A good case in point would be if a neonatal patient presented with a fever. The physician then did a urine catheterization (51701) and a spinal tap (62270) in the office. In many cases, the medical biller might have bundled these claims together but that would be incorrect as they are two distinctly different procedures even though they were performed at the same visit.

Also, a urine catheterization (51701, Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) and lumbar puncture (62270, Spinal puncture, lumbar, diagnostic);do not have edits placed on the code pair by NCCI so no modifier would be required for reporting this procedure. If you do use modifier 51, expect Medicare to reduce reimbursement by roughly 50%.

However, in the case of this type of procedure, your medical documentation documenting both the necessity of the procedures as well as the outcome should be iron clad to insure that you get maximum reimbursements on your medical billing for these services.

A patient that recently had a hysterectomy presented to the ED with symptoms needing treatment. The physician noted that the patient was suffering from “estrogen withdrawal with menopausal symptoms.” A level three evaluation and management service was performed on the patient; what diagnosis code would you use? There’s no specific code for estrogen withdrawal.

Stumped? In this case you should use more than one code as there is no specific code for this service. Break out the claim to show the patient’s main complaint and reason for the ED visit and then to show that she is a recent hysterectomy patient.

You will want to report code 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) for the E/M service. Then you will want to pair that coding with 627.4 (Symptomatic states associated with artificial menopause) to 99283 to represent the patient’s estrogen withdrawal. Then, to back up the history of patient by attaching V45.77 (Acquired absence of organ; genital organs) to 99283 to signify that the patient had a hysterectomy.

Good documentation will show that this patient had a legitimate need for treatment and management and you are more likely to receive reimbursement for your medical billing claim if you meet this criteria.

Further, your medical billing claim must have the time limits observed for locum tenens doctors. Otherwise, Medicare won’t pay for their services rendered to patients. Also, you can’t hire a locum tenens as extra staff. This includes situations where the regular attending physician goes on vacation, has an illness with a lengthy recovery time, maternity or family healthy leave, or educational reasons such as attending continuing medical education classes. When you use a locum tenens physician it must always be in the capacity as a temporary replacement that substitutes for the services of a specific physician.

Remember to use Modifier Q6 on all your locum tenens claims. There are some extra steps that must be taken in order for your locum tenens claims to be reimbursed by Medicare. The Q modifier should be listed as a procedure code so Medicare knows you’re claiming services rendered by a locum tenens physician. If you don’t use the modifier, you claim will likely be denied. Also the maximum time limit for billing for locum tenens physicians is currently sixty days for Medicare and private payers will have different criteria for length of service. Call before you file is a good rule of thumb, you may be missing reimbursements if you don’t. Some good questions to ask would be if the payer requires the locum tenens be credentialed even for a short period of service time; also, which provider’s ID would they prefer to be reported?

Using the correct modifier and a call before you file can save you a lot of hassles and delays in receiving your reimbursements for the locum tenens type of medical billing claims.

If you’re wondering if there is a single code, the answer is yes. A parent conference falls under V65.19 (Other persons seeking consultation; other person consulting on behalf of another person). In other words, the code describes a person seeking “advice or treatment for non-attending third party.” Since a parent has the right to discuss the treatment and medical issues for their minor child it’s per missable to bill for the consultation.

The counseling diagnosis code can be used when the patient is present or when counseling the parent/guardian(s) when the patient is not physically present as in over the telephone. Although carriers may require supporting documentation for coverage of the encounter, so make sure you indicate the discussion’s topic and the documentation should be signed off on by the attending physician. In case of an as yet undiagnosed concern, you can also check if payers want a secondary diagnosis that indicates the topic.

There are numerous reasons for consultations that include these top four common reasons:

• ADD/ADHD — 314.00, Attention deficit disorder; without mention of hyperactivity; 314.01, Attention deficit disorder; with hyperactivity
• anxiety — e.g., 300.00, Anxiety state, unspecified
• depression — e.g., 311, Depressive disorder, not elsewhere classified
• obesity — 278.00, Obesity, unspecified.

Use the total face-to-face time that the pediatrician spends with the parents to select the service code. Careful supporting documentation of the time elements is critical and will result in reimbursement for your medical billing claim.

One important thing to learn is when you should also list a diagnosis code for the wound in I3. The I3 is important to complete when you’re doing medical billing for long term care patients as it reports additional conditions that affect a patient’s health. 

Since pressure ulcers are extremely common in long term care for patients that are invalids, there is a Section M that provides options for identifying both pressure ulcers and stasis ulcers but not for other types of ulcers. If another type of ulcer is to be reported on your medical billing claim, use the form and then also list the corresponding ICD-9 codes at I3, says Smith. In this case, you should list:

A confusing part of medical billing for long term care comes from the I3 itself where some I3 coding training indicates that you don’t need to include diagnoses codes for conditions that are addressed elsewhere on the MDS. However, many carriers, including Medicare do require that the type of wound be specifically spelled out. Additionally, once the ulcer is healed, be certain to take it out of section I3.

Now we have codes for codes and modifiers and the need to when to bundle and when to not bundle with the goal being fair reimbursement for procedures done. Modifiers cause a lot of confusion for many medical billers. One such confusing modifier that is worth clarifying is Q6.

This applies to Medicare medical billing claims only, but in a nutshell when one of your staff physicians takes a leave of absence for any reason and a substitute physician fills in, you need to add the Q6 modifier to Medicare claims the sub handles if you want to ensure reimbursement for the services that the sub provides.

If you’re wondering why, the reason is that when a substitute or locum tenens physician handles patients, Medicare wants to see specific modifiers on claims. This is to make sure that the time limits on locum tenens doctors are strictly observed.

In order to be reimbursed, make sure that modifier Q6 (Service furnished by a locum tenens physician) is attached to all codes for procedures performed by the substitute physician. This lets the Medicare carrier know that you are coding for a locum tenens physician. Without the modifier, you’ll likely receive a denial for the claim.

Since many private carriers are adopting more and more of Medicare’s standards for payment on services; before filing a locum tenens claim with a private insurer, verify with the plans as to their requirements for locum tenens billing — and whether or not they even recognize it. Some good questions to ask are:

• Do you recognize modifier Q6?
• Which provider’s ID should be reported for the services?
• Does the locum tenens provider need to be credentialed with the payer, even if only temporary privileges?

As always – write down the full name and position of whomever you speak with and the time and date of your call in case you need to track that person down again.

To determine which modifier applies to your physician’s claim, check out the following list of what Medicare and other payers include in each description:

Class A Finding:Nontraumatic amputation of foot or integral skeletal portion thereof

Class B Findings:Absent posterior tibial pulse
Advanced trophic changes such as (three of the following sub-categories qualify as one class finding): hair growth (decrease or absence), nail changes (thickening), pigmentary changes (discoloration), skin texture (thin, shiny), skin color (rubor or redness)
Absent dorsalis pedis pulse

Class C Findings: Claudication
Temperature changes (e.g., cold feet)
Edema
Paresthesias (abnormal spontaneous sensations in the feet, e.g., numbness, prickling, or tingling)
Burning

For proper use, be sure to place the Q modifiers to indicate class findings before modifiers LT (Left side) and RT (Right side). Additionally, not all carriers will require it but it is a good idea to include detailed documentation about the necessity of the foot care and tie in the use of the Q modifier.

For starters, it is very important that you do not bill more than once for physicians that are from the same group. This is a situation that calls for a choice of only one. For example, even though you may have two individual physicians, if they are from the same group they cannot both be billed, even if the patient receive observation care from the both of them. 

Next up, you are going to really make sure that you document everything possible. When it comes to billing codes 92234-92236, you will want to include all information such as timed physician and nursing notes, the time that it took for treatment status and so on. This is important to show for any evidence that the physician had contact with the patient, took the time to observe him or her, time checking in on the condition and even looking over the diagnostic tests.

After all of this and some other steps to ensure documentation, you should find that you will have less and less in terms of glitches when it comes to all of your observation coding needs.

Many times, a physician will end up seeing a patient that shows up in search of a visit to fall into the category of preventative medicine. Then, upon further evaluation, the doctor will then need to look at the patient further for some sort of significant problem that they have. As a coder, you may end up finding yourself in a situation where you are not sure if you are to code the visit under a new or established patient. 

This type of a situation definitely calls for a swift bit of judgment on your part. In order to make sure that the practice receives reimbursement and avoids denial, you can always go with a new patient code to begin with. Then, after you look through and take all of the medical documentation into account, you can see if there is a modifier that you can add on.

No matter what you decide on when coding in such a predicament, you need to realize that you can come into problems with insurers. Always take the procedure, documentation and time lapse between visits into account before you record the code.

If you’re ready to get rid of the hassles that a rejected claim or multiple claims can cause, it might be time to consider outsourcing your medical billing claims to a third party partner that can get your claims submitted, double check your billing and get your reimbursements.

The beautiful thing about outsourcing your medical billing claims is the average return rate due to errors is less than 1%. Plus you’ll see up to 25% of your reimbursements increased due to your claims being handled in an efficient manner. Best of all, your staff will be free to help you run your practice instead of chasing paperwork for medical billing claims.