​Guideline:
The same physician planned, at time of original surgery/procedure, a return trip to operating or procedure room within 10 or 90 day post op days



​

WHEN IT IS APPROPRIATE:

• Treatment of problem requiring a return to operating/procedure room
• More extensive than original procedure
• Unanticipated clinical condition
• Therapy following a diagnostic, surgical procedure                                
• Each case requires surgical documentation and evaluation

Modifier 58 appropriate for example; hardware removal was planned as part of therapeutic approach involving multiple, staged procedures to the surgical intervention

Physicians in same specialty, same group are to bill and are reimbursed as a single physician

Key to Remember!  Use modifier 78 (not 58!) for treatment problems unplanned requiring return trip to operating room

If hardware removed in unplanned surgery return for a complication, (e.g. infection of the wound site or rejection of the hardware itself), modifier 78 appropriate

It is NOT APPROPRIATE WHEN:

• Not appropriate for E/M - Evaluation and Management! or assistant surgery services

References:
CMS Medicare Website
Coding Books
​Payers Websites

​ Per the Current Procedure Terminology® (CPT®) manual, the descriptor of modifier 79 is:
• "Unrelated procedure or service by the same physician during the postoperative period."
As indicated, this modifier is used to bill an unrelated procedure or service performed by the same physician during the postoperative period of a previous surgical procedure.
When a patient has surgery performed, there is a postoperative period -- a period after the surgery has been performed when additional surgical care related to the initial surgery is considered already covered (and paid for) by the allowance provided for the initial surgery. The postoperative period can be zero or 10 days (minor surgical procedure) or 90 days (major surgical procedure). (Note that some surgeries are considered so minor that they have a zero day postoperative period, usually a very quick outpatient procedure.)

Modifier 79 should be used when a surgical procedure is:

• Performed during the postoperative period, where the original surgery had a global period of 10 or 90 days.
• Performed by the same physician or physician of the same specialty within the same group, and
• Unrelated to the original surgical procedure

REMEMBER! 
When the 79 modifier is used, a new postoperative period for the second surgical procedure begins. Additionally, the remainder of the postoperative period of the original surgery is still applicable.

References:
Medicare CMS Website
American Medical Association CPT
Coding Books
Payers Websites

​Chronic Care Management Services and the New Changes for 2017
CMS Medicare recognizes the Chronic Care Management (CCM) as a critical component of primary care services that contributes to better health and care for individuals.
So in 2015, Medicare began paying separately under the Medicare Physician Fee Schedule for CCM services furnished to Medicare patients with multiple chronic conditions.

Beginning January 1, 2017, the CCM codes are:

Code 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
• Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
• Comprehensive care plan established, implemented, revised, or monitored
• Assumes 15 minutes of work by the billing practitioner per month

Keys to Remember:
Let’s try to describe what CCM is or Chronic Care Management Services. These are services rendered by a Physician or Non-Physician Practitioners such as Nurse Practitioners, Physician Assistants, Clinical Nurse Specialist, Certified Nurse-Midwife and the CLINICAL Staff ---  per month, for patients with two or more chronic medical conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Take note that ONLY (1) One Practitioner can report and bill for Chronic Care Management per month.
The included services are:
○ Access and use of a Certified Electronic Health Record (EHR)
○ Continuity of Care with Designated Care Team Member
○ Comprehensive Care Management and Care Planning
○ Transitional Care Management
○ Coordination with Home and Community-Based Clinical Service Providers
○ 24/7 Access to Address Urgent Needs
○ Enhanced Communication (email, and telephone for example)
○ Advance Consent CCM Changes in 2017 are the following:

• Increased payment and additional codes the single CCM code paid approximately $42.
• Now there are 3 codes and payment can range from approximately $43 to over $141, depending on how complex a patient’s needs are;
• A given patient can receive either regular (often referred to as “non-complex”) CCM or complex CCM during a service period if applicable (not both)

The difference between complex and non-complex CCM is the amount of clinical staff time, the extent of care planning, and the complexity of the problems addressed by the billing practitioner during the month;
There is a more complex care and we describe it as Complex Chronic Care Management services;

Here are your two new codes for the Complex CCM - Complex Chronic Care Management services:
CPT 99487
Complex chronic care management services, with the following required elements:
● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the
death of the patient;
● Chronic conditions place the patient at significant risk of death, acute exacerbation/
decompensation, or functional decline;
● Establishment or substantial revision of a comprehensive care plan
● Moderate or high complexity medical decision making
● 60 minutes of clinical staff time directed by a physician or other qualified health care
professional, per calendar month
(Novitas Part B NJ North $102.36)

CPT +99489     --- (this is an add-code and cannot be billed by itself!)    
Each additional 30 minutes of clinical staff time directed by a physician or other qualified    health care professional, per calendar month (List separately in addition to code for primary procedure)
Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately(Novitas Part B NJ North $50.98)
Supervision
The CCM codes (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required.
Patient Eligibility
Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at signifcant risk of death, acute exacerbation/decompensation, or functional decline are eligible for CCM services.
● Billing practitioners may consider identifying patients who require CCM services using criteria suggested in CPT guidance (such as number of illnesses, number of medications or repeat admissions or emergency department visits) or the profile of typical patients in the CPT prefatory language.
● There is a need to reduce geographic and racial/ethnic disparities in health through provision of CCM services. Table 2 provides a number of resources for identifying and engaging subpopulations to help reduce these disparities.
The billing practitioner cannot report both complex and regular (non-complex) CCM for a given patient for a given calendar month. In other words, a given patient receives either complex or non-complex CCM during a given service period, not both.
Examples of chronic conditions include, but are not limited to, the following:
● Alzheimer’s disease and related dementia
● Arthritis (osteoarthritis and rheumatoid)
● Asthma
● Atrial fbrillation
● Autism spectrum disorders
● Cancer
● Cardiovascular Disease
● Chronic Obstructive Pulmonary Disease
● Depression
● Diabetes
● Hypertension
● Infectious diseases such as HIV/AIDS
Initiating Visit
For new patients or patients not seen within one year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner (an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visit with the billing practitioner).  

This initiating visit is not part of the CCM service and is separately billed.
Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506 (Comprehensive assessment of and care planning by the physician or other qualifed health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service]).
G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation.
Patient Consent Obtaining advance consent for CCM services ensures the patient is engaged and aware of applicable cost sharing. It may also help prevent duplicative practitioner billing. A practitioner must obtain patient consent before furnishing or billing CCM. Consent may be verbal or written but must be documented in the medical record, and includes informing them about:
● The availability of CCM services and applicable cost-sharing
● That only one practitioner can furnish and be paid for CCM services during a calendar month
● The right to stop CCM services at any time (effective at the end of the calendar month)

So, meaning, when you bill for $2000.00 and the insurance made their determination at 100% of your charges… you bill $2,000, they allowed $2,000 – would you be happy?
Honestly, if I see EOB like this, I will be very very nervous! Your provider could have been paid more than the practice submitted charges, isn’t it?

Interestingly, most of my readers said they’ll be happy if they were paid at 100% of their charges… now, would you?

What if the allowed amount could have been $2,500? – how much is the difference? Yep, $500! How can the payer allow $2,500 if you have only submitted a charged amount of $2,000?!
Make sense?

Ok, now, here’s the deal! — if you got paid at 100% based on your charged amount you should find out about your fee schedule or contracted rate or what is usual and customary if you are out of network provider. Make sure you know you are not under-charging the insurance payer.
But what if you have realized that you did under-charge the insurance payer? what will you do? can you recover the money that you could have been paid for? The answer is YES! you can recover that money!
Now, don’t wait too long! Take action immediately!

Based on my experience, you can go back as far as 3 years from the date the claims were paid. I haven’t tried more than 3 years of claim to recover due to undercharges! After all, just like the insurance payer, they can always go back as far as more than 3 years I think to recover overpayments. Or depending on where state you are located.
Pay attention on your EOBs! I think that’s the key. As soon as you discover there is an undercharging and you were paid 100% on your charged amount. Pick up the phone and call that insurance payer immediately.
Connect with us today, we will show you better strategies on how to run an effective revenue cycle management!

​Here are our Unlisted Service or Procedure Codes
A service encounter or surgical procedure may be provided that is not listed in this edition of the CPT code book. When reporting such a encounter or service, the appropriate “Unlisted Procedure” code may be used to indicate the service, identifying it by “Special Report” as discussed in the section below.

The “Unlisted Procedures” and accompanying codes for Surgery are as follows:
15999 Unlisted procedure, excision pressure ulcer
17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue
19499 Unlisted procedure, breast
20999 Unlisted procedure, musculoskeletal system, general
21089 Unlisted maxillofacial prosthetic procedure
21299 Unlisted craniofacial and maxillofacial procedure
21499 Unlisted musculoskeletal procedure, head
21899 Unlisted procedure, neck or thorax
22899 Unlisted procedure, spine
22999 Unlisted procedure, abdomen, musculoskeletal system
23929 Unlisted procedure, shoulder
24999 Unlisted procedure, humerus or elbow
25999 Unlisted procedure, forearm or wrist
26989 Unlisted procedure, hands or fingers
27299 Unlisted procedure, pelvis or hip joint
27599 Unlisted procedure, femur or knee
27899 Unlisted procedure, leg or ankle
28899 Unlisted procedure, foot or toes
29799 Unlisted procedure, casting or strapping
29999 Unlisted procedure, arthroscopy
30999 Unlisted procedure, nose
31299 Unlisted procedure, accessory sinuses
31599 Unlisted procedure, larynx
31899 Unlisted procedure, trachea, bronchi
32999 Unlisted procedure, lungs and pleura
33999 Unlisted procedure, cardiac surgery
36299 Unlisted procedure, vascular injection
37501 Unlisted vascular endoscopy procedure
37799 Unlisted procedure, vascular surgery
38129 Unlisted laparoscopy procedure, spleen
38589 Unlisted laparoscopy procedure, lymphatic system
38999 Unlisted procedure, hemic or lymphatic system
39499 Unlisted procedure, mediastinum
39599 Unlisted procedure, diaphragm
40799 Unlisted procedure, lips
40899 Unlisted procedure, vestibule of mouth
41599 Unlisted procedure, tongue, floor of mouth
41899 Unlisted procedure, dentoalveolar structures
42299 Unlisted procedure, palate, uvula
42699 Unlisted procedure, salivary glands or ducts
42999 Unlisted procedure, pharynx, adenoids, or tonsils
43289 Unlisted laparoscopy procedure, esophagus
43499 Unlisted procedure, esophagus
43659 Unlisted laparoscopy procedure, stomach
43999 Unlisted procedure, stomach

44238 Unlisted laparoscopy procedure, intestine (except rectum)
44799 Unlisted procedure, intestine
44899 Unlisted procedure, Meckel’s diverticulum and the mesentery
44979 Unlisted laparoscopy procedure, appendix
45399 Unlisted procedure, colon
45499 Unlisted laparoscopy procedure, rectum
45999 Unlisted procedure, rectum
46999 Unlisted procedure, anus
47379 Unlisted laparoscopic procedure, liver
47399 Unlisted procedure, liver
47579 Unlisted laparoscopy procedure, biliary tract
47999 Unlisted procedure, biliary tract
48999 Unlisted procedure, pancreas
49329 Unlisted laparoscopy procedure, abdomen, peritoneum and omentum
49659 Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
49999 Unlisted procedure, abdomen, peritoneum and omentum
50549 Unlisted laparoscopy procedure, renal
50949 Unlisted laparoscopy procedure, ureter
51999 Unlisted laparoscopy procedure, bladder
53899 Unlisted procedure, urinary system
54699 Unlisted laparoscopy procedure, testis
55559 Unlisted laparoscopy procedure, spermatic cord
55899 Unlisted procedure, male genital system
58578 Unlisted laparoscopy procedure, uterus
58579 Unlisted hysteroscopy procedure, uterus
58679 Unlisted laparoscopy procedure, oviduct, ovary

​Can you bill a Medicare Patient for Missed Appointment or No-Show?

When patients missed their appointments, it does cost you your time and your staff. In this article, you are wondering if you can bill Medicare when their beneficiaries missed and appointment or has no-show. Below you will find clarifications.

​According to Chapter 1, section 30.3.13 of the Medicare Claims Processing Manual, which is attached to CR5613, CMS policy allows physicians, providers, and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge nonMedicare patients for missed appointments and the charges for Medicare and non-Medicare patient are the same. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (Medicare and non-Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly.
The other key points of CR5613 are:

• The provider may bill the Medicare beneficiary directly. • Medicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers.
• Claims for missed appointments sent to Medicare will be denied with the reason code 204 (This service/equipment/drug is not covered under the patient’s current benefit plan.).
• In most instances, a hospital outpatient department can charge a beneficiary a missed appointment charge.
• In the event, however, that a hospital inpatient misses an appointment in the hospital outpatient department, it would violate 42 CFR 489.22 for the outpatient department to charge the beneficiary a missed appointment fee. 

According to Medicare guideline; "make certain that your billing staff is aware that you may bill the beneficiary directly, that Medicare itself does not make any payments for missed appointments, and that Medicare should not be billed for these charges".
"The Centers for Medicare & Medicaid Services (CMS) policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments. However, Medicare itself does not pay for missed appointments, so such charges should not be billed to Medicare."
"Providers may not charge ONLY Medicare beneficiaries for missed appointments; they must also charge non-Medicare patients. The amount the physician/supplier charges Medicare beneficiaries for missed appointments must be the same as the amount that they charge non-Medicare patients.​"

Source: MLN: MM5613 Related Change Request Number: 5613

(1) Incorrect demographic information (insurance ID , date of birth, even the gender!)
Always scan a copy of your patient's primary and secondary insurance card. Make sure to get a copy of their new card (if there is a change)
(2) Patient's non-coverage or terminated coverage at the time of service may also be the reason of denial. That is why, it is very important that you check on your patient's benefits and eligibility before seeing the patient (unfortunately, I have seen practices who does not check benefits and eligibility on their patients so they end up being not paid for the service they have rendered for the patient
(3) Coding Issues (requires 5th digit, outdated codes)--- be careful also with your secondary/additional codes! Claims may be denied even if the problem was just because of the secondary codes!Again as I previously pointed out with my other articles on tracking your claims, with this problem, discuss solving the coding error rather than how much you want to get reimbursed. Most of the insurance companies will help you with codes (in fairness!!) and they also inform you on outdated codes, or codes that requires a 5th digit. You can also clarify by asking them more information on their reimbursement and utilization guidelines
(4) Improper use of modifiers (be careful with bilateral procedures!, modifiers for professional and technical component, modifiers for multiple procedures, postoperative period, etc.)
(5) No precertification or preauthorization obtained. It is so hard to file an appeal when the claim or service was non-precertified. Avoid this from happening! So be careful with your Surgical Procedures, Therapy Services and DME Services. 
(6) No referral on file. HMOs or the Managed Care normally requires a referral! (remember that!). Most Therapy Services would require a an order or script from the referring provider. Make sure the referring provider's NPI appears on Box 17 on your HCFA 1500 Claim Form
(7) The patient has other primary insurance, the patient turn out to be a Workman's Comp case or an MVA case. Call our office, we can give you an example of our template of benefits eligibility verification. Remember, WC/MVA cases services are normally always require Prior Auth so make sure you have the claim information, connect with the Adjustor and the Nurse Case Manager
(8) Claim requires documentation, require additional notes to support medical necessity. A well documented medical records is a good practice!
(9) Claim requires referring physician's information (very common for Therapy Services and DME Billing requirements)
(10) Untimely filing. So how can you prove that you did submit the claims in a timely manner? When unfortunately, most of the insurances does not accept your billing records on your practice management software that shows that date(s) you billed the insurance! They want a receipt from your electronic receipt or for postal mail, obviously they want a receipt too! a tracking number maybe? certified letter receipt? If you are submitting claims by electronic, make sure you generate transmission reports/receipts. Your reports must read "accepted" or "in process" and not "rejected". If you are sending claims by paper or postal mail, it is a good idea to send your claims as certified mail with tracking number, keep your transmission receipts!

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