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.

There are some simple rules to follow to ensure that you’re getting the best reimbursements for your claims. First of all, make sure that you know exactly what the payer requires for reimbursement on these claims. Next, make sure you document exactly what caused the encounter and what the outcome was. This shows a logical flow of information and will better help the payer see that the services rendered will qualify for full reimbursements.

Additionally, be aware that the RVU system makes no adjustment for codes with modifier 25. Although a plan may pay such claims as the policy allows, insurers that follow CPT rules should generally be paying each CPT code in full in this instance as long as a distinct entry is made on the medical billing form. Additionally, make sure that your charges are consistent and reflect real pricings for services rendered.

A red flag for many payers is two of the following scenarios:

• Enter a $0 charge for the sick visit service (99201-99215), and bill the preventive medicine service (99381-99397) above the contracted rate
• Split the well care charge in half and apply it to the sick visit.

  Remember, raising your price on a single visit may get your entire claim denied. The right way is to charge the usual amount for your services and back up all services with strong documentation.

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.

The answer to this question will be different depending on which entity is paying the medical billing claim. When you code for the use of tissue adhesives, including Dermabond; Medicare has its own guidelines for reporting this procedure that you need to follow to be reimbursed. You should report G0168 for Medicare patients only. If you are reporting the procedure for a non-Medicare patient, you should use the CPT code that is the equivalent and that is 12001-12018 series (Simple repair of superficial wounds …). 

Another tip for reporting this claim to Medicare is you may only use G0168 for Dermabond-only laceration repairs in both the inpatient and outpatient settings. If sutures or staples were also used you will have to report this as a layered laceration code on your medical billing form.

Something you may not be aware of is that Medicare assigns a payment status indicator of “N” to G0168, meaning it represents an incidental service. You can report the code but you won’t receive any reimbursement for it from Medicare payers.

Private payers will have different guidelines, a quick check with the payers to see if they follow Medicare guidelines for this type of procedure will let you know whether or not to expect a reimbursement for the service.

Colonoscopies are part of a check up for most individuals over the age of 50, however when the colonscopy finds a polyp, you should normally use the polyp diagnosis in your medical billing claim and not the screening V code. The exception to this rule would be if the physician discovers a polyp during the screening, you should instead report a diagnostic colonoscopy (45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple). 

The coding changes for a situation where the surgeon visualizes and biopsies the polyp, you should change the primary diagnosis from V76.51 (Special screening for malignant neoplasms; colon) to, for instance, 211.3 (Benign neoplasm of other parts of digestive system; colon).

The majority of carriers have states they want to switch the polyp diagnosis for the excision a few want to keep the V code. If you’re not sure in your medical billing, avoid a delay or rejection by asking what the carrier’s preference is.

You may have had every intention of doing your own medical billing for your practice from the day you opened until the day you retired, however with the never ending changes and nuances in medical billing claims varying from cancelled codes to nonpayment of certain procedures because they simply weren’t reported correctly – there comes a time when you need to look at your revenue flow from your reimbursements and decide it might be time to outsource your medical billing claims.

Another reason to outsource is the small fact that many practices are losing up to one solid forth of their revenue due to small inconsistencies in reporting. Medical billing codes can change, the way a particular carrier wants their medical billing claim reported can change and Medicare never seems to stop updating and changing their criteria for what constitutes a fully reimbursable procedure.

Your staff can spend valuable office time researching medical billing claims or you can outsource your medical billing and let your staff do what they do best : service your patients and help keep your practice running smoothly.

If you’re ready to get away from the paper chase of never ending medical billing changes, consider outsourcing a proactive way to begin 2010.

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.