billing service $xxxxxx.  They then demand that one half of the amount the provider paid to the billing service during that time frame be repaid to Medicaid.  The amounts Medicaid is demanding are staggering.  We were sent a copy of one letter demanding $48,151.66.  To add flame to the fire Medicaid is charging 9% interest on top of this.
What can we, as a medical community, do about this?  Some are hiring attorneys to fight it.   Some are checking into it with their professional associations.   We know of one family practice that is going out of business.  They have notified their patients and are closing up.  Other doctors will drop out of the Medicaid program.  How will all this affect Medicaid patients if doctors give up participation with the program?

We have been saying for several years that charging a percentage is considered fee splitting in several states including New York.  The problem is that most providers want to be charged a percentage because they feel that this is the best way to make sure that the billing service is doing their job.  They are only paid if and when the provider is paid.  However, at the end of the day it is still considered fee splitting.

At this time it appears that it is only straight New York State Medicaid however we have heard rumors that the Medicaid Managed Care Plans may follow.   Commercial insurances could also decide to follow suit.  The letter sent out by NYS Medicaid indicates that providers can actually lose their license for violating fee splitting laws.

If you or one of your providers have received a letter from Medicaid requesting a refund due to percentage billing please let us know what your office is doing about this.  What are you hearing?  We will post responses anonymously to let others know what is happening.